vascular system - nursing edinto the aorta through the arteries to the capillary bed where cellular...

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Vascular System

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CHAPTER SIXTEEN

PHYSIOLOGY OF THE VASCULAR SYSTEM

VesselsA. Arteries:high-pressuresystemthatdeliversoxygenand

nutrientstocellularlevel.B. Capillaries:capillarybedistheareaofcirculationwhere

thearteriolesbranchintocapillariesandwhereexchangebetweenthecirculatingvolumeandtheinterstitialfluidoccurs.

C. Veins: low-pressure system that returns blood andwaste products from the cells to the heart; valves topreventthebackflowofbloodandmaintaindirectionofbloodflow.

D. Circulatorysystems.1. Systemic circulation: flow of blood from the heart

intotheaortathroughthearteriestothecapillarybedwherecellularnutritionandoxygenationoccur.

2. Pulmonarycirculation:flowofbloodfromtherightventriclethroughthepulmonaryarteryintothelungs,through the capillary beds of the lungs where theblood picks up oxygen and releases carbon dioxideand returnsback into the left ventricle through thepulmonaryveins.

3. Hepatic-portal circulation: flow of blood from thevenoussystemofthestomach,intestines,spleen,andpancreasintotheportalveinandthroughtheliverforabsorptionofnutrients;venousbloodleavestheliverthroughthehepaticveinandflowsintothevenacavaforreturntotheheart.

E. Lymphaticsystem:returnsfluidandproteintocircula-tion;maintainshomeostasisofthebloodproteins;assiststomaintainbloodvolume.

Mechanics of Blood FlowA. Bloodflowiscontrolledby:

1. Thediameterofthevessel.2. Thelengthofthevessel.3. Thepressureateitherendofthevessel.4. Theviscosityoftheblood.

B. Physiologiccontrol.1. Autoregulation:theabilityoftissuetocontrolitsown

bloodflow.a. Lack of oxygen and accumulation of metabolic

wasteproductsinitiatetheautoregulatorysystem;

enablesbloodsupplytovitalorgans(brain,kidney,heart)toremainrelativelyconstant.

b. Collateral circulation is part of autoregulatorymechanismforlong-termcontrolofbloodflow;isespeciallyeffectivewhenobstructiontobloodflowoccursgradually.

2. Nervoussystemcontrol.a. Parasympatheticnervoussystem.

(1) Regulationoftheheartratethroughthevagusnerve.

(2) Baroreceptorsarelocatedinaorticarchandincarotid sinuses (carotid bodies) and are verysensitivetochanges inpressurewithinvesselwalls; an increase inpressurecauses stimula-tionofthevagusnerve,whichinturndecreasestheheartrate.

b. Sympatheticnervoussystem.(1) Primaryinfluenceisonarteriolesfordilation

and constriction of the vessels to maintainperipheralresistanceandvasomotortone.

(2) Peripheralresistanceisresistanceofarteriolestoflowofblood.

(3) Dilationdecreasesperipheralresistance,there-by decreasing BP; vasoconstriction increasesperipheral resistance, thereby increasing BP.

3. Normal components of serum influenceBP regula-tion.a. Angiotensinandvasopressinarevasoconstrictors.b. Histamineisavasodilator.c. Epinephrine andnorepinephrine act as vasocon-

strictors.

Blood PressureA. Systolic BP represents the ejection of blood from the

heart; determined primarily by the amount of bloodejected,orthestrokevolume(seeChapter17).

B. Diastolic pressure represents the pressure remainingin the arteries at the end of systole; depends on theability of the arteries to stretch and handle the flowofblood.

C. Pulsepressureisthedifferencebetweenthesystolicanddiastolicpressures.

D. AutonomicnervoussysteminfluenceonBP.1. Parasympathetic system exerts control over BP

throughstimulationofthevagusnerve.

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304 CHAPTER 16 Vascular System

2. SympatheticnervoussystemcontrolsBPby:a. Maintaining peripheral resistance through con-

strictionanddilationofthevessels.b. Increasingheartrateandforceofcontraction.c. Causingconstrictionofthelargeveins,whichpro-

motes an increase in venous return to the heart,therebyincreasingcardiacoutput.

E. RenalinfluenceonBP.1. Renin is an enzyme released by the kidneys when

thereisadecreaseinrenalbloodflow.2. ReninbreaksdowntoangiotensinII,astrongvaso-

constrictor,therebyincreasingBP.3. Activationoftherenin-angiotensinsystemstimulates

the adrenal cortex to increase secretion of aldoste-rone, thusprecipitating sodiumandwater retentionandincreasingvascularvolume.

F. The hypothalamus is stimulated to secrete vasopressin(antidiuretic hormone) when BP falls below normal;thisincreasestheconservationofwater,thusincreasingBP.

G. Systemassessment:seeassessmentofindividualsysteminvolved(Box16-1).

DISORDERS OF THE VASCULAR SYSTEM

AtherosclerosisA gradual thickening and narrowing of the arterial lumen; sometimes referred to as “hardening of the arteries” (Figure 16-1).

Box 16-1 OLDER ADULT CARE FOCUS

Evaluation of Blood Pressure

• Ifaclienthashadhypertensionforalongtime,theclient’s“normal”BPmayneed tobehigher tomaintain adequatebloodflowandallowclienttoperformADLs.

• Teachclienthowtoavoidproblemswithorthostatichypo-tension.

• ObtainBPwhileclientisstanding,lying,andsitting.MakesureclienthasnothadanynicotineorcoffeeforaboutanhourbeforeBPismeasured.

• Palpate for disappearance of the brachial or radial pulsewhenassessingBPinordertoavoidtheauscultatorygap.

• Complianceproblemsoccurwhenclientmust take severalmedications for BP, as well as cope with other chronichealthproblems.

ADLs,Activitiesofdailyliving;BP,bloodpressure.

FIGURE 16-1 Progression of atherosclerosis. (From: deWit S: Medical surgical nursing: concepts and practices, St. Louis, 2009, Saunders.)

Adventitia

Media

Intima

Lipoproteins

Lipid-filledsmoothmuscle cell

Elastic fibersand collagenLipids

Dead tissue

ThrombusHemorrhage

LipidsCalcification

A. Irritated damaged endothelium

B. Fatty islands laid down

C. Fibrous plaque

D. Calcified plaque with thrombus

A. Process is slow and gradually leads to a significantdecreaseinbloodsupplytothetissue.

B. Arteries commonly affected by atherosclerosis and theensuingproblems.1. Coronaryarteries:myocardialinfarction.2. Cerebrovasculararteries:stroke,brainaccident.3. Aorta:aorticaneurysm,peripheralocclusivedisease.4. Renalartery:hypertensionandrenalfailure.5. Largeperipheralarteries:peripheralvasculardisease.

AssessmentA. Modifiableriskfactors.

1. Elevated serumcholesterol (LDLover100mg/dL)andtriglyceridelevels.

2. Smoking.3. Sedentarylifestyle,obesity.4. Stress.

B. Nonmodifiableriskfactors.1. Familialtendencies.2. Age.3. Gender: men at greater risk than women until

age60.C. Conditionsacceleratingatheroscleroticdevelopment.

1. Diabetesmellitus.2. Hypertension.

D. Clinicalmanifestations:dependonarteryinvolved.E. Diagnostics(seeAppendix16-1).

ALERT Conduct cholesterol screening sessions and adapt a diet to meet the special needs of a client.

TreatmentA. Decreasecholesterolindiet.B. Decrease risk factors (exercise, stop smoking, decrease

weight,decreasestress).C. Antihyperlipidemicmedications(seeAppendix16-2).

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CHAPTER 16 Vascular System 305

D. Peripheralvasodilatingmedications(seeAppendix16-5).E. Vascularsurgery.

Nursing InterventionsGoal: Toidentifyindividualsathighrisk.A. Screenforandrecognizemodifiableandnonmodifiable

riskfactors.B. Recognize significant deviations of lab values (Table

16-1).C. Identify and control conditions that accelerate athero-

scleroticdevelopment.D. Recognize common signs and symptoms of athero-

sclerosis.

HypertensionA persistent systolic BP greater than 140 mg Hg and/or diastolic BP greater than 90 mm Hg.A. Classification.

1. Primaryhypertension(essentialoridiopathic):causeunknown;accountsforapproximately90%to95%ofcasesofhypertension.

2. Secondaryhypertension:sustainedelevationduetoasecondary underlying health problem; accounts for10%to15%ofcasesofhypertension.a. Pheochromocytoma.b. Renalarterystenosis.c. Cushing’ssyndrome.d. Coarctation of the aorta (most common in

children).e. Medications:oralcontraceptives,glucocorticoids.f. Pregnancy-inducedhypertension.

3. Hypertensivecrisis:asuddensustainedincreaseinthediastolicpressureabove140mmHg,whichmaybelife-threatening.a. Medicationnoncompliance;undermedicating.b. Drugabuse(cocaine,crack).c. Preeclampsiaoreclampsia(Chapter24).d. Headinjury,IICP(Chapter20).

