CH 30 VASCULAR DISORDERS AND PROBLEMS
ARTERIES
IN PERIPHERAL CIRCULATION
VASCULAR SYSTEM
 Function is to maintain blood flow to
supply adequate oxygen and nutrients to
all tissues
 Delivery of oxygen and nutrients to the
tissues depends on adequate perfusion
(blood flow) which requires a functionally
intact cardiovascular system
 When the vascular system is compromised
by vascular disease, homeostasis of the
body is affected
 Any interruption of the blood flow results
in tissue hypoxia which can lead to tissue
necrosis if untreated
 Vascular diseases can affect the arterial and
venous components of the circulation
 Arteries distribute oxygenated blood from
the left side of the heart to the tissues.
 Veins carry deoxygenated blood from the
tissues to the right side of the heart.
 Capillary vessels located within the tissues
connect the arterial and venous system.
The vessel permit the exchange of
nutrients and metabolic waste between the
circulatory system and tissues.
 Arterioles and venules immediately
adjacent to the capillaries, together with
the capillaries, make up the
microcirculation.
3 TYPES OF BLOOD VESSELS
 ARTERY
 VEIN
 CAPILLARY
1.
 Vessels that carry blood away from the
heart towards the tissues.
 Thick walls with 3 layers: intima, media,
and adventitia.
 Smooth muscles encircle and control the
diameter
 Contraction of muscles constrict arteries
 Relaxation of muscles dilate arteries
2. VEINS
 The vessels that return blood to the heart
 Composed of the same layers as the
arteries and arterioles, but layers are less
defined, thinner and less muscular but
stretched more than those of the arteries.
Can store large volume of blood
 Veins have valves to:
 allow blood to move in only one direction
 prevent backflow of blood in the
extremities
3. CAPILLARIES
 Arterioles branch into progressively
smaller vessels to form capillaries (single
layer of endothelial cells) that:
 allow efficient delivery of nutrients and
oxygen into the tissues
 removal of metabolic wastes from the
tissues
 Venules are tiny vessels/smallest veins that
receive blood from the capillaries
4. LYMPHATIC VESSELS
 Collects the lymphatic fluid from the
tissues and organs, and transports the fluid
to the venous circulation.
  Two main structure: thoracic duct and
right lymphatic duct
 These ducts empty into the junction of the
subclavian and internal jugular veins.
 Right Lymphatic Duct conveys lymph
primarily from the right side of the head,
neck, thorax, and upper arms.
 Thoracic Duct conveys lymph from the
remainders of the body
 Lymph nodes play an important role in
filtering foreign particles
FACTORS THAT AFFECT BLOOD FLOW
1. Resistance within the vessels is controlled
by the diameter of the vessels:
 When vascular diameter increases
(vasodilation), peripheral resistance falls
and blood flow increases.
 Sympathetic nervous system stimulation
causes release of epinephrine and
norepinephrine, kidneys release
angiotensin II which can cause
vasoconstriction.
 When vascular diameter decreases
(vasoconstriction), peripheral resistance
increases, reducing blood flow.
 Vasodilation is due to release of kinins,
histamine, serotonins and prostaglandin.
 The diameter of peripheral blood vessels is
regulated by the vasomotor center in the
medulla and pons
2. Blood viscosity: thickness of the blood
 An increase in RBC or decrease in the body
water produces hemoconcentration which
increases blood viscosity
 When blood is concentrated, kidneys begin
to retain water.
 Important factor: capillary permeability.
 Hydrostatic pressure and osmotic (oncotic)
pressure maintain balanced movement of
fluids in and out of the capillaries
AGE RELATED CHANGES
ARTERIOSCLEROSIS is the primary age-related
change.
 Stiffening of the vessel walls: delivery of
oxygen and nutrients to tissues is
compromised; buildup of waste products in
tissue
 Loss of elasticity: increases peripheral
resistance which impairs blood flow which
