Chapter 38 Vascular Disorder

Peripheral Vascular
Diseases
Presented by: Dave Jay Manriquez RN.
Focus on Disorders
of the Aorta
(Relates to Chapter 38, Nursing
Management: Vascular Disorders, in the
textbook)
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Aortic Aneurysms
Definition
Outpouchings or dilations of the
arterial wall
Common problems involving aorta
Occur in men more often than in
women
Incidence with age
Aortic Aneurysms
Etiology and Pathophysiology
May involve the aortic arch, thoracic
aorta, and/or abdominal aorta
Most are found in abdominal aorta below
renal arteries
of aortic aneurysms occur in abdominal aorta
found in thoracic
Most common cause is atherosclerosis
Aortic Aneurysms
Atherosclerotic plaques deposit
beneath the intima
Plaque formation is thought to cause
degenerative changes in the media
Leading to loss of elasticity,
weakening, and aortic dilation
Male gender and smoking stronger
risk factors than hypertension and
diabetes.inflammation and endotheil
Aortic Aneurysms
Classification
True aneurysm
true aneurysm is one that involves all three layers of
the wall of an artery
Further subdivided
Fusiform
Circumferential, relatively uniform in
shape
Saccular
Pouchlike with narrow neck connecting
bulge to one side of arterial wall
Types of Aneurysms
Fig. 38-3
Aortic Aneurysm
Clinical Manifestations
Thoracic aorta aneurysms
Often asymptomatic
Most common manifestation
Deep diffuse chest pain
Pain may extend to the interscapular area
(between the scapul or shoulder blades)
Aortic Aneurysm
Ascending aorta/aortic arch
Produce angina
Hoarseness
If presses on superior vena cava
Decreased venous return can cause
Distended neck veins
Edema of head and arms
Aortic Aneurysm
Abdominal aortic aneurysms (AAA)
Often asymptomatic
Frequently detected
On physical exam
Pulsatile mass in periumbilical area
Bruit may be auscultated
When patient examined for unrelated
problem (i.e., CT scan, abdominal x-ray)
Aortic Aneurysm
AAA, cont
May mimic pain associated with
abdominal or back disorders
May spontaneously embolize plaque
Causing blue toe syndrome
patchy mottling of feet/toes with
presence of palpable pedal pulses
Aortic Aneurysm
Complications
Rupture- serious complication
related to untreated aneurysm
Bleeding may be tamponaded by
surrounding structures, thus preventing
exsanguination and death
Severe pain
May/may not have back/flank ecchymosis
Aortic Aneurysm
Diagnostic Studies
X-rays
Chest - Demonstrate mediastinal silhouette
and any abnormal widening of thoracic
aorta
Abdomen -May show calcification within
wall of AAA
ECG -to rule out MI

Echocardiography
Ultrasonography
Aortic Aneurysm
Diagnostic Studies
CT scan
Most accurate test to determine
MRI
Diagnose and assess the location and
severity
Angiography of Aneurysm
Fig. 38-2
Aortic Aneurysm
Collaborative Care
Goal - prevent aneurysm from
rupturing
Early detection/treatment
imperative
Once detected
Studies done to determine size and
location
Aortic Aneurysm
Collaborative Care
If carotid and/or coronary artery
obstructions present
May need to be corrected before repair
Small aneurysm (<4 cm)

Conservative therapy used
Risk factor modification
Blood pressure
Ultrasound, MRI, CT scan monitoring q 6
months
Aortic Aneurysm
Collaborative Care
5.5 cm is threshold for repair
Intervention at <5.5 cm in women with AAA
Surgical intervention may occur earlier

in
Younger, low risk patients

Rapidly expanding aneurysm
Symptomatic patient
High rupture risk
Aortic Aneurysm
Collaborative Care
Surgical Therapy
If ruptured, emergent surgical
intervention required
33%-94% mortality with ruptured AAAs
Preop
Hydration
Electrolyte, coagulation, hematocrit
stabilized
Endovascular Stent
Fig. 38-5
Nursing Management
Assessment
Thorough history and physical exam
Watch for signs of cardiac,
pulmonary, cerebral, lower
extremity vascular problems
Establish baseline data to compare
postoperatively
Nursing Management
Assessment
Note quality and character of
peripheral pulses and neurologic
status
Mark/document pedal pulse sites and
any skin lesions on lower extremities
before surgery
Nursing Management
Assessment
Monitor for indications of rupture
Diaphoresis
Paleness
Weakness
Tachycardia
Hypotension
Abdominal, back, groin or periumbilical pain

Changes in level of consciousness
Nursing Management
Planning
Overall goals include
Normal tissue perfusion
Intact motor and sensory function
No complications related to surgical
repair
Nursing Management
Nursing Implementation
Health Promotion
Alert for opportunities to teach health
promotion to patients and their
families
Encourage patient to reduce
cardiovascular risk factors
These measure help ensure graft patency
after surgery
Nursing Management
Acute Intervention
Patient/family teaching
Providing support for patient/family
Careful assessment of all body systems
Nursing Management
Acute Intervention
Pre-op teaching
Brief explanation of disease process
Planned surgical procedure
Preop routines
Bowel prep
NPO
Shower
Nursing Management
Acute Intervention
Pre-op teaching
Expectations after surgery
Recovery room, tubes, drains
ICU
Nursing Management
Acute Intervention
Postop
Maintain graft patency

