NURS 305 UNIT V11 Circulatory Functions PDF

1 NURS 305: UNIT V11 CIRCULATORY FUNCTIONS Nurs 305  2 Review of the anatomy and physiology of the system Assessment and management of patients with cardiovascular disorders and problems with peripheral circulation An understan...

1 NURS 305: UNIT V11 CIRCULATORY FUNCTIONS Nurs 305  2 Review of the anatomy and physiology of the system Assessment and management of patients with cardiovascular disorders and problems with peripheral circulation An understanding of the structure and functions of the heart in health and disease is essential to develop cardiovascular assessment skills The heart is a hollow muscular organ located in the center of the thorax It occupies the space between the lungs (mediastinum) and rests on the diaphragm It weights approximately 300 grans (10.6 oz)  3 Location of the Heart 4 5  6 Anatomy of the Heart 7 8 9  10 The weight and size of the heart are influenced by Age Gender Body weight Extent of physical exercise and conditioning Heart disease The heart is composed of three layers The inner layer or endocardium, consists of endothelial tissue and lines the inside of the heart and valves The middle layer or myocardium is made up of muscle , fibers and responsible for the pumping action of the heart The external layer is call the epicardium  11 The heart is encased in a thin fibrous sac called pericardium which is composed of two layers Adhering to the viscera pericardium is the parietal pericardium, a tough fibrous tissue that attaches to the great vessels, diaphragm, sternum and vertebral Colum and supports the heart in the mediastinum The space between these two layers (pericardial space) is normally filled with about 20 ml if fluid which lubricates the surface of the heart and reduces friction during systole 12 13 Function of the heart 14  15 Nursing Assessment of the Cardiovascular functions The frequency and extent of the nursing assessment of cardiovascular function are based on several factors including The severity of the patient’s condition The presence of risk factors The practice setting and The purpose of the assessment. For instance, a person who is acutely ill with CVD and who is admitted into the emergency department ED or intensive care unit IC will require a very different assessment than a person who is being examined for a chronic stable condition  16 Although the assessment of key components of the cardiovascular system remain the same, the assessment priorities vary according to the needs of the patient For example, an ED nurse performs a rapid and focused assessment of a person in which acute coronary syndrome ACS, with signs and symptoms which may be caused by ruptured athermanous plague. A diseased coronary artery may be suspected. Diagnosis and treatment must be started within minutes of arrival to the ED. The physical assessment is ongoing and concentrates on evaluating the patient for ACS complications, such as dysrhythmias and HF and determining the effectiveness of medical treatment.  17 HEALTH HISTORY The signs and symptoms experienced by people with cardiovascular diseases CVD are related to dysrhythmias and conduction problems Structural, infectious and inflammatory disorders of the heart Complications of CVD such as HF and cardiogenic shock. These disorders have many common signs and symptoms, thus, the nurse must be skillful at recognizing these signs and symptoms and that the patients are given timely and lifesaving care.  18 SIGNS AND SYMPTOMS OF CVD WITH RELATED MEDICAL DIAGNOSIS Chest pain or discomfort ( angina pectoris; acute cardiac syndrome ACS; dysrhymias; valvular heart disease The nurse must keep the following important points in mind while assessing for pain: Location The severity of the pain The duration of the pain or discomfort to determine the seriousness. Tell the patient to rate the severity on a scale or 1-10 More than one clinical condition cardiac condition may occur simultaneously. For instance, in MI, the patient may report chest pain from myocardia ischemia , shorness of breathe from HF, and palpitation from dysrhymias. Both HF and dysrhythmias can be complications of acute MI.  19 Pain or discomfort in other areas of the upper body, including one or both arms, back, jaw, or stomach (ACS) Shortness of breath or dyspnea (ACS), cardiogenic shock; HF, valvular heart disease Peripheral edema, weight gain, abdominal distention due to enlarged spleen and liver or ascites (HF) Palpitations (tachycardia from a variety of causes including ACS, caffeine or other stimulants, electronic imbalance, stress, valvular heart disease, ventricular aneurysm Unusual fatigue, usually referred to as a vital exhaustion ( an early warning sign of ACS, HF, OR valvular heart disease characterized by usually feeling tired or fatigued or irritable and dejected.  20 Past history, Family history and Social history The health history provides opportunity for the nurse to assess the patient’s understanding of their personal risk factors for peripheral vascular , cerebrovascular and CAD and any measures they are taking to modify these risk factors Some risk factors include Increasing age Sex  21 Heredity may not be modifiable However, some risk factors are modifiable. These can be modified by lifestyle changes. These include Smoking Hypertension High cholesterol Diabetes Obesity Physical inactivity Medications.  22 The nurse should ask the following questions so as to perceive the how the patients sees their condition How is your health? Have you noticed any changes from the last year. 5 years? Do you have a cardiologist? Or a primary care provider? Hoe often do you see him? What health concerns do you have now? Do you have any family history of genetic disorders that place you at risk for cardiovascular disease? What do you do to stay healthy and take care of your heart?  23 Medications Obtain the full list of all the medications that the patient is taking including multivitamins, herbal preparations, and over the counter medications During the this aspect of the health assessment, the nurse also asks the following questions What are the names and doses of your medications What are the purposes of these medications? Why are you taking them? How and when are these medications taken?  24 Do you ever skip a dose or your forgot to take it? Are there any special precautions associated with talking these medications? What special symptoms or problems do you need to report to your primary health care provider? A comprehensive and thorough medication history often uncovers common medication errors and causes of non-adherence to the medication regimen.  