The Management of Vascular Disorders

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The Management of Vascular Disorders

• Camille N. Scronce, BSN, RNMSN Candidate, Duke
  University School of NursingOctober 24, 2014

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Objectives

• Discuss pathophysiological changes to the
  vascular system and lifestyle risk factors that
  predispose individuals to vascular disorders.
• Discuss the clinical manifestations,
  complications, diagnostic studies and
  collaborative care for abdominal aortic
  aneurysms.
• Discuss the lifestyle changes needed to avoid or
  minimize lower extremity peripheral vascular
  disease.
• Distinguish between the signs and symptoms of
  peripheral arterial and peripheral venous
  disease.
• Describe the assessment and nursing management of
  a patient following peripheral artery bypass
  graft surgery.

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Objectives

• Describe signs of acute arterial ischemia (the
  six Ps).
• Discuss management of venous thromboembolism,
  chronic venous insufficiency and venous leg
  ulcers.
• Recognize the clinical manifestations of aortic
  dissection as a medical emergency and when to
  seek appropriate assistance.

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Peripheral Vascular Disease (PVD)

• reduction in blood flow and oxygen through the
  peripheral vessels
•  PVD commonly referred to as peripheral arterial
  disease (PAD)
• Factors that can contribute to the development of
  peripheral vascular disorders
• atherosclerotic changes
• thrombus formation
• embolus
• ? coagulability of blood
• hypertension
• inflammatory process/infection

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Overview of Disorders

• Peripheral Arterial Disease (PAD)
• Aneurysms
• Aortic Dissection
• Acute Arterial Ischemia
• Chronic Peripheral Artery Disease of the Lower
  Extremities
• Venous Disorders
• Chronic Venous Insufficiency
• Venous Thrombosis

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Peripheral Arterial Disease (PAD)

• Atherosclerosis - most common cause of peripheral
  arterial disease
• Risk Factors
• Smokers
• Older Age
• High Cholesterol
• High Blood Pressure
• Diabetes
• Metabolic Syndrome
• S/Sx
• Intermittent claudication Hallmark of the
  disease
• Abnormal pulses in lower extremities

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Common Locations of Atherosclerotic Lesions
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Aneurysms
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Abdominal Aortic Aneurysms (AAA)
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AAA Risk Factors

• Men
• Older Age
• Smokers
• CAD
• PAD
• High Blood Pressure
• High Cholesterol

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AAA Diagnosis

• S/Sx
• Often asymptomatic
• Pain or tenderness in the mid-or upper abdomen
• Auscultation of a bruit over the aneurysm
• Presence of a pulsating abdominal mass
• The aneurysm may extend to impinge on the renal,
  iliac, or mesenteric arteries
• Rupture of the aneurysm most feared
  complication
• Can occur if the aneurysm is large
• Can lead to death MEDICAL EMERGENCY
• Diagnosed with Ultrasound
• CT Scan, MRI and Arteriogram

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AAA Treatment Management

• Depends on size
• Watchful waiting if lt5.5 cm
• Risk factor modification
• Stop smoking
• Control lipids and hypertension
• Statins
• ASA
• Surgery
• Graft. (pg. 869) with transabdominal approach
• Transfemoral endovascular repair w/ stents
  (graft) (pg. 870)

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AAA Treatment Management
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AAA Post-Op Management

• Maintain patency of graft renal perfusion
• maintain adequate BP
• check skin temp/color/ pulses in lower
  extremities
• watch for sudden increase in pain.
• Also GI concerns (if open approach)
• Watch for infection (Pt teaching)
• Pain control
• Fluid electrolyte balance/renal function
• Avoid heavy lifting for 4-6 weeks

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Aortic Dissection

• Tear develops in the inner layer of the aorta
• S/Sx
• Sudden onset of severe and persistent pain
• Tearing or ripping sensation
• Hypotension, sweating, pale, tachycardia
• MEDICAL EMERGENCY!!!!
• Diagnosed with TEE, CT Scan or MRI
• Treatment
• Pain management BP control Surgery
• Complications cardiac tamponade

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Aortic Dissection
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Acute Arterial Insufficiency

