Nursing of Adults with Medical

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Nursing of AdultswithMedical Surgical
Conditions

• Disorders
• of the
• Peripheral Vascular System

2
Risk Factors

• Similar to risk factors for heart disorders
• Age
• Gender
• Smoking
• Hypertension
• Hyperlipidemia
• Obesity
• Lack of exercise
• Emotional stress
• Diabetes Mellitus
• Family History

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Assessment of Vascular Disorders

• Arterial Assessment
• First symptom is usually pain
• Occurs due to arterial insufficiency and ischemia
• Dull ache in calf muscles
• Leg fatigue and cramping
• Intermittent claudication
• Pain brought on by exercise
• Later symptoms of pain
• Pain at rest
• Burning, tingling, and numbness at night even
  lying down
• Pulses
• May be weak, thready, or absent
• Scale for documentation
• 0 absent
• 1 barely palpable, intermittent
• 2 weak , possibly thready, but constantly
  palpable
• 3 normal strength and quality
• 4 bounding, easily palpable, may be visible

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• Assessment and Documentation
• PATCHES
• P for Pulses
• Absence of pulses in generally a medical
  emergency
• Compare with previous findings
• Look for other symptoms may just be hard to
  feel
• Use Doppler device if necessary
• A for Appearance
• Pale, mottled, cyanotic or discolored (red,
  black, brown)
• Necrosis or bleeding (ulcers)
• Size, depth, and location
• Edges jagged or smooth
• Painful to touch
• Shiny or dull
• Shiny may indicate edema
• Dull may indicate inadequate arterial blood
  supply
• Superficial veins, erythema, or inflammation
• Varicosities
• Have patient to stand

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• T for Temperature
• Cool
• Possible arterial problem
• Warm
• Possible venous problem
• Temperature changes may be caused by other
  problems as well
• C for Capillary refill
• Less than 2 seconds
• H for Hardness
• Supple or hard and inelastic
• Hardness may indicate chronic problems
• E for Edema
• Pitting edema
• Usually acute problem
• Assessment Press on skin for 5 seconds and
  release (Page 317 --Figure 8-17 and Table
  8-3)
• Non-pittting
• May be chronic condition
• Assessment Measure circumference of the
  extremity

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• S for Sensation
• Patient states extremity FEELS
• Numbness
• Tingling
• Hot
• Cold

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• Venous Assessment
• First symptom is usually edema
• Dark pigmentation
• Dryness and scaling
• Ulcerations
• Pain, aching, and cramping
• Usually relieved by rest or elevation
• Comparison of Arterial and Venous Disorders
• Page 331 Table 8-5

8
Diagnostic Tests

• Noninvasive Procedures
• Treadmill Test
• Exercise to determine blood flow to extremities
• Plethysmography
• Assesses blood volume in the veins
• Digital Subtraction Angiography (DSA)
• IV contrast is administered
• Blood vessels are visualized by radiography using
  an image intensifier video system and monitor
• Doppler Ultrasound
• Measures blood flow in arteries or veins

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Diagnostic Tests

• Invasive Procedures
• Phlebography or venography
• Radiographic visualization of veins
• IV contrast is administered in a foot vein
• X-rays are taken to detect filling defects
• Assesses for condition of deep veins and to
  diagnose deep vein thrombosis
• 125 I-fibrinogen Uptake Test
• Assesses for acute calf vein thrombosis
• Fibrinogen is tagged with iodine 125 and given IV
  - it can then be detected in the blood stream by
  a gamma ray detector
• Angiography
• IV contrast is administered
• X-ray to visualize arteries

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• D-dimer Serum Test
• D-dimer forms when fibrin is broken down
• When a thrombus is present D-dimer levels are
  elevated usually greater than 1591 ng/ml
• Normal value 68-494 ng/ml
• Duplex Scanning
• Combination of ultrasound imaging and Doppler
• Determines location and extent of thrombus within
  veins

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Arteriosclerosis Atherosclerosis

