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Nursing of Adults with Medical & Surgical Conditions Disorders of the Peripheral Vascular System Risk Factors Similar to risk factors for heart disorders – – – – – – – – – – Age Gender Smoking Hypertension Hyperlipidemia Obesity Lack of exercise Emotional stress Diabetes Mellitus Family History Assessment of Vascular Disorders Arterial Assessment – First symptom is usually pain Occurs due to arterial insufficiency and ischemia Dull ache in calf muscles Leg fatigue and cramping Intermittent claudication – – Later symptoms of pain – Pain brought on by exercise Pain at rest Burning, tingling, and numbness at night even lying down Pulses May be weak, thready, or absent – Scale for documentation • 0 – absent • +1 – barely palpable, intermittent • +2 – weak , possibly thready, but constantly palpable • +3 – normal strength and quality • +4 – bounding, easily palpable, may be visible Assessment and Documentation – PATCHES P for Pulses – Absence of pulses in generally a medical emergency • Compare with previous findings • Look for other symptoms – may just be hard to feel • Use Doppler device if necessary A for Appearance – – – – – Pale, mottled, cyanotic or discolored (red, black, brown) Necrosis or bleeding (ulcers) • Size, depth, and location • Edges jagged or smooth • Painful to touch Shiny or dull • Shiny may indicate edema • Dull may indicate inadequate arterial blood supply Superficial veins, erythema, or inflammation Varicosities • Have patient to stand T for Temperature – Cool Possible arterial problem Warm • Possible venous problem Temperature changes may be caused by other problems as well • – – C for Capillary refill – H for Hardness – Less than 2 seconds Supple or hard and inelastic • Hardness may indicate chronic problems E for Edema – – Pitting edema • Usually acute problem • Assessment: Press on skin for 5 seconds and release (Page 317 --Figure 8-17 and Table 8-3) Non-pittting • May be chronic condition • Assessment: Measure circumference of the extremity S for Sensation – Patient states extremity FEELS: • Numbness • Tingling • Hot • Cold Venous Assessment – – – – – First symptom is usually edema Dark pigmentation Dryness and scaling Ulcerations Pain, aching, and cramping Usually relieved by rest or elevation Comparison of Arterial and Venous Disorders Page 331 – Table 8-5 Diagnostic Tests Noninvasive Procedures – Treadmill Test – Plethysmography – Assesses blood volume in the veins Digital Subtraction Angiography (DSA) – Exercise to determine blood flow to extremities IV contrast is administered Blood vessels are visualized by radiography using an image intensifier video system and monitor Doppler Ultrasound Measures blood flow in arteries or veins Diagnostic Tests Invasive Procedures – Phlebography or venography – 125 I-fibrinogen Uptake Test – Radiographic visualization of veins IV contrast is administered in a foot vein X-rays are taken to detect filling defects Assesses for condition of deep veins and to diagnose deep vein thrombosis Assesses for acute calf vein thrombosis Fibrinogen is tagged with iodine 125 and given IV - it can then be detected in the blood stream by a gamma ray detector Angiography IV contrast is administered X-ray to visualize arteries – D-dimer Serum Test D-dimer forms when fibrin is broken down When a thrombus is present D-dimer levels are elevated – usually greater than 1591 ng/ml Normal value: 68-494 ng/ml – Duplex Scanning Combination of ultrasound imaging and Doppler Determines location and extent of thrombus within veins Arteriosclerosis & Atherosclerosis Arteriosclerosis – thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply Atherosclerosis – – narrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium sized arteries a type of arteriosclerosis Atherosclerosis Hypertension Etiology/Pathophysiology – – A sustained elevated systolic blood pressure greater than 140 mm Hg and /or a sustained elevated diastolic blood pressure greater than 90 mm Hg. Vasoconstriction (increases B/P) caused by stimulation of the sympathetic nervous system and the release of epinephrine and/or norepinephrine. Decreased blood flow to the kidneys causes the release of renin and the formation of angiotensin which is a vasoconstrictor. Hypertension – Essential (primary) hypertension 90-95% of all diagnosed cases Theories of causes: – – arteriolar changes, sympathetic nervous system activation, hormonal influence, genetic factors, obesity, sedentary lifestyle, increased sodium intake, excessive alcohol intake. Secondary hypertension Attributed – – – – – to an identifiable medical diagnosis renal vascular disease diseases of the adrenal cortex coarctation of the aorta head trauma or cranial tumor pregnancy-induced hypertension Hypertension – Malignant hypertension severe, rapidly progressive elevation in blood pressure that causes damage to the small arterioles in major organs (heart, kidneys, brain, eyes) Hypertension Signs & Symptoms – – – – – headache blurred vision epistaxis angina s/s of: MI, CHF, renal failure, and stroke Hypertension Treatment – Antihypertensive medications