Cardiovascular status
Infection
Neurologic status
Gastrointestinal status
Peripheral perfusion status
Renal perfusion status
Nursing Management
Evaluation
Expected Outcomes
Patent arterial graft with adequate
distal perfusion
Adequate urine output
Normal body temperature
No signs of infection
Aortic Dissection
Occurs most commonly in thoracic aorta
Result of a tear in the intimal lining of
arterial wall
Tear in intimal lining allows blood to

track between intima and media
Creates a false lumen of blood flow
Aortic Dissection
Affects men more often than women
Occurs most frequently between
fourth and seventh decades of life
Acute and life threatening
Mortality rate 90% if not surgically
treated
Aortic Dissection
Tear in intimal lining allows blood to
track between intima and media
Creates a false lumen of blood flow
Aortic Dissection
As heart contracts, each systolic
pulsation pressure on damaged
area
Further dissection
May occlude major branches of aorta
Cutting off blood supply to brain,
abdominal organs, kidneys, spinal cord,
and extremities
Dissection of Thoracic Aorta
Aortic Dissection
Depend on location of intimal tear
and extent of dissection
Pain characterized as
Sudden, severe pain, in anterior part of
chest or intrascapular pain radiating
down spine to abdomen or legs
Described as tearing or ripping
May mimic that of MI
Aortic Dissection
Depend on location of intimal tear
and extent of dissection
Pain characterized as
Sudden, severe pain, in anterior part of
chest or intrascapular pain radiating
down spine to abdomen or legs
Described as tearing or ripping
May mimic that of MI
Aortic Dissection
Complications
Aorta may rupture
Results in exsanguination and death
Hemorrhage may occur in

mediastinal, pleural, or abdominal
cavities
Occlusion of arterial supply to vital
organs
Aortic Dissection
Diagnostic Studies
Health history and physical exam

ECG
Echocardiogram
Chest x-ray
May show widening of mediastinal silhouette
and left pleural effusion
MRI or multi-detector row CT scan

Aortic Dissection
Collaborative Care
Initial goal
BP and myocardial contractility to
diminish pulsatile forces within aorta
Aortic Dissection
Collaborative Care
Drug therapy
IV -adrenergic blocker
Esmolol (Brevibloc)
Other hypertensive agents

Calcium channel blockers
Sodium Nitroprusside
Angiotensin-converting enzyme
Aortic Dissection
Collaborative Care
Conservative therapy
If no symptoms
Can be treated conservatively for a period
of time
Success of the treatment judged by

relief of pain
Emergency surgery is needed if
involves ascending aorta
Aortic Dissection
Nursing Management
Preop
Semi-Fowlers position
Maintaining a quiet environment
Anxiety and pain management
Opioids and tranquilizers as ordered
Continuous IV administration of
antihypertensive agents
Aortic Dissection
Nursing Management
Preop, continued
Continuous ECG and intraarterial
pressure monitoring
Observation of changes in quality of
peripheral pulses
Frequent vital signs
Aortic Dissection
Nursing Management
Postop
See aneurysm postop care (discussed
earlier)
Discharge teaching
Therapeutic regimen
Antihypertensive drugs and side effects
If pain returns or symptoms progress,

instruct patient to seek immediate help
Arteries
are thick-walled vessels that transport 02 and blood via
the aorta from the heart to the tissues
3 Layers of Arteries
1. inner layer of endothelium (intima)
2. middle layer of connective tissue, smooth muscle and elastic
fibers (media)
3.outer layer of connective tissue (adventitia)
. have smooth muscles that contracts & relaxes to respond
changes in blood volume.
Veins
are thin-walled vessels that transport deoxygenated blood
from the capillaries back to the right side of the heart
3 Layers intima, media, adventitia
there is little smooth muscle &
connective tissue makes
the veins more distensible
they accumulate large volumes of blood
Major veins, particularly in the lower
extremities, have one-way valves
---allow blood flow against gravity
Valves allow blood to be pumped back
to the heart but prevent it from
draining back into the periphery
Peripheral Vascular Diseases
charac. by a reduction in blood flow and hence 02 through

the peripheral vessels
when the need of the tissues for 02 exceeds the supply,
areas of ischemia and necrosis will develop
Factors that can contribute to the development of

peripheral vascular disorders :
atherosclerotic changes
thrombus formation
embolization
coagulability of blood
hypertension
inflammatory process/infection
Arterial Insufficiency
there is a deceased blood flow toward the tissues, producing
ischemia
pulses one usually diminished or absent
sharp, stabbing pain occurs because of the ischemia,
particularly with activity
there is interference with nutrients and 02 arriving to the
tissues, leading to ischemic ulcers and changes in the skin.
Venous Insufficiency
there is deceased return of blood from the tissues to the
heart
leads to venous congestion and stasis of blood
pulses are present
lead to edema, skin changes and stasis ulcers
Comparison of characteristics of Arterial & Venous

