PERIPHERAL VASCULAR DISEASE

OVERVIEW OF ANATOMY AND PHYSIOLOGY STRUCTURE & FUNCTION OF BLOOD VESSELS BLOOD VESSELS channels blood distributed to body tissues

WALLS OF AN ARTERY OR VEIN 3 LAYERS 1- tunica intima 2-tunica media 3-tunica adventitia the thickness of the walls and amount of connective tissue and smooth muscle depend upon the amount of pressure the vessel must endure

DIVIDED INTO THE ARTERIAL & VENOUS SYSTEM ARTERIAL SYSTEM consist of high pressure vessels, the largest of which is the aorta

some branch into arterioles measures less than 0.5 mm in diameter functions to deliver blood to various tissues for nourishment and contribute to tissue temperature regulation

VENOUS SYSTEM Consist of large diameter, thin walled vessels that are under much less pressure

Some veins, most commonly in the legs, contain valves to regulate one-way flow Functions to return blood from the capillaries to the right atrium for circulation and acts as a reservoir for blood volume

B. CIRCULATION AND DYNAMICS OF BLOOD FLOW BLOOD FLOW is the amount of fluid moved per unit of time through a vessel, organ or throughout the entire circulatory system

Systemic circulation supplies nourishment to all of the tissue located throughout your body, with the exception of the heart and lungs because they have their own systems. Systemic circulation is a major part of the overall circulatory system. The blood vessels (arteries, veins, and capillaries) are responsible for the delivery of oxygen and nutrients to the tissue. Oxygen-rich blood enters the blood vessels through the heart's main artery called the aorta. The forceful contraction of the heart's left ventricle forces the blood into the aorta which then branches into many smaller arteries which run throughout the body. The inside layer of an artery is very smooth, allowing the blood to flow quickly. The outside layer of an artery is very strong, allowing the blood to flow forcefully. The oxygen-rich blood enters the capillaries where the oxygen and nutrients are released. The waste products are collected and the waste-rich blood flows into the veins in order to circulate back to the heart where pulmonary circulation will allow the exchange of gases in the lungs. During systemic circulation, blood passes through the kidneys. This phase of systemic circulation is known as renal circulation. During this phase, the kidneys filter much of the waste from the blood. Blood also passes through the small intestine during systemic circulation. This phase is known as portal circulation. During this phase, the blood from the small intestine collects in the portal vein which passes through the liver. The liver filters sugars from the blood, storing them for later.

BLOOD FLOW THROUGH THE HEART 1. deoxygenated blood returning from the body enters the heart through the superior vena cava and inferior vena cava. 2. blood passes into the right atrium and right ventricle 3. right ventricle pushes the blood through the pulmonary arteries 4. blood passes through the lungs where it loses carbon dioxide and picks up oxgen 5. this oxygenated blood returns to the heart via the pulmonary veins 6. blood enters the left atrium and left ventricle 7. the left ventricle pushes the blood out through the main artery, the aorta 8. blood travels to all parts of the body where it delivers oxygen and picks up carbon dioxide

CIRCULATION IS REGULATED BY THE FOLLOWING: PRESSURE -there is pressure difference between the arterial and venous vessels -blood flows from the arterial side of the capillaries to the lower pressured venous side

VELOCITY -the distance blood must travel in the unit of time

RESISTANCE -opposition to blood flow -increased resistance leads to decreased blood flow -peripheral vascular resistance is determined by blood viscosity. Length of vessel and diameter of the vessel COMPLIANCE -increase in volume a vessel can accommodate for a given increase in pressure -veins are much more compliant than arteries and thus can serve as storage areas in the circulatory system

C. BLOOD PRESSURE CONTROL SYMPATHETIC NERVOUS SYSTEM -increases the heart rate -the speed of impulse conduction through the atrioventricular [AV] node -the force of atrial and ventricular contractions

PARASYMPATHETIC NERVOUS SYSTEM -causes a decrease in HR by the action of the sinoatrial [SA] node and slows conduction through the AV node

BARORECEPTORS -stimulation of these receptors located in the aortic arch and carotid sinus causes information to be sent to the vasomotor center in the brain stem to enhance the parasympathetic system causing a decrease in HR and peripheral VASODILATION or widening of the blood vessel

CHEMORECEPTORS -areas stimulated by decreased arterial oxygen pressure -increased carbon dioxide pressure -decreased plasma pH to stimulate the vasomotor center -increase cardiac activity

ANTIDIURETIC HORMONE [ADH] -a decrease in total blood volume in the circulatory system leads the posterior pituitary gland to release ADH causing reabsorption of water by the kidney resulting in increased blood plasma volume and increased blood pressure

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM -in response to sympathetic stimulation or decreased blood flow through the kidneys the kidneys produce renin that generates angiotensin I which is converted to angiotensin II these powerful vasoconstrictors stimulate release of aldosterone from adrenal glands allowing for sodium retention in the kidneys and then suppression of renin