AssessmentA. Riskfactors(Table16-2).B. Clinicalmanifestationsofprimaryhypertension.

Table 16-1 CHOLESTEROL AND LIPOPROTEIN LEVELS

Cholesterol(total) 140-200mg/dLLowdensitylipoprotein(LDL) Lessthan130mg/dLHighdensitylipoprotein(HDL) 37-70males,40-88femalesTriglycerides 40-190mg/dL

NURSING PRIORITY BP should be evaluated with the client lying, sitting, and standing; readings should be obtained from both arms. Legs should not be crossed.

Table 16-2 RISK FACTORS IN ESSENTIAL HYPERTENSION

Nonmodifiable FactorsAge Developsbetween30and50yearsof

age.Poorerprognosiswhendevelopedatyoungerage.

Gender Moreprevalentinmenunder55years;afterage55itismoreprevalentinwomen.

Ethnicgroup TheincidenceofhypertensionistwiceashighamongAfricanAmericansasamongwhites.

Familyhistory ClientswithparentsorsiblingswhohavehypertensionareatgreaterriskforhighBPatayoungerage.

Modifiable FactorsObesity Weightgainisassociatedwith

increasedfrequencyofhypertension.Centralabdominalobesityposesgreatestrisk;regularexercisecanreduceobesityandBP.

Stress Peopleexposedtorepeatedstressmaydevelophypertensionmorefrequently.

Substanceabuse Thesefactorsareallassociatedwithhypertension:drugabuse,drinkingmorethan1ozofalcoholperday,andsmokingcigarettes(nicotine).

Excesssodiumintake Cancausewaterretentionandhypertensioninsomeindividuals;especiallythosewhoarealreadyoverweight.

Elevatedserumlipids Elevatedlevelsofcholesterolandtriglyceridesareprimaryriskfactorsinatherosclerosis,whichisacontributingfactortohypertension.

Sedentarylifestyle Regularphysicalactivityhelpsdecreaserisk.

Diabetesmellitus Vesseldiseaseassociatedwithdiabetesmellitusleadstohighriskforhypertension.

BP,Bloodpressure.

1. Mostoften asymptomatic;headache,dizziness, pal-pitations,epistaxismayoccur.

2. Sustained(twoelevatedpressurereadingsobtainedatleast1weekapart)averageincreaseinsystolicBPat140mmHgorhigher and increase indiastolicBPabove90mmHg.

3. Cardiaceffects.a. Coronaryarterydisease,heartfailure.b. Leftventricularhypertrophy.

4. Cerebrovasculareffects.a. Transientischemicattack.b. Stroke(cerebrovascularaccident,brainattack).

5. Progressivedecrease in the functionofheart, brain,kidneys,andretinasasvesseldamagetotheseorgansincreases.

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C. Clinicalmanifestationsofhypertensivecrisis.1. Diastolicpressuregreaterthan140mmHg.2. Classifiedbyleveloforgandamage.3. Morecriticalinclientswithpreviouslycompromised

cardiovascularsystem.4. BPisunresponsivetooralantihypertensivemedica-

tions.

ALERT Intervene to prevent potential neurologic complications; assess for abnormal neurologic status.

TreatmentA. Dietarymanagement.

1. Decreasesodium,cholesterolandsaturatedfats.2. Reducecalories(shouldbewithin10%ofidealbody

weight).3. Limitalcoholconsumption.

B. Regularexercise(walking,jogging,orswimming).C. Stressmanagement.D. Avoidtobaccoproducts.E. Antihypertensivemedications (seeAppendix 16-5 and

Table16-3).F. Diureticstodecreasecirculatingvolume(seeAppendix

16-6).

Nursing InterventionsGoal: ToreduceBPinhypertensivecrisis.A. Calculateandmonitorthemeanarterialpressure(MAP).

1. MAP=systolicbloodpressure(SBP)+2×diastolicbloodpressure(DBP)÷3.

2. The BP is decreased by 25% of the MAP withinminutesto1hour.

3. Gradualreductionsovernext24-48hours.4. LoweringBPtoorapidlymaycompromisecerebral,

renal,orcoronarycirculation.B. BPshouldbemonitoredviaanintraarterialline;titrate

medicationaccordingly.

ALERT Plan and participate in the screening and education of individuals in the community (e.g., BP screenings, health fairs, school education, etc.).

B. Educatethepublicregardingriskfactors(seeTable16-2).C. Identifyhealth-promotingbehavior forhigh-risk indi-

viduals.1. Decreaseweight.2. Avoidsmoking;limitalcoholintake.3. Controldiabetes.4. HaveregularBPcheckups.5. Engage in regular exercise: 30 to 45 minutes, three

tofivetimesaweek.

ALERT Compare client’s current vital signs and baseline vital signs; intervene when abnormal.

Table 16-3 BLOOD PRESSURE MANAGEMENT

1: Prehypertension—SBP120-139,DBP80-89:Lifestylemodificationssuchasweightloss,regularexercise,managementofcholesterollevels,reductionofsodiumintake,andalcoholandtobaccocessation.

2: Stage1hypertension—SBP140-159,DBP90-99:Begindiuretics(thiazide,loopdiuretics,orpotassiumsparing);mayconsiderACEinhibitororotherantihypertensivedrugforcontrol.

3: Stage2hypertension—SBPgreaterthan160orDBPgreaterthan100:Continuediuretics;addasecondmedication,suchasabetaadrenergicblocker,anACEinhibitor,oracalciumchannelblocker,orotherantihypertensivedrug.

BP, Blood pressure, SBP, systolic blood pressure, DBP, diastolic bloodpressure,ACE,angiotensin-convertingenzyme.ModifiedfromJointNationalCommittee:TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,EvaluationandTreatmentof High Blood pressure. NIH Publication No 03-5233. Bethesda, Md,2003.

C. Hourlyurineoutputtomonitorrenalperfusion.D. Frequentneurologicchecks.E. Maintainclientonbedrestwhilereceivingintravenous

antihypertensivemedications.Goal: Toidentifyhigh-riskindividuals.A. ConductcommunityBPscreeningprograms.

ALERT Identify side effects and adverse effects/contraindications; evaluate client’s understanding of medications; educate client and family about medications.

Goal: ToreduceBPandassistclienttomaintaincontrol.A. Assessresponsetomedicationregimen.

1. Educate client and family member on how to takeBP.a. Clientshouldbeseatedwitharmatheartlevel.b. No smokingor caffeine30minutesbeforemea-

surementofBP.c. Useappropriatecuffsize.d. Twoormorereadingsshouldbeaveraged.

2. BP should be monitored frequently during initialmedicationdosageadjustments,andat least twiceaweekthereafter.

3. Instructclientregardingpossiblesideeffects(Figure16-2).a. Donotstoptakingmedications;reportsideeffects

tohealthcareprovider.b. Assureclientthatsideeffectsareoftentemporary.c. Sexualproblems,impotenceshouldbereported.

4. WhenBPisinitiallydecreased,evaluateclient’stoler-ancetodecrease.a. Postural(orthostatic)hypotension.b. Urinaryoutput.c. Changeinenergylevelandmentalalertness.

5. Assess factors contributing to noncompliance withmedications.a. Costofthemedication.b. Failuretorememberortounderstandmedication

scheduleorregimen.

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Home CareA. Low-cholesterol,low-sodiumdiet.B. Maintainoptimumweight;exerciseregularly.C. Adheretomedicationregimen.

1. Takemedicationatregulartimes.2. Do not stop taking medications; call health care

provider.3. Planwithclientamethodtokeeptrackofmedica-

tions (e.g., using daily pill box or marking oncalendar).

D. Avoid hot baths, steam rooms, and spas (increasesvasodilation).

E. Decreaseandorpreventproblemsoforthostatichypo-tension.1. Get up slowly, sit at the bedside to regain equilib-

rium,andthenstandslowly.2. Wearelasticsupporthose.3. Lieorsitdownwhendizzinessoccurs.4. Donotstandorsitforprolongedperiodsoftime.

FIGURE 16-2 Antihypertensives. (From Zerwekh J, Claborn J, Gaglione T: Mosby’s pharmacology memory notecards, ed 2, St. Louis, 2008, Mosby.)

ALERT Instruct client about self-administration of prescribed medications; evaluate client’s compliance with prescribed therapy; evaluate and document client’s response to therapy.

ALERT Inform client/family/significant others of actions to maintain health and prevent disease (e.g., smoking cessation, diet, weight loss).

AneurysmAn aneurysm is a dilation or sac formed on the wall of an arterial vessel. The aneurysm may involve only one layer or all layers of the arterial wall.A. Typesofaneurysms.

1. Berryaneurysm(seeChapter20).2. Abdominalaorticaneurysm:occursprimarily inthe

abdominalaortabelowtherenalarteries.3. Thoracicaorticaneurysm:locatedintheaortainthe

thoracicarea.4. Dissectinganeurysm:bleedingbetweenthelayersof

thevesselwall;withcontinualbleeding,dissectionofthewallofthevesseloccurs.Thoracicareaisthemostcommonsitefordissection.

