ARTERIAL AND VENOUS DISORDERS
MAIN POINTS
Raynaud’s diseaseBuerger’s diseaseAssessment of aortic aneurysmsHypertensionClient instructions related to arterial and
venous disorders
SITES FOR PALPATING PERIPHERAL PULSES
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
VEINS IN THE LEG
From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders
VENOUS THROMBOSIS
DESCRIPTION Thrombus can be associated with an inflammatory
process When a thrombus develops, inflammation occurs that
thickens the vein wall leading to embolization
TYPES OF VENOUS THROMBOSISTHROMBOPHLEBITIS
A thrombus associated with inflammationPHLEBOTHROMBUS
A thrombus without inflammationPHLEBITIS
Vein inflammation associated with invasive procedures such as IVs
DEEP VEIN THROMBOPHLEBITIS (DVT) More serious than a superficial thrombophlebitis
because of the risk for pulmonary embolism
RISKS FACTORS FOR VENOUS THROMBOSIS
Venous stasis from varicose veins, heart failure, immobility
Hypercoagulability disordersInjury to the venous wall from IV injections,
fractures, traumaFollowing surgery, particularly hip surgery
and open prostate surgeryPregnancy Ulcerative colitisUse of oral contraceptives
PHLEBITISASSESSMENT
Red, warm area radiating up an extremity Pain and soreness Swelling
IMPLEMENTATION Apply warm, moist soaks as prescribed to dilate the
vein and promote circulation Assess temperature of soak prior to applying Assess for signs of complications such as tissue
necrosis, infection, or pulmonary embolus
DEEP VEIN THROMBOPHLEBITIS (DVT)
ASSESSMENT Calf or groin tenderness or pain with or without
swelling Positive Homans’ sign Warm skin that is tender to touch
DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION Provide bed rest Elevate the affected extremity above the level of the
heart as prescribed Avoid using the knee gatch or a pillow under the
knees Do not massage the extremity Provide thigh-high compression or antiembolism
stockings as prescribed to reduce venous stasis and to assist in the venous return of blood to the heart
DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION Administer intermittent or continuous warm, moist
compresses as prescribed Palpate the site gently, monitoring for warmth and
edema Measure and record the circumference of the thighs
and calves Monitor for shortness of breath and chest pain, which
can indicate pulmonary emboli
DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION Administer thrombolytic therapy (t-PA, tissue
plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms
Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots
Monitor APTT during heparin therapy Administer warfarin (Coumadin) therapy as
prescribed when the symptoms of DVT have resolved
DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION Monitor PT and INR during warfarin (Coumadin)
therapy Monitor for the hazards and side effects associated
with anticoagulant therapy Administer analgesics as prescribed to reduce pain Administer diuretics as prescribed to reduce lower
extremity edema Provide client teaching
ASSESSING FOR PERIPHERAL EDEMA
From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders
DEEP VEIN THROMBOPHLEBITIS (DVT)
CLIENT EDUCATION Hazards of anticoagulation therapy Signs and symptoms of bleeding Avoid prolonged sitting or standing, constrictive
clothing, or crossing legs when seated Elevate the legs for 10 to 20 minutes every few hours
each day Plan a progressive walking program
DEEP VEIN THROMBOPHLEBITIS (DVT)
CLIENT EDUCATION Inspect the legs for edema and how to measure the
circumference of the legs Antiembolism stockings (hose) as prescribed Avoid smoking Avoid any medications unless prescribed by the
physician Importance of follow-up physician visits and
laboratory studies Obtain and wear a Medic Alert bracelet
ANTIEMBOLISM HOSE
From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.
VENOUS INSUFFICIENCY
DESCRIPTION Results from prolonged venous hypertension that
stretches the veins and damages the valves The resultant edema and venous stasis causes venous
stasis ulcers, swelling, and cellulitis Treatment focuses on decreasing edema and
promoting venous return from the affected extremity Treatment for venous stasis ulcers focuses on healing
the ulcer and preventing stasis and ulcer recurrence
VENOUS INSUFFICIENCYASSESSMENT
Stasis dermatitis or discoloration along the ankles extending up to the calf
Edema The presence of ulcer formation
PERIPHERAL VASCULAR DISEASE
From Bryant RA (1992): Acute and chronic wounds: nursing management, St. Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.
