Nursing Care & Interventions for Clients with Vascular Problems

1. Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN

2. Today’s Objectives… Review the pathophysiology of arteriosclerosis, including the factors that cause arterial injury Discuss drug therapy for hypertension Evaluate the effectiveness of interdisciplinary interventions to improve hypertension Prioritize nursing care for the patient experiencing vascular disorders Develop a continuing care plan for a client who has hypertension Prioritize postoperative care for clients who have undergone peripheral bypass surgery.

3. Serum Lipids:Cholesterol • One of the several types of fats (lipids) • Important component of cell membranes, and bile acids • Building blocks in certain types of hormones • Predominant substance in atherosclerotic plaques • Circulates in the blood in combination with triglycerides, encapsulated by special fat-carrying proteins called lipoproteins • <200 is desirable for total cholesterol

4. Lipoproteins LDL = Low Density Lipoproteins - “bad cholesterol” • <130 is desirable HDL = High Density Lipoproteins - “good cholesterol” • >30 is desirable- the higher the HDL, the lower the risk of CAD Triglycerides- combination of glycerol with 3 fatty acids • Transportable fuel- energy source • Strongly influenced by diet

5. Cholesterol Levels • LDL Cholesterol • <100 Optimal • 100-129 Near optimal/above optimal • 130-159 Borderline High • 160-189 High • >190 Very high • Total Cholesterol • <200 Desirable • 200-239 Borderline High • >240 High • HDL Cholesterol • <40 Low • >60 High

6. Hypertension • “Vascular Disease” • Affects 1 in every 4 adults in the US • Major risk factor for cardiovascular disease (CVD) • Stroke, MI, Heart Failure • Other Target Organ Damage • LV hypertrophy • Nephropathy • Vascular Disorders • PVD • Retinopathy

7. Categories Primary (Essential)- without identified cause • 90-95% of all hypertension • Pathophysiology: (exact cause unknown) • Heredity • H2O & Na+ retention • Altered renin-angiotensin mechanism • Stress and increase sympathetic nervous system activity • Insulin resistance and hyperinsulinemia • Endothelial cell dysfunction Secondary- results from identifiable cause • renal disease, endocrine disorders, neuro disorders, meds, PIH

8. Stages of Hypertension Category SBP(mmHg) DBP(mmHg) • Normal <120 <80 • Prehypertension 120-139 80-89 • Hypertension, Stage 1: 140-159 90-99 • Hypertension, Stage 2: 160-179 100-109 • Hypertension, Stage 3: >180 >110

9. Clinical Manifestations Early • Elevated BP • Asymptomatic (silent killer) Later • Symptoms secondary to effects on blood vessels in various organs or tissues • Fatigue, reduced activity tolerance, dizziness, palpitations, angina, dyspnea

10. Age Alcohol use Cigarette smoking DM Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress Risk Factors for Primary Hypertension

11. Knowledge Deficit • Encourage healthy lifestyles • Lifestyle modifications for all patients with prehypertension and hypertension • Components of lifestyle modifications include: • weight reduction, • DASH eating plan • dietary sodium reduction • aerobic physical • activity • moderation of alcohol consumption • Stress reduction

12. Risk for Ineffective Therapeutic Regimen Management • Interventions: • Teach medication compliance, usually for the rest of life. • goals of therapy • potential side effects • Assist client to understand therapeutic regimen. • Discuss consequence of noncompliance • Most African American clients will need at least 2 medications to achieve blood pressure control • ACE inhibitor and calcium channel blocker .

13. Diuretics • Loop • Bumetanide (Bumex) • Furosemide (Lasix) • Thiazide-Type • Chlorothiazide • Hydrochlorothiazide (HCTZ) • Potassium-Sparing • Spironolactone (aldactone)

14. Pharmacologic: Diuretics • Mechanism of Action: • Thiazides, Loop, Potassium Sparing • S/E: • fluid and electrolyte imbalances • K+, Mg++ • CNS effects • GI effects • Nursing Considerations: • Monitor for orthostatic hypotension • dehydration • Hypokalemia

15. Adrenergic Inhibitors:Beta Blockers • Cardioselective (β1) • Atenolol (Tenormin) • Metoprolol (Lopressor) • Non-cardioselective (β1, β2) • Propranolol (Inderal) • Mechanism of Action • Blocks beta actions causing: • decreased heart rate • decreased BP • decreased contractility

16. Adrenergic Inhibitors:Beta Blockers • S/E: • Orthostatic hypotension • Bradycardia • Hypotension • Fatigue • Weakness • Nursing considerations • Use in caution with heart failure • Diabetes who take BB may not have sx of hypoglycemia monitor pulse regularly

17. ACE Inhibitors • Drug Interactions: • NSAIDS (decrease BP control) • Diuretics (excessive hypotensive effect) • Potassium supplements, potassium-sparing diuretics (increased risk of hyperkalemia) • Lithium (increased lithium serum levels) • Precautions: • “First dose effect “– severe hypotension. Remain in bed for 3 to 4 to prevent falls. • Obtain BP before giving - hold if hypotensive • Change positions slowly due to orthostatic hypotension • Monitor liver and kidney function

18. Angiotensin Receptor Antagonists (Blockers) Losartan (Cozaar) • Mechanism: • Inhibit binding of angiotensin II receptors in blood vessels and other tissues • vascular smooth muscle relaxation • increased salt and water excretion • reduced plasma volume • Side Effects: • Hypotension • Dizziness • Cough, • Heart failure • Angioedema • Drug Interactions: • Potassium-sparing diuretics ( serum K+)

