Chapter 36

1. Chapter 36 Vascular Disorders

2. Learning Objectives • Identify specific anatomic and physiologic factors that affect the vascular system and tissue oxygenation. • Indicate appropriate parameters for assessing a patient with peripheral vascular disease, aneurysm, and aortic dissection. • Discuss tests and procedures used to diagnose selected vascular disorders and the nursing considerations for each. • Describe the pathophysiology, signs and symptoms, complications, and medical or surgical treatments for selected vascular disorders. • Assist in developing a plan of care for patients with selected vascular disorders.

3. Anatomy and Physiology of the Vascular System

4. Arteries Vessels that carry blood away from the heart toward the tissues Thick-walled structures with three layers: intima, media, and adventitia Smooth muscles encircle and control the diameter

5. Capillaries Arterioles branch into progressively smaller vessels, then form the capillaries A single layer of endothelial cells that allow the efficient delivery of nutrients and oxygen into the tissues and the removal of metabolic wastes from the tissues Tiny vessels that receive blood from the capillaries are venules, the smallest veins

6. Figure 36-1

7. Figure 36-2

8. Veins The vessels that return blood to the heart Formed as capillaries organize into larger and larger vessels Composed of the same layers as the arteries and arterioles, but the layers are less defined

9. Veins Valves Allow blood to move in only one direction and prevent backflow of blood in the extremities Innervation The sympathetic nervous system acts on the musculature of the veins to stimulate venoconstriction Blocking of sympathetic nerve stimulation permits venodilation

10. Figure 36-3

11. Lymph Vessels Lymph system: small, thin-walled vessels that resemble the capillaries Accommodate the collection of lymph fluid from the peripheral tissues and the transportation of the fluid to the venous circulatory system Lymph fluid is composed of plasma-like fluid, large protein molecules, and foreign substances Movement by the contraction of muscles that encircle the lymphatic walls and surrounding tissues

12. Factors That Affect Blood Flow Resistance Controlled by the diameter of the vessels When vascular diameter increases, peripheral resistance falls and blood flow increases When vascular diameter decreases, peripheral resistance increases, thereby reducing blood flow

13. Factors That Affect Blood Flow Blood viscosity Thickness of the blood Can be affected by changes in the proportions of the solid or liquid components Capillary permeability affects blood viscosity If capillary permeability altered, the amount and direction of fluid movement changes; results in change in viscosity

14. Age-Related Changes Arteriosclerosis Stiffening of the vessel walls Delivery of oxygen and nutrients to tissues is compromised; buildup of waste products in tissue Decrease of hemoglobin Produces a decline in the oxygen-carrying capacity of the blood Slowing heart rate and decrease in stroke volume

15. Chief Complaint and History of Present Illness Focuses on the six classical “Ps” of peripheral vascular disease: pain, pulselessness, poikilothermy, pallor, paresthesia, and paralysis

16. Past Medical History Document a history of hypertension, coronary artery disease, myocardial infarction, or atherosclerosis

17. Family History Relevant diseases: hypertension, coronary artery disease, myocardial infarction, atherosclerosis, aneurysm, and diabetes

18. Assessment of the Vascular System Review of systems Changes associated with PVD: thick, brittle nails; shiny, taut, scaly, dry skin; skin temperature variations; skin ulcerations; muscle atrophy; localized redness and hardness; and hair loss on the extremities Assess for chest pain and dyspnea Assess for symptoms of aneurysms: hoarseness, dysphagia, dyspnea, abdominal or back pain, or swelling of the head and arms

19. Assessment of the Vascular System Functional assessment Determines the effect of the disease on the patient’s life

20. Assessment of the Vascular System Physical examination Inspect the skin for color and lesions Capillary refill time in the nail beds Palpate affected areas to evaluate temperature, detect edema, and assess peripheral pulses Homans’ sign Allen test

21. Figure 36-4

22. Diagnostic Tests and Procedures Ultrasonography Pressure measurements Plethysmography Segmental plethysmography Exercise (treadmill) test Angiography Tomographic angiography Magnetic resonance angiography Arteriography Venography

23. Therapeutic Measures Exercise programs Stress management Pain management Smoking cessation Elastic stockings Intermittent pneumatic compression Positioning Thermotherapy Protection Patient teaching

24. Figure 36-5

25. Figure 36-6

26. Therapeutic Measures Surgical procedures Embolectomy Percutaneous transluminal angioplasty Endarterectomy Sympathectomy Vein ligation and stripping Sclerotherapy

27. Nursing Care Related to Surgery Preoperative nursing care Patient with severe cardiovascular disease may have activity restrictions to reduce demands on circulatory system until the surgical procedure is done Affected extremity should be maintained in a level or slightly dependent position as ordered Optimize peripheral circulation: keep extremity warm Protect the limb from further injury

28. Nursing Care Related to Surgery Postoperative nursing care Primary goal of the postoperative period is to stimulate circulation by encouraging movement and preventing stasis within the extremity

29. Nursing Care Related to Surgery Drugs Anticoagulants Thrombolytics Platelet aggregation inhibitors Vasodilators Nonsteroidal anti-inflammatory drugs Analgesics

