NUR 201NUR 201

Vascular systemVascular system

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Anatomy& physiologyAnatomy& physiology The vascular systemThe vascular system consists of two interdependentconsists of two interdependent

systems:systems:Right side of the heart pumpRight side of the heart pump

( pulmonary circulation)( pulmonary circulation)Left side of the heart pumpLeft side of the heart pump

(systemic circulation)(systemic circulation)

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BLOOD VESSELSBLOOD VESSELS Consists of arteries, veins, and cappillaries.Arteries and veins are innervated by Automated Nervous System

Arteries and arteriols:Arteries and arteriols: High-pressure system, thick wall, Located in protected areas High-pressure system, thick wall, Located in protected areas away from skin surfaceaway from skin surfaceWall of arteries and arteriols composed of 3 layersWall of arteries and arteriols composed of 3 layers

Intema: inner indothelial layer, contact with blood, very Intema: inner indothelial layer, contact with blood, very thinthinMedia: smmoth elastic tissue, constrict & dilate vesselsMedia: smmoth elastic tissue, constrict & dilate vesselsAdventitia: connective tissue, anchors vessels to Adventitia: connective tissue, anchors vessels to surrounding surrounding

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CapillariesCapillaries

Network for exchange Network for exchange

O2 and CO2 between O2 and CO2 between

Arterioles and VenulesArterioles and Venules

Veins and venulesVeins and venulesLarger in diameter than arteries but the wall are thinner Larger in diameter than arteries but the wall are thinner which allow them to distend more than arterieswhich allow them to distend more than arteriesIn contrast to arties, veins have one-way valves that prevent In contrast to arties, veins have one-way valves that prevent blood to back flow (CABG)blood to back flow (CABG)Transport deoxygenated blood from the body to the heart Transport deoxygenated blood from the body to the heart

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The amount of blood flow is constantly changes

When metabolic needs increase (fever, activity, infection, heat), the vessels dilates to increase blood flow.

When metabolic needs decrease (cold, rest, OR), the vessels constrict to decrease blood flow.

When body fail to meet metabolic needs, ischemia develops.

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Systemic areriovenous systemSystemic areriovenous system Oxygen sat in vena cava (VO2) is less than oxgen sat in artery by Oxygen sat in vena cava (VO2) is less than oxgen sat in artery by

25%.25%. If this value changes this mean that there is low CO, high If this value changes this mean that there is low CO, high

metabolic needs, and/ or low FIO2.metabolic needs, and/ or low FIO2.

Peripheral vascular resistance:Peripheral vascular resistance: Vessels oppose blood flow (depends on vessels diameter, blood Vessels oppose blood flow (depends on vessels diameter, blood

viscosityviscosity “ “% of Hct% of Hct””) ) Innervated by sympathetic “adrenergic” nervous system which Innervated by sympathetic “adrenergic” nervous system which

control the diameter of the vessels “Norepinephrine”control the diameter of the vessels “Norepinephrine” Epi, hormon released from adrenal medullaEpi, hormon released from adrenal medulla Angiotensin, hormon released from kidney.Angiotensin, hormon released from kidney. All these hormons cause vasocnstrictionAll these hormons cause vasocnstriction

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Clinical ManifestationsClinical Manifestations

Intermittent claudicationIntermittent claudication: : Its cramp-type pain in the Its cramp-type pain in the extremities reproduce with extremities reproduce with the same degree of exercise the same degree of exercise or activity & relieved by restor activity & relieved by rest

Rest pain: worse at night & may interfere with sleepRest pain: worse at night & may interfere with sleepAs general role, the pain of intermittent claudication As general role, the pain of intermittent claudication occurs one joint level below the disease process occurs one joint level below the disease process

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Changes in skinChanges in skin :RT low perfusion :RT low perfusionInadequate blood flow cause cool & pale extremitiesInadequate blood flow cause cool & pale extremitiesBlue discoloration of extremitiesBlue discoloration of extremitiesloss of hair, dry skin, atrophy, ulceration, gangreneloss of hair, dry skin, atrophy, ulceration, gangrene

PulsesPulses Determining the quality of peripheral pulses to Determining the quality of peripheral pulses to assess the status of peripheral arterial circulation.assess the status of peripheral arterial circulation.Absence of pulse may indicates the size of stenosis Absence of pulse may indicates the size of stenosis (narrowing or constriction ) (narrowing or constriction )

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Diagnostic EvaluationDiagnostic EvaluationDopplerDoppler

Doppler used when pulses cannot Doppler used when pulses cannot

be palpated.be palpated.

Exercise TestingExercise Testing Measure systolic BP in response to walkingMeasure systolic BP in response to walking If there is drops, means true claudicationIf there is drops, means true claudication. .