OTHER FACTORS THAT MAY AFFECT BLOOD PRESSURE CONTROL temperature [cold=vasoconstriction] substances such as nicotine [vasoconstrictor] alcohol [vasodilation] diet [sodium and fat intake] age, gender, weight, physical health and emotional state

DIAGNOSTIC TESTS AND ASSESSMENT DOPPLER ULTRASOUND measures the velocity of the blood flow through a vessel emits an audible signal when arterial palpation is difficult or impossible because of occlusive disease useful in determining blood flow palpable pulse & Doppler pulse are not equivalent & should not be used interchangeably

PLETHYSMOGRAPHY records biologic changes in volume in a portion of the body associated with cardiac contractions or in response to pneumatic venous occlusion can detect & quantify vascular disease on the basis of changes in pulse contour, blood pressure. or arterial /venous blood flow A plethysmography test is performed by placing blood pressure cuffs on the extremities to measure the systolic pressure. The cuffs are then attached to a pulse volume recorder (plethysmograph) that displays each pulse wave. The test compares the systolic blood pressure of the lower extremity to the upper extremity, to help rule out disease that blocks the arteries in the extremities

DIGITAL INTRAVENOUS ANGIOGRAPHY utilizing computer technology visualization of blood vessels occurs after IV injection of contrast material allows for small peripheral venous injections of contrast medium, compared with large doses that must be injected via arterial cannulation

DIGITAL INTRAVENOUS ANGIOGRAPHY

VENOGRAPHY injection of radiopaque dye into veins serial x-rays are taken to detect deep vein thrombosis and incompetent valves ANGIOGRAPHY injection of radiopaque dye into arteries to detect plaques, occlusions, injury, etc…

ANKLE-BRACHIAL INDEX most commonly used parameter for overall evaluation of extremity status ankle pressure normally is the same or slightly higher than brachial systolic pressure expected ABI is 0.8 to 1.0

ANKLE-BRACHIAL INDEX gives the ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery of the arm

COMPUTED TOMOGRAPHY allows for visualization of the arterial wall and its structures used in the diagnosis of abdominal aortic aneurysm [AAA] and postoperative vascular complications such as graft occlusion and hemorrhage

MAGNETIC RESONANCE IMAGING [MRI] uses magnetic fields rather than radiation used with angiography to detect abnormalities especially in people who are unable to have dye injected

MRI

COMMON NURSING TECHNIQUES AND PROCEDURES: BLOOD PRESURE MEASUREMENT A. BLOOD PRESSURE is primarily a function of cardiac output and systemic vascular resistance B. ARTERIAL BLOOD PRESSURE=CARDIAC OUTPUT X SYSTEMIC VASCULAR RESISTANCE

C. PROPER TECHNIQUE 1. Client should be seated with arm bared, supported and at heart level 2. Client should not have smoked or ingested caffeine 30 minutes prior 3. BP should be taken in both arms initially 4. Appropriate sized cuff must be used -rubber bladder should at least encircle the arm by 80 %

5. After palpating the brachial or radial pulse, inflate the cuff 30 mmHg above the level at which the pulse disappears 6. Record systolic and diastolic sounds---known as Korotkoff sounds the disappearance of sound is the diastolic reading 7. Two or more readings separated by 2 minutes should be averaged 8. If the clients arms are inaccessible, you can obtain readings from the thigh or calf, auscultating the popliteal or posterior tibial arteries, respectively cuff size must be adjusted for larger extremity

PRIMARY HYPERTENSION

DESCRIPTION a disorder characterized by blood pressure consistently exceeds 140/90 confirmed on at least two visits several weeks apart onset is primarily in people 25 to 55 greatest occurrence is in African Americans

B. ETIOLOGY AND PATHOPHYSIOLOGY 1. Hypertension primary [essential] secondary PRIMARY HYPERTENSION accounts for 90 to 95 % of all cases there is no known cause but risk factors include: positive family history high sodium intake obesity inactivity excessive alcohol intake

2. PATHOPHYSIOLOGY A. for arterial pressure to rise there must be an increase in either cardiac output or systemic vascular resistance later in the course of the disease systemic vascular resistance continues to rise as the cardiac output stabilizes B. there is no single cause for primary hypertension

C. ASSESSMENT 1. Subjective data a. past history of cardiovascular, cerebrovascular, renal or thyroid diseases, diabetes, smoking or alcohol use b. family history of hypertension or cardiovascular disease c. possible absence of symptoms d. reports of fatigue, nocturia, dyspnea on exertion, palpitations, angina, headaches, weight gain, edema, muscle cramps or blurred vision symptoms may be caused by target organ damage rather than the high blood pressure itself

2.OBJECTIVE DATA a. BP consistently >140 mmHg systolic and >90 mmHg diastolic prehypertension category of at risk population is systolic BP > 130 or diastolic > 85 b. peripheral edema, retinal vessel changes, diminished/ absent peripheral pulses, bruits, murmurs and S 3 and S 4 heart sounds