increases ventricular workload.
 Decrease of hemoglobin: produces a
decline in the oxygen carrying capacity of
the blood.
 Slowing heart rate and decrease in stroke
volume: may result in 30 to 40% decrease
in cardiac output
FOCUSES ON 6 CLASSIC P’s OF PERIPHERAL
VASCULAR DISEASE
1. PAIN
 Angina is pain due to decrease perfusion
aggravated by exercise and relieved by rest
 It is a feeling of tightness, burning, fatigue,
aching or cramping.
 When blood supply to the muscle group is
decreased, the muscles are unable to
receive adequate blood flow to supply
nutrients and oxygen and remove
metabolic waste, ischemia develops
causing pain. When activity stops, pain
subsides
 Acute arterial occlusion indicates severe
arterial occlusion can cause tissue ischemia
 in the extremity with severe, burning pain
in the legs and feet after lying flat for a
period of time.
 Pain is relieved when legs are elevated that
promotes blood flow by gravity
Review of systems:
2. PULSELESSNESS
 palpate peripheral pulses for rate,
rhythm and quality.
 Compare pulses bilaterally to determine
differences
3. PARALYSIS
 Impairment of motor functions (impaired
conduction of nerve impulses)
4. PALLOR
PHYSICAL EXAMINATION
 Due to reduced blood supply. Detected by
inspecting site and compare skin color with
other skin areas.
5. PARESTHESIA
 Abnormal sensation (numbness, tingling
“pins and needles” sensation or crawling
sensation.
6. POIKILOTHERMIA
 Is creased temperature at the ischemic site
detected by palpating the affected and
surrounding areas. Feels cooler than the
rest.
ASSESSMENT OF THE VASCULAR SYSTEM
a. Past Medical History: cardiovascular
history, CAD, Ml, hypertension,
atherosclerosis, DM
b. Family History: relevant diseases:
hypertension, CAD, Ml, atherosclerosis,
aneurysm, and diabetes
c. Functional assessment: determines the
effect of the disease on the patient's life:
pain, inactivity, amputation
d. Smoking history, dietary habits (high fat
intake), exercise
 Changes associated with PVD: thick, brittle
nails; shiny, taut, scaly, dry skin; skin
temperature; skin ulcers; muscle atrophy;
localized redness and hardness; hair loss on
extremities
 Assess for chest pain and dyspnea {PE)
 Assess for symptoms of aneurysms:
hoarseness, dysphagia, dyspnea, abdominal
or back pain, or swelling of the head and
arms
 determine whether it is arterial or venous
in nature. Arterial complications involve
multiple areas. Venous complications are
more localized
Inspect the skin for color and lesions:
 Pallor is vasoconstriction (inadequate
blood flow)
 Reddish brown 'rubor' in lower extremities
is arterial occlusion
 Brownish discoloration is venous disorders
 Open ulcers, scars around ankles, stasis
dermatitis (brown pigmentation with flaky
skin over edematous areas)
 Arterial stasis: begins with ulcers in the
toes, painful pale and crusty
 Venous stasis: ulcers in the ankle areas,
develop slowly, painless, difficult to heal
  Capillary refill time to determine adequacy
of peripheral perfusion: >3 seconds is
reduction in peripheral perfusion
 Palpate affected areas to evaluate
temperature (cool limb is arterial problem;
warm limb is venous disorder)
 Pulsating mass in the abdomen maybe an
aneurysm
THERAPEUTIC INTERVENTIONS
Detect edema
 Buerger-Allen exercises allow gravity to fill
 press thumb in the edematous area for 5
and empty the blood vessel.
seconds.
 Stress management: emotional stress
Severity is graded as: causes vasoconstriction
 Pain management: when intermittent
 less than 1/4 inch is 1
claudication occurs, stops exercise, once
 ¼ to ½ inch is 2
pain goes away, activity is resumed
 ½ to 1 inch is 3
 Smoking cessation: vasoconstriction occurs
 more than 1 inch is 4
for up to 1 hour after a cigarette has been
 If depression remains, it is pitting edema
smoked. Smoking causes vasospasm
Peripheral pulses for presence, symmetry,
 Elastic stockings: proper size, applied in
volume, and rhythm
the morning. Remove 10-20min twice a

