Vascular Disorders Bridging 13-14

8/12/2019 Vascular Disorders Bridging 13-14

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Management of Patients with

Vascular Disorders

Venous

Arterial

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LEARNING OBJECTIVES

On completion of this chapter, the students will be able to: Identify factors that affect peripheral blood flow and tissue

oxygenation.

Use appropriate parameters for assessment of peripheral

circulation. Use the nursing process as a framework of care for

patients with circulatory insufficiency of the extremities.

Compare the various diseases of the arteries, their

causes, pathologic and physiologic changes, clinicalmanifestations, management, and prevention.

Describe the prevention and management of venous

thrombosis.

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Venous Disorders

1. DEEP VEIN THROMBOSIS (DVT)

2. CHRONIC VENOUS INSUFFICIENCY

3. LEG ULCERS4. VARICOSE VEINS

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Management of Venous

Disorders

DEEP VEIN THROMBOSIS (DVT)

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Pathophysiology of DVT

Three factors, known as Virchows triad, are

believed to play a significant role in

development of DVT:

1. Stasis of blood (venous stasis)

2. Vessel wall injury (endothelial damage)

3. Altered blood coagulation (Coagulopathy)

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Risk Factors for Deep Vein Thrombosis1. Venous stasis

A. Bed rest or immobilization

B. Obesity

C. History of varicose veins

D. Age (>65 yr)

2. Endothelial damage

A. TraumaB. Surgery

C. Pacing wires

D. Central venous catheters

E. Dialysis access catheters

3. Coagulopathy (abnormal coagulation)4. Cancer

5. Pregnancy

6. Oral contraceptive use

7. Septicemia

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Clinical Manifestations of DVT

Edema and swelling of the extremity

because the outflow of venous blood isinhibited

The affected extremity may feel warmer

than the unaffected extremity, and thesuperficial veins may appear moreprominent.

Tenderness, which usually occurs later, isproduced by inflammation of the vein wall

Homans sign (pain in the calf after the footis sharply dorsiflexed)

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Homans sign

Is not specific for deep vein thrombosisbecause it can be elicited in any painful

condition of the calf.

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Complications of Venous Thrombosis

1. Pulmonary emboli from dislodgedthrombi

2. Varicose veins

3. Venous ulcers

4.Fluid stasis and edema

5. Venous gangrene

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Medical Management

I - Thrombolytic Therapy

Causes the thrombus to lyse and dissolve in

50% of patients.

tissue plasminogen activator (t-PA)

Streptokinase

Is given within the first 3 days after acute

thrombosis. Results in greater incidence of bleeding than

heparinshould be discontinued

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Medical Management of DVT

II-ANTICOAGULATION THERAPY

1- HeparinIs administered for 5 - 7 days to prevent the

extension of thrombus and the development of

new thrombi.

Unfractionated Heparin

1. Subcutaneously

2. Intermittent intravenous injection

3. Continuous infusionMedication dosage is regulated by monitoring the partial

thromboplastin time ( PTT)

Low-Molecular-Weight Heparin (LMWH)

Subcutaneously11


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Medical ManagementII-ANTICOAGULATION THERAPY

2 - Oral anticoagulants

warfarin (Coumadin)

Are administered with heparin therapy. Medication dosage is regulated by

monitoring:

Prothrombin time (PT) International normalized ratio (INR)

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Nursing Management of DVT

Assessment and Diagnostic Findings1. History of any of the risk factors

2. Limb pain

3. Feeling of heaviness

4. Ankle edema5. Differences in leg circumference bilaterally

6. Increase in the temperature of the leg

7. Areas of tenderness

8. Superficial thrombosis (ie, cordlike venoussegment).

9. Homans sign (not a reliable or valid sign forDVT)

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ASSESSING AND MONITORINGANTICOAGULANT THERAPY

If the patient is receiving anticoagulant therapy, youmust frequently monitor:

Partial thromboplastin time (PTT) Prothrombin time(PT)

Hemoglobin and hematocrit values

Platelet count

Fibrinogen level Close observation is also required to detect bleeding

If bleeding occurs, it must be reported immediatelyand anticoagulant therapy discontinued.