• A sudden decrease in limb perfusion
• Usually caused by thrombus, embolus or trauma to
  an artery
• S/Sx 6 Ps
• pain
• pallor
• pulselessness
• paresthesia
• Polar/poikilothermia (cool to touch)
• paralysis (late sign)

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Acute Arterial Insufficiency

• Tissue Ischemia ? Gangrene
• No time to lose H H
• (Hospitalization (Arteriography) Heparin (IV)
• Surgery if limb threatened usually embolectomy
• Post surgery
• Anti-platelet therapy?
• Patient family education Assess for return of
  ischemic symptoms

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Chronic Peripheral Artery Disease of the Lower
Extremities

• What is the hallmark sign? ___________________
• Precipitated by_________?
• Resolves in _________minutes?
• Reproducible???
• Why?
• May progress to rest pain ulcers
• Diagnosed by doppler, ankle-brachial index (ABI),
  angiography

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Physical Examination
Examination What do to
Inspection Expose the skin and look for Thick Shiny Skin Hair Loss Brittle Nails Color Changes (pallor) Ulcers
Palpation Temperature (cool, bilateral/unilateral) Pulses diminished or absent Capillary Refill gt 5 seconds Sensation/Movement decreased
Auscultation Femoral Bruits
Ankle Brachial Index (ABI) Systolic BP in ankle Systolic BP in brachial artery
Buergers Test Elevate the leg to 45 - and look for pallor Place the leg in a dependent position 90 look for a red flushed foot before returning to normal Pallor at lt20 severe PAD.
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Chronic Peripheral Artery Disease of the Lower
Extremities
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Chronic Peripheral Artery Disease of the Lower
Extremities

• Prevention treatment by lifestyle modifications
  such as _____?
• Avoid tight knee highs, socks
• Supervised walking most effective exercise!!
• Meds ASA or other meds anticoag/antiplatelets
• Teaching low fat diet, regular exercise, no
  smoking, foot care
• Surgery/Stents if symptoms are incapacitating
  (pain at rest)
• Amputation if ulcers/gangrene/limb threatened

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Bypass Surgery
Fem-pop
Fem-tib
Aorto bi-fem
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Bypass Surgery Nursing Care

• Maintaining circulation by
• Check pulses, color, temp, sensory and motor
  function of the affected extremities (Compare
  extremities)
• Disappearance of a pulse that was present may
  indicate occlusion of the graft
• Maintain skin integrity and prevent infection by
• Meticulous foot care, comfortable well-fitting
  shoes, avoid applying direct heat over
  extremities, never go barefoot
• Assess wound for redness, swelling and drainage
• Patient education upon discharge
• No smoking, no constrictive clothing, avoid
  crossing legs, encourage pt. to walk

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• Venous Disorders

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Venous Disorders

• Alteration in the transport/flow of blood from
  the capillary back to the heart
• Changes in smooth muscle and connective tissue
  make the veins less distensible with limited
  recoil capacity
• Valves may malfunction, causing backflow of blood
• Virchows triad blood stasis, vessel wall
  injury, and altered blood coagulation

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Venous Thrombosis
Virchows Triad
Venous Stasis
Hypercoagulability
Varicose veins Surgery Obesity Pregnancy Bed
rest CHF A fib
Blood dyscrasias Oral contraceptives Smoking Sepsi
s
Injury
IV therapy Fractures Abdominal pelvic surgery
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Venous Stasis

• S/Sx
• Lower leg edema, itching, brown pigmentation,
  cyanosis of skin of lower leg/foot
• Complication Venous stasis ulcer
• Treatment
• Keep feet elevated above heart level, follow
  guidelines for skin and foot care, walk, avoid
  anything that pinches skin, do not cross legs
  avoid pressure behind knees
• Compression therapy
• Debridement of ulcer to promote healing

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Compression Therapy

• Compression bandages with..
• Example Unna boots or ace bandages w/ glycerin,
  calamine lotion, zinc oxide, gelatin.
• Clean technique.
• Treat infection
• Refer to wound/ostomy clinicWOCN RN
• Compression stockings

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Venous Ulcer
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Venous Thrombophlebitis

