Vascular Disorders PDF

VASCULAR DISORDERS Prepared by: Nathaniel Dean G. Arcipe  VENOUS THROMBOSIS VENOUS THROMBOSIS Thrombi can be associated with an inflammatory process Thrombus Thickened vein development wall Inflammation Embolization 3 VENOUS THROMBOSIS...

VASCULAR DISORDERS Prepared by: Nathaniel Dean G. Arcipe  VENOUS THROMBOSIS VENOUS THROMBOSIS Thrombi can be associated with an inflammatory process Thrombus Thickened vein development wall Inflammation Embolization 3 VENOUS THROMBOSIS Types rombophlebiti lh ebothrombosi Phlebitis Vein Thrombophleb h ep T s P s itis De Vein More serious Thrombus Thrombus inflammation than superficial associated without vein associated with thrombophlebitis with vein inflammation invasive due to risk of inflammation procedures, such pulmonary as IV lines embolism 4 VENOUS THROMBOSIS RISK FACTORS Venous stasis Hypercoagulability disorders Injury to venous wall from IV injections Post-surgery Pregnancy Ulcerative colitis Oral contraceptives Certain malignancies Pelvic or lower extremity fracture/injury 5 PHLEBITIS ASSESSMENT FINDINGS o Red, warm area Radiates up the vein & extremity o Pain o Swelling 6 PHLEBITIS INTERVENTIONS ✓ Apply warm, moist soaks Dilates veins ✓ Assess temperature of soak first ✓ Assess for signs of complications such as: Tissue necrosis Infection Pulmonary embolus 7 DEEP VEIN THROMBOPHLEBITIS ASSESSMENT FINDINGS o Calf or groin tenderness o Pain with or without swelling o Positive Homan’s Sign Unreliable False-positives are common o Warm, tender skin 8 DEEP VEIN THROMBOPHLEBITIS How to assess HOMAN’S SIGN o EXTEND client’s knee o Dorsiflex client’s ankle o Observe for pain/discomfort on calf muscles (+) Homan’s sign 9 DEEP VEIN THROMBOPHLEBITIS INTERVENTIONS ✓ Bed rest ✓ Elevate affected extremity above heart level ✓ AVOID: Knee gatch Pillow under knees Massaging extremity 10 DEEP VEIN THROMBOPHLEBITIS INTERVENTIONS ✓ Antiembolism stockings as prescribed ✓ Teach application and removal ✓ Intermittent or continuous warm, moist compresses ✓ Palpate gently ✓ Monitor for warmth and edema ✓ Measure circumference of thigh and 11 calves DEEP VEIN THROMBOPHLEBITIS INTERVENTIONS ✓ Monitor for dyspnea & chest pain ✓ Thrombolytics if prescribed tPA ✓ Initiate within 5 days after onset ✓ Heparin as prescribed ✓ Monitor aPTT ✓ Warfarin as prescribed ✓ After heparin therapy ✓ When S/Sx have resolved ✓ Monitor PT and INR ✓ Monitor for complications 12 DEEP VEIN THROMBOPHLEBITIS INTERVENTIONS Normal Values aPTT: 20 to 36 seconds PT: Normal → ± 2 seconds of the control Male: 9.6 to 11.8 seconds Female: 9.5 to 11.3 seconds INR: Standard warfarin: 2.0 to 3.0 High-dose warfarin: 3.0 to 4.5 13  DEEP VEIN THROMBOPHLEBITIS CLIENT EDUCATION ✓ Hazards of anticoagulants ✓ Recognize S/Sx of bleeding ✓ AVOID: X Prolonged sitting or standing X Constrictive clothing X Sitting with legs crossed X Smoking X Any drugs unless prescribed by physician ✓ Elevate legs above heart level for 10-20 minutes every few hours each day 14 DEEP VEIN THROMBOPHLEBITIS CLIENT EDUCATION ✓ Plan a progressive walking program ✓ Inspect leg for edema ✓ Measure circumference of legs ✓ Anti-embolism stockings ✓ Follow-up checkups and laboratory tests ✓ MedicAlert bracelet 15  VENOUS INSUFFICIENCY Due to prolonged venous hypertension Veins are stretched and damaged Venous Veins are Venous hypertension stretched damage Edema Venous stasis Cellulitis Swelling Venous stasis ulcers 16 VENOUS INSUFFICIENCY Treatment focuses on: Decreasing edema Promoting venous return Venous stasis ulcer treatment focuses on: Healing the ulcer Preventing stasis Preventing recurrence VENOUS INSUFFICIENCY ASSESSMENT FINDINGS o Stasis dermatitis o Edema o Ulcer formation o Uneven edges o Pink ulcer bed o (+) Granulation o Usual site: lateral malleolus VENOUS INSUFFICIENCY INTERVENTIONS ✓ Leg elevation ✓ Elastic or compression