Vascular Disorders.pdf

Peripheral Arterial Disease (PAD) A. Peripheral arterial disease 1. Description a. Chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients b. Tissue damage occurs below the level of the arterial...

Peripheral Arterial Disease (PAD) A. Peripheral arterial disease 1. Description a. Chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients b. Tissue damage occurs below the level of the arterial occlusion. c. Atherosclerosis is the most common cause of peripheral arterial disease. 2.Risk Factors Tobacco use Atherosclerosis Diabetes HTN High cholesterol Age greater than 60 3. Assessment a. Intermittent claudication (pain in the muscles resulting from an inadequate blood supply) HALLMARK SIGN OF ARTERIAL VASCULAR DISORDER!!! b. Rest pain, characterized by numbness, burning, or aching in the distal portion of the lower extremities, which awakens the client at night and is relieved by placing the extremity in a dependent position c. Lower back or buttock discomfort d. Loss of hair and dry scaly skin on the lower extremities, shiny and taut e. Thickened toenails f. Cold and gray-blue color of skin in the lower extremities g. Elevational pallor and dependent (dAngling legs) rubor (redness) in the lower extremities h. Decreased or absent peripheral pulses i. Signs of arterial ulcer formation occurring on or between the toes or on the upper aspect of the foot that are characterized as painful. j. BP measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally, BP readings in the thigh and calf are higher than those in the upper extremities). K. Paresthesia Numbness or tingling in the toes or feet from nerve tissue ischemia (loss of pressure and deep pain sensations from reduced blood flow) 4. Complications Prolonged ischemia leads to: Atrophy of skin and underlying muscles Delayed healing Wound infection Tissue necrosis Most serious: Non Healing arterial ulcers and gangrene  Collateral circulation may prevent gangrene (seen in the elderly) May result in amputation, If adequate blood flow is not restored and if severe infection occurs Indicated with uncontrolled pain and spreading infection 5. Arterial Ulcers Characteristics (PRETTY ULCERS) Often located on toes or pressure points Pale or cyanotic appearance w/ irregular margins Painful, sometimes severe, often at night Surrounding skin shiny and taut 6. Diagnostic Studies Doppler ultrasound and duplex imaging -maps blood flow throughout the entire region of an artery. Segmental blood pressure-obtained using Doppler ultrasound and a sphygmomanometer at the thigh, below the knee, and at ankle level while the patient is supine. A drop in segmental BP of greater than 30 mm Hg suggests PAD Ankle-brachial index (ABI)-PAD screening tool. It is done using a hand-held Doppler. The ABI is calculated by dividing the ankle systolic BPs (SBPs) by the higher of the left and right brachial SBPs Angiography and magnetic resonance angiography-Used for imaging vascular occlusive disease and abdominal aortic aneurysms. Same as MRI but with use of gadolinium as IV contrast medium. 7. Drug Therapy ACE inhibitors—reduce PAD symptoms Ramipril (Altace) Increases peripheral blood flow, ABI Antiplatelet agents Aspirin Clopidogrel (Plavix) Drugs prescribed for treatment of intermittent claudication Cilostazol (Pletal) Inhibits platelet aggregation Increased vasodilation Pentoxifylline (Trental) Improves flexibility of RBCs and WBCs Decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity Walking is most effective exercise for individuals with claudication  30 to 45 minutes daily, 3 times/wk Women have faster decline and mobility loss than men Daily exercise increases survival rates 8. Interventions Because swelling in the extremities prevents arterial blood flow, the client with peripheral arterial disease is instructed to elevate the feet at rest but to refrain from elevating them above the level of the heart, because extreme elevation slows arterial blood flow to the feet. In severe cases of peripheral arterial disease, clients with edema may sleep with the affected limb hanging from the bed, or they may sit upright (without leg elevation) in a chair for