ࡱ> egd 2bjbj %\jj.l$%$%$%8\%x%5&LT&"v&v&v&v&v&v&{5}5}5}5}5}5}5$6 85v&v&v&v&v&52v&v&5222v&v&v&{52v&{5223Z3{5v&% %z"$%d*k5{5505s5n91"n9{52Peripheral Vascular Disease Teresa Kelechi, PhD, RN June 2, 2003 Brief Overview Two interdependent systems central (pump) peripheral Arterial and venous systems arterial (100 mmHg pressure) venous (4 mmHg pressure) Overview L side of heart aorta arteries arterioles capillaries venules veins vena cava R side of heart the site of exchange of nutrients and metabolic wastes and fluids occurs in the capillaries in tissues intravascular/extravascular Heart Overview Circulation under the influence of physical and hormonal stressors: chemical hormonal nervous system (sympathetic) norepinephrine (constriction) epinephrine Overview Lymph system serves to collect fluid (extravascular/interstitial) from tissues and organs and transports fluid to into two main structures thoracic duct right lymphatic duct collects large molecules (proteins) regional lymph nodes filter foreign particles Overview Hydrostatic vs osmotic pressure affect vascular system demands for flow exercise, physical activity, fever, infection, local application of heat, inflammation = increased needs for blood flow rest, decreased physical activity, local cold application, cooling of body, certain nerve blocks = decreased demands for flow Overview Problems with flow to the tissues ischemia, malnutrition, death (necrosis, gangrene) Related to: heart failure atherosclerotic plaque arteriosclerosis trauma Gangrene Gangrene Overview Venous problems thrombus, valve incompetence, bed rest Obstruction of lymphatic vessels Aging Overview Peripheral vascular diseases arterial (PAD, LEAD) venous (CVI) lymphatics Peripheral Vascular Disease Arterial Signs and symptoms Arterial intermittent claudication - pain absent/diminished pulses dry skin shiny appearance of skin decreased/absent hair growth thick nails cold to touch purplish/dependent rubor Venous Signs and symptoms Venous aching/cramping edema telangiectasis hyperpigmentation dermatitis lipodermatosclerosis Venous Diagnostic/evaluation Doppler ultrasound flow studies segmental pressures exercise testing duplex ultrasound CT/MRI angiography air plethysmography Diagnostic/evaluation Ankle/brachial index Transcutaneous oximetry laser Doppler imaging/flowmetry Risk factors Modifiable smoking diet hypercholesterolemia diabetes stress sedentary lifestyle Risk factors Non-modifiable age gender Nursing Management Goals increase blood supply to the extremities positioning exercise avoid constrictive clothing do not cross legs drugs smoking cessation Compression Compression Nursing Management Stress management Injury prevention Keep patient warm Unreasonable lifestyle accommodations relieve pain maintain tissue integrity promote self care hygiene nutrition Peripheral arterial disease Surgical management limb-salvaging surgery type of procedure depends on: degree and location of stenosis or occlusion overall health of patient length of procedure that can be tolerated patients life expectancy Surgery Endarterectomy Incision into artery to remove atheromatous obstruction check incision/dressing listen for bruits Bypass graft Reroute blood around stenosis or occlusion anastomosis femoral/popliteal femoral/posterior tibial or anterior tibial or peroneal autologous (native) or prosthetic material autologous can be in situ or reversed vein graft Nursing Management Check incision lines pulses color warmth hematoma I&O edema Elevate? TED hose? Nursing Management Signs and symptoms of failure pain severe edema decreased sensation coolness below cyanosis Upper extremity occlusions Result from atherosclerosis or trauma unilateral coolness, pallor, arm fatigue, BP difference of 20 mmHg No needle sticks to arm, keep warm (dont apply heat), no tape or constrictive dressings Buergers disease Also known as: Thromboangitis Obliterans autoimmune disease pain paresthesias cold sensitivity bilateral and symmetric Other diseases Aorititis - inflammation Aortoiliac disease Aortic aneurysm sac vs fusiform vs mycocytic causes: trauma, congenital, inflammatory, pregnancy, ***atherosclerosis dissecting common is thoracic aneurysm Abdominal aortic aneurysm Surgical repair if > 5 cm (2 inches) symptoms: complaints that pants too tight, see a throbbing mass, blue toe syndrome Surgical complications: bleeding, hematoma, infection, distal ischemia, embolism, dissection or perforation, rupture, renal failure low back pain, decreased BP, Hct AAA Surgical repair Embolism/thromosis Thrombus - slowly developing clot that usually occurs where the arterial wall has been damaged as a result of atherosclerosis form occlusion related to trauma, surgical event Signs and symptoms 5 Ps: pain, pallor, paralysis, paresthesia, pulsesness Treatment Depends on its cause surgical vs. medical management Usually patients are heparinized 5,000 to 10,000 unit bolus IV - 1000 u/hr may use intra-arterial thrombolytic agents streptokinase, urokinase Nursing Management Pre-op: same as for arterial occlusion Raynauds disease/phenomena Form of intermittent arteriolar vasoconstriction which results in: coldness, pain, pallor, cyanosis, rubor Disease often accompanies immunologic disorders such as lupus, scleroderma, rheumatoid arthritis Episodes triggered by emotional factors, cold Raynauds Raynauds Raynauds Management Teach patient to: avoid cold exposure, smoking cessation may be taking calcium channel blockers (Procardia) may have surgery (sympathectomy) stress management/reassure layer clothing/injury prevention avoid alcohol intake Venous disorders Deep vein thrombosis (blood clot) causative factors: thrombophlebitis (inflammation of vein walls) pregnancy and postpartum period (6 months) Bedrest more than 3 days/immobility/long flight trauma of lower limbs (esp. fractures in cast) major surgery within 1 month oral contraceptives obesity cancer in active phase S&S Often completely symptom free Edema/swelling Pain in calf while