30. Nursing Care Related to Surgery Dietary interventions Low-fat diets reduce serum cholesterol levels Weight-reduction diet if the patient is obese Adequate vitamin B, vitamin C, and protein needed to promote healing and improve tissue integrity

31. Disorders of the Peripheral Vascular System

32. Arterial Embolism Pathophysiology Usually forms in the heart, but a roughened atheromatous plaque in any artery also can lead to thrombus formation If a thrombus breaks loose, it becomes an embolus and travels through the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion

33. Arterial Embolism Signs and symptoms Severe, acute pain Gradual loss of sensory and motor function in the affected areas Pain aggravated by movement or pressure Absent distal pulses Pallor and mottling (irregular discoloration) Sharp line of color and temperature demarcation: tissue beyond the obstruction is pale and cool

34. Arterial Embolism Medical and surgical treatment Intravenous anticoagulants and thrombolytic agents Embolectomy

35. Interventions Ineffective Tissue Perfusion Fear Impaired Physical Mobility Impaired Skin Integrity Ineffective Therapeutic Regimen Management

36. Peripheral Arterial Occlusive Disease Atherosclerosis obliterans, arterial insufficiency, and peripheral vascular disease Pathologic changes in the arteries, typically plaque formations that arise where the arteries branch, veer, arch, or narrow Common sites for arterial occlusion are the distal superficial femoral and the popliteal arteries Occlusions prevent delivery of oxygen and nutrients to the tissues Hypoxia affects all tissues distal to the occlusion

37. Figure 36-7

38. Peripheral Arterial Occlusive Disease Signs and symptoms Intermittent claudication Absence of peripheral pulses below occlusive area Rest pain Tingling or numbness or both in the toes Extremity is cold, numb, and pale Shiny, scaly skin; subcutaneous tissue loss; hairlessness on the affected extremity; and ulcers with a pale gray or yellowish hue, especially at ankles

39. Peripheral Arterial Occlusive Disease Medical diagnosis Duplex imaging Angiography

40. Peripheral Arterial Occlusive Disease Medical and surgical treatment Lifestyle changes Smoking cessation, exercise, weight management Treatment for hypertension, hyperlipidemia, or diabetes Drugs for claudication: cilostazol and pentoxifylline Surgical interventions Percutaneous transluminal angioplasty, atherectomy, and endarterectomy

41. Peripheral Arterial Occlusive Disease Assessment Assess the pulses distal to the surgical site and compare with the same pulses in the unaffected extremity Assess vital signs, color, and temperature of affected extremity, fluid intake and output, central venous pressure, and mental status

42. Peripheral Arterial Occlusive Disease Interventions Activity Intolerance Chronic Pain Impaired Skin Integrity Pain Disturbed Body Image Ineffective Tissue Perfusion Risk for Infection Decreased Cardiac Output Ineffective Tissue Perfusion Ineffective Therapeutic Regimen Management Impaired Physical Mobility

43. Thromboangiitis Obliterans Also called Buerger’s disease Inflammatory thrombotic disorder of arteries and veins in lower and upper extremities Cause is unknown, but it occurs only in smokers Signs and symptoms: intermittent claudication, rest pain, skin color/temperature changes in affected areas, cold sensitivity, abnormal sensation, ulceration, gangrene Diagnosis based on physical findings and arteriography Most important treatment is smoking cessation Palliative treatments include sympathectomy and drugs, such as calcium channel blockers, antibiotics, and anticoagulants

44. Raynaud’s Disease Pathophysiology Intermittent constriction of arterioles; affects hands primarily, but it can affect the toes and tip of the nose Signs and symptoms Chronically cold hands, numbness, tingling, and pallor During an arterial spasm, the skin color changes from pallor to cyanosis to redness Medical diagnosis Based on the signs and symptoms and on the absence of evidence of occlusive vascular disease

45. Raynaud’s Disease Medical and surgical treatment Drugs Calcium channel blockers, transdermal nitroglycerin, an endothelin receptor antagonist, phosphodiesterase inhibitors, and intravenous prostaglandins Sympathectomy

46. Interventions Pain and Ineffective Tissue Perfusion Fear

47. Aneurysms Pathophysiology A dilated segment of an artery caused by weakness and stretching of the arterial wall; can be congenital or acquired

48. Aneurysms Signs and symptoms Thoracic aneurysms usually have no symptoms, though some report deep, diffuse chest pain If aneurysm puts pressure on the recurrent laryngeal nerve, patient may complain of hoarseness Pressure on the esophagus may cause dysphagia If superior vena cava compressed, edema of the head and arms Signs of airway obstruction may be present if the aneurysm presses against pulmonary structures Abdominal aneurysms may be palpated as a pulsating mass in the area slightly left of the umbilicus

49. Aneurysms Complications Rupture, thrombus formation that obstructs blood flow, emboli, pressure on surrounding structures Medical diagnosis Physical findings, echocardiography, ultrasonography, computed tomography, aortography Medical and surgical treatment Repair of aneurysms done by replacing the dilated segment of the artery with synthetic graft or, in some cases, by suturing or patching the defective area

50. Aneurysms Preoperative nursing care It is important to document chronic conditions, such as emphysema or heart disease, that increase the risk of postoperative complications