25 Nutrition Dietary modification, exercise, weight loss and careful monitoring are important strategies for managing three major cardiovascular risk factors : hyperlipidemia, hypertension and diabetes Diets that are restricted in sodium, fat, cholesterol or calories are commonly prescribed The nurse obtains the following information The patient’s current height and weight to determine their body mass index (BMI) Waist measurement to assess for obesity Laboratory test results such as blood glucose, glycosylated hemoglobin (diabetes)  26 Total blood cholesterol (HDL, LDL levels and triglyceride levels to assess hyperlipidemia How often the patient self-monitors BP, blood glucose and weight as appropriate to the medical diagnosis The patient’s level of awareness regarding their target goals for each of the risk factors and any problems achieving or maintaining these goals. Eating habits What the patient typically eats in a day Who prepares the meals  27 ELIMINATION Ask about the patient’s bowel patterns Ask about bloating, gas, constipation, stomach upset Heart burn, Loss of appetite Vomiting Nausea Screening for blood for patients are taking platelets  28 ACITIVITY LEVEL The nurse assesses for any changes in the patient’s activity level and determines if it has changed from what it was a few weeks earlier Activity induced angina or shortness of breath of breath may indicate CAD CAD-related symptoms occur when myocardial ischemia is present due to inadequate arterial blood supply to the myocardium in the setting of increased demand e.g. exercise, stress or anemia Additional areas to explore include the presence of architectural barriers in the home such as stairs, multilevel home The patient’s participation in cardiac rehabilitation and his or her current exercise pattern including intensity, duration and frequency  29 SLEEP AND REST Clues to worsening cardiac disease such as HF can be revealed by sleep related events. Patients with worsening HF often experience orthopnea that is the need to sleep upright or stand to avoid feeling short of breath Sudden awakening with shortness of breath called paroxysmal nocturnal dyspnea is an additional symptom of worsening HF This nighttime symptom is caused by the redistribution of fluid from the dependent areas of the body (arms and legs) back into the circulatory system within hours of lying in bed This fluid shift increases preload and places increased demand on the heart of patients with HF causing sudden pulmonary congestion The nurse also asks the patients if they snore, have frequent bouts of awakening from sleep, awaken with headache or experience daytime sleepiness these are indication of sleep disordered breathing SDB  30 Self-perception and self-concept These related to cognitive and emotional processes that people use to formulate their health and feelings about themselves Having a chronic illness such as HF or experiencing an acute cardiac illness such as MI can alter a person’s self- perception and self-concept People’s perception about their illness are key determinants of adherence to self-care recommendations To reduce the risk of future cardiovascular-related health problems, people are asked to make lifestyle changes such as smoking cessation, People with misconceptions about their health conditions may not adhere with treatment prescriptions  31 Roles and responsibilities To assess the patient’s roles and responsibilities, in their families and their relationships, The nurse asks each patient Who do you live with ? Who is your primary care giver? who helps you to manage your health? do you have adequate finances and support? Answers to these question will help to determine if the patient have adequate social support or they need additional help or referral to the social worker  32 Sexuality and reproduction Sexual dysfunction affects people with CVD twice more than the general population. There is a general concern that the physical activity involved in sexual relations may result in sudden death, heart attack, untoward symptoms such as angina, dyspnea or palpitation Coping and stress tolerance Assess patient for depression, feeling of worthlessness or guilt, problems with sleep or staying awake Stress initiates increasing levels of catecholamine, and cortisol which as been strongly linked to cardiovascular diseases  33 PHYSICAL ASSESSMENT Physical assessment is conducted to confirm the information obtained from the health history establish the patient’s current or baseline data or condition in subsequent assessment to evaluate the patient’s response to treatment once the initial assessment is completed, the frequency of future assessment is determined by the purpose of the encounter and the patient’s condition  34 during the physical assessment, the nurse evaluates the cardiovascular system for any deviations from normal with regard to the following the heart as a pump (reduced pulse pressure; displacement from the fifth intercostal space midclavicular line, gallop sounds, murmurs) Arterial and ventricular filling volumes and pressures ( elevated jugular venous distension, peripheral edema, ascites, crackles, postural changes in BP Cardiac output (reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy or disorientation Compensatory mechanisms ( peripheral vasoconstriction, tachycardia)  35 GENERAL APPEARANCE Assessment of the patient’s level of consciousness (alert, lethargic, stuporous, comatose Mental status ( orientation to person, place, time, coherence Changes in level of consciousness and mental status may be attributed to inadequate perfusion of the brain from a compromised cardiac output or a thromboembolic event e.g. stroke Patients is observed for signs of distress, which include pain or discomfort, shortness of breath or anxiety The nurse takes notes of the size of the patient’s normal, overweight, underweight, or cachectic The patient’s height and weight are measured to calculate the BMI (Body Mass Index) (weight in kilograms/ square of the height in meters) as well as the waist circumference The measures are used to determine obesity (BMI greater than 30 kg?m 2 and abdominal fat (males: waist greater than 40in; in females waist greater than 35 are placing the patient at risk for CAD (Coronary Arterial Disease).  36 ASSESSSMENT OF THE SKIN Examination of the skin includes all body surfaces starting from the head and finishing with the lower extremities Observe for color, temperature, and texture to assess for acute and chronic problems with arterial or venous circulation Signs and symptoms of acute obstruction of arterial blood flow in the extremities, referred to as the 6Ps include Pain Pallor Pulselessness Paresthesia Poikilothermia (coldness) Paralysis  37 Major blood vessels of the arms and legs may be used for catheter insertion and the access sites must be frequently observed until homeostasis is adequately achieved Edemas of the feet, ankles or legs are called peripheral edema. They can be observed by placing a firm pressure on the area to be assessed for 5seconds Pitting edema is used for the indentation that occurs as a result of the pressure  38 BLOOD PRESSURE Systemic arterial BP is the pressure exerted on the walls of the arteries during ventricular systole and diastole It is affected by cardiac output, distension of the arteries, velocity and volume viscosity of the blood A normal systolic BP is less than 120mmHg A normal diastolic is considered to be less than 80mmHg A systolic pressure consistently higher than 140 is regarded as high A diastolic consistently higher than 90 mmHg is considered high A abnormally low systolic and