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MONITORING AND MANAGING POTENTIAL

COMPLICATIONS OF ANTICOAGULANT

THERAPY

1. Bleeding

2. Thrombocytopenia (low platelet count)3. Drug Interactions

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Management of Arterial

Disorders

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Arterial Disorders

1. ARTERIOSCLEROSIS& ATHEROSCLEROSIS2. ARTERIAL EMBOLISM / PULMONARY EMBOLISM

3. ARTERIAL THROMBOSIS

4. PERIPHERAL ARTERIAL DISEASE

5. THROMBOANGIITIS OBLITERANS(BUERGERS DISEASE)

6. AORTITIS

7. AORTIC ANEURYSM

8. DISSECTING AORTA

9. RAYNAUDS DISEASE

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Pulmonary Embolism

Pulmonary Embolus is a fragment of thethrombus that breaks off and travels in theblood until it lodges at the pulmonaryvasculature.

Acute pulmonary embolism (PE) is a commonand often fatal disease. Mortality can bereduced by prompt diagnosis and therapy.

The majority of clinically significant pulmonaryemboli begin in the pelvic or lower extremityveins.

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Predisposing Factors

Minor risk factorsMajor risk factors

Obesity

Bed RestEstrogen therapy

Surgery

Major TraumaCancerCongestive Heart failure

Myocardial infarctionImmobilization


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Clinical Manifestations / Symptoms of PE

The presentation of pulmonary embolism may varyfrom sudden catastrophic hemodynamic collapse to

gradually progressive dyspnea

Patients with pulmonary embolism may present

with atypical symptoms The diagnosis of pulmonary embolism should be

sought actively in patients with respiratory

symptomsunexplained by an alternative diagnosis.

The symptoms of pulmonary embolism arenonspecific; therefore, a high index of suspicion is

required, particularly when a patient has risk

factorsfor the condition.


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Clinical Manifestations / Symptoms of PE

Angina-Like pain Wheezing

Hemoptysis

Palpitations

Productive cough Syncope

Abdominal pain

Fever

Decreasing level of consciousness Pleuritc Pain

Leg Swelling / Leg Pain


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Clinical Manifestations / Signs of PE

Tachypnea (respiratory rate >16/min) - 96% Rales - 58%

Accentuated second heart sound - 53%

Tachycardia (heart rate >100/min) - 44%

Fever (temperature >37.8C) - 43% Diaphoresis - 36%

S3 or S4 gallop - 34%

Clinical signs and symptoms suggesting

thrombophlebitis - 32%

Lower extremity edema - 24%

Cardiac murmur - 23%

Cyanosis - 19%

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Diagnosis of Pulmonary Embolism

(PE)1-Clinical picture

2-Look for risk or predisposing factors

4-Testing for PE:

1. High D-dimer level: a degradation product produced by

plasmin-mediated proteases of cross-linked fibrin,

2. Arterial blood gas: hypoxemia, hypocapnia, and

respiratory alkalosis

3. Chest radiograph ( X-ray )

4. ECG5. Ventilation-perfusion scanning (V/Q scanning).

6. Spiral CT

7. Angiography


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Treatment of Pulmonary Embolism

1. Treatment of respiratory distress including:

1. O2

2. Monitoring

3. Fluid resuscitation for secondary right-sided heart failure

4. Inotropic agents2. Anticoagulant : Heparin, LMWH , and oral

anticoagulant

3. Thrombolytic agent

4. Caval Interruption.


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Anticoagulant

A - Heparin

A loading dose of 5,000-10,000 U followed byapproximately 1,000 U/h.

weight-based dosing.

A bolus with 80 U/kg and then start a drip at10- 18 U/kg/h.