Capoten, Vasotec, Altace, Lotensin, Zestril, Accupril, Monopril – Diuretics Lasix, – HCTZ, Aldactone Diet weight control, reduction of saturated fats, and low sodium – No smoking Hypertension – – – Decreased alcohol intake Regular aerobic exercise Relaxation techniques/stress management Arteriosclerosis Obliterans Etiology/Pathophysiology – – narrowing or occlusion of the blood vessel with plaque formation little or no blood flow to the affected extremity Arteriosclerosis Obliterans Signs & Symptoms – Five P’s Pain – intermittent claudication Pulselessness Pallor Paresthesia Paralysis Arteriosclerosis Obliterans Treatment – Anticoagulants Heparin – and Coumadin Fibrinolytics Urokinase administered – directly into the thrombus Surgery embolectomy- removal of the embloism endarterectomy- removal of the lining of the artery arterial bypass percutaneous transluminal angioplasty amputation Percutaneous Transluminal Angioplasty Arterial Embolism Etiology/Pathophysiology – – Blood clots in the arterial bloodstream May originate in the heart arterial – dysrhythmia, MI, valvular heart disease, CHF Foreign substances plaque, tissue, etc. Arterial Embolism Signs & Symptoms – – – – – Pain Absent distal pulses Pale, cool, and numb extremity Necrosis S/S of shock with occlusion of a major vessel Arterial Embolism Treatment – Anticoagulants Heparin – – – and Coumadin Fibrinolytics Endarterectomy Embolectomy Arterial Aneurysm Etiology/Pathophysiology – – Enlarged, dilated portion of an artery Causes: arteriosclerosis trauma congenital – defect Commonly affected arteries popliteal thoracic and abdominal aorta coronary cerebral Arterial Aneurysm Signs & Symptoms – – – Asymptomatic Large pulating mass Pain, if large enough to press on other structures Arterial Aneurysm Treatment – – – Assess for s/s of rupture, thrombi, ischemia Control hypertension Surgery Ligation Grafts Surgical Repair of Arterial Aneurysm Thromboangitis Obliterans (Buerger’s Disease) Etiology/Pathophysiology – Occlusive vascular condition in which the small and medium size arteries become inflamed and thrombotic affects – – the small arteries in the hands and feet Cause not known Affects men 20-40 years old who smoke Thromboangitis Obliterans (Buerger’s Disease) Signs & Symptoms – Pain may – – – – – be frequent and persistent Sensitivity to cold Skin cold and pale Ulcerations on feet or hands Gangrene Superficial thrombophlebitis Thromboangitis Obliterans (Buerger’s Disease) Treatment – – – No smoking Exercise to develop collateral circulation Surgery amputation of gangrenous fingers and toes sympathectomy – clip nerves to prevent pain and vasospasm Raynaud’s Disease Etiology/Pathophysiology – – Intermittent arterial spasms Primarily affects fingers, – – toes, ears and nose Exposure to cold or emotional stress Secondary: scleroderma rheumatoid arthritis, SLE, drug intoxication, occupational trauma – Commonly affects women 20-40 years of age Raynaud’s Disease Signs & Symptoms – – – – Chronically cold hands and feet Pallor, coldness, numbness, cyanosis, and pain during spasms Erythema following a spasm Ulcerations on the fingers and toes with chronic disease Raynaud’s Disease Treatment – – – No smoking Avoid exposure to cold Medications vasodilators calcium antagonists muscle relaxants – Surgery sympathectomy amputation for gangrene Thrombophlebitis Etiology/Pathophysiology – – – Inflammation of a vein in conjunction with the formation of a thrombus More common in women Risk factors venous stasis hypercoagulability truama to the blood vessel immobilization after surgery Thrombophlebitis Signs & Symptoms – – – – Pain Edema Positive Homan’s sign Erythema, warmth, and tenderness along the vein Thrombophlebitis Treatment – Superficial Bedrest Moist heat Elevate extremity NSAID’s – – Motrin aspirin Thrombophlebitis – Deep Bedrest Anticoagulants – Heparin & Coumadin Fibrinolytics Elevate extremity Antiembolism stockings Surgery – – thrombectomy vena cava umbrella (Greenfield filter) Greenfield Filter Varicose Veins Etiology/Pathophysiology – – – Tortuous, dilated vein with incompetent valves Most common in women 40-60 years of age Caused by: congenital defective valves, absent valve, valve that becomes incompetent Pregnancy or obesity prolonged standing constrictive clothing Varicose Veins Varicose Veins Signs & Symptoms – – – – – – Dark, raised, tortuous veins Fatigue Dull aches Cramping of the muscles Heaviness or pressure of extremity Edema, pain, changes in skin color, and ulcerations with venous stasis Varicose Veins Treatment – – – – Elastic stockings Rest Elevate legs Sclerotherapy injection – of sclerosing solution Surgery Vein ligation and stripping Venous Stasis Ulcers Etiology/Pathophysiology – – – Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue Causes varicose veins, burns trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factors Venous Stasis Ulcers Signs & Symptoms – – – Pain Ulceration with dark pigmentation Edema Venous Stasis Ulcers Treatment – Diet Increased protein Vitamin A & C and Zinc – Debridement of necrotic tissue wet-to-dry dressings Elase cream surgical – – Antibiotics Unna boot