3. DIAGNOSTIC TESTS a. abnormal potassium level [ may be low if taking loop diuretics or high if taking potassium-sparing diuretics] b. elevated blood urea nitrogen [BUN], creatinine, glucose, cholesterol and triglycerides c. abnormal urinalysis d. cardiomegaly on x-ray e. abnormal ECG showing left ventricular hypertrophy

D. PRIORITY NURSING DIAGNOSES Ineffective health maintenance Risk for noncompliance Decreased cardiac output

E. PLANNING AND IMPLEMENTATION 1. Tell client the numeric blood pressure readings so he or she can keep an on-going record 2. Inform client that hypertension is usually asymptomatic, and symptoms will not reliably indicate BP levels 3. Explain that long-term followup and therapy will be necessary 4. Accurately record intake and output and daily weights of hospitalized clients

F. MEDICATION THERAPY 1. no one primary drug is used a combination of drugs are used until desired blood pressure is achieved with the fewest side effects 2. medications used include diuretics, beta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors [ACE] inhibitors. Angiotensin II receptor blockers [ARBs] and vasodilators

3. the stepped care approach is often used to guide treatment this protocol begins with lifestyle changes and adds medications based on response to previous therapy

G. CLIENT EDUCATION 1. Lifestyle modification a. sodium restriction b. weight reduction c. DASH [dietary approach to stop hypertension] diet includes prescribed number of servings of food in the following categories grains and grain products vegetables fruits low-fat or nonfat dairy foods meats, poultry and fish nuts, seeds and legumes fats and oils sweets

d. moderation of alcohol intake e. exercise f. relaxation techniques g. no smoking 2. General medication therapy and potential side effects a. supllement potassium if taking loop diuretics b. prevent orthostatic hypotension a drop in blood pressure of 10 to 20 mmHg with upright posture by rising out of the bed or chair slowly c. avoid hot baths and strenuous exercise within 3 hours of taking vasodilators

3. Importance of adhering to treatment plan compliance may be an issue if client does not understand that treatment can reduce risk of target organ damage r if the disorder is not taken seriously because there are no symptoms H. EXPECTED OUTCOMES / EVALUATION 1. a decrease in bood pressure to less than 140 / no target organ damage [kidneys, heart, nervous system, eyes] 3. client voices understanding of the management of hypertension

PERIPHERAL ARTERIAL DISEASE DESCRIPTION disorders that interrupt or impede arterial peripheral blood flow due to vessel compression, vasospasm and / or structural defects in the vessel wall

ETIOLOGY AND PATHOPHYSIOLOGY 1. peripheral arterial occlusive disease is primarily caused by atherosclerosis local accumulation of lipid and fibrous tissue along the intimal layer of an artery may also be caused by trauma, embolism, thrombosis, vasospasm, inflammation or autoimmunity 2. by the time symptoms appear, the vessel is about 75 % narrowed

3. the femoral-popliteal area is the site most commonly affected in nondiabetics diabetic clients most aften develop disease in the arteries below the knees 4. Chronic arterial obstruction leads to inadequate oxygenation of the tissues causing intermittent claudication which is ischemic muscle pain precipitated by a predictable amount of exercise and relieved by rest

C. ASSESSMENT 1. Subjective a. client reports aching, cramping, fatigue or weakness in the legs that is relieved by rest [claudication] this is an early indication of disease b. client reports rest pain occurs while resting that may even awaken the client at night usually at the distal portion of the extremity toes, arch, forefoot, heel relieved when foor is placed in the dependent position this indicates more advanced disease c. client complians of coldness or numbness in the LE

2. Objective a. extremities may be cool and pale with a cyanotic color on elevation b. bruits may be auscultated c. peripheral pulses may be diminished or absent d. nails may be thickened and opaque [trophic change] e. skin on the legs may be shiny with sparse hair growth [trophic change] f. ulcers may be present on the LE reduced circulation with deep pale base, demarcated edges, pianful treated with wet to moist saline dressings or surgical revascularization

3. Diagnostic testing a. digital subtraction angiography [DSA] b. angiography c. doppler ultrasound d. plethysmography

PRIORITY NURSING DIAGNOSES Ineffective tissue perfusion Impaired skin integrity Pain

E. PLANNING AND IMPLEMENTATION 1. Goal: ADEQUATE TISSUE PERFUSION a. assess and record strength of pulses b.encourage client to stop smoking as nicotine causes vasoconstriction & hypercoagulability of blood c. teach client to change position at least hourly and avoid crossing the legs d. encourage client to exercise and walk to the point of pain as this decreases claudication explain to stop walking when pain occurs to decrease oxygen needs to affected area and to resume when pain has stopped in order to build tolerance to exercise and stimulate growth of collateral circulation e. teach client to avoid restrictive clothing, including girdles, garters and socks

