Nursing Care of Clients with Nursing Care of Clients with Nursing Care of Clients with Nursing Care of Clients with

Peripheral Vascular DisordersPeripheral Vascular DisordersPeripheral Vascular DisordersPeripheral Vascular Disorders

Overview of Disorders Overview of Disorders Overview of Disorders Overview of Disorders

PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE

DISEASEDISEASEDISEASEDISEASE� Upper extremity arterial occlusive disease � Arterial embolism; Arterial thrombosis� Thromboangiitis obliterans (buerger’s disease)� Aortitis� Aortoiliac disease� Aneurysms� Aneurysms

� Aortic aneurysm� Thoracic aortic aneurysm� Abdominal aortic aneurysm� Dissecting aorta� Other aneurysms

� Raynaud’s disease� Thoracic outlet syndrome

VENOUS DISORDERSVENOUS DISORDERSVENOUS DISORDERSVENOUS DISORDERS� Venous Thrombosis, Deep Vein Thrombosis (DVT),

Thrombophlebitis, and Phlebothrombosis

� Chronic Venous Insufficiency

� Leg Ulcers

� Varicose Veins� Varicose Veins

� Cellulitis

LYMPHATIC DISORDERSLYMPHATIC DISORDERSLYMPHATIC DISORDERSLYMPHATIC DISORDERS� Lymphangitis and Lymphadenitis

� Lymphedema and Elephantiasis

Peripheral vascular disease (PVD) � includes disorders that alter the natural flow of blood

through the arteries and veins of the peripheral circulation.

� affects the lower extremities much more frequently than the upper extremities.

� Generally, a client with a diagnosis of PVD has arterial � Generally, a client with a diagnosis of PVD has arterial disease (peripheral arterial disease [PAD]) rather than venous involvement.

� Some clients have both arterial and venous disease.

Peripheral Arterial/ Venous DiseasePeripheral Arterial/ Venous DiseasePeripheral Arterial/ Venous DiseasePeripheral Arterial/ Venous Disease

� A chronic disorder in which partial or total occlusion deprives the lower extremities of oxygen and nutrients

� Tissue damage occurs below the level of the arterial occlusion

� Atherosclerosis - most common cause of peripheral arterial � Atherosclerosis - most common cause of peripheral arterial disease

PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE PERIPHERAL ARTERIAL OCCLUSIVE

DISEASEDISEASEDISEASEDISEASE

Peripheral Arterial Disorders (PAD)� Aka: Peripheral arterial occlusive disease

� Arterial Occlusive Disorders

� Lower extremity arterial disease (LEAD)

� Is the arterial insufficiency of the extremities

� most common cause is Arteriosclerosis Obliterans (ASO)� most common cause is Arteriosclerosis Obliterans (ASO)

� lower extremities are more commonly affected.

� More prevalent among men 50-70 years old

Assessment � intermittent claudication: hallmark of the disease � rest pain: severe

� is a numbness or burning, often described as feeling like a toothache, that is severe enough to awaken clients at night.

� it may be so excruciating that it is unrelieved by opioids.elevating the extremity or placing it in a horizontal position � elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the extremity in a dependent position reduces the pain.

� In bed, some sleep with affected leg hanging over the side of the bed.

� Some patients sleep in a reclining chair in an attempt to relieve the pain.

Assessment� Coldness or cold sensitivity – Coldness in the feet with

exposure to a cold environment, associated with blanching or cyanosis due to ischemia

� extremity � Cold and pale when elevated � Cold and pale when elevated

� or ruddy and cyanotic when placed in a dependent position

� nails : thickened and opaque

� Skin: shiny, atrophic, and dry, with sparse hair growth.

� comparison of the right and left extremities.

� Bruits may be auscultated with a stethoscope

Assessment� Ulceration and gangrene. May be due to ischemia ot

trauma. Impaired tissue perfusion inhibits healing process

� Edema. Due to severe obstruction

� Sexual dysfunction. Occlusion of terminal aorta � Sexual dysfunction. Occlusion of terminal aorta decreases blood supply to the penile arteries

� Gangrene

� muscle atrophy

Assessment� peripheral pulses: important part of assessing arterial

occlusive disease.

� Unequal pulses between extremities or the absence of a normally palpable pulse is a sign of peripheral arterial disease. arterial disease.

� The femoral pulse in the groin and the posterior tibialpulse beside the medial malleolus are most easily palpated.

Diagnostic Findings� CW Doppler and ankle-brachial indices (ABIs)

� Treadmill testing for claudication

� duplex ultrasonography

Medical ManagementMedical ManagementMedical ManagementMedical Management� Control hypertension� Reduce risk factors:

� Control serum lipids� Weight reduction � Low fat low cholesterol diet� Daily walking� Daily walking

� Cessation of tobacco use� Note: Patients should not be promised that their symptoms will

be relieved if they stop tobacco use, because claudication may persist, and they may lose their motivation to stop using tobacco

� Skin and foot care

PHARMACOLOGIC THERAPY� hemorheologic and antiplatelet agents� Vasodilators� Antihyperlipidemics

hemorheologic agent � Pentoxifylline (Trental)

� Increase flexibility of RBCs

� decreases blood viscosity by inhibiting platelet aggregation and decreasing fibrinogen and thus increases blood flow in the extremities.extremities.

AntiplateletAntiplateletAntiplateletAntiplatelet agentsagentsagentsagents� aspirin (acetylsalicylic acid, Ancasal) : 325 or 81

mg/day

� clopidogrel (Plavix)

� ticlopidine (Ticlid)

� Cilostazol (Pletal) : inhibit platelet aggregation, inhibit � Cilostazol (Pletal) : inhibit platelet aggregation, inhibit smooth muscle cell proliferation, and increase vasodilation.

Surgical Management� Percutaneous transluminal angioplasty

� Balloon angioplasty

� Laser angioplasty

� Stent insertion

Atherectomy� Atherectomy

� Arterial revascularization : Arterial bypass; vascular grafting

� Endarterectomy

� Endovascular surgery

� Amputation

SURGICAL MANAGEMENT

� choice of the surgical procedure depends on the� degree and location of the stenosis or occlusion.

� overall health of patient and length of procedure that can be tolerated. tolerated.

� vascular grafting or endarterectomy� For patients, severe intermittent claudication and disabling or

when the limb is at risk for amputation because of tissue loss

� palliative therapy of primary amputation rather than an arterial bypass. arterial bypass.