Disorders
Arterial Disease
Venous Disease
Skin
cool or cold, hairless,

dry, shiny, pallor on
elevation, rubor on
dangling
warm, though,
thickened,
mottled, pigmented
areas
Pain
sharp, stabbing,
worsens w/ activity and
walking, lowering feet
may relieve pain
aching, cramping,
activity and walking
sometimes help,
elevating the feet
relieves pain
Ulcers
severely painful, pale,

gray base, found on
heel, toes, dorsum of
foot
moderately painful, pink

base, found on medial
aspect of the ankle
Pulse
often absent or
diminished
usually present
Edema
infrequent
frequent, esp. at the
Risk Factors
1.
2.
3.
4.
5.
6.
Age (elderly) blood vessels become less elastic, become

thin walled and calcified PVR BP
Sex (male)
Cigarette smoking
nicotine causes vasoconstriction and spasm of the
arteries circulation to the extremities
C02 inhaled in cigarette smoke reduces 02 transport to
tissues
Hypertension cause elastic tissues to be replaced by
fibrous collagen tissue arterial wall become less
distensible resistance to blood flow BP
Hyperlipedimia atherosclerotic plaque
Obesity places added burden on the heart & blood vessels
excess fat contribute to venous congestion
Risk Factors (cont.)

7.
8.
9.
10.
Lack of physical activity

Physical activity promotes muscle contraction
venous return to the heart
aids in development of collateral circulation
Emotional stress stimulates sympathetic N.S. - peripheral
vasoconstriction BP
Diabetes mellitus changes in glucose & fat metabolism
promote the atherosclerotic process
Family history of arthrosclerosis
Arteriosclerosis Obliterans
is a disorder in which there is an arteriosclerotic narrowing

or obstruction of the inner & middle layer of the artery
most common cause of arterial obstructive disease in the
extremities
the lower extremities are involved more than upper
extremities
common site of disease femoral artery, iliac arteries,
popliteal arteries
in a diabetic, the disease becomes more progressive, affects
the smaller arteries and often involves vessels below the
knee
Pathophysiology
Plaque formation on the intimal wall that causes partial or

complete occlusion
Calcification of the medial layer and a gradual loss of
elasticity weakens the arterial walls
predisposes to aneurysm, dilation or thrombus formation
artery is unable to transport an adequate blood volume to

the tissues during exercise or rest
Symptoms appear when the blood vessels can no longer
provide enough blood to supply 02 and nutrients and remove
metabolic waste products
Intermittent claudication most common

pain in the extremity that develops in a muscle that has an
inadequate blood supply during exercise
the cramping pain disappear w/in 1-2 mins. after stopping
the exercise or resting
the femoral artery is often affected pain in the calf
muscle common symptom
pain at rest is indicative of severe disease
gnawing, burning pain, occur more frequently at night
feelings of coldness
numbness
tingling sensation
advanced arteriosclerosis obliterans ischemia may lead to
necrosis, ulceration and gangrene toes and distal foot
Diagnostic Tests
Doppler ultrasonography high frequency sound waves

directed to artery or veins through a hand-held transducer
moved evenly across skin surface
audible tone produced in proportion to blood velocity
measure blood flow through vessels
Management
directed toward prevention of vessel occlusion
use of vasodilators
Surgical intervention in advanced disease ischemic changes
and pain severely impairs activity
Embolectomy
removal of a blood clot, done when large arteries are
obstructed
Endarterectomy
is removal of a blood clot and stripping of atherosclerotic
plaque along with the inner arterial wall.
Arterial by-pass surgery
an obstructed arterial segment may be bypassed by using
a prosthetic material (Teflon) or the pts. own artery or
vein (saphenous vein)
Endarterectomy
Management
Percutaneous Transluminal Angioplasty

The balloon tip of the catheter is inflated to provide
compression of the plaque
Amputation
with advanced atherosclerosis & gangrene of extremities
toes are the most often amputated part of the body
The surgical goal is the remove the least amt. of tissue
possible and create a stump adequate for the fitting of a
prosthesis
Assessment
condition of the skin: shiny, taut, absence of hair growth

