Vascular Disorders

THROMBOPHLEBITIS superficial: iatrogenic from intravenous catheter or infusion of caustic solution Deep vein thrombosis thrombophlebitis of the deep vein more in women than in men develops in patients older than 40 yrs old associated with major surgery,orthopedic surgery and acute MI high risk in clients with canceror history of clotting disorders Risk factors for thrombus formation venous stasis from varicose veins, HF and immobility Hypercoagulability disorders Injury to the venous wall from IV injections, fractures, trauma Following hip surgery and open prostate surgery pregnancy Ulcerative colitis Use of oral contraceptives Pathophysiology Inactive legs or pump is ineffective blood pooling in the veins Thrombus formation if large, cause obstruction( large vein)increase in the venous pressure and volumeinflammation destruction of vein valvesvenous insufficiency and post phlebitic syndrome Prevention Leg exercise and ambulation Passive leg contractions

Using sequential compression devices(SCD) Elevation of the foot of the bed Apply compression stockings Passive ROM meds to decrease hypercoagulabilty: warfarin, plt antiaggregation agents(aspirin, heparin)

Clinical manifestations Superficial thrombophlebitis o Redness, induration, calor and dolor Deep vein thrombosis o Unilateral leg swelling o Pain, redness, warmth of the leg o Dilated veins o Low grade fever o Homans sign Diagnostic test Venous duplex scanning Venography D-dimer blood test Plethysmography

Medical Management: detect thrombus early, prevent extension or embolization of thrombus Nursing management Promote venous return o elevation of legs o trendelenburg position o Elastic bandages Reduce discomfort Monitor anticoagulant therapy Monitor for pulmonary embolism Surgical management Thrombectomy VARICOSE VEINS
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Vascular Disorders
permanently distended veins due to loss of vascular competence Faulty valves elevate venous pressure causing distention and tortousity Common sites: saphenous veins and perforator vein Primary type: congenital or familial predisposition Secondary varicosities: due to trauma, obstruction, DVT or inflammation Prevalence increase with age and peaks at fifth to sixth decade of life More common in women Caused by prolonged standing Manifestation Aching with heaviness in the legs Itching Moderate swelling Superficial inflammation Nursing and medical Management Below the knee compression stockings Avoid standing in one position for extended periods of time Legs should be elevated when seated If (+) swelling elevate higher than the heart Wear elastic stockings or support hose Surgical management Sclerotherapy Vein ligation and stripping Saphenofemoral ligation CHRONIC VENOUS INSUFFICIENCY postphlebitic syndrome due to dysfunction of the valve causing reduction in venous return and venous stasis Manifestation o Chronically swollen legs o Thick , coarse, brownish skinaround the ankles o Venous stasis ulceration o Itchy, scaly skin

Management o Elevation of legs above the heart level o Avoid crossing the legs, o Avoid sitting in chairs to high to allow the feet to touch the floor o Wear garters or tight stockings o Elastic hose o Elastic wraps ARTERIAL DISORDERS PERIPHERAL ARTERY DISORDERS disorders of arterial, venous and lymphatic system Etiologic and Risk Factors o Atherosclerosis o Phlebitis o surgery o autoimmune disease Lower limbs are susceptible to arterial occlusion Acute occlusion caused by embolism, thrombus, trauma, vasospasm or edema Claudication is insidious in onset and generally occurs in men and in menopause women Pathophysiology Athrosclerosis decreased oxygenated blood(tissues) collateral circulation develop slowly vasodilation and anaerobic pathway develops (+) pyruvic acid and lactic acid byproduct intermittent claudication Clinical manifestation intermittent claudication rest pain Paresthesia
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Dependent rubor Aortoiliac stenosis and occlusion Impotence in Males ( Leriche syndrome) edema pulselessness of dorsalis pedis artery Diagnostic tests Hemoglobin level BUN and Creatinine sodium Lipid profile coagulation test Doppler ultrasound Transcutaneous oximetry treadmill examination Arteriography: definitive examination d. Risk for activity intolerance Surgical Management of PVD Revascularization 1. Endovascular intervention include angioplasty, atherectomy and stent placement Goal; remove blockages 2. Arterial bypass used to revascularized limbs arteriography done prior to artery bypass preop care: Assessment of cardiac and pulmonary function Hypertension should be controlled post op care: bed rest with leg flat on bed Complication- bleeding, compartment syndrome ACUTE ARTERIAL OCCLUSION caused by trauma, embolism or thrombosis 90% in the lower limbs Obstruction in artery from thrombus w/in the heart Etiology 1. atrial fibrillation 2. myocardial infarction 3. prosthetic heart valves 4. RHD 5. platelet emboli can initiate thrombus 6. Atheromatous emboli: small arteries In lower extremity emboli lodge on superficial femoral or popliteal artery Pathophysiology Acute occlusion decrease mean and pulse pressure decrease tissue perfusion and oxygenation Arterial thrombosis: obstruction by a blood clot
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Medical Management Goal: reduce progression of arterial disease, to promote artrial flow and save the limb of the client Reduce risk 1. Smoking cessation 2. Skin care meticulous care of the feet 4. Exercise 5. Dietary changes low fat, low cholesterol diet more fruits and vegetables 6. Promote Arterial flow Pentoxyfylline Cilostazol Clopidogrel Nursing management 1. Ineffective Tissue perfusion Interventions: a. promote arterial flow b. Prevent vasoconstriction Acute pain Interventions: a. Avoid standing in one position b. Avoid crossing the legs at the knees c. Risk for impaired skin integrity