• Arteriosclerosis
• thickening, loss of elasticity, and calcification
  of arterial walls, resulting in a decreased blood
  supply
• Atherosclerosis
• narrowing of the artery due to yellowish plaques
  of cholesterol, lipids, and cellular debris in
  the inner layers of the walls of large and medium
  sized arteries
• a type of arteriosclerosis

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Atherosclerosis
13
Hypertension

• Etiology/Pathophysiology
• A sustained elevated systolic blood pressure
  greater than 140 mm Hg and /or a sustained
  elevated diastolic blood pressure greater than 90
  mm Hg.
• Vasoconstriction (increases B/P)
• caused by stimulation of the sympathetic nervous
  system and the release of epinephrine and/or
  norepinephrine. Decreased blood flow to the
  kidneys causes the release of renin and the
  formation of angiotensin which is a
  vasoconstrictor.

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Hypertension

• Essential (primary) hypertension
• 90-95 of all diagnosed cases
• Theories of causes
• arteriolar changes, sympathetic nervous system
  activation, hormonal influence, genetic factors,
  obesity, sedentary lifestyle, increased sodium
  intake, excessive alcohol intake.
• Secondary hypertension
• Attributed to an identifiable medical diagnosis
• renal vascular disease
• diseases of the adrenal cortex
• coarctation of the aorta
• head trauma or cranial tumor
• pregnancy-induced hypertension

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Hypertension

• Malignant hypertension
• severe, rapidly progressive elevation in blood
  pressure that causes damage to the small
  arterioles in major organs (heart, kidneys,
  brain, eyes)

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Hypertension

• Signs Symptoms
• headache
• blurred vision
• epistaxis
• angina
• s/s of
• MI, CHF, renal failure, and stroke

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Hypertension

• Treatment
• Antihypertensive medications
• Capoten, Vasotec, Altace, Lotensin, Zestril,
  Accupril, Monopril
• Diuretics
• Lasix, HCTZ, Aldactone
• Diet
• weight control, reduction of saturated fats, and
  low sodium
• No smoking

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Hypertension

• Decreased alcohol intake
• Regular aerobic exercise
• Relaxation techniques/stress management

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Arteriosclerosis Obliterans

• Etiology/Pathophysiology
• narrowing or occlusion of the blood vessel with
  plaque formation
• little or no blood flow to the affected extremity

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Arteriosclerosis Obliterans

• Signs Symptoms
• Five Ps
• Pain
• intermittent claudication
• Pulselessness
• Pallor
• Paresthesia
• Paralysis

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Arteriosclerosis Obliterans

• Treatment
• Anticoagulants
• Heparin and Coumadin
• Fibrinolytics
• Urokinase
• administered directly into the thrombus
• Surgery
• embolectomy- removal of the embloism
• endarterectomy- removal of the lining of the
  artery
• arterial bypass
• percutaneous transluminal angioplasty
• amputation

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Percutaneous Transluminal
Angioplasty
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Arterial Embolism

• Etiology/Pathophysiology
• Blood clots in the arterial bloodstream
• May originate in the heart
• arterial dysrhythmia, MI, valvular heart disease,
  CHF
• Foreign substances
• plaque, tissue, etc.

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Arterial Embolism

• Signs Symptoms
• Pain
• Absent distal pulses
• Pale, cool, and numb extremity
• Necrosis
• S/S of shock with occlusion of a major vessel

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Arterial Embolism

• Treatment
• Anticoagulants
• Heparin and Coumadin
• Fibrinolytics
• Endarterectomy
• Embolectomy

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Arterial Aneurysm

• Etiology/Pathophysiology
• Enlarged, dilated portion of an artery
• Causes
• arteriosclerosis
• trauma
• congenital defect
• Commonly affected arteries
• popliteal
• thoracic and abdominal aorta
• coronary
• cerebral

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Arterial Aneurysm

• Signs Symptoms
• Asymptomatic
• Large pulating mass
• Pain, if large enough to press on other structures

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Arterial Aneurysm

• Treatment
• Assess for s/s of rupture, thrombi, ischemia
• Control hypertension
• Surgery
• Ligation
• Grafts

