Vascular Disorders

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Vascular Disorders
2010-03-11 16:19:24
Med Surg I Vascular Disorders

Med Surg I Vascular Disorders
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  1. What is aortic aneurysm?
    • Weakened, bulging area of vessel wall
    • Results from atherosclerosis which weakens media
    • Incidence is 5-7% over age of 60
    • Risk factors: smoking, diabetes, HTN, hyperlipidemia
    • Diagnosing: Sonogram (screening), CT more accurate to determine length and diameter
  2. Clinical manifestations of aortic aneurysm
    • Often asymptomatic
    • Found on sonogram or CT
    • May note pulsatile mass on exam
    • Thrombi and plaque can embolize to lower extremities causing blue toe syndrome
    • Rupture is usually fatal
    • Posterior rupture may be tamponaded
    • Leads to retroperitoneal bleed
    • Grey turner's sign
  3. Treatment of aortic aneurysm
    • Small aneurysm: less than 4cm may be watched; control of BP; risk factor modification
    • Repair indicated for > 5-6cm unless not a surgical candidate (e.g. terminal illness, unlikely to survive surgery)
    • Endovascular repair: synthetic graft threaded into aneurysm via femoral artery; much less invasive; risk of leakage
    • Open repair: aorta cross-clamped for 30-45minutes; diseased segment removed and synthetic graft is sutured in; risk for ischemia below cross-clamped area (kidney damage, SCI, due to interruption of blood flow)
    • Open repair is more definitive, but has severe surgical mortality
  4. Post-op nursing care of aneurysm repair
    • SICU post-op (pt will be intubated, will likely have CVP monitor, A-line, NG tube, multiple IVs, foley, tele)
    • Thoracic aneurysm will have thoracotomy (chest tubes)
    • Maintain BP (if BP too high, graft can rupture; if too low, thrombosis can occur)
    • Pain control
    • Monitor renal function (Cr, BUN, hourly urine output, electrolytes, CVP)
    • Monitor for infection (WBCs, fever, wound drainage, IV sites, foley, graft infection is serious complication)
    • Monitor GI function (bowel sounds, distention)
    • Monitor neuro status (especially peripheral neuro, make sure no damage below level of cross-clamping; LOC)
  5. Why is monitoring urine output critical?
    Cardiac output and renal perfusion
  6. Aortic aneurysm repair discharge teaching
    • No lifting for 4-6 weeks
    • Monitor for infection (fever, inflammation at site, drainage, redness)
    • Antibiotic prophylaxis
    • Risk factor modification
  7. What is aortic dissection?
    • Tear in the intima
    • Allows blood to enter between intima and media (false lumen)
    • May impede blood flow to brain, spinal cord, kidneys, and extremities
    • Rupture is usually fatal
    • Risk factors: Marfan's syndrome (connective tissue disorder), chronic HTN (incr stress on arteries), elderly
    • Dx: Chest x-ray shows widened mediastinum, CT
    • Tx: Lower BP with nitroprusside or beta blocker, plan for surgical repair
  8. Clinical manifestations of aortic dissection
    • Sudden severe chest pain described as tearing radiating to back and shoulders
    • Significantly different BP and pulses between extremities (uneven perfusion between limbs)
    • Neurological compromise
    • Aortic valve insufficiency
    • Cardiac tamponade
  9. Aortic dissection nursing care
    • Critical care monitoring (a-line, tele)
    • Titrate med to BP (Esmolol beta blocker; adjust drips to keep BP within parameters)
    • On-going assessment (peripheral pulses, neuro status, heart and lung sounds)
    • Pain management (continue to assess and admin analgesics based on assessment and orders)
    • Psychological support
    • Prepare patient for surgery (consent signed, pre-op meds, NPO)
  10. What is peripheral arterial disease?
    • Severe atherosclerosis occludes blood flow to extremities
    • Results in ischemia of muscle and nerve tissue
    • Risk factors: smoking, diabetes, HTN, hyperlipidemia
  11. Clinical manifestations of peripheral arterial disease
    • Intermittent claudication (pain during exertion from anaerobic metabolism and lactic acid build-up; resolves with rest; one of first symptoms)
    • Neuropathy (especially in diabetics; nerve damage from chronic ischemia resulting in numbness, tingling, burning pain)
    • Diminished or absent pulses
    • Trophic changes (skin is thin, pale, shiny; no hair growth; fungus in toenails)
    • Arterial ulcers (minor trauma may lead to difficult to heal ulcers because perfusion is so poor; teach pt to check feet daily especially if have neuropathy)
    • Gangrene (may necessitate amputation)
  12. Diagnosing peripheral arterial disease
    • Arterial duplex: non-invasive sonogram to determine degree of arterial flow and location of blockages
    • Ankle-Brachial Index (ABI)
    • Angiography: invasive study, dye is injected and x-rays are taken; definitive study of degree and location of stenosis; done if surgery is planned (stent or bypass); NPO, consent, dye allergies, no Metformin for 48 hours
