ARTERIAL AND VENOUS DISORDERS

MAIN POINTS
y Raynauds disease y Buergers disease y Assessment of aortic aneurysms y Hypertension y Client instructions related to arterial and venous

disorders

SITES FOR PALPATING PERIPHERAL PULSES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

VEINS IN THE LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

VENOUS THROMBOSIS
y DESCRIPTION  Thrombus can be associated with an inflammatory process  When a thrombus develops, inflammation occurs that thickens the vein wall leading to embolization

TYPES OF VENOUS THROMBOSIS

y THROMBOPHLEBITIS  A thrombus associated with inflammation y PHLEBOTHROMBUS  A thrombus without inflammation y PHLEBITIS  Vein inflammation associated with invasive procedures such as IVs y DEEP VEIN THROMBOPHLEBITIS (DVT)  More serious than a superficial thrombophlebitis because of the risk for pulmonary embolism

RISKS FACTORS FOR VENOUS THROMBOSIS

y Venous stasis from varicose veins, heart failure, y y y y y y

immobility Hypercoagulability disorders Injury to the venous wall from IV injections, fractures, trauma Following surgery, particularly hip surgery and open prostate surgery Pregnancy Ulcerative colitis Use of oral contraceptives

PHLEBITIS
y ASSESSMENT  Red, warm area radiating up an extremity  Pain and soreness  Swelling y IMPLEMENTATION  Apply warm, moist soaks as prescribed to dilate the vein and promote circulation  Assess temperature of soak prior to applying  Assess for signs of complications such as tissue necrosis, infection, or pulmonary embolus

DEEP VEIN THROMBOPHLEBITIS (DVT)

y ASSESSMENT  Calf or groin tenderness or pain with or without swelling  Positive Homans sign  Warm skin that is tender to touch

DEEP VEIN THROMBOPHLEBITIS (DVT)

y IMPLEMENTATION  Provide bed rest  Elevate the affected extremity above the level of the heart as prescribed  Avoid using the knee gatch or a pillow under the knees  Do not massage the extremity  Provide thigh-high compression or antiembolism stockings as prescribed to reduce venous stasis and to assist in the venous return of blood to the heart

DEEP VEIN THROMBOPHLEBITIS (DVT)

y IMPLEMENTATION  Administer intermittent or continuous warm, moist compresses as prescribed  Palpate the site gently, monitoring for warmth and edema  Measure and record the circumference of the thighs and calves  Monitor for shortness of breath and chest pain, which can indicate pulmonary emboli

DEEP VEIN THROMBOPHLEBITIS (DVT)

y IMPLEMENTATION  Administer thrombolytic therapy (t-PA, tissue plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms  Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots  Monitor APTT during heparin therapy  Administer warfarin (Coumadin) therapy as prescribed when the symptoms of DVT have resolved

DEEP VEIN THROMBOPHLEBITIS (DVT)

y IMPLEMENTATION  Monitor PT and INR during warfarin (Coumadin) therapy  Monitor for the hazards and side effects associated with anticoagulant therapy  Administer analgesics as prescribed to reduce pain  Administer diuretics as prescribed to reduce lower extremity edema  Provide client teaching

ASSESSING FOR PERIPHERAL EDEMA

From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders

DEEP VEIN THROMBOPHLEBITIS (DVT)

y CLIENT EDUCATION  Hazards of anticoagulation therapy  Signs and symptoms of bleeding  Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated  Elevate the legs for 10 to 20 minutes every few hours each day  Plan a progressive walking program

DEEP VEIN THROMBOPHLEBITIS (DVT)

y CLIENT EDUCATION  Inspect the legs for edema and how to measure the circumference of the legs  Antiembolism stockings (hose) as prescribed  Avoid smoking  Avoid any medications unless prescribed by the physician  Importance of follow-up physician visits and laboratory studies  Obtain and wear a Medic Alert bracelet

ANTIEMBOLISM HOSE

From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

VENOUS INSUFFICIENCY
y DESCRIPTION  Results from prolonged venous hypertension that stretches the veins and damages the valves  The resultant edema and venous stasis causes venous stasis ulcers, swelling, and cellulitis  Treatment focuses on decreasing edema and promoting venous return from the affected extremity  Treatment for venous stasis ulcers focuses on healing the ulcer and preventing stasis and ulcer recurrence

VENOUS INSUFFICIENCY
y ASSESSMENT  Stasis dermatitis or discoloration along the ankles extending up to the calf  Edema  The presence of ulcer formation

PERIPHERAL VASCULAR DISEASE

From Bryant RA (1992): Acute and chronic wounds: nursing management, St. Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.

