vascular disorders bridging 13-14
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Management of Patients with
Vascular Disorders
Venous
Arterial
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LEARNING OBJECTIVES
On completion of this chapter, the students will be able to: Identify factors that affect peripheral blood flow and tissue
oxygenation.
Use appropriate parameters for assessment of peripheral
circulation. Use the nursing process as a framework of care for
patients with circulatory insufficiency of the extremities.
Compare the various diseases of the arteries, their
causes, pathologic and physiologic changes, clinicalmanifestations, management, and prevention.
Describe the prevention and management of venous
thrombosis.
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Venous Disorders
1. DEEP VEIN THROMBOSIS (DVT)
2. CHRONIC VENOUS INSUFFICIENCY
3. LEG ULCERS4. VARICOSE VEINS
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Management of Venous
Disorders
DEEP VEIN THROMBOSIS (DVT)
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Pathophysiology of DVT
Three factors, known as Virchows triad, are
believed to play a significant role in
development of DVT:
1. Stasis of blood (venous stasis)
2. Vessel wall injury (endothelial damage)
3. Altered blood coagulation (Coagulopathy)
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Risk Factors for Deep Vein Thrombosis1. Venous stasis
A. Bed rest or immobilization
B. Obesity
C. History of varicose veins
D. Age (>65 yr)
2. Endothelial damage
A. TraumaB. Surgery
C. Pacing wires
D. Central venous catheters
E. Dialysis access catheters
3. Coagulopathy (abnormal coagulation)4. Cancer
5. Pregnancy
6. Oral contraceptive use
7. Septicemia
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Clinical Manifestations of DVT
Edema and swelling of the extremity
because the outflow of venous blood isinhibited
The affected extremity may feel warmer
than the unaffected extremity, and thesuperficial veins may appear moreprominent.
Tenderness, which usually occurs later, isproduced by inflammation of the vein wall
Homans sign (pain in the calf after the footis sharply dorsiflexed)
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Homans sign
Is not specific for deep vein thrombosisbecause it can be elicited in any painful
condition of the calf.
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Complications of Venous Thrombosis
1. Pulmonary emboli from dislodgedthrombi
2. Varicose veins
3. Venous ulcers
4.Fluid stasis and edema
5. Venous gangrene
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Medical Management
I - Thrombolytic Therapy
Causes the thrombus to lyse and dissolve in
50% of patients.
tissue plasminogen activator (t-PA)
Streptokinase
Is given within the first 3 days after acute
thrombosis. Results in greater incidence of bleeding than
heparinshould be discontinued
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Medical Management of DVT
II-ANTICOAGULATION THERAPY
1- HeparinIs administered for 5 - 7 days to prevent the
extension of thrombus and the development of
new thrombi.
Unfractionated Heparin
1. Subcutaneously
2. Intermittent intravenous injection
3. Continuous infusionMedication dosage is regulated by monitoring the partial
thromboplastin time ( PTT)
Low-Molecular-Weight Heparin (LMWH)
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Medical ManagementII-ANTICOAGULATION THERAPY
2 - Oral anticoagulants
warfarin (Coumadin)
Are administered with heparin therapy. Medication dosage is regulated by
monitoring:
Prothrombin time (PT) International normalized ratio (INR)
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Nursing Management of DVT
Assessment and Diagnostic Findings1. History of any of the risk factors
2. Limb pain
3. Feeling of heaviness
4. Ankle edema5. Differences in leg circumference bilaterally
6. Increase in the temperature of the leg
7. Areas of tenderness
8. Superficial thrombosis (ie, cordlike venoussegment).
9. Homans sign (not a reliable or valid sign forDVT)
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Nursing Management of DVT
ASSESSING AND MONITORINGANTICOAGULANT THERAPY
If the patient is receiving anticoagulant therapy, youmust frequently monitor:
Partial thromboplastin time (PTT) Prothrombin time(PT)
Hemoglobin and hematocrit values
Platelet count
Fibrinogen level Close observation is also required to detect bleeding
If bleeding occurs, it must be reported immediatelyand anticoagulant therapy discontinued.
