PVS Power Point - Student PDF

Peripheral Vascular System u Learning Objectives 1. Understand the pathophysiology, risk factors, clinical manifestations, treatment options of peripheral arterial disease and develop a nursing care plan. 2. Understand the pathophysiology, risk factors, clinical manifestations, treatment opti...

Peripheral Vascular System u Learning Objectives 1. Understand the pathophysiology, risk factors, clinical manifestations, treatment options of peripheral arterial disease and develop a nursing care plan. 2. Understand the pathophysiology, risk factors, clinical manifestations, treatment options of peripheral venous disease and develop a nursing care plan. 3. Recognize complications associated with peripheral vascular disease and develop a nursing care plan. 4. Develop a discharge care plan for peripheral vascular disease. 5. Perform a focused peripheral vascular assessment. 6. Demonstrate understanding of peripheral vascular assessment techniques and related findings (normal and abnormal). Diseases and conditions covered in this lecture Arterial Disorders 1. Peripheral Artery Disease 2. Acute Arterial Ischemic Disorders 3. Aortic Aneurysms 4. Aortic Dissection Venous Disorders 1. Superficial Thrombophlebitis/Thrombosis 2. Venous thrombosis 3. Venous Thrombo-embolism 4. Varicose Veins 5. Chronic Venous Insufficiency + Venous Leg Ulcers 6. Pulmonary embolism A Quick Review… u The vascular system= Blood vessels of the body u Veins vs. Arteries ARTERIES VEINS Pump oxygenated blood Drain deoxygenated blood and waste products High pressure system Low pressure system Walls are strong, tough and tense Walls are thinner, larger in diameter, more distensible Contain elastic fibers Need 3 mechanisms to keep blood moving… Each HB creates a pulse No pulse created  Major Blood Vessels of the Body: Arteries Of the upper Of the lower body… body… uTemporal uFemoral uCarotid uPopliteal u**Pulmonary uDorsalisPedis u**Aorta uPosterior Tibial uBrachial uUlnar uRadial Veins… Of the upper body… uJugular uSuperior/Inferior Vena Cava u2 sets of deep & superficial veins u**Pulmonary vein** Of the lower body… uDeep veins are femoral and popliteal uSuperficial veins are great and small saphenous Peripheral Vascular Disease affects both artery and veins! Peripheral arterial disease (PAD) u Affects arteries in the neck, abdomen & extremities u Occlusive disease, aneurysmal disease & vaso-spastic phenomenon Peripheral venous disease (PVD) u Primarily affects lower extremities u Venous thrombosis vs. Chronic venous insufficiency Lab work related to PVD What will the nurse look for? u Lipids – increase cholesterol are a direct correlation with CAD u Blood Glucose and HbA1c – Diabetic or prediabetes at risk for PVD u Coagulation – INR & aPTT esp if on anticoagulation medication u If ct presents with chest pain – Tropinin u D – Dimer – diagnosis Disorders of the Arteries  Pathophysiology u Leading cause…Atherosclerosis u Risk factors: üSmoking üDyslipidemia üHypertension üDiabetes üMay also include… u Most common site: Femoral-Popliteal u Signs and Symptoms u Depends on site u **Intermittent Claudication** u Numbness/tingling in toes and feet u Shooting/burning pain in neuropathy u Thin, shiny and taut skin u Loss of hair to lower legs u Diminished/Absent pulses u Pallor in response to leg elevation u Redness to foot in response to hanging limb u Without revascularization: Ulceration and Gangrene Complications: u Progresses slowly u Delayed healing u Arterial Ulcers u Gangrene u Amputation of affected limb u See Table 40-1p. 900 Lewis  Diagnostic Tests and Treatment Diagnostic Tests u Doppler Ultrasound u Ankle-Brachial Index (ABI) u Angiography Treatment u Interventional Radiological Procedures Ø Used with increased pain Ø Pain at rest Ø Ulceration or gangrene present Ø Percutaneous Transluminal balloon Angioplasty  Treatments cont. Surgical Therapy uMost common is Peripheral Arterial Bypass uEndarterectomy uPatchGraft angioplasty uAmputation  Acute Arterial