Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3


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Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3: Arterial disorders such as Arterial occlusive disease, Arterial embolism, Arterial thrombosis, Thromboangiitis obliterans (Buerger’s disease), Aortitis, Aortoiliac disease, Aneurysms, Raynaud’s disease, and Thoracic outlet syndrome

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Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3

  1. 1. Nursing Care of Clients withPeripheral Vascular Disorders
  2. 2. Overview of Disorders
  3. 3. PERIPHERAL ARTERIAL OCCLUSIVEDISEASE Upper extremity arterial occlusive disease Arterial embolism; Arterial thrombosis Thromboangiitis obliterans (buerger’s disease) Aortitis Aortoiliac disease Aneurysms Aortic aneurysm Thoracic aortic aneurysm Abdominal aortic aneurysm Dissecting aorta Other aneurysms Raynaud’s disease Thoracic outlet syndrome
  4. 4. VENOUS DISORDERSVenous Thrombosis, Deep Vein Thrombosis (DVT),Thrombophlebitis, and PhlebothrombosisChronic Venous InsufficiencyLeg UlcersVaricose VeinsCellulitis
  5. 5. LYMPHATIC DISORDERS Lymphangitis and Lymphadenitis Lymphedema and Elephantiasis
  6. 6. Peripheral vascular disease (PVD) includes disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation. affects the lower extremities much more frequently than the upper extremities. Generally, a client with a diagnosis of PVD has arterial disease (peripheral arterial disease [PAD]) rather than venous involvement. Some clients have both arterial and venous disease.
  7. 7. Peripheral Arterial/ Venous Disease A chronic disorder in which partial or total occlusion deprives the lower extremities of oxygen and nutrients Tissue damage occurs below the level of the arterial occlusion Atherosclerosis - most common cause of peripheral arterial disease
  9. 9. Peripheral Arterial Disorders (PAD) Aka: Peripheral arterial occlusive disease Arterial Occlusive Disorders Lower extremity arterial disease (LEAD) Is the arterial insufficiency of the extremities most common cause is Arteriosclerosis Obliterans (ASO) lower extremities are more commonly affected. More prevalent among men 50-70 years old
  10. 10. Assessment intermittent claudication: hallmark of the disease rest pain: severe is a numbness or burning, often described as feeling like a toothache, that is severe enough to awaken clients at night. it may be so excruciating that it is unrelieved by opioids. elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the extremity in a dependent position reduces the pain. In bed, some sleep with affected leg hanging over the side of the bed. Some patients sleep in a reclining chair in an attempt to relieve the pain.
  11. 11. Assessment Coldness or cold sensitivity – Coldness in the feet with exposure to a cold environment, associated with blanching or cyanosis due to ischemia extremity Cold and pale when elevated or ruddy and cyanotic when placed in a dependent position nails : thickened and opaque Skin: shiny, atrophic, and dry, with sparse hair growth. comparison of the right and left extremities. Bruits may be auscultated with a stethoscope
  12. 12. Assessment Ulceration and gangrene. May be due to ischemia ot trauma. Impaired tissue perfusion inhibits healing process Edema. Due to severe obstruction Sexual dysfunction. Occlusion of terminal aorta decreases blood supply to the penile arteries Gangrene muscle atrophy
  13. 13. Assessment peripheral pulses: important part of assessing arterial occlusive disease. Unequal pulses between extremities or the absence of a normally palpable pulse is a sign of peripheral arterial disease. The femoral pulse in the groin and the posterior tibial pulse beside the medial malleolus are most easily palpated.
  14. 14. Diagnostic Findings CW Doppler and ankle-brachial indices (ABIs) Treadmill testing for claudication duplex ultrasonography
  15. 15. Medical Management Control hypertension Reduce risk factors: Control serum lipids Weight reduction Low fat low cholesterol diet Daily walking Cessation of tobacco use Note: Patients should not be promised that their symptoms will be relieved if they stop tobacco use, because claudication may persist, and they may lose their motivation to stop using tobacco Skin and foot care
  16. 16. PHARMACOLOGIC THERAPYhemorheologic and antiplatelet agentsVasodilatorsAntihyperlipidemics
  17. 17. hemorheologic agent Pentoxifylline (Trental) Increase flexibility of RBCs decreases blood viscosity by inhibiting platelet aggregation and decreasing fibrinogen and thus increases blood flow in the extremities.
  18. 18. Antiplatelet agents aspirin (acetylsalicylic acid, Ancasal) : 325 or 81 mg/day clopidogrel (Plavix) ticlopidine (Ticlid) Cilostazol (Pletal) : inhibit platelet aggregation, inhibit smooth muscle cell proliferation, and increase vasodilation.
  19. 19. Surgical Management Percutaneous transluminal angioplasty Balloon angioplasty Laser angioplasty Stent insertion Atherectomy Arterial revascularization : Arterial bypass; vascular grafting Endarterectomy Endovascular surgery Amputation
  20. 20. SURGICAL MANAGEMENTchoice of the surgical procedure depends on the degree and location of the stenosis or occlusion. overall health of patient and length of procedure that can be tolerated.
  21. 21. vascular grafting or endarterectomy For patients, severe intermittent claudication and disabling or when the limb is at risk for amputation because of tissue loss palliative therapy of primary amputation rather than anarterial bypass.