VENOUS INSUFFICIENCY
y WOUND CARE  Provide care to the wound as prescribed by the physician  Assess the clients ability to care for the wound, and initiate home care resources as necessary  If an Unna boot (a dressing constructed of gauze moistened with zinc oxide) is prescribed, it will be changed by the physician weekly

VENOUS INSUFFICIENCY
y WOUND CARE  The wound is cleansed with normal saline prior to application of the Unna boot; providone-iodine (Betadine) or hydrogen peroxide is not used because they destroy granulation tissue  The Unna boot is covered with an elastic wrap that hardens, to promote venous return and prevent stasis  Monitor for signs of arterial occlusion from an Unna boot that may be too tight  Keep tape off of the clients skin

VENOUS INSUFFICIENCY
y MEDICATIONS  Apply topical agents to wound as prescribed to debride the ulcer, eliminate necrotic tissue, and promote healing  When applying topical agents, apply an oil-based agent as petroleum jelly (Vaseline) on surrounding skin, because debriding agents can injure healthy tissue  Administer antibiotics as prescribed if infection or cellulitis occur

VENOUS INSUFFICIENCY
y CLIENT EDUCATION  Wear elastic or compression stockings during the day and evening as prescribed  Put on elastic stockings upon awakening before getting out of bed  Put a clean pair of elastic stockings on each day and that it will probably be necessary to wear the stockings for the remainder of life

VENOUS INSUFFICIENCY
y CLIENT EDUCATION  Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated  Elevate the legs for 10 to 20 minutes every few hours each day  Elevate legs above the level of the heart when in bed

VENOUS INSUFFICIENCY
y CLIENT EDUCATION  The use of an intermittent sequential pneumatic compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening  Advise the client with an open ulcer that the compression system is applied over a dressing

VARICOSE VEINS
y DESCRIPTION  Distended protruding veins that appear darkened and tortuous  Vein walls weaken and dilate, and valves become incompetent y ASSESSMENT  Pain in the legs with dull aching after standing  A feeling of fullness in the legs  Ankle edema

NORMAL VEINS AND VARICOSITIES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

VARICOSE VEINS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby

VARICOSE VEINS
y TRENDELENBURG TEST  Place the client in a supine position with the legs elevated  When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end

TRENDELENBURG TEST

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

VARICOSE VEINS
y IMPLEMENTATION  Assist with the Trendelenburg test  Emphasize the importance of antiembolism stockings as prescribed  Instruct the client to elevate the legs as much as possible  Instruct the client to avoid constrictive clothing and pressure on the legs  Prepare the client for sclerotherapy or vein stripping, as prescribed

SCLEROTHERAPY
y DESCRIPTION  A solution is injected into the vein followed by the application of a pressure dressing  An incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours

VEIN STRIPPING
y DESCRIPTION  Varicose veins are removed if they are larger than 4 mm in diameter or if they are in clusters y PREOPERATIVE  Assist the physician with vein marking  Evaluate pulses as a baseline for comparison postoperatively

VEIN STRIPPING
y POSTOPERATIVE  Maintain elastic (Ace) bandages on the clients legs  Monitor the groin and leg for bleeding through the elastic bandages  Monitor the extremity for edema, warmth, color, and pulses  Elevate the legs above the level of the heart

VEIN STRIPPING
y POSTOPERATIVE  Encourage range-of-motion exercises of the legs  Instruct the client to avoid leg dangling or chair sitting  Instruct the client to elevate the legs when sitting  Emphasize the importance of wearing elastic stockings after bandage removal

PERIPHERAL ARTERIAL DISEASE (PAD)

y DESCRIPTION  A chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients  Tissue damage occurs below the level of the arterial occlusion  Atherosclerosis is the most common cause of PAD