walking/tenderness or ache during rest Redness may not be present + homans sign not indicative of DVT - concurrent pain, tenderness and edema strongly suggest DVT (59%); each sign alone indicates thrombosis in only 11 22% of cases S&S Edema in calf and ankle; may involve whole leg if thrombosis in iliac vein more than a 3-cm difference in circumference of calves Deep palpable tenderness over the involved vein Warmth of skin when compared to other leg Prominent superficial collateral veins Management Compression stockings intermittent pneumatic compression device anticoagulation therapy low molecular weight heparin (LMWH) in 1 or 2 doses (i.e., dalteparin 200 IU/kg/day) if distal thrombus older than 7 days stop therapy when after starting warfarin (coumadin) and INR in target range (2.0 3.0) for at least 2 days continue therapy for 2 to 6 months Coumadin given concomitantly when starting LMWH monitor INR, PTT not indicated when target range met thrombolytic therapy thrombectomy (vena cava filter to trap emboli) Care of patients on anticoagulation therapy Goal: detect and/or prevent bleeding IV (although currently not recommended, patients may have IV in hospital LMWH has replaced IV heparin) oral: INR (2.0 to 3.0) or PTT (1.5 to 2X normal) check urine for blood, nosebleeds, bleeding gums Only 25% of untreated distal (below the knee) thrombi proceed above the knee Counseling regarding diet: Vitamin K or foods containing Vit. K drugs (check page 709 of text) NSAIDs, ASA, antibiotics, cold medicines Patient may be: on bedrest, stockings, elevation, analgesics, warm moist packs, dorsiflexion exercises Stockings Antiembolism (12 to 18 mmHg) Avoid rolling at knee check circulation by checking toes Other measures Intermittent pneumatic compression devices Exercise/positioning deep breathing, calf muscle pumping actions, elevate and lower legs Avoid alcohol Weekly blood tests may or may not be ordered Chronic venous insufficiency Goals for nursing: good skin care compression: graduated, knee high, moderate to high compression elevation walk!!!! pain management CVI Varicose veins Dilated tortuous superficial veins due to incompetent valves that occur mostly in the legs (deep veins are intact) ache, muscle cramps, muscle fatigue, heaviness Surgical ligation stripping sclerotherapy Venous Management Post-surgical compression for 1 week, elevate, walk, check bleeding and dressings through stockings, analgesics may experience burning after sclerotherapy Disorders of the Lymphatics Lymphangitis - acute inflammation of lymphatic channel due to infection (strept) - enlarged nodes, red, tender treat with antibiotics Lymphedema - swelling of tissues in extremities due to obstruction of lymph vessels or nodes Lymphedema Bad edema Lymphatics Elephantiasis - extremity edema with abnormal skin changes thought to be related to parasitic infection HYPERLINK "http://www.niaid.nih.gov/newsroom/focuson/bugborne01/filar.htm"http://www.niaid.nih.gov/newsroom/focuson/bugborne01/filar.htm HYPERLINK "http://elephantiasis.freeyellow.com/pictures.html"http://elephantiasis.freeyellow.com/pictures.html major problem with lymph disorders is edema Management Goal: reduce/control edema/prevent infection compression garments controversy about pumping the leg of an obstruction manual therapy elevation surgical interventions Hypertension Primary unidentified cause also called essential (most common type) Secondary identified cause such as from renal disease Clinical guidelines HYPERLINK "http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf"http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf HYPERLINK "http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf"http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf The hypertensive patient Your role is to: Monitor BP Support and teach the patient to adhere to the treatment regiment Lifestyle changes Take meds as prescribed Attend regular follow-up appointments Nursing role Instruction (p. 721) Lose weight Limit alcohol intake Increase exercise Reduce sodium intake Maintain adequate potassium Stop smoking What to report Headache, nosebleeds Symptoms of low blood pressure: dizziness edema anginal pain shortness of breath alterations in speech, vision or balance, Nocturia Potential complications: LVH MI Heart failure TIAs/ stroke Renal insufficiency Retinal hemorrhage Goal is to promote self care Understand expected side effects of medications How to measure BP at home Recognize orthostatic hypotension How to simplify regimen Involve family members Recognize progression of disease Blurred vision Diminshed visual acuity Spots in front of eyes Prevent end-organ damage Recognize hypertensive emergency (crisis) BP requires immediate lowering which are acute and life-threatening Conditions associated with HE: Acute MI Dissecting aortic aneurysm Intracranial hemorrhage Hypertensive urgency BP requires lowering within a few hours Case study You are assigned to care for LJ, 70, a truck driver, admitted for R leg DVT. A thrombus in the external iliac vein extending distally to the lower leg, was diagnosed via Doppler. Labs were PT 12.4 sec, INR 1.11, PTT 25 sec, cholesterol 206 mg/dl. He has a 48 pack/year smoking history, has at fib, and arthritis. He was SOB and had leg swelling. Identify at least five problems from his history that represent his personal risk factors for DVT. What are the characteristics of the physical assessment for this patient? What is the most serious complication of DVT? What instructions will you give him about his activity? You identify pain as a key issue in the care of the patient. List four interventions you would choose to address pain. The patient is started on LMWH and coumadin. What pertinent laboratory values/tests would you expect the physician to order and you to monitor? His INR is at target. He is excited about discharge because he is flying to his grandsons wedding in Arizona. What would you say to him? 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