Endarterectomy� an incision is made into the artery

� atheromatous obstruction is removed.

� artery is then sutured closed to restore vascular integrity

Bypass grafts � are performed to reroute the blood flow around the stenosis

or occlusion.

� Before bypass grafting, the surgeon determines where the distal anastomosis (site where the vessels are surgically joined) will be placed. joined) will be placed.

� The distal outflow vessel must be at least 50% patent for the graft to remain patent.

� A higher bypass graft patency rate is associated with keeping the length of the bypass as short as possible.

femoral-to-popliteal graft� surgical procedure of choice if atherosclerotic occlusion is

below the inguinal ligament in the superficial femoral artery

� Class. based on location of distal anastomosis� above-knee

� below-knee grafts� below-knee grafts

� Bypass grafts may be synthetic or autologous vein. � Native vein or autologous vein

� greater or lesser saphenous vein or a combination of one of the saphenousveins and an upper extremity vein such as the cephalic vein are used to meet the required length.

� woven or knitted Dacron, expanded polytetrafluoroethylene� woven or knitted Dacron, expanded polytetrafluoroethylene(ePTFE, such as Gore-Tex or Impra), collagen-impregnated, and umbilical vein.

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Maintaining circulation

� Maintain skin integrity and prevent infection

� Monitoring and managing potential complications

� Promoting home and community-based care

Maintaining circulation: Post op care� Monitor the ff q hour for first 8 hours and then every 2 hours

for 24 hours� Pulses� color and temperature of the extremity� capillary refill � capillary refill � Sensory and motor function of the affected extremities � Note: Compare extremities � Doppler evaluation � ABI : at least once q 8 hrs for 1st 24 hrs and then OD until

discharge (not usually assessed for pedal artery bypasses).

� Disappearance of a pulse that was present may indicate thrombotic occlusion of the graft� Notify surgeon STAT

Maintain circulation� Warm environmental temperature� Place legs in slight dependency to promote arterial flow� Avoid pressure on affected extremity; use padding for support� Avoid vigorous massage of extremities� Avoid

� Chilling and exposure to cold� Chilling and exposure to cold� Avoid contrictive clothing� Crossing legs

� Quit smoking� Do not go barefootd� Trim toenails straight� Avoid scratching or rubbing feet

Exercise� may improve arterial blood flow to the affected limb through

buildup of the collateral circulation.

� is individualized for each client

� Contrindicated: severe rest pain, venous ulcers, or gangrene

� Initiate gradually and is slowly increased� Initiate gradually and is slowly increased

� nurse instructs the client to walk until the point of claudication, stop and rest, and then walk a little farther. Eventually, clients are able to walk longer distances as collateral circulation develops.

PositioningPositioningPositioningPositioning� To promote circulation

� Still controversial

� Some have swelling in extremities

� Because swelling prevents arterial flow, should elevate feet at rest, but shld be taught to refrain raising legs above heart level. but shld be taught to refrain raising legs above heart level. � Extreme elevation slows arterial blood flow to the feet.

� In severe cases, clients with PAD and swelling may sleep with the affected limb hanging from the bed, or they may sit upright in a chair for comfort.

� avoid crossing their legs, which may interfere with blood flow.

Maintain skin integrity and prevent

infection

� Examine skin on a daily basis

� Take daily bath and dry the skin gently

� Apply moisturizing cream/lotion in the skin. Avoid using alcohol

� Foot care� Foot care

� Wear comfortable, well fitted pair of shoes

� Avoid direct heat application over the extremities

Monitoring and managing potential

complications

� UO

� central venous pressure

� mental status

� pulse rate and volume

permit early recognition and treatment of fluid imbalances. � permit early recognition and treatment of fluid imbalances.

Monitoring and managing potential

complications� Bleeding / Hematoma

� can result from the heparin administered during surgery or from an anastomotic leak.

� Avoid leg crossing and prolonged extremity dependency � to prevent thrombosis.

� EdemaEdema� normal postoperative finding� elevating the extremities and encouraging the patient to exercise the

extremities while in bed reduces edema. � Elastic compression stockings

� care must be taken to avoid compressing distal vessel bypass grafts.

� Severe edema of the extremity, pain, and decreased sensation of toes or fingers can be an indication of compartment syndrome.

Promoting home and community-based

care

� Assess patient’s ability to manage independently.

� Determine if patient has a network of family and friends to assist with ADL

� Encourage to make the lifestyle changes necessary with a chronic disease, including pain management and chronic disease, including pain management and modifications in diet, activity, and hygiene (skin care).

� Ensure has knowledge and ability to assess for any postopcomplications such as infection, occlusion of the artery or graft, and decreased blood flow.

� Assists in developing a plan to stop using tobacco.

Promote activity� Regular aerobic exercises such as walking, swimming,

jogging , bicycling

� Do exercises 30-45 minutes 3-4 times a week

Prevention � Primary – provide info on the effects of the following:

� Cigarrete smoking. Nicotene causes vaso-constriction, spasms of the arteries, reduced circulation to the extremities. CO2 reduces O2 transport to the tissues

� Hypertension. Cause elastic tissue in the arteries to be replaced by fibrous collagen tissue reducing arterial elasticity and by fibrous collagen tissue reducing arterial elasticity and increases resistance.

� Hyperlipidemia. Contribute to atherosclerotic plaques in vessels

� Obesity. Added burden on the heart and blood vessels

� Physical inactivity. Compromises circulation

� Emotional stress. Stimulates the sympathetic response which results to vasocontrictionresults to vasocontriction

� DM. Changes in glucose and fat metabolism enhances atherosclerosis

� Secondary prevention� Encourage clients with early symptoms to seek medical care to

prevent complications

� Tertiary prevention� Tertiary prevention� Rehabilitation . Exercises to develop collateral circulation.

Acute Peripheral Arterial Occlusion Acute Peripheral Arterial Occlusion Acute Peripheral Arterial Occlusion Acute Peripheral Arterial Occlusion

ACUTE PERIPHERAL ARTERIAL ACUTE PERIPHERAL ARTERIAL ACUTE PERIPHERAL ARTERIAL ACUTE PERIPHERAL ARTERIAL

OCCLUSION OCCLUSION OCCLUSION OCCLUSION � Aka: Arterial embolism and arterial thrombosis� arterial occlusions : sudden and dramatic. � Occlusion may affect the upper extremities, but it is more

common in the lower extremities. � most common cause : embolus or local thrombus � most common cause : embolus or local thrombus

� Emboli originating from heart: are most common

� Risk factors� AMI within the preceding weeks� atrial fibrillation � infective endocarditis� chronic heart failure

AssessmentAssessmentAssessmentAssessment� severe pain below level of the occlusion

� occurs even at rest.