stockings during the day and evening ✓ Put on upon awakening – BEFORE getting out of bed May be necessary for life ✓ Elevate legs above heart level for 10-20 minutes every few hours each day 20 VENOUS INSUFFICIENCY INTERVENTIONS ✓ AVOID X Prolonged sitting or standing X Constrictive clothing X Sitting with legs crossed ✓ Intermittent sequential pneumatic compression system BID ▪ 1 hour in the morning and evening ▪ (+) Ulcer ✓ Apply dressing first VENOUS INSUFFICIENCY WOUND CARE ✓ Care for wound as prescribed ✓ Assess client’s self-care ability ✓ Initiate home care resources ✓ Change Unna boot weekly ✓ Occlusive dressings to cover ulcer: Polyethylene film Hydrocolloid dressing VENOUS INSUFFICIENCY WOUND CARE Unna boot Application steps 1. Cleanse wound with normal saline 2. Apply Unna boot 3. Cover with elastic wrap 4. Monitor for signs of arterial occlusion 5. Keep tape off client’s skin 6. Change every week AVOID Povidone-iodine Hydrogen peroxide VENOUS INSUFFICIENCY MEDICATIONS Topical agents Purpose ▪ Debridement ▪ Eliminate necrotic tissue ▪ Promote healing Considerations: ✓ Apply oil-based agents on surrounding skin ❖Petroleum jelly Antibiotics For infection or cellulitis  VARICOSE VEINS Distended, protruding veins that appear darkened and tortuous Vein walls weaken and dilate Valves become incompetent 25 VARICOSE VEINS ASSESSMENT FINDINGS o Leg pain o With dull aching after standing o Feeling “full” in the leg o Ankle edema 26  VARICOSE VEINS TRENDELENBURG’S TEST 1. Place client in a supine position 2. Elevate client’s legs above heart level 3. Apply tourniquet in upper thigh 4. Ask patient to stand upright 5. Assess venous filling Normally, the veins fill from the distal end. If varicosities are present, the veins fill from the proximal end. 27 VARICOSE VEINS INTERVENTIONS ✓ Anti-embolism stockings ✓ Elevate legs as much as possible ✓ AVOID X Constrictive clothing X Pressure on the legs ✓ Procedures: Sclerotherapy Laser therapy Vein stripping 28  VARICOSE VEINS SCLEROTHERAPY STEPS 1. Solution is injected into vein 2. Application of pressure dressing 3. Incision and drainage of trapped blood in sclerosed vein 14-21 days after injection 4. Application of pressure dressing Duration: 12-18 hours 29 VARICOSE VEINS LASER THERAPY Laser fiber is used to heat and close the main vessel contributing to the varicosity 30 VARICOSE VEINS VEIN STRIPPING Removal of varicosities Criteria: o Veins > 4 mm in diameter o Clustered varicosities Other treatments are tried first 31  ARTERIAL DISORDERS PERIPHERAL ARTERIAL DISEASE Chronic Partial or total arterial occlusion ↓ Nutrients in lower extremities Tissue damage occurs below level of occlusion Most common cause: ATHEROSCLEROSIS 33 PERIPHERAL ARTERIAL DISEASE ASSESSMENT FINDINGS o Intermittent claudication o Rest pain o Numbness, burning, or aching o Distal portion of extremities o Client awakes at night o Relieved by dependent position o Lower back or buttock discomfort o Loss of hair o Dry scaly skin 34 PERIPHERAL ARTERIAL DISEASE ASSESSMENT FINDINGS o Thickened toenails o Cold and gray-blue skin o Elevational pallor o Dependent rubor o Decreased or absent peripheral pulses o Painful arterial ulcers On or between toes Upper aspect of foot 35 PERIPHERAL ARTERIAL DISEASE ASSESSMENT FINDINGS o BP in thigh, calf, and ankle are lower than brachial pressure N: lower extremity BP > upper extremity BP 36 PERIPHERAL ARTERIAL DISEASE INTERVENTIONS In patients with swelling ✓ Elevate feet at rest ✓ NOT above heart level Severe PAD with edema ✓ Sleep with affected limb hanging ✓ May sit upright for comfort 37 PERIPHERAL ARTERIAL DISEASE INTERVENTIONS ✓ Assess pain ✓ Monitor for color, motion, sensation, and pulses ✓ Measure BP ✓ Assess signs of ulcer or gangrene ✓ Individual exercise program ✓ Initiate gradually ✓ Increase slowly 38 Develops collateral circulation PERIPHERAL