VENOUS INSUFFICIENCYWOUND CARE
Provide care to the wound as prescribed by the physician
Assess the client’s ability to care for the wound, and initiate home care resources as necessary
If an Unna boot (a dressing constructed of gauze moistened with zinc oxide) is prescribed, it will be changed by the physician weekly
VENOUS INSUFFICIENCYWOUND CARE
The wound is cleansed with normal saline prior to application of the Unna boot; providone-iodine (Betadine) or hydrogen peroxide is not used because they destroy granulation tissue
The Unna boot is covered with an elastic wrap that hardens, to promote venous return and prevent stasis
Monitor for signs of arterial occlusion from an Unna boot that may be too tight
Keep tape off of the client’s skin
VENOUS INSUFFICIENCYMEDICATIONS
Apply topical agents to wound as prescribed to debride the ulcer, eliminate necrotic tissue, and promote healing
When applying topical agents, apply an oil-based agent as petroleum jelly (Vaseline) on surrounding skin, because debriding agents can injure healthy tissue
Administer antibiotics as prescribed if infection or cellulitis occur
VENOUS INSUFFICIENCYCLIENT EDUCATION
Wear elastic or compression stockings during the day and evening as prescribed
Put on elastic stockings upon awakening before getting out of bed
Put a clean pair of elastic stockings on each day and that it will probably be necessary to wear the stockings for the remainder of life
VENOUS INSUFFICIENCY
CLIENT EDUCATION Avoid prolonged sitting or standing, constrictive
clothing, or crossing legs when seated Elevate the legs for 10 to 20 minutes every few hours
each day Elevate legs above the level of the heart when in bed
VENOUS INSUFFICIENCY
CLIENT EDUCATION The use of an intermittent sequential pneumatic
compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening
Advise the client with an open ulcer that the compression system is applied over a dressing
VARICOSE VEINSDESCRIPTION
Distended protruding veins that appear darkened and tortuous
Vein walls weaken and dilate, and valves become incompetent
ASSESSMENT Pain in the legs with dull aching after standing A feeling of fullness in the legs Ankle edema
NORMAL VEINS AND VARICOSITIES
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
VARICOSE VEINS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby
VARICOSE VEINSTRENDELENBURG TEST
Place the client in a supine position with the legs elevated
When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end
TRENDELENBURG TEST
From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders
VARICOSE VEINSIMPLEMENTATION
Assist with the Trendelenburg test Emphasize the importance of antiembolism stockings
as prescribed Instruct the client to elevate the legs as much as
possible Instruct the client to avoid constrictive clothing and
pressure on the legs Prepare the client for sclerotherapy or vein stripping,
as prescribed
SCLEROTHERAPYDESCRIPTION
A solution is injected into the vein followed by the application of a pressure dressing
An incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours
VEIN STRIPPING
DESCRIPTION Varicose veins are removed if they are larger than 4
mm in diameter or if they are in clusters
PREOPERATIVE Assist the physician with vein marking Evaluate pulses as a baseline for comparison
postoperatively
VEIN STRIPPING
POSTOPERATIVE Maintain elastic (Ace) bandages on the client’s legs Monitor the groin and leg for bleeding through the
elastic bandages Monitor the extremity for edema, warmth, color,
and pulses Elevate the legs above the level of the heart
VEIN STRIPPINGPOSTOPERATIVE
Encourage range-of-motion exercises of the legs Instruct the client to avoid leg dangling or chair
sitting Instruct the client to elevate the legs when sitting Emphasize the importance of wearing elastic
stockings after bandage removal
PERIPHERAL ARTERIAL DISEASE (PAD)
DESCRIPTION A chronic disorder in which partial or total arterial