(indicates poor circulation)
ulcerations/ necrotic tissues
Extremely cold to touch
Peripheral pulses: diminished, weak, absent, bilateral inequality
Grading 0 absent
1+ weak & thready
2+ normal
3+ full & bounding
Prolonged (> 3 sec.) or absent capillary refill of nailbeds
loss of muscle tone or weakness
Nursing Interventions
prevent further progression of existing disease
Acute care
monitor the limb distal to the affected site for changes in

color or temperature
arterial flow pale & cool (initially) bluish/darker
tissue become necrotic & black
activities that cause pain should be avoided
give vasodilators if prescribed relaxation of vascular
smooth muscle decreases the pain
comfort measures proper body positioning to dec. pressure
on affected area
Post operative care for arterial

surgery
1.
2.
pt. is monitored for signs of circulation in the affected limb

and interventions done to promote circulation & comfort
Assess and report changes in skin color and temperature distal
to the surgical site, every 2-4 hrs.
assess peripheral pulses
sudden absence of pulse may indicate thrombosis

mark location of pulse with a pen to facilitate frequent assessment
use a dapper if pulse in difficult to palpate
3.
4.
5.
assess wound for redness, swelling and drainage

promote circulation
reposition pt. every 2 hrs.
tell pt. not to cross legs
encourage progressive activity when permitted
medication with analgesics to reduce pain
Arterial by-pass surgery

Post-operative care
assess sensation and movement of the limb
monitor extremity for edema
monitor & report signs of complications increase pain,
fever, limitation of movement or paresthesia
avoid sharp flexion in the area of the graft to prevent
decreased circulation to the graft.
Thromboangitis Obliterans
( Buergers Disease)
characterized by acute inflammatory lesions and occlusive

thrombosis of the arteries & veins
has a very strong assoc. with cigarette smoking
commonly occurs in male bet. 20-40 y.o
may involve the arteries of the upper extremities (wrists)
usually affect the lower leg. toes, feet
Clinical Manifestation
intermittent claudication in the arch of the foot

pain during rest toes
coldness due to persistent ischemia
paresthesia
pulsation in posterior tibial, dorsalis pedis weak or absent
extremities are red or cyanotic
ulceration & gangrene are frequent complications early
can occur spontaneously but often follow trauma
Thromboangitis Obliterans
Interventions
advise the person to stop smoking

vasodilators
prevent progression of disease
avoid trauma to ischemic tissues
relieve pain
provide emotional support
whiskey or brandy may be of some value during periods of
exacerbations vasodilation
advise pt. to avoid mechanical, chemical or thermal injuries
to the feet
Amputation of the leg is done only when the ff. occurs:
gangrene extends well into the foot
pain is severe and cannot be controlled
severe infection or toxicity occurs
Raynauds phenomenon
refers to intermittent episodes during which small arteries

or arterioles of L and R arm constrict (spasm) causing
changes in skin color and temperature
generally unilateral and may affect only 1 or 2 fingers
may occur after trauma, neurogenic lesions, occlusive
arterial disease, connective tissues disease
charac. by reduction of blood flow to the fingers manifested
by cutaneous vessel constriction and resulting in blanching
(pallor)
Raynauds Disease
unknown etiology, may be due to immunologic abnormalities

common in women 20-40 y.o
maybe stimulated by emotional stress, hypersensitivity to
cold, alteration in sympathetic innervation
Raynauds Disease
usually bilateral (both arms or feet are affected)

during arterial spasm sluggish blood flow causes pallor,
coldness, numbness, cutaneous cyanosis and pain
following the spasm the involve area becomes intensely
reddened with tingling and throbbing sensations
with longstanding or prolonged Raynauds disease
ulcerations can develop on the fingertips and toes
Raynauds Disease
Medical Management
aimed at prevention
person is advised to protect against exposure to cold
quit smoking
Drug therapy calcium channel blockers, vascular smooth
muscle relaxants, vasodilators to promote circulation and
reduce pain
sympathectomy ( cutting off of sympathetic nerve fibers)
to relieve symptoms in the early stage of advanced
ischemia
if ulceration/gangrene occur, the area may need to be
amputated
Nursing Interventions
similar to other arterial disorders

collect data on effect of assoc. factors emotional stress,
exposure to cold, cigarette smoking
prevent injury, promote circulation
provide comfort
teach pt. on effects of smoking, advise to quit
discuss ways of avoiding exposure to cold
wear adequate clothing to promote warmth
wear gloves and socks
use caution when cleaning ref. & freezer
wear gloves when handling frozen foods
avoid drugs that will cause vasoconstriction (birth control
pills, ergotamine)
suggest anti-inflammatory analgesics to promote comfort
Aneurysm
is a localized or diffuse enlargement of an artery at some

point along its course
can occur when the vessel becomes weakened from trauma,
congenital vascular disease, infection or atherosclerosis
Pathophysiology
enlargement of a segment of an artery the tunica media
(middle layer composed of smooth muscle & elastic tissue) is
damaged progressive dilation, degeneration risk of
rupture
* most common site is the aorta
may develop in any blood vessel
Types of Aneurysm
Saccular aneurysm involves only part of the
circumference of the artery, it takes the form of a sac or
pouch-like dilation attached to the side of the artery
2. Fusiform aneurysm spindle shaped, involves the entire
circumference of the arterial wall
3. Dissecting aneurysm involves hemorrhage into a vessel
wall, which splits and dissects the wall causing a widening of
the vessel
caused by degenerative defect in the tunica media and
tunica intima
Diagnostic Tests
. chest & abdominal x-rays helpful in preliminary diagnosis
of aortic aneurysm
. Ultrasound is useful in determining the size, shape and
location of the aneurysm
1.
Throracic Aortic Aneurysm

