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Vascular Problems, Stroke, Aneurysms, and HTN Crisis. By Diana Blum MSN MCC NURS 2140. Vascular Disorders. Common disorders in America: hypertension atherosclerosis arterial occlusive disease abdominal aortic aneurysms (AAA) deep vein thrombosis (DVT)

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vascular disorders
Vascular Disorders
  • Common disorders in America:
  • hypertension
  • atherosclerosis
  • arterial occlusive disease
  • abdominal aortic aneurysms (AAA)
  • deep vein thrombosis (DVT)
  • venous insufficiency
  • C reactive protein is a marker for cardiac inflammation
    • Increases mean: risk of damage
  • Homocysteine: protein that promotes coagulation by increasing factor 5 and factor 11 while depressing activation of protein C and increasing thrombus formation risk
    • Vitamin b6 and b12 and folate lowers homocysteine levels
arterial diseases
Arterial diseases:
  • Arteriosclerosis (atherosclerosis)
  • Aneurysm formation
  • Arteriosclerosis obliterans
  • Raynaud’s phenomenon
  • Arterial embolism
  • Thromboangiitis obliterans
  • Diabetic arteriosclerotic disease
  • hypertension
manifestations arterial 50 occulsion before symptoms
Manifestations :ARTERIAL(50% occulsion before symptoms)
  • Ischemia (reduced oxygenation)
  • - leads to pain
  • Paresthesia (decreased sensation in
  • extremities = tingling/numbing)
  • Pain (in feet/leg muscles = burning,
  • throbbing, cramping)
  • -usually from exercise BUT also
  • with elevation of lower extremities
  • Hallmark sign: Intermittent claudication (pain in
  • exercising muscles – usually in calf
  • - directly related to decreased
  • blood supply during activity &
  • recedes with rest
  • Temperature: (COLD)
  • Skin color changes: skin pale on
  • elevation but red dependent
  • Reactive hyperemia: (reduced blood flow

to extremity results in arteriolar dilation so when the blood supply is restored,

the affected area becomes warm/red

from congestion

  • Pulse changes: Peripheral diminished or


  • Prolonged capillary refill:
  • - 3 seconds or more
  • Ulcers:
  • - open lesions on feet from diminished distal perfusion
  • -describes arterial disorders in which
  • degenerative changes result in
  • decreased blood flow
  • Atherosclerosis:
  • - most common form of arteriosclerosis, excessive accumulation of lipids
major risk factors of arteriosclerosis
Major risk factors of arteriosclerosis:
  • Hypertension (MOST SIGNIFICANT)
  • Cigarette smoking (nicotine has DIRECT
  • vasoconstricting effect)
  • Elevated serum cholesterol (fat causes
  • obstructive plaques)
  • Obesity (increased work to heart)
  • Diabetes (hyperglycemia causes damage to vessel wall)
  • Other: increase age, inactivity, family hx
most common affected areas from arteriosclerosis
Most common affected areas from arteriosclerosis:
  • Heart: coronary arteries (angina, MI,
  • death)
  • Brain (transient ischemic attacks =TIAs
  • CVA, death)
  • Kidneys (renal arterial stenosis lead to
  • chronic renal failure)
  • Extremities (gangrene of digits &
  • intermittent claudication)
pathophysiology of atherosclerosis
Pathophysiology of atherosclerosis
  • -inflammatory process, begins as fatty streaks that are deposited in the intima of the arterial wall
  • Genetics and environment play a factor in the progression
  • Elastic arteries: aorta, carotid, lg & med. sized muscular arteries (popliteals) most

susceptible arteries.

  • Endothelial injury: may be initiated by smoking, hypertension, diabetes, hyperlipidemia, 