� affected extremity : cool or cold, pulseless, and mottled.

� Minute areas on the toes may be blackened or gangrenous.

"six P's" of ischemia: � "six P's" of ischemia: � pain, pallor, pulselessness, paresthesia, paralysis, and

poikilothermia (coolness) of the involved extremity.

InterventionsInterventionsInterventionsInterventions� initiate treatment promptly to avoid permanent damage or

loss of an extremity.

� Anticoagulant therapy with unfractionated heparin (UFH; Hepalean*) is usually the first intervention to prevent further clot formation. clot formation. � bolus of up to 10,000 units

� angiography

Surgical treatment � Emergencysurgical thrombectomy or embolectomy

with local anesthesia � to remove the occlusion.

� physician makes an incision, which is followed by an arteriotomy (a surgical opening into an artery). arteriotomy (a surgical opening into an artery).

� then inserts a Fogarty catheter into artery and retrieves embolus.

� may be necessary to close artery with patch graft.

Fogarty catheter

Preop nursing care� bed rest with extremity level or slightly dependent (15

degrees). � affected part is kept at room temperature and

protected from trauma. � Heating and cooling pads are contraindicated Heating and cooling pads are contraindicated

� ischemic extremities are easily traumatized by alterations in temperature.

� If possible, tape and electrocardiogram electrodes should not be used on the extremity

� sheepskin and foot cradles are used to protect the leg from mechanical trauma.

PostopNursing care � Monitor affected extremity for improvement in color,

temperature, and pulse, other extremities for s/s of new thrombi or emboli.

� mild incisional pain is normal

� Watch closely for complications caused by reperfusing the artery after thrombectomy or embolectomyafter thrombectomy or embolectomy� spasms and swelling of the skeletal muscle. � Swelling of the skeletal muscles is characterized by edema, pain on

passive movement, poor capillary refill, numbness, and muscle tenseness.

� Fasciotomy (surgical opening into the tissues) may be necessary to prevent further injury and save the limb.

Buerger’s disease

Buerger’s disease � Inflammatory, non-lipid occlusive condition of small to medium

arteries followed by vein that impairs circulation to the legs, feet and occasionally hands

� Rare, occurs most often in men, ages of 20 and 35 years, all races

Cause � Unknown

� believed to be autoimmune disease (autoimmune vasculitis)

� Linked to smoking or chewing of tobacco (suggesting a hypersensitivity reaction to nicotine)

Pathophy� characterized by recurring inflammation of the intermediate and

small arteries and veins of the lower and (in rare cases) upper extremities.

� Polymorphonuclear leukocytes infiltrate the walls of small and medium sized arteries and veins

� Thrombus formation and occlusion of vessels

� Diminished blood flow produces ulceration and later on gangrene

� lower extremities; upper extremities or viscera can also be involved

� Generally bilateral and symmetric with focal lesions.

� Superficial thrombophlebitis may be present.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� intermittent claudication

� Most characteristic manifestation

� foot cramps, especially of the arch (instep claudication), after exercise.

� relieved by rest� relieved by rest

� often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling.

� Cold sensitivity of the Raynaud type is found in one half the patients and is frequently confined to the hands.

� Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� intense rubor (reddish blue discoloration) of the foot

� absence of pedal pulse but normal femoral and poplitealpulses.

� absent or diminished radial and ulnar artery pulses

� Various types of paresthesia may develop.� Various types of paresthesia may develop.

� As the disease progresses, definite redness or cyanosis of the part appears when the extremity is in a dependent position.

� generally bilateral, but color changes may affect only one extremity or only certain digits.

� Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.

The feet of a patient with Buerger

disease.

� Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes.

� Though the patient's right � Though the patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.

http://emedicine.medscape.com/article/460027-overview#showall

� Superficial thrombophlebitis of the great toe in a patient with Buerger disease.

http://emedicine.medscape.com/article/460027-overview#showall

� The tobacco smoke–stained fingers of this patient suggested the man's diagnosis (Buerger disease).

� The patient presented with � The patient presented with small, painful ulcers on the tips of his thumb and ring finger.

http://emedicine.medscape.com/article/460027-overview#showall

� This lower extremity arteriogram of the peroneal and tibial arteries of a patient with Buergerdisease demonstrates the disease demonstrates the classic findings of multiple small- and medium-sized arterial occlusions with formation of compensatory "corkscrew collaterals."

http://emedicine.medscape.com/article/460027-overview#showall

Diagnostic FindingsDiagnostic FindingsDiagnostic FindingsDiagnostic Findings� Allen's test� Segmental limb blood pressures

� Demonstrate distal location of the lesions or occlusions.

� Duplex ultrasonography/ Doppler ultrasonography� used to document patency of the proximal vessels and to � used to document patency of the proximal vessels and to

visualize the extent of distal disease.

� Contrast angiography � Demonstrate diseased portion of anatomy.

� Arteriography� Plethysmography� Venography

ManagementManagementManagementManagement� main objectives: improve circulation to extremities,

prevent progression of disease, and protect extremities from trauma and infection.

� Treatment same as that for atherosclerotic peripheral arterial disease. arterial disease.

ManagementManagementManagementManagement� Exercise programs that

us gravity to fill and drain the blood vessels to promote adequate circulation

� Monitor pulses

� Avoid injury to the extremities

� Antibiotics , analgesics� débridement of necrotic

tissue: Minimize infection� Monitor pulses� Stop smoking

� Absolute discontinuation of tobacco use is the only strategy proven to prevent the progression of Buergerdisease.

tissue: Minimize infection� Regional sympathetic

block or ganglionectomy� produce vasodilation and

increase blood flow.

� Amputation

Other treatmentsOther treatmentsOther treatmentsOther treatments� Other treatment approaches exist but are less effective.