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Angiography Angiography

Used to confirm the diagnosis of Used to confirm the diagnosis of

occlusive arterial disease.occlusive arterial disease. Contrast agent usually usedContrast agent usually used

phlebography ( venography )phlebography ( venography ) angiogram for the effect veinangiogram for the effect veinContrast usually usedContrast usually used

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ARTERIAL DISORDERSARTERIAL DISORDERSArteriosclerosisArteriosclerosis: : Its hardening of the arteries.Its hardening of the arteries. The muscle fiber & endothelial walls of small arteries & arteriols The muscle fiber & endothelial walls of small arteries & arteriols become thickenedbecome thickened

AtherosclerosisAtherosclerosis: : Accumulation of lipids, calcium, blood components, fibrous, Accumulation of lipids, calcium, blood components, fibrous, carbohydrates on the internal layer, which decreases the peripheral carbohydrates on the internal layer, which decreases the peripheral perfusion. perfusion.

Risk factorsRisk factorsModifiable: diet, DM, high BP, stress, life style Modifiable: diet, DM, high BP, stress, life style Non modifiable: age, gender Non modifiable: age, gender

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Clinical manifestationsClinical manifestations : RT Arterial disorders : RT Arterial disorders Depends on tissue or organ affected, Depends on tissue or organ affected, Coronary: (angina, MI ), cerebrovascular ( TIA, strocke), Coronary: (angina, MI ), cerebrovascular ( TIA, strocke), Aorta ( aneurysm ), renovascular ( hypertension ) Aorta ( aneurysm ), renovascular ( hypertension )

Medical managementMedical management Modification of risk factors to improve Modification of risk factors to improve circulationcirculation Surgical management (PTA, stent)Surgical management (PTA, stent) Medications (heparin, warfarine, TPA)Medications (heparin, warfarine, TPA)

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PERIPHERAL ARTERIAL OCCLUSIVE DISEASEPERIPHERAL ARTERIAL OCCLUSIVE DISEASE Found in older than 50 yrs, most often in men, DM, legs are Found in older than 50 yrs, most often in men, DM, legs are most frequently affectedmost frequently affected

Clinical manifestation Clinical manifestation Intermittent claudication. Intermittent claudication. Fatigue, weakness in joint muscles below stenosis or Fatigue, weakness in joint muscles below stenosis or occlusion areaocclusion areaDecrease ability to walk, increase pain with ambulationDecrease ability to walk, increase pain with ambulationIschemic pain at rest & worse at night Ischemic pain at rest & worse at night Absence of peripheral pulse, cold extremitiesAbsence of peripheral pulse, cold extremitiesNumbness Numbness

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Medical managementMedical management Exercise program with weight reductionExercise program with weight reduction Smoking cessation Smoking cessation Trental (decrease blood viscosity which increase Trental (decrease blood viscosity which increase

perfusion).perfusion). antiplatelets. antiplatelets.

Surgical managementSurgical management

- Grafting- Grafting

- Endarterectomy (removing of clot)- Endarterectomy (removing of clot)

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Nursing ManagementNursing Management1- Maintaining circulation1- Maintaining circulation

Check pulses of affected extremities, note symmetry, Check pulses of affected extremities, note symmetry, color, temp., capillary refill, sensory & motor hourly color, temp., capillary refill, sensory & motor hourly Doppler evaluation of vessels distal to bypass graftDoppler evaluation of vessels distal to bypass graft

2- Monitoring & managing potential complications2- Monitoring & managing potential complicationsUrine output, CVP, pulse, leak, hematoma & edemaUrine output, CVP, pulse, leak, hematoma & edema

3- Promoting home & community based care3- Promoting home & community based careDischarge plan, pt education, assess ability to change Discharge plan, pt education, assess ability to change life style & self carelife style & self care/ /١٤٤٤ ٠٩ ٢٨/ /١٤٤٤ ٠٩ ٢٨ 1515

Aortic AneurysmAortic Aneurysm Dilation in the wall of AortaDilation in the wall of Aorta can be thoracic or abdominal can be thoracic or abdominal

Thoracic Aortic AneurysmThoracic Aortic Aneurysm

Clinical manifestationClinical manifestation Pain in supine position, dyspnea, hoarseness or Pain in supine position, dyspnea, hoarseness or

aphonia ( complete loss of voice ), dysphagia aphonia ( complete loss of voice ), dysphagia