diastolic pressure is regarded as hypotension and it can lead to lightheadedness’ or fainting 39  40 PULSE PRESSURE This is the difference between systolic and diastolic blood pressure It is a reflection of stroke volume, ejection velocity and systemic vascular resistance The normal reading is 30-40mm hg indicated how well the patient maintains cardiac output A pulse pressure less than 30 mmHg signifies a serious reduction in cardiac output and requires further cardiovascular assessment  41 POSTORAL (ORTHOSTATICE ) BLOOD PRESSURE CHANGES This is a gravitational redistribution of approximately 300- 800 ml of blood into the lower extremities and the gastrointestinal system immediately upon standing This changes reduces venous return to the heart Postural hypotension is a sustained decrease of at least 20mmHg in systolic BP or 10mmHg in diastolic within 3 minutes of moving from a lying or sitting position to a standing position It is usually accompanied by dizziness, lightheadedness or syncope  42 ARTERIAL PULSES The arteries are palpated to evaluate the pulse rate, rhythm, amplitude, contour and obstruction to blood flow. JUGULAR VENOUS PULSATION Right sided heart function can be estimated by observing the pulsations of the jugular vein of the neck which reflects the central venous pressure CVP The CVP is the pressure in the right atrial or the right ventricle at the end of a diastole Obvious distension of the veins with the patient’s head elevated at 450 to 900 indicates abnormal increase in CVP This abnormality is observed in patients with right-sided HF, due to hypervolemia, pulmonary hypertension and pulmonary stenosis, less commonly with obstruction of blood flow in the superior vena cava abd rarely with acute massive pulmonary embolism  43 HEART INSPECTION AND PALPATION The heart is examined by inspection, palpation, and auscultation of the precordium or anterior chest wall that covers the heart and lower thorax A systematic approach is used to examine the precordium in the following six areas Aortic area – second intercostal space to the right of the sternum Pulmonic area—second intercostal space tot eh left of the sternum Erb point—third intercostal space to the left of the sternum Tricuspid area—fourth intercostal space to the left of the sternum Mitral (apical) area—left fifth intercostal space at the mid-clavicular line Epigastric area—below the xiphoid process  44 HEART AUSCULTATION During auscultation, you listen for both normal and abnormal heart sounds ASSESSMENT OF OTHER SYSTEMS Lungs Findings usually indicative of heart cardiac disorders include Hemoptysis (coughing up of blood); pink, frothy sputum indicative of acute pulmonary edema Cough: a dry hacking cough from irritation of the small airway is , common in patients with pulmonary congestive HF Crackles: HF or atelectasis associated with bed rest, splinting from ischemic pain or the effects of analgesic, sedation, or anesthetic agents often results in the development of crackles Wheezers: compression of the small airways by interstitial pulmonary edema may cause wheezing  45 ABDOMEN For a patient with cardiovascular disease, several components of abdominal examination are relevant Abdominal distention indicated ascites which can be as a result of right ventricular of biventricular HF Hepatojugular reflux: is carried out when right ventricular or biventricular HF is suspected Bladder distension: Urine output is an indication of the cardiac function Reduced renal output may indicate inadequate renal perfusion  46 GERONTOLOGICAL CONSIDERATIONS While Performing cardiovascular examination in an older person, the nurse may notice some differences including Palpable peripheral pulses because of decreased elasticity of the skin and loss of adjacent connective tissue Palpation of the pericardium in the older person is affected by changes in the shape of the chest Isolated systolic hypertension is directly correlated to the ageing process Postural orthostatic hypotension is common in the older person placing the older person at risk for a fall  47 DIAGNOSITC EVALUATION A wide range of diagnostic studies may be performed in patients with cardiovascular conditions The nurse should educate the patient on the purpose, what to expect and any possible side effects related to these examinations prior to testing The nurse should note trends in results because they provide information about disease progression as well as the patient’s response to therapy  48 LABORATORY TESTS Samples of the patient’s blood are sent to the laboratory for the following reasons To assist in making diagnosis To screen for risk factors associated with CAD Too establish baseline values before initiating other diagnostic tests, procedures or therapeutic interventions To assess for abnormalities in the blood that affect prognosis Normal values for laboratory tests may vary depending on the laboratory and the health care institution. This variation is due to the differences in equipment and methods of measurement across organizations  49 CARDIAC BIOMARKER ANALYSIS The diagnosis of MI is made by evaluating the history and physical examination, the 12-lead electrocardiogram (ECG) and the results of laboratory tests that measures serum cardiac biomarkers BLOOD CHEMISTRY, HEMATOLOGY, AND COAGULATION STUDIES Lipid profile—cholesterol, triglycerides and lipoproteins are measures to evaluate a person’s risk for developing CAD Brain (B-Type) Natriuretic Peptide__ BNT is a neurohormone that helps to regulate BP and fluid volume. It is secreted from the ventricles in response to increased reload with resulting elevated ventricular pressure. The level of BNT in the blood increases as the ventricular walls expand from pressure making it helpful in the diagnosis, monitoring, and prognostic tool in the setting of HF  50 C-reactive protein: CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis Homocystein: Homocystein , an amino acid is linked to the development of atherosclerosis because it can damage the endothelial lining of arteries and promote thrombus formation. Therefore, an elevated blood level of homocystein is thought to indicate a high risk for CAD, stroke, and peripheral vascular disease. Genetic factors and a diet low in foliate, vitamin B and vitamin 6, B12 are associated with elevated homocysteine levels. A 12- hour fast is necessary before drawing a blood sample for an accurate serum measurements  51 Chest X-ray and Fluoroscopy: a chest X-ray is obtained to determine the size, contour and position of the heart. It revels cardiac and pericardial calcification and demonstrates physiologic alterations in the pulmonary circulation. Electrocardiography: ECG is a graphic representation of the electrical currents of the heart Continuous electrocardiographic monitoring: is the standard of care for patients who are at high risk for dysrhythmias. It detects abnormalities in heart rate and rhythm  52 Hardwire cardiac monitoring Telemetry Lead systems Ambulatory electrocardiography Continuous monitors Continuous real-time monitors Cardiac event monitors Cardiac implantable electronic devices  53 Hardwire cardiac