� Intermittent compression of the arms and legs to increase blood flow to extremities

� Spinal cord stimulation

� therapeutic angiogenesis� therapeutic angiogenesis� Medications to stimulate growth of new blood vessels

� Vasodilators: rarely prescribed

� Lumbar sympathetectomy� cut nerves to affected area to control pain and increase blood

flow; controversial

SURGICAL MANAGEMENT OF

COMPLICATIONS

� Amputations� If gangrene of a toe develops as a result of arterial occlusive

disease in the leg,

� below-knee amputation (BKA) or above-knee amputation

� toe amputation or even transmetatarsal amputation� toe amputation or even transmetatarsal amputation

� Indications � worsening gangrene, especially if the infected area is moist,

severe rest pain, or fulminating sepsis.

NURSING MANAGEMENT OF

COMPLICATIONS� Postop care amputation

� Elevate stump for first 24 hours to promote venous return and minimize edema.

� The incision is monitored for signs of hematoma (unapproximatedsuture line, discoloration or ruddy color changes of the skin along the suture line, tenderness with palpation, or oozing of dark blood from suture line, tenderness with palpation, or oozing of dark blood from the suture line).

� Assess fit of elastic bandages and ensures integrity of wrap and continued ability to fit two fingers between layers of wrap.

� Distal skin color and warmth are assessed, if accessible, and recorded.

� Elastic bandages are removed and reapplied as prescribed by the surgeon (eg, every 6 hours using figure-of-eight turns).

NURSING MANAGEMENT� grief, fear, or anxiety r/t loss of limb.

� Encourage discuss his or her feelings.

� Spiritual advisors and other health care team members are consulted

� Recovery and rehabilitation require multidisciplinary care � Recovery and rehabilitation require multidisciplinary care (e.g., physicians, physical and occupational therapists, prosthetists, dietitians, nurses, discharge coordinators).

� prosthetic device fitting

Discharge planning � Assess ability to manage independently. � Assist in developing a plan to stop using tobacco and to

manage pain. � Encourage to make the lifestyle changes necessary with a

chronic disease, including modifications in diet, activity, and hygiene (skin care). chronic disease, including modifications in diet, activity, and hygiene (skin care).

� Determine whether patient has a network of family and friends to assist with ADL.

� Ensure that patient has knowledge and ability to assess for any postoperative complications such as infection and decreased blood flow.

Lifestyle and home remediesLifestyle and home remediesLifestyle and home remediesLifestyle and home remedies� Take care of fingers and toes � Check the skin on arms and legs daily for cuts and scrapes, � keep in mind that if lost feeling to a finger or toe may not feel, for

example, a cut when it happens. � Keep your fingers and toes protected and avoid exposing them to cold. � Low blood flow to extremities means body can't resist infection as easily.

Small cuts and scrapes can easily turn into serious infections. � Small cuts and scrapes can easily turn into serious infections. � Clean any cut with water, apply antibiotic ointment and cover it with a clean

bandage. � Keep an eye on any cuts or scrapes to make sure they're healing. � If they get worse or heal slowly, see doctor promptly.

� Visit your dentist regularly to keep gums and teeth in good health and avoid gum disease, which in its chronic form is associated with Buerger'sdisease.

http://www.mayoclinic.com/health/buergers-disease/DS00807/METHOD=print&DSECTION=all

AORTIC ANEURYSM

AORTIC ANEURYSM� Abnormal dilatation of

the arterial wall caused by localized weakness and stretching in the medial layer or wall of an arteryartery

� An aneurysm is a localized sac or dilation formed at a weak point in wall of aorta

� Can be located anywhere along the aorta

Classification

classified by shape or formclassified by shape or formclassified by shape or formclassified by shape or form

� saccular aneurysm � projects from one side of

the vessel onlythe vessel only

� fusiform aneurysm� If an entire arterial

segment becomes dilated

� mycotic aneurysms� very small aneurysms due

to localized infection

What is the diference between true

and false aneurysm?

True True True True anuerysmanuerysmanuerysmanuerysm false aneurysmsfalse aneurysmsfalse aneurysmsfalse aneurysms

� all three tunica layers are involved

� or pseudoaneurysm� one in which the entire wall is

injured blood escapes between tunica layers and they separate. tunica layers and they separate.

� the blood is contained by the surrounding tissues, with eventual formation of a sac communicating with the artery (or heart).

� If the separation continues, a clot may form, resulting in a dissecting aneurysm.

Classification

By location By location By location By location

� Abdominal

� Thoracic

� Cerebral , etc � Cerebral , etc

Etiologic Classification of Arterial Etiologic Classification of Arterial Etiologic Classification of Arterial Etiologic Classification of Arterial

AneurysmsAneurysmsAneurysmsAneurysms� atherosclerotic changes in the aorta� Congenital: Primary connective tissue disorders (Marfan’s

syndrome, Ehlers-Danlos syndrome) and other diseases (focal medial agenesis, tuberous sclerosis, Turner’s syndrome, Menkes’ syndrome)

� Mechanical (hemodynamic): Poststenotic and arteriovenousfistula and amputation-relatedfistula and amputation-related

� Traumatic (pseudoaneurysms): Penetrating arterial injuries, blunt arterial injuries, pseudoaneurysms

� Inflammatory (noninfectious): Associated with arteritis(Takayasu’s disease, giant cell arteritis, systemic lupus erythematosus, Behçet’s syndrome, Kawasaki’s disease) and periarterial inflammation (ie, pancreatitis)

Etiologic Classification of Arterial Etiologic Classification of Arterial Etiologic Classification of Arterial Etiologic Classification of Arterial

AneurysmsAneurysmsAneurysmsAneurysms

� Infectious (mycotic): Bacterial, fungal, spirochetalinfections

� Pregnancy-related degenerative: Nonspecific, inflammatory variant

� Anastomotic (postarteriotomy) and graft aneurysms: � Anastomotic (postarteriotomy) and graft aneurysms: Infection, arterial wall failure, suture failure, graft failure

Risk factors � Genetic predisposition

� smoking (or other tobacco use)

� Hypertension

� Obesity

� Stress

� Hypercholesterolemia

Aortitis

AortitisAortitisAortitisAortitis� is inflammation of the aorta, particularly of the aortic arch.

� Two types � Takayasu’s disease

� occlusive thromboaortopathy

� is uncommon� is uncommon

� syphilitic aortitis� Rare

AortaAortaAortaAorta� main trunk of arterial system

� divided into � (1) ascending aorta (5 cm [2 inches] in diameter, contained in

the pericardium)

� (2) aortic arch (extending upward, backward, and downward) � (2) aortic arch (extending upward, backward, and downward)

� (3) descending aorta

� Thoracic aorta is above diaphragm

� Abdominal aorta is below the diaphragm. � further divided as

� suprarenal (above renal artery level)

� perirenal level (at renal artery level)� perirenal level (at renal artery level)

� infrarenal (below renal artery level).

