Download Vascular Problems, Stroke, Aneurysms, and HTN Crisis

Vascular Problems, Stroke,
Aneurysms, and HTN Crisis
By Diana Blum MSN
MCC
NURS 2140
Vascular Disorders
• Common disorders in America:
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hypertension
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atherosclerosis
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arterial occlusive disease
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abdominal aortic aneurysms (AAA)
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deep vein thrombosis (DVT)
•
venous insufficiency
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hormones
• C reactive protein is a marker for cardiac
inflammation
– Increases mean: risk of damage
• Homocysteine: protein that promotes
coagulation by increasing factor 5 and
factor 11 while depressing activation of
protein C and increasing thrombus
formation risk
– Vitamin b6 and b12 and folate lowers
homocysteine levels
PAD
Arterial diseases:
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Arteriosclerosis (atherosclerosis)
Aneurysm formation
Arteriosclerosis obliterans
Raynaud’s phenomenon
Arterial embolism
Thromboangiitis obliterans
Diabetic arteriosclerotic disease
hypertension
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Manifestations :ARTERIAL
(50% occulsion before symptoms)
• Ischemia (reduced oxygenation)
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- leads to pain
• Paresthesia (decreased sensation in
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extremities = tingling/numbing)
• Pain (in feet/leg muscles = burning,
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throbbing, cramping)
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-usually from exercise BUT also
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with elevation of lower extremities
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(continued):
• Hallmark sign: Intermittent
claudication (pain in
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exercising muscles – usually in calf
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- directly related to decreased
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blood supply during activity &
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recedes with rest
• Temperature: (COLD)
• Skin color changes: skin pale on
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elevation but red dependent
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(continued)
• Reactive hyperemia: (reduced blood flow
to extremity results in arteriolar dilation so
when the blood supply is restored,
the affected area becomes warm/red
from congestion
• Pulse changes: Peripheral diminished or
absent
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(continued)
• Prolonged capillary refill:
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- 3 seconds or more
• Ulcers:
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- open lesions on feet from
diminished distal perfusion
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Arteriosclerosis
-describes arterial disorders in which
degenerative changes result in
decreased blood flow
Atherosclerosis:
- most common form of
arteriosclerosis, excessive
accumulation of lipids
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Major risk factors of arteriosclerosis:
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Hypertension (MOST SIGNIFICANT)
Cigarette smoking (nicotine has DIRECT
vasoconstricting effect)
Elevated serum cholesterol (fat causes
obstructive plaques)
Obesity (increased work to heart)
Diabetes (hyperglycemia causes damage to
vessel wall)
• Other: increase age, inactivity, family hx
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Most common affected areas from
arteriosclerosis:
Heart: coronary arteries (angina, MI,
death)
Brain (transient ischemic attacks =TIAs
CVA, death)
Kidneys (renal arterial stenosis lead to
chronic renal failure)
Extremities (gangrene of digits &
intermittent claudication)
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Pathophysiology of atherosclerosis
• -inflammatory process, begins as fatty
streaks that are deposited in the intima of
the arterial wall
• Genetics and environment play a factor in
the progression
• Elastic arteries: aorta, carotid, lg & med.
sized muscular arteries (popliteals) most
susceptible arteries.
• Endothelial injury: may be initiated by
smoking, hypertension, diabetes,
hyperlipidemia, 
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• Inflammatory cells(including
macrophages) become attracted to the
wall
• Macrophages infiltrate wall and ingest
lipid which turns them into foam cells
• They then release biochemical
substances that cause further damage
and attract platelets which then causes
clots to form
Ankle-brachial index of blood pressure:
Used to diagnose peripheral vascular disease
• -compares the blood pressure at ankle
with that of the arm.
• -normally these should be the same
(with a ratio of 1)
• -lesser number than 1 shows decreased
blood pressure at the ankle compared
to upper extremity = = which indicates
peripheral vascular disease to lower
extremities
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SURGERY
• Indications for fem-pop bypass:
• diabetes
• hypertension
• vasculitis
• collagen disease
• Bueger’s disease
• Also, Embolectomy (surgical removal)
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Fem-pop bypass
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MEDICAL MANAGEMENT
• ANTIPLATELET THERAPY
– Aspirin, ticlid, plavix, pletal, trental
• Beta blockers
• ARBs
• Statins
• Radiation therapy
• Angioplasty with stents
Nursing Interventions
• Monitor BP for difference between arms
– Could be indicative of aortic coarctation
• Narrowing of aorta lumen
• Monitor for carotid bruits
• Assess cap refill, pulses,skin
Acute arterial stenosis
• Monitor for the 5 P’s
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pain, sudden
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pallor
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pulselessness
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paresthesias
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paralysis
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Acute peripheral arterial
occlusion
• may result from rupture and thrombosis of
an atherosclerotic plaque, an embolus
from the heart or thoracic or abdominal
aorta, an aortic dissection, or acute
compartment syndrome
• Symptoms and signs are sudden
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Buerger Disease
• Autoimmune disease
• Recurrent inflammation of small arteries and veins of the extremities
resulting in thrombus formation and occlusion.