monitoring Telemetry Lead systems Ambulatory electrocardiography Continuous monitors Continuous real-time monitors Cardiac event monitors Cardiac implantable electronic devices  54. Computed tomography Magnetic Resonance Angiography. Echocardiography Cardiac Catheterization: right heart catheterization, left heart cauterization Electrophysiological testing Homodynamic Monitoring Central venous Pressure Monitoring Pulmonary Artery Pressure Monitoring  55 Intra-Arterial Blood Pressure monitoring Minimally Invasive Cardiac Output Monitoring Devices A good way to go with all these tests is to read them up when they are recommended for your patients  56 PERIPHERAL ARTERIAL OCCLUSIVE DISEASE  57 PERIPHERAL ARTERIAL OCCLUSIVE DISEASE Arterial insufficiency of the extremities occurs most in men and it is a cause of disability The legs are the most frequently affected, however, the upper extremities may be affected too The age of onset and the severity are influenced by the number of atherosclerotic risk factors In PAD (Peripheral Arterial Disease), obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below the renal arteries to the popliteal artery Distal occlusion is frequently seen in patients with diabetes and in older patients  58 CLINICAL MANIFESTATIONS IN PAD Intermittent claudication described as aching, cramping, or inducing fatigue or weakness that occurs with some degree of exercise or activities which is relieved with rest The pain often occurs in muscle groups distal to the area of stenosis or occlusion As the disease progresses, the patient may have a decreased ability to walk the same distance as before or may notice increased pain with ambulation When the arterial insufficiency becomes severe, the patient has rest pain The pain is associated with critical ischemia of the distal extremities and is described as persistent, aching, or boring  59 CLINICAL MANIFESTATIONS IN PAD It may be excruciating and that it is unrelieved by opioids and can be disabling Ischemic pain is usually worse at night and often wakes the patient Elevating the extremities or placing it in a horizontal position increases the pain Placing the extremities in a dependent position reliefs the pain Some patients sleep with the leg with the affected leg hanging over the side of the bed Some patients sleep on reclining chair in an attempt to prevent or relief pain  60 Warning signs of clogged arteries  61 CLINICAL MANIFESTATIONS IN PAD  62 ASSESSMENT AND DIAGNOSTC FINDINGS A sensation of coldness or numbness in the extremities may accompany intermittent claudication and it is a result of reduced arterial flow The extremity is pale and cool when elevated and cyanotic when placed in a dependent position Skin and nail changes Ulceration, gangrene and muscle atrophy may be evident Bruits may be auscultated with stethoscope Peripheral pulses may be diminished or absent Unequal pulses between extremities or absence of a normal palpable pulse is a sign of PAD  63 ASSESSMENT AND DIAGNOSTC FINDINGS contd. Careful history of the symptoms and physical extermination will help in determining the location, and the extent of the occlusion The color and temperature of the extremities are noted and pulses are palpated The nails may be thickened and opaque The skin may be shining, atrophic, dry with sparse hair growth Comparison of the right and left extremities Diagnosis may be made using treadmill testing for claudication, duplex ultrasonography and other imaging studies  64 Management MEDICAL MANAGEMENT Walking exercise programs Cessation of smoking, weight control Giving true information to patients PHARMACOLOGIC THERAPY Pentaxoxifylline and cilostazol are administered for treatment of intermittent claudication Antiplatelet such as Aspirin or clopidogrel (Plavix) prevent the formation of thromboembolism which can lead to myocardial infarction Aspirin have been shown to reduce cardiovascular event such as myocardial infarction, and stroke in patients with vascular diseases. However, adverse reaction that associate with aspirin include gastrointestinal upset or bleeding  65 Statins improve endothelial function in patients with PAD Statins improve symptoms of intermittent claudication and also increases walking distance at the onset of claudication These medications have been shown to have beneficial effects on vascular inflammation, plaque stabilization, endothelial dysfunction and thrombosis and have been linked to reduce rates of repeat peripheral interventions, amputation is a major adverse cardiovascular event  66 ENOVASCULAR MANAGEMENT Radiological intervention (endovascular management can include a balloon angioplasty, stent, stent graft or artherectomy These revascularizations procedures are less invasive than conventional surgery Their objective is to ensure adequate blood flow in the distal vesicles  67 SURGICAL MANAGEMENT Surgical management is reserved for the treatment of severe and disabling claudication or when the limb is at risk for amputation because of necrosis The choice of the surgical procedure depends on the degree and location of the stenosis or occlusion, Overall health of the patient and the length of the procedure that can be tolerated For patients whose overall health is compromised that they cannot tolerate an extensive vascular surgical procedure, it is sometimes necessary to provide the palliative therapy of primary amputation rather than arterial bypass  68 Bypass grafts are performed to reroute the blood flow around the stenosis or occlusion Before bypass grafting, the surgeon determines where the distal anastomosis will be placed The distal outflow vessel must be at least 50% patent for the graft to remain patent  69 NURSING MANAGEMENT The nursing care of patients with peripheral vascular disease centers around promoting vasodilatation and preventing compression and relieving pain Nursing diagnosis may include: Ineffective peripheral tissue perfusion related to compromised circulation Goal: increased blood flow to the extremities Decrease venous congestion Promotion of vasodilatation and prevention of vascular compression Nursing Diagnosis: chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen Goal: relief of pain  70 Nursing diagnosis: risk for impaired skin integrity related to compromised circulation Attainment / maintenance of skin integrity Deficient knowledge regarding self-care activities Adherence to self-care program The primary objective in the postoperative period is to maintain adequate circulation through arterial repair. And monitoring and managing potential complications  71 Gerontological consideration In older patients the symptoms of PAD may be more pronounced than in younger people In older patients who are inactive, limb ischemia or gangrene may be the first sign of disease Circulation may be decreased. This may not be apparent until injury occurs. This situation may further aggravate leg ischemia Intermittent claudication may occur after walking short distance Any prolonged pressure on the leg or foot can cause pressure areas that become easily ulcerated, infected and gangrenous The outcomes of insufficient circulation