Nursing of Adults with Medical & Surgical Conditions

1. Nursing of AdultswithMedical & Surgical Conditions Disorders of the Peripheral Vascular System

2. Risk Factors • Similar to risk factors for heart disorders • Age • Gender • Smoking • Hypertension • Hyperlipidemia • Obesity • Lack of exercise • Emotional stress • Diabetes Mellitus • Family History

3. Assessment of Vascular Disorders • Arterial Assessment • First symptom is usually pain • Occurs due to arterial insufficiency and ischemia • Dull ache in calf muscles • Leg fatigue and cramping • Intermittent claudication • Pain brought on by exercise • Later symptoms of pain • Pain at rest • Burning, tingling, and numbness at night even lying down • Pulses • May be weak, thready, or absent • Scale for documentation • 0 – absent • +1 – barely palpable, intermittent • +2 – weak , possibly thready, but constantly palpable • +3 – normal strength and quality • +4 – bounding, easily palpable, may be visible

4. Assessment and Documentation • PATCHES • P for Pulses • Absence of pulses in generally a medical emergency • Compare with previous findings • Look for other symptoms – may just be hard to feel • Use Doppler device if necessary • A for Appearance • Pale, mottled, cyanotic or discolored (red, black, brown) • Necrosis or bleeding (ulcers) • Size, depth, and location • Edges jagged or smooth • Painful to touch • Shiny or dull • Shiny may indicate edema • Dull may indicate inadequate arterial blood supply • Superficial veins, erythema, or inflammation • Varicosities • Have patient to stand

5. T for Temperature • Cool • Possible arterial problem • Warm • Possible venous problem • Temperature changes may be caused by other problems as well • C for Capillary refill • Less than 2 seconds • H for Hardness • Supple or hard and inelastic • Hardness may indicate chronic problems • E for Edema • Pitting edema • Usually acute problem • Assessment: Press on skin for 5 seconds and release (Page 317 --Figure 8-17 and Table 8-3) • Non-pittting • May be chronic condition • Assessment: Measure circumference of the extremity

6. S for Sensation • Patient states extremity FEELS: • Numbness • Tingling • Hot • Cold

7. Venous Assessment • First symptom is usually edema • Dark pigmentation • Dryness and scaling • Ulcerations • Pain, aching, and cramping • Usually relieved by rest or elevation Comparison of Arterial and Venous Disorders Page 331 – Table 8-5

8. Diagnostic Tests • Noninvasive Procedures • Treadmill Test • Exercise to determine blood flow to extremities • Plethysmography • Assesses blood volume in the veins • Digital Subtraction Angiography (DSA) • IV contrast is administered • Blood vessels are visualized by radiography using an image intensifier video system and monitor • Doppler Ultrasound • Measures blood flow in arteries or veins

9. Diagnostic Tests • Invasive Procedures • Phlebography or venography • Radiographic visualization of veins • IV contrast is administered in a foot vein • X-rays are taken to detect filling defects • Assesses for condition of deep veins and to diagnose deep vein thrombosis • 125 I-fibrinogen Uptake Test • Assesses for acute calf vein thrombosis • Fibrinogen is tagged with iodine 125 and given IV - it can then be detected in the blood stream by a gamma ray detector • Angiography • IV contrast is administered • X-ray to visualize arteries

10. D-dimer Serum Test • D-dimer forms when fibrin is broken down • When a thrombus is present D-dimer levels are elevated – usually greater than 1591 ng/ml • Normal value: 68-494 ng/ml • Duplex Scanning • Combination of ultrasound imaging and Doppler • Determines location and extent of thrombus within veins

11. Arteriosclerosis & Atherosclerosis • Arteriosclerosis • thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply • Atherosclerosis • narrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium sized arteries • a type of arteriosclerosis

12. Atherosclerosis

13. Hypertension • Etiology/Pathophysiology • A sustained elevated systolic blood pressure greater than 140 mm Hg and /or a sustained elevated diastolic blood pressure greater than 90 mm Hg. • Vasoconstriction (increases B/P) • caused by stimulation of the sympathetic nervous system and the release of epinephrine and/or norepinephrine. Decreased blood flow to the kidneys causes the release of renin and the formation of angiotensin which is a vasoconstrictor.

14. Hypertension • Essential (primary) hypertension • 90-95% of all diagnosed cases • Theories of causes: • arteriolar changes, sympathetic nervous system activation, hormonal influence, genetic factors, obesity, sedentary lifestyle, increased sodium intake, excessive alcohol intake. • Secondary hypertension • Attributed to an identifiable medical diagnosis • renal vascular disease • diseases of the adrenal cortex • coarctation of the aorta • head trauma or cranial tumor • pregnancy-induced hypertension

15. Hypertension • Malignant hypertension • severe, rapidly progressive elevation in blood pressure that causes damage to the small arterioles in major organs (heart, kidneys, brain, eyes)

16. Hypertension • Signs & Symptoms • headache • blurred vision • epistaxis • angina • s/s of: • MI, CHF, renal failure, and stroke

17. Hypertension • Treatment • Antihypertensive medications • Capoten, Vasotec, Altace, Lotensin, Zestril, Accupril, Monopril • Diuretics • Lasix, HCTZ, Aldactone • Diet • weight control, reduction of saturated fats, and low sodium • No smoking