comfort. a. Assess pain. b. Monitor the extremities for color, motion and sensation, and pulses. c. Obtain BP measurements. d. Assess for signs of ulcer formation or signs of gangrene. e. Assist in developing an individualized exercise program, which is initiated gradually and increased slowly to improve arterial flow through the development of collateral circulation. f. Instruct the client to walk to the point of claudication pain, stop and rest, and then walk a little farther. g. Instruct the client with peripheral arterial disease to avoid crossing the legs, which interferes with blood flow. h. Instruct the client to avoid exposure to cold (causes vasoconstriction) to the extremities and to wear socks or insulated shoes for warmth at all times. i. Instruct the client never to apply direct heat to the limb, such as with a heating pad or hot water, because the decreased sensitivity in the limb can cause burning. PARESTHESIA! j. Instruct the client to inspect the skin on the extremities daily and to report any signs of skin breakdown. k. Instruct the client to avoid tobacco and caffeine because of their vasoconstrictive effects. l. Instruct the client in the use of hemorheological and antiplatelet medications as prescribed. Procedures to improve arterial blood flow A. Percutaneous transluminal angioplasty, with or without intravascular stent Catheter w/balloon tip is inflated dilating the vessel & stent is placed to hold artery open B.Atherectomy-Catheter w/balloon tip is inflated dilating the vessel & stent is placed to hold artery open C.Cryoplasty Combines PTA and cold therapy D.Endarterectomy open artery and remove plaque E.˜Amputation—considered if necrosis, gangrene, or osteomyelitis develop F. Peripheral arterial bypass surgery: Graft material is sutured above and below the occlusion to facilitate blood flow around the occlusion. Inflow procedures bypass the occlusion above the superficial femoral arteries and include aortoiliac, aortofemoral, and axillofemoral bypasses; outflow procedures bypass the occlusion at or below the superficial femoral arteries and include femoropopliteal and femorotibial bypass. Aortic Aneurysm: there are different types causes: ○ degenerative, congenital, infectious, mechanical, inflammatory strong genetic link permanent, localized outpouching or dilation of the wall of the aorta abdominal aortic aneurysm: most common ○ extreme risk for rupture  ○ when you hear a pulse and bruit over the stomach notify the provider immediately ascending aorta: ○ causes angina from decreased blood flow to the arteries ○ jugular vein distention due to pressure against vena cava Thoracic: ○ often asymptomatic; may present with chest pain extended to interscapular area Classifications: ○ True: wall of the artery forms the aneurysm fusiform and saccular fusiform: uniform in shape saccular: pouch-like ○ False: not a true aneurysm; disruption of all layers of arterial wall bleeding that is contained by other anatomic structures Diagnostics: ○ x-rays, ECGs, Echo, ultrasonography, CT/MRI, angiography Interprofessional care: ○ prevent aneurysm from rupturing ○ early detection is key ○ small aneurysm: imaging and monitor frequently ○ surgical therapy: larger, more severe aneurysms Aortic Dissection: tear or opening in the aorta that causes blood to leak from open site classified by location ○ Type A: emergent surgery intervention ○ Type B: conservation therapy ○ nontraumatic AD: caused by weakened elastic fibers in the arterial wall can cause death HTN is the most important risk factor Assessment: ○ “worse pain ever”, sharp extending through the scapulas, tearing/stabbing ○ MI pain is gradual, AD pain is sudden and severe Diagnostics: ○ X-ray ○ ECG ○ MRI Management: ○ pain management ○ position patient in a semi-fowlers and calm environment to reduce HR and BP ○ observe for worsening s/s ○ teach pt about HR and BP control Thromoboangitis Obliterans Buerger’s Disease Nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium arteries and veins of the arms and legs Most common in men younger than 45 years old with history of tobacco and/or marijuana use Acute phase Inflammatory thrombus blocks vessel Chronic