1. Check PTT every 6 hours.

2. Keep the PTT at 1.5 to 2 times control.

3. Adjust dose as per protocol in.

4. Use clinical judgment!


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B - low-molecular-weight heparin LMWH

Enoxaparin: (Clexan)

Tinzaparin sodium (Innohep)

1. No need to follow PT / INR / PTT.

2. Use with caution in renal and hepatic disease.

3. The dose must be adjusted for renal function.

4. Dose: 100 IU/kg (1 mg/kg) twice daily

5. Oral anticoagulant should be initiated andEnoxaparin sodium should be continued until

therapeutic effect (INR 2-3)


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CWarfarin

It is taken orally. Begin with 5 mg QHS.

Warfarin therapy can begin on day one ofheparin therapy.

The range of INR(Internationalnormalization ratio) of 2 - 3 is considered

therapeutic. Monitor daily using the PT(Prothrombin

time), until a stable INR for 2 days.

Heparin should be continued for at least 4

days total and for at least 2 days after atherapeutic INR is obtained.

Continue using anticoagulation (warfarin) forat least 6 months.


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Nursing Management for patient with

Pulmonary Embolism

1. PREVENTING OR MINIMIZING THE RISK OF

THROMBUS FORMATION & PE

2. MONITORING THROMBOLYTIC THERAPY3. MANAGING PAIN

4. MANAGING OXYGEN THERAPY

5. RELIEVING ANXIETY6. MONITORING FOR COMPLICATIONS

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PREVENTING OR MINIMIZING THE RISK OF


1. Identify patients at high risk for PE and to

minimize the risk of PE in all patients.

2. Encourage ambulation and active and passiveleg exercises to prevent venous stasis in patients

on bed rest.

3. Instruct the patient to move the legs in a

pumping exercise so that the leg muscles can

help increase venous flow.

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Pulmonary Embolism


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PREVENTING OR MINIMIZING THE RISK OF


4. Advise the patient not to sit or lie in bed for

prolonged periods, not to cross the legs, and

not to wear constricting clothing.5. Legs should not be dangled or feet placed in a

dependent position while the patient sits on

the edge of the bed; instead, the patients feetshould rest on the floor or on a chair.

6. Intravenous catheters should not be left in

place for prolonged periods31


Pulmonary Embolism


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Pulmonary Embolism

MONITORING THROMBOLYTIC THERAPY1. During thrombolytic infusion, the patient remains onbed rest, vital signs are assessed every 2 hours, and

invasive procedures are limited

2. Because of the prolonged clotting time, only essentialarterial punctures or venipunctures are performed,

and manual pressure is applied to any puncture site

for at least 30 minutes.

3. Pulse oximetry is used to monitor changes inoxygenation.

4. Immediately discontinue the infusion if uncontrolled

bleeding occurs.


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Pulmonary Embolism

MANAGING PAIN

1. A semi-Fowlers position provides a more

comfortable position for breathing.

2. continue to turn the patient frequently andreposition the patient to improve the

ventilationperfusion ratio in the lung.

3. Administer opioid analgesics as prescribedfor severe pain.


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Pulmonary Embolism

MANAGING OXYGEN THERAPY1. Ensure that the patient understands the need forcontinuous oxygen therapy.

2. Assess the patient frequently for signs of hypoxemia

and monitors the pulse oximetry values to evaluatethe effectiveness of the oxygen therapy.

3. Deep breathing and incentive spirometry are

indicated for all patients to minimize or prevent

atelectasis and improve ventilation.4. Nebulizertherapy or percussionandpostural

drainagemay be used for management of secretions


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Pulmonary Embolism

RELIEVING ANXIETY1. Encourage the stabilized patient to talk about

any fears or concerns related to this

frightening episode2. Answer the patients and familys questions

concisely and accurately

3.Explain the therapy, and describes how torecognize untoward effects early


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Pulmonary Embolism

MONITORING FOR COMPLICATIONS

Be alert for the potential complication as :

1. Cardiogenic shock

2. Right ventricular failure

3. Shock


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Arteriosclerosis

Is the most common

disease of the arteries The term means hardening

of the arter ies. It is a diffuse process

whereby the muscle fibers

and the endothelial lining of

the walls of small arteriesand arterioles become

thickened.