2. Goal: RELIEF OF PAIN a. assess pain on a 1 to 10 scale and provide analgesics as ordered b. teach relaxation techniques because stress increases vasoconstriction c. keep feet warm and in a dependent position do not elevate feet if pain is present

3. Goal: INTACT, HEALTHY SKIN ON EXTREMITIES a. teach client skills in skin care and daily inspection of feet b. teach client to always wear shoes / slippers and avoid trauma to the feet bath water should be checked with the hands, not with the feet,to prevent burns to tissue at high risk for injury that may also have decreased sensation c. teach client to have toenail care performed by a professional only d. if an ulcer develops, healing will be slow unless arterial blood flow to the affected limb is improved through a surgical revascularization procedure

4. If surgery is indicated, provide appropriate postoperative care a. angioplasty 1] monitor neurovascular status color, motion, sensitivity, temperature and presence of distal peripheral pulses to the affectd extremity every 15 minutes x 4, every 30 min x 4, then q 1-4 hrs after sheath removal 2] notify physician if client experiences weak or thready pulses, coolness, numbness or tingling in the extremity

3] monitor the sheath site for signs of external and subcutaneous bleeding at the same frequency s neurovascular assessment 4] instruct the client to notify the nurse and apply manual pressure to the site should a sensation of warmth or wetness be felt at the site 5] maintain immobilization of affected extremity for at least 6 hours by reminding client to keep extremity still or lightly immobilize ankle with sheet tucked under both sides of mattress 6] maintain a pressure dressing and sand bag [or other occlusive device] at site

b. bypass grafting 1] provide standard postoperative care 2] assess for occlusion of graft by assessing for severe ischemic pain, loss of pulses, decreasing ankle-brachial index, numbness / tingling in extremity, coolness of the extremity c. Endarterectomy opening the artery and removing obstructing plaque or amputation in severe cases use same principles of care

F. MEDICATION THERAPY 1. Aspirin inhibits platelet aggregation 2. Pentoxifylline [Trental] decreases blood viscosity to increase blood flow to the microcirculation and tissues of the extremities 3. Cilostazol [Pletal] inhibits platelet aggregation and enhances vasodilation 4. Clopidogrel [Plavix] inhibits platelet aggregation

G. CLIENT EDUCATION 1. Promote vasodilation -provide warmth [never by direct heat to the limb] -prevent long periods of exposure to cold -avoid use of restrictive clothing 2. Proper positioning -keep feet dependent to increase blood flow to legs -may elevate feet at rest but not above level of the heart -never crooslegs or ankles -following bypass surgery, may keep legs level with rest of the body

3. Stop smoking 4. Meticulous foot care as would be performed by clients with diabetes mellitus 5. Trental and Plavix should be taken with food and any effects may take 6 to 8 weeks to notice 6. Notify caregiver of any platelet aggregate inhibitors before undergoing any invasive procedures 7. Exercise program with weight reduction is helpful

CLIENT & FAMILY EDUCATION FOR PERIPHERAL ARTERIAL DISEASE stop smoking lose weight and eat a low fat diet do not cross legs while sitting elevate feet at rest, but not above heart level do not stand or sit for long periods of time do not wear restrictive clothing keep affected extremity warm but never apply direct heat inspect feet daily and keep them clean & dry avoid walking barefoot; wear proper fitting shoes avoid mechanical or thermal injury to the legs and feet begin and maintain an exercise & walking program notify healthcare provider of any changes in color, sensation, temperature or pulses in extremities

H. EXPECTED OUTCOMES / EVALUATION 1. Improved peripheral tissue perfusion manifested by palpable or audible pedal pulses and the absence of claudication 2. Absence of arterial ulcers 3. Improved activity tolerance

ARTERIAL EMBOLISM

DESCRIPTION arterial emboli usually arise from thrombi that developed in the heart as a result of atrial fibrillation, myocardial infarction, prosthetic valves or congestive heart failure

B. ETIOLOGY AND PATHOPHYSIOLOGY thrombi become detached and are carried from the left side of the heart into the arterial system where they may lodge and cause obstruction the symptoms may be abrupt and will depend on the size and location of the embolus ischemia will progress to necrosis and gangrene within hours

C. ASSESSMENT: the six Ps 1- pain 2- pallor [pale color] 3- pulselessness [diminished or absent pulses] 4- paresthesia [altered local sensation] 5- paralysis [weakness or inability to move extremity] 6- POIKILOTHERMIA [body temperature that varies with environment]

D. PRIORITY NURSING DIAGNOSES Ineffective peripheral tissue perfusion Impaired protection

E. PLANNING AND IMPLEMENTATION 1- assess peripheral pulses and neurovascular status every 2 to 4 hours 2- place affected extremity in a neutral position with no restrictive bedding / clothing ---keep extremity warm 3- assess level of pain using a 1 to 10 scale 4- change position every 2 hours to increase or improve collateral circulation