Inflammatory cells(including macrophages) become attracted to the wall

  • Macrophages infiltrate wall and ingest lipid which turns them into foam cells
  • They then release biochemical substances that cause further damage and attract platelets which then causes clots to form
ankle brachial index of blood pressure used to diagnose peripheral vascular disease
Ankle-brachial index of blood pressure:Used to diagnose peripheral vascular disease
  • -compares the blood pressure at ankle with that of the arm.
  • -normally these should be the same (with a ratio of 1)
  • -lesser number than 1 shows decreased blood pressure at the ankle compared to upper extremity = = which indicates peripheral vascular disease to lower extremities
  • Indications for fem-pop bypass:
  • diabetes
  • hypertension
  • vasculitis
  • collagen disease
  • Bueger’s disease
  • Also, Embolectomy (surgical removal)
medical management
    • Aspirin, ticlid, plavix, pletal, trental
  • Beta blockers
  • ARBs
  • Statins
  • Radiation therapy
  • Angioplasty with stents
nursing interventions
Nursing Interventions
  • Monitor BP for difference between arms
    • Could be indicative of aortic coarctation
      • Narrowing of aorta lumen
  • Monitor for carotid bruits
  • Assess cap refill, pulses,skin
acute arterial stenosis
Acute arterial stenosis
  • Monitor for the 5 P’s
  • pain, sudden
  • pallor
  • pulselessness
  • paresthesias
  • paralysis
acute peripheral arterial occlusion
Acute peripheral arterial occlusion
  • may result from rupture and thrombosis of an atherosclerotic plaque, an embolus from the heart or thoracic or abdominal aorta, an aortic dissection, or acute compartment syndrome
  • Symptoms and signs are sudden
buerger disease
Buerger Disease
  • Autoimmune disease
  • Recurrent inflammation of small arteries and veins of the extremities resulting in thrombus formation and occlusion.
  • Unknown cause
  • Men 20-35 years old
  • All races
  • Link to heavy smoking/chewing tobacco
  • s/s: rubor (reddish blue) color to foot, no Pedal pulse, discolored legs when dangled, eventually gangrene sets in
aneurysms of central arteries
Aneurysms of Central Arteries
  • Enlargement of artery to @ least 2X its normal
  • Aortic dissection
    • Medial & intimal layers separate
  • Risk Factors:
  • -hypertension
  • -cocaine use
  • - Marfan syndrome
thoracic aortic aneurysm
Thoracic Aortic Aneurysm
  • 85% are caused by atherosclerosis
  • More frequent in men b/w 40-70 years old
  • Most common site for dissection
  • 1/3 of pts with this die from rupture
  • Asymptomatic
  • Pain is primary symptom—constant
  • Dyspnea
  • Cough
  • Hoarseness
  • Stridor
  • Aphonia (weakness or complete loss of voice)
  • Unequal pupils
  • Chest x-ray
  • TEE
  • CT
signs symptoms of aortic dissection
Signs/symptoms of aortic dissection:
  • n/v, diaphoresis with pain
  • “tearing” pain
  • Sudden onset
  • not relieved with change of position
  • Dissection of ascending aorta: anterior CP with
  • radiation to neck, throat, jaw
  • Dissection of descending: interscapular back pain
  • radiation to lower back or abdomen
treatment of hypertension for aortic dissection
Treatment of hypertension for aortic dissection:
  • IV propranolol
  • Nitropresside drip after beta blocker ( nitropresside by itself causes tachycardia AND  left vent. contractility that is why a beta-blocker should be given first, then start nitropresside drip)
  • Diagnosis:
  • CXR (but 10% normal) see medialstinal
  • widening
  • Contrast CT
  • MRI

GOAL: to keep blood pressure to lowest

  • possible but yet allows tissue perfusion
    • Per physican recommendations
surgery for distal dissections
Surgery for distal dissections:
  • Mortality in 1st 48 hrs if unrepaired proximal aortic dissections is 40%
  • Usually distal dissections treated medically unless:
  • rapid expansion
  • saccular formation
  • persistent pain
  • hemodynamic compromised
  • blood leakage
  • impending rupture
abdominal aortic aneurysm aaa
Abdominal Aortic Aneurysm (AAA)
  • 75% of all aneurysms

Located between renal arteries & aortic bifurcation

Symptoms from pressure exerted in surrounding structures.

Many nonsymtomatic until ruptures

Look for pulsating abdominal mass

With rupture: hypovolemic shock & mortality

around 90%

nonsurgical management of aaa
Nonsurgical management of AAA
  • Monitor growth: freq. CT scans
  • Antihypertensives
  • graft
post op nursing interventions for graft
Post-op nursing interventions for graft:
  • Vitals
  • Pulses distal to graft
  • Report:
  • changes in pulse
  • cool extremities distal to graft
  • white/blue to extremities distal to graft
  • severe pain
  • abd. distention
  • decreased UO
post op nursing intervention continued post graft
Post-op nursing intervention (continued)Post graft
  • Elevation of head to 45° or less
  • Renal function lab
  • Respiratory status
  • Paralytic ileus (NG tube)
  • Assess for dysrhythmias post thoracic
venous diseases
Venous diseases:
  • Venous thrombosis (thrombophlebitis)
  • known as DVT
  • Varicose veins
  • Venous stasis ulcers
venous manifestations
Venous manifestations:
  • Pain:
  • - in feet/ leg muscles; aching/throbbing
  • - results from venous stasis & increases
  • as day progresses (esp with sitting
  • or standing)
  • Temperature changes:
  • - warm to touch since blood can enter
  • but cannot leave affected parts
venous manifestations1
Venous manifestations:
  • Skin color changes: reddened or
  • cyanotic
  • Edema: pooling of fluid results in edema
  • Venous stasis ulcers: skin breakdown
  • due to increased pressure from
  • chronic pooling of blood
  • Decreased mobility: may result from
  • the edema

