CARDIO VASCULAR SYSTEM

Prepared by/ Eman Abd Alrahman MS1 Lecturer

VENOUS DISORDERS

Venous Thromboembolism (VTE)

Deep vein thrombosis (DVT) and pulmonary embolism (PE) collectively make up the condition known as (VTE)DVT:

Is a blood clot in a major vein that usually develops in the legs and/or pelvis.PE:

is an obstruction of a blood vessel in the lungs, usually due to a blood clot, which blocks a coronary artery.

The incidence of VTE

-10% to 20% in general medical patients -20% to 50% in patients who have had a stroke

-up to 80% in critically ill patients

30% of patients hospitalized with VTE develop long-term post thrombotic complications

Risk Factors for (DVT) &(PE)

1 -Endothelial Damage •Trauma • Surgery

•Pacing wires • Central venous catheter •Dialysis access catheters • Local vein damage

•Repetitive motion injury

2 -Venous Stasis •Bed rest or immobilization • Obesity

•History of varicosities • Spinal cord injury •Age (greater than 65 years)

3 -Altered Coagulation• Cancer • Pregnancy

•Oral contraceptive use •Protein C deficiency •Protein S deficiency

•Antiphospholipid antibody syndrome •Factor V Leiden defect

•Prothrombin 20210A defect •Hyperhomocysteinemia

•Elevated factors II, VIII, IX, XI •Antithrombin III deficiency

•Polycythemia •Septicemia

Clinical ManifestationsUn common, phlegmasia cerulea dolens (massive iliofemoral venous thrombosis), in which the entire extremity becomes massively swollen, tense, painful, and cool to the touch

1 -Deep Veins obstruction: -Edema and swelling of the extremity

→The amount of swelling can be determined by measuring the another extremity size

→If both extremities are swollen, a size difference may be difficult to detect

-The affected extremity may feel warmer, and the superficial veins may appear more prominent

-Tenderness, which usually occurs later, can be detected by gently palpating the affected extremity .

-Homans’ sign (pain in the calf after the foot is sharply dorsiflexed) , but it is not a reliable sign for DVT

-Superficial Veins -pain or tenderness, redness, and warmth in the involved

area-The risk of the superficial venous thrombi becoming

dislodged or fragmenting into emboli is very low because most of them dissolve spontaneously

Sotreated at home with bed rest, elevation of the leg, analgesic agents, and possibly anti-inflammatory medication

Assessment and Diagnostic Findings -Assess Patients with a history of high risk factors

-key concerns during nursing assessment include:1 -limb pain, a feeling of heaviness, functional

impairment, ankle engorgement, and edema 2 -differences in leg circumference bilaterally from thigh

to ankle 3 -increase in the surface temperature of the leg,

particularly the calf or ankle4 -areas of tenderness or superficial thrombosis (ie,cord

like venous segment).

Complications of VenousThrombosis

Valvular destruction •Chronic venous insufficiency

•Increased venous pressure •Varicosities

•Venous ulcers

Venous obstruction •Increased distal pressure

•Fluid stasis •Edema

•Venous gangrene

Prevention1-Application of graduated compression stockings

2 -Use of intermittent pneumatic compression devices3-Encouragement of early mobilization and leg exercises

4 -For surgical patients, administration of subcutaneous un fractionated or low-molecular- weight heparin (LMWH)

5 -lifestyle changes as appropriate, which may includeweight loss, smoking cessation, and regular exercise

Medical Management

A- Pharmacologic Therapy:1 -Unfractionated Heparin

-Subcutaneously to prevent development of DVT -Intermittent or continuous IV infusion for 5 days to

prevent the extension of a thrombus and the development of new thrombi

-Oral anticoagulants, such as warfarin, are administered with heparin therapy

2 -Low-Molecular-Weight Heparin (LMWHs)

-Subcutaneous ,such as (dalteparin and enoxaparin)

-One or two SC injections each day

-fewer bleeding complications and lower risks of heparin-induced thrombocytopenia (HIT) than unfractionated heparin

-Used safely in pregnant women

-Expensive

3 -Oral AnticoagulantsWarfarin is a vitamin K antagonist that is indicated for extended anticoagulant therapy , and have a slow onset of action

4 -Factor Xa Inhibitor-given daily SC at a fixed dose, as Fondaparinux

-has a half-life of 17 hours -Must be used with caution in patients with renal

insufficiency-Also effective in conjunction with warfarin

5-Thrombolytic Therapy-catheter-directed thrombolytic (fibrinolytic) therapy lyses and

dissolves thrombi in at least 50% of patients.