 Upper extremities: brachial, ulnar and day, check skin for irritation

radial
BUERGER-ALLEN EXERCISE
 Lower extremities: femoral, popliteal,
A: 2 to 3 minutes
dorsalis pedis, and posterior tibial arteries
 Sclerotic vessel feels stiff and cordlike B: 5 to 10 minutes
 Normal vessel is soft and springy
 Homan’s Sign; pain in the calf area or
behind the knee after dorsiflexing the foot
while the knee is slightly flexed
 Allen Test; to determine the adequacy of
arterial circulation in the hand when the
palm return to normal color when pressure
is released from the ulnar artery.
 Bruit; turbulent, fast moving fluid when Surgical Procedures:
vessel is auscultated.
Nursing Care related to Surgery
Palpating Distal Pulses (Lower Extremities)
Preoperative nursing care
  Patient with severe cardiovascular disease
have activity restrictions to reduce
demands on circulatory system until the
surgical procedure is done
 Optimize peripheral circulation: keep
extremity warm
 Protect the limb from further injury

Postoperative nursing care

 Primary goal: to stimulate circulation by

ARTERIAL EMBOLISM
encouraging movement and preventing
stasis within the extremity  If a thrombus breaks up and travel, it

 Evaluate tissue perfusion: color, becomes an embolus (thromboembolism)

temperature, pain, tenderness, cap refill, traveling in the circulatory system until it

edema, quality of peripheral pulses, lodges in a vessel blocking blood flow distal

exercise tolerance to the occlusion.

 Do not cross legs, avoid keeping legs in  Embolism: sudden obstruction of a blood

dependent position for long periods of vessel by a debris. Effects of arterial

time. Elevate legs occlusion depend on the size of embolus

ARTERIAL DISORDERS
Substances that can become an embolus:
 Thrombus is a clot that adheres to the
vessel wall
Thrombi tends to develop in areas where:
 injury to an arterial wall intravascular
factors stimulate coagulation sluggish flow
vessel lumen partially obstructed, wall
Signs and Symptoms:
damaged and rough by atherosclerosis
Other causes:
 Polycythemia, dehydration, repeated
arterial sticks, infection or inflammation of
the vessel
 Developing thrombus can occlude arterial
blood flow thru the vessel leading to
ischemia of tissues supplied by the artery
and organs involved
 Atherosclerotic plaque, masses of bacteria,
cancer cells, amniotic fluid, bone marrow
fat
 Foreign bodies such as air bubble, broken
IV catheter
 abrupt onset with acute arterial occlusion
with severe pain (intermittent
claudication)
 pain aggravated by movement or pressure
 gradual loss of sensory and motor function
in the affected areas
 absent distal pulses, pallor and mottling
(irregular discoloration), can be sharp line
of color.
  temperature demarcation: tissue beyond
the obstruction is pale and cool

6 clinical signs of acute arterial occlusion:

1. Pain (severe, acute)

2. Pallor (mottling, irregular discoloration)
3. Pulselessness (absent distal pulses)
4. Paresthesia (numbness)
5. Paralysis (gradual loss of function)
6. Poikilothermia (feels cold)

Nursing Diagnosis:
Diagnosis:

- Ineffective Tissue perfusion related to

 Arteriography: injection of dye in the
compromised circulation: administer meds,
vascular system to examine the arteries
ROM exercise as ordered
 Side effects: hemorrhage, allergic
- Fear related to risk of death: encourage
reactions to dye, thrombosis at
expression of feelings of helplessness and
insertion site, embolus, infection, exposure
anxiety, identify coping mechanisms
to high doses of radiation
- Impaired physical mobility related to
 Doppler ultrasound: low
surgery, compromised circulation: develop
intensity, high frequency sound waves
progressive exercise plan impaired skin
are directed toward the artery
integrity related to ischemic changes:
 Management: Goal is to protect and save
protect extremities from pressure, trauma,
the affected extremity. If treatment not
extreme heat and cold
initiated immediately, can progress to
- Impaired skin integrity: protect skin of
tissue necrosis and gangrene within hours
limb from trauma, pressure and extreme
 Surgery: Thrombectomy, embolectomy
hot or cold especially edematous area
(procedure of choice)
- Ineffective therapeutic regimen
 Anticoagulant therapy: IV heparin,
management: medication compliance and
coumadin
discharge planning
 Thrombolytic agents
Nursing Management:

- Before an intervention or surgery, the

patient remains on bed rest with the
affected extremity level or slightly
dependent (15 degrees).
- The affected extremity is kept at room
temperature and protected from trauma.
 - Heating and cooling pads are
contraindicated.
- Pressure injury prevention through
offloading the heel with a heel device and
lifting the bedsheets using a bed
PERIPHERAL ARTERIAL DISEASE (PAD)
- Chronic progressive narrowing of arterial
vessels that leads to obstruction or
occlusion. Usually affects the lower
extremities resulting from atherosclerosis.
- Atherosclerosis is the leading cause of
occlusive disease
- Common in men older than 50 years
- Also called peripheral artery disease,
peripheral vascular disease, lower
extremity arterial disease (LEAD), distal
occlusive disease.
Etiology:
- Organic: caused by structural changes from
plaque or inflammation of vessel
- Functional: short-term localized spasm in
the blood vessel such as in Raynaud's
disease
Contributory factors:
- atherosclerosis, thrombosis, embolism,
hyperlipidemia, DM, HTN, cigarette
smoking, stress, obesity, familial
disposition, age, trauma, vasospasm,
inflammation, autoimmune responses
- Common sites for arterial occlusion are the
distal superficial femoral and the popliteal
arteries. Tissue damage occurs below the
arterial obstruction
Pathophysiology:
- arteries deliver oxygen rich blood to the
tissues. Anything that impedes flow causes
imbalance in supply and demand. Hypoxia
affects all tissues distal to the occlusion
- Pathologic changes in the arteries, typically
plaque formations causing occlusions
prevent delivery of oxygen and nutrients to
the tissues
- Severe oxygen deprivation lead to ischemia
and necrosis (tissue death)
Signs and Symptoms: no early symptoms
- Tingling or numbness of toes, cool to touch
and numb, muscle atrophy
- Skin color: extremity is pale when elevated,
reddish purple when dependent, toenails
are thickened
- Shiny, thin scaly, dry flaky skin,
subcutaneous tissue loss, hairlessness on
the affected extremity, and ulcers with a
pale gray or yellowish hue.
Intermittent Claudication
- Hallmark sign
- pain in the calves of the lower
extremities associated with activity or
exercise. It is aching, cramping, tiredness,
weakness in the legs that occur with
walking relieved by rest
Diminished/Absence of peripheral pulses
below occlusive area
- persistent and aching pain that occurs
during inactivity, increases when leg is
elevated and decreases when dependent.
This indicates severe arterial occlusion.
Diagnostic:
 - ankle/brachia I pressure index (ABPI): <0.8
is suggestive of arterial occlusion; doppler
ultrasound, arteriography
Complications:
- gangrene with extremity amputation,
infection, sepsis, aneurysm, rupture.
Management:
- make lifestyle changes including
- Smoking cessation (high priority): nicotine
(patch, spray, gum, inhalers), varenicline
(Chantix), bupropion
- Exercise: 3 sessions each week for at least 6
months
- Weight management, low-fat, low-
cholesterol, low-calorie diet
- Treatments for hypertension,
hyperlipidemia or diabetes if present
Nursing Interventions:
- Assess/monitor peripheral circulation
(pulses, color, temperature, cap refill,
edema, skin breakdown) fluid status,
coagulation status, pain exercise tolerance,
intermittent claudication
- Encourage exercise to build up collateral
circulation- initiate gradually, increase
slowly: walk until point of pain
(claudication), stop and rest until pain
subsides and walk a little farther (this
builds collateral circulation)
Positioning:
- avoid crossing legs, no pillows under knees,
avoid prolonged sitting, both feet on floor
when sitting, refrain from wearing
restrictive clothing, elevate legs to reduce
swelling but not above level of the heart
- Explain healthy lifestyle, daily foot care,
drug regimen
Promote vasodilatation and avoid
vasoconstriction:
- provide warm environment, wear warm
insulated socks, no direct heat to skin
(sensitivity is decreased), avoid exposure to
cold
- {vasoconstriction)
- Avoid stress nicotine and caffeine.
Vasoconstriction effects last for 1
- hour after each cigarette smoked
Administer medications as prescribed:
- pentoxyfyline (Trental) increase flexibility
of RBC and decrease blood viscosity can
increase blood flow to extremities (prevent
claudication)
- Antiplatelet agents such as ASA,
clopidogrel (Plavix), cilostazol (Pletal)
- Anticholesterol drugs and vasodilators
- Antihypertensives to improve tissue
perfusion
Surgical interventions:
1. Percutaneous transluminal angioplasty:
- intra-arterial procedure using a balloon
and intravascular stent to open and
maintain the patency of a vessel
2. Atherectomy:
- use of high speed rotary metal burr to
scrape out affected arteries to improve
blood flow
3. Endarterectomy with bypass grafts:
- use of graft materials, can be autogenous
{harvested) or synthetic
Post op care: - Impaired Skin integrity related to
inadequate circulation: avoid tissue
- assess distal pulses to surgical site, palpate
trauma, avoid infections of the ulcers. Foot
or use a doppler, compare with unaffected
care (no barefoot, fitted shoes, inspect feet
extremity
daily, toenails cut straight across)
- Assess 6Ps, cap refill, edema, redness, VS,
- Risk for Infection: of the surgical incision
1&0, fluid status
and the grafts. Monitor temperature,
- Limit ROM to prevent clot formation
report fever to surgeon. Inspect site for
Nursing Diagnosis: redness, edema and drainage. Administer