Ischemic Disorders Ø Caused by embolisms, thrombus, or severe narrowing Ø Can occur suddenly and without warning signs! Ø Blood flow to distal arteries substantially diminished Ø Most commonly due to…  Clinical Manifestations uAbrupt onset uUsually present with existing PAD u“6 P’s”… ØPain,pallor, pulselessness, parethesia, poikilothermia, paralysis uParalysis is a very late sign uCan progress to necrosis and gangrene  PAD - Assess, Do, Teach DO u Administer ordered medications u Administer IV fluids/blood u Maintain BP within normal range u Perform proper wound care and dressing changes u with presence of any of 6 “P’s”  PAD - Assess, Do, Teach u Disease process u Encourage client & family to express concerns u Signs and symptoms of infection u Signs and symptoms of decreased perfusion u Risk factors such as... u Smoking cessation u Diabetic teaching, ensuring blood sugar’s are within range. PAD - Assess, Do, Teach cont’d ü Daily inspection of skin on legs and feet ü Importance of change in skin temperature ü Appropriate foot apparel ü Medication compliance ü Formulate exercise plan ü Encourage healthy food choices ü Teach care of ulcers and limb ischemia u Outpunching/dilation of arterial wall u Involves… u Does not usually involve peripheral arteries u Occur more often in men, then women. u Ruptured AAA’s-13th leading cause of death in Canada u Risk Factors: presence of CAD or PAD, high BP, elevated cholesterol, genetics Aortic Arch Thoracic Aorta Abdominal Aorta Pathophysiology u Most aortic aneurysms found in abdominal aorta u Largerthe aneurysm = greater risk of rupture. u Can block the lower branches of the aorta u Most common cause: Atherosclerosis u Other causes…  Classifications: ØTrue vs. False (Pseudo) ØTrue Aneurysms: Wall of artery forms aneurysm At least one layer still intact Divided into fusiform and saccular Classifications cont. Ø False (Pseudo) Aneurysms Not actual aneurysms Disruptions in layers of arterial wall Bleeding!!! May result from…  Clinical Manifestations Thoracic Aorta Aneurysms Abdominal Aortic u Usually asymptomatic, Aneurysms when they present have u Often asymptomatic! deep, diffuse chest pain u Abdominal/back pain u Hoarseness u Audible bruits u Distended neck veins if pressure on superior vena u May see a pulsatile mass cava in periumbilical area slightly to the left of u Dysphagia due to pressure midline. on esophagus. u Edema of head and arms Ø Noted with aneurysms in superior vena cava  Complications ***Rupture!!!*** Posterior Anterior u Retroperitoneal u Poor survival rate space. Bleeding u Massive blocked by hemorrhage surrounding structures u Severe hypovolemic shock u Severe back (Discussed in CNUR pain/flank 204) ecchymosis (bruising)  Diagnostic Studies u X-ray u Routine physical u ECG u Ultrasound u CT scan u MRI u Angiography Treatment: Ø **Goal** Prevent rupture of aneurysm Ø Early detection is very important Ø Aneurysms less then 4 cm- usually treated conservatively. uBP- What is the target? uMonitor aneurysm Surgical Therapy uIncises diseased segment of aorta uRemove thrombus/plaque uInsert graft uSuture aortic wall uRenal complications u Not an aneurysm! u Mostcommonly seen in the thoracic aorta u Results from tear in intimal lining of arterial wall u Blood enters b/w intimal & media layers. u Affects more men, than women u Acute and life-threatening!!!!  Clinical Manifestations u Depend on location of dissection u Sudden, severe chest pain u Radiating pain down spine, back, abdomen, or legs u Can mimic an MI u Described as “_______” “_____” u Altered LOC, dizziness, weakened carotid pulses (esp if aortic arch involved) u High pitched, diastolic murmur Aortic Dissections - Assess, Do, Teach DO u Administer ordered medications u Administer IV fluids/blood u Maintain BP within normal range u Always use aseptic technique u Bed rest u Notify physician immediately with presence of any of 6 “P’s” Teach u Medication compliance u Monitoring BP u F/U with regularly scheduled CTs and MRIs u Signs and symptoms