ARTERIES IN THE LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

PERIPHERAL ARTERIAL DISEASE (PAD)

y ASSESSMENT  Intermittent claudication (pain in the muscles resulting from an inadequate blood supply)  Rest pain, characterized by numbness, burning or aching in the distal portion of the lower extremities, that awakens the client at night and is relieved by placing the extremity in a dependent position  Lower back or buttock discomfort

PERIPHERAL ARTERIAL DISEASE (PAD)

y ASSESSMENT  Loss of hair and dry scaly skin on the lower extremities  Thickened toenails  Cold and gray-blue color of skin in the lower extremities  Elevational pallor and dependent rubor in the lower extremities  Decreased or absent peripheral pulses

PERIPHERAL ARTERIAL DISEASE (PAD)

y ASSESSMENT  Signs of arterial ulcer formation occurring on or between the toes, or on the upper aspect of the foot, that are characterized as painful  Blood pressure measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally BP readings in the thigh and calf are higher than those in the upper extremities)

ARTERIAL OBSTRUCTIONS AND CORRESPONDING AREAS OF CLAUDICATION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

ARTERIAL INSUFFICIENCY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

GANGRENE

From Auerbach PS: Wilderness Medicine: Management of wilderness and environmental emergencies, ed. 3, St. Louis, 1995, Mosby.

PERIPHERAL ARTERIAL DISEASE (PAD)

y IMPLEMENTATION  Assess pain  Monitor the extremities for color, motion and sensation, and pulses  Obtain BP measurements  Assess for signs of ulcer formation or signs of gangrene  Assist in developing an individualized exercise program that is initiated gradually and slowly increased

PERIPHERAL ARTERIAL DISEASE (PAD)

y IMPLEMENTATION  Encourage prescribed exercise, which will improve arterial flow through the development of collateral circulation  Instruct the client to walk to the point of claudication, stop and rest, then walk a little further

PERIPHERAL ARTERIAL DISEASE (PAD)

y IMPLEMENTATION  As swelling in the extremities prevents arterial blood flow, instruct the client to elevate his or her feet at rest, but to refrain from elevating them above the level of the heart, because extreme elevation slows arterial blood flow to the feet  In severe cases of PAD, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright in a chair for comfort

PERIPHERAL ARTERIAL DISEASE (PAD)

y CLIENT EDUCATION  Avoid crossing the legs, which interferes with blood flow  Avoid exposure to cold (causes vasoconstriction) to the extremities and to wear socks or insulated shoes for warmth at all times  Never to apply direct heat to the limb such as with a heating pad or hot water, because the decreased sensitivity in the limb may result in burning

PERIPHERAL ARTERIAL DISEASE (PAD)

y CLIENT EDUCATION  Inspect the skin on the extremities daily and to report any signs of skin breakdown  Avoid tobacco and caffeine because of their vasoconstrictive effects  Use of hemorrheologic and antiplatelet medications as prescribed  Importance of taking all medications prescribed by the physician

PERIPHERAL ARTERIAL DISEASE (PAD)

y PROCEDURES TO IMPROVE ARTERIAL BLOOD

FLOW
   

Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy Bypass surgery (aortofemoral or femoral-popliteal)

RAYNAUDS DISEASE
y DESCRIPTION  Vasospasms of the arterioles and arteries of the upper and lower extremities  Vasospasm causes constriction of the cutaneous vessels  Attacks are intermittent and occur with exposure to cold or stress  Affects primarily fingers, toes, ears, and cheeks

RAYNAUDS DISEASE
y ASSESSMENT  Blanching of the extremity, followed by cyanosis during vasoconstriction  Reddened tissue when the vasospasm is relieved  Numbness, tingling, swelling, and a cold temperature at the affected body part

RAYNAUDS PHENOMENON

From Barkauskas VH et al (1998) Health and physical assessment (2nd ed.). St. Louis: Mosby.