AssessmentA. Clinical manifestations: abdominal aortic aneurysm

(AAA).1. Maybeasymptomatic.2. Epigastric,back,flankorabdominalpain.3. Pulsatingabdominalmassmaybepalpable.4. Signsofrupture.

a. Severebackpain.b. Rapidhypotensionandshock.c. Abdominaldistentionandtenderness.d. Hematomaformationintheflankregion.

B. Clinicalmanifestations:thoracicaorticaneurysm.1. Frequentlyasymptomatic.2. Compressionofstructuresintheadjacentarea.3. Dysphagiaduetopressureontheesophagus.4. Hoarsenessduetopressureonthelaryngealnerve.5. Pressureonthevenacavamaycauseedemaofhead

andarms.6. Signsofdissectionandrupture.

a. Sudden constant, excruciating back and/or chestpain.

b. Rapidhypotensionprogressingtoshock.C. Diagnostics(seeAppendix16-1).D. Complications: graft thrombosis, emboli, hemorrhage,

paralyticileus,andrenalfailure.

TreatmentA. Surgicalrepairofaneurysmassoonaspossible.

1. Endovascularstentgraft.2. Surgicalresectionandgraft.

B. Paincontrol.

Nursing InterventionsGoal: To prepare client and family for anticipated

surgery.A. Providepreoperativecare(seeChapter3).B. Identifyotherchronichealthproblems.C. Evaluatecharacteristicsofpulsesinthelowerextremities

and mark for evaluation and comparison after surgery(Figure16-3).

D. Donotvigorouslypalpatetheabdomen.E. Monitorforindicationsofdissectionorrupture.

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B. Report any signsof infection, redness, swelling,drain-age,orfever.

C. Reportchangesinpulses,temperature,color,andsensa-tionofextremities.

ShockShock is a failure of the circulatory system to maintain adequate perfusion of vital organs.A. Commonclassificationsofshock(Table16-4).

1. Hypovolemic shock: results from inadequate bloodvolume.

2. Cardiogenic shock: results fromtheheart’s inabilitytoadequatelycirculatebloodvolume.

3. Distributiveshock(vasogenic):resultsfromachangein size of the vascular space without an increase inbloodvolume.

AssessmentSigns and symptoms of shock are essentially the same,regardlessoftheprecipitatingcause.A. Riskfactors.

1. Increasedincidenceintheveryyoungandveryold.2. Increased incidence inclientswithchronicprogres-

sivediseasestates.3. Trauma.4. Postoperativehemorrhage.

B. Stagesofshock.1. Compensatory stage (initial, early, nonprogressive):

the body is able to compensate (vasoconstriction,shunting);BPin lownormalrangebutsufficienttoperfusevitalorgans.

2. Progressivestage(decompensated,intermediate):thebodycanno longermaintainanadequate supplyofoxygenated blood to the tissues and vital organs;worsening of symptoms associated with decreasedtissueperfusion.

3. Refractory (late, irreversible): cellular ischemia andnecrosisleadtoorganfailureanddeath.

C. Clinicalmanifestations.1. Compensatorystage(early).

a. Clientisorientedtotime,place,anddatebutmayberestlessorapprehensivewithincreasedanxiety.

b. BP—low normal; pulse—increased or normal;respirations—increased; temperature—normal orsubnormal.

c. Urineoutputmaybeslightlydecreased,butwithinnormalrange.

d. MAP may decrease from 10-15 mmHg frombaseline; poor perfusion of extremities withdecreasing pulse pressure; vital organs areperfused.

e. Complaints of thirst and feeling cool; skin paleandcool.

f. Nausea/vomitingcommonasBPdecreases.2. Progressivestage(intermediate).

a. Decreasingsensoryperception;decreasedrespon-sivenesstostimuli.

FIGURE 16-3 Common sites for palpating arteries. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)

Carotid

Brachial

Radial

Ulnar

Femoral

Popliteal

Posterior tibialDorsalis pedis

F. Maintain BP at level low enough to decrease risk forrupture,yethighenoughtomaintainperfusion.

Goal: Topromotegraftpatencyandcirculation.A. Generalpostoperativecare(seeChapter3).B. Maintain adequate BP to facilitate filling of the

graft.C. Monitorforhemorrhage.

1. Increasingabdominalgirth,backpain.2. Symptomsofhypovolemiaorshock.

D. Checkperipheralcirculation,sensation,andmovementhourlyforfirst24hours.

E. If chest tubes are present, monitor function anddrainage.

F. Hourlyurineoutput;hemodynamicmonitoring.G. Evaluatebloodureanitrogenandserumcreatininelevels

toassessrenalfunction.

ALERT Assess client for abnormal peripheral pulses after a procedure/surgery; determine what data need to be reported immediately.

Home CareA. Activityrestrictions.

1. Noheavyliftingfor6-12weeks.2. Avoid activities that involve pushing, pulling, or

straining.

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Table 16-4 CLASSIFICATION OF SHOCK

Classification Pathophysiology Conditions Treatment and Clinical Implications

Hypovolemic Reducedvenousreturnduetoreducedbloodvolume;15%to25%reductioninvolume.

Hemorrhage,burns,severefluidloss—dehydration

1. Administervolumereplacement:bloodtransfusionandvolumeexpanders.

2. Administeroxygen.

Cardiogenic Heartunabletoeffectivelycirculatetheintravascularvolume.

Dysrhythmias,MI,CHF 1. MonitorECGcontinuously.2. Medicationstoincreasecardiacoutput.3. Evaluatehemodynamicparameters(see

Appendix17-5).4. Treatdysrhythmias.

Obstructive Physicalimpedimenttotheflowofblood.

Pericardialtamponade,pulmonaryembolism,venacavacompression,tensionpneumothorax

1. WillhaveincreasedCVP.2. Treatmentdirectedtowardreleaseof

obstruction.

Neurogenic Increasedvenouscapacityduetoalossofperipheralvasomotortone.

Cardiacfunctionandbloodvolumemaybenormal.

Spinalcordinjury(T5orhigher),drugOD,hypoglycemia,spinalanesthesia

1. Administervasoconstrictormedications.2. Evaluatecloselyforfluidoverload.3. Bradycardiamayrequiretreatment

(atropine).

Systemicinflammatoryresponsesyndrome(SIRS)

Dilationofbloodvesselsbyhumoralorvasoactivesubstances.

Overwhelminginfection;generallygram-negativeorganism

1. Evaluatefororiginofinfection.2. IVfluids,volumeexpanders.3. Cardiotonics.4. Administeroxygen.

Anaphylactic Antigen-antibodyreactionwithreleaseofhistamine,causingvasodilationandfluidshift.

Transfusionreactions,insectbites,sideeffectofmedications,dye/foodallergies

1. Maintainairway:problemwithlaryngealedema.

2. Oxygenasindicated.3. EpinephrineandBenadryl,IV.

NURSING PRIORITY Shock is a dynamic condition. The client’s status is constantly changing, either improving or deteriorating.

CHF,Congestiveheartfailure;ECG,electrocardiogram;IV,intravenous;MI,myocardialinfarction;OD,overdose.

b. Vitalsigns.(1) BPdecreaseinMAPof20mmHgormore.(2) Pulse rate increased with weak or thready

peripheralpulses.(3) Respirations—rateisincreasedwithdyspnea.

c. Cold,moistskin;pallor.d. Decreaseinurinetooliguriclevels.

3. Refractory(irreversible,late).a. Progressivelydecreasinglevelofconsciousnessto

unresponsiveness.b. BP—not measurable (unable to perfuse vital

organs);pulse—slowandirregular;respirations—irregular,labored.

c. Anuria.d. Client becomes hypoxic and develops metabolic

acidosis.4. Diagnostics:basedontheclinicalmanifestationsand

historyofunderlyingproblems.

TreatmentDepends on the underlying problem and promptness ofintervention.A. Treatunderlyingcause.B. IVaccessandfluidresuscitation.

C. Positionsupinetoincreasevenousreturnbutnotcom-promisepulmonarystatus.

D. Medicationtherapy(Appendix16-7).E. Oxygentherapy.F. Hemodynamicmonitoring(Appendix17-9).

Nursing InterventionsGoal: Toidentifyandcorrectcauseofshock.A. Rapidresponsetodevelopingsignorsymptoms.

1. Maintainbedrest.2. Positionsupine;mayelevatelegs.3. Maintainairway;providesupplementaloxygen.4. Keepwarm;nochilling.5. Protectfromfallsandinjury.

B. Evaluate for progression of shock—compensating tononcompensating.1. Systemic inflammatory response syndrome (SIRS,

Chapter6).2. Multiple organ dysfunction syndrome (MODS,

Chapter6).Goal: Tomaintainadequaterespiratoryfunction.A. Administerhigh-flowoxygen(100%).

1. Nonrebreathermask,bag-valvemask.2. Mechanicalventilation.

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B. Monitoroxygenation.1. Pulseoximetry,ABGs.2. Breathsounds.3. Orientation,presenceofconfusion.