  13. What is the Ankle-Brachial Index?
    • Ratio of ankle SBP (post tibial artery) to highest brachial SBP
    • BP in legs should be higher than BP in arms
    • Normally 0.9 to 1.3
    • 0.5 to 0.9 indicates mild to moderate disease
    • Less than 0.5 indicates severe disease
  14. Treatment of peripheral arterial disease
    • Risk factor modification (smoking cessation, control of BP, lipids, diabetes)
    • Exercise (slightly beyond point of claudication to try to get cells to utilize O2 and develop collateral circulation)
    • Medications (stains, anti-platelets)
    • Pentoxipfylline (Trental): older med; makes red cells a little more slippery so can get into tighter spaces; better able to deliver O2 to tissue; anti-platelet characteristics
    • Cilostizol (Pletal): newer med; inhibits platelet aggregation and promotes vasodilation; can worsen heart failure
    • Angioplasty with stent placement
    • Bypass surgery
    • Amputation
  15. Patient education
    • Smoking cessation
    • Inspect feet daily (don't cut own toenails)
    • Protect feet from injury
    • Podiatry referral
  16. Arterial bypass surgery post-op nursing care
    • Monitor surgical site (bleeding, signs of infection)
    • Monitor peripheral neurovascular status distal to site, "6 P's": pallor, pain, paralysis, parasthesia (tingling, numbness), pulselessness, poikilothermia (one extremity is colder than the other)
    • Pain management
    • Promote mobility (early ambulation to promote blood flow thru graft)
    • Discharge teaching (medications and side effects, foot care, monitor incision, need for exercise, monitor changes in perfusion, color changes)
  17. Vein function
    • Low pressure, high volume system
    • Valves prevent back flow of blood against gravity
    • Muscle activity compresses vessel and pushes blood back towards heart
    • Thrombophlebitis (inflammation and thrombosis of vein)
    • Relies on valves, muscle activity, and changes in thoracic pressure to push blood back up to heart
  18. Virchow's Triad
    • Venous stasis (immobility)
    • Endothelial damage
    • Hypercoagulability
    • Factors predisposing to thrombophlebitis (elderly, immobility, CHF, atrial fib, bedrest, CVA, varicose veins, pregnancy, orthopedic surgery)
    • IVs, trauma, previous clot, leg fracture
    • Smoking, dehydration, malignancy, oral contraceptives, hormone replacement therapy, coagulation defects, sepsis
  19. What is superficial thrombophlebitis?
    • Palpable cordlike vein
    • Upper extremity usually at IV site; lower extremity usually trauma to varicose vein
    • Clinical manifestations: tenderness, erythema, low grade fever
    • No embolization risk
    • Tx: remove IV, analgesics (aspirin), elevate extremity, warm moist heat
  20. Deep vein thrombosis (DVT)
    • High risk of embolization
    • Effects 5% of surgical patients
    • Clinical manifestations: unilateral edema, pain, erythema, low grade fever, +/- Homan's sign
    • Complications: pulmonary embolism (SOB, pleuritic chest pain, hypoxia, tachycardia), chronic vein insufficiency, arterial compromise due to severe edema (rare)
  21. DVT prevention
    • Mobilization (get post-op and post partum patients out of bed ASAP)
    • Ankle pumps (promote venous return back to heart)
    • TEDs (compression hose encourage venous return; important that they are properly fitted without wrinkles)
    • Sequential Compression Devices (SCDs)
    • Anticoagulation (low molecular weight heparin is becoming tx of choice for DVT prevention in orthopedic and trauma patients; fewer bleeding complications; no need to titrate)
  22. DVT diagnosis and treatment
    • Venous doppler (non-invasive; usually sufficient to make dx)
    • Anticoagulation with Heparin and Warfarin (initiate both because Warfarin takes 3-5 days to become therapeutic)
    • INR goal of 2.0 to 3.0
    • Admission for IV unfractionated heparin or outpatient treatment with low molecular weight heparin
    • Heparin drip APTT 1.5 to 2.5 x control; monitor for HIT and bleeding; Must teach patient or family LMWH subq injection technique
    • Continue Warfarin 3 to 6 months after resolution
    • TEDs when ambulating
    • Recurrent DVT requires life long anticoagulation
    • Inferior Vena Cava filter for high risk of embolization or recurrent DVT (IVC filter placed in interventional radiology; catches clots)
    • Catheter-Directed Thrombolysis (CDT)
  23. Bleeding complications
    • Monitor CBC, coagulation studies (PTT & PT/INR; look for new anemia; platelet counts)
    • Assess for bruising, mental status change, hematuria, GI bleed, epistaxisis (observe for indication of hemorrhage or excessive anticoagulation)
    • Protamine sulfate: antidote to heparin
    • Vitamin K: antidote to coumadin
    • Fresh frozen plasma (for acute hemorrhage; contains multiple activated clotting factors)
    • Monitor PTT when on heparin; heparin can cause heparin induced thrombocytopenia
  24. Warfarin (Coumadin) teaching
    • Observe for bleeding (report to health care provider or ER if severe)
    • PT/INR (routine lab monitoring)
    • Missed dose (don't double up unless instructed to)
    • Avoid OTC, especially aspirin and NSAIDs
    • Multiple drug interactions
    • Avoid excessive intake or fluctuations in intake of Vitamin K rich foods
    • Avoid trauma (use soft toothbrush, electric razor; no contact sports)