  22. 22. Endarterectomy an incision is made into the artery atheromatous obstruction is removed. artery is then sutured closed to restore vascular integrity
  23. 23. Bypass grafts are performed to reroute the blood flow around the stenosis or occlusion. Before bypass grafting, the surgeon determines where the distal anastomosis (site where the vessels are surgically joined) will be placed. The distal outflow vessel must be at least 50% patent for the graft to remain patent. A higher bypass graft patency rate is associated with keeping the length of the bypass as short as possible.
  24. 24. femoral-to-popliteal graftsurgical procedure of choice if atherosclerotic occlusion isbelow the inguinal ligament in the superficial femoral arteryClass. based on location of distal anastomosis above-knee below-knee grafts
  25. 25. Bypass grafts may be synthetic or autologous vein. Native vein or autologous vein greater or lesser saphenous vein or a combination of one of the saphenous veins and an upper extremity vein such as the cephalic vein are used to meet the required length. woven or knitted Dacron, expanded polytetrafluoroethylene (ePTFE, such as Gore- Tex or Impra), collagen-impregnated, and umbilical vein.
  26. 26. Nursing Management Maintaining circulation Maintain skin integrity and prevent infection Monitoring and managing potential complications Promoting home and community-based care
  27. 27. Maintaining circulation: Post op care Monitor the ff q hour for first 8 hours and then every 2 hours for 24 hours Pulses color and temperature of the extremity capillary refill Sensory and motor function of the affected extremities Note: Compare extremities Doppler evaluation ABI : at least once q 8 hrs for 1st 24 hrs and then OD until discharge (not usually assessed for pedal artery bypasses).
  28. 28. Disappearance of a pulse that was present mayindicate thrombotic occlusion of the graft Notify surgeon STAT
  29. 29. Maintain circulation Warm environmental temperature Place legs in slight dependency to promote arterial flow Avoid pressure on affected extremity; use padding for support Avoid vigorous massage of extremities Avoid Chilling and exposure to cold Avoid contrictive clothing Crossing legs Quit smoking Do not go barefootd Trim toenails straight Avoid scratching or rubbing feet
  30. 30. Exercise may improve arterial blood flow to the affected limb through buildup of the collateral circulation. is individualized for each client Contrindicated: severe rest pain, venous ulcers, or gangrene Initiate gradually and is slowly increased nurse instructs the client to walk until the point of claudication, stop and rest, and then walk a little farther. Eventually, clients are able to walk longer distances as collateral circulation develops.
  31. 31. Positioning To promote circulation Still controversial Some have swelling in extremities Because swelling prevents arterial flow, should elevate feet at rest, but shld be taught to refrain raising legs above heart level. Extreme elevation slows arterial blood flow to the feet. In severe cases, clients with PAD and swelling may sleep with the affected limb hanging from the bed, or they may sit upright in a chair for comfort. avoid crossing their legs, which may interfere with blood flow.
  32. 32. Maintain skin integrity and preventinfection Examine skin on a daily basis Take daily bath and dry the skin gently Apply moisturizing cream/lotion in the skin. Avoid using alcohol Foot care Wear comfortable, well fitted pair of shoes Avoid direct heat application over the extremities
  33. 33. Monitoring and managing potentialcomplications UO central venous pressure mental status pulse rate and volume permit early recognition and treatment of fluid imbalances.
  34. 34. Monitoring and managing potentialcomplications Bleeding / Hematoma can result from the heparin administered during surgery or from an anastomotic leak. Avoid leg crossing and prolonged extremity dependency to prevent thrombosis. Edema normal postoperative finding elevating the extremities and encouraging the patient to exercise the extremities while in bed reduces edema. Elastic compression stockings care must be taken to avoid compressing distal vessel bypass grafts. Severe edema of the extremity, pain, and decreased sensation of toes or fingers can be an indication of compartment syndrome.
  35. 35. Promoting home and community-basedcare Assess patient’s ability to manage independently. Determine if patient has a network of family and friends to assist with ADL Encourage to make the lifestyle changes necessary with a chronic disease, including pain management and modifications in diet, activity, and hygiene (skin care). Ensure has knowledge and ability to assess for any postop complications such as infection, occlusion of the artery or graft, and decreased blood flow. Assists in developing a plan to stop using tobacco.
  36. 36. Promote activity Regular aerobic exercises such as walking, swimming, jogging , bicycling Do exercises 30-45 minutes 3-4 times a week
  37. 37. Prevention Primary – provide info on the effects of the following: Cigarrete smoking. Nicotene causes vaso-constriction, spasms of the arteries, reduced circulation to the extremities. CO2 reduces O2 transport to the tissues Hypertension. Cause elastic tissue in the arteries to be replaced by fibrous collagen tissue reducing arterial elasticity and increases resistance.
  38. 38. Hyperlipidemia. Contribute to atherosclerotic plaques in vesselsObesity. Added burden on the heart and blood vesselsPhysical inactivity. Compromises circulationEmotional stress. Stimulates the sympathetic response whichresults to vasocontrictionDM. Changes in glucose and fat metabolism enhancesatherosclerosis
  39. 39. Secondary prevention Encourage clients with early symptoms to seek medical care to prevent complicationsTertiary prevention Rehabilitation . Exercises to develop collateral circulation.
