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Nursing Care & Interventions
for Clients with Vascular
Problems
Keith Rischer RN, MA, CEN
1
Today’s Objectives…
 Review
the pathophysiology of arteriosclerosis,
including the factors that cause arterial injury
 Discuss drug therapy for hypertension
 Evaluate the effectiveness of interdisciplinary
interventions to improve hypertension
 Prioritize nursing care for the patient
experiencing vascular disorders
 Develop a continuing care plan for a client who
has hypertension
 Prioritize postoperative care for clients who have
undergone peripheral bypass surgery.
2
Serum Lipids:Cholesterol
One of the several types of fats (lipids)
 Important component of cell membranes, and bile
acids
 Building blocks in certain types of hormones
 Predominant substance in atherosclerotic
plaques
 Circulates in the blood in combination with
triglycerides, encapsulated by special fat-carrying
proteins called lipoproteins
 <200 is desirable for total cholesterol

3
Lipoproteins
LDL = Low Density Lipoproteins - “bad
cholesterol”

<130 is desirable
HDL = High Density Lipoproteins - “good
cholesterol”

>30 is desirable- the higher the HDL, the lower the
risk of CAD
Triglycerides- combination of glycerol with 3 fatty
acids
Transportable fuel- energy source
 Strongly influenced by diet

4
Cholesterol Levels

LDL Cholesterol






Optimal
Near optimal/above optimal
Borderline High
High
Very high
Total Cholesterol




<100
100-129
130-159
160-189
>190
<200
200-239
>240
Desirable
Borderline High
High
HDL Cholesterol


<40
>60
Low
High
5
Hypertension
 “Vascular Disease”
Affects 1 in every 4 adults in the US
 Major risk factor for cardiovascular disease (CVD)
 Stroke, MI, Heart Failure
 Other Target Organ Damage
 LV hypertrophy
 Nephropathy
 Vascular Disorders
 PVD
 Retinopathy

6
Categories
Primary (Essential)- without identified cause
 90-95% of all hypertension
 Pathophysiology: (exact cause unknown)
 Heredity
 H2O & Na+ retention
 Altered renin-angiotensin mechanism
 Stress and increase sympathetic nervous system activity
 Insulin resistance and hyperinsulinemia
 Endothelial cell dysfunction
Secondary- results from identifiable cause
 renal disease, endocrine disorders, neuro disorders, meds, PIH
7
Stages of Hypertension
Category





SBP(mmHg)
Normal
<120
Prehypertension
120-139
Hypertension, Stage 1: 140-159
Hypertension, Stage 2: 160-179
Hypertension, Stage 3: >180
DBP(mmHg)
<80
80-89
90-99
100-109
>110
8
Clinical Manifestations
Early
 Elevated
BP
 Asymptomatic (silent killer)
Later
 Symptoms
secondary to effects on blood
vessels in various organs or tissues
 Fatigue,
reduced activity tolerance, dizziness,
palpitations, angina, dyspnea
9
Risk Factors for Primary Hypertension







Age
Alcohol use
Cigarette smoking
DM
Elevated serum lipids
Excess dietary
sodium
Gender






Family history
Obesity
Ethnicity
Sedentary lifestyle
Socioeconomic status
Stress
10
Knowledge Deficit



Encourage healthy lifestyles
Lifestyle modifications for all patients with
prehypertension and hypertension
Components of lifestyle modifications include:
 weight reduction,
 DASH eating plan
 dietary sodium reduction
 aerobic physical
 activity
 moderation of alcohol consumption
 Stress reduction
11
Risk for Ineffective Therapeutic
Regimen Management
 Interventions:
 Teach
medication compliance, usually for the
rest of life.
 goals

of therapy
potential side effects
 Assist
client to understand therapeutic regimen.
 Discuss consequence of noncompliance
 Most African American clients will need at least 2
medications to achieve blood pressure control
 ACE
inhibitor and calcium channel blocker
12
.
Diuretics
 Loop
 Bumetanide
(Bumex)
 Furosemide (Lasix)
 Thiazide-Type
 Chlorothiazide
 Hydrochlorothiazide
(HCTZ)
 Potassium-Sparing
 Spironolactone
(aldactone)
13
Pharmacologic: Diuretics


