Module 3C - Vascular Disorders.pdf

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory,...

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture [TRANS] UNIT XX: VASCULAR DISORDERS ↓ Module 3C Tissue ischemia occurs Vascular Disorders ↓ Necrosis Outline 1. Describe the pathophysiology, clinical manifestations, Arterial Disorders and treatment of coronary atherosclerosis. Cause ischemia and tissue necrosis. 2. Recognize the assessment findings and clinical These disorders may occur because of chronically manifestations of peripheral arterial occlusive disease progressive pathologic changes to the arterial vasculature and upper extremity arterial occlusive disease. (e.g., atherosclerotic changes) or due to an acute loss of 3. List the medical/surgical and nursing management of blood flow to tissues (e.g., aneurysm rupture). peripheral arterial occlusive disease and upper extremity arterial occlusive disease. Arteriosclerosis and Atherosclerosis 4. Identify the nursing interventions for clients with atherosclerosis and arteriosclerosis. A. Arteriosclerosis Factors Contributes to Blood Pressure Hardening of the arteries (muscular wall) which is the most Cardiac output common disease of the arteries. Primarily due to aging Peripheral resistance It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles Type of diet: LSLF become thickened. o Sodium will attract water. The more water = tumataas fluid volume = tumataas cardiac output = increased B. Atherosclerosis workload of the heart = high blood pressure. Accumulation of lipids, calcium, blood components To Maintain Normal Blood Pressure (platelets, sickle cell anemia – hemoglobin s), Diet carbohydrates, and fibrous tissue on the intimal layer of the o Alcohol intake – in moderation, it causes vasodilation artery; referred to as atheromas or plaques. Habits Arteriosclerosis and Atherosclerosis o Smoking cessation – it causes vasoconstriction Exercise that are tolerated Monitoring of lipid profile CTTO: https://www.pinterest.ph CTTO: https://www.vectorstock.com Difference between Artery and a Vein Pathophysiology The most common direct results of atherosclerosis in Artery Vein arteries include stenosis (narrowing) of the lumen, Carries oxygen-rich blood Carries oxygen-depleted obstruction by thrombosis, aneurysm, ulceration, and away from the heart. blood towards the heart. rupture. High pressure Low pressure Its indirect results are malnutrition and the subsequent Has valves to prevent fibrosis of the organs that the sclerotic arteries supply with No valves regurgitation of blood blood → because of ischemia. Thick muscular walls Thin muscular walls o If the reduction of blood flow becomes very severe → cell damage will occur → ischemic necrosis Blood Impede o Atherosclerosis can develop in any point in the body When there is a blockage in the arteries: but there are certain arteries which are more ↓ vulnerable (high risk) → proximal lower extremity Cannot supply adequate amount of blood to the different parts arteries. of the body. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 1  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture All actively functioning tissue cells require an abundant Predominantly found on abdominal aorta (including its supply of nutrients and oxygen and are sensitive to any branches – coronary arteries, popliteal artery, internal reduction in the supply of these nutrients. carotid artery. If such reductions are severe and permanent, the cells undergo → ischemic necrosis → replaced by fibrous tissue, which requires much less blood flow. Proximal lower extremity include: o Distal abdominal aorta o Common iliac arteries o Orifice of the superficial femoral and profunda femoris arteries o Superficial femoral artery in the adductor canal Distal to the knee, atherosclerosis can occur anywhere along the artery. Reaction-to-Injury Theory CTTO: https://www.phytecs.com When there is cell injury in the lining of the blood vessel because of prolonged hemodynamic forces / increased forces. Vascular endothelial cell injury results from prolonged hemodynamic forces, such as shearing stresses and turbulent flow, irradiation, chemical exposure, or chronic hyperlipidemia. ↓ Injury to the endothelium increases the aggregation of platelets and monocytes at the site of the injury. ↓ Smooth muscle cells migrate and proliferate, allowing a matrix of collagen and elastic fibers to form. Pathogenesis of atherosclerosis. (A) Damaged endothelium. (B) Two Types of Atherosclerotic Lesions Fatty streak and lipid core formation. (C) Fibrous plaque. Raised plaques are visible: some are yellow; others are white. (D) A. Fatty Streaks Complicated lesion: thrombus is red; collagen is blue. Plaque is Yellow and smooth, protrude slightly into the lumen of the complicated by red thrombus deposition. artery, and are composed of lipids and elongated smooth muscle cells. CTTO: https://nursekey.com Can be found in all age groups (including infants) but when Risk Factors there is overaccumulation, then problem arises. B. Fibrous Plaques Modifiable Composed of smooth muscle cells, collagen fibers, plasma Nicotine