can include reduced mobility and activities as well as loss of independence They may have increased rates of hospitalization and experience a poorer quality of life  72 UPPER EXTREMETY ARTERIAL OCCLUSIVE DISEASE Arterial occlusions occur less frequently in the upper extremities (arms) than in the legs, and cause less severe symptoms because the collateral circulation is significantly better in the arms The arms also have less muscle mass and are not subjected to the workload of the legs  73 CLINICAL MANIFESTATIONS Stenosis and occlusions in the upper extremity result from atherosclerosis or trauma The stenosis usually occurs at the origin of the vessel proximal to the vertebral artery, setting up the vertebral artery as the major contributor of the flow The patient typically complaints of arm fatigue and pain with exercise (forearm claudication),  74 Inability to hold or grasp objects (e.g. combing hair, placing objects on the shelf above the head, and occasionally difficulty driving. The patient may develop subclavian steal syndrome characterized by reverse flow in the vertebral and basilar arteries to provide blood flow to the arm This syndrome may cause vertebrobasilar (cerebral) symptoms including vertigo, ataxia, syncope, or bilateral visual changes  75 ASSESSMENT AND DIAGNOSTIC FINDINGS Assessment findings include Coolness and pallor of the affected extremities Decreased capillary refill A difference in are blood pressures of more than 20mmHg Diagnostic evaluation Noninvasive studies performed to evaluate for upper extremity arterial occlusions include upper and forearm blood pressure determinations and duplex ultrasonography to identify the anatomic location of the lesion and to evaluate hemodynamics of the blood flow  76 Trans cranial Doppler evaluation is performed to evaluate the intracranial occlusion and to detect any siphoning of blood flow from the posterior circulation to provide blood flow to the affected arm If a surgical intervention procedure is planned a diagnostic arteriogram may be necessary  77 MEDICAL MANAGEMENT If a short lesion is identified in an upper extremity artery a PTA (percutaneous transluminal angioplasty also called angioplasty) with possible stent or stent graft placement may be performed If the lesion involves the subclavian artery with documented siphoning of blood flow from the intracranial circulation and an interventional radiologic (endovascular) procedure is not possible, A surgical bypass may be performed if  78 NURSING MANAGEMENT Nursing assessment include Bilateral comparison of the upper arm blood pressures (obtained by stethoscope and Doppler) Radial, ulnar and brachial pulses, motor and sensory functions, temperatures, color changes and capillary refill every 2 hours Disappearance of a pulse or Doppler flow that had been present may indicate an acute occlusion of the vessel and the primary care provider is notified immediately After surgery or endovascular procedure, the arm is kept at heart level or elevated, with fingers at the highest level Pulses are monitored with Doppler assessment of the arterial flow every hour for 2 hours and then every shift  79 Blood pressure (obtained by stethoscope and Doppler) is also assessed every hour for 4 hours and then every shift Motor and sensory function, warmth, color and capillary refill are monitored with each arterial flow  80 AORTOLIAC DISEASE If collateral circulation has developed, patients with a stenosis or occlusion of the aortoiliac segment may be asymptomatic or they may complain of buttock or low back discomfort associated with walking Men may experience impotence These patients may have decreased or absent femoral pulses 81 82 83  84 MEDICAL MANAGEMENT The treatment of aortoiliac disease is essentially the same as that for atherosclerotic peripheral arterial occlusive disease An endovascular procedure, such as bilateral common iliac stents may be attempted if the aorta has a less than 50% diameter reduction If there is significant aortic disease, the surgical procedure of choice is the aortoiliac graft If possible, the distal graft is anastomosed to the iliac artery and the entire surgical procedure is performed within the abdomen If the iliac vessels are occluded, the distal anastomosis is made to the femoral arteries (aortobifemoral graft) 85 86  87 NURSING MANAGEMENT Preprocedural or preoperative assessment Evaluation of the brachial, radial, ulnar, femoral, posterior tibial and dorsalis pulses to establish a baseline for follow up after arterial lines are placed and postoperatively Patient education includes an overview of the operation to be performed, preparation for surgery and anticipated postoperative plan of care Signs, sounds and sensation that the patient may experience are discussed Postoperative care involves monitoring for signs of thrombosis in arteries distal to the surgical site  88 The nurse should assesse for color and temperature of the extremity, capillary refill time, sensory and motor functions, and pulses by palpation and Doppler initially every 15 minutes and then progressively at longer intervals if the patient’s status remains stable Any dusky or bluish discoloration, coldness, decrease in sensory or motor function, or decrease in pulse quality is reported immediately to the primary care provider Postoperative care also include monitoring urine output and ensuring that output is at least 0.5ml/kg/hr  89 Renal function may be impaired as a result of hypo perfusion from hypotension, ischemia to the renal arteries during the surgical procedure, hypovolemia or embolization of the renal artery or renal parenchyma Vital signs, pain and intake and output are monitored with the pulse and extremity assessments Results of laboratory test are monitored and reported tot eh primary care provider Abdominal assessment for bowel sounds and paralytic ileus is performed at least every 8 hours. Bowel sounds may not return until the third day postoperatively  90 Absence of bowel sounds, absence of flatus and abdominal distension are indications of paralytic ileus Manual manipulation of the bowel during operation may have caused bruising, resulting in decreased peristalsis Nasogastric suction may be necessary to decompress the bowel until peristalsis returns A liquid bowel movement before the third day postoperatively may indicate bowel ischemia, which may occur when the mesenteric blood supply (celiac, superior mesenteric or inferior mesenteric arteries) are occluded) Ischemic bowel usually causes increased pain and a markedly elevated white blood cell count  91 ANEURYSMS  92 An aneurysm is a localized sac or dilatation formed at a weak point in the wall of an artery It may be classified by shape of form The most common forms of aneurysm are saccular and fusiform A saccular aneurysm project from only one side of the vessel If an entire arterial segment becomes dilated, a fusiform aneurysm develops A very small aneurysm due to localized infection are called mycotic aneurysms  93 Abdominal aortic aneurysm is the most common type of degenerative aneurysm and has been attributed to atherosclerotic changes in the