ARTERIAL DISEASE INTERVENTIONS ✓ Ambulation ✓ Walk to the point of claudication ✓ Stop and rest ✓ Walk a little farther ✓ Daily inspection ✓ Report signs of skin breakdown ✓ Wear socks or insulated shoes at all times 39 PERIPHERAL ARTERIAL DISEASE INTERVENTIONS ✓ AVOID X Crossing legs X Tobacco X Cold exposure X Caffeine X Direct heat Heating pad Hot water ✓Drugs Hemorheological drugs Antiplatelet drugs 40 PERIPHERAL ARTERIAL DISEASE PROCEDURES TO IMPROVE ARTERIAL BLOOD FLOW Percutaneous Transluminal Angioplasty (PTA) Laser-Assisted Angioplasty Atherectomy Peripheral Arterial Bypass Surgery 41 PERIPHERAL ARTERIAL DISEASE Peripheral Arterial Bypass Surgery Graft is sutured above and below occlusion Inflow Procedures Bypass occlusion above superficial femoral arteries Include: ▪ Aortoiliac bypass ▪ Aortofemoral bypass 42 ▪ Axillofemoral bypass PERIPHERAL ARTERIAL DISEASE Peripheral Arterial Bypass Surgery Outflow Procedures Bypass occlusion at or below the superficial femoral arteries Include: ▪ Femoropopliteal bypass ▪ Femorotibial bypass 43 PERIPHERAL ARTERIAL DISEASE PREOPERATIVE INTERVENTIONS ✓ Assess baseline VS ✓ Assess peripheral pulses ✓ Maintain a central venous catheter and/or arterial line 44 PERIPHERAL ARTERIAL DISEASE POST-OPERATIVE INTERVENTIONS ✓ Assess VS ✓ Monitor for hypotension May indicate hypovolemia ✓ Monitor for hypertension May place stress on the graft ▪ Clots may form ✓ Maintain bed rest for 24 hours 45 PERIPHERAL ARTERIAL DISEASE POST-OPERATIVE INTERVENTIONS ✓ Keep affected extremity straight ✓ Limit movement ✓ AVOID bending knee and hip ✓ Monitor for warmth, redness, and edema Expected due to ↑ blood flow ✓ Monitor for vessel or graft occlusion Often occurs within first 24 hours 46 PERIPHERAL ARTERIAL DISEASE POST-OPERATIVE INTERVENTIONS ✓ Assess peripheral pulses ✓ Assess for changes color and temperature changes ✓ Assess incision for drainage, warmth, or swelling ✓ Monitor for excessive bleeding ✓ Monitor for signs of infection ✓ If (+), notify physician 47 RAYNAUD’S DISEASE “Primary Raynaud’s Syndrome" Vasospasm of arterioles and arterioles of the upper and lower extremities Constriction of cutaneous vessels Caused by cold or stress Affects fingers, toes, ears, and cheeks 48 RAYNAUD’S DISEASE ASSESSMENT FINDINGS o Blanching → cyanosis o Reddened tissue due to relief of vasospasm o Numbness o Tingling o Swelling o Coldness of affected part 49 RAYNAUD’S DISEASE Raynaud’s Phenomenon “Secondary Raynaud’s Syndrome” Occurs due to an underlying condition, medication, or lifestyle factor 50 RAYNAUD’S DISEASE INTERVENTIONS ✓ Monitor pulses ✓ Administer vasodilators ✓ Instruct regarding drug therapy ✓ Avoid precipitating factors ✓ Avoid smoking ✓ Avoid injuries to fingers and hands ✓ Wear warm clothing, socks, and gloves in cold weather 51 BUERGER’S DISEASE “Thromboangiitis Obliterans” Occlusive disease of the median and small arteries and veins Distal upper and lower limbs are most commonly affected 52 BUERGER’S DISEASE ASSESSMENT FINDINGS o Intermittent claudication o Ischemic digital pain at rest o Aching pain that worsens at night o Cool, numb, or tingling sensation o ↓ Pulses in the distal extremities o Cool and red extremities when Interventions are similar to dependent those of Raynaud’s! o Ulcer formation 53  AORTIC ANEURYSMS AORTIC ANEURYSMS Abnormal arterial dilation Caused by weakness and stretching in the medial layer or aortic wall Can be anywhere along the abdominal aorta 55 AORTIC ANEURYSMS GOAL of Treatment Limit progression Modifying risk factors BP control Early symptom recognition Rupture prevention 56 AORTIC ANEURYSMS TYPES Normal Vessel Fusiform Saccular Dissecting False or Pseudoaneurysm 57 AORTIC ANEURYSMS TYPES FUSIFORM Diffuse dilation that involves the entire circumference of the arterial segment 58 AORTIC ANEURYSMS TYPES SACCULAR Distinct localized outpouching