  40. 40. Acute Peripheral Arterial Occlusion
  41. 41. ACUTE PERIPHERAL ARTERIALOCCLUSION Aka: Arterial embolism and arterial thrombosis arterial occlusions : sudden and dramatic. Occlusion may affect the upper extremities, but it is more common in the lower extremities. most common cause : embolus or local thrombus Emboli originating from heart: are most common Risk factors AMI within the preceding weeks atrial fibrillation infective endocarditis chronic heart failure
  42. 42. Assessment severe pain below level of the occlusion occurs even at rest. affected extremity : cool or cold, pulseless, and mottled. Minute areas on the toes may be blackened or gangrenous. "six Ps" of ischemia: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness) of the involved extremity.
  43. 43. Interventions initiate treatment promptly to avoid permanent damage or loss of an extremity. Anticoagulant therapy with unfractionated heparin (UFH; Hepalean*) is usually the first intervention to prevent further clot formation. bolus of up to 10,000 units angiography
  44. 44. Surgical treatment Emergencysurgical thrombectomy or embolectomy with local anesthesia to remove the occlusion. physician makes an incision, which is followed by an arteriotomy (a surgical opening into an artery). then inserts a Fogarty catheter into artery and retrieves embolus. may be necessary to close artery with patch graft.
  45. 45. Fogarty catheter
  46. 46. Preop nursing care bed rest with extremity level or slightly dependent (15 degrees). affected part is kept at room temperature and protected from trauma. Heating and cooling pads are contraindicated ischemic extremities are easily traumatized by alterations in temperature. If possible, tape and electrocardiogram electrodes should not be used on the extremity sheepskin and foot cradles are used to protect the leg from mechanical trauma.
  47. 47. PostopNursing care Monitor affected extremity for improvement in color, temperature, and pulse, other extremities for s/s of new thrombi or emboli. mild incisional pain is normal Watch closely for complications caused by reperfusing the artery after thrombectomy or embolectomy spasms and swelling of the skeletal muscle. Swelling of the skeletal muscles is characterized by edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness. Fasciotomy (surgical opening into the tissues) may be necessary to prevent further injury and save the limb.
  48. 48. Buerger’s disease
  49. 49. Buerger’s disease Inflammatory, non-lipid occlusive condition of small to medium arteries followed by vein that impairs circulation to the legs, feet and occasionally hands Rare, occurs most often in men, ages of 20 and 35 years, all races
  50. 50. Cause Unknown believed to be autoimmune disease (autoimmune vasculitis) Linked to smoking or chewing of tobacco (suggesting a hypersensitivity reaction to nicotine)
  51. 51. Pathophy characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare cases) upper extremities. Polymorphonuclear leukocytes infiltrate the walls of small and medium sized arteries and veins Thrombus formation and occlusion of vessels Diminished blood flow produces ulceration and later on gangrene lower extremities; upper extremities or viscera can also be involved Generally bilateral and symmetric with focal lesions. Superficial thrombophlebitis may be present.
  52. 52. Clinical Manifestations intermittent claudication Most characteristic manifestation foot cramps, especially of the arch (instep claudication), after exercise. relieved by rest often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling. Cold sensitivity of the Raynaud type is found in one half the patients and is frequently confined to the hands. Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.
  53. 53. Clinical Manifestations intense rubor (reddish blue discoloration) of the foot absence of pedal pulse but normal femoral and popliteal pulses. absent or diminished radial and ulnar artery pulses Various types of paresthesia may develop. As the disease progresses, definite redness or cyanosis of the part appears when the extremity is in a dependent position. generally bilateral, but color changes may affect only one extremity or only certain digits. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.
  54. 54. The feet of a patient with Buerger disease. Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes. Though the patients right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.
  55. 55. Superficial thrombophlebitis of the great toe in a patient with Buerger disease.
  56. 56. The tobacco smoke– stained fingers of this patient suggested the mans diagnosis (Buerger disease). The patient presented with small, painful ulcers on the tips of his thumb and ring finger.
  57. 57. This lower extremity arteriogram of the peroneal and tibial arteries of a patient with Buerger disease demonstrates the classic findings of multiple small- and medium-sized arterial occlusions with formation of compensatory "corkscrew collaterals."
  58. 58. Diagnostic Findings Allens test Segmental limb blood pressures Demonstrate distal location of the lesions or occlusions. Duplex ultrasonography/ Doppler ultrasonography used to document patency of the proximal vessels and to visualize the extent of distal disease. Contrast angiography Demonstrate diseased portion of anatomy. Arteriography Plethysmography Venography
  59. 59. Managementmain objectives: improve circulation to extremities,prevent progression of disease, and protect extremitiesfrom trauma and infection.Treatment same as that for atherosclerotic peripheralarterial disease.