- ineffective Tissue Perfusion related to antibiotics

vascular occlusion: administer vasodilator - Disturbed Body Image related to muscle

agents to improve blood flow, encourage atrophy, stasis ulcers, skin discoloration:

exercise, discourage smoking. Elevation of identify coping strategies to deal with

extremities is not recommended with feelings.

arterial diseases BUERGER’S DISEASE

- Acute pain related to impaired circulation:
- Thromboangitis obliterans; which affects
administer analgesics, vasodilators,
blood vessels most commonly in the arms
calcium- channel blockers
and legs.
- Decreased Cardiac Output: monitor for
- Recurring inflammation and thrombosis of
signs and symptoms of deficient fluid
small and medium arteries and veins of
volume (tachycardia, restlessness,
lower and upper extremities
decreases urine output, pallor,
- Arteries and veins inflamed and spastic
hypotension) and bleeding. Monitor daily
causing clots to form resulting in occlusion
weights
or total obstruction of blood vessels of
- Ineffective Self-Health management: to
hands and feet.
cope, patient must understand the disease
- With the degree of ischemia, ulcers and
process and treatment. Fears and concerns
gangrene may be present
have enormous effects on patient's
- Cause unknown, can be autoimmune
perception of situation. Lifestyle changes is
disorder
important to management
- Almost always affects men, age 25-40 with
- Activity Intolerance related to impaired
history of smoking or chewing tobacco
blood flow to extremities: monitor
- Occurs only in smokers
tolerance to planned activities and exercise
- Cigarette smoking is the single most
regimen
significant cause
- Chronic Pain related to ischemia: rest
extremities, administer analgesics,
relaxation techniques
Signs and Sx: - If gangrene develops: amputation {40%
who continue tobacco use require
- affected extremity pain: Intermittent
amputations).
claudication, rest pain
- Medic alert bracelet
- Six Ps: extremities pale, abnormal
sensation (numbness, decreased
sensation), ulcers, gangrene, pulses
RAYNAUD’S DISEASE
diminished
- skin color and temperature changes in - Vasoconstrictive response causing ischemia

