NSG 5130:
Level III
Nursing Theory
Med-Surg Week 5: Vascular Disorders
Rachael Jaffray, RN, MScN
Vascular
Disorders
Arteries
Atherosclerotic
Aneurysmal
Veins
Nonatherosclerotic
Lymphatic
Phlebitis
Venous Thrombo-Embolism
(VTE)
Venous Leg Ulcers
Peripheral artery disease
Acute arterial ischemic
disorders
Aortic Aneurysm
Today’s topics in green
Vascular Disorders
• Can lead to impaired perfusion
• Ischemia
• Blood supply is available, but decreased
• Reversible cellular injury caused by:
• Lack of blood flow
• Lack of oxygen
• What could cause Ischemia?
• Infarction/necrosis
• Indicates death of tissue with an inability to regenerate
• What could cause cell death?
Vascular Disorders
• Causes of arterial insufficiency
• Arteriosclerosis
• Walls of arteries become “hardened”, occurs with aging
• Atherosclerosis (central and peripheral)
• Accumulation of lipids, blood components & other cells on the innermost layer of
arterial wall
• Emboli
• Clot in artery
• Causes of venous insufficiency
• Dysfunction of valves
• Prolonged time standing (nursing work)
• Prevention & Treatment: compression stockings & vein treatments
• Smoking – chronic vasoconstriction
Risk Factors:
Vascular Disorders and Impaired Perfusion
• Smoking
• High cholesterol
• Sedentary lifestyle
• Obesity
• Diabetes
• Hypertension
• Age
• Sex
(Lewis et. al., 2019)
Why is smoking a risk factor?
Tobacco use is one of the main risk factors for
vascular disorders
• Acts as a vasoconstrictor
• Impairs transport of oxygen
• Impairs cellular use of oxygen
• Increases blood viscosity
• Increases homocysteine levels
(Lewis et. al., 2019)
Arterial Disorders
PAD, AAI & Aneurysms
Peripheral Artery Disease
Peripheral Artery Disease
•
•
•
•
Narrowing of the arteries (upper and lower extremities)
Related to other types of cardiovascular disease (CVD)
More likely to have coronary artery disease (next week)
Higher risk of premature death:
• CVD, coronary events, stroke
• Causes:
• Atherosclerosis (thickening of artery walls)
• Can be caused by:
• Lipid accumulation
• Connective tissue deposits
• Replication of muscle cells
• Infiltration of types of immune cells
Most common sites of PAD:
• Iliac
• Femoral
• Popliteal
• Tibial
• Carotid (not shown here)
• Coronary (not shown here)
(Lewis et. al., 2019)
Peripheral Artery Disease: Risk Factors
• Smoking
• Hyperlipidemia
• lipid accumulation
• C-reactive protein
• chronic inflammation
• Uncontrolled hypertension
• Sedentary lifestyle
• Obesity
• Diabetes mellitus
(Lewis et. al., 2019)
PAD: Clinical Manifestations in Lower Extremities
(most common)
•
•
•
•
Often no symptoms until 60-75% of the vessel is occluded
Depends on site
~20% adults over 60 show symptoms of PAD (Bailey et al., 2014)
Classic: intermittent claudication
• ischemic muscle ache/pain
• precipitated by constant level of exercise and relieved with 10 minutes of rest,
and is repeatable (predictable)
• Pain = accumulation of end products of anaerobic activity (no oxygen from
blood flow), like lactic acid (exercise example)
• Numbness and tingling r/t nerve tissue ischemia
(McMillan, 2020)
Examples:
• PAD site - Iliac
• Claudication in
buttocks and thighs
• PAD site – Femoral or
popliteal
• Claudication in calves
(Lewis et. al., 2019)
PAD: Diagnostics
• Doppler U/S
• Map blood flow
• Segmental BPs while patient is supine (laying)
• Thigh
• BTK (below the knee)
• Ankle
• Drop in BP >30mm Hg suggests PAD
• ABI (ankle-brachial pressure index)
• Ratio of BP in upper extremity vs. lower (ankle/brachial) (Nead et al., 2013)
• <0.9 ratio = PAD & twice the risk of CVD death (Bailey et al., 2014)