RAYNAUDS DISEASE
y IMPLEMENTATION  Monitor pulses  Administer vasodilators as prescribed  Assist the client to identify and avoid precipitating factors such as cold and stress y CLIENT EDUCATION  Medication therapy  Avoid smoking  Wear warm clothing, socks, and gloves in cold weather  Avoid injuries to fingers and hands

BUERGER'S DISEASE
y DESCRIPTION  An occlusive disease of the median and small arteries and veins  The distal upper and lower limbs are most commonly affected  Also known as thromboangiitis obliterans

BUERGER'S DISEASE
y ASSESSMENT  Intermittent claudication  Ischemic pain occurring in the digits while at rest  Aching pain that is more severe at night  Cool, numb, or tingling sensation  Diminished pulses in the distal extremities  Extremities are cool and red in the dependent position  Development of ulcerations in the extremities

BUERGER'S DISEASE
y IMPLEMENTATION  Instruct the client to stop smoking  Monitor pulses  Instruct the client to avoid injury to the upper and lower extremities  Administer vasodilators as prescribed  Instruct the client regarding medication therapy

AORTIC ANEURYSMS
y DESCRIPTION  Abnormal dilation of the arterial wall, caused by localized weakness and stretching in the medial layer or wall of an artery  The aneurysm can be located anywhere along the abdominal aorta  The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture

ARTERIAL OCCLUSION AND ANEURYSMS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

TYPES OF ANEURYSMS
y FUSIFORM  Diffuse dilation that involves the entire circumference of the arterial segment y SACCULAR  Distinct localized outpouching of the artery wall

TYPES OF ANEURYSMS
y DISSECTING  Created when blood separates the layers of the artery wall forming a cavity between them y FALSE (PSEUDOANEURYSM)  Occurs when the clot and connective tissue are outside the arterial wall  Formed after complete rupture and subsequent formation of a scar sac

TYPES OF ANEURYSMS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

THORACIC AORTIC ANEURYSM

y ASSESSMENT  Pain extending to neck, shoulders, lower back, or abdomen  Syncope  Dyspnea  Increased pulse  Cyanosis  Weakness

ABDOMINAL AORTIC ANEURYSM

y ASSESSMENT  Prominent, pulsating mass in abdomen, at or above the umbilicus  Systolic bruit over the aorta  Tenderness on deep palpation  Abdominal or lower back pain

RUPTURING ANEURYSM
y ASSESSMENT  Severe abdominal or back pain  Lumbar pain radiating to the flank and groin  Hypotension  Increased pulse rate  Signs of shock

RUPTURED ABDOMINAL AORTIC ANEURYSM

From Cotran RS, Kumar V, Collins T: Robbins pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

AORTIC ANEURYSMS
y DIAGNOSTIC TESTS  Done to confirm the presence, size, and location of the aneurysm  Includes abdominal ultrasound, CT scan, and arteriography

AORTIC ANEURYSMS
y IMPLEMENTATION  Monitor vital signs  Obtain information regarding back or abdominal pain  Question the client regarding the sensation of palpation in the abdomen  Inspect the skin for the presence of vascular disease or breakdown

AORTIC ANEURYSMS
y IMPLEMENTATION  Check peripheral circulation including pulses, temperature, and color  Observe for signs of rupture  Note any tenderness over the abdomen  Monitor for abdominal distention

AORTIC ANEURYSMS
y NONSURGICAL IMPLEMENTATION  Modify risk factors  Instruct the client regarding the procedure for monitoring BP  Instruct the client on the importance of regular physician visits to follow the size of the aneurysm

AORTIC ANEURYSMS
y NONSURGICAL IMPLEMENTATION  Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs, to notify the physician immediately  Instruct the client with a thoracic aneurysm to immediately report the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness

AORTIC ANEURYSMS
y PHARMACOLOGICAL IMPLEMENTATION  Administer antihypertensives to maintain the BP within normal limits and to prevent strain on the aneurysm  Instruct the client in the purpose of the medications  Instruct the client about the side effects and schedule of the medication

ABDOMINAL AORTIC ANEURYSM RESECTION

y DESCRIPTION  Surgical resection or excision of the aneurysm  The excised section is replaced with a graft that is sewn end-toend

ANEURYSM RESECTION WITH GRAFT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