) -eg, alteplase (is given within the first 3 days after acute thrombosis, if initiated more than 14 days it will be less effective.The advantages:

-less long-term damage to the venous valves and a reduced incidence of post thrombotic syndrome and chronic venous insufficiency

↑incidence of bleeding than heparin, so if bleeding can not stopped, the thrombolytic agent is discontinued

B- Endovascular Management:

is necessary for DVT when anticoagulant or thrombolytic therapy is contraindicated

A thrombectomy may be necessary. This mechanical method of clot removal may involve using intraluminal catheters with a balloon or other devices.

Nursing ManagementA-Assessing and Monitoring Anticoagulant Therapy:

1 -unfractionated heparin is administered by continuous IV infusion using an electronic infusion device

2 -Dosage calculations are based on the patient’s weight3 -possible bleeding tendencies are detected by a

pretreatment clotting profile4 -If renal insufficiency exists, lower doses of heparin are

required.

5 -Periodic coagulation tests and hematocrit levels areobtained

6 -Oral anticoagulants are monitored by the PT or the INR

7 -Oral anticoagulants administered with heparin until desired anticoagulation has been achieved

B- Monitoring and Managing Potential Complications►Bleeding

1 -Microscopic examination of the urine2- Bruises, nosebleeds, and bleeding gums

3 -IV injections of protamine sulfate may be effective with heparin

→Risks of protamine administration include bradycardia and hypotension, can be minimized by slow administration

4- Administration of vitamin K and/or infusion of fresh-frozen plasma or prothrombin concentrate are effective with anticoagulant agent

5-Oral and low-dose IV vitamin K significantly reduces the INR within 24 hours

►ThrombocytopeniaA complication of heparin therapy may be heparin induced thrombocytopenia (HIT)

-It is a sudden decrease in the platelet count by at least 30% of baseline levels

1 -it is preferable not to use unfractionated heparin over the long term for the greatest risks

2 -The administration of LMWH is less frequently associated with HIT

3 -Beginning warfarin with unfractionated heparin can provide a stable INR or PT by day 5 of heparin treatment, at which time the heparin may be discontinued.

4 -Regular monitoring of platelet counts5 -Early signs include :

-appearance of skin necrosis, either at the site of injection or at distal sites where thromboses occur

-skin discoloration consisting of large hemorrhagic areas -hematomas

-Purpura ,and blistering

6 -If thrombocytopenia does occur, platelet aggregation studies are performed, the heparin is discontinued, and alternate anticoagulant therapy is rapidly initiated

►Drug Interactions:1 -close monitoring of the patient’s medication schedule

is necessary .

2 -Check if any medications or supplements are contraindicated with warfarin, Many medications and supplements inhibit oral anticoagulants

C- Providing Comfort

1 -Elevation of the affected extremity 2 -graduated compression stockings, and analgesic

agents.3 -Warm, moist packs applied to the affected extremity

4 -encouraged to walk once anticoagulation therapy has been initiated

5 -instruct the patient that walking is better than standing or sitting for long periods

6 -Bed exercises, such as repetitive dorsiflexion of the foot

D- Compression Therapy:► Stockings

1 -Graduated compression stockings usually are prescribed

2 -The amount of pressure gradient is determined by the amount and severity of venous disease

3 -Are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins .

4 -These stockings may be knee high, thigh high, or pantyhose

5-When the stockings are off, the skin is inspected forsigns of irritation, and the calves are examined for tenderness.

6-Any skin changes or signs of tenderness are reported.

7 -Stockings are contraindicated in patients with severe pitting edema because they can produce severe pitting at the knee

N B

For ambulatory patientsgraduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning.

►External Compression Devices and Wraps1 -Short stretch elastic wraps may be applied from the toes

to the knee in a 50% spiral overlap.

2-The Unna boot: -consists of a paste bandage impregnated with zinc oxide,

glycerin, gelatin, and sometimes calamine, is applied without tension in a circular fashion from the base of the toes to the tibial tuberosity with a 50% spiral overlap .