  60. 60. ManagementExercise programs that Avoid injury to theus gravity to fill and drain extremitiesthe blood vessels to Antibiotics , analgesicspromote adequate débridement of necroticcirculation tissue: Minimize infectionMonitor pulses Regional sympatheticStop smoking block or Absolute discontinuation ganglionectomy of tobacco use is the only produce vasodilation and strategy proven to prevent increase blood flow. the progression of Buerger disease. Amputation
  61. 61. Other treatments Other treatment approaches exist but are less effective. Intermittent compression of the arms and legs to increase blood flow to extremities Spinal cord stimulation therapeutic angiogenesis Medications to stimulate growth of new blood vessels Vasodilators: rarely prescribed Lumbar sympathetectomy cut nerves to affected area to control pain and increase blood flow; controversial
  62. 62. SURGICAL MANAGEMENT OFCOMPLICATIONS Amputations If gangrene of a toe develops as a result of arterial occlusive disease in the leg, below-knee amputation (BKA) or above-knee amputation toe amputation or even transmetatarsal amputation Indications worsening gangrene, especially if the infected area is moist, severe rest pain, or fulminating sepsis.
  63. 63. NURSING MANAGEMENT OFCOMPLICATIONS Postop care amputation Elevate stump for first 24 hours to promote venous return and minimize edema. The incision is monitored for signs of hematoma (unapproximated suture line, discoloration or ruddy color changes of the skin along the suture line, tenderness with palpation, or oozing of dark blood from the suture line). Assess fit of elastic bandages and ensures integrity of wrap and continued ability to fit two fingers between layers of wrap. Distal skin color and warmth are assessed, if accessible, and recorded. Elastic bandages are removed and reapplied as prescribed by the surgeon (eg, every 6 hours using figure-of-eight turns).
  64. 64. NURSING MANAGEMENTgrief, fear, or anxiety r/t loss of limb. Encourage discuss his or her feelings. Spiritual advisors and other health care team members are consultedRecovery and rehabilitation require multidisciplinary care(e.g., physicians, physical and occupational therapists,prosthetists, dietitians, nurses, discharge coordinators).prosthetic device fitting
  65. 65. Discharge planning Assess ability to manage independently. Assist in developing a plan to stop using tobacco and to manage pain. Encourage to make the lifestyle changes necessary with a chronic disease, including modifications in diet, activity, and hygiene (skin care). Determine whether patient has a network of family and friends to assist with ADL. Ensure that patient has knowledge and ability to assess for any postoperative complications such as infection and decreased blood flow.
  66. 66. Lifestyle and home remedies Take care of fingers and toes Check the skin on arms and legs daily for cuts and scrapes, keep in mind that if lost feeling to a finger or toe may not feel, for example, a cut when it happens. Keep your fingers and toes protected and avoid exposing them to cold. Low blood flow to extremities means body cant resist infection as easily. Small cuts and scrapes can easily turn into serious infections. Clean any cut with water, apply antibiotic ointment and cover it with a clean bandage. Keep an eye on any cuts or scrapes to make sure theyre healing. If they get worse or heal slowly, see doctor promptly. Visit your dentist regularly to keep gums and teeth in good health and avoid gum disease, which in its chronic form is associated with Buergers disease.
  68. 68. AORTIC ANEURYSMAbnormal dilatation ofthe arterial wall causedby localized weaknessand stretching in themedial layer or wall of anarteryAn aneurysm is a localizedsac or dilation formed at aweak point in wall of aortaCan be located anywherealong the aorta
  69. 69. Classificationclassified by shape or form saccular aneurysm projects from one side of the vessel only fusiform aneurysm If an entire arterial segment becomes dilated mycotic aneurysms very small aneurysms due to localized infection
  70. 70. What is the diference between trueand false aneurysm?True anuerysm false aneurysms all three tunica layers are or pseudoaneurysm one in which the entire wall is involved injured blood escapes between tunica layers and they separate. the blood is contained by the surrounding tissues, with eventual formation of a sac communicating with the artery (or heart). If the separation continues, a clot may form, resulting in a dissecting aneurysm.
  71. 71. Classification By location Abdominal Thoracic Cerebral , etc
  72. 72. Etiologic Classification of ArterialAneurysms atherosclerotic changes in the aorta Congenital: Primary connective tissue disorders (Marfan’s syndrome, Ehlers-Danlos syndrome) and other diseases (focal medial agenesis, tuberous sclerosis, Turner’s syndrome, Menkes’ syndrome) Mechanical (hemodynamic): Poststenotic and arteriovenous fistula and amputation-related Traumatic (pseudoaneurysms): Penetrating arterial injuries, blunt arterial injuries, pseudoaneurysms Inflammatory (noninfectious): Associated with arteritis (Takayasu’s disease, giant cell arteritis, systemic lupus erythematosus, Behçet’s syndrome, Kawasaki’s disease) and periarterial inflammation (ie, pancreatitis)
  73. 73. Etiologic Classification of ArterialAneurysms Infectious (mycotic): Bacterial, fungal, spirochetal infections Pregnancy-related degenerative: Nonspecific, inflammatory variant Anastomotic (postarteriotomy) and graft aneurysms: Infection, arterial wall failure, suture failure, graft failure
  74. 74. Risk factors Genetic predisposition smoking (or other tobacco use) Hypertension Obesity Stress Hypercholesterolemia
  75. 75. Aortitis
  76. 76. Aortitis is inflammation of the aorta, particularly of the aortic arch. Two types Takayasu’s disease occlusive thromboaortopathy is uncommon syphilitic aortitis Rare
  77. 77. Aorta main trunk of arterial system divided into (1) ascending aorta (5 cm [2 inches] in diameter, contained in the pericardium) (2) aortic arch (extending upward, backward, and downward) (3) descending aorta
  78. 78. Thoracic aorta is above diaphragmAbdominal aorta is below the diaphragm. further divided as suprarenal (above renal artery level) perirenal level (at renal artery level) infrarenal (below renal artery level).