phase Thrombosis and fibrosis causes ischemia Symptoms Intermittent claudication of feet, hands, or arms; rest pain, ischemic ulcerations, changes in color and temperature, paresthesia, superficial vein thrombosis and cold sensitivity Treatment -No smoking tobacco or marijuana; no nicotine replacements -Avoid cold exposure; walking program, antibiotics for ulcers, analgesia for pain, avoid trauma IV iloprost—promotes vasodilation Surgeries Bypass surgery Amputation Raynaud’s Phenomenon Episodic, vasospastic disorder of small cutaneous arteries; fingers and toes Pathogenesis—abnormalities in vascular, intravascular, and neuronal mechanisms that cause vasodilation Characteristic change in color of fingers, toes, ears, and nose White, blue, and red (Fig. 37-3) Also: coldness, numbness followed by throbbing, aching pain, tingling, and swelling (several minutes to hours) Prolonged, frequent attacks causes thick skin, brittle nails, punctate lesions and gangrenous ulcers Triggers: exposure to cold, emotional upset, tobacco use and caffeine May occur alone or w/ other diseases Contributing factors ○ Vibrating machinery ○ Cold environments ○ Heavy metal exposure ○ High homocysteine levels (don't get enough folate (also called folic acid), vitamin B6, or vitamin B12 in their diet.)  Diagnosis- Persistent symptoms for at least two years Nursing Management ○ PATIENT EDUCATION- Prevent episodes by avoiding extreme temps, no tobacco and caffeine, no vasoconstrictor meds (i.e. blood pressure meds) ○ Drug Therapy- Sustained release calcium channel blockers to decrease vasospams; use of vasodilators ○ Digital ulceration or critical ischemia Prostacyclin infusion(vasodilator), abx, analgesics Surgical debridement Botox and statins Sympathectomy Phlebitis Definition- Acute inflammation of the walls of small cannulated veins of the hands or arms related to an IV Manifestations- pain, tender,warm, erythema, swelling (SHEP) Risk Factors- Irritation from IV, infusion irritating drugs, and catheter location (IV placed in area of flexion such as antecubital) Treatment- remove IV ○ Edema- Elevate ○ Pain and inflammation- NSAIDS, warm, moist compress Venous Thrombosis Definition- Formation of a thrombus (clot) w/ vein inflammation MOST COMMON VENOUS DISORDER Could be deep vein thrombosis (DVT) or superficial vein thrombosis Venous thromboembolism (VTE) - Clot that traveled DVT to pulmonary embolism (PE) - Clot that traveled to LUNGS Venous Stasis ○ Dysfunctional valves due to INACTIVE EXTREMITY OF MUSCLES ○ Risk Factors Obese, pregnant, long distance travel Chronic HF or a fib Prolonged surgery Prolonged immobility ○ Detached thrombus results in embolus Travels through venous system to right side of heart and lodges in pulmonary circulation to become a PE Venous Thromboembolism VTE- Endothelial damage (thin membrane that lines the inside of the heart and blood vessels) ○ Stimulates platelet activation and starts coagulation cascade ○ Direct damage- surgery, burns, IV catheter, trauma, prior VTE ○ Indirect damage-Chemotherapy, diabetes, sepsis Hypercoagulability of Blood ○ High Risk Tobacco use Childbearing age and take estrogen based BC Post menopausal and take oral hormone therapy  Over age 35 Family history of VTE VTE Manifestations ○ Lower extremity Unilateral edema Pain, tenderness w/ palpation Dilated superficial veins Full sensation in thigh/calf Parenthesis Red, warm Fever greater than 100.4 VTE Diagnostic Studies ○ Blood: ACT (Activated coagulation time), aPTT, INR, Hgb, HCT, platelet count, D-Dimer-protein fragment (small piece) that's made when a blood clot dissolves in your body, fibrin monomer complex ○ Noninvasive venous: venous compression (the result of compression of a vein causing venous hypertension or venous thrombosis), ultrasound, duplex ultrasound ○ Invasive venous: CT venography, MR, venography, contrast venography VTE Prevention Measures ○ Early and progressive mobilization ○ Graduated compression stockings (NOT FOR EXISTING VTE) ○ Intermittent pneumatic compression devices (SCD) VTE: Drug Therapy ○ ANTICOAGULANTS (BLOOD THINNERS) Prophylaxis: prevent clot formation Existing VTE-prevent new clots, spread of