occlusion deprives the lower extremities of oxygen and nutrients
Tissue damage occurs below the level of the arterial occlusion
Atherosclerosis is the most common cause of PAD
ARTERIES IN THE LEG
From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders
PERIPHERAL ARTERIAL DISEASE (PAD)
ASSESSMENT Intermittent claudication (pain in the muscles
resulting from an inadequate blood supply) Rest pain, characterized by numbness, burning or
aching in the distal portion of the lower extremities, that awakens the client at night and is relieved by placing the extremity in a dependent position
Lower back or buttock discomfort
PERIPHERAL ARTERIAL DISEASE (PAD)
ASSESSMENT Loss of hair and dry scaly skin on the lower
extremities Thickened toenails Cold and gray-blue color of skin in the lower
extremities Elevational pallor and dependent rubor in the
lower extremities Decreased or absent peripheral pulses
PERIPHERAL ARTERIAL DISEASE (PAD)
ASSESSMENT Signs of arterial ulcer formation occurring on or
between the toes, or on the upper aspect of the foot, that are characterized as painful
Blood pressure 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)
ARTERIAL OBSTRUCTIONS AND CORRESPONDING AREAS OF
CLAUDICATION
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
ARTERIAL INSUFFICIENCY
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
GANGRENE
From Auerbach PS: Wilderness Medicine: Management of wilderness and environmental emergencies, ed. 3, St. Louis, 1995, Mosby.
PERIPHERAL ARTERIAL DISEASE (PAD)
IMPLEMENTATION Assess pain Monitor the extremities for color, motion and
sensation, and pulses Obtain BP measurements Assess for signs of ulcer formation or signs of
gangrene Assist in developing an individualized exercise
program that is initiated gradually and slowly increased
PERIPHERAL ARTERIAL DISEASE (PAD)
IMPLEMENTATION Encourage prescribed exercise, which will improve
arterial flow through the development of collateral circulation
Instruct the client to walk to the point of claudication, stop and rest, then walk a little further
PERIPHERAL ARTERIAL DISEASE (PAD)
IMPLEMENTATION As swelling in the extremities prevents arterial blood
flow, instruct the client to elevate his or her 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 PAD, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright in a chair for comfort
PERIPHERAL ARTERIAL DISEASE (PAD)
CLIENT EDUCATION Avoid crossing the legs, which interferes with blood
flow Avoid exposure to cold (causes vasoconstriction) to
the extremities and to wear socks or insulated shoes for warmth at all times
Never to apply direct heat to the limb such as with a heating pad or hot water, because the decreased sensitivity in the limb may result in burning
PERIPHERAL ARTERIAL DISEASE (PAD)
CLIENT EDUCATION Inspect the skin on the extremities daily and to report
any signs of skin breakdown Avoid tobacco and caffeine because of their
vasoconstrictive effects Use of hemorrheologic and antiplatelet medications as
prescribed Importance of taking all medications prescribed by
the physician
PERIPHERAL ARTERIAL DISEASE (PAD)
PROCEDURES TO IMPROVE ARTERIAL BLOOD FLOW Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy Bypass surgery (aortofemoral or femoral-popliteal)
RAYNAUD’S DISEASEDESCRIPTION
Vasospasms of the arterioles and arteries of the upper and lower extremities
Vasospasm causes constriction of the cutaneous vessels
Attacks are intermittent and occur with exposure to cold or stress
Affects primarily fingers, toes, ears, and cheeks
RAYNAUD’S DISEASE
ASSESSMENT Blanching of the extremity, followed by cyanosis
during vasoconstriction Reddened tissue when the vasospasm is relieved Numbness, tingling, swelling, and a cold temperature
at the affected body part
RAYNAUD’S PHENOMENON
From Barkauskas VH et al (1998) Health and physical assessment (2nd ed.). St. Louis: Mosby.