aorta Aneurysm are potentially serious and if they are located in large vessels that rupture, this can lead to hemorrhage and death 94  95 Thoracic aortic Aneurysm  96 ABDOMINAL AORTIC ANEURYSM  97 The most common cause of abdominal aortic aneurysm is atherosclerosis This condition affects men 2 to 6 times more often than women Is 2 to 3 times more common in Caucasians versus Black men and more prevalent in patients older than 65 years Most of these aneurysms occur below the renal arteries (infrarenal aneurysm) Untreated, the eventual outcome may be rupture and death  98 PATHOPHYSIOLOGY All aneurysms involve a damage to the medial layer of the vessel. This may be caused by congenital weakness, trauma, or a disease After an aneurism develops, it tends to enlarge Risk factors include genetic predisposition, tobacco use, and hypertension. More than half of patients with aneurysms have hypertension  99 CLINICAL MANIFESTATIONS Only about 40% of patients with abdominal aneurysm have symptoms Some patients complain that they can fell their heart beating in their abdomen when lying down Or they feel an abdominal mass or abdominal throbbing If the abdominal aneurysm is associated with thrombus, a major vessel may be occluded or smaller distal occlusions may result from emboli Small cholesterol, platelet, or fibrin emboli may lodge in the interosseous or digital arteries, causing cyanosis and mottling or the toes  100 Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumber nerves Indications of rupturing abdominal aneurysm include Constant intense back pain Falling blood pressure Decreasing hematocrit  101 Rupture into the peritoneal cavity is rapidly fatal A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, peritoneum, flank, or penis Signs of heart failure or a loud bruit ma suggest a rupture into the vena cava Rupture into the vena cava results in higher blood pressure The high blood pressure and increased blood volume returning to the right side of the heart from the vena cava may cause right-sided heart failure  102 Assessment and Diagnostic Findings The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen Ultrasound is used to determine the size, length and location of the aneurysm When the aneurysm is small, ultrasonography is conducted at 6-month intervals until the aneurysm reaches a size that surgery to prevent rupture is of more benefit than possible complications of a surgical procedure. Some aneurysms remain stable over many years of monitoring  103 GENRONTOLOGICAL CONSIDERATIONS Most abdominal aortic aneurysms occur in patients between 60-90 years of age Rupture is likely with coexisting hypertension and with aneurysms more than 6 cm wide. In most cases at this point, the chances of rupture are greater than the chances of death during surgical repair If the patients is considered at risk for complications related to surgery or anesthesia, the aneurysm is not repaired until it is at least 5.5 cm (2in wide)  104 MEDICAL & SURGICAL MANAGEMENT If the aneurysm is stable in size based on ultrasound, the blood pressure is closely monitored over time, because there is an association between increased blood pressure and aneurysm rupture Anti-hypertensive agents including diuretics are administered Endovascular or surgical management An expanding or enlarging abdominal aortic aneurysm is likely to rupture When an abdominal aortic aneurysm measures 5.5 cm (2in) or was enlarging, the standard treatment had been open surgical repair of the aneurysm Endovascular aortic repair has become a mainstay of therapy for treating infrarenal abdominal aortic aneurysm and it involves the transluminal placement and attachment of a sutureless aortic graft prosthesis across an aneurysm. This procedure can be performed under local or regional anesthesia  105 NURSING MANAGEMENT Before the endovascular repair or surgery, nursing assessment is guided by anticipating a rupture and by recognizing the patient may have cardiovascular, cerebral, pulmonary and renal impairment from atherosclerosis The functional capacity of all organs should be assessed Medical therapies designed to stabilize physiologic functions should be promptly implemented Hemorrhage that leads to shock is a serious adverse consequence that must be treated decisively The patient who has had endovascular repair must lie supine for 6 hours , the head of bed must be elevated up to 45 degrees for 2 hours  106 The patient will need to use bedpan while on bed rest Vital signs and Doppler assessment of peripheral pulse are performed initially every 15 minutes and then at progressively longer intervals if the patient’s status remains stable The access site usually the femoral artery is assessed when vital signs and pulses are monitored The nurse assesses for bleeding, pulsation, swelling, pain, and hematoma formation Skin changes of the lower extremities, lumber area or buttocks that might indicate signs of embolization, such as extremely tender, irregularly shaped, cyanotic area, as well as any changes in vital signs, pulse quality, bleeding, swelling, pain or hematoma, are immediately reported to the primary care provider  107 The patient’s temperature should be monitored every 4 hors Any signs of post implantation syndrome which typically occurs after 24 hours of stent graft and which include a spontaneously occurring fever, leukocytosis, and occasionally transient thrombocytopenia should be monitored and reported Because of increased risk of hemorrhage, the primary care provider is also notified of persistent coughing, sneezing, vomiting or systolic pressure greater than 180 mmHg Most patients can resume their preprocedure diets and are encouraged to drink of fluids An IV infusion may be continued until the patients can drink normally. fluids are essential to maintain blood flow through the arterial repair site and to assists the kidneys with excreting IV contrast agents and other medications used during the procedure  108 Six hours after the procedure, the patient may be able to roll from side to side and may be able to ambulate with assistance to the bathroom Once the patient can take adequate fluids orally, the IV fluids may be discontinued Postoperative care requires frequent monitoring of pulmonary, cardiovascular, renal and neurologic status Possible complications of surgery include arterial occlusion, hemorrhagic infection, ischemic bowel, kidney injury and impotence 109  110 VENOUS DISORDERS Venous disorders cause reduction in venous blood flow, causing blood stasis. This may them cause a host of pathologic changes including coagulation defects, edema formation and tissue breakdown and increased susceptibility to infection VENOUS THROMBOEMBOLISM Deep vein thrombosis (DVT) and pulmonary embolism (PE) make up the condition called VTE Venous thromboembolism. VTE is usually not diagnosed because DVT AND PE are often clinically silent It is estimated that 30% of patients hospitalized with VTE develop long-term post-thromboembolic complications  111 VENOUS DISORDERS contd. The majority of symptomatic thromboembolic complications in surgical patients occur after hospital discharge due