• Unknown cause
• Men 20-35 years old
• All races
• Link to heavy smoking/chewing tobacco
• s/s: rubor (reddish blue) color to foot, no Pedal pulse, discolored
legs when dangled, eventually gangrene sets in
Aneurysms of Central Arteries
• Enlargement of artery to @ least 2X
its normal
• Aortic dissection
– Medial & intimal layers separate
• Risk Factors:
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-hypertension
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-cocaine use
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- Marfan syndrome
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Thoracic Aortic Aneurysm
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85% are caused by atherosclerosis
More frequent in men b/w 40-70 years old
Most common site for dissection
1/3 of pts with this die from rupture
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S/S
Asymptomatic
Pain is primary symptom—constant
Dyspnea
Cough
Hoarseness
Stridor
Aphonia (weakness or complete loss of
voice)
• Unequal pupils
Diagnostics
• Chest x-ray
• TEE
• CT
Aortic dissection
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Aortic Dissections: Type III most
common type
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Abdominal Aortic Aneurysm Size and Rupture Risk*
AAA Diameter (cm)
Rupture Risk (%/yr)
<4
0
4–4.9
1%
5–5.9*
5–10%
6–6.9
10–20%
7–7.9
20–40%
>8
30–50%
*Elective surgical repair should be considered for aneurysms > 5.0–5.5 cm.
Signs/symptoms of aortic dissection:
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n/v, diaphoresis with pain
“tearing” pain
Sudden onset
not relieved with change of position
Dissection of ascending aorta: anterior CP with
radiation to neck, throat, jaw
Dissection of descending: interscapular back pain
radiation to lower back or abdomen
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Treatment of hypertension for aortic
dissection:
• IV propranolol
• Nitropresside drip after beta blocker ( nitropresside by itself
causes tachycardia AND  left vent. contractility that is
why a beta-blocker should be given first, then start
nitropresside drip)
• Diagnosis:
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CXR (but 10% normal) see medialstinal
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widening
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Contrast CT
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MRI
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• GOAL: to keep blood pressure to lowest
• possible but yet allows tissue perfusion
– Per physican recommendations
Surgery for distal dissections:
• Mortality in 1st 48 hrs if unrepaired proximal aortic
dissections is 40%
• Usually distal dissections treated medically unless:
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rapid expansion
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saccular formation
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persistent pain
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hemodynamic compromised
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blood leakage
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impending rupture
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Dacron tube
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Abdominal Aortic Aneurysm (AAA)
• 75% of all aneurysms
Located between renal arteries & aortic bifurcation
Symptoms from pressure exerted in surrounding
structures.