  79. 79. Takayasu’s disease chronic inflammatory disease of the aortic arch and its branches affects young or middle-aged women; Asian descent Cause nonatherosclerotic exact pathologic mechanism is unknown thought to be immune complex mediated progresses from a systemic inflammation with localized arteritis to end-organ ischemia bcoz of large vessel stenosis or obstruction. Lesions are typically long, smooth areas of narrowing with or without aneurysms
  80. 80. Takayasu’s disease: Diagnostic exams diagnose and evaluate the lesions Magnetic resonance angiography CT Duplex ultrasonography Arteriography
  81. 81. Takayasu’s disease Management early stage Corticosteroids cytotoxic immunosuppressive agents. Selective PTA & Surgical revascularization performed after suppression of the systemic vascular inflammation.
  82. 82. Aortoiliac disease
  83. 83. AORTOILIAC DISEASE If collateral circulation has developed, patients with a stenosis or occlusion of the aortoiliac segment may be asymptomatic, or they may complain of buttock or low back discomfort associated with walking. Men may experience impotence. decreased or absent femoral pulses.
  84. 84. Medical Management Treatment same as that for atherosclerotic peripheral arterial occlusive disease. aortobi iliac graft distal anastomosis is made to iliac artery, and entire surgical procedure can be performed within abdomen. aortobifemoral graft if iliac vessels are diseased distal anastomosis is made to femoral arteries Bifurcated woven or knitted Dacron grafts are preferred for this surgical procedure.
  85. 85. Nursing Management Preoperative assessment brachial, radial, ulnar, femoral, posterior tibial, and dorsalis pedis pulses ; establish baseline for follow-up after arterial lines are placed
  86. 86. Nursing Management Postoperative care monitoring for signs of thrombosis in arteries distal to the surgical site. Assess color and temperature of the extremity, capillary refill time, sensory and motor function, and pulses by palpation and Doppler q 1 hr for 1st first 8 hrs and then q 2 hrs for 1st 24 hrs. Report STAT to physician Any dusky or bluish discoloration, coolness, capillary refill time greater than 3 seconds, decrease in sensory or motor function, or decrease in pulse quality
  87. 87. Nursing Management Postoperative care Monitor UO Renal function may be impaired as a result of hypoperfusion from hypotension, involvement of the renal arteries during the surgical procedure, hypovolemia, or embolization of the renal artery or renal parenchyma. V VS, pain, and intake and output are monitored with the pulse and extremity assessments. Lab results monitored and reported Ischemic bowel usually causes increased pain and elevated white blood cell count (20,000 to 30,000 cells/mm3).
  88. 88. Nursing Management Abdominal assessment bowel sounds and paralytic ileus is performed at least q 8 hrs. BS may not return b4 third postop day (normal) (-) bowel sounds, (-) flatus, and (+) abdominal distention: indicates of paralytic ileus. Manual manipulation of the bowel during surgery may have caused bruising, resulting in decreased peristalsis. Nasogastric suction may be necessary to decompress bowel until peristalsis returns. liquid bowel movement b4 3rd postop day may indicate bowel ischemia may occur when mesenteric blood supply (celiac, superior mesenteric, or inferior mesenteric arteries) is occluded.
  90. 90. THORACIC AORTIC ANEURYSM Atherosclerosis: most common cause occur most frequently in men, 40 and 70 years. thoracic area - most common site for a dissecting aneurysm. About one third of patients with thoracic aneurysms die of rupture of the aneurysm
  91. 91. Clinical Manifestations Symptoms are variable and depend on how rapidly the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures. Some :asymptomatic. chest pain- most prominent symptom usually constant and boring but may occur only when the person is supine unequal pulses and arterial pressure in upper extremities, tracheal deviation, cyanosis, weakness
  92. 92. Clinical Manifestations1. Dyspnea 1. result of pressure of the sac against the trachea, a main bronchus, or the lung itself2. Cough 2. frequently paroxysmal and with a brassy quality3. Hoarseness, stridor, 3. resulting from pressure or weakness or against the left recurrent complete aphonia laryngeal nerve
  93. 93. Clinical Manifestations4. Dysphagia 4. due to impingement on the esophagus by the aneurysm.5. Dilated superficial 5. when large veins in chest veins of the chest, are compressed by the neck, or arms aneurysm6. Unequal pupils 6. Pressure against the cervical sympathetic chain
  94. 94. Diagnostic Findings chest x-ray transesophageal echocardiography CT
  96. 96. ABDOMINAL AORTIC ANEURYSMAtherosclerosis: most common causecommon among Caucasians; affects men four times moreoften than women; most prevalent in elderly patientsMost occur below the renal arteries (infrarenal aneurysms).Untreated, the eventual outcome may be rupture and death.