ABDOMINAL AORTIC ANEURYSM RESECTION

y PREOPERATIVE  Assess all peripheral pulses as a baseline for postoperative comparison  Instruct the client on coughing and deep-breathing exercises  Administer bowel preparation as prescribed

ABDOMINAL AORTIC ANEURYSM RESECTION

y POSTOPERATIVE  Monitor vital signs  Monitor peripheral pulses distal to the graft site  Monitor for signs of graft occlusion, including changes in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention  Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft

ABDOMINAL AORTIC ANEURYSM RESECTION

y POSTOPERATIVE  Monitor for hypovolemia and renal failure due to significant blood loss during surgery  Monitor urine output hourly, and notify the physician if it is less than 50 ml per hour  Monitor serum creatinine and BUN daily  Monitor respiratory status and auscultate breath sounds to identify respiratory complications

ABDOMINAL AORTIC ANEURYSM RESECTION

y POSTOPERATIVE  Encourage turning, coughing and deep breathing, and splinting the incision; ambulate as prescribed  Maintain nasogastric tube to low suction until bowel sounds return  Assess for bowel sounds and report their return to the physician  Monitor for pain and administer medication as prescribed  Assess incision site for bleeding or signs of infection

ABDOMINAL AORTIC ANEURYSM RESECTION

y POSTOPERATIVE  Prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions  Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks  Advise the client to avoid activities requiring pushing, pulling, or straining  Instruct the client not to drive a vehicle until approved by the physician

THORACIC AORTIC ANEURYSM REPAIR

y DESCRIPTION  A thoracotomy or median sternotomy approach is used to enter the thoracic cavity  The aneurysm is exposed, excised, and a graft or prosthesis is sewn onto the aorta  Total cardiopulmonary bypass is necessary for excision of aneurysms in the ascending aorta  Partial cardiopulmonary bypass is used for clients with an aneurysm in the descending aorta

THORACIC AORTIC ANEURYSM REPAIR

y POSTOPERATIVE  Monitor vital signs  Monitor for signs of hemorrhage such as a drop in BP, increased pulse rate and respirations, and report to the physician immediately  Monitor chest tubes for an increase in chest drainage, which may indicate bleeding or separation at the graft site

THORACIC AORTIC ANEURYSM REPAIR

y POSTOPERATIVE  Assess sensation and motion of all extremities and notify the physician if deficits occur, which can be due to a lack of blood supply during surgery  Monitor respiratory status and auscultate breath sounds to identify respiratory complications  Encourage turning, coughing, and deep breathing, splinting the incision  Monitor cardiac status for dysrhythmias

THORACIC AORTIC ANEURYSM REPAIR

y POSTOPERATIVE  Monitor for pain and administer medication as prescribed  Assess the incision site for bleeding or signs of infection  Prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions

THORACIC AORTIC ANEURYSM REPAIR

y POSTOPERATIVE  Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks  Advise the client to avoid activities requiring pushing, pulling, or straining  Instruct the client not to drive a vehicle until approved by the physician

EMBOLECTOMY
y DESCRIPTION  Removal of an embolus from an artery using a catheter  A patch graft may be required to close the artery

EMBOLECTOMY
y PREOPERATIVE  Obtain a baseline vascular assessment  Administer anticoagulants as prescribed  Administer thrombolytics as prescribed  Place a bed cradle on the bed  Avoid bumping or jarring the bed  Maintain the extremity in slightly dependent position

EMBOLECTOMY
y POSTOPERATIVE  Assess cardiac, respiratory, and neurological status  Monitor affected extremity for color, temperature, and pulse  Assess sensory and motor function of the affected extremity  Monitor for signs and symptoms of new thrombi or emboli  Administer oxygen as prescribed  Monitor pulse oximetry

EMBOLECTOMY
y POSTOPERATIVE  Monitor for complications caused by reperfusion of the artery, such as spasms and swelling of the skeletal muscles  Monitor for signs of swollen skeletal muscles, such as edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness  Maintain bed rest initially, with the client in semi-Fowlers position  Place a bed cradle on the bed