Goal: To maintain adequate circulation and/or tissueperfusion.

A. Controlbleeding.B. Maintainfluidvolume.

1. Bloodand/orbloodproducts.2. Intravenous(IV)fluids.3. Volumeexpanders(colloidsolutions).4. MonitorI&O.

C. Ensureclientvenousaccess.1. Two large-bore (14- to 16-gauge) peripheral lines

or central line for IV medications and fluid resus-citation.

2. IM,subcutaneous,andoralmedsgenerallynotgivenduetoinadequateand/orunpredictableperfusion.

D. Cardiogenicshockandneurogenicshockdonotinvolvedecreasedcirculatingbloodvolume;monitorcloselyforfluidoverload.

Goal: Tomaintaincardiacoutputandvasculartone.A. Monitorhemodynamicchanges.

1. Monitor CVP, MAP, PAWP; integrate data withassessmentdata(seeAppendix17-9).

2. Administerfluidstoincreasecirculatingvolume.3. Assessadequacyofendorganperfusion(urineoutput,

orientation,peripheralpulses).B. Medicationtherapy(seeAppendix16-7).

Peripheral Arterial Occlusive DiseasePeripheral arterial occlusive disease involves narrowing and obstruction of the arteries, especially the lower extremities. The chronic arterial obstruction progressively leads to decreased oxygen delivery to the tissues.A. Lesions are predominantly found in the lower aorta

belowtherenalarteriesandextendthroughthepoplitealarea.

B. Bythetimesymptomsoccur,thearteryisapproximately85%to95%occluded.

C. The bifurcations at the renal, femoral, popliteal, andaorticiliacarteriesarethemostcommonlyaffectedsites.

AssessmentA. Riskfactors:seeatherosclerosis.B. Characteristicsofarterialulcers(Table16-5).C. Intermittentclaudication.

1. Musclepainandcrampingwithexercise;painrelievedwithrest.

2. Painthatoccurswhilerestingoratnightisindicationofadvancedstages.

D. Diagnostics(seeAppendix16-1).

TreatmentA. Medical.

1. Medicationtherapy.a. Antiplateletagents(seeAppendix16-4).b. Anti-plateletagents(seeAppendix16-4).c. Antihypertensiveagents(seeAppendix16-5).d. Antihyperlipidemic medications (see Appendix

16-2).2. Stopsmoking.3. Dietarymanagement.

a. Decreasecholesterolandtriglycerideintake.b. Reduceweightifneeded.c. Controlsodiumintake.

4. Exerciseprogramastolerated.5. Controldiabetesandhypertension.

B. Surgical.1. Peripheralatherectomy:removalofplaquewithinthe

artery.2. Bypassgraft:bypassofanobstructionbysuturinga

graftproximallyanddistallytotheobstruction.3. Patch graft angioplasty: artery is opened, plaque is

removed, and a patch is sutured in the opening towidenthelumen.

4. Amputation:usedasalastresortwhenotherthera-pieshavefailedandgangreneorinfectionisextensive.

C. Nonsurgical.1. Percutaneoustransluminalangioplasty:useofabal-

loon catheter to compress the plaque against thearterialwall.

2. Laser-assisted angioplasty: a probe is advancedthrough a cannula to the area of occlusion; a laseris used to vaporize the atherosclerotic plaque.

3. Intravascularstent:placementofastentwithinanar-rowedvesseltomaintainpatency.

ALERT Adjust/titrate dosage of medications based on assessment of physiologic parameters (e.g., titrating medication to maintain a specific BP). Assess client for continued decreased cardiac output; interpret data that needs to be reported immediately.

C. Monitorrenalresponseandurinaryoutput.1. Foleycatheterandhourlyoutputmeasurements.2. Maintainoutputgreaterthan30mL/hr.3. MonitorBUNandcreatinine.

Goal: Tomaintainhomeostasis.A. Ongoingneurologicevaluation.

1. CheckorientationstatusandLOCfrequently.2. Reorientclientasneeded.3. Minimize sensory overload caused by hospital

environment.B. EvaluateGIstatus.

1. MaintainNPOstatus;provideoralhygiene.2. Monitorbowelsoundsanddistention.3. PossibleNGtubeinpresenceofparalyticileusand/

orvisceralischemia.C. Provideemotionalsupport.

1. Keepclientinformedofproceduresandtests.2. Solicitsupportforfamilymembers(i.e.socialworker,

clergy,etc.).3. Keepfamilymembersinformedofclient’scondition.

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FromLewisSLetal:Medical-surgical nursing: assessment and management of clinical problems,ed7,St.Louis,2007,Mosby.

Table 16-5 COMPARISON OF ARTERIAL AND VENOUS LEG ULCERS

Characteristic Arterial Venous

Peripheralpulses Decreasedorabsent Present;maybedifficulttopalpatewithedemaCapillaryrefill >3sec <3secAnkle-brachialindex <0.70 >0.91Edema Absentunlesslegconstantlyin

dependentpositionLowerlegedema

Hair Lossofhaironlegs,feet,toes HairmaybepresentorabsentUlcerlocation Tipsoftoes,foot,orlateralmalleolus NearmedialmalleolusUlcermargin Rounded,smooth,looks“punchedout” IrregularlyshapedUlcerdrainage Minimal ModeratetolargeamountUlcertissue Blackescharorpalepinkgranulation Yellowsloughordarkred,“ruddy”granulationPain Intermittentclaudicationorrestpainin

foot;ulcermayormaynotbepainfulDullacheorheavinessincalforthigh;ulcer

oftenpainfulNails Thickened;brittle NormalorthickenedSkincolor Dependencyrubor;elevationpallor Bronze-brownpigmentation;varicoseveins

maybevisibleSkintexture Thin,shiny,friable,dry Skinthick,hardened,andinduratedSkintemperature Cool,temperaturegradientdowntheleg Warm,notemperaturegradientDermatitis Rarelyoccurs FrequentlyoccursPruritus Rarelyoccurs Frequentlyoccurs

Nursing Interventions

ALERT Identify client with a condition that increases the risk for insufficient vascular perfusion; assess client for abnormal peripheral pulses.

Goal: To evaluate level of involvement of the extremity(Figure16-4).

A. Assess and compare quality of peripheral pulses (seeFigure16-3).

B. Evaluateskinoftheaffectedextremity.1. Color,warmth,capillaryrefill.2. Conditionoftheskinandnailbeds.3. Presenceofulcersorlesions.

C. Assess tolerance to activity; determine at what pointclaudicationoccursandwhetherpainatrestispresent.

ALERT Interpret client data that need to be reported immediately.

Goal: Topreventinjuryandinfection.A. Avoidvigorousrubbingoftheextremity.B. Preventskinbreakdownatpressuresites.C. Use heel covers and bed cradle to prevent pressure on

thetoesandheels.D. Visually inspectextremities fordiscoloredareas,breaks

inskin,andsignsofinfection.Goal: Toincreasearterialbloodsupply.A. Encouragemoderateexercise(e.g.,walking).

1. Levelofpain shouldbeaguide toexercise;activityshouldbestoppedwhenpainoccurs.

2. Goalis30to60minutesperday,3to5daysaweek.

B. Promotebloodflowtolegs.1. Avoidstandinginonepositionforprolongedperiods.2. Avoid crossing legs at the knees or ankles while

inbed.3. Provide warmth (room temperature, extra clothing,

blankets).C. Avoid pressure in the posterior popliteal area; avoid

positions,clothing,orbandagesthatrestrictcirculationtothelowerextremities(hose,girdles,elasticbandages,etc.).

D. Stopsmoking.Goal: To protect the extremity with critical limb

ischemia.A. Inspection,cleansing,andlubricationofbothfeet.B. Donotsoakfeet;keepcleananddry.C. Coverulcerationswithdrysteriledressing.D. Donotapplyanychemicals;donotapplyheatorcold.E. Protectheelsfrompressure.F. Healing is not likely to occur unless circulation is

restored;protectulcersfrominfection.Goal: To evaluate and promote circulation in affected

extremityaftervascularsurgery.A. Frequentassessment todetermineadequacyofcircula-

tionandpatencyofgraft(seeFigure16-4).1. Circulationchecksdistaltothegraftevery15minutes

× 4, thenhourly× 24hrs–notifyhealth carepro-viderimmediatelyofanychangesinneurocirculatorystatus of extremities.

2. Monitorankle-brachialindex(ABI)measurements.3. Assessforcompartmentalsyndrome(seeChapter21)

andgraftthrombosis.B. Encouragemovementoftheextremityassoonasclient

isawake;avoidflexionintheareaofthegraft(femoralorpoplitealarea).

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Chronic Venous Insufficiency and Venous Stasis Ulcers

Chronic venous insufficiency results from damage to the valves of the veins in the legs. This valvular incompetence leads to regurgitation of blood, venous pooling, and edema in the lower extremities; eventually resulting in develop-ment of venous stasis ulcers.

AssessmentA. Riskfactors.