to short length of stay Although the cause of VTE remains unclear three factors known as Virchow triad are believed to play significant role in its development Endothelial damage Venous stasis Altered coagulation Damage to the intimal lining of blood vessels creates a site for clot formation Direct trauma to the veins may occur with fractures or dislocation, diseases of the veins and chemical irritation of the veins from IV infusion medications or solutions Venous stasis occurs when blood flow is reduced as in heart failure or shock; when veins are dilated, as an effect of some medications, and when skeletal muscle contractions is reduced as in immobility, paralysis of the extremities, or anesthesia  112 PATHOPHYSIOLOGY Altered coagulation occurs most commonly inpatients for whom anticoagulation medications have been abruptly withdrawn Oral contraceptive use and several blood dyscrasias (abnormalities) can also lead to hypercoagulability with prevalence depending on the ethnicity of the patient Pregnancy is also considered as an hypercoagulable state Formation of a thrombus frequently accompanies phlebitis which is inflammation of the vein walls When a thrombus develops initially in the veins as a result of stasis or hypercoagulability but without inflammation, the process is referred to as phlebothrombosis  113 Pathophysiology of VENOUS DISORDERS contd Venous thrombosis can occur in any vein, but it occurs more often in the veins of the lower extremities The superficial and deep veins of the extremities may be affected Upper limb thrombosis accounts for up to 2% of all cases of DVT, but its incidence may be as high as 65% in the presence of central venous cannulation or upper extremity compression It typically involves more than one venous segment, with the subclavian vein the most often affected In addition, upper extremity venous thrombosis is more common in patients with IV catheters or patients with underlying disease that cause hypercoagulability  114 Pathophysiology of VENOUS DISORDERS contd Internal trauma may result from pacemaker leads, chemotherapy ports, dialysis catheter or parenteral nutrition lines The lumen of the vein may be reduced from catheter or from external compression, such as by neoplasms or an extra cervical rib Venous thrombi are aggregates of platelets attached to the vein wall that have a tail-like appendage containing fibrin, white blood cells and many red blood cells The tail can grow or propagate in the direction of blood flow as successive layers of the thrombus form  115 Pathophysiology of VENOUS DISORDERS contd A propagating venous thrombosis is dangerous because parts of the thrombus can break off and occlude the pulmonary blood vessels Fragmentation of the thrombus can occur spontaneously as it dissolve naturally, or it can occur with an elevated venous pressure as it occurs after standing suddenly or engaging in muscular activity after prolonged inactivity After an episode of acute DVT, recanalization i.e. reestablishment of the lumen of the vessel typically occurs Lack of recanalization within the first 6 months after DVT appears to be an important predictor of postthrombotic syndrome, which is one complication of venous thrombosis  116 CLINICAL MANIFESTATION The signs are non-specific Deep vein clinical manifestation include Edema and swelling of the extremities because the outflow of venous blood in inhibited The affected extremities may feel warmer than the unaffected extremity The superficial vein may appear more prominent Tenderness, which usually occurs later is produced by inflammation of the vein wall and can be detected by gently palpating the affected extremity In some cases, signs and symptoms of a PE are the first indication of DVT  117 CLINICAL MANIFESTATION Superficial veins clinical manifestations: The thrombosis of superficial veins produces pain and tenderness, redness, and warmth in the involved are The risk of the superficial venous thrombi becoming dislodged ir fragmenting into emboli is very low because most of them dissolve spontaneously This condition can be treated at home with bed rest. Elevation of the leg, analgesic agents and possibly anti-inflammatory medications.  118 Medical Management Medical Management. The objectives of treatment for DVT are to prevent the thrombus from growing and fragmenting Anticoagulant therapy can meet these objectives. Anticoagulants cannot dissolve a thrombus that has already formed. Combining anticoagulation therapy with mechanical and ultrasonic-assisted thrombolytic therapy may eliminate venous obstruction, maintain venous patency and prevent post thrombotic syndrome by early removal of the thrombus  119 Pharmacologic therapy Pharmacologic therapy Medications for preventing or reducing blood clotting within the vascular system are indicated in patients with thrombophlebitis, recurrent embolus formation and persistent leg edema from heart failure They are also indicated in older patients with a hip fracture and that may result in lengthy immobilization Anticoagulant therapy are contraindicated in patients with bleeding from the following systems: respiratory , gastrointestinal, genitourinary reproductive systems and in the following conditions: aneurysms, severe trauma, alcoholism, recent or impending surgery of the eye, spinal cord or brain, severe hepatic or renal disease, infections open ulcerative wounds occupation that involve a significant hazard for injury and recent childbirth.  120 Nursing management of a Patient Receiving anticoagulant therapy If the patient is receiving anticoagulant therapy, the nurse monitors the appropriate laboratory values The PTT, prothrombine time (PT), INR, ACT, hemoglobin and hematocrit values, platelet counts and fibrinogen levels are affected depending on the type of anticoagulant prescribed Close observation is required to detect blessing, if bleeding occurs, it must be reported immediately and anticoagulant therapy discontinued  121 ASSESSING AND MONITORING ANTICOAGULANT THERAPY To prevent inadvertent infusion of large volume of unfractionated heparin, which could cause hemorrhage, anticoagulant unfractionated heparin is always given by continuous IV infusion using an electronic infusion device Dosage calculation are usually based on patient’s weight Any possible bleeding tendencies are detected by a pretreatment-clotting profile If renal insufficiency exists, lower doses of heparin are required Periodic coagulation tests and hematocrit levels are obtained Heparin is in the effective or therapeutic range when the aPTT is 1.5 times the control  122 Oral anticoagulants such as warfarin are monitored before the PT or INR because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually given concurrently with heparin until the desired anticoagulation has been achieved that is when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0 (Harter et al., 2015).  