affected areas: red or cyanotic, cool from exposure to cold and stress. Mainly

extremities, cold sensitivity affects the hands.

- shiny, nail thickened and malformed, skin Two Types:

is thin
1. Primary (Raynaud’s Disease)
2. Secondary (Raynaud’s Phenomenon)

Patho:

- Characterized by episodes of intense

vasospasm in small arteries of the fingers
and sometimes toes, ears and nose.
- Prevents arterial blood from perfusing
fingertips (ischemia).
Diagnostics: physical findings, arteriography
- Can progress overtime. If remain
Management: constricted, can lead to gangrenous and
necrotic fingers
- no cure or effective treatment
- Cause is unknown, related to
- Stop smoking: participate in cessation
hypersensitivity to cold or serotonin.
program
- Common to young women ages 16 to 40 are
- Administer aspirin, prostaglandin iloprost,
affected especially during winter months.
vasodilators (calcium-channel blockers),
Stress can aggravate
antibiotics, anticoagulant
- Cardinal signs: chronically cold hands,
- Avoid activities that impede blood flow:
numb, tingling.
avoid crossing legs and pillows under
- Phases: blanching, ischemic pain then
knees, prolonged sitting. Place extremities
reddening
below level of heart
- Decreased sensation, stiffness, fingertips
- Avoid alcohol, caffeine
thicken, nail brittle. Asymmetric finger
- Care of the feet, protect extremity from
involvement, thumb not affected
trauma. Shoes that fit well. Inspect skin.
Keep extremities warm with socks and
blanket

- During arterial spasm, color changes from
pallor to cyanosis to redness.
- White: pallor (blanching) is sudden
vasoconstriction.
- Blue: cyanosis is inadequate oxygenation.
- Redness: due to vasodilation (hyperemia)
allowing blood flow to return.
Diagnosis:
- Signs and symptoms and on the absence of
evidence of occlusive vascular disease
Management:
- Goals are to prevent pain, promote
vasodilation in the extremities.
Drugs:
- Vasodilators
- Calcium channel blockers (diltiazem)
- Transdermal nitroglycerin, an endothelin
receptor antagonist (bosentan),
phosphodiesterase inhibitors (sildenafil),
and intravenous prostaglandins (iloprost).
Surgery:
- Sympathectomy to interrupt sympathetic
nerves
Nursing Intervention:
 Acute Pain and Ineffective tissue
perfusion related to vasospasm: Reduce
pain and improve tissue perfusion by
avoiding stimuli that causes
vasoconstriction (exposure to cold,
smoking, and excessive stress)
 Keep hands warm, use mittens than
gloves, warming devices (warm water,
warm hair-dryer) during attacks.
- Check pulses, cap refill, color, temperature
edema
 Protect from trauma and injury due to
lack of sensation during periods of
vasoconstriction that results in serious
burns. Check skin for ulcers, infection.
Avoid activities that impede blood flow
 Cessation of smoking, avoid alcohol
and caffeine, OTC cold remedies that
contain vasoconstrictor
 Stress reduction: exercise, massage
therapy, maintain normal body weight
 Wear medical alert bracelet
ANEURYSMS
- Dilated segment of an artery caused by
weakness and stretching of the arterial wall
- Bulging, ballooning or dilatation at a
weakened point of an artery, diameter
increased to 50% the normal size
- The most common form is saccular and
fusiform.
 - Mycotic aneurysm are very small - Aneurysms less than 6cm have a 15-20%
aneurysms due to localized infections chance of rupture in one year
- Aneurysm <4cm is usually silent
Cause unknown. Other causes can be:
- Abdominal aorta most common site of
 Congenital: aneurysm formation!!
- congenital aneurysms are Marfan
Types of Aneurysms:
syndrome {inherited connective tissue
disease) and Ehlers-Danlos syndrome
{inherited collagen disease)
 Acquired:
- Arteriosclerosis, smoking, hypertension
trauma, infection
 Mechanical (hemodynamic)
- Poststenotic and arteriovenous fistula and
amputation related.
 Traumatic (pseudoaneurysms)
- Penetrating arterial injuries, blunt arterial
injuries, pseudoaneurysms. 1. Fusiform – dilatation of the entire