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Clinical Manifestationsdepend on the organ or tissue affected.

Coronary atherosclerosis (heart disease): Angina

Acute myocardial infarction

Cerebrovascular diseases:

Transient ischemic attacks

Stroke

Atherosclerosis of the aorta:

Aneurysm Lesions of the extremities

Renovascular disease:

Renal artery stenosis / hypertension

End-stage renal disease 38


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PERIPHERAL ARTERIAL DISEASE

(PAD) Arterial insufficiency of the

extremities

1. Usually found in

individuals > 50 Y/O2. Most often in men

3. The legs are most

frequently affected4. Frequently seen in

patients with diabetes

mellitus 39


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Risk Factors for Peripheral Arterial Disease

(PAD)

Modifiable

1. Nicotine use

2. Hypertension

3. Diet

4. Obesity

5. Sedentary lifestyle

6. Stress7. Diabetes mellitus

Non-modifiable

1. Age

2. Gender

3. Familial

predisposition

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Cli i l M if t ti f


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Clinical Manifestations of

PAD

The hallmark is intermittent claudication.

Pain aching, cramping, fatigue, or

weakness that is consistently occur with

the same degree of exercise or activity

and relieved with rest.

When the arterial insufficiency becomes

severe, the patient begins to have rest

pain.

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Assessment and Diagnostic Findings of

PAD

Examining the peripheral

pulses is an important part

of assessing arterial

occlusive disease.

Unequal pulses between

extremities or the absence

of a normally palpablepulse is a sign of peripheral

arterial disease.

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Assessment and Diagnostic Findings of

PAD

Extremity1. Feel coolto the touch and look

palewhen elevated or ruddy and

cyanotic when placed in a

dependent position.2. Nailsmay be thickenedand

opaque,

3. Skinmay be shiny, atrophic, and

dry, with sparse hair growth4. Ulcerations, gangrene, and

muscle atrophy

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Medical Management of PAD

PHARMACOLOGIC THERAPY Pentoxifylline (Trental)

increases erythrocyte (red blood cells) flexibility

and reduces blood viscosity

Anti-plateletaggregating agents such as:

Aspirin Ticlopidine (Ticlid)

Clopidogrel (Plavix)

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SURGICAL MANAGEMENT OF PAD

EndarterectomyIncision is made into the

artery, and the

atheromatous

obstruction is removed

Bypass grafts

Performed to reroute

the blood flow

around the stenosis

or occlusion.

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NURSING PROCESS

THE PATIENT WHO HAS

PERIPHERALARTERIAL INSUFFICIENCY

OF THE EXTREMITIES

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Assessment

Complete health and medication history andidentification of risk factors for peripheralartery disease.

Signs and symptoms detected during thenursing assessment may include:

1. Claudication pain

2. Rest pain in the forefoot

3. Pallor, rubor, or cyanosis4. Weak or absent peripheral pulses

5. Skin breakdown or ulcerations

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Nursing Diagnosis

Based on assessment data :

1. Ineffective peripheral tissue perfusion related

tocompromised circulation

2. Chronic pain related to impaired ability of

peripheral vessels to supply tissues withoxygen

3. Risk for impaired skin integrity related to

compromised circulation4. Deficient knowledge regarding self-care

activities

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Planning and Goals

1. Increased arterial blood supply to the

extremities

2. Promotion of vasodilation

3. Prevention of vascular compression

4. Relief of pain

5. Maintenance of tissue integrity6. Adherence to the self-care program

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Nursing Care Plan


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Nursing Care Plan

The Patient With Peripheral Vascular Problems

Expected OutcomesRationaleNursing Interventions

Nursing Diagnosis: Ineffective peripheral tissue perfusion related tocompromised circulation

Goal: Increased arterial blood supply to extremities

1. Extremities warm to

touch

2. Color of extremities

improved

3. Experiences

decreased musclepain with exercise

1- Dependency of lower

extremities enhances

arterial blood supply

1- Lower the extremities

below the level of the

heart

2- Muscular exercise

promotes blood flowand the development of

collateral circulation.