Vascular Disorders
develop in popliteal artery aneurysm Arterial emboli: Form in the terminal end of the artery Lead to distinct areas of necrotic tissues Clinical manifestations 1. Pain or loss of sensation 2. Pulselessness 3. Poikilothermia 4. Pallor 5. paresthesia and loss of position sense 6. Paralysis Intervention Surgery o arterial embolism: embolectomy o Thrombosis: reconstruction for revascularization of the leg Anticoagulants ( heparin) Fibrinolytic agents ARTERIAL ULCERS area of ischemic foot or leg Site: medial and lateral metatarsal o heads of the tip of the toes Painful with sharp edge and pale base Surrounded by atrophic tissues Heals poorly ARTERIAL ULCERS Management Patient can undergo limb amputation Skin grafting Arterial bypass surgery Bed rest Debridement ANEURYSM permanent localized dilation, stretching of an artery Cause: unknown Risk factors o atherosclerosis o hypertension o infection( bacterial or fungal) o weakening of connective tissues of arterial wall o trauma Location: thoracic and abdominal aorta, iliac arteries and popliteal arteries Venous or arterial in origin Classification 1. True aneurysm saccular fusiform dissecting 2. False aneurysm Abdominal aneurysm Most common type 40-70 yrs old Asymptomatic Seen in abdominal x ray or physical assessment Palpated if 5 cms in size Pulsating mass in the abdomen Abdominal pain and back pain Mottling of extremities Definitive Dx: UTZ or CT scan Management Medical: (asymptomic)Antihypertensiv es Types of Surgical management: resection- definitive treatment Endovascular procedure Aneurysm repair Complication of surgery: prerenal failure, emboli, spinal cord ischemia, change in sexual function Nursing Management 1. Risk for hemorrhage monitor for signs of bleeding
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Monitor increase in PR, BP, clammy skin, restlessness, decreasing LOC, pallor, cyanosis, thirst, oliguria Monitor chest tube output and chest pain Monitor CVP., left atrial pressure, pulmonary artery pressure and pCWP 2. Risk for gas exchange Monitor setting of ventilator Assess lung sound 3. Acute pain Opioids via PCA or epidural catheter Assess degree of pain 4. Risk for ischemia of the bowel Maintain adequate I and O Monitor BUN and Crea Keep patient on NPO Rupture of abdominal aortic aneurysm seen in aneurysm 5cm or larger Manifestation Pulsating mass in the abdomen Sudden, severe, persistent or constant pain Abdominal rigidity Manifestation of shock Intervention: surgery AORTIC DISSECTION longitudinal splitting of the medial layer of the aorta most common catastrophe of the aorta dissection occurs following a Tear in the intima of the aortablood follow to arteries are blocked blood flow to organs severed occur in hypertensive men (50-70 yrs old) Etiology and Classification Unknown Marfans Syndrome Types
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Type A: ascending : require surgery Type B: other areas Clinical manifestation Abrupt excruciating pain Pain: ripping or knife like tearing sensation radiating to the back, abdomen, anterior chest and extremities Hypertension Unequal pulses Different pulse pressure in both arms Paraplegia or hemiplegia Decreased urine output or hematuria Mental status change Diagnostics Chest x ray Transesophageal echocardiography CT or MRI Complications Cardiac tamponade Ischemia of organs Management Vasodilators Beta blockers Stable patient: reduce pain( opioids) Blood transfusion Surgery: unstable patient Semi fowlers position Tranquilizers Observe pain for further tearing or rupture RAYNAUDS SYNDROME small arteries and arterioles constrict classification: vasospastic or obstructive Vasospastic o Induced by cold, nicotine, caffeine and stress Obstructive
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Vascular Disorders
o Associated with SLE, scleroderma or rheumatoid arthritis benign primary disorder( Raynauds disease) secondary to other diseases ( Raynaud's Phenomenon) seen in men and directly related to smoking maybe autoimmune