19. Calcium Channel Blockers Amlodipine (Norvasc) Diltiazem (Cardizem) Nifedipine (Procardia) • Mechanism of Action • Blocks slow channels of Calcium • Decreases contractility • Vasodilation • AV node slows

20. Calcium Channel Blockers • S/E: • Hypotension • Bradycardia • AV block • Nausea • H/A • Peripheral edema • Monitor I&O closely • Nursing considerations: • Always obtain BP-HR before giving • use with caution in patients with heart failure • Orthostatic changes • Change position slowly • contraindicated in patients with 2nd or 3rd degree heart block • Concurrent use w/b-blockers incr risk of CHF

21. HTN Case Study • 45yr African American male • Complaint: new onset severe global HA • VS: P-88 R-20 BP-210/142 sats 96% RA • Slightly confused to place, time • PMH: HTN x10 yrs-unable to afford meds, not taking the last week • Labs: K+ 4.2, Na+ 138, creat 2.5, trop neg, 12 lead EKG no acute changes • Nursing/medical priorities…

22. HTN Case Study • MD orders: • Metoprolol 5mg IV push q5” x3 for SBP 160-180 • 5mg/5cc….administer over 2”…how much every 15-30 seconds??? • Nursing priorities/considerations… • Admit to ICU • VS before transfer: P-68 R-20 BP-192/118

23. In ICU… • Started on Nipride gtt • Started at 0.5mcg • BP 180/90….in 2 hours • Next am 140/90 • Started on po: • Lisinopril • Diltiazem • Metoprolol Concerns to address upon DC???

24. Peripheral Arterial Disease • Altered flow of blood through arteries/veins of peripheral circulation • Manifestation of systemic atherosclerosis • a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

25. Physical Assessment • Intermittent claudication • Pain that occurs even while at rest; numbness and burning • Inflow disease affecting the lower back, buttocks, or thighs • Distal aorta • Outflow disease causing cramping in calves, ankles, and feet • Superficial femoral artery (knee and down) • Hair loss and dry, scaly, mottled skin and thickened toenails • Ulcers • arterial ulcers • diabetic ulcers • venous stasis ulcers .

26. Nonsurgical Management • Exercise • Positioning • avoid extreme raising legs above heart, do elevate for edema • Promoting vasodilation • warmth and avoid cold temp, stop smoking • Drug therapy • clopidogrel (Plavix), Pentoxifylline (Trental), ASA • Percutaneous transluminal angioplasty • Atherectomy .

27. Surgical Management • Preoperative care • Documentation of distal pulses • Postoperative care • Assessment for graft occlusion • Promotion of graft patency • Treatment of graft occlusion • Monitoring for compartment syndrome • Assessment for infection .

28. Acute Peripheral Arterial Occlusion • Embolus • most common cause of occlusions, although local thrombus may be the cause • Assessment • pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (coolness) • Surgical therapy • arteriotomy • Nursing care • CMS • Pain assessment • Spasms/swelling • Compartment syndrome .

29. Anticoagulation Therapy:Heparin • Inhibits (does not dissolve) thrombus and clot formation • Given IV/SQ • Never given IM D/T risk of hematoma • Does not cross placental barrier • Antidote • Protamine sulfate: Fast acting, short ½ life • Note: If sx’s of bleeding stop infusion, be prepared to give antidote

30. Patho Middle layer weakened Stretching of intima Fusiform aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissections) Thoracic aortic aneurysms Abdominal aortic aneurysms Aneurysms of Central Arteries .

31. Thoracic & Abdominal Aortic Aneurysm • Thoracic • Back pain • shortness of breath hoarseness, and difficulty swallowing • Sudden excruciating back or chest pain is symptomatic of thoracic rupture • Abdominal • Pain steady with a gnawing quality • unaffected by movement-may last for hours or days • abdomen, flank, or back. • Abdominal mass is pulsatile • Rupture is the most frequent complication and is life threatening.

32. Patho Pain Emergency care goals include: Elimination of pain Reduction of blood pressure Immediate OR Surgical treatment Aortic Dissection

33. Preoperative care Assess peripheral pulses Operative procedure Postoperative care Monitor vital signs Assess for complications Paralytic ileus Assess for graft occlusion or rupture Change in CMS Severe pain Decreased u/o Abdominal Aortic Aneurysm Repair .

34. Thoracic Aortic Aneurysm Repair • Preoperative care • Operative procedure • Postoperative care assessments: • Vital signs • CMS changes • Complications • Respiratory distress • Cardiac dysrhythmias • Hemorrhage • Paraplegia .

35. Raynaud’s Phenomenon • Patho • Sx • Blanching >cyanosis • Pain • Aggravated by cold/stress • Treatment • Procardia • Side effects • Education • Cold exposure • Stop smoking • Stress reduction .

36. Thrombus Virchows Triad Venous blood stasis Endothelial injury hypercoagubility Thrombophlebitis Thrombus w/inflammation Deep vein thrombosis (DVT) Pulmonary embolism Phlebitis Inflammation of superficial veins Assessment: Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Localized edema Venous flow studies-US Lab:D-Dimer Venous Thromboembolism .

37. Nonsurgical Management • Treatment Priorities • Prevent complications • Rest • Drug therapy includes: • Heparin IV therapy • Low–molecular weight heparin-Subq • Lovenox q 12 hours • Warfarin therapy • Thrombolytic therapy • TPA

38. Venous Insufficiency • Patho • Sx • Edema • TEDS • Stasis dermatitis • Stasis ulcers • Occlusive dressings .