EMBOLECTOMY
y POSTOPERATIVE  Check the incision site for bleeding or hematoma  Administer anticoagulants as prescribed  Monitor laboratory values related to anticoagulant therapy  Instruct the client to recognize the signs and symptoms of infection and edema  Instruct the client to avoid prolonged sitting or crossing the legs when sitting

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

y VENA CAVAL FILTER  Insertion of an intracaval filter (umbrella) that partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli y LIGATION  Suturing or placing clips on the inferior vena cava to prevent pulmonary emboli

VENA CAVAL FILTERS

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

y PREOPERATIVE  If the client has been taking an anticoagulant, consult with the physician regarding discontinuation of the medication to prevent hemorrhage

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

y POSTOPERATIVE  Monitor vital signs  Assess cardiac and respiratory status  Administer oxygen as prescribed  Monitor pulse oximetry  Maintain semi-Fowlers position  Avoid hip flexion  Maintain antiembolism stockings as prescribed

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

y POSTOPERATIVE  Provide activity as prescribed  Check the insertion site for bleeding and hematoma  Assess for peripheral edema  Monitor laboratory values related to anticoagulant therapy

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

y CLIENT EDUCATION  Signs and symptoms of infection and edema  Avoid prolonged sitting or crossing legs when sitting  Elevate the legs when sitting  Wear antiembolism stockings as prescribed and how to remove and reapply the stockings  Ambulate daily  About anticoagulant therapy and the hazards associated with anticoagulants

HYPERTENSION
y DESCRIPTION  Persistent elevation of the systolic blood pressure above 140 mmHg and the diastolic blood pressure above 90 mmHg  Most significant predictor of developing coronary artery disease and a major risk factor for coronary, cerebral, renal, and peripheral vascular disease  The disease is initially asymptomatic

HYPERTENSION
y DESCRIPTION  The goals of treatment include to reduce the blood pressure and to prevent or lessen the extent of organ damage  Nonpharmacological approaches, such as lifestyle changes, may be initially prescribed and if the BP cannot be decreased after a reasonable time period (1 to 3 months), then the client may require pharmacological treatment

HYPERTENSION ORGAN INVOLVEMENT

y EYES  Visual changes y BRAIN  Cerebrovascular accident (CVA) y CARDIOVASCULAR SYSTEM  Congestive heart failure (CHF), hypertensive crisis y KIDNEYS  Renal failure

HYPERTENSIVE RETINOPATHY

From Michelson JB, Friedlaender MH (1996) The eye in clinical medicine. London: Times Mirror International Publishers.

HYPERTROPHY OF THE LEFT VENTRICLE IN HYPERTENSION

From Cotran RS, Kumar V, Collins T: Robbins pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

HYPERTENSION
y TYPES  Primary or essential  Secondary

PRIMARY OR ESSENTIAL HYPERTENSION

y DESCRIPTION  No known etiology y RISK FACTORS  Aging  Family history  Black race with higher prevalence in males  Obesity  Smoking  Stress

SECONDARY HYPERTENSION
y DESCRIPTION  Occurs as a result of other disorders or conditions  Treatment depends on the cause and the organs involved y PRECIPITATING CONDITIONS  Cardiovascular disorders  Renal disorders  Endocrine system disorders  Pregnancy  Medications

HYPERTENSION
y ASSESSMENT  May be asymptomatic  Headache  Visual disturbances  Dizziness  Chest pain  Tinnitus  Flushed face  Epistaxis

HYPERTENSION
y IMPLEMENTATION: GOALS  To reduce the blood pressure  To prevent or lessen the extent of organ damage

HYPERTENSION

y IMPLEMENTATION  Question the client regarding the signs and symptoms indicative of hypertension  Obtain the blood pressure (BP) two or more times on both arms with the client supine and standing; compare the BP with prior documentation  Determine family history of hypertension  Identify current medication therapy  Obtain weight  Evaluate dietary patterns and sodium intake

HYPERTENSION
y IMPLEMENTATION  Assess for visual changes or retinal damage  Assess for cardiovascular changes, such as distended neck veins, increased heart rate, dysrhythmias  Evaluate chest x-ray for heart enlargement  Assess neurological system  Evaluate renal function  Evaluate results of diagnostic and laboratory studies