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Nursing Management of DVT
MONITORING AND MANAGING POTENTIAL
COMPLICATIONS OF ANTICOAGULANT
THERAPY
1. Bleeding
2. Thrombocytopenia (low platelet count)3. Drug Interactions
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Management of Arterial
Disorders
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Arterial Disorders
1. ARTERIOSCLEROSIS& ATHEROSCLEROSIS2. ARTERIAL EMBOLISM / PULMONARY EMBOLISM
3. ARTERIAL THROMBOSIS
4. PERIPHERAL ARTERIAL DISEASE
5. THROMBOANGIITIS OBLITERANS(BUERGERS DISEASE)
6. AORTITIS
7. AORTIC ANEURYSM
8. DISSECTING AORTA
9. RAYNAUDS DISEASE
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Pulmonary Embolism
Pulmonary Embolus is a fragment of thethrombus that breaks off and travels in theblood until it lodges at the pulmonaryvasculature.
Acute pulmonary embolism (PE) is a commonand often fatal disease. Mortality can bereduced by prompt diagnosis and therapy.
The majority of clinically significant pulmonaryemboli begin in the pelvic or lower extremityveins.
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Predisposing Factors
Minor risk factorsMajor risk factors
Obesity
Bed RestEstrogen therapy
Surgery
Major TraumaCancerCongestive Heart failure
Myocardial infarctionImmobilization
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Clinical Manifestations / Symptoms of PE
The presentation of pulmonary embolism may varyfrom sudden catastrophic hemodynamic collapse to
gradually progressive dyspnea
Patients with pulmonary embolism may present
with atypical symptoms The diagnosis of pulmonary embolism should be
sought actively in patients with respiratory
symptomsunexplained by an alternative diagnosis.
The symptoms of pulmonary embolism arenonspecific; therefore, a high index of suspicion is
required, particularly when a patient has risk
factorsfor the condition.
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Clinical Manifestations / Symptoms of PE
Angina-Like pain Wheezing
Hemoptysis
Palpitations
Productive cough Syncope
Abdominal pain
Fever
Decreasing level of consciousness Pleuritc Pain
Leg Swelling / Leg Pain
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Clinical Manifestations / Signs of PE
Tachypnea (respiratory rate >16/min) - 96% Rales - 58%
Accentuated second heart sound - 53%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8C) - 43% Diaphoresis - 36%
S3 or S4 gallop - 34%
Clinical signs and symptoms suggesting
thrombophlebitis - 32%
Lower extremity edema - 24%
Cardiac murmur - 23%
Cyanosis - 19%
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Diagnosis of Pulmonary Embolism
(PE)1-Clinical picture
2-Look for risk or predisposing factors
4-Testing for PE:
1. High D-dimer level: a degradation product produced by
plasmin-mediated proteases of cross-linked fibrin,
2. Arterial blood gas: hypoxemia, hypocapnia, and
respiratory alkalosis
3. Chest radiograph ( X-ray )
4. ECG5. Ventilation-perfusion scanning (V/Q scanning).
6. Spiral CT
7. Angiography
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Treatment of Pulmonary Embolism
1. Treatment of respiratory distress including:
1. O2
2. Monitoring
3. Fluid resuscitation for secondary right-sided heart failure
4. Inotropic agents2. Anticoagulant : Heparin, LMWH , and oral
anticoagulant
3. Thrombolytic agent
4. Caval Interruption.
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Anticoagulant
A - Heparin
A loading dose of 5,000-10,000 U followed byapproximately 1,000 U/h.
weight-based dosing.
A bolus with 80 U/kg and then start a drip at10- 18 U/kg/h.