1. Advancingage,increasedvenouspressure.2. Diabetes,obesity.3. Varicosities,prolongedimmobility.

B. Clinicalmanifestations(seeTable16-5).1. Stasiseczemaisoftenthefirstindication.2. “Brawny”leatheryappearancetoskinoflowerleg.3. Sclerosisoccursasaresultoflongstandingedema;leg

becomeslargeratthecalf.4. Ulcerationsmorecommonlyneartheouterankle.5. Ulcerappearance:irregularmargins,copiousexudate.6. Verypainful.

C. Diagnostics:historyandclinicalmanifestations.D. Complications.

1. Infection,cellulitisiscommon.2. Delayedorpoorhealing.

TreatmentA. Medicaltherapy.

1. Compressiontherapy.a. Elasticcompressionstockings.b. Sequentialcompressiondevices.c. Unnaboot(apastebandage).

2. Moistdressingsforopenwoundcare.3. Goodnutritionalstatus.4. Treatmentofvaricoseveins.

B. Surgicaltherapy:excisionofulcerwithskingrafting.

Nursing InterventionsGoal: Topreventandtreatvenousstasis(Box16-2).A. Compressiondevices:preventionofvenousstasisisthe

keytohealing.1. Compression boots/stockings: extremity may be

coveredwithcontinuouscompressionbandage,boot,orstocking.

2. Intermittent or sequential pneumatic compressiondevices: always check arterial circulation with anytypeofcompressiondevice.

3. Alwaysassessadequacyofarterialcirculationpriortocompressiontherapy.

FIGURE 16-4 Neurovascular assessment (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.)

C. Assistclienttoambulateassoonaspossible.D. Donotraisethekneegatchofthebed.E. Monitoranticoagulationmedications;maintainbleeding

precautions.F. Assess for development of dependent edema; may

requirecompressiondressingsordiuretic.

Home CareA. Decreaseweightifappropriate.B. Avoid standing or sitting for prolonged periods of

time.C. Teach client methods to increase circulation during

normalworkday (donot cross legs;useagoodchair;getupandwalkeveryhourifworkingatadesk).

D. Avoidtightsocks,stockings,orclothing.E. Avoidtraumatotheextremities—alwayswearshoes. F. Avoidtobaccoproducts.G. Washandvisuallyinspectfeetdaily.H. Do not apply any type of direct heat or cold to

thelegs. I. Lubricatedryskin;donotuse lotionsonopenlesions

orbetweenthetoes. J. Seekprofessionalcareforcalluses,corns,blisters,ulcers,

etc.K. Filetoenailsstraightacross.L. Wearshoesthatfitwell;avoidshoesthatcausefeetto

perspire.M. Notifyhealthcareproviderof:

1. Presence of lesions or blisters that do not heal orinfectionsonanextremity.

2. Increaseinpainordecreaseinexercisetolerance.

ALERT Implement measures to promote venous return, to manage potential circulatory complications, and to monitor wounds for signs and symptoms of infection.

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6. Commonfindingsthatoccurasperfusionisrestored.a. Rubor(redness)ofthetissue.b. Throbbing,aching,burningoftheinvolvedarea.

7. Mayprogresstoulceration/gangreneinseverecases.8. Attacksareusuallybilateralandintermittent;usually

lastonlyafewminutes.

TreatmentA. Nocure;treatmentisbasedonsymptoms.B. Medications:vasodilators,calciumchannelblockers.

Nursing InterventionsGoal: To assist client to understand disease implications

andmeasurestodecreaseepisodicattacks.A. Preventvasospasms.

1. Weargloveswhenhandlingcoldobjects(itemsfromtherefrigeratororfreezer).

2. Protect feet,hands,nose,andearswhenexposed tocoldweather.

3. Maintainwarmenvironment.4. Avoidcaffeineandtobaccoproducts.5. Stressmanagement.

Thromboangiitis Obliterans (Buerger’s Disease)

Thromboangiitis obliterans is a condition that causes vas-culitis of the small and medium-size arteries and veins of the extremities.


1. Verystrongrelationshipwithtobaccouse.2. Atypeofarteritisthatdamagesarterialwalls.

B. Clinicalmanifestations.1. Intermittent claudication; pain at rest in advanced

stages.2. Usuallybeginsdistallyandspreadsupward.3. Temperaturechangesinaffectedlimb.4. Increasedsensitivitytocoldintheextremity.5. Peripheralpulsesmaybediminishedorabsent.

C. Diagnostics.1. Basedonclinicalmanifestations.2. Sometimes difficult to distinguish from peripheral

arterialdisease.D. Complications:ulcerationsandgangrene.

TreatmentA. Nocure; treatment isbasedonsymptoms;cessationof

smoking early in the disease can stop symptoms andprogressionofthedisease.

B. Medications:vasodilators,antiplatelets,calciumchannelblockers.

C. Surgicaltherapy.1. Sympathectomy.2. Revascularization.3. Amputationinextremecases.

Goal: Topreventinfectionandpromotehealing.A. Keep feet clean and dry; assess for development of

venousulcers.B. Usehydrocolloiddressingsforopenulcers.C. Maintain compression devices; monitor arterial

circulation.D. Assess for development of infections—may require

debridement.

ALERT Perform or assist with dressing changes; provide wound care (e.g., central line dressing or wound dressings).

Raynaud’s PhenomenonRaynaud’s phenomenon consists of intermittent episodic spasms of the arterioles, most frequently in the fingers and toes. Spasms are not necessarily correlated with other peripheral vascular problems.

AssessmentA. Clinicalmanifestations.

1. Increasedincidenceinwomenage20to40years.2. Often associated with other systemic connective

tissuediseases(e.g.,lupus,scleroderma,andrheuma-toidarthritis).

3. Symptomsareprecipitatedby:a. Exposuretocold.b. Emotionalupset.c. Nicotineandcaffeineintake.

4. Vasospasminfingers,toes,ears,and/ornoseleadsto:a. Pallorandwaxyappearanceofthetissue.b. Numbnessandtingling.

5. Pulsesusuallyremainadequate.

Box 16-2 NURSING MEASURES TO DECREASE VENOUS STASIS

• Encouragemobility;evenstandingatthebedsidepromotesvenoustone.

• Elasticsupportstockings:Hospitalizedclientsshouldwearthemallthetime.Homeclientsgenerallywearthemduringtheday.Stockings shouldbeputonbefore clientgetsoutof bed and removed when client goes to bed. Toe holeshouldbeunderthetoesandheelpatchovertheheel.Checkforconstrictionbehindthekneeandaroundthethigh.Donot hang feet dependently when putting stockings on;elevatethelegsorputthemparallelonthebed.Makesurethatstockingsarethecorrectfitbymeasuringthelegsandorderingtheappropriatesizeandlength.

• Teachclienttoelevatelegsforabout20minutesevery4or5hours.

• Avoidprolongedsitting;walkaroundevery1to2hours.• Don’tcrosslegswhensittingorlyinginbed.• Donotwearrestrictiveclothing.• Maintainadequatefluidintake;avoiddehydration.• Use pneumatic compression devices to facilitate venous

return.

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Nursing InterventionsGoal: Toevaluatelevelofinvolvementoftheextremityand

increasecirculationtotheextremity.A. Decreaseorstopsmoking(alsoexposuretosecond-hand

smoke).B. Evaluatetolerancetoactivity.C. Inspectfeetforvascularchanges.D. Avoidextremecold.E. Clientshouldnotusenicotinereplacementproducts.

Venous Thrombosis (Thrombophlebitis)Thrombophlebitis is the formation of a thrombus that is associated with inflammation. May be superficial or a deep vein thrombosis (DVT).

AssessmentA. Riskfactors(Virchow’sTriad).

1. Venousstasis.a. Surgery (hip, pelvic and orthopedic surgery are

associatedwithhighrisk).b. Pregnancy,obesity.c. Prolonged immobility (bed rest, long trips, pro-

longedsitting).d. Heartdisease (atrialfibrillation, congestiveheart

failure).2. Hypercoagulability.

a. Malignancies,dehydration.b. Blooddyscrasias.c. Oral contraceptives, hormone replacement ther-

apy.d. Pregnancyandpostpartum.

3. Endothelialdamage.a. IV fluids and drugs (IV catheterization, drug

abuse,causticsolutionsordrugs).b. Abdominalandpelvicsurgery.c. Fractures and dislocations (especially of the

pelvis,hip,orleg).d. HistoryofDVT.

NURSING PRIORITY The vascular problem has a direct relationship to cigarette smoking. For the condition to be controlled, the client must quit smoking.

Varicose VeinsVaricose veins occur when veins in the lower trunk and extremities become congested and dilated as a result of incompetent valves in the vessels and loss of elasticity of the vessel walls.


1. Congenitalweaknessofthevesselwalls.2. Obesity,pregnancy.3. Increasingage,prolongedstanding.

B. Clinicalmanifestations.1. Dilated,tortuoussubcutaneousveins.2. Cosmeticappearanceoftheveinisobjectionable.3. Achingtypepainafterprolongedstanding.4. Painisgenerallyrelievedbyelevatingtheextremity.