RAYNAUD’S DISEASE
IMPLEMENTATION Monitor pulses Administer vasodilators as prescribed Assist the client to identify and avoid precipitating
factors such as cold and stressCLIENT EDUCATION
Medication therapy Avoid smoking Wear warm clothing, socks, and gloves in cold
weather Avoid injuries to fingers and hands
BUERGER'S DISEASE
DESCRIPTION An occlusive disease of the median and small arteries
and veins The distal upper and lower limbs are most commonly
affected Also known as thromboangiitis obliterans
BUERGER'S DISEASE
ASSESSMENT Intermittent claudication Ischemic pain occurring in the digits while at rest Aching pain that is more severe at night Cool, numb, or tingling sensation Diminished pulses in the distal extremities Extremities are cool and red in the dependent position Development of ulcerations in the extremities
BUERGER'S DISEASE
IMPLEMENTATION Instruct the client to stop smoking Monitor pulses Instruct the client to avoid injury to the upper and
lower extremities Administer vasodilators as prescribed Instruct the client regarding medication therapy
AORTIC ANEURYSMS
DESCRIPTION Abnormal dilation of the arterial wall, caused by
localized weakness and stretching in the medial layer or wall of an artery
The aneurysm can be located anywhere along the abdominal aorta
The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture
ARTERIAL OCCLUSION AND ANEURYSMS
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
TYPES OF ANEURYSMS
FUSIFORM Diffuse dilation that involves the entire circumference
of the arterial segment
SACCULAR Distinct localized outpouching of the artery wall
TYPES OF ANEURYSMS
DISSECTING Created when blood separates the layers of the artery
wall forming a cavity between them
FALSE (PSEUDOANEURYSM) Occurs when the clot and connective tissue are
outside the arterial wall Formed after complete rupture and subsequent
formation of a scar sac
TYPES OF ANEURYSMS
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
THORACIC AORTIC ANEURYSM
ASSESSMENT Pain extending to neck, shoulders, lower back, or
abdomen Syncope Dyspnea Increased pulse Cyanosis Weakness
ABDOMINAL AORTIC ANEURYSM
ASSESSMENT Prominent, pulsating mass in abdomen, at or above
the umbilicus Systolic bruit over the aorta Tenderness on deep palpation Abdominal or lower back pain
RUPTURING ANEURYSMASSESSMENT
Severe abdominal or back pain Lumbar pain radiating to the flank and groin Hypotension Increased pulse rate Signs of shock
RUPTURED ABDOMINAL AORTIC ANEURYSM
From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.
AORTIC ANEURYSMS
DIAGNOSTIC TESTS Done to confirm the presence, size, and location of the
aneurysm Includes abdominal ultrasound, CT scan, and
arteriography
AORTIC ANEURYSMS
IMPLEMENTATION Monitor vital signs Obtain information regarding back or abdominal pain Question the client regarding the sensation of
palpation in the abdomen Inspect the skin for the presence of vascular disease
or breakdown
AORTIC ANEURYSMS
IMPLEMENTATION Check peripheral circulation including pulses,
temperature, and color Observe for signs of rupture Note any tenderness over the abdomen Monitor for abdominal distention
AORTIC ANEURYSMS
NONSURGICAL IMPLEMENTATION Modify risk factors Instruct the client regarding the procedure for
monitoring BP Instruct the client on the importance of regular
physician visits to follow the size of the aneurysm
AORTIC ANEURYSMS
NONSURGICAL IMPLEMENTATION Instruct the client that if severe back or abdominal
pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs, to notify the physician immediately
Instruct the client with a thoracic aneurysm to immediately report the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness
AORTIC ANEURYSMS
PHARMACOLOGICAL IMPLEMENTATION Administer antihypertensives to maintain the BP
within normal limits and to prevent strain on the aneurysm
Instruct the client in the purpose of the medications Instruct the client about the side effects and schedule
of the medication
ABDOMINAL AORTIC ANEURYSM RESECTION
DESCRIPTION Surgical resection or excision of the aneurysm The excised section is replaced with a graft that is
sewn end-to-end
ANEURYSM RESECTION WITH GRAFT
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders
ABDOMINAL AORTIC ANEURYSM RESECTION