DVT risk for pulmonary embolism

  • - legs
  • - seen post hip surgery, knee replacement

pregnancy, ulcerative colitis, hrt failure, immobility

  • Groin tenderness/pain
  • Unilateral sudden onset edema leg
  • Homan’s sign (appears in only 10% of pt
  • with DVT)
  • Ultrasonography
dvt interventions
DVT interventions:
  • Rest (do NOT massage area)
  • Low-molecular weight heparin
  • Coumadin
  • TPA
  • ****Contraindications to anticoagulant therapy
        • Pt compliance, bleeding, aneurysms, trauma, alcohol, recent surgery, liver or kidney disease, hazard jobs, pregnancy
nursing cares
Nursing cares
  • Monitor for hemorrhage
  • Monitor PT/PTT
    • Heparin is therapeutic b/w 60-92 on ptt
    • Coumadin is therapeutic b/w 2-3 on PT/INR
  • Monitor for Thrombocytopenia
    • Monitor Platelets
    • s/s; purpura, bruising, hematomas
  • Provide bedrest
  • Ted Hose or ace wraps for prevention of DVT
  • SCDs for prevention of DVT
  • Pain meds
  • - excessive tension exerted on arterial walls which places pts at increased risk for target organ damage
  • -asymptomatic until complications develop
  • - elevation may be systolic or diastolic or both
  • - normal <120 mmHg systolic
  • <80 mmHg diastolic
  • Often none
  • Occipital headache more severe on rising
  • Lightheadedness
  • Epistaxis
  • Known as the ‘Silent Killer’
factors that determine arterial pressure
Factors that determine arterial pressure
  • Cardiac output which is the volume of blood pumped by the heart in 1 minute
  • Peripheral vascular resistance which is the force in the peripheral blood vessels that the left ventricular must overcome to eject blood out of the heart
pathophysiologic processes for hypertension
Pathophysiologic processes for hypertension:
  • BP=CO X peripheral resistance
  • Elevated BP is direct result of increased
  • peripheral resistance, increased CO or
  • both
  • Renin-angiotensin-aldosterone system
  • Aldosterone: increased water/Na+ retention thus increasing ECF volume which leads to increased CO with subsequent increase BP
possible causes of pvr
Possible Causes of PVR
  • Narrowing of blood vessels, PVD, CAD, kidney disease: > renin/angiotensin =vasoconstriction
  • Release of catecholamine (epinephrine and adrenalin) = vasoconstriction
  • > blood volume= more work to pump
  • > Blood viscosity=harder to pump
  • Ability of blood vessel to stretch

95% of cases of hypertension are 1st degree (essential)

  • 2nd degree hypertension: CHAPS
  • Cushing’s syndome
  • Hyperaldosteronism
  • Aortic coarctation
  • Pheochromocytoma
  • Stenosis of renal arteries
  • Damage to blood vessels of the eyes, heart, kidney, brain resulting in:
  • Stroke
  • CHF
  • AMI
  • Renal failure
  • Blindness
target organ disease from hypertension
Target Organ Disease from hypertension
  • Large vessels: aneurysmal dilation
  • accelerated atherosclerosis
  • aortic dissection
  • Cardiac:
  • acute= pulm edema, MI
  • chronic= LVH
  • Cerebrovascular:
  • acute= Intracranial bleed, coma, seizure
  • mental status changes, TIA, stroke
  • chronic=TIA, stroke
target organ disease from hypertension1
Target organ disease from hypertension:
  • Renal: acute=hematuria, azotemia
  • chronic=elevated creatinine
  • proteinuria
  • Retinopathy:
  • acute=papilledema, hemorrhages
  • chronic=hemorrhages,exudates,
treatment of hypertension
Treatment of hypertension:
  • Lifestyle modification