Many nonsymtomatic until ruptures
Look for pulsating abdominal mass
With rupture: hypovolemic shock & mortality
around 90%
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Nonsurgical management of AAA
• Monitor growth: freq. CT scans
• Antihypertensives
• SURGICAL:
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graft
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Post-op nursing interventions for graft:
• Vitals
• Pulses distal to graft
• Report:
• changes in pulse
• cool extremities distal to graft
• white/blue to extremities distal to
graft
• severe pain
• abd. distention
• decreased UO
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Post-op nursing intervention (continued)
Post graft
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Elevation of head to 45° or less
Renal function lab
Respiratory status
Paralytic ileus (NG tube)
Assess for dysrhythmias post thoracic
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Venous diseases:
• Venous thrombosis (thrombophlebitis)
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known as DVT
• Varicose veins
• Venous stasis ulcers
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Venous manifestations:
• Pain:
• - in feet/ leg muscles; aching/throbbing
• - results from venous stasis & increases
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as day progresses (esp with sitting
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or standing)
• Temperature changes:
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- warm to touch since blood can enter
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but cannot leave affected parts
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Venous manifestations:
Skin color changes: reddened or
cyanotic
Edema: pooling of fluid results in
edema
Venous stasis ulcers: skin breakdown
due to increased pressure from
chronic pooling of blood
Decreased mobility: may result from
the edema
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• DVT risk for pulmonary embolism
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- legs
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- seen post hip surgery, knee replacement
pregnancy, ulcerative colitis, hrt failure,
immobility
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DVT :
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Groin tenderness/pain
Unilateral sudden onset edema leg
Homan’s sign (appears in only 10% of pt
with DVT)
Ultrasonography
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DVT interventions:
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Rest (do NOT massage area)
Low-molecular weight heparin
Coumadin
TPA
****Contraindications to anticoagulant therapy
– Pt compliance, bleeding, aneurysms, trauma, alcohol, recent
surgery, liver or kidney disease, hazard jobs, pregnancy
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Nursing cares
• Monitor for hemorrhage
• Monitor PT/PTT
– Heparin is therapeutic b/w 60-92 on ptt
– Coumadin is therapeutic b/w 2-3 on
PT/INR
• Monitor for Thrombocytopenia
– Monitor Platelets
– s/s; purpura, bruising, hematomas
• Provide bedrest
• Ted Hose or ace wraps for prevention of DVT
• SCDs for prevention of DVT
• Pain meds
Hypertension
• - excessive tension exerted on arterial
walls which places pts at increased risk
for target organ damage
• -asymptomatic until complications
develop
• - elevation may be systolic or diastolic or
both
• - normal <120 mmHg systolic
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<80 mmHg diastolic
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S/S
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Often none
Occipital headache more severe on rising
Lightheadedness
Epistaxis
Known as the ‘Silent Killer’
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Factors that determine arterial
pressure
• Cardiac output which is the volume of blood
pumped by the heart in 1 minute
• Peripheral vascular resistance which is the force
in the peripheral blood vessels that the left
ventricular must overcome to eject blood out of
the heart
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Pathophysiologic processes for
hypertension:
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BP=CO X peripheral resistance
Elevated BP is direct result of increased
peripheral resistance, increased CO or
both
Renin-angiotensin-aldosterone system
Aldosterone: increased water/Na+
retention thus increasing ECF volume
which leads to increased CO with
subsequent increase BP
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Possible Causes of PVR
• Narrowing of blood vessels, PVD, CAD, kidney
disease: > renin/angiotensin =vasoconstriction
• Release of catecholamine (epinephrine and adrenalin)
= vasoconstriction
• > blood volume= more work to pump
• > Blood viscosity=harder to pump
• Ability of blood vessel to stretch
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• 95% of cases of hypertension are 1st
degree (essential)
• 2nd degree hypertension: CHAPS
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Cushing’s syndome
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Hyperaldosteronism
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Aortic coarctation
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Pheochromocytoma
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Stenosis of renal arteries
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Complications
• Damage to blood vessels of the eyes, heart,
kidney, brain resulting in:
• Stroke
• CHF
• AMI
• Renal failure
• Blindness
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Target Organ Disease from hypertension
• Large vessels: aneurysmal dilation
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accelerated atherosclerosis
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aortic dissection
• Cardiac:
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acute= pulm edema, MI
• chronic= LVH
• Cerebrovascular:
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acute= Intracranial bleed, coma, seizure
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mental status changes, TIA, stroke
• chronic=TIA, stroke
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Target organ disease from hypertension:
• Renal: acute=hematuria, azotemia
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chronic=elevated creatinine
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proteinuria
• Retinopathy:
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acute=papilledema,
hemorrhages
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chronic=hemorrhages,exudates,
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Treatment of hypertension:
• Lifestyle modification
ABCD:
ACE inhibitors; ARB
B-blockers
Calcium channel blockers
Diuretics
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HTN CRISIS
• Sometimes rare sometimes fatal
• Diastolic BP 120-130
– Causes vascular damage
• Can be caused by renal failure, HTN,
Med withdrawal
Hypertensive Crisis:
Treatment
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Parenteral agents for immediate redux of BP
In ICU for monitoring
Arterial line
Drug of choice: sodium nitroprusside
=direct acting arterial & venous vasodilator
= reduces BP rapidly but lower mean arterial
pressure no more than 25% over 1st 2 hours
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= easily titratable
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= monitor closely for hypotension
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= shield this drip from light
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STROKE: occlusion of cerebral vasculature
• DUE TO:
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1. emboli that lodges in cerebral vasculature
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(from a-fib, vegetations on an infect valve)
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2. atherosclerotic plaque (occludes carotid arteries)
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3. venous occlusion (secondary to thrombosis)
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4. arterial dissection (in carotid or vertebrobasilar
system)
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5. severe hypotension ( infarct in cerebral areas)
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6. hemorrhage :occurs during activity
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TIA
• Sudden loss of function resulting from disrupted
blood supply to area in brain
• 5 types:
– Large artery
• Caused by atherosclerosis
– Small penetrating artery
• Most common
• Also called lacunar strokes because it creates a cavity
– Cardiogenic emboli
• Usually from afib
– Cryptogenic
• No known cause
– Other
• Caused from Drug use, migraines,spontaneous
Hemorrhagic stroke
• Bleeding into brain tissue or ventricles, subdural,
or subarachnoid spaces due to ruptured aneurysm
or from severe hypertension
• VASOSPASM (after a bleed)
– 4-14 days post hemorrhage
– Management is difficult
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manifestations
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Severe headache
LOC
Tinnitus
Dizziness
Hemiparesis
Prognosis: variable
diagnostics
• CT
• Lumbar puncture
• Angiography
Prevention
• Manage HTN
• Avoid alcohol
• Increase public awareness
Assessment Tools
• Neurological assessment upon admission
or change in client status, including:
– Level of consciousness
– Orientation
– Motor ability
– Pupils
– Speech/language
– Vital signs
– Blood glucose
• Risk assessment for complications
including fall, pressure ulcer, painful
hemiparetic shoulder,
spasticity/contractures, and deep vein
thrombosis
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Pain assessment
Administration and interpretation of dysphagia screen
Nutrition and hydration screening
Screening for alterations in cognition, perception, and
language using validated tools
• Assessment of activities of daily living (ADL) using
validated tools
• Assessment of bowel and bladder function
• Depression screening using a validated tool
• Assessment/screening of caregiver burden using a
validated tool
• Screening of stroke clients and their partners for
sexual concerns
• Assessment of stroke client and their caregivers'
learning needs, abilities, learning preferences and
readiness to learn
• Referral for further assessment and management, as
indicated
• Documentation of all assessments and screenings
Treatment for stroke:
(Note similar to measures for myocardial
ischemia/MI)
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Thrombolysis (who is not a candidate?)
Lower BP
Quit smoking
Decrease cholesterol
Antiplatelet (ASA)
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Stroke treatment (continued)
• ASA
• Heparin (SQ or IV contin infusion)
• Low-molecular wt heparin (lovenox)
• Warfarin (coumadin)
------------------------------------------------------Obtain PT, PTT prior to therapy
PT: monitor oral anticoag : goal=1.5 to 2 times pt baseline
PTT: monitor heparin: goal=1.5 to 2 times pt baseline
INR: monitor Warfarin: goal=2 to 3
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More stroke treatment:
• Carotid artery angioplasty
• Arteriovenous Malformation (gamma
radiation through Gamma knife)
• Aneurysms (coils)
• Craniotomy for clot removal
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Nursing assessment with anticoagulant
therapy:
• Observe for bleeding
• Also, antiplatelet meds (Plavix, Persantine)
cause
• bruising, hemorrhage, liver disease (need
liver function tests)
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GIVE clopidogrel (Plavix) with food
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Nursing Diagnosis
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Impaired physical mobility:
-flaccid, spasticity
Disturbed sensory perception:
-vision, proprioception, sensation
Unilateral neglect:
- use both sides of body (dress affected side first)
Impaired verbal communication::
-expressive, receptive, both
Impaired swallowing:
– must be evaluated, must prevent aspiration !!! But yet meet caloric needs
• Urinary and/or bowel incontinence
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Complications
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Rebleed
Vasospasm
Hydrocephalus
Hypoxia of brain
Nursing interventions
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Administer oxygen
Provide adequate hydration
Evaluate swallow function
Frequent neuro checks
Strict I/O
Seizure precautions
Monitor ICP
Monitor BP closely
Teach stress reduction techniques
Manage agitation
Surgery and complications
• Evacuation of blood via craniotomy
• Goal of surgery is to prevent further
rupture/bleed
• Post op complications
– Disoriented
– Amnesia
– Korsaff’s syndrome (psychosis caused by lack of
thiamine)
– Personality changes
– Intraop emboli
– Electrolyte disturbances
– GI bleed
QUESTIONS???