aneurysm in the thoracic area
occur most frequently in hypertensive men bet. 40-70 y.o
can develop in the ascending, transverse or descending aorta
S/Sx
chest pain most frequent; perceived when pt. is in a supine
position
cough
related to the pressure of the sac of
dyspnea
aneurysm pressing against internal
hoarseness
structures
dysphagia
Abdominal Aortic Aneurysm

most common site for the formation of an aortic aneurysm
abdominal aorta below the renal arteries
S/Sx:
presence of a pulsatile abdominal mass on palpation
pain or tenderness in the mid-or upper abdomen
the aneurysm may extend to impinge on the renal, iliac, or
mesenteric arteries
stasis of blood favors thrombus formation along the wall
of the vessel
Rupture of the aneurysm most feared complication
can occur if the aneurysm is large
can lead to death
Tx: Surgery resection of the lesion and replacement with a
graft
Arterial Embolism
blood clots floating in the circulating arterial blood.
the embolus is frequently a fragment of arterioscherotic
plaque loosened from the aorta
emboli will tend to lodge in femoral or popliteal arteries,
blood flow is impaired and ischemia develops
Clinical manifestations:
S/Sx depends on the size of the embolus, the presence of
collateral circulation and if it is close to a major organ
abrupt onset of severe pain from the sudden cessation of
circulation
muscular weakness and burning, aching pain occur
distal pulses are absent and extremity becomes cold, numb
and pale
symptoms of shock may develop if the embolus blocks a large
artery
Medical Management
bed rest
anticoagulants prolong the clotting time of the blood and are
used to prevent clot extension and new clot formation
Ex. 1. heparin inhibits thrombin action prevents clotting
IV or SQ, antidote Protamine sulfate
2. Warfarin sodium inhibits Vit. K dependent clotting factor
(Coumadin)
synthesis, prothrombin activity
- oral (10-15 mg/day) antidote Vit. K
Fibrinolytics or thrombolytics are useful for dissolving existing
thrombus or clot when rapid dissolution of the clot is required to
preserve organ and limb function
Ex. Streptokinase, Urokinase IV side effect - bleeding
Embolectomy surgical removal of a blood clot, when large
arteries are obstructed
must be performed w/in 6-10 hrs. to prevent muscle necrosis
and loss of the extremity
Nursing Management
Monitor the pt. during the acute phase for changes in color &
temp. of the extremity distal to the clot
assess for increasing pallor, cyanosis, coldness of the skin
indicates vessel occlusion
keep the extremity warm, but do not apply heat, avoid chilling
monitor peripheral pulses quality weak/absent
CBR - to prevent further progression of the embolism
keep affected extremity flat or slightly dependent position to
promote circulation
monitor anticoagulant or fibrinolytic therapy & assess for signs of
bleeding nose or gum bleeding , petechiae (pinpoint red areas on
skin), ecchymosis (bruising) , hematoma formation
monitor urine, stool, emesis and gastric secretions for blood
avoid IM injections, use soft toothbrush, use electric razor
rather than razor blade, avoid rectal thermometer
Venous Disorders
alteration in the transport/flow of blood from the capillary

back to the heart
changes in smooth muscle and connective tissue make the
veins less distensible with limited recoil capacity
valves may malfunction, causing backflow of blood
Virchows triad: blood stasis, vessel wall injury, and
altered blood coagulation
Thrombophlebitis
inflammation of the veins caused by thrombus or blood clot
Factors assoc. with the devt. of Thrombophlebitis
venous stasis
damage to the vessel wall
hypercoagulability of the blood oral contraceptive use
common to hospitalized pts. , undergone major surgery
(pelvic or hip surgery), MI
Pathophysiology
develops in both the deep and superficial veins of the lower
extremity
deep veins femoral, popliteal, small calf veins
superficial veins saphenous vein
Thrombus form in the veins from accumulation of platelets,
fibrin, WBC and RBC
Deep Vein Thrombosis (DVT)

tends to occur at bifurcations of the deep veins, which are sites
of turbulent blood flow
a major risk during the acute phase of thrombophlebitis is
dislodgment of the thrombus embolus
pulmonary embolus is a serious complication arising from DVT
of the lower extremities
Clinical Manifestations:
pain and edema of extremity obstruction of venous flow
circumference of the thigh or calf
(+) Homans sign dorsiflexion of the foot produces calf pain
Do not check for the Homans sign if DVT is already known to be
present risk of embolus formation
* if superficial veins are affected - signs of inflammation may
be noted redness, warmth, tenderness along the course of the
vein, the veins feel hard and thready & sensitive to pressure
Deep Vein
Thrombosis
(DVT)
Medical Management
Superficial thrombophlebitis
bed rest with legs elevated
apply moist heat
NSAIDs ( Non steroidal anti-inflammatory drugs) - aspirin
Deep vein thrombosis
requires hospitalization
bed rest w/ legs elevated to 15-20 degrees above heart level
( knees slightly flexed, trunk horizontal (head may be raised) to
promote venous return and help prevent further emboli and prevent
edema
application of warm moist heat to reduce pain, promotes venous return
elastic stocking or bandage
anticoagulants, initially with IV heparin then coumadin
fibrinolytic to resolve the thrombus
vasodilator if needed to control vessel spasm and improve circulation
Surgery
if the thrombus is recurrent and extensive or if the pt. is at