• Screening tool contraindicated with calcified/noncompressible arteries
PAD: Clinical Manifestations
• Peripheral skin assessment
• Thin, shiny, taut, hair loss,
• Temperature
• Cool due to decreased blood supply
• Pulses
• Diminished or absent pulses: pedal,
popliteal, femoral
• Sensation
• Paresthesia: Numbness/tingling in
toes and feet
(McMillan, 2020)
PAD: Clinical Manifestations
• Positional changes
• Elevation: foot blanching (elevational
pallor);
• Dependent: foot redness (reactive
hyperemia/dependent rubour)
• arterioles and capillaries no longer
constrict when increased pressures
are present
• Patient with darker skin
• Purple, blue or eggplant
PAD: Clinical Manifestations
• Rest Pain
• Increasing pain at rest, intermittent
claudication becomes continuous
• Forefoot & toes
• Aggravated by limb elevation
• Occurs b/c insufficient blood
supply available to meet
metabolic requirements
• More common at night
• Patients often dangle legs for relief
(McMillan, 2020)
PAD: Nursing Diagnoses and Outcomes
Nursing Diagnoses:
• Ineffective tissue perfusion
• Acute Pain
• Activity intolerance
• Impaired skin Integrity
Outcomes:
• Adequate tissue perfusion
• Relief of pain
• Increased exercise tolerance
• Intact, healthy skin on extremities
(McMillan, 2020)
PAD: Complications
• Atrophy of skin and muscle
• Related to chronic hypoxemia
• Minor trauma to feet result in:
• Delayed healing, wound infection, tissue necrosis, especially in diabetics
• Arterial ulcers
• Bony prominences of toes, feet, lower legs
• May result in amputation if become gangrenous (next slide)
• Critical Limb Ischemia (next slide)
(McMillan, 2020)
PAD: Complications
Gangrene: Death of cells/ tissue
• Signs and symptoms may include:
• Skin discoloration — ranging from pale to blue, purple,
black, bronze or red, depending on the type of gangrene
you have
• Swelling or the formation of blisters filled with fluid on
the skin
• A clear line between healthy and damaged skin
• Sudden, severe pain followed by a feeling of numbness
• A foul-smelling discharge leaking from a sore
• Thin, shiny skin, or skin without hair
• Skin that feels cool or cold to the touch
(Mayo Clinic, 2019)
PAD Complications:
Critical Limb Ischemia
• Chronic rest pain > 2 weeks, arterial ulcers or gangrene
• Goals of therapy
• Protect from further trauma, good foot care
• Decreasing ischemic pain
• Opioids and positioning (reverse Trendelenburg)
• Proper wound care and prevent/control infection
• *remember that unlike pressure ulcers, arterial ulcers do not
have the same blood supply, so will likely not heal
• PAD/CVD prevention measures
• Can undergo revascularization therapies
• Bypass graft around atherosclerosed artery
• Removal of obstructive plaque
• Amputation is least desirable end-stage option
(Lewis, 2019)
PAD: Management
• Risk Factor Modification
• Nursing Management
• Medical Management (Drug Therapy)
PAD: Risk Factor Modification
• Prevention:
• Lifestyle modifications:
• BP <140/80, reduce sodium intake, ideal body weight BMI <25kg/m2,
glycemic control
• Physical activity (walking is best!)
• Smoking cessation
• Aggressive management of LDL and HDL
(Lewis, 2019)
PAD: Nursing Management
• Assess and identify those at risk
• Encourage and educate re: lifestyle modifications
• Teach foot care:
•
•
•
•
•
Clean, dry, all cotton or all wool socks
Comfortable, non pointed shoes, not tight
Monitor limbs for changes
Report to health care team if ulcers or inflammation develop
Go to skilled practitioners for nail care (ex. Podiatrist)
• If post-surgical repair
• Monitor for complications, infections, circulation etc.