E. PLANNING AND IMPLEMENTATION 5- assess for and report unusual bleeding from anticoagulant therapy 6- monitor lab vaues, including APTT, PT and INR levels 7- if necrosis is present, surgical treatment is required; ---an emergency embolectomy needs to be performed within 4 to 5 hours of embolism to prevent necrosis and permanent damage to the extremity

F. MEDICATION THERAPY ---if no necrosis present thrombolytic therapy with streptokinase t-PA or heparin warfarin therapy at home

G. CLIENT EDUCATION 1- PRE AND POSTOPERATIVE TEACHING IF EMBOLECTOMY IS PERFORMED 2- MEASURES TO PROMOTE PERIPHERAL CIRCULATION AND MAINTAIN TISSUE INTEGRITY

H. EXPECTED OUTCOMES / EVALUATION 1- peripheral pulses strong bilaterally 2- no tissue damage or necrosis 3- therapeutic lab values for anticoagulant therapy a- warfarin: monitor INR value 1.a- nornal 0.75 to a- therapeutic 2.0 to 3.0 b- heparin: nomitor PTT value; therapeutic value is 1.5 to 2.5 times the control

BUERGERS DISEASE [THROMBOANGIITIS OBLITERANS]

A. DESCRIPTION an inflammatory disease of the small and medium sized veins and arteries accompanied by thrombi and sometimes vasospasm of arterial segments may occur in upper or lower extremities but is most common in the leg or foot

ETIOLOGY & PATHOPHYSIOLOGY 1- the cause of Buergers disease is unknown but since it occurs mostly in young men who smoke it is currently thought to be a reaction to something in cigarettes nd/ or to have a genetic or autoimmune component

ETIOLOGY & PATHOPHYSIOLOGY 2- inflammation occurs mirothrombi form these can lead to vasospasm this process ultimately obstructs blood flow

ASSESSMENT 1- bluish cast to a toe or finger and a feeling ofcoldness in the affected limb 2- nerves alsoinflamed there may be severe pain & constriction of smal blood vessels controlled by them rest pain is common 3- overactive sympathetic nerves may cause the feet to sweat excessively---even they feel cold

C. ASSESSMENT 4- blood vessels become blocked intermittent claudication other symptoms similar to those of chronic obstructive arteril disease aften appear 5- ischemic ulcers and gangrene common complications of progressive Buergers disease

D. PRIORITY NURSING DIAGNOSES INEFFECTIVE TISSUE PERFUSION PAIN

E. PLANNING AND IMPLEMENTATION 1- arrest progress of disease by smoking cessation 2- take measures to promote vasodilation [similar to other arteril disorders] 3-provide for pain relief 4-provide emotional support

F. MEDICATION THERAPY analgesic pain medications calcium channel blockers to ease vasospasm pentoxifylline [Trental] to reduce blood viscosity

G. CLIENT EDUCATION 1- stop smoking 2- take measures to promote peripheral circulation maintain tissue integrity

H. EXPECTED OUTCOMES / EVALUATION 1- absence of ulcers / impaired skin integrity 2- relief of pain 3- cessation of smoking

RAYNAUDS DISEASE

A. DESCRIPTION - LOCALIZED - INTERMITTENT EPISODES OF VASOCONSTRICTION OF SMALL ARTERIES OF THE HANDS - LESS COMMONLY THE FEET - CAUSING COLOR AND TEMPERATURE CHANGES

B. ETIOLOGY AND PATHOPHYSIOLOGY 1- a vasospastic disorder of unknown origin that primarily affects young women 2- vasospastic attacks tend to be bilateral and manifestations usually begin at the tips of the digits causing pallor, numbness and sensation of cold 3-attacks are triggered by exposure to cold, emotional stress, caffeine ingestion, and tobacco use

C. ASSESSMENT 1- symptoms may appear in the hands after exposure to cold and / or stress bilateral and symmetrical 2- classic triphasic color changes in the hands with accompanying reduction in skin temperature pallor cyanosis rubor 3- the intensity of pain increases as disease progresses 4- the skin of the fingertips may thicken and nails may become brittle

D. PRIORITY NURSING DIGNOSES INEFFECTIVE TISSUE PERFUSION CHRONIC PAIN

E. PLANNING AND IMPLEMENTATION 1- keep hands warm and free from injury 2- avoid stressful situations 3- in severe cases, a sympathectomy surgical dissection of thenerve fibers that allows vasoconstriction to occur -may be performed to relieve symptoms associated with vasospasm

F. MEDICATION THERAPY 1- analgesics for pain 2- vasodilators may provide some relief of symptoms, as well as vascular smooth muscle relaxants and calcium channel blockers

G. CLIENT EDUCATION 1- keep hands warm -wear gloves when out of doors, in air- conditioned environments or when handling cold food 2- avoid injury to hands 3- lifestyle changes -stop smoking -employ stress relief---eg. biofeedback

