Nursing of Adults with Medical & Surgical Conditions

Nursing of Adultswith

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

– Pain brought on by exercise

– Later symptoms of pain 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– Less than 2 seconds

H for Hardness– 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 DisordersPage 331 – Table 8-5

Diagnostic Tests

Noninvasive Procedures– Treadmill Test

Exercise to determine blood flow to extremities

– Plethysmography Assesses blood volume in the veins

– Digital Subtraction Angiography (DSA) 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

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

– 125 I-fibrinogen Uptake Test 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