ACE inhibitors; ARB


Calcium channel blockers


htn crisis
  • Sometimes rare sometimes fatal
  • Diastolic BP 120-130
    • Causes vascular damage
  • Can be caused by renal failure, HTN, Med withdrawal
hypertensive crisis treatment
Hypertensive Crisis:Treatment
  • Parenteral agents for immediate redux of BP
  • In ICU for monitoring
  • Arterial line
  • Drug of choice: sodium nitroprusside
  • =direct acting arterial & venous vasodilator
  • = reduces BP rapidly but lower mean arterial pressure no more than 25% over 1st 2 hours
  • = easily titratable
  • = monitor closely for hypotension
  • = shield this drip from light
stroke occlusion of cerebral vasculature
STROKE: occlusion of cerebral vasculature
  • DUE TO:
  • 1. emboli that lodges in cerebral vasculature
  • (from a-fib, vegetations on an infect valve)
  • 2. atherosclerotic plaque (occludes carotid arteries)
  • 3. venous occlusion (secondary to thrombosis)
  • 4. arterial dissection (in carotid or vertebrobasilar system)
  • 5. severe hypotension ( infarct in cerebral areas)
  • 6. hemorrhage :occurs during activity
  • Sudden loss of function resulting from disrupted blood supply to area in brain
  • 5 types:
    • Large artery
      • Caused by atherosclerosis
    • Small penetrating artery
      • Most common
      • Also called lacunar strokes because it creates a cavity
    • Cardiogenic emboli
      • Usually from afib
    • Cryptogenic
      • No known cause
    • Other
      • Caused from Drug use, migraines,spontaneous
hemorrhagic stroke
Hemorrhagic stroke
  • Bleeding into brain tissue or ventricles, subdural, or subarachnoid spaces due to ruptured aneurysm or from severe hypertension
  • VASOSPASM (after a bleed)
    • 4-14 days post hemorrhage
    • Management is difficult
  • Severe headache
  • LOC
  • Tinnitus
  • Dizziness
  • Hemiparesis

Prognosis: variable

  • CT
  • Lumbar puncture
  • Angiography
  • Manage HTN
  • Avoid alcohol
  • Increase public awareness
assessment tools
Assessment Tools
  • Neurological assessment upon admission or change in client status, including:
    • Level of consciousness
    • Orientation
    • Motor ability
    • Pupils
    • Speech/language
    • Vital signs
    • Blood glucose

Risk assessment for complications including fall, pressure ulcer, painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis


Pain assessment

  • Administration and interpretation of dysphagia screen
  • Nutrition and hydration screening
  • Screening for alterations in cognition, perception, and language using validated tools
  • Assessment of activities of daily living (ADL) using validated tools
  • Assessment of bowel and bladder function
  • Depression screening using a validated tool

Assessment/screening of caregiver burden using a validated tool

  • Screening of stroke clients and their partners for sexual concerns
  • Assessment of stroke client and their caregivers' learning needs, abilities, learning preferences and readiness to learn
  • Referral for further assessment and management, as indicated
  • Documentation of all assessments and screenings
treatment for stroke note similar to measures for myocardial ischemia mi
Treatment for stroke:(Note similar to measures for myocardial ischemia/MI)
  • Thrombolysis (who is not a candidate?)
  • Lower BP
  • Quit smoking
  • Decrease cholesterol
  • Antiplatelet (ASA)
stroke treatment continued
Stroke treatment (continued)
  • ASA
  • Heparin (SQ or IV contin infusion)
  • Low-molecular wt heparin (lovenox)
  • Warfarin (coumadin)


Obtain PT, PTT prior to therapy

PT: monitor oral anticoag : goal=1.5 to 2 times pt baseline

PTT: monitor heparin: goal=1.5 to 2 times pt baseline

INR: monitor Warfarin: goal=2 to 3

more stroke treatment
More stroke treatment:
  • Carotid artery angioplasty
  • Arteriovenous Malformation (gamma radiation through Gamma knife)
  • Aneurysms (coils)
  • Craniotomy for clot removal
nursing assessment with anticoagulant therapy
Nursing assessment with anticoagulant therapy:
  • Observe for bleeding
  • Also, antiplatelet meds (Plavix, Persantine) cause
  • bruising, hemorrhage, liver disease (need liver function tests)
  • GIVE clopidogrel (Plavix) with food
nursing diagnosis
Nursing Diagnosis
  • Impaired physical mobility:
  • -flaccid, spasticity
  • Disturbed sensory perception:
  • -vision, proprioception, sensation
  • Unilateral neglect:
  • - use both sides of body (dress affected side first)
  • Impaired verbal communication::
  • -expressive, receptive, both
  • Impaired swallowing:
    • must be evaluated, must prevent aspiration !!! But yet meet caloric needs
  • Urinary and/or bowel incontinence
  • Rebleed
  • Vasospasm
  • Hydrocephalus
  • Hypoxia of brain
nursing interventions1
Nursing interventions
  • Administer oxygen
  • Provide adequate hydration
  • Evaluate swallow function
  • Frequent neuro checks
  • Strict I/O
  • Seizure precautions
  • Monitor ICP
  • Monitor BP closely
  • Teach stress reduction techniques
  • Manage agitation
surgery and complications
Surgery and complications
  • Evacuation of blood via craniotomy
  • Goal of surgery is to prevent further rupture/bleed
  • Post op complications
    • Disoriented
    • Amnesia
    • Korsaff’s syndrome (psychosis caused by lack of thiamine)
    • Personality changes
    • Intraop emboli
    • Electrolyte disturbances
    • GI bleed