1. Check PTT every 6 hours.
2. Keep the PTT at 1.5 to 2 times control.
3. Adjust dose as per protocol in.
4. Use clinical judgment!
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B - low-molecular-weight heparin LMWH
Enoxaparin: (Clexan)
Tinzaparin sodium (Innohep)
1. No need to follow PT / INR / PTT.
2. Use with caution in renal and hepatic disease.
3. The dose must be adjusted for renal function.
4. Dose: 100 IU/kg (1 mg/kg) twice daily
5. Oral anticoagulant should be initiated andEnoxaparin sodium should be continued until
therapeutic effect (INR 2-3)
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CWarfarin
It is taken orally. Begin with 5 mg QHS.
Warfarin therapy can begin on day one ofheparin therapy.
The range of INR(Internationalnormalization ratio) of 2 - 3 is considered
therapeutic. Monitor daily using the PT(Prothrombin
time), until a stable INR for 2 days.
Heparin should be continued for at least 4
days total and for at least 2 days after atherapeutic INR is obtained.
Continue using anticoagulation (warfarin) forat least 6 months.
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Nursing Management for patient with
Pulmonary Embolism
1. PREVENTING OR MINIMIZING THE RISK OF
THROMBUS FORMATION & PE
2. MONITORING THROMBOLYTIC THERAPY3. MANAGING PAIN
4. MANAGING OXYGEN THERAPY
5. RELIEVING ANXIETY6. MONITORING FOR COMPLICATIONS
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PREVENTING OR MINIMIZING THE RISK OF
THROMBUS FORMATION & PE
1. Identify patients at high risk for PE and to
minimize the risk of PE in all patients.
2. Encourage ambulation and active and passiveleg exercises to prevent venous stasis in patients
on bed rest.
3. Instruct the patient to move the legs in a
pumping exercise so that the leg muscles can
help increase venous flow.
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Nursing Management for patient with
Pulmonary Embolism
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PREVENTING OR MINIMIZING THE RISK OF
THROMBUS FORMATION & PE
4. Advise the patient not to sit or lie in bed for
prolonged periods, not to cross the legs, and
not to wear constricting clothing.5. Legs should not be dangled or feet placed in a
dependent position while the patient sits on
the edge of the bed; instead, the patients feetshould rest on the floor or on a chair.
6. Intravenous catheters should not be left in
place for prolonged periods31
Nursing Management for patient with
Pulmonary Embolism
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Nursing Management for patient with
Pulmonary Embolism
MONITORING THROMBOLYTIC THERAPY1. During thrombolytic infusion, the patient remains onbed rest, vital signs are assessed every 2 hours, and
invasive procedures are limited
2. Because of the prolonged clotting time, only essentialarterial punctures or venipunctures are performed,
and manual pressure is applied to any puncture site
for at least 30 minutes.
3. Pulse oximetry is used to monitor changes inoxygenation.
4. Immediately discontinue the infusion if uncontrolled
bleeding occurs.
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Nursing Management for patient with
Pulmonary Embolism
MANAGING PAIN
1. A semi-Fowlers position provides a more
comfortable position for breathing.
2. continue to turn the patient frequently andreposition the patient to improve the
ventilationperfusion ratio in the lung.
3. Administer opioid analgesics as prescribedfor severe pain.
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Nursing Management for patient with
Pulmonary Embolism
MANAGING OXYGEN THERAPY1. Ensure that the patient understands the need forcontinuous oxygen therapy.
2. Assess the patient frequently for signs of hypoxemia
and monitors the pulse oximetry values to evaluatethe effectiveness of the oxygen therapy.