PREOPERATIVE Assess all peripheral pulses as a baseline for
postoperative comparison Instruct the client on coughing and deep-breathing
exercises Administer bowel preparation as prescribed
ABDOMINAL AORTIC ANEURYSM RESECTION
POSTOPERATIVE Monitor vital signs Monitor peripheral pulses distal to the graft site Monitor for signs of graft occlusion, including changes
in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention
Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft
ABDOMINAL AORTIC ANEURYSM RESECTION
POSTOPERATIVE Monitor for hypovolemia and renal failure due to
significant blood loss during surgery Monitor urine output hourly, and notify the physician
if it is less than 50 ml per hour Monitor serum creatinine and BUN daily Monitor respiratory status and auscultate breath
sounds to identify respiratory complications
ABDOMINAL AORTIC ANEURYSM RESECTION
POSTOPERATIVE Encourage turning, coughing and deep breathing, and
splinting the incision; ambulate as prescribed Maintain nasogastric tube to low suction until bowel
sounds return Assess for bowel sounds and report their return to the
physician Monitor for pain and administer medication as
prescribed Assess incision site for bleeding or signs of infection
ABDOMINAL AORTIC ANEURYSM RESECTION
POSTOPERATIVE Prepare the client for discharge by providing
instructions regarding pain management, wound care, and activity restrictions
Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks
Advise the client to avoid activities requiring pushing, pulling, or straining
Instruct the client not to drive a vehicle until approved by the physician
THORACIC AORTIC ANEURYSM REPAIR
DESCRIPTION A thoracotomy or median sternotomy approach is
used to enter the thoracic cavity The aneurysm is exposed, excised, and a graft or
prosthesis is sewn onto the aorta Total cardiopulmonary bypass is necessary for
excision of aneurysms in the ascending aorta Partial cardiopulmonary bypass is used for clients
with an aneurysm in the descending aorta
THORACIC AORTIC ANEURYSM REPAIR
POSTOPERATIVE Monitor vital signs Monitor for signs of hemorrhage such as a drop in BP,
increased pulse rate and respirations, and report to the physician immediately
Monitor chest tubes for an increase in chest drainage, which may indicate bleeding or separation at the graft site
THORACIC AORTIC ANEURYSM REPAIR
POSTOPERATIVE Assess sensation and motion of all extremities and
notify the physician if deficits occur, which can be due to a lack of blood supply during surgery
Monitor respiratory status and auscultate breath sounds to identify respiratory complications
Encourage turning, coughing, and deep breathing, splinting the incision
Monitor cardiac status for dysrhythmias
THORACIC AORTIC ANEURYSM REPAIR
POSTOPERATIVE Monitor for pain and administer medication as
prescribed Assess the incision site for bleeding or signs of
infection Prepare the client for discharge by providing
instructions regarding pain management, wound care, and activity restrictions
THORACIC AORTIC ANEURYSM REPAIR
POSTOPERATIVE Instruct the client not to lift objects greater than 15 to
20 pounds for 6 to 12 weeks Advise the client to avoid activities requiring pushing,
pulling, or straining Instruct the client not to drive a vehicle until
approved by the physician
EMBOLECTOMY
DESCRIPTION Removal of an embolus from an artery using a
catheter A patch graft may be required to close the artery
EMBOLECTOMY
PREOPERATIVE Obtain a baseline vascular assessment Administer anticoagulants as prescribed Administer thrombolytics as prescribed Place a bed cradle on the bed Avoid bumping or jarring the bed Maintain the extremity in slightly dependent position
EMBOLECTOMY
POSTOPERATIVE Assess cardiac, respiratory, and neurological status Monitor affected extremity for color, temperature, and
pulse Assess sensory and motor function of the affected
extremity Monitor for signs and symptoms of new thrombi or
emboli Administer oxygen as prescribed Monitor pulse oximetry
EMBOLECTOMY
POSTOPERATIVE Monitor for complications caused by reperfusion of
the artery, such as spasms and swelling of the skeletal muscles
Monitor for signs of swollen skeletal muscles, such as edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness
Maintain bed rest initially, with the client in semi-Fowler’s position
Place a bed cradle on the bed
EMBOLECTOMY
POSTOPERATIVE Check the incision site for bleeding or hematoma Administer anticoagulants as prescribed Monitor laboratory values related to anticoagulant
therapy Instruct the client to recognize the signs and
symptoms of infection and edema Instruct the client to avoid prolonged sitting or
crossing the legs when sitting
VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA
VENA CAVAL FILTER Insertion of an intracaval filter (umbrella) that
partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli
LIGATION Suturing or placing clips on the inferior vena cava to
prevent pulmonary emboli
VENA CAVAL FILTERS
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders
VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA
PREOPERATIVE If the client has been taking an anticoagulant, consult
with the physician regarding discontinuation of the medication to prevent hemorrhage
VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA
POSTOPERATIVE Monitor vital signs Assess cardiac and respiratory status Administer oxygen as prescribed Monitor pulse oximetry Maintain semi-Fowler’s position Avoid hip flexion Maintain antiembolism stockings as prescribed
VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA
POSTOPERATIVE Provide activity as prescribed Check the insertion site for bleeding and hematoma Assess for peripheral edema Monitor laboratory values related to anticoagulant
therapy
VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA
CLIENT EDUCATION Signs and symptoms of infection and edema Avoid prolonged sitting or crossing legs when sitting Elevate the legs when sitting Wear antiembolism stockings as prescribed and how
to remove and reapply the stockings Ambulate daily About anticoagulant therapy and the hazards
associated with anticoagulants
HYPERTENSION
DESCRIPTION Persistent elevation of the systolic blood pressure
above 140 mmHg and the diastolic blood pressure above 90 mmHg
Most significant predictor of developing coronary artery disease and a major risk factor for coronary, cerebral, renal, and peripheral vascular disease
The disease is initially asymptomatic
HYPERTENSION
DESCRIPTION The goals of treatment include to reduce the blood
pressure and to prevent or lessen the extent of organ damage
Nonpharmacological approaches, such as lifestyle changes, may be initially prescribed and if the BP cannot be decreased after a reasonable time period (1 to 3 months), then the client may require pharmacological treatment
HYPERTENSION ORGAN INVOLVEMENT
EYES Visual changes
BRAIN Cerebrovascular accident (CVA)
CARDIOVASCULAR SYSTEM Congestive heart failure (CHF), hypertensive crisis
KIDNEYS Renal failure
HYPERTENSIVE RETINOPATHY
From Michelson JB, Friedlaender MH (1996) The eye in clinical medicine. London: Times Mirror International Publishers.
HYPERTROPHY OF THE LEFT VENTRICLE IN HYPERTENSION
From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.
HYPERTENSION
TYPES Primary or essential Secondary
PRIMARY OR ESSENTIAL HYPERTENSION
DESCRIPTION No known etiology
RISK FACTORS Aging Family history Black race with higher prevalence in males Obesity Smoking Stress
SECONDARY HYPERTENSION DESCRIPTION
Occurs as a result of other disorders or conditions Treatment depends on the cause and the organs
involvedPRECIPITATING CONDITIONS
Cardiovascular disorders Renal disorders Endocrine system disorders Pregnancy Medications
HYPERTENSION
ASSESSMENT May be asymptomatic Headache Visual disturbances Dizziness Chest pain Tinnitus Flushed face Epistaxis
HYPERTENSION
IMPLEMENTATION: GOALS To reduce the blood pressure To prevent or lessen the extent of organ damage
HYPERTENSION
IMPLEMENTATION Question the client regarding the signs and
symptoms indicative of hypertension Obtain the blood pressure (BP) two or more
times on both arms with the client supine and standing; compare the BP with prior documentation
Determine family history of hypertension Identify current medication therapy Obtain weight Evaluate dietary patterns and sodium intake
HYPERTENSION
IMPLEMENTATION Assess for visual changes or retinal damage Assess for cardiovascular changes, such as distended