Classic symptom: circumference of the artery

2. Saccular – bulging on only one side
- back pain, flank pain caused by aneurysm
3. Dissecting – when a cavity is formed from a
pressing against nerves of vertebrae
tear in the artery wall (intima) fill with
Risk Factors: blood. Prone to rupture.
4. False aneurysm – a pulsating hematoma,
- Atherosclerosis (most common cause),
the clot and connective tissues are outside
uncontrolled hypertension
the arterial wall
- Marfan Syndrome (connective tissue
5. True aneurysm – one or three layers of the
disorder)
artery may be involved.
- Cigarette smoking, trauma, infections
(syphilis), Thoracic Aortic Aneurysm
- Congenital abnormalities
- 70% of all cases are caused by
- Heredity
atherosclerosis.
- Men older than age 50 (highest risk of
- Most common site for dissecting
death from AAA)
aneurysms
Risk for Rupture:
Signs and Sx:
- Aneurysms greater than 6cm (2.4 in
- Thoracic AA: usually no symptom, can be
diameter) have a 50% chance of rupture
deep diffuse chest pain
within one year)
 - Aneurysm that presses on laryngeal nerve: Patho:
hoarseness, stridor, aphonia (complete loss
- Involves a damaged media layer of the
of voice)
vessels
- On esophagus: dysphagia
- Caused by congenital weakness, trauma, or
- if SVC is compressed: edema of arms and
disease
legs compression of pulmonary structures:
- Risk factors include: heredity, tobacco use,
airway obstruction
and hypertension
Diagnostic:
Manifestations:
- CXR
- Gnawing constant abdominal, back or
- MRI
flank pain (classic) caused by aneurysm
- Transesophageal echocardiogram.
pressing against nerves of vertebrae
Management: - Common symptom: Abdominal pain,
feeling of fullness, nausea, constipation,
- Control the blood pressure; systolic must
elevated BP, bruit over the abdominal
maintain at 90 to 120 mmHg. And maintain
aneurysm.
a mean arterial pressure of 65 to 75 mmHg
- Lower back pain suggests rapid expansion
with beta blockers
and impending rupture.
- Beta blockers (metoprolol, esmolol,
- Rupture to the peritoneal cavity is rapidly
carvedilol)
fatal
- Sodium nitroprusside given IV drip to
- Signs of heart failure or a loud bruit may
emergently lower the blood pressure
suggest a rupture in the vena cava
- Repair of thoracic aneurysm using
- Rupture to the vena cava results in higher
endovascular grafts; are made of Gore-Tex
pressure arterial blood entering the lower
material reinforced with nitinol or titanium
pressure venous system and causing
stents.
turbulence.
- To decrease chances of spinal cord
- May cause right-sided heart failure.
ischemia and paraplegia, lumbar spinal
- AAA rupture: severe sudden onset of
drains are usually placed in patients
'tearing', 'ripping' and 'stabbing' back,
undergoing an endovascular repair.
flank, abdominal pain. When signs and
Abdominal Aortic Aneurysm symptoms come suddenly, aneurysm is