Manifestations Classic color changes in the hands Pallor Tissue hypoxia Rubor Criteria for Raynauds disease manifestation for 2 years intermittent attack of pallor or cyanosisof digits by exposure to cold or emotional stimuli bilateral or symmetrical involvement no evidence of occlusive disease gangrene limited to tips of the digit Diagnostics Non invasive blood flow studies Management Keep hand and feet dry and warm Stop smoking Calcium antagonist Reassure patient hat the condition will not lead to permanent disability Encourage to limit intake of caffeine and chocolates BUERGERS DISEASE thromboangiitis obliterans inflammatory disease of the small and medium sized arteries andveins of extremities

Manifestations Pain Ischemia Cold sensitivity Claudication type pain Weak or absent pulsation in posterior tibialis and dorsalis pedis Severe case: cyanosis or red Complication: ulceration and gangrene Edema in severe cases Management o Smoking cessation o Avoid exposure to cold o Adequate pain control o Calcium antagonist o Wound care for ulceration o Amputation HYPERTENSION persistent elevation of the systolic blood pressure at the level of 140mmHg or higher and diastolic blood pressure at the level of 909mmHg or higher common in African Americans end result : heart attack primary(essential) hypertension:90% of all cases secondary Hypertension: due to renal failure Malignant hypertension: resistant or persistent severe hypertension

Non modifiable factors Family history Age Gender Ethnicity Modifiable risk factors Stress
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Vascular Disorders
Obesity Nutrients Substance abuse Pathophysiology Primary hypertension Four control system play a role in maintaining blood pressure 1.Arterial baroreceptor and chemoreceptor 2. regulation of body fluid volume 3. renin angiotensin system 4. vascular auto regulation Secondary hypertension chronic renal disease ( Chronic GN and renal artery stenosis) primary aldosteronism pheochromocytoma Cushings syndrome Vessel changes Sclerosis of large arteries Management Lifestyle modification Weight reduction Sodium restriction Dietary fat modification Exercise Alcohol restriction Caffeine restriction Relaxation techniques Smoking cessation Potassium supplementation Antihypertensive medications o diuretics o alpha and beta adrenergic antagonist o vasodilators o calcium antagonist o ACE inhibitors o angiotensin receptor blockers Hypertensive emergency Blood pressure >180/120 and must be lowered immediately to prevent damage to target organs.
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Hypertensive urgency Blood pressure is very high but no evidence of immediate or progressive target organ damage. HYPERTENSIVE EMERGENCY Reduce BP 25% in first hour Reduce to 160/100 over 6 hours Then gradual reduction to normal over a period of days Exceptions are ischemic stroke and aortic dissection Medications o IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin Need very frequent monitoring of BP and cardiovascular status HYPERTENSIVE URGENCY Patient requires close monitoring of blood pressure and cardiovascular status. Assess for potential evidence of target organ damage. Medications o Fast-acting oral agents: betaadrenergic blocker- labetalol; angiotensin-converting enzyme inhibitors: captopril or alpha2-agonists-clonidine