123 MONITORING AND MANAGING POTENTIAL COMPLICATIONS Bleeding: The principal complication of anticoagulant therapy is spontaneous bleeding Bleeding from the kidneys is detected by microscopic examination of urine and it is often the first sign of excessive dosing Bruises, nose bleeds and bleeding gums are also early signs To promptly reverse the effects of heparin, IV injections of protamine sulfate may be given  124 Risks of protamine administration include bradycardia and hypotension, which can be minimized through slow administration Protamine sulphate can be used to reverse the effects of LMWH, but it is less effective with LMWH than with unfractionated heparin Reversing the anticoagulant effect of warfarin is more difficult, but effective measures that may be prescribed include administration of vitamin K and or infusion of fresh-frozen plasma or prothrombin complex concentrate (PPC) Oral and low doses of IV vitamin K significantly decrease the INR within 24 hrs. (Dobesh & Fanikus, 2014).  125 Idarucizumad (Praxbind) is a humanized monoclonal antibody fragment that has been approved as a reversal agent for dabigatran (Pradaza). It is administered IV at dosages of 5g, provided in two separate infusions of 2.5 g/50ml At this time, there are no specific antidotes for the factor Xa inhibitants although they are under development The only option for reversal is withholding the drugs, which have a relatively rapid rate of systemic clearance  126 It is recommended that activated charcoal be given within one or two hours following the dose PCC may be used for patients with major bleeding, but its use carries the risk of disseminated intravascular coagulation (DIC) (Mohantry et al., 2014) Thrombocytopenia Thrombocytopenia may be a complication of anticoagulant therapy  127 DRUG INTERACTIONS Oral anticoagulants particularly warfarin interact with many other medications and herbal and nutritional supplements. Thus, close evaluation of the patient’s medications is necessary Many medications and supplements potentiate or inhibit oral anticoagulants, it is essential to check and see if any medications or supplements are contraindicated with warfarin.  128 PROVIDING COMFORT Elevation of the affected extremity, graduated compression stockings, and analgesic agents help to relief pain They help improve circulation and improve comfort Warm moist packs applied to the affected extremity reduce the discomfort associated with DVT The patient is encouraged to walk once anticoagulation therapy has been initiated The nurse should instruct the patient that walking is better than standing or sitting for long periods Bed exercises such as repetitive dorsiflexion of the foot are recommended  129 Providing Compression Therapy Stockings External compression devices and wraps Intermittent compression devices These devices can be used to prevent DVT  130 Positioning the body and encouraging exercise Positioning the body and encouraging exercise When the patient is on bed rest, the feet and the lower legs should be elevated periodically above the level of the heart. This position allows superficial and tibial veins to empty rapidly and also to remain collapsed Active and passive leg exercises particularly those involving the calf muscles should be performed to increase Venus flow  131 Early ambulation is effective in preventing Venus stasis Deep breathing exercises are beneficial because they produce increased negative pressure in the thorax, which assist in emptying the large veins Once ambulatory, the patient is instructed to avoid sitting for more than one hour at a time The goal is to walk for about 10 minutes every 1 to 2 hours The patient is also instructed to perform active and passive leg exercises as frequently as possible when she or he cannot ambulate, such as during long car drives, bus or train, and plane trips.  132 Gerontological considerations Because of decreased strength, and manual dexterity, older patient may not be able to apply graduated compression stockings properly. If this is the case, a family member or friend should be taught to assist the patient to apply the stockings, so that they do not cause undue pressure on any part of the feet or leg Frames have been designed to assist patients in applying stockings and if there are any concerns regarding patient’s physical abilities, they should be referred to the occupational therapists who can provide examples of and training in the use of stockings assistive devices.  133 Promoting home, community-based and transitional care In addition to instructing the patient on how to apply graduated compression stockings and explaining the importance of elevating the legs and exercising adequately, the nurse educates the patient about prescribed anticoagulant, its purpose, and the need to take the correct amount at the specific times, especially if warfarin is prescribed The patient should also be aware that if warfarin is prescribed, periodic blood tests are necessary to determine if a change in medication or dosage is required.  134 If the patient fails to adhere to the therapeutic regimen, continuation of the medication therapy should be questioned Caution should be used in a patient who refuses to discontinue the use of alcohol, because chronic alcohol use decreases the effectiveness of anticoagulation therapy In patients with liver disease, the potential for bleeding may be exacerbated by anticoagulants therapy  135 PATIENT EDUCATION ON TAKING ANTICOAGULANT MEDICATIONS The nurse instructs the patient to: Take the anticoagulant medications at the same time each day, usually between 8.00 and 9.00 an Wear or carry identification indicating the anticoagulant being taken Keep all appointments for blood tests  136 Because other medications may affect the action of the anticoagulant medication, so not take any of the following medications or supplements without consulting your primary care giver: vitamins, cold medications, antibiotics, aspirin, mineral oils and anti-inflammatory agents such as ibuprofen (Motrin) and similar medications or herbal nutritional supplements.  137 Your primary care provider should be contacted before taking any over-the-counter drugs Avoid alcohol if taking warfarin because it may change the body’s response to an anticoagulant medication Avoid fat foods, crash diets or marked changes in eating habits if taking warfarin, dietary habits have no interactions with the oral factor Xa inhibitors Do not take any anticoagulant therapy unless directed Do not stop taking your anticoagulation therapy (when prescribed) unless directed  138 When seeking treatment from any health care provider, be sure to inform the caregiver that you are taking an anticoagulant medication Contact your provider who manages your coagulation therapy before having dental work or elective surgery If any of the following signs occur, report them immediately to your provider: faintness, dizziness, or increased weakness, severe headache or abdominal pain, reddish or brownish urine, any bleeding—e.g. cuts that do not stop bleeding, bruises that enlarge, nosebleeds or unusual bleeding from any part of the body, red or black bowel movement Avoid injury that can cause bleeding For women, notify your primary care provider and obstetrical provider if you suspect pregnancy.  139 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH HYPERTENSION