2- Encourage moderate

amount of walking orgraded extremity

exercises.

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Nursing Care Plan


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Nursing Care Plan



Nursing Diagnosis: Ineffective peripheral tissue perfusion related to

compromised circulation

Goal: Promotion of vasodilation and prevention of vascular

compression

Protects

extremities

from exposure

to cold

Avoids nicotine

Uses stress-management

program to

minimize

emotional upset

1 - Warmth promotes

arterial flow by preventing

the vasoconstriction effects

of chilling.

1- Maintain warm

temperature and avoid

chilling.

2 - Nicotine causes

vasospasm, which

impedes peripheral

circulation

2- Discourage nicotine

use.

3 - Emotional stress causes

peripheral vasoconstriction

3 -Instruct in ways to

avoid emotional upsets;

stress management 52

Nursing Care Plan


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Goal: Promotion of vasodilation and prevention of vascularcompression

Avoids constricting

clothing and

accessories

Avoids leg crossing

Takes medication as

prescribed

4- Constrictive clothing

and accessories

impede circulation and

promote venous stasis.

4- Encourage avoidance

of constrictive clothing

and accessories.

5- Compression of

vessels with

subsequent

impediment of

circulation venousstasis.

5- Encourage avoidance

of leg crossing

6- Relax smooth

muscle

6- Administer vasodilator

and adrenergic

blocking agents

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Nursing Care Plan


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Nursing Care Plan



Nursing Diagnosis: Chronic pain related to impaired ability of

peripheral vessels to supply tissues with oxygen

Goal: Relief of pain

1. Uses measures to

increase arterial

blood supply to

extremities

2. Uses analgesics

as prescribed

1-Increases the oxygen

supplied to the muscle

and decreases the

accumulation of

metabolites that cause

muscle spasm.

1-Promote increased

circulation.

2-Reduce pain and allowthe patient to participate

in activities and exercises

that promote circulation.

2 - Administeranalgesics as

prescribed

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Nursing Care Plan


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Nursing Diagnosis: Risk for impaired skin integrity related tocompromised circulation

Goal: Maintenance of tissue integrity

1- Inspects skin daily

for evidence of injury

or ulceration

2- Avoids trauma and

irritation to skin

3-Wears protective

shoes

4-Eats a healthy dietthat contains adequate

protein and vitamins A

and C

1-healing of wounds is

delayed or inhibited due

to poor tissue perfusion.

1-Instruct in ways to

avoid trauma to

extremities.

2-prevent foot injuries

and blisters.

2-Encourage wearing

protective shoes and

padding for pressure

areas.

3- promotes healing

and

prevents tissue

breakdown

3- adequate intake

of vitamins A and C,

protein, and zinc;

control of obesity.

55

Nursing Care Plan


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Nursing Diagnosis: Deficient knowledge regarding self-care activitiesGoal: Adherence to the self-care program

Practices frequent

position changes

Practices postural

exercises Takes medications

Avoids

vasoconstrictors

Uses measures to

prevent trauma Accepts condition as

chronic but amenable

to therapies that will

decrease symptoms

Adherence to the self-

care program is

enhanced when the

patient receives supportfrom family

1. Include family in

teaching program

Written instructions serve

as reminder

and reinforcement of

information.

2. Provide written

instructions about foot

care, leg care, and

exercise program.

Constrictive clothing and

accessories impede

circulation and promote

venous stasis

3. Assist to obtain

properly fitting

clothing, shoes,

stockings

Date post:	03-Jun-2018
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Vascular Disorders Bridging 13-14

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