Mechanism of Action:
Thiazides, Loop,
Potassium Sparing

S/E:

fluid and electrolyte
imbalances
– K+, Mg++



CNS effects
GI effects
Nursing
Considerations:

Monitor for orthostatic
hypotension
– dehydration

Hypokalemia
14
Adrenergic Inhibitors:
Beta Blockers

Cardioselective (β1)
 Atenolol
(Tenormin)
 Metoprolol (Lopressor)

Non-cardioselective (β1, β2)
 Propranolol

(Inderal)
Mechanism of Action
 Blocks beta actions causing:
decreased heart rate
 decreased BP
 decreased contractility

15
Adrenergic Inhibitors:
Beta Blockers

S/E:
 Orthostatic hypotension
 Bradycardia
 Hypotension
 Fatigue
 Weakness

Nursing considerations

Use in caution with heart failure
 Diabetes
who take BB may not have sx of
hypoglycemia monitor pulse regularly
16
ACE Inhibitors
Drug Interactions:
 NSAIDS (decrease BP control)
 Diuretics (excessive hypotensive effect)
 Potassium supplements, potassium-sparing diuretics
(increased risk of hyperkalemia)
 Lithium (increased lithium serum levels)
 Precautions:
 “First dose effect “– severe hypotension. Remain in bed
for 3 to 4 to prevent falls.
 Obtain BP before giving - hold if hypotensive
 Change positions slowly due to orthostatic hypotension
 Monitor liver and kidney function

17
Angiotensin Receptor Antagonists
(Blockers)
Losartan (Cozaar)



Mechanism:
 Inhibit binding of angiotensin II receptors in blood vessels and other
tissues
 vascular smooth muscle relaxation
 increased salt and water excretion
 reduced plasma volume
Side Effects:
 Hypotension
 Dizziness
 Cough,
 Heart failure
 Angioedema
Drug Interactions:
 Potassium-sparing diuretics ( serum K+)
18
Calcium Channel Blockers
Amlodipine (Norvasc)
Diltiazem (Cardizem)
Nifedipine (Procardia)

Mechanism of Action

Blocks slow channels of
Calcium



Decreases contractility
Vasodilation
AV node slows
19
Calcium Channel Blockers

S/E:






Hypotension
Bradycardia
AV block
Nausea
H/A
Peripheral edema


Monitor I&O closely
Nursing considerations:

Always obtain BP-HR before giving

use with caution in patients with heart failure
Orthostatic changes




Change position slowly
contraindicated in patients with 2nd or 3rd degree heart block
Concurrent use w/b-blockers incr risk of CHF
20
HTN Case Study

45yr African American male
 Complaint:
new onset severe global HA
 VS: P-88 R-20 BP-210/142 sats 96% RA
 Slightly
confused to place, time
 PMH:
HTN x10 yrs-unable to afford meds, not
taking the last week
 Labs: K+ 4.2, Na+ 138, creat 2.5, trop neg,
12 lead EKG no acute changes

Nursing/medical priorities…
21
HTN Case Study

MD orders:
 Metoprolol
5mg IV push q5” x3 for SBP 160-
180
 5mg/5cc….administer over 2”…how much
every 15-30 seconds???
 Nursing
priorities/considerations…
 Admit
to ICU
 VS before transfer: P-68 R-20 BP-192/118
22
In ICU…

Started on Nipride gtt
 Started
at 0.5mcg
 BP 180/90….in 2 hours
 Next am 140/90

Started on po:
 Lisinopril
 Diltiazem
 Metoprolol
Concerns to address upon DC???
23
Peripheral Arterial Disease


Altered flow of blood
through arteries/veins of
peripheral circulation
Manifestation of systemic
atherosclerosis

a chronic condition in
which partial or total arterial
occlusion deprives the
lower extremities of oxygen
and nutrients
24
Physical Assessment