-It is important to keep the foot dorsiflexed at a 90 degree angle, thus avoiding excess pressure or trauma to the anterior ankle area

-Once the bandage dries, it provides a constant and consistent compression of the venous system, remain in place for as long as 1 week

►Intermittent Pneumatic Compression Devices1 -can be used with elastic or graduated compression stockings2 -consist of an electric controller that is attached by air hoses to

plastic knee high or thigh-high sleeves3-The leg sleeves are divided into compartments, which

sequentially fill to apply pressure to the ankle, calf, and thigh at 35 to 55 mm Hg of pressure

4 -increase blood velocity beyond that produced by the stockings .

5 -Ensuring that prescribed pressures are not exceeded, assessing for patient comfort, and ensuring compliance to therapy

E- Positioning the Body and Encouraging Exercise

1 -The feet and lower legs should be elevated periodically above the level of the heart

2 -Active and passive leg exercises, particularly those involving calf muscles

3 -Early ambulation is most effective4 -Deep-breathing exercises

5 -avoid sitting for more than an hour at a time6 -Walk at least 10 minutes every 1 to 2 hours.

3 -Chronic Venous Insufficiency/( Post thrombotic Syndrome)

-It results from obstruction of the venous valves in the legs or a reflux of blood through the valves.

-Superficial and deep leg veins can be involved

↑ ↓↓↓↓↑

↑ ↑

↑↑ ↑

↑↑

↑ ↑

↑

Gravity

Bloodpressure

↑↓

Competent valves showing blood flow patterns when the valve is open (A) and closed (B), allowing blood to flow against gravity .

C, With faulty or incompetent valves, the blood cannot move toward the heart

A B C

INFECTIOUS DISEASES OF THE HEART1 -Endocarditis

A- Rheumatic Endocarditis

Patients with rheumatic fever may develop rheumatic heart diseaseAcute rheumatic fever, which occurs most often in school age children, may develop after an episode of group A beta hemolytic streptococcal pharyngitis

B- Infective Endocarditisis a microbial infection of the endothelial surface of the heart. It usually develops in people with prosthetic heart valves or structural cardiac defects

2 -Myocarditisinflammatory process involving the myocardium, can cause heart dilation, thrombi on the heart wall (mural thrombi), infiltration of circulating blood cells around the coronary vessels and between the muscle fibers,

and degeneration of the muscle fibers themselves

3 -Pericarditisinflammation of the pericardium, the membranous sac enveloping the heart .

-Primary illness-Secondary, it may develop during various medical and

surgical disorders .For example

→After pericardectomy (opening of the pericardium) following cardiac surgery .

→also may occur 10 days to 2 months after acute myocardial infarction (MI)

ARTERIAL DISORDERS 1 -Arteriosclerosis and Atherosclerosis

Arteriosclerosis :is the most common disease of the arteries; the term

means “hardening of the arteries ”.It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened

Atherosclerosis:A different process, affecting the intima of the large and medium-sized arteries.

These changes consist of the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as atheromas or plaques.It may be complicated by :

-hemorrhage, ulceration -calcification, or thrombosis

-Myocardial infarction

-stroke, or gangrene.

2 -Peripheral Arterial Occlusive Disease-Arterial insufficiency of the extremities occurs most often

in men and is a common cause of disability .

-The legs are most frequently affected; however, the upper extremities may be involved. The age of onset and the severity are influenced by the type and number of atherosclerotic risk factors

-In PAD, obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta

below the renal arteries to the popliteal artery .-frequently seen in patients with diabetes mellitus and in

elderly patients

-pain may be described as aching, cramping, or inducing fatigue or weakness that occurs with the same degree of exercise or activity and is relieved with rest.

-The pain commonly occurs in muscle groups distal to the area of stenosis or occlusion.

-Elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the extremity in a dependent position reduces the pain

Thromboangiitis Obliterans (Buerger’s Disease)

It is characterized by recurring inflammation of the intermediate and small arteries,veins, and valves of the lower and upper extremities

It results in thrombus formation and segmental occlusion of the vessels

There is considerable evidence that heavy smoking or chewing of tobacco is a causative or an aggravating factor

Raynaud’s Phenomenon -Is a form of intermittent arteriolar vasoconstriction

that results in coldness, pain, and pallor of the fingertips or toes

-There are two forms of this disorder.1 -Primary or idiopathic (Raynaud’s disease) occurs in

the absence of an underlying disease

2 -Secondary Raynaud’s occurs in association with an underlying disease, usually a connective tissue disorder, such as systemic lupus erythematosus, rheumatoid arthritis, or scleroderma; trauma; or obstructive arterial lesions.

Thanks