• Avoid knee-flexed positions
• Avoid dependent positions for long periods of time (ex prolonged sitting)
(Lewis, 2019)
Acute Arterial Ischemia (AAI): Clinical manifestations
(6 Ps)
P
• Pain
P
• Pallor
P
• Paralysis
P
• Pulselessness
P
• Parasthesia
P
• Poikilothermia
(Lewis et. al., 2019)
Acute Arterial Ischemia: Management
• Early treatment is essential – nurse must report IMMEDIATELY
• Anticoagulation therapy
• Continuous IV heparin (and long term oral therapy at home) +
• Removal of embolus/thrombus
• Via catheter insertion with/with out thrombolytic therapy (actively
breaks up clot)
(McMillan, 2020)
Aneurysms
Aneurysm
• Aneurysm: permanent, localized, outpouching or dilation of the vessel wall
• Can be congenital or acquired
• If acquired, often due to atherosclerosis (plaque formation leads to weakening of vessel wall)
• Risk of rupture, which leads to hypovolemia, ischemia/infarction to other cells
and organs
• May never rupture
• May require surgical intervention
(Lewis et. al., 2019)
Aortic Aneurysm
• Aneurysm’s are one of the most common
problems affecting the aorta
• Involves arch, thoracic or abdominal part of
aorta
• 75% occur in abdominal (AAA)
• 25% occur in arch
• Risk factors for AAA:
• Male sex, 65 years or older, tobacco use are major
risk factors
• CAD, PAD also related factors
(Lewis et. al., 2019)
Aortic Aneurysm: Clinical Manifestations
*Often no symptoms (asymptomatic), discovered by accident due to other testing/assessments*
• Upper thoracic area:
• Tenderness or pain in the
chest
• Back pain
• Hoarseness
• Cough
• Shortness of breath
• Dysphagia
• Abdominal area:
• Pain in abdomen or back
• Bruit over site of aneurysm
(Lewis et. al., 2019)
Aortic Aneurysm Complication
• Most serious complication is rupture
• Medical emergency
• Bleeding into surrounding structures, leads to
ischemia and infarction of cells/organs
• Clinical Manifestations:
• Severe back pain
• Hypotension, tachycardia, pale clammy skin,
altered level of consciousness, decreased
urinary output (signs of hypovolemic shock)
(Lewis et. al., 2019)
Aortic Aneurysm: Clinical Manifestations
• Prevention by decreasing or managing risk factors
• Control blood pressure
• Tobaccos cessation
• Physical activity, ideal weight
• Healthy Eating
• Early detection and prompt intervention through surgical repair (if indicated)
(Lewis et. al., 2019)
Venous Disorders
Phelbitis, Venous Thrombo-Embolism (DVT and PE) & Venous Ulcers
Vascular
Disorders
Veins
Venous
Disorders
Phlebitis
Venous
ThromboEmbolism
(VTE)
DVT
PE
Venous Leg
Ulcers
Phlebitis
Phlebitis
• Phlebitis – Inflammation of a vein;
may be accompanied by pain,
erythema, edema, streak formation
and/or palpable cord;
• Negative outcomes:
• Infection, necrosis, limits access
points in patient
• Causes:
• 65% of patients receiving IV
therapy
Redness, tender, warm to touch, mild swelling
(Lewis et. al., 2019)
Venous Thrombosis
Venous Thrombosis
• Venous Thrombosis – formation of a clot
• Superficial vein thrombosis or Deep vein thrombosis (iliac/femoral)
• Venous thrombo-embolism (VTE)
• Clots has now “embolized” – and can move
• If becomes emboli can flow through venous circulation to heart or
lungs (PE)
(Lewis et. al., 2019)
“Virchow’s triad”
Damage to Endothelium
• Vein trauma
• Direct
• Indirect
Hypercoagulability
Venous Stasis
• Blood disorders (clotting)
• Certain medications
(estrogen)
• Dysfunctional valves
• Muscles of extremities
are inactive
Venous
Thrombosis
(Lewis et. al., 2019)
DVT: Risk Factors
Strong
• Major general surgery
• Major trauma
• Spinal cord injury
Intermediate
Weak
• Chronic Heart Failure
• Hormone Replacement
Therapy (oral)
• Oral Contraceptive
• Cerebrovascular Accident
(stroke)
• Pregnancy or postpartum
• Prior DVT
• Bed rest >3 days
• Car or air travel >8 hours
(or other prolonged
sitting)
• Advanced age
• Morbid Obesity(BMI >40)
(McMillan, 2020)