Intermittent claudication
 Pain that occurs even while at rest; numbness and burning
Inflow disease affecting the lower back, buttocks, or thighs
 Distal aorta
Outflow disease causing cramping in calves, ankles, and feet
 Superficial femoral artery (knee and down)
Hair loss and dry, scaly, mottled skin and thickened toenails
Ulcers
 arterial ulcers
 diabetic ulcers
 venous stasis ulcers
25
.
Nonsurgical Management
Exercise
 Positioning
 avoid extreme raising legs above heart, do elevate for
edema
 Promoting vasodilation
 warmth and avoid cold temp, stop smoking
 Drug therapy
 clopidogrel (Plavix), Pentoxifylline (Trental), ASA
 Percutaneous transluminal angioplasty
 Atherectomy

26
.
Surgical Management

Preoperative care


Documentation of distal
pulses
Postoperative care





Assessment for graft
occlusion
Promotion of graft patency
Treatment of graft
occlusion
Monitoring for compartment
syndrome
Assessment for infection
27
.
Acute Peripheral Arterial Occlusion




Embolus
 most common cause of occlusions, although local thrombus may
be the cause
Assessment
 pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
(coolness)
Surgical therapy
 arteriotomy
Nursing care
 CMS
 Pain assessment
 Spasms/swelling
 Compartment syndrome
28
.
Anticoagulation Therapy:Heparin
 Inhibits
(does not dissolve) thrombus and clot
formation
 Given IV/SQ
 Never
given IM D/T risk of hematoma
 Does
not cross placental barrier
 Antidote
 Protamine
sulfate: Fast acting, short ½ life
 Note:
If sx’s of bleeding stop infusion, be
prepared to give antidote
29
Aneurysms of Central Arteries

Patho







Middle layer weakened
Stretching of intima
Fusiform aneurysm
Saccular aneurysm
Dissecting aneurysm
(aortic dissections)
Thoracic aortic
aneurysms
Abdominal aortic
aneurysms
30
Thoracic & Abdominal Aortic
Aneurysm

Thoracic




Back pain
shortness of breath hoarseness,
and difficulty swallowing
Sudden excruciating back or
chest pain is symptomatic of
thoracic rupture
Abdominal

Pain steady with a gnawing
quality




unaffected by movement-may
last for hours or days
abdomen, flank, or back.
Abdominal mass is pulsatile
Rupture is the most frequent
complication and is life
threatening.
31
Aortic Dissection



Patho
Pain
Emergency care goals include:
Elimination of pain
 Reduction of blood pressure
 Immediate OR


Surgical treatment
32
Abdominal Aortic Aneurysm Repair

Preoperative care



Assess peripheral pulses
Operative procedure
Postoperative care


Monitor vital signs
Assess for complications


Paralytic ileus
Assess for graft occlusion
or rupture



Change in CMS
Severe pain
Decreased u/o
33
.
Thoracic Aortic Aneurysm Repair



Preoperative care
Operative procedure
Postoperative care
assessments:
 Vital signs
 CMS changes
 Complications
 Respiratory
distress
 Cardiac
dysrhythmias
 Hemorrhage
 Paraplegia
34
.
Raynaud’s Phenomenon


Patho
Sx


Blanching >cyanosis
Pain


Treatment

Procardia


Aggravated by cold/stress
Side effects
Education



Cold exposure
Stop smoking
Stress reduction
35
.
Venous Thromboembolism

Thrombus

Virchows Triad




Thrombophlebitis


Pulmonary embolism
Phlebitis


Thrombus w/inflammation
Deep vein thrombosis (DVT)


Venous blood stasis
Endothelial injury
hypercoagubility
Inflammation of superficial veins
Assessment:





Calf or groin tenderness or pain
Sudden onset of unilateral swelling of the leg
Localized edema
Venous flow studies-US
Lab:D-Dimer
36
.
Nonsurgical Management
Treatment Priorities
 Prevent complications
 Rest
 Drug therapy includes:
 Heparin IV therapy
 Low–molecular weight heparin-Subq
 Lovenox q 12 hours
 Warfarin therapy
 Thrombolytic therapy
 TPA

37
Venous Insufficiency


Patho
Sx

Edema

TEDS
Stasis dermatitis
 Stasis ulcers


Occlusive dressings
38
.