H. EXPECTED OUTCOMES / EVALUATION 1- decrease in or absence of attacks 2- no injury to hands and / or wounds heal quickly

AORTIC ANEURYSM

A. DESCRIPTION -localized dilation -outpouching of a weakened area in the aorta is classified by region as thoracic or abdominal, or s dissecting

B. ETIOLOGY AND PATHOPHYSIOLOGY 1- aorta is susceptible to aneurysm formation because of constant stress on the vessel wall 2- aneurysms occur in men more often than women and their incidence increases with age 3- most aneurysms are found in the abdominal aorta below the level of the renal arteries 4- the growth rate of n aneurysm is unpredictable 5-half of all aneurysms greater than 6 cm in size will rupture within 1 year 6- the major risk factor is atherosclerosis

C. ASSESSMENT 1- THORACIC ANEURYSMS asymptomatic with the first sign being rupture a- symptoms pain in the back, neck and substernal area that may only occur when lying supine b-client may experience dysphagia dyspnea stridor or cough when pressing on the esophagus or laryngeal nerve

C. ASSESSMENT 2- ABDOMINAL ANEURYSMS may also be asymptomatic until rupture a- the client may report a heartbeat in the abdomen when lying down b- a pulsating abdominal mass may be present c- moderate to severe abdominal or lumbar back pain may be present severe pain may be a sign of impending rupture

C. ASSESSMENT 2- ABDOMINAL ANEURYSMS d- the client may experience claudication e- cool or cyanotic extremities may be noted f- systolic bruit my be heard

3- DISSECTING ANEURYSMS present with sudden, severe and persistent pain described as tearing or ripping in the anterior chest or the back a- pain may extend to the shoulder, epigastric area or abdomen b- pallor, sweating and tachycardia will be evidenced c- initially the client may have an elevated BP that may be different in one arm from the other d- possible syncope and paralysis of lower extremities may be present

D. PRIORITY NURSING DIAGNOSES INEFFECTIVE TISSUE PERFUSION PAIN ANXIETY

E. PLANNING AND IMPLEMENTATION 1. Diagnostic test that may be ordered a- chest x-ray b- transesophageal echocardiography c- aortography d- ultrasound e- CT scan or MRI 2- The overall goals for a client with an aneurysm a- normal tissue perfusion b- intact motor and neurologic function c- reduction in anxiety d- no complications of surgical repair

3. Surgical care a- surgical management may be performed on an emergency or elective basis surgery not usually performed on aneurysms less than 4 to 5 cm in size b- emergency surgery is the only intervention for clients with a ruptured aneurysm c- hematomas into the scrotum, perineum, flank or penis indicate retroperitoneal rupture d- once the aorta ruptures anteriorly into the peritoneal cavity, death is almost certain

3. Surgical care e- surgical technique involves excision of the aneurysm with replacement of the excised segment with a synthetic graft f- preoperatively the nurse marks and assesses all peripheral pulses for comparison postoperatively g- postoperatively the nurse assesses for complications, which may include: 1- graft occlusion 2-hypovolemia / renal failure 3- respiratory distress 4-cardiac dysrhythmias 5- paralytic ileus 6- paraplegia / paralysis

F. MEDICATION THERAPY 1- the goal of nonsurgical management is to maintain blood pressure at a normal level to decrese the pressure on the arterial system and reduce the risk of rupture 2- antihypertensive therapy and diuretics may be prescribed 3- pulsatile flow may be reduced by medications that reduce cardiac contractility 4-postoperatively clients will be placed on anticoagulant therapy heparin while the client is in the hospital and warfarin [Coumadin] when discharged to home

G. CLIENT EDUCATION 1- clients who do not undergo operative repair must be urged to receive routine physical exminations to monitor the status of the aneurysm 2- be aware of signs and symptoms of impending rupture [see assessment of dissecting aneurysms] 3-self monitor blood pressure and report any increases immediately 4-how to self-manage anticoangulant therapy

G. CLIENT EDUCATION 5- for postoperative clients, teach routine postoperative care a- do limited lifting for 4 to 6 weeks after surgery [no heavy lifting at all] b- monitor the incision site for bleeding / infection c- assess neurovascular status of the extremities and presence of pulses d- clients who receive a synthetic graft may require prophylactic antibiotics before invasive procedures

H. EXPECTED OUTCOMES / EVALUATION 1- client has normal tissue perfusion 2- the aneurysm does not rupture 3- for surgical clients, absence of postoperative complications and maintenance of normal tissue perfusion postsurgical grafting

THROMBOPHLEBITIS

A. DESCRIPTION The formation of a thrombus [CLOT] in association with inflammation of the vein Classified as superficial or deep

ETIOLOGY & PATHOPHYSIOLOGY 1- ETIOLOGY VIRCHOWS TRIAD [at least 2 or 3 present for thrombosis to occur] a-stasis of venous flow b-damage to the inner lining of the vein [endothelial layer] c-hypercoagulability of the blood