Takayasu’s disease� chronic inflammatory disease of the aortic arch and its branches

� affects young or middle-aged women; Asian descent

� Cause� nonatherosclerotic

� exact pathologic mechanism is unknown � exact pathologic mechanism is unknown

� thought to be immune complex mediated

� progresses from a systemic inflammation with localized arteritis to end-organ ischemia bcoz of large vessel stenosis or obstruction.

� Lesions are typically long, smooth areas of narrowing with or without aneurysms

Takayasu’s disease: Diagnostic exams

� diagnose and evaluate the lesions

� Magnetic resonance angiography

� CT

� Duplex ultrasonography

Arteriography� Arteriography

Takayasu’s disease Management � early stage

� Corticosteroids

� cytotoxic immunosuppressive agents.

� Selective PTA & Surgical revascularization � performed after suppression of the systemic vascular � performed after suppression of the systemic vascular

inflammation.

Aortoiliac disease

AORTOILIAC DISEASEAORTOILIAC DISEASEAORTOILIAC DISEASEAORTOILIAC DISEASE� If collateral circulation has developed, patients with a stenosis

or occlusion of the aortoiliac segment may be asymptomatic, or they may complain of buttock or low back discomfort associated with walking.

� Men may experience impotence. � Men may experience impotence.

� decreased or absent femoral pulses.

Medical ManagementMedical ManagementMedical ManagementMedical Management� Treatment same as that for atherosclerotic peripheral arterial

occlusive disease.

� aortobi iliac graft� distal anastomosis is made to iliac artery, and entire surgical

procedure can be performed within abdomen. procedure can be performed within abdomen.

� aortobifemoral graft� if iliac vessels are diseased

� distal anastomosis is made to femoral arteries

� Bifurcated woven or knitted Dacron grafts are preferred for this surgical procedure.

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Preoperative assessment

� brachial, radial, ulnar, femoral, posterior tibial, and dorsalispedis pulses ; establish baseline for follow-up after arterial lines are placed

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Postoperative care

� monitoring for signs of thrombosis in arteries distal to the surgical site.

� Assess color and temperature of the extremity, capillary refill time, sensory and motor function, and pulses by palpation and time, sensory and motor function, and pulses by palpation and Doppler q 1 hr for 1st first 8 hrs and then q 2 hrs for 1st 24 hrs.

� Report STAT to physician� Any dusky or bluish discoloration, coolness, capillary refill time greater

than 3 seconds, decrease in sensory or motor function, or decrease in pulse quality

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Postoperative care � Monitor UO

� Renal function may be impaired as a result of hypoperfusionfrom hypotension, involvement of the renal arteries during the surgical procedure, hypovolemia, or embolization of the renal artery or renal parenchyma. Vartery or renal parenchyma. V

� VS, pain, and intake and output are monitored with the pulse and extremity assessments.

� Lab results monitored and reported� Ischemic bowel usually causes increased pain and elevated white

blood cell count (20,000 to 30,000 cells/mm3).

Nursing ManagementNursing ManagementNursing ManagementNursing Management� Abdominal assessment

� bowel sounds and paralytic ileus is performed at least q 8 hrs.� BS may not return b4 third postop day (normal)� (-) bowel sounds, (-) flatus, and (+) abdominal distention: indicates of

paralytic ileus. � Manual manipulation of the bowel during surgery may have caused

bruising, resulting in decreased peristalsis. bruising, resulting in decreased peristalsis. � Nasogastric suction

� may be necessary to decompress bowel until peristalsis returns. � liquid bowel movement b4 3rd postop day

� may indicate bowel ischemia� may occur when mesenteric blood supply (celiac, superior

mesenteric, or inferior mesenteric arteries) is occluded.

THORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSM

THORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSMTHORACIC AORTIC ANEURYSM� Atherosclerosis: most

common cause� occur most frequently in

men, 40 and 70 years. � thoracic area - most

common site for a thoracic area - most common site for a dissecting aneurysm.

� About one third of patients with thoracic aneurysms die of rupture of the aneurysm

Clinical Manifestations� Symptoms are variable and depend on how rapidly the

aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures.

� Some :asymptomatic.

� chest pain- most prominent symptom� chest pain- most prominent symptom� usually constant and boring but may occur only when the

person is supine

� unequal pulses and arterial pressure in upper extremities, tracheal deviation, cyanosis, weakness

Clinical Manifestations1. Dyspnea

2. Cough

1. result of pressure of the sac against the trachea, a main bronchus, or the lung itself

2. frequently paroxysmal 2. Cough

3. Hoarseness, stridor, or weakness or complete aphonia

2. frequently paroxysmal and with a brassy quality

3. resulting from pressure against the left recurrent laryngeal nerve

Clinical Manifestations4. Dysphagia

5. Dilated superficial veins of the chest,

4. due to impingement on the esophagus by the aneurysm.

5. when large veins in chest are compressed by the veins of the chest,

neck, or arms

6. Unequal pupils

are compressed by the aneurysm

6. Pressure against the cervical sympathetic chain

Diagnostic FindingsDiagnostic FindingsDiagnostic FindingsDiagnostic Findings� chest x-ray

� transesophageal echocardiography

� CT

ABDOMINAL AORTIC ANEURYSM ABDOMINAL AORTIC ANEURYSM ABDOMINAL AORTIC ANEURYSM ABDOMINAL AORTIC ANEURYSM

(AAA)(AAA)(AAA)(AAA)

ABDOMINAL AORTIC ANEURYSMABDOMINAL AORTIC ANEURYSMABDOMINAL AORTIC ANEURYSMABDOMINAL AORTIC ANEURYSM� Atherosclerosis: most common cause

� common among Caucasians; affects men four times more often than women; most prevalent in elderly patients

� Most occur below the renal arteries (infrarenal aneurysms).

� Untreated, the eventual outcome may be rupture and death.� Untreated, the eventual outcome may be rupture and death.

Pathophysiology� All aneurysms involve a

damaged media layer of the vessel.

� After an aneurysm develops, it tends to develops, it tends to enlarge.