3. Deep breathing and incentive spirometry are
indicated for all patients to minimize or prevent
atelectasis and improve ventilation.4. Nebulizertherapy or percussionandpostural
drainagemay be used for management of secretions
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Nursing Management for patient with
Pulmonary Embolism
RELIEVING ANXIETY1. Encourage the stabilized patient to talk about
any fears or concerns related to this
frightening episode2. Answer the patients and familys questions
concisely and accurately
3.Explain the therapy, and describes how torecognize untoward effects early
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Nursing Management for patient with
Pulmonary Embolism
MONITORING FOR COMPLICATIONS
Be alert for the potential complication as :
1. Cardiogenic shock
2. Right ventricular failure
3. Shock
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Arteriosclerosis
Is the most common
disease of the arteries The term means hardening
of the arter ies. It is a diffuse process
whereby the muscle fibers
and the endothelial lining of
the walls of small arteriesand arterioles become
thickened.
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Clinical Manifestationsdepend on the organ or tissue affected.
Coronary atherosclerosis (heart disease): Angina
Acute myocardial infarction
Cerebrovascular diseases:
Transient ischemic attacks
Stroke
Atherosclerosis of the aorta:
Aneurysm Lesions of the extremities
Renovascular disease:
Renal artery stenosis / hypertension
End-stage renal disease 38
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PERIPHERAL ARTERIAL DISEASE
(PAD) Arterial insufficiency of the
extremities
1. Usually found in
individuals > 50 Y/O2. Most often in men
3. The legs are most
frequently affected4. Frequently seen in
patients with diabetes
mellitus 39
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Risk Factors for Peripheral Arterial Disease
(PAD)
Modifiable
1. Nicotine use
2. Hypertension
3. Diet
4. Obesity
5. Sedentary lifestyle
6. Stress7. Diabetes mellitus
Non-modifiable
1. Age
2. Gender
3. Familial
predisposition
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Cli i l M if t ti f
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Clinical Manifestations of
PAD
The hallmark is intermittent claudication.
Pain aching, cramping, fatigue, or
weakness that is consistently occur with
the same degree of exercise or activity
and relieved with rest.
When the arterial insufficiency becomes
severe, the patient begins to have rest
pain.
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Assessment and Diagnostic Findings of
PAD
Examining the peripheral
pulses is an important part
of assessing arterial
occlusive disease.
Unequal pulses between
extremities or the absence
of a normally palpablepulse is a sign of peripheral
arterial disease.
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Assessment and Diagnostic Findings of
PAD
Extremity1. Feel coolto the touch and look
palewhen elevated or ruddy and
cyanotic when placed in a
dependent position.2. Nailsmay be thickenedand
opaque,
3. Skinmay be shiny, atrophic, and
dry, with sparse hair growth4. Ulcerations, gangrene, and
muscle atrophy
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Medical Management of PAD
PHARMACOLOGIC THERAPY Pentoxifylline (Trental)
increases erythrocyte (red blood cells) flexibility
and reduces blood viscosity
Anti-plateletaggregating agents such as:
Aspirin Ticlopidine (Ticlid)
Clopidogrel (Plavix)
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SURGICAL MANAGEMENT OF PAD
EndarterectomyIncision is made into the
artery, and the
atheromatous
obstruction is removed
Bypass grafts
Performed to reroute
the blood flow
around the stenosis
or occlusion.
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NURSING PROCESS
THE PATIENT WHO HAS
PERIPHERALARTERIAL INSUFFICIENCY
OF THE EXTREMITIES
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Assessment
Complete health and medication history andidentification of risk factors for peripheralartery disease.
Signs and symptoms detected during thenursing assessment may include:
1. Claudication pain
2. Rest pain in the forefoot
3. Pallor, rubor, or cyanosis4. Weak or absent peripheral pulses
5. Skin breakdown or ulcerations
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Nursing Diagnosis
Based on assessment data :
1. Ineffective peripheral tissue perfusion related
tocompromised circulation
2. Chronic pain related to impaired ability of
peripheral vessels to supply tissues withoxygen
3. Risk for impaired skin integrity related to
compromised circulation4. Deficient knowledge regarding self-care
activities
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Planning and Goals
1. Increased arterial blood supply to the
extremities
2. Promotion of vasodilation
3. Prevention of vascular compression
4. Relief of pain
5. Maintenance of tissue integrity6. Adherence to the self-care program
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Nursing Care Plan
The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Nursing Diagnosis: Ineffective peripheral tissue perfusion related tocompromised circulation
Goal: Increased arterial blood supply to extremities
1. Extremities warm to
touch
2. Color of extremities
improved
3. Experiences
decreased musclepain with exercise
1- Dependency of lower
extremities enhances
arterial blood supply
1- Lower the extremities
below the level of the
heart
2- Muscular exercise
promotes blood flowand the development of
collateral circulation.
