Disorders In Tissue Perfusion

1. Disorders In Tissue Perfusion Disorders Of The Peripheral Vascular System Liz Mathewson

2. Summary • normal A&P of peripheral vasc. system • risk factors and causes • prevention and health teaching • assessments • nsg. diagnosis • medical/surgical/pharmatherapeutic • nursing measures

3. Categories of Disorders • Obstruction: thrombus, embolus, lymphedema • Inflammation: phlebitis, thrombophlebitis • Degeneration: arteriosclerosis, atherosclerosis, aneurysm, varicose veins, stasis ulcer • Unknown causes: Buerger’s disease, Raynauds Disease

4. Pharmacology Classifications: • anticoagulants (and their reversal agents) • antilipidemics (antihyperlipidemic) • platelet inhibitors • thrombolytics • peripheral vasodilators

5. Obstructive Disease • Can affect both venous and arterial circulation as well as lymph system

8. To the Brain To the stomach To the liver To the Kidneys Iliac Artery Femoral Artery

11. Arterial Obstructive Disease • (degenerative condition leading to obstructive condition) • Arteriosclerosis: “hardening of the arteries” • muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened

12. Obstructive Arterial Disease Atherosclerosis: affects the intima of the large and medium-sized arteries • caused by an accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intima layer = plaque Direct effects: Indirect effects:

13. Atherosclerosis • Risk factors: • diet - age • high blood pressure - gender • diabetes - family hx • stress • sedentary lifestyle • smoking

14. Assessment • Health history and clinical manifestations • Pain (where) • Skin appearance and temperature • Rubor • cyanosis • brittle nails, • dry scaling skin, atrophy, decrease hair growth, ulceration

15. Signs and Symptoms • Occur when vessel is 60% occluded • Early include pain, changed appearance, or changed sensation • Pain or “intermittent claudication” • Pain on exertion or pain at rest? • Chronic = collateral circulation

16. Assessment • Pulses • present or absent, volume, quality, symmetry “pedal pulses present bilaterally” • Posterior tibial; dorsalis pedis; popliteal;

18. Assessment • Mental status • Edema (Pitting or non-pitting) • Risk factors: • controllable (modifiable) • not controllable (non-modifiable)

19. Arterial Assessment Tools • Doppler U/S flow Studies • Ankle blood pressures • Exersize tests • CT • CT Angiography • MRI • Angiography

21. Progression of Disease • Decreased oxygen leads to ischemia • Ischemia leads to infarction • Infarction leads to necrosis • Ischemia Infarction Necrosis

22. Arterial ulcers Ischemia Infarction Necrosis

23. Venous Ulcers (characteristics)

24. Nsg. Diagnosis • Alteration in peripheral tissue perfusion related to compromised circulation • Pain related to impaired ability of peripheral vessels to supply tissues with oxygen • Risk for impaired skin integrity related to compromised circulation • Knowledge deficit regarding self-care activities

25. Nursing Diagnosis • Alteration in peripheral tissue perfusion related to compromised circulation • Goal: Increase arterial blood supply to extremities

26. Medical Management • Medical: modification of risk factors; a controlled exercise program to increase circulation; and medication

27. Surgical Management • Surgical: Inflow procedures and outflow procedures • Bypass (artificial graft/insitu graft) • Endarterectomy

28. Grafts

29. Endarterectomy

31. Post-op Care • Maintaining circulation – how? • Assessment: pulses, colour, temperature, capillary refill, sensory and motor functions • use doppler (at PRCH, use doppler on Dr.Thompson pts.) • Complications: decreased urinary output, CVP, mental status, pulse rate and volume = fluid imbalance

32. Post-op Care • Bleeding, hematoma • Edema • Infection • Discharge planning

33. Upper extremity Obstruction • Arm fatigue and pain with exercise and inability to hold or grasp objects. • Avoid venopuncture, injury, using tape, taking BP, protect from cold. Assess frequently • May need bypass

34. Arterial Embolism • Usually originate in the chamber of the heart as a result of atrial fibrillation, or CHF, infective endocarditis or MI. • Carried to left side of heart and into arterial system • May be caused by catheters, stents, intra-aortic balloon pump. • Trauma, crush injury, penetrating wound

35. Signs and Symptoms • 6 “P”s • pain • pallor • pulselessness • paresthesia • paralysis • poikothermia X

36. Treatment • FAST to prevent tissue infarction • heparin • surgery (embolectomy) • ? Thrombolytic therapy if no contraindications

37. Venous Obstruction • Venous Thrombosis • Deep Vein Thrombosis • Thrombophlebitis • Phlebothrombosis • * not identical disease processes but for clinical purposes used interchangeably

38. Pathophysiology Stasis of Blood Virchow’s Triad Altered Blood Coagulation Vessel Wall Injury

39. Venous Stasis • Reduced Blood Flow due to : • heart failure or shock • dilated veins due to medications • decreased skeletal muscle contractions due to paralysis, anesthesia, and bed rest

40. Vessel Wall Injury • Damage to the Intima Due to: • direct trauma (fractures, dislocations) • diseases of the veins, (infection/inflammation) • chemical irritation (IV meds and solutions

41. Increased blood coaguability • Due to: • abrupt withdrawal of anticoagulants • oral contraceptives • blood dyscrasias (abnormalities)

42. Clinical Manifestations Often Non-Specific: • inflammation or redness along a superficial vein • limb pain, feeling of heaviness • functional impairment • ankle engorgement, edema • unilateral increase in leg circumference • increased warmth to touch of leg/foot • tenderness to touch, rosy colour

43. Thrombus to Embolus • Platelets attach to vein wall with a tail-like appendage containing fibrin, RBC, WBC • grows in direction of blood flow • elevation in venous pressure (sudden movement, increased muscle movement) cause fragment to break off and travel

44. Deep Vein Thrombosis • Sign and symptoms are non specific, sometimes PE is the first sign • deep veins have thinner walls and less muscle mass in the media than superficial veins • run parallel to arteries and have the names • have valves as do the superficial veins

45. Deep Vein Obstruction • Creates swelling and edema in extremity because the outflow of venous blood is inhibited • limb may be warm and superficial veins appear more prominent • tenderness • Howman’s sign

46. Superficial thrombosis • Pain or tenderness, redness and warmth in involved area • embolus rare as these thrombi usually dissolve spontaneously • treated with bed rest at home, elevation of leg, analgesics, and sometimes anti inflammatory

47. Medical Management for DVT • Medication • Surgery: only if anticoagulant or thrombolytic therapy is contraindicated, the danger of PE is extreme, and the venous drainage is so severely compromised that permanent damage to the extremity will result.

48. Nursing Interventions • Assessing and monitoring meds • observing for complications • providing comfort • applying elastic stockings • positioning pt and encouraging exercise

49. Venous Ulcers (characteristics)