Clinical Manifestations� feel heart beating in their

abdomen when lying down

� feel abdominal mass or abdominal throbbing

� pulsatile mass in

� If associated with thrombus, a major vessel may be occluded or smaller distal occlusions may result from emboli.

� pulsatile mass in middle and upper abdomen� most important diagnostic

indication

� systolic bruit over mass

from emboli.

� A small cholesterol, platelet, or fibrin emboli may lodge in the interosseous or digital arteries, causing blue toes

� Atheroemboli from small AAAA produce livedoreticularis of the feet (ie, blue toe syndrome).

http://emedicine.medscape.com/article/756735-overview#showall

Diagnostic Findings� Duplex ultrasonography or CT

� used to determine the size, length, and location of the aneurysm

� Ultrasonography� Watchful Waiting Period

� For sml aneurysm � For sml aneurysm

� conducted at 6-month intervals until aneurysm reaches a size at which surgery to prevent rupture is of more benefit than the possible complications of a surgical procedure.

� Some aneurysms remain stable over many years of observation.

Conventional angiographyConventional angiographyConventional angiographyConventional angiography� Angiography is used to diagnose the renal area. In this

instance, an endoleak represented continued pressurization of the sac.

Gerontologic ConsiderationsGerontologic ConsiderationsGerontologic ConsiderationsGerontologic Considerations� Most occur ages of 60 and 90 years.

� Rupture is likely with coexisting hypertension and with aneurysms wider than 6 cm.

� In most cases at this point, the chances of rupture are greater than the chance of death during surgical repair. than the chance of death during surgical repair.

� If the elderly patient is considered at moderate risk for complications related to surgery or anesthesia, the aneurysm is not repaired until it is at least 5 cm (2 inches) wide.

MANAGEMENT: Aneursyms

MANAGEMENT: Aneursyms� Goals

� Limit progression

� Control BP

� Recognizing early symptoms

� Prevent rupture� Prevent rupture

ManagementManagementManagementManagement� Size- <5cm and asymptomatic- follow up with serial

ultrasound every 3-12 months� >5cm elective repair

� Growth rate- normally 2-8mm/year, if > 4mm/year consider elective surgery

� Symptomatic – mandates repairSymptomatic – mandates repair

� control blood pressure � Systolic pressure is maintained at about 100 to 120 mm Hg with

antihypertensive medications � Correct risk factors � Pulsatile flow is reduced by medications that reduce cardiac

contractility (eg, propranolol [Inderal]).

SURGICAL MANAGEMENT� Surgery : treatment of choice for abdominal aneurysms wider than

5 cm (2 inches) wide or those that are enlarging

� Endoaneurysmorrhaphy- opening the sac and suturing a prosthetic graft to the normal aorta within the aneurysm (Teflon/Dacron/Gortex)

� Endovascular repair� Endovascular repair

� Elective aneurysm repair� Via traditional open laparotomy� standard treatment � open surgical repair of the aneurysm by resecting the vessel and

sewing a bypass graft in place.

standard preoperative care � Type and crossmatch blood� Administer prophylactic antibiotics (cefazolin, 1 g intravenous

piggyback)� Insert a Foley catheter� Establish large-bore intravenous access� Monitor central venous pressure or establish Swan-Ganz� Monitor central venous pressure or establish Swan-Ganz

catheterization (if indicated)� Prepare the skin from the nipples to the mid thigh� Administer general anesthesia (with or without epidural

anesthesia)� Cell Saver use has become popular� Insert a nasogastric tube

http://emedicine.medscape.com/article/756735-overview#a11

Post Surgical Complications� Post op Renal failure� Ischemic colitis� Acute leg ischemia� Spinal cord ischemia- ligation of the artery of

Adamkiewicz which supplies the spinal cordAdamkiewicz which supplies the spinal cord� anterior spinal artery syndrome-paraplegia, rectal and

urinary incontinence, loss of pain and vibratory sense with preservation of vibratory and proprioception

� Aortic Graft infection� Sexual Dysfunction

Post Op Nursing Interventions� Thoracic Aneurysm Repair

� Thoracotomy or median sternotomy approach is used � Aneurysm is exposed and excised and a graft or prosthesis is

sewn onto the aorta� Total cardiopulmonary bypass is necessary for excision of

aneurysms in the ascending and arch of the aortaaneurysms in the ascending and arch of the aorta� Partial cardiopulmonary bypass for descending aneurysms

� Monitor for signs of hemorrhage

� Monitor chest tubes for an increase in chest drainage

� Assess sensation and motion of all extremities and notify physician for deficits

� Monitor serum creatinine, BUN and hourly outputs� Monitor serum creatinine, BUN and hourly outputs

� Monitor for dysrhythmias

� Monitor respiratory status

� Encourage coughing and deep breathing

� No lifting of heavy objects for 6-12 weeks

Avoid straining � Avoid straining

SURGICAL MANAGEMENT:� Endovascular grafting

� placement of endovascular stents

� alternative for treating an infrarenal abdominal aortic aneurysm

� Involves transluminal placement and attachment of a suturelessaortic graft prosthesis across an aneurysm aortic graft prosthesis across an aneurysm

� can be performed under local or regional anesthesia.

� performed if abdominal aorta and iliac arteries are not extremely tortuous and if the aneurysm does not begin at the level of the renal arteries.

SURGICAL MANAGEMENT:

Endovascular grafting� Potential complications

� bleeding� hematoma, or wound infection at the femoral insertion site � Distal ischemia or embolization� dissection or perforation of the aorta� graft thrombosis� graft thrombosis� graft infection� break of the attachment system� graft migration� proximal or distal graft leaks� delayed rupture� bowel ischemia

Nursing Management� Preop

� Anticipate rupture

� Recognize that patient may have cardiovascular, cerebral, pulmonary, and renal impairment from atherosclerosis.atherosclerosis.

� Assess functional capacity of all organ systems

� Medical therapies designed to stabilize physiologic function should be promptly implemented.

Nursing Management

Signs of impending rupture Signs of impending rupture Signs of impending rupture Signs of impending rupture

Indications of a rupturing Indications of a rupturing Indications of a rupturing Indications of a rupturing

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� severe back pain or abdominal pain� may be persistent or

intermittent localized in the middle or lower abdomen to left

� constant, intense back pain

� falling BP

� decreasing hematocritmiddle or lower abdomen to left of midline

� Low back pain � because of pressure of the

aneurysm on the lumbar nerves. � a serious symptom, usually

indicating that the aneurysm is expanding rapidly and is about to rupture.