clots, and embolization (traveling clots) Three classes of drug therapy Vitamin K antagonists (VKA) ○ Warfarin-long term or extended blood thinner, takes 48-72 hours to be effective, overlaps with Parenteral blood thinner for 5 days ○ Monitor INR (therapeutic range 2.0-3.0) ○ Antidote: Vitamin K ○ DO NOTS FOR WARFARIN Give w/ antiplatelets or NSAIDS WHY?????? Avoid vitamin K in diet due to altering INR (green leafy vegetables) Thrombin inhibitors (direct and indirect) ○ Unfractionated Heparin Prophylaxis- SubQ Existing VTE- continuous IV, monitor PTT (normal range 25-35)  Serious side effect- HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) Long term side effect: OSTEOPOROSIS ○ LMWH-Enoxaparin More predictable, longer half-life, fewer bleeding complications Antidote: Protamine Direct Thrombin Inhibitors ○ Dabigatran (Pradaxa, oral) VTE Prevention after elective joint replacement, for stroke prevention in afib, treatment for VTE Antidote: Idrarucizmab Why use over Warfarin????? Rapid onset, no monitoring, few, drug-food interactions, decreased risk of bleeding, predictable response Thrombolytic Therapy (Clot Busters) ○ TPA, urokinase administered via catheter to dissolve clots, reduce acute symptoms, improve deep venous flow ○ Indication: Patients with low risk of bleeding and acute, extensive, symptomatic, proximal VTE ○ Systemic anticoagulation before, during, and after thrombolysis VTE surgical and interventional radiology therapies ○ Surgical options: Open Venous thromboectomy (incision in vein to remove clot) Inferior vena cava interruption devices Filters placed via right femoral or internal jugular vein to trap clots w/o impeding blood flow Varicose Veins Patho- Superficial veins in legs become dilated and tortuous from retrograde blood flow and increase venous pressure Risk Factors- Family HTX of venous problems, female, tobacco use, aging, obesity, multiparty, Hx of VTE, venous obstruction, phlebitis, prolonged standing or sitting Manifestations- Heavy, achy feeling or pain after prolonged standing, or sitting, relieved by walking or limb elevation Complications- superficial venous thrombosis Diagnosis-Examination; Duplex ultrasound Conservative ○ Rest with limb elevation ○ Graduated compression stockings ○ Leg strengthening exercises  ○ Weight Loss Interventional and Surgical Therapies ○ Sclerotherapy- ablates (destroys) vein by direct injection of sclerosis agent Complications: residual pigmentation, matting, thrombophlebitis and ulcers Wear compression stockings and limit travel ○ Transcutaneous laser therapy Complications: pain, blistering, hyperpigmentation Nursing Management ○ Prevention Avoid prolonged sitting or standing Maintain ideal weight Avoid injury Avoid restrictive Walk every day ○ Postoperative Deep breathing Neurovascular assessment Elevate legs Graduated compression stockings-remove every 8 hours for short time then reapply ○ Long-term management Improve circulation and appearance Relieve discomfort Avoid ulcers Patient teaching Graduated compression stockings Elevate legs Weight Management Position changes Dietary amd herbal supplements Chronic Venous Insufficiency (CVI) and Venous Leg Ulcers Abnormalities of venous system include edema, skin changes, and venous leg ulcers Patho- primary varicose veins and PTS Ambulatory venous hypertension ○ Serous fluid and RBC leak results in edema and inflammation ○ Brown skin discoloration (leathery and edematous) ○ Skin is hard, thick, and contracted Clinical Manifestations ○ Eczema w/ itching and scratching ○ Venous ulcers Pain in dependent position (dangling) Risk of infection  Lower leg brown discoloration Nursing Management ○ Compression for healing and prevention of recurrence Stockings, bandages, wraps Teach proper fit and application Assess for PAD prior to compression ○ Activity guidelines Avoid prolonged standing/sitting ELEVATE legs above heart Daily walking Avoid trauma Daily foot and leg care ○ Other patient teaching Moist environment Nutrition (adequate protein), vitamin A and C, zinc Diabetic- normal blood glucose level Monitor for infection Debridement, excision, abx Drug Therapy- Pentoxifylline or flavonoid Daily Moisturizing