high risk for pulmonary embolism
Thrombectomy incising the common femoral vein in the
groin and extracting the clots
Vena caval interruption transvenous placement of a grid or
umbrella filter in the vena cava to block the passage of
emboli
Assessment
characteristic of the pain
onset & duration of symptoms
history of thrombophlebitis or venous disorders
color & temp. of extremity
edema of calf of thigh - use a tape measure, measure both
legs for comparison
Nursing Intervention
Preventive care
prevent long periods of standing or sitting that impair

venous return
elevate legs when sitting, dorsiflex feet at regular intervals
to prevent venous pooling
if edema occurs, elevate above heart level
regular exercise program to promote circulation
avoid crossing legs at the knees
avoid wearing constrictive clothing such as tight bands
around socks or garters
use elastic stocking on affected leg
do leg exercises during periods of enforced immobility such
as after surgery
Nursing Management
Acute care
explain purpose of bed rest and leg elevation
use elastic stockings
monitor pt. on anticoagulant & fibrinolytic therapy for signs of
bleeding
monitor for signs of pulmonary embolism sudden onset of chest
pain, dyspnea, rapid breathing, tachycardia
Nsg. intervention often surgery of vena caval interruption
assess insertion site bleeding, hematoma, apply pressure over
site and inform physician
keep pt. on bed rest for 1st 24 hrs. then encourage ROM
exercises to promote venous return
assist pt. in ambulation when permitted, elevate legs when sitting
keep elastic bandage
avoid rubbing or massaging the affected extremity
give analgesic and anti-inflammatory agents to promote comfort
Chronic Venous Insufficiency
Results from obstruction of venous valves in legs

or reflux of blood back through valves
Venous ulceration is serious complication
Pharmacological therapy is antibiotics for
infections
Debridement to promote healing
Topical Therapy may be used with cleansing and
debridement
Venous ulceration
Varicose Veins
are abnormally dilated veins with incompetent valves,
occurring most often in the lower extremities
usually affected are woman 30-50 years old.
Causes:
congenital absence of a valve
incompetent valves due to external pressure on the veins
from pregnancy, ascites or abdominal tumors
sustained in venous pressure due to CHF, cirrhosis
Prevention
wear elastic stockings during activities that require long
standing or when pregnant
moderate exercise, elevation of legs
Pathophysiology
the great and small saphenous veins are most often involved
weakening of the vein wall does not withstand normal pressure
veins dilate , pooling of blood
valves become stretched and incompetent
more accumulation of blood in the veins
Primary varicosities gradual onset and affect superficial

veins, appearance of dark tortuous veins
S/sx dull aches, muscle cramps, pressure, heaviness or
fatigue arising from reduced blood flow to the tissues
Secondary Varicosities affect the deep veins
occur due to chronic venous insufficiency or venous
thrombosis
S/sx edema, pain, changes in skin color, ulcerations may
occur from venous stasis
Trendelenburg test
assess competency of venous valves through measurement
of venous filling time
the pt. lies down with the affected leg raised to allow for
venous emptying
a tourniquet is then applied above the knee and the pt.
stands. The direction and filling time are recorded both
before & after the tourniquet is removed
* Incompetent valves are evident when the veins fill rapidly
from backward blood flow
Surgical Intervention
indicated or done for prevention or relief of edema, for

recurrent leg ulcers or pain or for cosmetic purposes
Vein ligation and stripping
the great sapheneous vein is ligated (tied) close to the
femoral junction
the veins are stripped out through small incisions at the
groin, above & below the knee and at the ankles.
sterile dressing are placed over the incisions and an elastic
bandage extending from the foot to the groin is firmly
applied
Vein ligation and

stripping
Nursing care after vein ligation & stripping
Monitor for signs of bleeding, esp. on 1st post-op day