18. Hypertension • Decreased alcohol intake • Regular aerobic exercise • Relaxation techniques/stress management

19. Arteriosclerosis Obliterans • Etiology/Pathophysiology • narrowing or occlusion of the blood vessel with plaque formation • little or no blood flow to the affected extremity

20. Arteriosclerosis Obliterans • Signs & Symptoms • Five P’s • Pain • intermittent claudication • Pulselessness • Pallor • Paresthesia • Paralysis

21. Arteriosclerosis Obliterans • Treatment • Anticoagulants • Heparin and Coumadin • Fibrinolytics • Urokinase • administered directly into the thrombus • Surgery • embolectomy- removal of the embloism • endarterectomy- removal of the lining of the artery • arterial bypass • percutaneous transluminal angioplasty • amputation

22. Percutaneous Transluminal Angioplasty

23. Arterial Embolism • Etiology/Pathophysiology • Blood clots in the arterial bloodstream • May originate in the heart • arterial dysrhythmia, MI, valvular heart disease, CHF • Foreign substances • plaque, tissue, etc.

24. Arterial Embolism • Signs & Symptoms • Pain • Absent distal pulses • Pale, cool, and numb extremity • Necrosis • S/S of shock with occlusion of a major vessel

25. Arterial Embolism • Treatment • Anticoagulants • Heparin and Coumadin • Fibrinolytics • Endarterectomy • Embolectomy

26. Arterial Aneurysm • Etiology/Pathophysiology • Enlarged, dilated portion of an artery • Causes: • arteriosclerosis • trauma • congenital defect • Commonly affected arteries • popliteal • thoracic and abdominal aorta • coronary • cerebral

27. Arterial Aneurysm • Signs & Symptoms • Asymptomatic • Large pulating mass • Pain, if large enough to press on other structures

29. Arterial Aneurysm • Treatment • Assess for s/s of rupture, thrombi, ischemia • Control hypertension • Surgery • Ligation • Grafts

30. Surgical Repair of Arterial Aneurysm

31. Thromboangitis Obliterans(Buerger’s Disease) • Etiology/Pathophysiology • Occlusive vascular condition in which the small and medium size arteries become inflamed and thrombotic • affects the small arteries in the hands and feet • Cause not known • Affects men 20-40 years old who smoke

32. Thromboangitis Obliterans(Buerger’s Disease) • Signs & Symptoms • Pain • may be frequent and persistent • Sensitivity to cold • Skin cold and pale • Ulcerations on feet or hands • Gangrene • Superficial thrombophlebitis

33. Thromboangitis Obliterans(Buerger’s Disease) • Treatment • No smoking • Exercise to develop collateral circulation • Surgery • amputation of gangrenous fingers and toes • sympathectomy • clip nerves to prevent pain and vasospasm

34. Raynaud’s Disease • Etiology/Pathophysiology • Intermittent arterial spasms • Primarily affects • fingers, toes, ears and nose • Exposure to cold or emotional stress • Secondary: • scleroderma • rheumatoid arthritis, SLE, drug intoxication, occupational trauma • Commonly affects women 20-40 years of age

35. Raynaud’s Disease • Signs & Symptoms • Chronically cold hands and feet • Pallor, coldness, numbness, cyanosis, and pain during spasms • Erythema following a spasm • Ulcerations on the fingers and toes with chronic disease

36. Raynaud’s Disease • Treatment • No smoking • Avoid exposure to cold • Medications • vasodilators • calcium antagonists • muscle relaxants • Surgery • sympathectomy • amputation for gangrene

37. Thrombophlebitis • Etiology/Pathophysiology • Inflammation of a vein in conjunction with the formation of a thrombus • More common in women • Risk factors • venous stasis • hypercoagulability • truama to the blood vessel • immobilization after surgery

38. Thrombophlebitis • Signs & Symptoms • Pain • Edema • Positive Homan’s sign • Erythema, warmth, and tenderness along the vein

39. Thrombophlebitis • Treatment • Superficial • Bedrest • Moist heat • Elevate extremity • NSAID’s • Motrin • aspirin

40. Thrombophlebitis • Deep • Bedrest • Anticoagulants • Heparin & Coumadin • Fibrinolytics • Elevate extremity • Antiembolism stockings • Surgery • thrombectomy • vena cava umbrella (Greenfield filter)

41. Greenfield Filter

42. Varicose Veins • Etiology/Pathophysiology • Tortuous, dilated vein with incompetent valves • Most common in women 40-60 years of age • Caused by: • congenital defective valves, absent valve, valve that becomes incompetent • Pregnancy or obesity • prolonged standing • constrictive clothing

43. Varicose Veins

44. Varicose Veins • Signs & Symptoms • Dark, raised, tortuous veins • Fatigue • Dull aches • Cramping of the muscles • Heaviness or pressure of extremity • Edema, pain, changes in skin color, and ulcerations with venous stasis

45. Varicose Veins • Treatment • Elastic stockings • Rest • Elevate legs • Sclerotherapy • injection of sclerosing solution • Surgery • Vein ligation and stripping

46. Venous Stasis Ulcers • Etiology/Pathophysiology • Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs • Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue • Causes • varicose veins, burns trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factors

47. Venous Stasis Ulcers • Signs & Symptoms • Pain • Ulceration with dark pigmentation • Edema

48. Venous Stasis Ulcers • Treatment • Diet • Increased protein • Vitamin A & C and Zinc • Debridement of necrotic tissue • wet-to-dry dressings • Elase cream • surgical • Antibiotics • Unna boot