� decreasing hematocrit

� Rupture into peritoneal cavity : rapidly fatal

� Retroperitoneal rupture of an aneurysm � May result in hematomas in the scrotum, perineum, flank, or penis.

� Rupture into vena cava� Signs of heart failure or a loud bruit� results in higher-pressure arterial blood entering the lower-pressure � results in higher-pressure arterial blood entering the lower-pressure

venous system and causing turbulence, which is heard as a bruit. � high BP and increased blood volume returning to right heart from

vena cava may cause R heart to fail.

� The overall surgical mortality rate associated with a ruptured aneurysm is 50% to 75%.

Postoperative care Postoperative care Postoperative care Postoperative care

Possible complications Possible complications Possible complications Possible complications of of of of

surgery surgery surgery surgery

� intense monitoring of pulmonary, cardiovascular, renal, and neurologic

� arterial occlusion

� hemorrhage

� Infectionrenal, and neurologic status.

� Infection

� ischemic bowel

� renal failure

� impotence

DISSECTING AORTADISSECTING AORTADISSECTING AORTADISSECTING AORTA

DISSECTING AORTADISSECTING AORTADISSECTING AORTADISSECTING AORTA� Occasionally, in an aorta diseased by arteriosclerosis, a tear

develops in the intima or the media degenerates, resulting in a dissection

PathophysiologyPathophysiologyPathophysiologyPathophysiology� Arterial dissections (separations) are commonly associated with poorly

controlled hypertension; � three times more common in men than in women� occur most commonly in the 50- to 70-year-old age group � Dissection is caused by rupture in the intimal layer. � A rupture may occur through adventitia or into the lumen through the intima,

allowing blood to reenter the main channel and resulting in chronic dissection allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta.

� As the separation progresses, the arteries branching from the involved area of the aorta shear and occlude. The tear occurs most commonly in the region of the aortic arch, with the highest mortality rate associated with ascending aortic dissection. The dissection of the aorta may progress backward in the direction of the heart, obstructing the openings to the coronary arteries or producing hemopericardium (effusion of blood into the pericardial sac) or aortic insufficiency, or it may extend in the opposite direction, causing occlusion of the arteries supplying the gastrointestinal tract, kidneys, spinal cord, and legs.

Clinical Manifestations� Onset of symptoms - usually sudden.

� Severe and persistent pain� tearing or ripping

� anterior chest or back

� extends to shoulders, epigastric area, or abdomen. � extends to shoulders, epigastric area, or abdomen.

� May be mistaken for an AMI

Clinical Manifestations� Cardiovascular, neurologic, and gastrointestinal symptoms are

responsible for other clinical manifestations, depending on the location and extent of the dissection.

� may appear pale

� Sweating and tachycardiaSweating and tachycardia

� elevated BP

� BP markedly different from one arm to the other � if dissection involves the orifice of the subclavian artery on one side.

� early diagnosis is usually difficult� because of the variable clinical picture associated with this condition

Diagnostic Findings� Arteriography

� CT

� transesophageal echocardiography

� Duplex ultrasonography

magnetic resonance imaging� magnetic resonance imaging

Management

Medical ManagementMedical ManagementMedical ManagementMedical Management Nursing ManagementNursing ManagementNursing ManagementNursing Management

� Medical or surgical treatment depends on the type of dissection present

� same nursing care with an aortic aneurysm requiring surgical interventiontype of dissection present

and follows the general principles outlined for the treatment of thoracic aortic aneurysms.

surgical intervention

OTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMS

OTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMS� peripheral vessels: subclavian artery, renal artery, femoral

artery, or popliteal artery

� most often result of atherosclerosis

� s/s � pulsating mass � pulsating mass

� disturbs peripheral circulation distal to it.

� Pain and swelling develop because of pressure on adjacent nerves and veins.

OTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMS� Diagnostic exam

� Duplex ultrasonography and CT to determine the size, length, and extent of the aneurysm.

� Arteriography may be performed to evaluate the level of proximal and distal involvement.proximal and distal involvement.

OTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMSOTHER ANEURYSMS� Surgical repair

� replacement grafts or endovascular repair using a stent-graft or wall graft, which is a Dacron or PTFE (polytetrafluroethylene) graft with external structures made from a variety of materials (nitinol, titanium, stainless steel) for additional support.

Nursing Management: Nursing Management: Nursing Management: Nursing Management: endovascular

repair postop care

� Supine 6 hours; head of bed elevated up to 45 degrees after 2 hours.

� needs to use bedpan or urinal while on bed rest, or a Foley catheter may be used.

� VS and Doppler assessment of peripheral q 15 min four � VS and Doppler assessment of peripheral q 15 min four times, then q 30 min for four times, then q hour for four times, and then as directed by the physician or unit standards.

� catheterization site is assessed when vital signs and pulses are monitored.

Nursing Management: Nursing Management: Nursing Management: Nursing Management: endovascular

repair postop care� Assess bleeding, swelling, pain, and hematoma formation. � Any changes in vital signs, pulse quality, bleeding, swelling, pain,

or hematoma are reported to the physician. � also notify if persistent coughing, sneezing, vomiting, or systolic

blood pressure above 180 mm Hg� Coz of increased risk hemorrhage. Coz of increased risk hemorrhage.

� If able to resume preprocedure diet encouraged drink fluids. � IV infusion may be continued until able drink normally.� Fluids are important to maintain blood flow through arterial repair

site and assist kidneys excreting IV contrast agent and other medications used during procedure.

� 6 hrs post procedure� may able roll side to side and may ambulate with assistance to

bathroom.

RAYNAUD’S DISEASERAYNAUD’S DISEASERAYNAUD’S DISEASERAYNAUD’S DISEASE

Raynaud’sRaynaud’sRaynaud’sRaynaud’s disease disease disease disease � is a form of intermittent arteriolar vasoconstriction that

results in coldness, pain, and pallor of the fingertips or toes.

� Vasospasm of the arterioles and arteries of the upper and lower extremities; causes constriction of the cutaneousvessels vessels

� occurs more frequently in cold climates and during winter

Raynaud'sRaynaud'sRaynaud'sRaynaud's phenomenon phenomenon phenomenon phenomenon Raynaud'sRaynaud'sRaynaud'sRaynaud's disease disease disease disease

� usually unilaterally.