- Can be palpated as a pulsating mass about to rupture

abdominal mass slightly left of the - With rupture: hypovolemic shock

umbilicus. Often silent if <4cm. (tachycardia, hypotension); diaphoresis,

- Men over 50 yrs old has highest risk of nausea, vomiting, faintness, apprehension,

death. More common in Caucasian men decreased or absent peripheral pulses,

- Most of these aneurysm occur below the neuro deficits. Mortality is high

renal arteries
 - Rupturing aneurysm is an emergency Postoperative nursing care:
surgery!!
- Impaired Urinary Elimination: aorta is
Diagnosis: clamped for a period of time, there is risk
for renal damage {renal failure).
- Physical findings, ULZ, MRA, CT scan,
- Monitor l&O, report less than Sml/hr, daily
echocardiography, aortography.
weights, BUN and creatinine to detect
Treatment: signs of altered renal perfusion

- Antihypertensives; to prevent arterial wall Nursing Diagnosis:

rupture
- Risk for Injury: NGT attached to suction to
- Avoid lifting heavy objects
avoid gastric and bowel distention (stress
Surgical repair and grafts: the incision)

- AAA resection: excision of aneurysm and - Ineffective Breathing Patterns: high risk for

placement of a Dacron graft atelectasis and pneumonia. Use of

- Percutaneous insertion of endothelial stent incentive spirometers, CBDE, analgesics,

grafts: placement of a stent graft via monitor lung sounds

femoral artery, blood flow thru the stent to - Decreased Cardiac Output: risk for

reduce pressure hemorrhage. Monitor VS, wound dressings.

- Preop care: document chronic conditions Early signs: restlessness and tachycardia.

like emphysema or heart disease, that Late signs: hypotension, cyanosis,

increase risk of postoperative decreased alertness

complications - Ineffective Tissue Perfusion: Inspect and

- Priority: keep systolic BP between 100 and palpate the extremities for color, warmth,

120mm Hg and peripheral pulses, sensation and

- Postop care: Admit to ICU/CCU for 24 to movement of extremities, increased pain

48hrs level

- Monitor VS, hemodynamic status, cap

refill, renal function and fluid balance. AORTIC DISSECTING
- IV fluids to maintain hydration and renal
- Small tear in the intima that permits blood
perfusion
to escape into the space between the
- Monitor BP. Prolonged hypotension can
intima and the media usually due to
cause thrombus formation within the graft,
hypertension.
severe hypertension can cause leakage or
- Blood accumulates between layers, causing
rupture of the anastomosis suture line.
the media to split lengthwise. The split
Avoid flexion of the graft, Keep HOB at 45
may extend up and down the aorta, where
degrees•
it can occlude major arteries
Management:

- If no complications, patient managed with

antihypertensives to decrease the strength
of cardiac contractions
- Replacement with a synthetic graft
- Postop- care: keep blood pressure at lowest
possible level
- Nursing care is similar to that of a patient
who has had an aneurysm repair.

VENOUS DISORDERS

PERIPHERAL VENOUS DISEASE

- Disease of the veins that interferes with

adequate flow of blood from the
extremities

Disorders:

 Venous thromboembolism (VTE):

- deep vein thrombosis (DVT}
- pulmonary embolism (PE)
 Venous insufficiency
 Varicose veins

Three causes:

- thrombus formation
- defective valves
- lack of skeletal muscle contractility

Risk factors:

- sitting or standing for long periods

- obesity, pregnancy, thrombophlebitis,
systemic diseases
- family history, heart failure, immobilit
hip/knee surgery, aging

1. VENOUS THROMBOEMBOLISM
(VTE)
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