use (e.g., tobacco smoking or chewing) components, and lipids. o Causes vasoconstriction They are white to white-yellow and protrude in various Diet (contributing to hyperlipidemia) degrees into the arterial lumen, sometimes completely o It is important to maintain lipid profile in normal ranges. obstructing it. Hypertension Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 2  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Diabetes hyperlipidemia Nursing Management Stress Sedentary lifestyle Improving Peripheral Arterial Circulation o Fat is not used for energy metabolism → this will stick Position the part below the level of the heart. For the lower on the arteries. extremities, this is accomplished by elevating the head of Elevated C-reactive protein the patient’s bed or by having the patient use a reclining o This is increased when there is inflammation. chair or sit with the feet resting on the floor. Hyperhomocysteinemia o To promote blood flow due to gravity. Important to know: diet, lifestyle (exercise, stress, etc.) Assist the patient with walking or other moderate or graded isometric exercises. Non-Modifiable Instruct the patient to walk to the point of pain, rest until the Increasing age pain subsides, and then resume walking so that endurance o Ina-ani na. can be increased as collateral circulation develops. Female gender o When there is ischemia or a lack of blood supply, there o As women get older, estrogen production decreases is pain. (menopause). o If the occluded artery supplies the lower extremities, Familial predisposition/genetics there might be pain. o Resting would relieve the client’s discomfort. Prevention Intermittent claudication is a symptom of generalized Promoting Vasodilation and Preventing Vascular atherosclerosis and may be a marker of occult coronary Compression artery disease. Apply warmth to promote arterial flow. Diet modification Instruct patient to avoid exposure to cold temperatures, Medications which causes vasoconstriction. Adequate clothing and Exercise warm temperatures protect the patient from chilling. If chilling occurs, a warm bath or drink is helpful. Clinical Manifestations A hot water bottle or heating pad may be applied to the Clinical signs and symptoms resulting from atherosclerosis patient’s abdomen, causing vasodilation throughout the depend on the organ or tissue affected. lower extremities. o Heart – MI Inform of the effects of nicotine on circulation and encourage to stop. Medical Management o Nicotine causes vasoconstriction. Diet modification Stress avoidance of emotional upsets which stimulate the Controlled exercise program to improve circulation and its sympathetic nervous system, resulting in peripheral functioning capacity vasoconstriction. Medication therapy Instruct to avoid constrictive clothing and accessories o Lipid-lowering agents such as: such as tight socks or shoelaces may impede circulation to ▪ HMG-CoA reductase inhibitors (Statins) the extremities and promote venous stasis. ▪ Fenofibrate - fibric acid derivatives - check liver Discourage crossing the legs for more than 15 minutes at and kidney function a time because it compresses vessels in the legs. Liver – elevation of ALT and AST Kidney – elevation of creatinine land BUN Relieving Pain Interventional or surgical graft procedures. Administration of analgesic agents such as hydrocodone plus acetaminophen, oxycodone, oxycodone plus Surgical Management acetylsalicylic acid, or oxycodone plus acetaminophen. Vascular surgical procedures are divided into two groups: Maintaining Tissue Integrity A. Inflow Procedures Stress to patient to avoid trauma to the extremities. Improve blood supply from the aorta into the femoral Recommend neutral soaps and body lotions may prevent artery. drying and cracking of skin. With diseases of the aorta. Inform the patient to abstain from scratching and vigorous B. Outflow Procedures rubbing which can abrade skin and create sites for bacterial invasion. Provide blood supply to vessels below the femoral artery. Recommend special shoe inserts which may be needed to Procedures with peripheral arterial occlusive disease. prevent calluses from recurring. Radiologic Interventions Tell patient that all signs of blisters, ingrown toenails, Isolated lesion or lesions are identified during: infection, or other problems should be reported to health o Arteriogram - checks the patency of arteries care professionals for treatment and follow-up. o Angioplasty, also called percutaneous transluminal Assist patients with diminished vision and with angioplasty (PTA) disabilities that limit mobility of the arms or legs in ▪ Insertion of catheter (balloon or stent) that will examining the lower extremities for trauma or evidence of widen the lumen of the artery. inflammation or infection. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 3  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Promote Good Nutrition for Healing and Prevent When the arterial insufficiency becomes severe, the patient Tissue Breakdown has rest pain due to decreased blood flow to the nerves. For clients who are obese or overweight, help formulate a This pain is associated with critical ischemia of the distal weight reduction plan which may be necessary for extremity and is described as persistent, aching, or boring; lifestyle modification. it may be so excruciating that it is unrelieved by opioids and A diet low in lipids may be indicated for patients with can be disabling. atherosclerosis. Ischemic rest pain is usually worse at night and often wakes the patient. Peripheral Arterial Occlusive Disease (PAD) Elevating the extremity or placing it in a horizontal position Arterial insufficiency of the extremities occurs most often in increases the pain, whereas placing the extremity in a men and is a common cause of disability. dependent position reduces the pain. The legs are most frequently affected; however, the upper **See ss for stages of PAD Peripheral Artery Disease extremities may be involved. o Because the blood has to travel more than the arms. The age of onset and the severity are influenced by the type and number of atherosclerotic risk factors. o Affected arteries in PAD in legs: ▪ Renal arteries ▪ Popliteal arteries In PAD, obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below the renal arteries to the popliteal artery. Clinical Manifestations The hallmark symptom (very common sign) is intermittent claudication. o Intermittent claudication - episodic pain in the area 6 P's of ischemia: that is affected because of the decrease in blood Pain supply. Oftentimes, this pain will be relieved if the client Pallor Pulselessness will rest the area. Paresthesia (numbness) o Intermitted means it only happens in a period of time Paralysis (nagsusumpong-sumpong ang pain). Poikilothermia (coolness) This pain may be described as aching, cramping, or inducing fatigue or weakness that occurs with the same CTTO: https://www.ciccenters.com degree of exercise or activity and is relieved with rest. Assessment and Diagnostic Findings Peripheral Arterial Disease (PAD) Assessment of extremities. Skin is mottled. The extremity is cool and pale when elevated or ruddy and cyanotic when placed in a dependent position. Prolonged ischemia causes skin and nail changes, ulcerations, gangrene, and muscle atrophy may be evident. Bruits may be auscultated with a stethoscope. o Bruits are murmurs or vascular sounds that is CTTO: https://www.sarh.org associated with turbulent blood flow (not smooth). If the ischemia or reduction in blood flow is very severe, Peripheral pulses may be diminished or absent because even the patient is at rest (e.g., asleep), it will manifest pain. there is no blood flow. o The client will wake up from pain during sleep. The presence, location, and extent of arterial occlusive When elevating the affected extremity, the pain becomes disease are determined by a careful history of the more severe. But when it is placed in a dependent position, symptoms and by physical examination. the pain lessens. CW Doppler and ABI (ankle brachial index). **see ss for more info The pain commonly occurs in muscle groups distal to the o Doppler machine is used in order to check for the area of stenosis or occlusion. pulses or flow of blood of the patient. As the disease progresses, the patient may have a Treadmill testing for claudication decreased ability to walk the same distance as before or o This is an activity. may notice increased pain with ambulation. o If the patient suffers from claudication or pain, they will suspect that the blood going to the legs is not enough. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 4  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Duplex ultrasonography, or other imaging studies o Balloon angioplasty, stent, stent graft, atherectomy. o To check the ultrasound of the affected areas. Bypass grafts are performed to reroute the blood flow around the stenosis or occlusion. Ankle-Brachial Index Four Main Treatment Approaches for PAD CTTO: https://www.otsuka.co.jp There are four main treatment approaches for PAD: drug treatment, physical therapy, endovascular treatment, and surgery including intravascular treatment. Nursing Management Maintaining Circulation Pulses, Doppler assessment, color and temperature, Comparing the blood pressure of the ankle and the arm. capillary refill, and sensory and motor function of the o If ever they find low ankle-brachial index → indicates affected extremity are checked and compared with those of narrowing of the blood vessels or the arteries I the the other extremity. lower legs. o Check for the color of the extremity. The extremity that CTTO: https://edu.glogster.com lacks blood is cyanotic (bluish discoloration) and pale. o For the temperature, the skin can be cold to touch. Medical Management o Capillary refill, normal: within 3 seconds. Exercise program ▪ Capillary refill = 3 seconds If a walking program is combined with weight reduction ▪ Capillary refill = > 3 seconds and cessation of tobacco use, patients often can further o Sensory and motor function, when there is ischemia, improve their activity tolerance. there is a feeling of numbness in the area. When we Arm-ergometer exercise training effectively