neck veins, increased heart rate, dysrhythmias Evaluate chest x-ray for heart enlargement Assess neurological system Evaluate renal function Evaluate results of diagnostic and laboratory studies
HYPERTENSION
NONPHARMACOLOGICAL Weight reduction, if necessary, or maintenance of
ideal weight Dietary sodium restriction to 2 g daily as prescribed Moderate intake of alcohol and caffeine-containing
products Initiation of a regular exercise program
HYPERTENSION
NONPHARMACOLOGICAL Avoidance of smoking Relaxation techniques and biofeedback therapy Elimination of unnecessary medications that may
contribute to the hypertension
HYPERTENSION: STEPPED CARE APPROACH
DESCRIPTION If a pharmacological approach to treating
hypertension is required, a single medication is prescribed and monitored for its effectiveness
Medications are added to the treatment regimen until the BP is controlled
Refer to the module entitled Cardiovascular Medications, for information regarding medications to treat hypertension
HYPERTENSION: STEPPED CARE APPROACH
STEP 1 A single medication is prescribed, which may be
a diuretic, beta blocker, calcium channel blocker, or angiotensin-converting enzyme (ACE) inhibitor
STEP 2 Step 1 therapy is evaluated after 1 to 3 months If the response is not adequate, compliance is
evaluated The medication may be increased or a new
medication is prescribed, or a second medication is added to the treatment plan
HYPERTENSION: STEPPED CARE APPROACH
STEP 3 Compliance is evaluated Further evaluation of Step 2 If a therapeutic response is not adequate, a second
medication is substituted or a third medication is added to the treatment plan
STEP 4 Compliance is evaluated Careful assessment of factors limiting the
antihypertensive response is done A third or fourth medication may be added to the
treatment plan
HYPERTENSION: CLIENT EDUCATION
Importance of compliance with the treatment plan
The disease process, explaining that symptoms usually do not develop until organs have suffered damage
Planning a regular exercise program, avoiding heavy weight lifting and isometric exercises
Importance of beginning the exercise program gradually
Express feelings about daily stressIdentify ways to reduce stress
HYPERTENSION: CLIENT EDUCATION
Relaxation techniquesIncorporate relaxation techniques into the
daily living patternTechnique for monitoring blood pressureMaintain a diary of blood pressure readings Importance of lifelong medication and the
need for follow-up treatmentDietary restriction, which may include
sodium, fat, calories, and cholesterol
HYPERTENSION: CLIENT EDUCATION
How to shop and prepare low-sodium mealsList of products that contain sodiumRead labels of products to determine sodium
content focusing on substance listed as sodium, NaCl, and MSG
Bake, roast, or boil foods, avoid salt in preparation of foods, and avoid using salt at the table
Fresh foods are best to consume and to avoid canned foods
HYPERTENSION: CLIENT EDUCATION
The action, side effects, and scheduling of medications
If uncomfortable side effects occur, to contact the physician and not to stop the medication
Avoid over-the-counter medicationImportance of follow-up care
HYPERTENSIVE CRISIS
DESCRIPTION Any clinical condition requiring immediate reduction
in blood pressure An acute and life-threatening condition The accelerated hypertension requires emergency
treatment, since target organ damage (brain, heart, kidneys, retina of the eye) can occur quickly
Death can be caused by stroke, renal failure, or cardiac disease
HYPERTENSIVE CRISIS
ASSESSMENT A diastolic pressure above 120 mmHg Headache Drowsiness Confusion Changes in neurological status Tachycardia and tachypnea Dyspnea Cyanosis Seizures
HYPERTENSIVE CRISIS
IMPLEMENTATION Maintain a patent airway Administer IV antihypertensive medications as
prescribed Monitor vital signs assessing BP every 5 minutes Assess for hypotension during the administration of
antihypertensives Place the client in a supine position if hypotension
occurs
HYPERTENSIVE CRISIS
IMPLEMENTATION Have emergency medications and resuscitation
equipment readily available Maintain bed rest, with the head of the bed elevated
at 45 degrees Monitor IV therapy assessing for fluid overload Monitor I&O Insert Foley catheter as prescribed Monitor urinary output, and if oliguria or anuria
occurs, notify the physician