DVT: Clinical Manifestations
• Symptoms
• Unliateral edema
• Extremity pain
• Sense of fullness in thigh/calf
• Due to inability of blood to flow back to the heart via venous system
• Paresethisias (pins & needles)
• Warm, red, tender
• Inferior vena cava – legs edematous/cyanotic
• Super vena cava – arms, neck, back, face
(McMillan, 2020)
DVT: Diagnostics
• Labs
• Coags (PTT/INR, platelets)
• D-Dimer (reflect fragments of fibrin associated with clot formation)
• Ultrasounds
• Exam veins and valves
• CTV
• CT specific for veins, uses contrast
• MRV
• MRI specific for veins
(McMillan, 2020)
DVT: Prevention
• Prophylaxis
• Early and aggressive mobilization
• Strict position changes (q2h)
• Antiembolism stockings
• Sequential compression device (inflatable
pressure socks)
DVT: Prevention and Treatment with Drug Therapy
• Drug therapy
• Vit K antagonists: Warfarin (coumadin)
• Inhibits vit. K dependent clotting factors
• Takes time to take effect (48 to 72 hours)
• Indirect thrombin inhibitors
• Unfragmented heparin (heparin sodium)
• Low molecular weight heparin (enoxaparin, Fragmin)
• Preferred to unfragmented heparin because of greater bioavailability,
higher predictability of dose response, longer ½ life, lower incidence of
bleeding complications
(Lewis et. al., 2019)
DVT: Additional Management
• Often treated with medical management
• May be candidate for TPA: Tissue Plasminogen Activator (tPA, Alteplase)
• Clot buster
• Will discuss more during Stroke week
• Surgical therapy option
• Nursing assessment and management:
• Prevention of DVT
• If DVT occurs, report to physician
• Monitor for signs of bleeding (due to drug therapy)
(Lewis et. al., 2019)
Pulmonary Emboli
Pulmonary Emboli
• Pulmonary embolism is a blockage in one or
more arteries in the lungs
• *arteries in lungs carry deoxygenated blood from
venous system
• Caused by blood clots that travel to lungs from
another part of your body
• most commonly legs (DVT)
(McMillan, 2020)
Pulmonary Emboli: Clinical Manifestations
• Varied and nonspecific
• Classic symptoms ‘Triad’
• Only 20%
• Dyspnea, chest pain, hemoptysis
• Mild to moderate hypoxemia
• Other:
• Cough, crackles, fever, change in mental status, tachycardia, tachypnea,
apprehension, anxiety
(Lewis et. al., 2019)
Pulmonary Emboli
• Figure 30-11. Large embolus
from the femoral vein lying in the
main left and right pulmonary
arteries. (Source: From the
teaching collection of the
Department of Pathology,
University of Texas Southwestern
Medical School, Dallas.)
View JPG
Pulmonary Emboli: Management
• Continuous monitoring (VS, dysrhythmias, pulse oximetry, ABGs)
• Oxygen therapy
• Patient positioning
• bedrest & semi-fowler (facilitates breathing)
• Anticoagulation support
• Fibrinolytics TPA (tissue plasminogen activator) or alteplase (Activase) dissolve clot;
• Heparin (LMWH) prevents further clots but does not dissolve clots
• Pain management
• Cardiopulmonary support (may require intubation & mechanical ventilation)
• Emotional support
(Lewis et. al., 2019)
Venous Ulcers
Venous Ulcers
Caused by chronic venous insufficiency from:
• Vein incompetent, deep vein obstruction, congenital
abnormalities
Clinical Manifestations:
• Leathery
• Edema
• “Brawny” Brownish skin discoloration seen is the
leaking of RBCs (enzymes from RBC breakdown make
skin brown)
• Eczema (dermatitis) - itchy
• Venous ulcers occur above ankle (medial malleolus)
Venous Ulcers: Management
• Compression is an essential treatment
• Various forms of compression stockings available
• Moist environment dressings are also indicated (vs. dry in arterial ulcers)
• Encourage high protein diet, meet nutritional demands
• Avoid standing and sitting for long periods of time
• Elevate legs above the heart (reduce edema)
• Medication available to promote healing
• Teaching: avoid trauma, inspect legs frequently, good foot care
(Lewis et. al., 2019)