ETIOLOGY & PATHOPHYSIOLOGY 2-PATHOPHYSIOLOGY a-RBCs, WBCs and platelets adhere to form a thrombus [usually in valve cusps of veins] b- as thrombus enlarges it eventually occludes the lumen of the vein c- if only partial occlusion of the vein occurs, blood flow continues and the thrombotic process stops if detechment does not occur, it will become firmly organized and attached within 24 to 48 hours d- it detachment occurs, emboli from which generally flow through the venous system, back to the heart, and into the pulmonary circulation

ASSESSMENT 1-SUBJECTIVE: history of thrombophlebitis pelvic/ abdominal surgery obesity neoplasm [hepatic & pancreatic] congestive heart failure atril fibrillation prolonged immobility myocardial infarction pregnancy & / or postpartum period IV therapy hypercoagulable states [polycythemia, dehydration / malnutrition]

2- OBJECTIVE-signs vary according to thrombus size, location and adequacy of collateral circulation a. Superficial -palpable, firm, subcutaneous, cordlike vein -surrounding area warm, red, teder to the touch -edema may or may not be present -most common cause in the arms is IV therapy in the legs it is often related to varicose veins

B- deep -unilteral edema -pain -warm skin and elevated temperature -if the inferior vena cava is involved, both legs will be edematous -if the superior vena cava is involved, both upper extremities, neck, back, and face may become edematous or cyanotic -if the calf is involved, Homans signmay be present [pain on dorsiflexion of the foot, especially when the leg is raised]

DIAGNOSTIC STUDIES a-venous duplex scanning b-Doppler ultrasonic flowmeter c-D-dimer, a poduct of fibrin degradation, indicates fibrinolysis [that occurs as a reaction to thrombosis] d-venography & plethysmography, former gold standards for diagnosis are rarely used today e-MRI f.Lung scan

PRIORITY NURSING DIAGNOSES PAIN INEFFECTIVE TISSUE PERFUSION RISK FOR IMPAIRED SKIN INTEGRITY

C. PLANNING & IMPLEMENTATION 1-educate client about diagnostic tests that may be performed 2-provide for relief of pain a-assess pain on a scale of 1 to 10 b-elevate affected leg higher than the heart to promote venous drainage c-provide analgesics as ordered 3-decreased edema a-apply warm,moist compresses, intermittent or continuous, to affected extremity b-measure and monitor leg/arm circumference when edema is present c-monitor status of peripheral pulses

4-prevent skin ulceration a-keep bed covers from touching affected limb by using an overbed cradle b- do not allow use of restrictive clothing 5-prevent pulmonary emboli a-maintain strict bedrest, usually enforced until anticoagulant therapy is therapeutic b-never massage affected extremity c- instruct client to report any pink-tinged sputum and monitor for tachypnea, tachycardia, shortness of breath, chest pain and apprehension, which may indicate a pulmonary embolism d-prepare client for vena cava filter [greenfield filter] placement

MEDICATION THERAPY 1-anticoagulant therapy a-inhibits clotting factors that would extend thrombus formation b-will not induce thrombolysis but prevents clot extension c-heparin: intravenously or subcutaneous while in the hospital d-warfarin: home therapy for 2 to 4 months

2-thrombolytics a-dissolve blood clots by imitating natural enzymatic processses b-approved drugs include streptokinase [streptase] and alteplase [activase] c-is usually effective in less than 72 hours d-higher risk for hemorrhage exists than when using heparin therapy

CLIENT EDUCATION 1-prevention a-early ambulation postoperatively b-use of compression stockings or sequential device c-low dose anticoagulant therapy d-avoid prolonged standing or sitting avoid sitting with crossed legs e-avoid restrictive clothing f-stop smoking 2-provide education about anticoagulant therapy

H. EXPECTED OUTCOME / EVALUATION 1-no pain, edema or tenderness 2- no impaired skin integrity 3- no embolus

VENOUS INSUFFICIENCY

DESCRIPTION INADEQUATE VENOUS RETURN OVER A LONG PERIOD OF TIME THAT CAUSES PATHOLOGIC CHANGES AS A RESULT OF ISCHEMIA I THE VASCULATURE, SKIN, AND SUPPORTING TISSUES

ETIOLOGY & PATHOPHYSIOLOGY 1- occurs after prolonged venous hypertension, which stretches the veins and damages the valves, preventing blood return 2-occurs after thrombus formation or when valves are not functioning correctly,which may result from a-prolonged standing/ sitting b-pregnancy and obesity 3-with time, stasis results in edema of the lower limbs, discoloration to the skin of the legs & feet, venous stasis ulceration

ASSESSMENT 1-subjective a-past history of thrombophlebitis, hypertension and varicosities b-past history oflong periods of sitting and / or standing 2-objective a-edema of the lower legs,may extend to the knee b-thick, coarse, brownish skin around the ankles [gaiter area] and the feet c-stasis ulcers, usually in the malleolar area [ruddy base, uneven edges]