  97. 97. Pathophysiology All aneurysms involve a damaged media layer of the vessel. After an aneurysm develops, it tends to enlarge.
  98. 98. Clinical Manifestations feel heart beating in their If associated with abdomen when lying down thrombus, a major vessel feel abdominal mass or may be occluded or smaller abdominal throbbing distal occlusions may result pulsatile mass in from emboli. middle and upper A small cholesterol, abdomen platelet, or fibrin emboli most important diagnostic may lodge in the indication interosseous or digital systolic bruit over mass arteries, causing blue toes
  99. 99. Atheroemboli from small AAAA produce livedo reticularis of the feet (ie, blue toe syndrome).
  100. 100. Diagnostic Findings Duplex ultrasonography or CT used to determine the size, length, and location of the aneurysm Ultrasonography Watchful Waiting Period For sml aneurysm conducted at 6-month intervals until aneurysm reaches a size at which surgery to prevent rupture is of more benefit than the possible complications of a surgical procedure. Some aneurysms remain stable over many years of observation.
  101. 101. Conventional angiography Angiography is used to diagnose the renal area. In this instance, an endoleak represented continued pressurization of the sac.
  102. 102. Gerontologic Considerations Most occur ages of 60 and 90 years. Rupture is likely with coexisting hypertension and with aneurysms wider than 6 cm. In most cases at this point, the chances of rupture are greater than the chance of death during surgical repair. If the elderly patient is considered at moderate risk for complications related to surgery or anesthesia, the aneurysm is not repaired until it is at least 5 cm (2 inches) wide.
  103. 103. MANAGEMENT: Aneursyms
  104. 104. MANAGEMENT: Aneursyms Goals Limit progression Control BP Recognizing early symptoms Prevent rupture
  105. 105. Management Size- <5cm and asymptomatic- follow up with serial ultrasound every 3-12 months >5cm elective repair Growth rate- normally 2-8mm/year, if > 4mm/year consider elective surgery Symptomatic – mandates repaircontrol blood pressure Systolic pressure is maintained at about 100 to 120 mm Hg with antihypertensive medicationsCorrect risk factorsPulsatile flow is reduced by medications that reduce cardiaccontractility (eg, propranolol [Inderal]).
  106. 106. SURGICAL MANAGEMENTSurgery : treatment of choice for abdominal aneurysms wider than5 cm (2 inches) wide or those that are enlargingEndoaneurysmorrhaphy- opening the sac and suturing a prostheticgraft to the normal aorta within the aneurysm(Teflon/Dacron/Gortex) Endovascular repairElective aneurysm repair Via traditional open laparotomy standard treatment open surgical repair of the aneurysm by resecting the vessel and sewing a bypass graft in place.
  107. 107. standard preoperative care Type and crossmatch blood Administer prophylactic antibiotics (cefazolin, 1 g intravenous piggyback) Insert a Foley catheter Establish large-bore intravenous access Monitor central venous pressure or establish Swan-Ganz catheterization (if indicated) Prepare the skin from the nipples to the mid thigh Administer general anesthesia (with or without epidural anesthesia) Cell Saver use has become popular Insert a nasogastric tube
  108. 108. Post Surgical Complications Post op Renal failure Ischemic colitis Acute leg ischemia Spinal cord ischemia- ligation of the artery of Adamkiewicz which supplies the spinal cord anterior spinal artery syndrome-paraplegia, rectal and urinary incontinence, loss of pain and vibratory sense with preservation of vibratory and proprioception Aortic Graft infection Sexual Dysfunction
  109. 109. Post Op Nursing Interventions Thoracic Aneurysm Repair Thoracotomy or median sternotomy approach is used Aneurysm is exposed and excised and a graft or prosthesis is sewn onto the aorta Total cardiopulmonary bypass is necessary for excision of aneurysms in the ascending and arch of the aorta Partial cardiopulmonary bypass for descending aneurysms
  110. 110. Monitor for signs of hemorrhageMonitor chest tubes for an increase in chest drainageAssess sensation and motion of all extremities and notifyphysician for deficitsMonitor serum creatinine, BUN and hourly outputs
  111. 111. Monitor for dysrhythmiasMonitor respiratory statusEncourage coughing and deep breathingNo lifting of heavy objects for 6-12 weeksAvoid straining
  112. 112. SURGICAL MANAGEMENT:Endovascular grafting placement of endovascular stents alternative for treating an infrarenal abdominal aortic aneurysm Involves transluminal placement and attachment of a sutureless aortic graft prosthesis across an aneurysm can be performed under local or regional anesthesia. performed if abdominal aorta and iliac arteries are not extremely tortuous and if the aneurysm does not begin at the level of the renal arteries.
  113. 113. SURGICAL MANAGEMENT:Endovascular grafting Potential complications bleeding hematoma, or wound infection at the femoral insertion site Distal ischemia or embolization dissection or perforation of the aorta graft thrombosis graft infection break of the attachment system graft migration proximal or distal graft leaks delayed rupture bowel ischemia
  114. 114. Nursing Management Preop Anticipate rupture Recognize that patient may have cardiovascular, cerebral, pulmonary, and renal impairment from atherosclerosis. Assess functional capacity of all organ systems Medical therapies designed to stabilize physiologic function should be promptly implemented.