u Most common cause of death in long term survivors is aortic rupture from re-dissection or aneurysm formation. Disorders of the Veins  Superficial Thrombophlebitis u Inflammation of the vein u Palpable, firm, subcutaneous vein u Tender to touch, reddened & warm u Upper extremities vs. lower extremities u Usually seen during physical assessment  Nursing Care uElevate affect limb uApply warm, moist heat uRemove IV’s from affected site uApply compression stockings uAdminister pain medications Ø Formation of a ______ Ø Associated with inflammation of the vein Ø Superficial Thrombophlebitis vs. Deep Vein Thrombosis (DVT) Ø ***Virchow’s Triad 1. Venous stasis 2. Endothelium damage 3. Hypercoagulability Patho Cont… u A thrombus is a combination of… u Commonly found on cusps of valves u Continue to grow as more blood particles adhere to clot u Can grow a “tail” once large enough and occlude lumen u Process stops when thrombus is covered with endothelial cells. This organized thrombus may detach. u Major complication: Pulmonary embolism ***http://Deep Vein Thrombosis***  Venous Thrombo-embolism u Can be a superficial vein thrombus or a deep vein thrombosis (DVT) u DVTs usually affects …. u Possibly Asymptomatic u Unilateral Edema u Pain, warm skin, tenderness on palpation u Positive Homan’s sign u Inferior Vena Cava= lower extremity edema and cyanosis u Superior Vena Cava= Symptoms in neck, back and face  Complications: Ø Pulmonary Embolism Ø Chronic Venous Insufficiency u Destruction of valves u Allows backflow (retrograde) of blood flow u Signs and symptoms often do not show up for years following a DVT  Diagnostic Tests and Treatments Diagnostic Tests uSee Table 40-9, page 916 u Common tests Ø D-Dimer Ø Venous Doppler Ultrasound Ø Spiral CT Scan Ø aPTT, PT, INR  Treatments: Prevention u Early mobilization post op u Frequent position change/foot exercises u Compression stockings. Is it okay to roll down? u Calf compressors (Sequential Compression Devices). u Anticoagulants Non-pharmacological Therapy u Bed rest u Limb elevation u Compression stockings  Treatment Cont. Drug Therapy u Anticoagulants: Low Molecular weight heparin, Warfarin, IV heparin u Warfarin INR 2-3 seconds; unless otherwise specified u Vitamin K Warfarin antagonist u Antiplatelet medications are contraindicated u Monitor for signs of bleeding u What medications increase risk of bleeding with warfarin? u What foods are high in Vitamin K? Surgical Therapy u Generally not needed u Decrease risk of Chronic Venous Insufficiency u Venous Thrombectomy u Vena Cava Interruption devices  Varicose Veins u AKA: Varicosities u Primary u Secondary u Tortuous, dilated superficial veins u Usually affect saphenous veins u Can be small or large and bulging u Usually affect legs bilaterally Etiology and Pathophysiology: u Etiology is unknown u Dilation can happen because of increased venous pressure u May result from congenital weakness u Valve incompetence  Clinical Manifestations + Treatment u Symptoms are very individual u Achiness/pain after standing for long periods u Leg cramps u Vein rupture u Diagnosed by appearance u Usually no tx required u Sclerotherapy is… u Compression stockings u Laser therapy u Surgery  Chronic Venous Insufficiency + Venous Leg Ulcers u Ulcers caused from Chronic venous insufficiency u Non-life threatening u Painful Etiology: u CVI causes include… u Main cause is valve incompetence u Thick, hardened, contracted skin u Hemosiderin… u Pathophysiology unknown  Clinical Manifestations u Leathery, brownish, skin u Edema u Usually located at medial malleolus u Eczema u Complaint of pruritus. u Wound shape u Drainage u Painful u Will erode further if untreated u Infection u Cellulitis u Amputation  Pulmonary Embolism u What is it? u Why are the lower lung lobes most often affected? u Most common pulmonary complication u Arise from DVTs, Right side of the heart, upper extremities, pelvis or tumor embolisms u Usually found in… u Most lethal PE’s arise from femoral/ iliac veins u Can