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Surgical Repair of Arterial Aneurysm
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Thromboangitis Obliterans(Buergers Disease)

• Etiology/Pathophysiology
• Occlusive vascular condition in which the small
  and medium size arteries become inflamed and
  thrombotic
• affects the small arteries in the hands and feet
• Cause not known
• Affects men 20-40 years old who smoke

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Thromboangitis Obliterans(Buergers Disease)

• Signs Symptoms
• Pain
• may be frequent and persistent
• Sensitivity to cold
• Skin cold and pale
• Ulcerations on feet or hands
• Gangrene
• Superficial thrombophlebitis

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Thromboangitis Obliterans(Buergers Disease)

• Treatment
• No smoking
• Exercise to develop collateral circulation
• Surgery
• amputation of gangrenous fingers and toes
• sympathectomy
• clip nerves to prevent pain and vasospasm

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Raynauds Disease

• Etiology/Pathophysiology
• Intermittent arterial spasms
• Primarily affects
• fingers, toes, ears and nose
• Exposure to cold or emotional stress
• Secondary
• scleroderma
• rheumatoid arthritis, SLE, drug intoxication,
  occupational trauma
• Commonly affects women 20-40 years of age

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Raynauds Disease

• Signs Symptoms
• Chronically cold hands and feet
• Pallor, coldness, numbness, cyanosis, and pain
  during spasms
• Erythema following a spasm
• Ulcerations on the fingers and toes with chronic
  disease

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Raynauds Disease

• Treatment
• No smoking
• Avoid exposure to cold
• Medications
• vasodilators
• calcium antagonists
• muscle relaxants
• Surgery
• sympathectomy
• amputation for gangrene

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Thrombophlebitis

• Etiology/Pathophysiology
• Inflammation of a vein in conjunction with the
  formation of a thrombus
• More common in women
• Risk factors
• venous stasis
• hypercoagulability
• truama to the blood vessel
• immobilization after surgery

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Thrombophlebitis

• Signs Symptoms
• Pain
• Edema
• Positive Homans sign
• Erythema, warmth, and tenderness along the vein

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Thrombophlebitis

• Treatment
• Superficial
• Bedrest
• Moist heat
• Elevate extremity
• NSAIDs
• Motrin
• aspirin

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Thrombophlebitis

• Deep
• Bedrest
• Anticoagulants
• Heparin Coumadin
• Fibrinolytics
• Elevate extremity
• Antiembolism stockings
• Surgery
• thrombectomy
• vena cava umbrella (Greenfield filter)

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Greenfield Filter
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Varicose Veins

• Etiology/Pathophysiology
• Tortuous, dilated vein with incompetent valves
• Most common in women 40-60 years of age
• Caused by
• congenital defective valves, absent valve, valve
  that becomes incompetent
• Pregnancy or obesity
• prolonged standing
• constrictive clothing

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Varicose Veins
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Varicose Veins

• Signs Symptoms
• Dark, raised, tortuous veins
• Fatigue
• Dull aches
• Cramping of the muscles
• Heaviness or pressure of extremity
• Edema, pain, changes in skin color, and
  ulcerations with venous stasis

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Varicose Veins

• Treatment
• Elastic stockings
• Rest
• Elevate legs
• Sclerotherapy
• injection of sclerosing solution
• Surgery
• Vein ligation and stripping

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Venous Stasis Ulcers

• Etiology/Pathophysiology
• Ulcerations of the legs from chronic deep vein
  insufficiency and stasis of blood in the venous
  system of the legs
• Open necrotic lesion due to an inadequate supply
  of oxygen-rich blood to the tissue
• Causes
• varicose veins, burns trauma, sickle cell anemia,
  diabetes mellitus, neurogenic disorders, and
  hereditary factors

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Venous Stasis Ulcers

• Signs Symptoms
• Pain
• Ulceration with dark pigmentation
• Edema

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Venous Stasis Ulcers

• Treatment
• Diet
• Increased protein
• Vitamin A C and Zinc
• Debridement of necrotic tissue
• wet-to-dry dressings
• Elase cream
• surgical
• Antibiotics
• Unna boot