• Inflammation of the veins caused by thrombus or
  blood clot
• Develops in both the deep and superficial veins
  of the lower extremity
• deep veins femoral, popliteal, small calf veins
• superficial veins saphenous vein, superficial
  veins in the arms

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Superficial

• Depends on site etiology
• Heat (warm moist soaks)
• Remove IV catheter if causative
• Pain NSAID
• Elastic compression stockings

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Deep Vein Thrombosis
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Deep Vein Thrombosis

• S/Sx pain and edema of extremity, ?
  circumference of the thigh or calf, () Homans
  sign
• Prevention early ambulation, post-op exercises,
  compression stockings, hydration, anticoagulation
  post-op. Avoid prolonged sitting avoid smoking.
  
• Diagnosis Ultrasound, D-dimer
• Treatment IV Heparin or LMWH then Coumadin
• Bed rest with Bathroom privileges (BR with BRPs)
  
• Measure extremity daily
• Elevation
• Elastic compression stockings
• Avoid rubbing or massaging leg

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Deep Vein Thrombosis
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Anticoagulation Therapy

• Heparin - IV (labs PTT)
• Low Molecular Weight Heparin (Lovenox)
• Antidote Protamine Sulfate
• Coumadin
• Antidote Vitamin K
• Patient teaching - no sudden diet changes in
  foods high in Vitamin K and risk for bleeding
• Labs to check INR or PT
• PT 12-15 sec
• INR 0.75-1.25 (Therapeutic Range 2-3)

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Arterial Disease Venous Disease
Skin cool or cold, hairless, dry, shiny, pallor on elevation, rubor on dangling warm, though, thickened, mottled, pigmented areas
Pain sharp, stabbing, worsens w/ activity and walking, lowering feet may relieve pain aching, cramping, activity and walking sometimes help, elevating the feet relieves pain
Ulcers severely painful, pale, gray base, found on heel, toes, dorsum of foot moderately painful, pink base, found on medial aspect of the ankle
Pulse often absent or diminished usually present
Edema infrequent frequent, esp. at the end of the day and in areas of ulceration
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Review

• Many factors contribute to PVD
• Educate patients on how to minimize the risk
  factors for venous disorders
• Know the signs and symptoms of AAA rupture
• Know the signs and symptoms of aortic dissection
  and educate patients on BP control
• Remember nursing management after peripheral
  arterial bypass surgery focuses on maintaining
  circulation, skin integrity, preventing infection
  and providing patient education.

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Review

• Three factors contribute to venous thrombosis
• The key to managing venous stasis is focusing
  interventions that increase blood flow to the
  heart
• Remember that the focus for DVTs is prevention
• There are differences between peripheral arterial
  and venous disease

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• Questions??

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References

• Ignatavicius, D.D. Workman, M.L. (2013).
  Medical-Surgical Nursing Patient-Centered
  Collaborative Care (7th ed.). St. Louis Mosby
• Kaufman, J. (2011). Vascular Disorders
  PowerPoint slides
• Leonard, C. (2013). Vascular Disorders
  PowerPoint slides
• Lewis, S.M., Dirksen, S.R., Heitkemper, M.M.
  Bucher, L. (2013). Medical-Surgical Nursing
  Assessment and Management of Clinical Problems
  (9th ed.). St, Louis Mosby
• National Guideline Clearinghouse. (2012).
  Diagnosis and management of peripheral arterial
  disease. A national clinical guide. Retrieved
  from http//www.guideline.gov/content.aspx?id9924
  
• Neschis, D.G. Golden, M.A. (). Clinical
  features and diagnosis of lower extremity
  peripheral artery disease. In K.A. Collins (Ed.),
  UpToDate. Retrieved from http//www.uptodate.com/
  contents/clinical-features-and-diagnosis-of-lower-
  extremity-peripheral-artery disease?sourcesearch_
  resultsearchperipheralvasculardiseaseselected
  Title1150

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10 Minute Break
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Socrative Space Race Game

• Get in groups based on the numbers you received
  when you walked into the class
• Have one person in the group use their laptop,
  IPAD, cell phone or any device with a web
  browser.
• Go to the following website to play this game as
  a group
• http//m.socrative.com
• Teacher Room Name 4a042f38