if there is bleeding, elevate the leg, apply pressure over
the wound and notify the surgeon
Keep pt. flat on bed for first 4 hrs. after surgery, elevate
leg to promote venous return when lying or sitting
Medicate 30 mins. before ambulation and assist patient
Keep elastic bandage snug and intact, do not remove bandage
Veins
are thin-walled vessels that transport
deoxygenated blood
from the capillaries back to the right side
of the heart
3 Layers intima, media, adventitia
there is little smooth muscle &
connective tissue makes
the veins more distensible
they accumulate large volumes of blood
Major veins, particularly in the lower
extremities, have one-way valves
---allow blood flow against gravity
Valves allow blood to be pumped back
to the heart but prevent it from
draining back into the periphery
Vein Disorders
Venous Thrombosis (Superficial
and Deep Vein Thrombosis),
Thrombophlebitis,
Phlebothrombosis
Varicose Veins
Venous Disorders
alteration in the transport/flow of blood from
the capillary back to the heart
changes in smooth muscle and connective
tissue make the veins less distensible with
limited recoil capacity
valves may malfunction, causing backflow of
blood
Virchows triad: blood stasis, vessel wall injury,
and altered blood coagulation
Thrombophlebitis
inflammation of the veins caused by thrombus or
blood clot
Factors assoc. with the devt. of Thrombophlebitis
venous stasis
damage to the vessel wall
hypercoagulability of the blood oral contraceptive
use
common to hospitalized pts. , undergone major
surgery (pelvic or hip surgery), MI
Pathophysiology
develops in both the deep and superficial veins of
the lower extremity
deep veins femoral, popliteal, small calf veins
superficial veins saphenous vein
Thrombus form in the veins from accumulation of
platelets, fibrin, WBC and RBC

tends to occur at bifurcations of the deep veins, which are sites
of turbulent blood flow
a major risk during the acute phase of thrombophlebitis is
dislodgment of the thrombus embolus
pulmonary embolus is a serious complication arising from
DVT of the lower extremities
Clinical Manifestations:
pain and edema of extremity obstruction of venous flow
circumference of the thigh or calf
(+) Homans sign dorsiflexion of the foot produces calf pain
Do not check for the Homans sign if DVT is already known to
be present risk of embolus formation
* if superficial veins are affected - signs of inflammation may be
noted redness, warmth, tenderness along the course of the
vein, the veins feel hard and thready & sensitive to pressure
Diagnostic Evaluation
Noninvasive Techniques:
Doppler Ultrasonography
Duplex Venous Imaging
Impedance Plethysmography
Invasive Techniques
I-labeled Fibrinogen Scanning
Contrast Phlebography
Medical Management
Superficial thrombophlebitis
bed rest with legs elevated
apply moist heat
NSAIDs ( Non steroidal anti-inflammatory drugs) - aspirin
Deep vein thrombosis
requires hospitalization
bed rest w/ legs elevated to 15-20 degrees above heart level
( knees slightly flexed, trunk horizontal (head may be
raised) to promote venous return and help prevent further
emboli and prevent edema
application of warm moist heat to reduce pain, promotes
venous return
elastic stocking or bandage
anticoagulants, initially with IV heparin then coumadin
fibrinolytic to resolve the thrombus
vasodilator if needed to control vessel spasm and improve
circulation
Nursing Assessment
characteristic of the pain
onset & duration of symptoms
history of thrombophlebitis or venous disorders
color & temp. of extremity
edema of calf of thigh - use a tape measure, measure
both legs for comparison
Identify areas of tenderness and any thrombosis
Surgery
if the thrombus is recurrent and extensive or if the pt.
is at high risk for pulmonary embolism
Thrombectomy incising the common femoral vein
in the groin and extracting the clots
Vena caval interruption transvenous placement of a
grid or umbrella filter in the vena cava to block the
passage of emboli
Nursing Intervention
Preventive care
prevent long periods of standing or sitting that
impair venous return
elevate legs when sitting, dorsiflex feet at regular
intervals to prevent venous pooling
if edema occurs, elevate above heart level
regular exercise program to promote circulation
avoid crossing legs at the knees
avoid wearing constrictive clothing such as tight
bands around socks or garters
use elastic stocking on affected leg
do leg exercises during periods of enforced
immobility such as after surgery
Nursing Management
Acute care
explain purpose of bed rest and leg elevation
use elastic stockings
monitor pt. on anticoagulant & fibrinolytic therapy for signs of
bleeding
monitor for signs of pulmonary embolism sudden onset of
chest pain, dyspnea, rapid breathing, tachycardia
Nsg. intervention often surgery of vena caval interruption
assess insertion site bleeding, hematoma, apply pressure
over site and inform physician
keep pt. on bed rest for 1st 24 hrs. then encourage ROM
exercises to promote venous return
assist pt. in ambulation when permitted, elevate legs when
sitting
keep elastic bandage
avoid rubbing or massaging the affected extremity
give analgesic and anti-inflammatory agents to promote comfort