C. Diagnostics:positiveTrendelenburgtest;clinicalmani-festations.

TreatmentA. Medical:preventvenousstasis(seeBox16-2).B. Surgical.

1. Noninvasive laser therapy or high-intensity pulsed-lighttherapy.

2. Sclerotherapy: injectionof sclerosingagent into theaffectedvein.

3. Surgicalligationoftheveins;maybecombinedwithveinstrippingaswell.

Nursing InterventionsGoal: Toimprovecirculationandpreventcomplications.A. Decreasevenousstasis(seeBox16-2).B. Facilitatevenousreturn.

1. Elasticstockingsorcompressionwraps.2. Pneumaticcompressiondevices.3. Rangeofmotionandactivemovementofextremities

topromotevenousreturn.C. Avoidconstrictiveclothing.D. Avoidprolongedstandingorsitting.

ALERT Provide measures to prevent complications of immobility.

B. Clinicalmanifestations.1. Superficialthrombophlebitis.

a. Firm,palpable,cordlikevein.b. Tender to touch; surrounding area warm and

reddened.2. Deepveinthrombosis(DVT).

a. Areaaroundveinistendertotouch,reddened,andwarm.

b. Temperatureelevation(above100.4°F).c. Extremitypainandedema.d. Homans’signisnotconsideredtobeanaccurate

indicator of thrombophlebitis (present only inabout10%ofcases).

e. Mayoccurindeeppelvicveins.C. Diagnostics(seeAppendix16-1).D. Complications.

1. DVTassociatedwithhighriskforpulmonaryemboli.2. Chronicvenousinsufficiencyandvenousstasisulcers.

TreatmentA. Medical.

1. Bedrest.2. Elevateextremity.3. Anticoagulant; antiinflammatory, and fibrinolytic

medications(seeAppendix16-3and17-5).

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4. Warmmoistpacks.5. Elastic support stocking if edema is present after

clientisambulatory.6. Elasticsupportstockingonunaffectedlegonlyduring

periodofbedrest.B. Surgical (done to prevent formation of pulmonary

emboli).1. Venousthrombectomy.2. Umbrellafilterdeviceinthevenacava.

Nursing InterventionsGoal: Topreventthrombophlebitis,DVT.

NURSING PRIORITY The most effective way to prevent the development of a pulmonary embolus is to prevent the development of DVT.

ALERT Identify client with condition that increases risk for insufficient vascular perfusion; intervene to promote venous return.

A. Nursing measures to decrease venous stasis (see Box16-2).

B. Preventcomplicationsofimmobilization(seeChapter3).

Home CareA. Avoidoralcontraceptives.B. Stopsmoking.C. Usemethodstodecreasevenousstasis(seeBox16-2).D. Exerciseregularly(especiallywalking).E. Decreaseweight,ifappropriate.F. Decreasesodiumindietifedemaispresent.G. Followinstructionsregardinganticoagulationtherapyat

home.H. Understandneedforfollow-uphealthcare.

C. Prophylacticanticoagulationforthehigh-riskclient.D. Intermittentcompressiondevicesforhigh-riskclients.

Appendix 16-1 VASCULAR DIAGNOSTICS

TEST NORMAL VALUE THERAPEUTIC VALUE NURSING IMPLICATIONSSerum StudiesFragmentd-dimer

(d-dimertest)<250ng/mL <250ng/mL 1. Producedbytheactionofplasmaonfibrin,verifies

fibrinolysishasoccurred.2. UsedindiagnosisofDICandtoscreenfor

thrombosis,acuteMIandPE.PT

(prothrombintime)10-13secrange 1.5-2.5timesnormal 1. SensitivetoalterationsinvitaminK.

2. Usedtoevaluateliverandwarfarinmedications.APTT

(activatedpartialthromboplastintime)

Activated:24-36sec 1.5-2.5timesnormal(46-70sec)

1. Indicatorofadequacyofanticoagulationwithheparin.

2. Donotdrawsamplefromextremitywithaheparinlockorinfusion.

INR(internationalnormalizedratio)

2-3(anticoagulation) 1. CalculatedlevelbasedonPT;methodofstandardizingvalues.

2. Usedtoevaluatewarfarin(Coumadin).ACT

(activatedcoagulationtime)

80-135sec 180-240secor2timesnormal

1. Usedtoevaluateanticoagulationwithheparin.

Invasive StudiesPeripheralarteriography

(angiography)Venography(phlebography)

Involvesinjectionofaradiopaquedyeintoeitherthearteryorthevein;x-rayfilmsareobtainedtoidentifyatheroscleroticplaques,occlusions,traumaticinjury,orpresenceofaneurysms.

1. Explainprocedurestoclient;mildsedativemaybeindicated.

2. Requiresinformedconsent.3. Afterprocedure:

a. Performcirculatorychecksdistaltothepuncturesite.

b. Observeclientforallergicreactionstothedye.c. Applypressuredressingstopuncturesites,and

monitorforbleeding.

Continued

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TEST NORMAL VALUE THERAPEUTIC VALUE NURSING IMPLICATIONSNoninvasive StudiesDoppler ultrasonography:Hand-heldDopplerdeviceused todetectflowofblood inperipheralarterialdisease; isnot sensitive to

earlydiseasechanges.Ankle-brachial index (ABI):CalculatedindexusingahandheldDoppler;dividetheankleSBPbythehighestbrachialSBP;normal

=0.91to1.30;moderatePAD=0.41to0.70.Venous duplex scan:usesultrasoundtoassessveinsforflowandpressure;hasbecometheprimarydiagnostictoolforDVTbecause

itallowsforvisualizationofthevein.Computed tomography (CT):Allowsforvisualizationofthearterialwallandadjacentstructures;usedfordiagnosisofabdominal

aorticaneurysm,graftocclusions.Trendelenburg test:Clientliessupinewithlegelevatedtopromotevenousdrainage;atourniquetisappliedatmid-thigh,andclient

isaskedtostand.Veinsnormallyfillfrombelowordistally;avaricoseveinwillfillfromaboveorproximallybecauseoftheincompetentvalves.Donotleavetourniquetinplacelongerthan1minute.

DIC, Diffuse intravascular coagulation; DVT, deep vein thrombosis; MI, myocardial infarction; PT, prothrombin time; SBP, systolic blood pressure;PAD,peripheralarterydisease.

Appendix 16-1 VASCULAR DIAGNOSTICS—cont’d

Appendix 16-2 ANTIHYPERLIPIDEMIC MEDICATIONS

Antihyperlipidemics Decrease LDL cholesterol, but preferably do not decrease the HDL cholesterol. Used in combination with dietary restrictions, exercise, and smoking cessation to reduce blood lipid levels.

General Nursing Implications—Serumliverenzymesshouldbemonitoredthroughouttherapy.—Medicationsshouldbetakenbeforemeals.—Medicationsshouldbeusedinconjunctionwithotherlipid-loweringtherapies(exercise,low-cholesterol

diet,smokingcessation).—Serumcholesterolandtriglyceridelevelsshouldbemonitoredpriortoandperiodicallythroughout

therapy.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSCholestyramine(Questran):POColestipol(Colestid):PO

GIdisturbancesConstipation

1. Supplementalfat-solublevitaminsinlong-termtherapy.2. Mixpowderwithseveralouncesoffluidforadministration.3. Usewithcautioninpresenceofconstipation;increasefiber

andfluidintaketopreventconstipation.

Nicotinicacid(Niacin, Nicolar):PO FlushingGIdisturbances

1. Immediatelyreportsignsofhepatotoxicity(darkeningofurine,lightcoloredstools,anorexia).

2. Flushingoccursinalmostallclients;willdiminishoverseveralweeks.

Gemfibrozil(Lopid):PO DiarrheaGIdisturbancesAbdominalpain

1. Assessforincreaseinmusclepain.2. Willpotentiatewarfarin-derivativeanticoagulants

(Coumadin).3. Donotconfusewithhyoscyamine(Levbid).

Lovastatin(Mevacor):POSimvastatin(Zocor):POFluvastatin(Lescol):POAtorvastatin(Lipitor):POPravastatin(Pravachol):PO

MusclebreakdownHepatotoxicGIdisturbances

1. Givewitheveningmeal.2. Shouldnotbegiventoclientswithpreexistingliverdisease.3. Assessforincreaseinmusclepain.4. Monitorliverenzymesclosely.5. Donotconfusepravastatin(Pravachol)withlansoprazole

(Prevacid).

GI,Gastrointestinal;HDL,high-densitylipoprotein;LDL,low-densitylipoprotein;PO,bymouth(orally).

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Appendix 16-3 ANTICOAGULANTS

Anticoagulants Prolong coagulation by inactivation of clotting factors (heparin) and by decreasing synthesis of clotting factors (Coumadin �).