dislodged spontaneously u Can be jarred from different movements  Clinical Manifestations u Symptoms depend on size of emboli + vessels involved u Anxiety, Sudden dyspnea, Tachypnea, Tachycardia, hemoptysis u Others such as… u Massive emboli… u 60% of patients with massive emboli die  Complications Ø Pulmonary Infarction u Occlusion of large pulmonary vessels u Results in necrosis and hemorrhage in alveoli u Dead tissue becomes infected Ø Pulmonary Hypertension u At least 50% of lung tissue is compromised u Results from… u Results in dilation of right ventricle Diagnostics u Lung scan Ventilation vs. Perfusion « D-Dimer– lab test that confirms the presence of clotting « Spiral CT scan « ABG analysis – not diagnostic but shows low PaO2, will identify respiratory alkolosis  Treatments Ø Goal of treatment is… Ø Conservative Therapy u Oxygen application to maintain adequate oxygenation u May require intubation/mechanical ventilation u Deep breathing + coughing exercises to prevent atelectasis u Frequent turning/repositioning Ø Drug Therapy u Anticoagulant therapy is # 1 u IV heparin protocol-adjusted according to PTT u Warfarin-Adjusted according to INR u tPA u Pain mgmt (i.e. opioids - related to pleural irritation or reduced coronary blood flow) Heparin Protocol ØSurgical Therapy Last resort Only with severe arterial obstruction No response to conservative treatment Pulmonary embolectomy High mortality rate – 50% Amputations u Risk Factors u Middle to older age due to effects of peripheral vascular disease u Cardiovascular Disease- Atherosclerosis u Vascular changes related to diabetes u Younger population- secondary to trauma u Hazardous occupations – men >women Amputations - Continued u Indications: u Dependent on the underlying disease or trauma u Circulatory impairment u Trauma u Tumors u Infection u Clinical Manifestations: u Loss of sensation u Inadequate circulation u Pallor u Infection Diagnostics Studies u Depends on the underlying problem u Vascular Studies u Arteriography u Doppler studies u Venography u Blood Tests u Elevated white blood cells  Collaborative Care u Elective u Emergency u Closed amputation u Create a weight bearing residual limb u Disarticulation- amputation performed through a joint u Open amputation- residual limb is not covered with skin u Goal: Preserve extremity length and function  Nursing Management u History & Physical Exam u Physical appearance of soft tissues u Skin temperature u Sensory function u Presence of peripheral pulses u Diagnostics u Goals of care u Relief of underlying health problem u Pain control u Reach maximum rehabilitation potential with the use of prosthesis u Support with body image changes u Support lifestyle adjustments Nursing Management - Continued u Health Promotion u Teach how to examine lower extremities u Report changes u Safety precautions u Acute Intervention u Psychological and social implications u Family social supports u Preoperative Management u Relevant teaching prior to surgery u Phantom limb sensation u Postoperative Management u Monitor for PTSD for emergent amputation u Prevention and early detection of complications (i.e. infection, hemorrhage) u Monitoring labs, vital signs, dressings, ensure sterile technique u Prosthetic fitting (immediate or delayed~ 3months after amputation) u Physiotherapy, Occupational therapy u Ambulatory and Home Care  PVD - Assess, Do, Teach DO u Ultimate task= Prevention u Administer all ordered medications; ensuring you know the side effects and adverse effects of each medication u Continuously remind patient to complete leg/foot exercises u Prevention is key u Encourage deep breathing and coughing exercises post op u Elevate affected legs u Apply compression stockings * priority for DVT  PVD - Assess, Do, Teach With amputations: u Avoid trauma to limb u ConsultOstomy and wound care in health region u Consult dietician u Elevate extremities u Foot/Leg care u Avoid prolonged sitting/standing  PVD - Assess, Do, Teach With PE: u InitiateIV access u Bed