improves check for sensation, we first ask the client to close physical fitness, central cardiorespiratory function, and their eyes first and start the test by pointing a walking capacity in patients with PAD claudication sensation in the extremities using an object. symptoms. ABI is monitored at least once every 8 hours for the first 24 o To elicit pain. hours and then once each day until discharge (not usually assessed with pedal artery bypasses. Pharmacologic Therapy Pentoxifylline (Trental) (xanthine derivatives – helps Monitoring and Managing Potential Complications improving blood flow in the arteries) and Cilostazol (Pletal) Continuous monitoring of urine output, central venous for the treatment of symptomatic claudication but the pressure, mental status, and pulse rate and volume permits beneficial response to pentoxifylline is small, and the overall early recognition, and treatment of fluid imbalances data are insufficient to support its widespread use. o Bleeding can result from the heparin administered o Contraindicated in patients with a history of congestive during surgery or from an anastomotic leak. heart failure or an ejection fraction less than 40%. ▪ Anticoagulant is a risk for bleeding to the patient. Antiplatelet agents such as aspirin or clopidogrel (Plavix). Instruct to avoid leg crossing and prolonged extremity o We prevent the platelets from sticking to the walls of dependency. the arteries. o In order to prevent occlusion. Statins improve endothelial function. Encourage the patient to exercise the extremities while in o This lowers the lipids that can cause fatty plaques that bed reduces edema. can adhere to the arterial walls. Promote the use of graduated compression or anti- Surgical Management embolism stocking. o This will help prevent blood stasis that causes Reserved for treatment of severe and disabling claudication blockage in the blood vessels. or when the limb is at risk for amputation because of tissue necrosis. Promoting Home and Community-Based Care The choice of the surgical procedure depends on the The nurse determines whether the patient has a network of degree and location of the stenosis or occlusion. family and friends to assist with ADLs. Endarterectomy Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 5  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Lifestyle changes necessitated by the onset of a chronic Medical Management disease, including pain management and modifications in PTA (percutaneous transluminal angioplasty) with possible diet, activity, and hygiene (skin care). stent or stent graft placement. Ensures that the patient has the knowledge and ability to If a short focal lesion is identified in an upper extremity assess for any postoperative complications such as artery may be performed. If the lesion involves the infection, occlusion of the artery or graft, and decreased subclavian artery with documented siphoning of blood flow blood flow. from the intracranial circulation and an interventional Instruct to stop using tobacco. radiologic procedure is not possible. Surgical bypass 3. Upper-Extremity Arterial Occlusive Disease May be performed if interventional radiologic procedure is Arterial occlusions occur less frequently in the upper not possible. extremities (arms) than in the legs and cause less severe symptoms because the collateral circulation is Nursing Management significantly better in the arms. Involves bilateral comparison of upper arm blood The arms also have less muscle mass and are not pressures (obtained by stethoscope and Doppler), radial, subjected to the workload of the legs. ulnar, and brachial pulses, motor and sensory function, temperature, color changes, and capillary refill every 2 Upper-Extremity Arterial Occlusive Disease hours. After surgery, the arm is kept at heart level or elevated, with the fingers at the highest level. o The arm should be also protected from cold temperature. o Avoid taking venipuncture to the area that is operated. o Avoid using constrictive clothing to the area that is operated. Pulses are monitored with Doppler assessment of the arterial flow every hour for 4 hours and then every shift. 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 (pulse) assessment. Take Time to Watch https://www.youtube.com/watch?v=zU6JgZuqMmk CTTO: https://reference.medscape.com Clinical Manifestations Arm fatigue Pain with exercise (forearm claudication) Inability to hold or grasp objects and occasionally difficulty driving. o Due to numbness. “Subclavian steal” syndrome characterized by reverse flow in the vertebral and basilar artery to provide blood flow to the arm. Cause vertebrobasilar (cerebral) symptoms, including vertigo, ataxia, syncope, or bilateral visual changes. o Subjective vertigo: individual o Objective vertigo: environment Assessment and Diagnostic Findings Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. Upper and forearm blood pressure determinations Duplex ultrasonography Transcranial Doppler Diagnostic arteriogram may be necessary if a surgical or interventional procedure is planned. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 6