    • Medic-alert bracelet
    • Direct pressure to stop bleeding
  25. What is a pulmonary embolism?
    • Blockage of pulmonary artery or main branches by thrombi, fat, or air (usually thrombus)
    • Sources: thrombi from deep veins in legs or right atrium, fat from long bone fractures, air from open central line
    • Pulmonary infarction is rare (due to bronchial circulation)
  26. Clinical manifestations of a PE
    • Dyspnea, tachycardia, tachypnea, hypoxia (caused by ventilation/perfusion mismatch)
    • Anxiety (caused by hypoxia)
    • Pleuritic chest pain (worse with cough, deep breath)
    • Cough, hemoptysis (pleural irritation)
    • HPN, Shock (impaired cardiac output due to inadequate return to left ventricle)
    • Pulmonary HTN (results from recurrent PEs)
    • Sudden collapse and death (if severe; due to lack of cardiac output)
  27. Diagnosing PE
    • Spiral CT (test of choice; minimally invasive, good specificity and sensitivity)
    • V/Q scan (Nuclear med; injection and inhalation of radioisotope tracer; looks for ventilation perfusion mismatch; reports probabilities; either high or low probability; not 100% confirmation)
    • D-Dimer (blood test looks for fibrin degradation products; if normal, low probability of PE; positive test indicates there is a clot somewhere)
    • Venous doppler (looks for source; confirms diagnosis if in doubt)
    • Pulmonary angiography (definitive; invasive)
  28. Treatment of PE
    • Hospitalization
    • Heparin drip (titrate heparin to APTT; target: 1.5 to 2.5)
    • O2 to maintain sats
    • Morphine for pain
    • Monitor ABGs, coags, vitals, EKG, cardiopulmonary status
    • Possible IVC filter
    • Emergent embolectomy low survival rate
  29. APTT calculation
    • 1.5 to 2.5 x control
    • Example1: Patient - 80, control - 28 (range 42-70); patient APTT is too high
    • Example2: Patient - 49, control - 28; patient APTT is within range
    • Example3: Patient - 30, control - 28; patient APTT is too low
  30. What are varicose veins?
    • Large, dilated subcutaneous veins
    • Familial, usually result from valvular incompetence
    • Risk factors: obesity, pregnancy, DVT, excessive standing
    • Symptoms: ache after prolonged standing, edema
    • Conservative treatment: avoid prolonged sitting or standing; avoid constrictive clothing; walking to promote venous return; support/compression stockings
    • Invasive treatment: sclerotherapy or vein stripping
  31. What is venous insufficiency?
    • Incompetent valves in deep veins; inadequate venous return
    • Results in increased hydrostatic pressure, interstitial edema, leak of RBCs
    • Causes edema, staining of skin (from hemoglobin in interstitial tissue), dermatitis
    • Compression: patients often require high grade medical compression stockings to control edema
    • Leg elevation above heart level
    • Low sodium diet to decrease edema
    • Skin care to treat dermatitis, prevent breakdown, cellulitis
  32. What are venous stasis ulcers?
    • Painful, weeping ulcers with irregular borders
    • Etiology: severe venous insufficiency
    • Often above medial malleolus
    • Must have compression to heal
    • Ensure adequate arterial circulation prior to applying high levels of compression (ABI to ensure adequate arterial flow, ABI < 0.8 contraindication to high grade compression)
    • Slow healing
    • Maintain moist wound bed but absorb excess drainage
    • Observe for cellulitis
    • May require grafting