of the artery wall 59 AORTIC ANEURYSMS TYPES DISSECTING Created when blood separates the arterial wall layers, forming a cavity between them 60 AORTIC ANEURYSMS TYPES FALSE (Pseudoaneurysm) Clot and connective tissue are outside the arterial wall due to vessel injury or trauma to all 3 layers of the arterial wall 61 AORTIC ANEURYSMS ASSESSMENT FINDINGS Thoracic Aneurysm o Pain extending to neck, shoulders, lower back, or abdomen o Syncope o Dyspnea o Increase pulse o Cyanosis o Hoarseness, difficulty swallowing 62 AORTIC ANEURYSMS ASSESSMENT FINDINGS Abdominal Aneurysm o Prominent, pulsating mass in abdomen – at or above umbilicus o Systolic bruit over the aorta o Tenderness on deep palpation o Abdominal or lower back pain 63 AORTIC ANEURYSMS ASSESSMENT FINDINGS Rupturing Aneurysm o Severe abdominal or back pain o Lumbar pain radiating to the flank and groin o Hypotension o ↑ Pulse rate o Signs of shock o Hematoma at flank area 64 AORTIC ANEURYSMS DIAGNOSTIC TESTS Confirm presence, size, and location Tests: Abdominal ultrasound Computed tomography scan Arteriography 65 AORTIC ANEURYSMS INTERVENTIONS ✓ Monitor VS ✓ Evaluate back or abdominal pain ✓ Question about pulsation in abdomen ✓ Check peripheral circulation: pulses, temperature, color ✓ Observe for signs of rupture ✓ Note any abdominal tenderness ✓ Monitor for abdominal distention 66 AORTIC ANEURYSMS NONSURGICAL INTERVENTIONS ✓ Modify risk factors ✓ Instruct about BP monitoring ✓ Instruct about follow-up visits ✓ Notify doctor if the ff are present: o Severe back or abdominal pain/fullness o Soreness over umbilicus o Sudden discoloration of extremities o Persistent elevation of BP 67 AORTIC ANEURYSMS PHARMACOLOGICAL INTERVENTIONS Antihypertensives ✓ Instruct about: ▪ Purpose ▪ Side effects ▪ Schedule 68 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Surgical excision of aneurysm Replaced with a graft Sewn end to end 69 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Preoperative Interventions ✓ Assess all peripheral pulses ✓ Instruct about coughing and DBE 70 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ Monitor: ✓ VS ✓ Distal peripheral pulses ✓ Signs of graft occlusion o Changes in pulse o Severe pain o Cool to cold extremities o Abdominal o White or blue distention 71 extremities/flanks AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ Limit HoB elevation to 45º ✓ Monitor for hypovolemia and kidney failure ✓ Monitor UO hourly ✓ Notify: < 30-50 mL/hr ✓ Monitor creatinine & BUN daily 72 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ AVOID X Lifting heavy objects Heavier than 15 to 20 lb 6-12 weeks X Activities requiring pushing, pulling, or straining X Driving until approved 73 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ Endovascular Aneurysm Grafting Graft insertion No need abdominal incision Interventions are similar to surgical abdominal aneurysm 74 repair AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Thoracic Aneurysm Repair Thoracotomy or median sternotomy approach Aneurysm is exposed and excised Graft or prothesis is sewn onto aorta 75 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Thoracic Aneurysm Repair Total cardiopulmonary bypass – aneurysms in ascending aorta Partial cardiopulmonary bypass – aneurysms in descending aorta 76 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ Monitor VS, neurological, and renal status ✓ Monitor for signs of hemorrhage ✓ Monitor chest tubes for ↑ chest drainage ✓ Assess sensation and motion of all extremities ✓ Monitor respiratory status 77 AORTIC ANEURYSMS ABDOMINAL AORTIC ANEURYSM RESECTION Postoperative Interventions ✓ Encourage turning, coughing, splinting, and DBE ✓ Prepare for discharge ✓ AVOID X Lifting heavy objects Heavier than 15 to 20 lb 6-12 weeks X Activities requiring pushing, pulling, or straining 78 X Driving until approved THANK YOU!