HYPERTENSION
y NONPHARMACOLOGICAL  Weight reduction, if necessary, or maintenance of ideal weight  Dietary sodium restriction to 2 g daily as prescribed  Moderate intake of alcohol and caffeine-containing products  Initiation of a regular exercise program

HYPERTENSION
y NONPHARMACOLOGICAL  Avoidance of smoking  Relaxation techniques and biofeedback therapy  Elimination of unnecessary medications that may contribute to the hypertension

HYPERTENSION: STEPPED CARE APPROACH

y DESCRIPTION  If a pharmacological approach to treating hypertension is required, a single medication is prescribed and monitored for its effectiveness  Medications are added to the treatment regimen until the BP is controlled  Refer to the module entitled Cardiovascular Medications, for information regarding medications to treat hypertension

HYPERTENSION: STEPPED CARE APPROACH

y STEP 1  A single medication is prescribed, which may be a diuretic, beta blocker, calcium channel blocker, or angiotensin-converting enzyme (ACE) inhibitor y STEP 2  Step 1 therapy is evaluated after 1 to 3 months  If the response is not adequate, compliance is evaluated  The medication may be increased or a new medication is prescribed, or a second medication is added to the treatment plan

HYPERTENSION: STEPPED CARE APPROACH

y STEP 3  Compliance is evaluated  Further evaluation of Step 2  If a therapeutic response is not adequate, a second medication is substituted or a third medication is added to the treatment plan y STEP 4  Compliance is evaluated  Careful assessment of factors limiting the antihypertensive response is done  A third or fourth medication may be added to the treatment plan

HYPERTENSION: CLIENT EDUCATION

y Importance of compliance with the treatment plan y The disease process, explaining that symptoms

y y y y

usually do not develop until organs have suffered damage Planning a regular exercise program, avoiding heavy weight lifting and isometric exercises Importance of beginning the exercise program gradually Express feelings about daily stress Identify ways to reduce stress

HYPERTENSION: CLIENT EDUCATION

y Relaxation techniques y Incorporate relaxation techniques into the daily y y y y

living pattern Technique for monitoring blood pressure Maintain a diary of blood pressure readings Importance of lifelong medication and the need for follow-up treatment Dietary restriction, which may include sodium, fat, calories, and cholesterol

HYPERTENSION: CLIENT EDUCATION

y How to shop and prepare low-sodium meals y List of products that contain sodium y Read labels of products to determine sodium content

focusing on substance listed as sodium, NaCl, and MSG y Bake, roast, or boil foods, avoid salt in preparation of foods, and avoid using salt at the table y Fresh foods are best to consume and to avoid canned foods

HYPERTENSION: CLIENT EDUCATION

y The action, side effects, and scheduling of

medications y If uncomfortable side effects occur, to contact the physician and not to stop the medication y Avoid over-the-counter medication y Importance of follow-up care

HYPERTENSIVE CRISIS
y DESCRIPTION  Any clinical condition requiring immediate reduction in blood pressure  An acute and life-threatening condition  The accelerated hypertension requires emergency treatment, since target organ damage (brain, heart, kidneys, retina of the eye) can occur quickly  Death can be caused by stroke, renal failure, or cardiac disease

HYPERTENSIVE CRISIS
y ASSESSMENT  A diastolic pressure above 120 mmHg  Headache  Drowsiness  Confusion  Changes in neurological status  Tachycardia and tachypnea  Dyspnea  Cyanosis  Seizures

HYPERTENSIVE CRISIS
y IMPLEMENTATION  Maintain a patent airway  Administer IV antihypertensive medications as prescribed  Monitor vital signs assessing BP every 5 minutes  Assess for hypotension during the administration of antihypertensives  Place the client in a supine position if hypotension occurs

HYPERTENSIVE CRISIS
y IMPLEMENTATION  Have emergency medications and resuscitation equipment readily available  Maintain bed rest, with the head of the bed elevated at 45 degrees  Monitor IV therapy assessing for fluid overload  Monitor I&O  Insert Foley catheter as prescribed  Monitor urinary output, and if oliguria or anuria occurs, notify the physician