General Nursing Implications—Increasedriskforbleedingwhenusedconcurrentlywithotherdrugs,herbalremedies,orfoodsaffecting

coagulation.—Maintainbleedingprecautions.—Secondhealthcareprovidershouldalwayscheckorder,calculationofdosage,and/orinfusionpump

settingswhenbeingadministeredintravenously(IV).—Donotautomaticallydiscontinueaccordingtoautomaticstoppolicies(procedures,surgery)without

verifyingtheorder;reevaluateallclientswhoseanticoagulantsarebeingheldforproceduresandassesstheneedtoreordertheanticoagulanttherapy.

NURSING PRIORITY Clarify all anticoagulant dosing for pediatric clients.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS�Heparin:IV,subQ

MaynotbegivenPOShort-termanticoagulation

Bleedingtendencies:hematuria,bleedinggums,orfrankhemorrhage

Heparin-inducedthrombocytopenia:associatedwithincreaseinthrombosis

1. ChecktheAPTTfornormallevelsversustherapeuticlevels.2. Protaminesulfateistheantidote.3. IVadministrationshouldbeadministeredviainfusionpump

toensureaccuratedosage.4. Willnotdissolveestablishedclots.5. Checkplateletlevelsevery2-3days.6. Effectiveimmediatelyafteradministration;anticoagulation

effecthasshorthalf-life.7. Beforestartinginfusion,andwitheachchangeofthe

containerorrateofinfusion,havesecondpractitionercheckdrug,dosage,route,andrate.

8. Donotstoreinsameareaasinsulin;botharegivenbyunits.

Low-Molecular-Weight HeparinEnoxaparin(Lovenox):subQDalteparinsodium

�(Fragmin):subQ

1. Use:prophylaxisforthromboembolicproblemsinhigh-riskclients(immobility,hiporkneereplacement).

2. Dosageis notinterchangeablewithheparin.3. Leavetheairlockintheprefilledsyringetopreventleakage.4. Lovenoxshouldbeinjectedintothe“lovehandles”ofthe

abdomen.

Warfarinsodium�(Coumadin):POLong-termanticoagulation

1. CheckthePTandINRtoevaluatelevelofanticoagulation;INRgreaterthan3mayindicateadversedrugreaction.

2. VitaminKistheantidote.3. Client teaching:

• Bleedingprecautions(seeBox14-1).• Adviseallhealthcareprovidersofmedication.• Notrecommendedifpregnantorlactating.• Maintainroutinechecksoncoagulationstudies.• Donotstoptakingmedicationunlesstoldtodosoby

healthcareprovider.4. Checkdrugliteraturewhenadministeringwithother

medications;druginteractionsarecommon.5. Oralcontraceptivesmaydecreaseeffectiveness.

ALERT Questions about anticoagulant medications are consistently found on the examination.

�:High-AlertMedication; APTT, activatedprothrombin time; INR, internationalnormalized ratio; IV, intravenously; PO, bymouth (orally); PT, pro-thrombintime;subQ,subcutaneously.

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Appendix 16-4 ANTIPLATELET MEDICATIONS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAspirin:PO GIbleeding,hemorrhagicstroke 1. Giveninsmalldoses(e.g.,81mgdaily).

2. ProphylactictherapyforpreventionofMIandthromboticstrokeinclientswithTIAs.

Clopidogrel(Plavix):PO Abdominalpain,dyspepsia,diarrheaBlooddyscrasias

1. ProphylactictreatmentforpreventionofMI,strokesinclientswithestablishedperipheralarterydisease.

2. Expensiveandslightlymoreeffectivethanaspirin.

Cilostazol(Pletal):PO Headache,dizziness,GIbleeding 1. Monitorforreliefofintermittentclaudication.2. Grapefruitjuiceinhibitsmetabolism.3. Administeronanemptystomach.

Ticlopidine(Ticlid):PO Diarrhea,bleeding,aplasticanemia 1. Monitorcoagulationstudiesthroughouttherapy.2. Monitorcholesterol/triglyceridelevels.3. Olderadultclientsmayhaveincreasedsensitivityto

Ticlid.

Blood Viscosity Reducing AgentPentoxifylline(Trental):PO GIdisturbances,dizziness 1. Monitorforreliefofintermittentclaudicationin

lowerextremities.2. Therapeuticeffectmaynotbenotedfor2-4weeks.3. Donotchew,crushorbreaktablets.

GI,Gastrointestinal;MI,myocardialinfarction;PO,bymouth(orally);TIA,transientischemicattack.

Appendix 16-5 ANTIHYPERTENSIVE MEDICATIONS

General Nursing Implications—Adviseclientthatposturalhypotensionmayoccurandexplainhowtodecreaseeffects.—Hypotensionmaybeincreasedbyhotweather,hotshowers,hottubs,andalcoholingestion.—Clientshouldnotabruptlydiscontinuemedicationorchangedosagewithoutconsultinghealthcare

provider.Abruptwithdrawalcancausereboundhypertension.—Encouragealow-sodiumdietandweightmaintenanceorreduction.—Encourageclienttostopsmoking.—Haveclientreportunpleasantsideeffectsrelatedtosexualdysfunction.—Adviseclientnottotakeover-the-countercoughmedicationsordecongestantsthatcontain

pseudoephedrine;thesemedicationscauseanincreaseinBP.—Administerwithmealstoenhanceabsorption.—MonitorBPandpulsefrequentlyduringinitialdosageadjustments;andweeklyduringinitialtherapy.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSVasodilators Act directly on vascular smooth muscle to produce vasodilation.

HydralazineHCl(Apresoline):PO,IM,IV

Tachycardia,headache,sodiumretention,drug-inducedlupussyndrome

1. Adviseclientthatposturalhypotensionmayoccur.2. VitaminB6maybeusedtopreventperipheral

neuritiswithlong-termtherapy.3. Maybeusedincombinationwithother

antihypertensivemedications.

�Nitroprusside(Nipride):IV Nausea/vomiting,headache,abdominalpain,dizziness

1. Usedtotreathypertensivecrisis;veryrapidresponse.2. Solutionmustbepreparedimmediatelybeforeuse

andprotectedfromlightduringadministration;usewithin24hours.

3. Administerviainfusionpumptoensureaccurateflowrate.

4. MaintaincontinuousECGandBPmonitoring,preferablyinacriticalcaresetting.

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MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSCentrally Acting Inhibitors (antiadrenergics) Decrease sympathetic effect (norepinephrine), resulting in decreased BP and peripheral resistance, decrease in heart rate, and no change in cardiac output.

Methyldopa:POMethyldopate:IV

Hepatotoxicity,hemolyticanemiasexualdysfunction,orthostatichypotension

1. Ifwithdrawnabruptly,mayprecipitateahypertensivecrisis.

2. Donotconfusemethyldopawithlevodopaorl-dopa.

3. AppearsonBeerslist:Olderadultclientsmayhaveincreasedsensitivitytomethyldopa.Monitorfordepressionoralteredmentalstatus.

ACE Inhibitors Reduce peripheral vasculature resistance without increasing cardiac output, rate, or contractility; angiotension antagonists.

Captopril(Capoten):POEnalapril(Vasotec):POLisinopril(Zestril):PORamipril(Altace):POMoexipril(Univasc):POBenazepril(Lotensin):PO

Posturalhypotension,hyperkalemia,insomnia,nonproductivecough,lossoftaste

1. Monitorcloselyonfirstdose;hypotensionandfirst-dosesyncopemayoccur.

2. Conservepotassium;may not needapotassiumsupplementwhengivenwithadiuretic.

3. Skippingdosesorstoppingdrugmayresultinreboundhypertension.

Beta-Adrenergic Blockers See Appendix 17-2.

Calcium Channel Blockers See Appendix 17-2.

ACE, Angiotensin-converting enzyme; BP, blood pressure; ECG, electrocardiogram; GI, gastrointestinal; IM, intramuscularly; IV, intravenously; PO, bymouth(orally).

Appendix 16-5 ANTIHYPERTENSIVE MEDICATIONS—cont’d

Appendix 16-6 DIURETICS (FIGURE 16-5)

General Nursing Implications—Inhospitalizedclients,evaluatedailyweightsforfluidlossorgain.—Maintainintakeandoutputratios.—Monitorforhypokalemia,anorexia,muscleweakness,numbness,tingling,paresthesia,confusion,and

excessivethirst.—Adviseclientoffoodsthatarerichinpotassium.—Administermedicationsinthemorning.—Teachclienthowtodecreaseeffectsofposturalhypotension.—MonitorBPresponsetomedication.—Interactions:

—Digitalisactionisincreasedinpresenceofhypokalemia.—Lithiumlevelsmaybeincreasedinpresenceofhyponatremia.

Loop Diuretics Block sodium and chloride reabsorption, which causes water and solutes to be retained in the nephrons. Prevention of reabsorption of water back into the circulation causes an increase in excretion of the water, and thus, diuresis.

Furosemide(Lasix):PO,IM,IVBumetanide(Bumex):PO,IM,IVTorsemide(Demadex):PO,IV

Dehydration,hypotension;excessivelossofpotassium,sodium,chloride;hyperglycemia,hyperuricemia;muscleweakness

1. Strongdiureticthatprovidesrapiddiuresis.2. Usewithcautioninolderadults;CNSproblemsof

confusion,headache.3. Monitorcloselyfortinnitus/hearingloss.4. DonotconfuseBumexwithbuprenorphine

(Buprenex).5. Donotconfusefurosemide(Lasix)withtorsemide

(Demadex).