PRIORITY NURSING DIAGNOSIS IMPAIRED SKIN INTEGRITY RISK FOR INFECTION RELATED TO SKIN ULCERATIONS DISTURBED BODY IMAGE INEFFECTIVE TISSUE PERFUSION

PLANNING & IMPLEMENTATION 1- increase venous blood return, decrease venous pressure -bedrest -keep legs elevated -avoid long periods of standing -wear elastic support or compression stockings a-apply stockings before getting out of the bed & placing the leg in a dependent position b-wear stockings during the day & evening, remove at night c-never push stockings down around the legthey will further impair circulation d-handwash stockings daily and air dry; machine washing or drying will damage elastic fibers

2-treat venous stasis ulcer/s a-open lesions are treated with a hydrocolloid dressing and compression wraps; a topical ointment, such as low-dose hydrocortisone, zinc oxide, or an antifungal may also be indicated b-ulcers may be treated with an Unna Boot or other compression wrap that is changed every 1 to 2 weeks and is usually applied over a base dressing c-severe ulcers may need surgical debridement

MEDICATION THERAPY 1-topical agents to skin ulcers, such as hydrocortisone, antifungals or zinc oxide, may be prescribed 2- oral or IV antibiotics may be prescribed when ulcers become infected or cellulitis occurs 3-sclerosing agents [called sclerotherapy] may be used to occlude blood flow in a vein, causing disappearance of the varicosity, this may be followed up with use of compression bandage for a short period of time

CLIENT EDUCATION 1-elevate legs for at least 20 minutes four times a day 2-keep legs above the level of the heart when in bed 3-avoid prolonged sitting or standing 4- do not cross legs when sitting 5-do not wear tight, restrictive pants, socks or boots avoid girdles and garters that restrict circulation in the upper leg 6- wear suppoert stockings as instructed

EXPECTED OUTCOMES/EVALUATION -reduction in edema - Healing / prevention of stasis ulcers

VARICOSE VEINS

DESCRIPTION A VEIN OR VEINS IN WHICH BLOOD HAS POOLED, PRODUCING DISTENDED, TORTUOUS AND PALPABLE VESSELS

ETIOLOGY & PATHOPHYSIOLOGY 1-one in 5 people worldwide will develop varicosities 2-they are more commonin women over 35. those who are obese, those with a positive family history of varicosities, and those who stand for long periods of time 3-develop from trauma or damages to a vein or valve or from gradual venous distension, which diminishes the action of the muscle pump, and increases the pull of gravity on blood within the legs 4-as the vein swells, increased hydrostatic pressure will push plasma through the stretched vessel walls and edema of surrounding tissue may occur

ASSESSMENT 1-subjective aching, heaviness, itching, sweling and unsightly appearance to the legs 2-objective a-dilated, tortuous superficial veins will be seen along the upper and lower leg b-superficial inflammation c-positive Trendelenburg test [ done to evaluate valve competence] -supine position, elevate legs -as client sits up, the veins would normally fill from the distal end -if [+] varicosities, veins fill from the proximal end

PRIORITY NURSING DIAGNOSIS PAIN INEFFECTIVE TISSUE PERFUSION RISK FORIMPAIRED SKIN INTEGRITY RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION

E. PLANNIG & IMPLEMENTATION 1-asses and provide pain relief a-assess pain scale of 1 to 10 b-provide analgesics as needed 2-improve venous circulation a-assess pulses and neurovascular status of lower extremities b-teach/ apply support stockings c-avoid prolonged sitting and standing never cross legs. Walking is encouraged d-elevate feet above heart level when lying down e-avoid restrictive clothing / shoes

3-prevent skin breakdown; teach proper skin care and importance of avoiding trauma to legs 4-teach preoperative and postoperative care if surgery is chosen a-sclerotherapy-palliative not curative -elastic bandage- until 6 weeks b-vein ligation surgery---ligation of the entire vein usually the saphenous and dissection and removal of the incompetent tributaries -post op-perform hourly circulation checks -elevate extremity to a15 degree angle to prevent stasis and edema -apply compression gradient stockings from foot to groin

MEDICATION THERAPY LOW DOSE ASPIRIN THERAPYto reduce platelet aggregation and subsequent clot development

CLIENT EDUCATION: PREVENTION 1-AVOID SITTING OR STANDING FOR LONG PERIODS 2-CHANGE POSITION OFTEN 3-AVOID CONSTRICTIVE CLOTHING 4-ELEVATE LEGS WHEN SITTING TO PROMOTE VENOUS RETURN 5-MAINTAIN IDEAL BODY WEIGHT

EXPECTED OUTCOMES/ EVALUATION 1-RELIEF OF DISCOMFORT 2-IMPROVED CIRCULATION 3-AVOIDANCE OF COMPLICATION SUCH AS THROMBOPHLEBITIS AND ULCERATIONS