  115. 115. Nursing Management Indications of a rupturingSigns of impending rupture AAA severe back pain or abdominal constant, intense back pain pain may be persistent or falling BP intermittent localized in the middle or lower abdomen to left decreasing hematocrit of midline Low back pain because of pressure of the aneurysm on the lumbar nerves. a serious symptom, usually indicating that the aneurysm is expanding rapidly and is about to rupture.
  116. 116. Rupture into peritoneal cavity : rapidly fatalRetroperitoneal rupture of an aneurysm May result in hematomas in the scrotum, perineum, flank, or penis.Rupture into vena cava Signs of heart failure or a loud bruit results in higher-pressure arterial blood entering the lower-pressure venous system and causing turbulence, which is heard as a bruit. high BP and increased blood volume returning to right heart from vena cava may cause R heart to fail.The overall surgical mortality rate associated with a rupturedaneurysm is 50% to 75%.
  117. 117. Possible complications ofPostoperative care surgery intense monitoring of arterial occlusion pulmonary, cardiovascular, hemorrhage renal, and neurologic Infection status. ischemic bowel renal failure impotence
  119. 119. DISSECTING AORTA Occasionally, in an aorta diseased by arteriosclerosis, a tear develops in the intima or the media degenerates, resulting in a dissection
  120. 120. Pathophysiology Arterial dissections (separations) are commonly associated with poorly controlled hypertension; three times more common in men than in women occur most commonly in the 50- to 70-year-old age group Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. As the separation progresses, the arteries branching from the involved area of the aorta shear and occlude. The tear occurs most commonly in the region of the aortic arch, with the highest mortality rate associated with ascending aortic dissection. The dissection of the aorta may progress backward in the direction of the heart, obstructing the openings to the coronary arteries or producing hemopericardium (effusion of blood into the pericardial sac) or aortic insufficiency, or it may extend in the opposite direction, causing occlusion of the arteries supplying the gastrointestinal tract, kidneys, spinal cord, and legs.
  121. 121. Clinical Manifestations Onset of symptoms - usually sudden. Severe and persistent pain tearing or ripping anterior chest or back extends to shoulders, epigastric area, or abdomen. May be mistaken for an AMI
  122. 122. Clinical Manifestations Cardiovascular, neurologic, and gastrointestinal symptoms are responsible for other clinical manifestations, depending on the location and extent of the dissection. may appear pale Sweating and tachycardia elevated BP BP markedly different from one arm to the other if dissection involves the orifice of the subclavian artery on one side. early diagnosis is usually difficult because of the variable clinical picture associated with this condition
  123. 123. Diagnostic Findings Arteriography CT transesophageal echocardiography Duplex ultrasonography magnetic resonance imaging
  124. 124. ManagementMedical Management Nursing Management Medical or surgical same nursing care with an treatment depends on the aortic aneurysm requiring type of dissection present surgical intervention and follows the general principles outlined for the treatment of thoracic aortic aneurysms.
  126. 126. OTHER ANEURYSMSperipheral vessels: subclavian artery, renal artery, femoralartery, or popliteal arterymost often result of atherosclerosiss/s pulsating mass disturbs peripheral circulation distal to it. Pain and swelling develop because of pressure on adjacent nerves and veins.
  127. 127. OTHER ANEURYSMSDiagnostic exam Duplex ultrasonography and CT to determine the size, length, and extent of the aneurysm. Arteriography may be performed to evaluate the level of proximal and distal involvement.
  128. 128. OTHER ANEURYSMSSurgical repair replacement grafts or endovascular repair using a stent-graft or wall graft, which is a Dacron or PTFE (polytetrafluroethylene) graft with external structures made from a variety of materials (nitinol, titanium, stainless steel) for additional support.
  129. 129. Nursing Management: endovascularrepair postop care Supine 6 hours; head of bed elevated up to 45 degrees after 2 hours. needs to use bedpan or urinal while on bed rest, or a Foley catheter may be used. VS and Doppler assessment of peripheral q 15 min four times, then q 30 min for four times, then q hour for four times, and then as directed by the physician or unit standards. catheterization site is assessed when vital signs and pulses are monitored.
  130. 130. Nursing Management: endovascularrepair postop care Assess bleeding, swelling, pain, and hematoma formation. Any changes in vital signs, pulse quality, bleeding, swelling, pain, or hematoma are reported to the physician. also notify if persistent coughing, sneezing, vomiting, or systolic blood pressure above 180 mm Hg Coz of increased risk hemorrhage. If able to resume preprocedure diet encouraged drink fluids. IV infusion may be continued until able drink normally. Fluids are important to maintain blood flow through arterial repair site and assist kidneys excreting IV contrast agent and other medications used during procedure. 6 hrs post procedure may able roll side to side and may ambulate with assistance to bathroom.