Results from obstruction of venous
valves in legs or reflux of blood back
through valves
Venous ulceration is serious
complication
Pharmacological therapy is antibiotics
for infections
Debridement to promote healing
Topical Therapy may be used with
cleansing and debridement
Venous ulceration
Varicose Veins
are abnormally dilated veins with incompetent valves,
occurring most often in the lower extremities
usually affected are woman 30-50 years old.
Causes:
congenital absence of a valve
incompetent valves due to external pressure on the
veins from pregnancy, ascites or abdominal
tumors
sustained in venous pressure due to CHF,
cirrhosis
Prevention
wear elastic stockings during activities that require
long standing or when pregnant
moderate exercise, elevation of legs
Pathophysiology
the great and small
saphenous veins are most
often involved
weakening of the vein wall
does not withstand normal
pressure
veins
dilate , pooling of blood
valves become stretched

and incompetent
more
accumulation of blood in the
veins
Primary varicosities gradual onset and
affect superficial veins, appearance of dark
tortuous veins
S/sx dull aches, muscle cramps, pressure,
heaviness or fatigue arising from reduced
blood flow to the tissues
Secondary Varicosities affect the deep
veins
occur due to chronic venous insufficiency or
venous thrombosis
S/sx edema, pain, changes in skin color,
ulcerations may occur from venous stasis
Diagnostic Evaluation
A. Bordie-Trendelenburg test
assess competency of venous valves
through measurement of venous filling time
the pt. lies down with the affected leg raised
to allow for venous emptying
a tourniquet is then applied above the knee
and the pt. stands. The direction and filling
time are recorded both before & after the
tourniquet is removed
* Incompetent valves are evident when the
veins fill rapidly from backward blood flow
B. Perthes test
C.Additional tests for the presence
of Varicose Veins are the Doppler
flow meter, Phlebography, and
Plethysmography.
Surgical Intervention
indicated or done for prevention or relief of
edema, for recurrent leg ulcers or pain or for
cosmetic purposes
the great sapheneous vein is ligated (tied)
close to the femoral junction
the veins are stripped out through small
incisions at the groin, above & below the
knee and at the ankles.
sterile dressing are placed over the incisions
and an elastic bandage extending from the
foot to the groin is firmly applied
Nursing care after vein ligation &

stripping
Monitor for signs of bleeding, esp. on 1st
post-op day
if there is bleeding, elevate the leg, apply pressure
over the wound and notify the surgeon
Keep pt. flat on bed for first 4 hrs. after

surgery, elevate leg to promote venous
return when lying or sitting
Medicate 30 mins. before ambulation and
assist patient
Keep elastic bandage snug and intact, do not
remove bandage
Reference:
Suzanne C. Smeltzer and Brenda G.
Bare. Brunner and Suddarths Textbook of
Medical-Surgical Nursing, 7th ed.
Philadelphia: J.B. Lippincott Company ,
1992. pp. 766-776
~ thank you ~
Presented by: Dave Jay S. Mariquez RN.

Chapter 38 Vascular Disorder

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Chapter 38 Vascular Disorder

Загружено:

Авторское право:

Доступные форматы

Peripheral Vascular

Most common cause is atherosclerosis

ECG -to rule out MI

Small aneurysm (<4 cm)

Surgical intervention may occur earlier

Younger, low risk patients

Abdominal, back, groin or periumbilical pain

Maintain graft patency

Tear in intimal lining allows blood to

Dissection of Thoracic Aorta

Hemorrhage may occur in

Health history and physical exam

MRI or multi-detector row CT scan

Other hypertensive agents

Success of the treatment judged by

If pain returns or symptoms progress,

Peripheral Vascular Diseases

charac. by a reduction in blood flow and hence 02 through

Factors that can contribute to the development of

Comparison of characteristics of Arterial & Venous

cool or cold, hairless,

severely painful, pale,

moderately painful, pink

frequent, esp. at the

Age (elderly) blood vessels become less elastic, become

Risk Factors (cont.)

Lack of physical activity

is a disorder in which there is an arteriosclerotic narrowing

Plaque formation on the intimal wall that causes partial or

artery is unable to transport an adequate blood volume to

Intermittent claudication most common

Doppler ultrasonography high frequency sound waves

Percutaneous Transluminal Angioplasty

condition of the skin: shiny, taut, absence of hair growth

prevent further progression of existing disease

monitor the limb distal to the affected site for changes in

Post operative care for arterial

pt. is monitored for signs of circulation in the affected limb

sudden absence of pulse may indicate thrombosis

assess wound for redness, swelling and drainage

Arterial by-pass surgery

characterized by acute inflammatory lesions and occlusive

intermittent claudication in the arch of the foot

advise the person to stop smoking

refers to intermittent episodes during which small arteries

unknown etiology, may be due to immunologic abnormalities

usually bilateral (both arms or feet are affected)

similar to other arterial disorders

is a localized or diffuse enlargement of an artery at some

Throracic Aortic Aneurysm

Abdominal Aortic Aneurysm

alteration in the transport/flow of blood from the capillary

Deep Vein Thrombosis (DVT)

if the thrombus is recurrent and extensive or if the pt. is at

prevent long periods of standing or sitting that impair

Chronic Venous Insufficiency

Results from obstruction of venous valves in legs

veins dilate , pooling of blood

valves become stretched and incompetent

more accumulation of blood in the veins

Primary varicosities gradual onset and affect superficial

indicated or done for prevention or relief of edema, for

Vein ligation and

Nursing care after vein ligation & stripping