rest u Immediately start anticoagulant therapy u Administer pain medications u Bed in semi-fowler’s positions u Monitor vital signs, ABGs, lung sounds, pulse oximetry, cardiac assessment u Apply O2 when required PVD-TEACH -Summary u Leg/Foot exercises (Either for bed rest or prolonged standing/sitting) u Teach patient and family signs and symptoms of PE u Medication use ie anticoagulants u Blood work schedule u What and when to report to health care professionals u Fall prevention  Assess, Do, Teach What about pts with diabetes? u Foot care importance u S & S of infection u S & S of worsening ulcers u Avoidance of trauma u Diet u Importance of exercise u When to seek medical attention PVS - Collaborative Care u Smoking cessation u Physical activity u Achieve/maintain ideal body weight u DASH diet u Blood glucose control u BP control u Treatment of dyslipidemia u Antiplatelets- prevent risk of CVD events/death  Lab - PVS Assessment Subjective Data u Leg pain or cramps u Skin changes on arms or legs u Swelling in the arms or legs u Medications u Past Health & family history u Trauma to vein, varicose veins, prolonged air travel, etc. u Medications (Current and previous) u Recent surgery/ Lengthy medical procedures u Pain assessment u PVS history-? Previous DVT’s ? Objective Data u Inspect skin colour & characteristics u Auscultate heart sounds u Ausculate abdominal sounds u Monitor for signs and symptoms of cardiac tamponade u Vital signs u Hair distribution on lower extremities u Ulcers? u Peripheral pulses u Capillary refill u 6 “P’s” of Acute arterial ischemia u Observe for changes in behaviour Think about what else you might look for specific to the PVS problem? u Assess for signs and symptoms of bleeding (especially with patient’s on anticoagulants) u S & S of DVT u Extremity comparison u Edema to neck, face and back (Superior Vena Cava) u Lower limb edema (Inferior Vena Cava) u Vital signs u Abnormal coags u Signs of Superficial thrombophlebitis u Drainage from wounds? u S& S of infection u Assess for concurrent PAD if PVD or visa versa u Respiratory assessment u Assess for signs and symptoms of PE, such as… u Pleural rub Assessment of upper extremities Inspection of Arms u Note color of skin & nail beds, texture, turgor u Note presence of lesions, edema or clubbing Palpation of Arms u Capillaryrefill u Upper extremity pulses- Note characteristics u Modified Allen test (not required to do) Assessment of lower extremities Inspection of the Legs u Inspect together at the same time u Note skin characteristics, hair distribution, venous patterns, size, and other ulcers and lesions u If legs look asymmetrical, measure calves at the same place on both legs Palpation of the Legs uCheck temperature u Pulses u **Homan’s Sign** u Edema u **Calf Circumference** New Assessment techniques: v Calf Circumference u Measure at widest point u Ensure to measure other leg at exactly the same place. u Asymmetry of calves of 1 cm or more is abnormal –DVT? ( see Jarvis p.561 for pain profile) v Color Changes u Used with arterial deficiency u Pallor u 2 Techniques v Doppler Ultrasound Used to detect non-palpable or weak pulses Can used to measure low blood pressures Magnifies pulsatile sounds (swishing, wooshing sound) v The Wells Score for Leg Deep Vein Thrombosis (p.556-557 Jarvis) QUESTIONS?? A patient is diagnosed with venous stasis. Which of the following would the nurse most likely observe? A. Weak dorsalis pedis pulses B. Brownish discoloration of the skin on the lower leg C. One leg is cooler than the other on palpation D. Thin, shiny atrophic skin A patient has been hospitalized with a deep vein thrombosis. What is an appropriate nursing intervention to prevent embolization of a thrombus? A. Apply compression stockings while the client is in bed B. Maintain bedrest C. Perform passive range of motion of the affected extremity to increase venous return D. Monitor vital signs and respiratory status q4h A patient is diagnosed with a small abdominal aortic aneurysm (