  132. 132. Raynaud’s disease is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Vasospasm of the arterioles and arteries of the upper and lower extremities; causes constriction of the cutaneous vessels occurs more frequently in cold climates and during winter
  133. 133. Raynauds phenomenon Raynauds disease usually unilaterally. occurs bilaterally. occurs in people older than occur between the ages of 30 years of age 17 and 50 years can occur in either sex more common in women
  134. 134. The pathophysiology is the same forboth entities. Clients often have an associated systemic connective tissue disease, such as systemic lupus erythematosus or progressive systemic sclerosis. As a result of vasospasm, the cutaneous vessels are constricted and blanching of the extremity occurs, followed by cyanosis. When the vasospasm is relieved, the tissue becomes reddened or hyperemic. The clients extremities are numb and cold, and he or she may complain of pain and swelling. Ulcers may also be present. These attacks are intermittent and can be aggravated by cold or stress. In severe cases, the attack lasts longer and gangrene of the digits can occur.
  135. 135. Cause The etiology is unknown. many have immunologic disorders (scleroderma, systemic lupus erythematosus, rheumatoid arthritis), obstructive arterial disease, or trauma associated with smoking Rarely leads to gangrene
  136. 136. Prognosis Varies some patients slowly improve, some become progressively worse, and others show no change. Ulceration and gangrene are rare however, chronic disease may cause atrophy of the skin and muscles. With appropriate patient teaching and lifestyle modifications, the disorder is generally benign and self-limiting.
  137. 137. Clinical Manifestations Classic clinical picture - Triphasic color changes in the hands Blanching (pallor or white) of the fingers after exposure to cold or stress due to vasoconstriction and spasm Cyanosis (blue) follows because of oxygen deprivation of the tissues Red skin as exaggerated reflow (hyperemia) when oxygenated blood returns to the digits after the vasospasm stops.The characteristic sequence of color change of Raynaud’s phenomenon is described aswhite, blue, and red.
  138. 138. SymptomsNumbness, tingling, and burning pain occur as the color changebilateral and symmetricmay result from defect in basal heat production that eventuallydecreases the ability of cutaneous vessels to dilate.Episodes may be triggered by emotional factors or by unusualsensitivity to cold.Generally unilateral and affecting only one or two digits, thephenomenon is always associated with underlying systemic disease.Attacks are intermittent and can occur with exposure to cold orstressAffects primarily the hands less commonly the feet
  139. 139. Diagnostics ANA titer Arteriography Doppler ultrasound
  140. 140. Medical Management Avoid trigggers (e.g., cold, tobacco, stress) that provoke vasoconstriction Medications Sympathectomy Amputation
  141. 141. Vasodilating agents Commonly prescribed drugs are nifedipine (Procardia) cyclandelate (Cyclospasmol) phenoxybenzamine (Dibenzyline) help to relieve the symptoms can cause uncomfortable S/E (facial flushing, headaches, hypotension, and dizziness)
  142. 142. Sympathectomy For severe symptoms that cannot be alleviated by drugs lumbar sympathectomy physician cuts sympathetic nerve fibers that cause vasoconstriction of blood vessels in the lower extremities. effective when experiencing foot symptoms. sympathetic ganglionectomy for upper extremities, a similar procedure may provide symptom relief. long-term effectiveness is questionable.
  143. 143. Education of client is important inprevention of complications. Minimize exposure to cold remain indoors as much as possible during cold weather wear layers of clothing when outdoors hats and mittens or gloves should be worn at all times when outside. Use fabrics specially designed for cold climates (e.g., Thinsulate) warm up vehicles before getting in To avoid touching cold steering wheel or door handle, which could elicit an attack. during summer, a sweater should be available when entering air- conditioned rooms. Maintain warm body temperature
  144. 144. Methods to prevent vasoconstriction Avoid all forms of nicotine; Smoking cessation, nicotine gum or patches used to help people quit smoking may induce attacks Avoid decongestants and caffeine
  145. 145. Nursing Management decrease stress help the client to identify stressors and provides suggestions for reducing them. Stress management classes Avoid situations that may be stressful or unsafe. Safety Handle sharp objects carefully to avoid injuring the fingers. Inform abt postural hypotension that may result from medications (ex: calcium channel blockers) safety precautions related to alcohol, exercise, and hot weather.
  146. 146. Complications serious but uncommon Gangrene Amputation
  148. 148. Thoracic outlet syndrome is a compression of the subclavian artery at thoracic outlet by anatomic structures, such as a rib or muscle. arterial wall may be damaged, producing thrombosis or embolization to distal arteries of the arms. three common sites of compression in the thoracic outlet • The interscalene triangle • Between the coracoid process of the scapula and the pectoralis minor tendon • Most commonly, the costoclavicular space
  149. 149. more common in femalespeople whose occupations require holding their arms up orleaning over, such as baseball players, golfers, or swimmers.trauma (whiplash or after clavicular fracture)
  150. 150. s/s neck, shoulder, and arm pain : may be intermittent. numbness and moderate edema of extremity. pain and numbness worse when arm is placed in certain positions, such as over head or out to side. Clients may have overdeveloped neck and shoulder muscles, and the affected arm may appear cyanotic.
  151. 151. COLLABORATIVE MANAGEMENTPTExercisesAvoiding aggravating positions, such as elevating the arms.Surgical treatment resection of anatomic structure that is compressing the artery. performed only if has severe pain, has lost hand function, or is responding poorly to conservative treatment.
  152. 152. References Brunner Ignatavicius disease/DS00807/METHOD=print&DSECTION=all