Medical managementMedical management Surgical repair, control BP, correcting risk factors, Surgical repair, control BP, correcting risk factors,

decrease contractility. decrease contractility. / /١٤٤٤ ٠٩ ٢٨/ /١٤٤٤ ٠٩ ٢٨ 1616

ABDOMINAL AORTIC ANEURYSMABDOMINAL AORTIC ANEURYSM• most common cause is atherosclerosis, affect men 4 most common cause is atherosclerosis, affect men 4 times than women, occur mostly below renal stenosis, times than women, occur mostly below renal stenosis, untreated outcome is rupture & deathuntreated outcome is rupture & death

Clinical manifestationsClinical manifestationsAbdominal heart beat on lying position,Abdominal heart beat on lying position, abdominal mass abdominal mass thrombingthrombing

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Medical managementMedical management Surgery is the treatment of choiceSurgery is the treatment of choice Bypass graft, endovascular graft ( suturless )Bypass graft, endovascular graft ( suturless )

Nursing managementNursing management Assessment before surgery, post op.Assessment before surgery, post op. systematic monitoring, neurological assessment, systematic monitoring, neurological assessment,

signs of impeding rupture ( abdominal & back pain) signs of impeding rupture ( abdominal & back pain) / /١٤٤٤ ٠٩ ٢٨/ /١٤٤٤ ٠٩ ٢٨ 1818

Arterial EmbolismArterial EmbolismIts acute vascular occlusion Its acute vascular occlusion

due to an embolus or due to an embolus or

acute thrombosisacute thrombosis

Causes Causes Iatrogenic injury ( insertion of catheters ), trauma Iatrogenic injury ( insertion of catheters ), trauma from fractures, crush injury, penetrating wound, from fractures, crush injury, penetrating wound, thrombi (AF, MI, CHF)thrombi (AF, MI, CHF)

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Clinical manifestationsClinical manifestations Cessation of distal blood flow.Cessation of distal blood flow. Gradual loss of sensory & motor function.Gradual loss of sensory & motor function. pain, pallor, cold, pulse lessens & paralysispain, pallor, cold, pulse lessens & paralysis

Medical managementMedical managementSurgery ( embolectomy ),Surgery ( embolectomy ),Medication : Heparin, Thrombolytic therapy (STK; Medication : Heparin, Thrombolytic therapy (STK; streptokainase)streptokainase)

Nursing managementNursing managementPre-op: bed rest, warm at room temp.Pre-op: bed rest, warm at room temp.Post-op: encourage movement & continue anticoogulantsPost-op: encourage movement & continue anticoogulants

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VENOUS DISORDERSVENOUS DISORDERS

DVT, Thrombophilibitis and PhlebothrombitisDVT, Thrombophilibitis and Phlebothrombitis

Clinical manifestationsClinical manifestationsMassive swelling, tenderness,Massive swelling, tenderness, warmer affected extremity,warmer affected extremity,heaviness & functional lossheaviness & functional loss

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Medical management Medical management

Anti coagulants: heparin, thrombolytic therapyAnti coagulants: heparin, thrombolytic therapy Surgical management: thromboectomy Surgical management: thromboectomy

Nursing managementNursing management Monitor PT, PTT, HgbMonitor PT, PTT, Hgb Monitor & manage complicationsMonitor & manage complications Provide comfort & apply elastic pressure Provide comfort & apply elastic pressure

stockings. stockings.

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Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)

Thrombosis in the deep veinsThrombosis in the deep veins Common in lower extrimitiesCommon in lower extrimities CausesCauses:: include immbolization, paralysis, anesthesia, direct include immbolization, paralysis, anesthesia, direct

trauma, cancer, CVC, obesity.trauma, cancer, CVC, obesity. S& S: S& S: swollen extrimities, cold, painfulswollen extrimities, cold, painful RxRx: anticoagulants, thromboetomy, elastic compression, bed : anticoagulants, thromboetomy, elastic compression, bed

rest, limbs elevation, exercise. rest, limbs elevation, exercise. / /١٤٤٤ ٠٩ ٢٨/ /١٤٤٤ ٠٩ ٢٨ 2323

Varicose VeinsVaricose Veins

•Abnormally dilation of Abnormally dilation of

superficial veins caused by incompetent venous valves.superficial veins caused by incompetent venous valves.

• Occur in lower extremities “sphenous veins”Occur in lower extremities “sphenous veins”

• common in occupation that requires prolonged standing (teacher, common in occupation that requires prolonged standing (teacher,

nurses).nurses).