� occurs in people older than 30 years of age

� occurs bilaterally.

� occur between the ages of 17 and 50 years30 years of age

� can occur in either sex

17 and 50 years

� more common in women

The pathophysiology is the same for

both entities. � Clients often have an associated systemic connective tissue

disease, such as systemic lupus erythematosus or progressive systemic sclerosis.

� As a result of vasospasm, the cutaneous vessels are constricted and blanching of the extremity occurs, followed by cyanosis. When the vasospasm is relieved, the tissue by cyanosis. When the vasospasm is relieved, the tissue becomes reddened or hyperemic. The client's extremities are numb and cold, and he or she may complain of pain and swelling.

� Ulcers may also be present. These attacks are intermittent and can be aggravated by cold or stress. In severe cases, the attack lasts longer and gangrene of the digits can occur.

Cause � The etiology is unknown.

� many have immunologic disorders (scleroderma, systemic lupus erythematosus, rheumatoid arthritis), obstructive arterial disease, or trauma

� associated with smoking� associated with smoking

� Rarely leads to gangrene

Prognosis � Varies

� some patients slowly improve, some become progressively worse, and others show no change.

� Ulceration and gangrene are rare

� however, chronic disease may cause atrophy of the skin and � however, chronic disease may cause atrophy of the skin and muscles.

� With appropriate patient teaching and lifestyle modifications, the disorder is generally benign and self-limiting.

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations� Classic clinical picture - Triphasic color changes in the

hands� Blanching (pallor or white) of the fingers after exposure to

cold or stress due to vasoconstriction and spasm

� Cyanosis (blue) follows because of oxygen deprivation of the � Cyanosis (blue) follows because of oxygen deprivation of the tissues

� Red skin as exaggerated reflow (hyperemia) when oxygenated blood returns to the digits after the vasospasm stops.

The characteristic sequence of color change of Raynaud’s phenomenon is described as white, blue, and red.

Symptoms � Numbness, tingling, and burning pain occur as the color change� bilateral and symmetric� may result from defect in basal heat production that eventually

decreases the ability of cutaneous vessels to dilate. � Episodes may be triggered by emotional factors or by unusual

sensitivity to cold. sensitivity to cold. � Generally unilateral and affecting only one or two digits, the

phenomenon is always associated with underlying systemic disease.

� Attacks are intermittent and can occur with exposure to cold or stress

� Affects primarily the hands less commonly the feet

Diagnostics� ANA titer

� Arteriography

� Doppler ultrasound

Medical ManagementMedical ManagementMedical ManagementMedical Management� Avoid trigggers (e.g., cold, tobacco, stress) that provoke

vasoconstriction

� Medications

� Sympathectomy

� Amputation� Amputation

Vasodilating agents � Commonly prescribed drugs are

� nifedipine (Procardia)

� cyclandelate (Cyclospasmol)

� phenoxybenzamine (Dibenzyline)

� help to relieve the symptoms� help to relieve the symptoms

� can cause uncomfortable S/E (facial flushing, headaches, hypotension, and dizziness)

Sympathectomy� For severe symptoms that cannot be alleviated by drugs

� lumbar sympathectomy� physician cuts sympathetic nerve fibers that cause

vasoconstriction of blood vessels in the lower extremities.

� effective when experiencing foot symptoms. � effective when experiencing foot symptoms.

� sympathetic ganglionectomy� for upper extremities, a similar procedure

� may provide symptom relief.

� long-term effectiveness is questionable.

Education of client is important in

prevention of complications. � Minimize exposure to cold

� remain indoors as much as possible during cold weather� wear layers of clothing when outdoors� hats and mittens or gloves should be worn at all times when

outside.� Use fabrics specially designed for cold climates (e.g., Thinsulate)� Use fabrics specially designed for cold climates (e.g., Thinsulate)� warm up vehicles before getting in

� To avoid touching cold steering wheel or door handle, which could elicit an attack.

� during summer, a sweater should be available when entering air-conditioned rooms.

� Maintain warm body temperature

Methods to prevent vasoconstriction

� Avoid all forms of nicotine; Smoking cessation, nicotine gum or patches used to help people quit smoking may induce attacks

� Avoid decongestants and caffeine

Nursing Management� decrease stress

� help the client to identify stressors and provides suggestions for reducing them.

� Stress management classes

� Avoid situations that may be stressful or unsafe. � Avoid situations that may be stressful or unsafe.

� Safety� Handle sharp objects carefully to avoid injuring the fingers.

� Inform abt postural hypotension that may result from medications (ex: calcium channel blockers)

� safety precautions related to alcohol, exercise, and hot weather.

Complications � serious but uncommon

� Gangrene

� Amputation

THORACIC OUTLET SYNDROME THORACIC OUTLET SYNDROME THORACIC OUTLET SYNDROME THORACIC OUTLET SYNDROME

Thoracic outlet syndrome � is a compression of the subclavian artery at thoracic outlet by

anatomic structures, such as a rib or muscle.

� arterial wall may be damaged, producing thrombosis or embolization to distal arteries of the arms.

� three common sites of compression in the thoracic outlet� three common sites of compression in the thoracic outlet• The interscalene triangle

• Between the coracoid process of the scapula and the pectoralisminor tendon

• Most commonly, the costoclavicular space

� more common in females

� people whose occupations require holding their arms up or leaning over, such as baseball players, golfers, or swimmers.

� trauma (whiplash or after clavicular fracture)

s/s s/s s/s s/s � neck, shoulder, and arm pain : may be intermittent.

� numbness and moderate edema of extremity.

� pain and numbness worse when arm is placed in certain positions, such as over head or out to side.

� Clients may have overdeveloped neck and shoulder muscles, � Clients may have overdeveloped neck and shoulder muscles, and the affected arm may appear cyanotic.

COLLABORATIVE MANAGEMENTCOLLABORATIVE MANAGEMENTCOLLABORATIVE MANAGEMENTCOLLABORATIVE MANAGEMENT� PT

� Exercises

� Avoiding aggravating positions, such as elevating the arms.

Surgical treatment � Surgical treatment � resection of anatomic structure that is compressing the artery.

� performed only if has severe pain, has lost hand function, or is responding poorly to conservative treatment.

References � Brunner

� Ignatavicius

� http://www.mayoclinic.com/health/buergers-disease/DS00807/METHOD=print&DSECTION=all