Continued

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Thiazide Diuretics Increase renal excretion of Na Cl, K, and water. Require adequate urine output to be effective.

Chlorothiazide(Diuril):IV,POChlorthalidone(Hygroton):POHydrochlorothiazide

(HydroDIURIL, Esidrix):POMetolazone(Zaroxolyn):PO

(athiazide-likediuretic)

Dehydration,hypotension;excessivelossofpotassium,hyperglycemia,hyperuricemia;muscleweakness

1. Frequentlyusedasfirst-linedrugtocontrolessentialhypertension.

2. Increasedriskfordigitalistoxicityiftakingdigoxinproducts.

3. Ifallergictothiazidesorsulfonamides,metolazonemaybecontraindicated.

Aldosterone Antagonist (potassium-sparing diuretics) Blocks the effect of aldosterone, inhibits the renal-angiotension-aldosterone system (RAAS); blocks receptors in the renal tubules, heart, and blood vessels. Used in treatment of heart failure, as well as hypertension.

Spironolactone(Aldactone):POTriamterene(Dyrenium):PO

Hyperkalemia,hyponatremia,impotence,hypotension

1. Maybeusedincombinationwithotherdiureticstoreducepotassiumloss.

2. Potassium-sparingeffectsmayresultinhyperkalemia.3. Notusedforclientsexperiencingrenalfailure.4. Avoidsaltsubstitutesandfoodscontaininglarge

amountsofsodiumorpotassium.

Osmotic Diuretic Increases osmotic pressure of the fluid in the renal tubules, preventing reabsorption of sodium and water.

Mannitol(Osmitrol):IV Pulmonaryedema,CHF,tissuedehydration,nausea,vomiting

1. StopinfusionifclientbeginstoshowsymptomsofCHForpulmonaryedema.

2. UseanIVfiltertopreventinfusionofcrystals;warmvialandshakevigorouslytodissolvecrystals.

3. Monitorinfusionsitecloselyforinfiltrationand/orextravasation.

BP,Bloodpressure;CHF,congestiveheartfailure;CNS,centralnervoussystem;IM,intramuscularly;IV,intravenously;PO,bymouth(orally).

Appendix 16-6 DIURETICS (FIGURE 16-5)—cont’d

FIGURE 16-5 Diuretic water slide. (From Zerwekh J, Claborn J, Gaglione T: Mosby’s pharmacology memory notecards, ed 2, St. Louis, 2008, Mosby.)

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Appendix 16-7 MEDICATIONS USED FOR TREATMENT OF SHOCK

General Nursing Implications—Mostoftenlimitedtocriticalcaresettings;constantmonitoringisrequired.—AdministeredIVindilutedsolutionbyinfusionpump.—MonitorIVinfusionsiteclosely;leakageintotissuemaycausetissuesloughing.—Administerviacentrallineifpossible.—CarefullyadministeredwithfrequentobservationandevaluationofBP.—ContinuousECGmonitoring;observeclientcloselyforcardiacdysrhythmias.—Monitorurinaryoutputeveryhour.—MedicationsshouldnotbeadministeredtoclientsreceivingMAOIsortricyclicantidepressants.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAdrenergics Increases myocardial contractility, thereby improving cardiac output, BP, and urine output.

�Dopamine(Intropin):IV Dysrhythmias(tachycardia),angina,hypertension,headaches

1. Shouldnotbegiventoclientswithtachydysrhythmiasorventricularfibrillation.

2. Havesecondpractitionercheckdrug,dosage,route,etc.

3. Ifextravasationoccurs,stopinfusionimmediately;areamaybeinfusedwithphentolaminemesylate(Regitine).

4. CloselymonitorVS,cardiacrhythm,andurinaryoutputduringadministration.

�Dobutamine(Dobutrex):IV Tachycardia,dysrhythmias,hypertension

1. Ifextravasationoccurs,stopinfusion;areamaybeinfusedwithphentolaminemesylate(Regitine).

�Epinephrinehydrochloride(Adrenalin):IV

Nervousness,restlessness,tremors,angina,dysrhythmias,tachycardia,hypertension.

1. Besuretoreadlabelcorrectlyandusecorrectstrength/concentration.

2. Useintreatmentofanaphylacticshockandcardiacarrest.

�:High-AlertMedication;ECG,electrocardiogram;IV,intravenous;MAOIs,monoamineoxidaseinhibitors;VS,vitalsigns.

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Study Questions Vascular System More questions on companion CD!

1. What is the correct reference point that the nursewouldusetomeasureaclient’scentralvenouspressure(CVP)?1 Right side, midclavicular line where it intersects

withthefifthintercostalspace2 Midaxillary lineat the levelof thefifth intercostal

space3 Left midsternal border at the level of the fourth

intercostalspace4 Anterioraspectofthethoraciccavity,leftsideatthe

fifthintercostalspace2. Whatisanimportantnursingactioninthesafeadmin-

istrationofheparin?1 Checktheprothrombintime(PT)andadminister

themedicationifitislessthan20seconds.2 Use a20-gauge, 1-inchneedle and inject into the

deltoidmuscleandgentlymassagethearea.3 Dilutein50mL5%dextroseinwater(D5W)and

infuse by intravenous piggyback (IVPB) over 15minutes.

4 Use a 25-gauge, 12 -inch needle and inject the

medication into the subcutaneous tissue of theabdomen.

3. Whilediscussingherdiagnosisofhypertension,aclientasksthenursehowlongsheisgoingtohavetotakeallofthemedicationsthathavebeenprescribed.Onwhatprincipleisthenurse’sresponsebased?1 Theclientwillbescheduledforanappointmentin

2months;thedoctorwilldecreasehermedicationsatthattime.

2 Assoonasherbloodpressure(BP)returnstonormallevels, the client will be able to stop taking hermedications.

3 TomaintainstablecontrolofherBP,theclientwillhavetotakethemedicationsindefinitely.

4 The nurse cannot discuss the medications withthe client; the client will need to talk with thedoctor.

4. The nurse is teaching a client about home care andtreatmentofvenousstasisulcersonhisleg.Whatshouldbe included in the nurse’s instructions? Select all thatapply:______ 1 Dressings do not need to be changed fre-

quentlybecausethereisminimaldrainage.______ 2 Healing will be facilitated by wearing leg

compressiondevices.______ 3 Whentheclientisinthesittingposition,he

shouldkeephislegselevated.______ 4 Avoid standing for prolonged periods of

time.______ 5 Cool packs can be applied to the ulcers to

decreaseinflammation.______ 6 Soak the affected extremity inwarmwater

everyevening

5. Thenurseiscaringforaclientwhois6hourspostpar-tum.Whatnursingactionsaredirectedtowardthepre-ventionofpostpartumthrombophlebitis?1 Encourage early ambulation and increased fluid

intake.2 Allow bathroom privileges only and elevate the

lowerextremities.3 Administeranticoagulantsandevaluatetheclotting

factors.4 Encouragetheclienttobreastfeedtheinfantassoon

aspossible.6. The nurse is preparing to administer spironolactone

(Aldactone)toaclient.Afterassessingtheclient,whatdataindicatetheneedtowithholdthemedication?1 Potassiumlevelof5.8mEq/L2 Apicalpulserateof58beats/min3 BPof130/90mmHg4 Urineoutputof30mL/hr

7. Whichnursingactionwouldbemosteffective inpre-ventingvenousstasisinthepostoperativesurgicalclient?1 Raisethefootofthebedfor1hour;thenlowerit

tostimulatebloodflow.2 Massagethelowerextremitiesevery6hours.3 Facilitateactiverangeofmotionoftheupperbody

tostimulatecardiacoutput.4 Help the client walk as soon as and as often as

possible.8. A client has had her blood pressure evaluated weekly

for 1 month. At the end of the month, the nurseaveragesouttheweeklybloodpressuresat150/96mmHg.Theclientis20poundsoverweight,andhercho-lesterol is240mg/dL.Whatis important informationfor the nurse to include in the teaching plan for thisclient?1 Refer her to the doctor for further follow-up and

medications.2 Increase the fiber in her diet and begin a daily

30-minuteworkout.3 Reducehersodiumintakeanddecreasethedietary

caloriesthatcomefromfat.4 Reduce her cholesterol intake for 1 month and

checkherBPthreetimesaweek.9. Fourhoursafteraortic-femoralbypassgraftsurgery,the

nurseassessestheclientandisunabletopalpatepulsesintheoperativeleg.Theclientcomplainsofpainintheleg.Whatisthefirstnursingaction?1 Massagethelegandapplywarmtowels.2 Elevatethelegandrecheckthepulse.3 Callthephysicianimmediately.4 Helptheclientambulate.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

vascular system - nursing edinto the aorta through the arteries to the capillary bed where cellular...

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