• also, common in pregnancy (due to high pressure by gravid also, common in pregnancy (due to high pressure by gravid

uterus which increseas blood volume. uterus which increseas blood volume. / /١٤٤٤ ٠٩ ٢٨/ /١٤٤٤ ٠٩ ٢٨ 2424

Clinical manifestationsClinical manifestations Muscle cramps, increase muscle fatigue, ankle edemaMuscle cramps, increase muscle fatigue, ankle edema

Prevention Prevention Avoid prolonged standing, wearing socks, elevating legs,

walking q one hour, wt loss

Medical managementMedical managementSurgery ( ligation ) Surgery ( ligation )

Nursing managementNursing managementBed rest 1Bed rest 1stst 24 hours & start walking at 2 24 hours & start walking at 2ndnd day. day.Elastic pressure stockings, elevate foot.Elastic pressure stockings, elevate foot.Discourage standing & sitting, promote comfort (analgesia). Discourage standing & sitting, promote comfort (analgesia).

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HYPERTENTIONHYPERTENTION Systolic above 140 mmhg & diastolic above 90 mmhgSystolic above 140 mmhg & diastolic above 90 mmhg”” over sustained periodover sustained period

Pathophsiology Pathophsiology :: there are 4 hypothesis there are 4 hypothesis

Increase SNS activity RT dysfunction of ANSIncrease SNS activity RT dysfunction of ANS

Increase renal reabsorption of Na, Cl, H2OIncrease renal reabsorption of Na, Cl, H2O

Increase activity of renin-angiotensin –aldosterone Increase activity of renin-angiotensin –aldosterone

systemsystem

DM type 2(high lipids, obesity) DM type 2(high lipids, obesity)

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ComplicationsComplications : : MI, heart failure, renal failure, MI, heart failure, renal failure, stoke, impaired visonsstoke, impaired visons

Types & causes Types & causes 1-1- Primary Primary (idiopathic essential ) hypertention(idiopathic essential ) hypertention

80-90% of cases are of unknown cause but 80-90% of cases are of unknown cause but predisposed by: old age over 60 yrs, obesity, predisposed by: old age over 60 yrs, obesity, black race, atherosclerosis black race, atherosclerosis

Benign or chronic hypertentionBenign or chronic hypertention Rise is usually slight to moderate & continue to Rise is usually slight to moderate & continue to

rise slowly often asymptomatic ( silent killerrise slowly often asymptomatic ( silent killer

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Malignant (accelerated) hypertentionMalignant (accelerated) hypertention BP very high & continue to raise rapidly, BP very high & continue to raise rapidly,

diastolic pressure in excess of 120 mmhg & the diastolic pressure in excess of 120 mmhg & the effects are quickly apparenteffects are quickly apparent

2- 2- Secondary hypertentionSecondary hypertention: : Increase BP from an Increase BP from an identified cause resulting from other diseaseidentified cause resulting from other disease

CausesCauses Renal disease, endocrine disorders, age & sex, Renal disease, endocrine disorders, age & sex,

stressful occupation & situation, family tendency, stressful occupation & situation, family tendency, DM, dyslipidemia, smoking & alcoholDM, dyslipidemia, smoking & alcohol

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Clinical manifestationsClinical manifestations High blood pressure readingHigh blood pressure reading Headache, epistaxis, angina,Headache, epistaxis, angina, dizziness, dyspnea, ringing in earsdizziness, dyspnea, ringing in ears Retinal changesRetinal changes A A common consequence M.I. & CADcommon consequence M.I. & CAD

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Medical managementMedical management

Treatment of underlying causeTreatment of underlying cause Life stile modification :-Life stile modification :- Management of predisposing factors Management of predisposing factors

( low salt diet, decease weight, stop ( low salt diet, decease weight, stop smoking, decrease stress level)smoking, decrease stress level)

Pharmacologic therapy (diuretics, Pharmacologic therapy (diuretics, vasodilation agents & agents to decrease vasodilation agents & agents to decrease cardiac output ) cardiac output )

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Nursing ProcessNursing ProcessNursing DiagnosisNursing Diagnosis

Knowledge deficit ( medication & disease process )Knowledge deficit ( medication & disease process )Non compliance with therapeutic regimen Non compliance with therapeutic regimen

PlanningPlanning Pt will understand disease process & its treatmentPt will understand disease process & its treatment Pt will participate in self care programPt will participate in self care program

ImplementationImplementationAllow pt to rest & relax, medication as prescribed, report Allow pt to rest & relax, medication as prescribed, report side effects, educate pt about rebound hypertention that occurs side effects, educate pt about rebound hypertention that occurs if therapy suddenly stoppedif therapy suddenly stoppedMeasure BP routinely.Measure BP routinely.Educate pt about Orthostatic hypotension so to stand Educate pt about Orthostatic hypotension so to stand gradually gradually Life style modification Life style modification

Conclusion Conclusion

Any Question ?Any Question ?

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