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Vascular Problems, Stroke, Aneurysms, and HTN Crisis

This article discusses common vascular disorders such as hypertension, atherosclerosis, and abdominal aortic aneurysms. It covers the manifestations and major risk factors of these disorders, as well as the medical and surgical management options. Nursing interventions and acute complications are also addressed.

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Vascular Problems, Stroke, Aneurysms, and HTN Crisis

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  1. Vascular Problems, Stroke, Aneurysms, and HTN Crisis By Diana Blum MSN MCC NURS 2140

  2. Vascular Disorders • Common disorders in America: • hypertension • atherosclerosis • arterial occlusive disease • abdominal aortic aneurysms (AAA) • deep vein thrombosis (DVT) • venous insufficiency

  3. hormones • 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

  4. PAD

  5. Arterial diseases: • Arteriosclerosis (atherosclerosis) • Aneurysm formation • Arteriosclerosis obliterans • Raynaud’s phenomenon • Arterial embolism • Thromboangiitis obliterans • Diabetic arteriosclerotic disease • hypertension

  6. 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

  7. (continued): • 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

  8. (continued) • 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 absent

  9. (continued) • Prolonged capillary refill: • - 3 seconds or more • Ulcers: • - open lesions on feet from diminished distal perfusion

  10. Arteriosclerosis • -describes arterial disorders in which • degenerative changes result in • decreased blood flow • Atherosclerosis: • - most common form of arteriosclerosis, excessive accumulation of lipids

  11. 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

  12. 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)

  13. 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, 

  14. 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

  15. 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

  16. SURGERY • Indications for fem-pop bypass: • diabetes • hypertension • vasculitis • collagen disease • Bueger’s disease • Also, Embolectomy (surgical removal)

  17. Fem-pop bypass

  18. MEDICAL MANAGEMENT • ANTIPLATELET THERAPY • Aspirin, ticlid, plavix, pletal, trental • Beta blockers • ARBs • Statins • Radiation therapy • Angioplasty with stents

  19. 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

  20. Acute arterial stenosis • Monitor for the 5 P’s • pain, sudden • pallor • pulselessness • paresthesias • paralysis

  21. 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

  22. 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

  23. 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

  24. 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

  25. S/S • Asymptomatic • Pain is primary symptom—constant • Dyspnea • Cough • Hoarseness • Stridor • Aphonia (weakness or complete loss of voice) • Unequal pupils

  26. Diagnostics • Chest x-ray • TEE • CT

  27. Aortic dissection

  28. Aortic Dissections: Type III most common type

  29. 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

  30. 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

  31. GOAL: to keep blood pressure to lowest • possible but yet allows tissue perfusion • Per physican recommendations

  32. 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

  33. Dacron tube

  34. 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%

  35. Nonsurgical management of AAA • Monitor growth: freq. CT scans • Antihypertensives • SURGICAL: • graft

  36. 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

  37. 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

  38. Venous diseases: • Venous thrombosis (thrombophlebitis) • known as DVT • Varicose veins • Venous stasis ulcers

  39. 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

  40. 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

  41. DVT risk for pulmonary embolism • - legs • - seen post hip surgery, knee replacement pregnancy, ulcerative colitis, hrt failure, immobility

  42. DVT : • Groin tenderness/pain • Unilateral sudden onset edema leg • Homan’s sign (appears in only 10% of pt • with DVT) • Ultrasonography

  43. 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

  44. 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

  45. Hypertension • - 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

  46. S/S • Often none • Occipital headache more severe on rising • Lightheadedness • Epistaxis • Known as the ‘Silent Killer’

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