2- Encourage moderate
amount of walking orgraded extremity
exercises.
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Nursing Care Plan
The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Nursing Diagnosis: Ineffective peripheral tissue perfusion related to
compromised circulation
Goal: Promotion of vasodilation and prevention of vascular
compression
Protects
extremities
from exposure
to cold
Avoids nicotine
Uses stress-management
program to
minimize
emotional upset
1 - Warmth promotes
arterial flow by preventing
the vasoconstriction effects
of chilling.
1- Maintain warm
temperature and avoid
chilling.
2 - Nicotine causes
vasospasm, which
impedes peripheral
circulation
2- Discourage nicotine
use.
3 - Emotional stress causes
peripheral vasoconstriction
3 -Instruct in ways to
avoid emotional upsets;
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The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Goal: Promotion of vasodilation and prevention of vascularcompression
Avoids constricting
clothing and
accessories
Avoids leg crossing
Takes medication as
prescribed
4- Constrictive clothing
and accessories
impede circulation and
promote venous stasis.
4- Encourage avoidance
of constrictive clothing
and accessories.
5- Compression of
vessels with
subsequent
impediment of
circulation venousstasis.
5- Encourage avoidance
of leg crossing
6- Relax smooth
muscle
6- Administer vasodilator
and adrenergic
blocking agents
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Nursing Care Plan
The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Nursing Diagnosis: Chronic pain related to impaired ability of
peripheral vessels to supply tissues with oxygen
Goal: Relief of pain
1. Uses measures to
increase arterial
blood supply to
extremities
2. Uses analgesics
as prescribed
1-Increases the oxygen
supplied to the muscle
and decreases the
accumulation of
metabolites that cause
muscle spasm.
1-Promote increased
circulation.
2-Reduce pain and allowthe patient to participate
in activities and exercises
that promote circulation.
2 - Administeranalgesics as
prescribed
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The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Nursing Diagnosis: Risk for impaired skin integrity related tocompromised circulation
Goal: Maintenance of tissue integrity
1- Inspects skin daily
for evidence of injury
or ulceration
2- Avoids trauma and
irritation to skin
3-Wears protective
shoes
4-Eats a healthy dietthat contains adequate
protein and vitamins A
and C
1-healing of wounds is
delayed or inhibited due
to poor tissue perfusion.
1-Instruct in ways to
avoid trauma to
extremities.
2-prevent foot injuries
and blisters.
2-Encourage wearing
protective shoes and
padding for pressure
areas.
3- promotes healing
and
prevents tissue
breakdown
3- adequate intake
of vitamins A and C,
protein, and zinc;
control of obesity.
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The Patient With Peripheral Vascular Problems
Expected OutcomesRationaleNursing Interventions
Nursing Diagnosis: Deficient knowledge regarding self-care activitiesGoal: Adherence to the self-care program
Practices frequent
position changes
Practices postural
exercises Takes medications
Avoids
vasoconstrictors
Uses measures to
prevent trauma Accepts condition as
chronic but amenable
to therapies that will
decrease symptoms
Adherence to the self-
care program is
enhanced when the
patient receives supportfrom family
1. Include family in
teaching program
Written instructions serve
as reminder
and reinforcement of
information.
2. Provide written
instructions about foot
care, leg care, and
exercise program.
Constrictive clothing and
accessories impede
circulation and promote
venous stasis
3. Assist to obtain
properly fitting
clothing, shoes,
stockings
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