MedSurg I Arterial Disorders

olanjones's version from 2016-12-06 16:52

Vascular / Peripheral Artery Disease Development & Diagnosis

Question Answer
Two main classifications1. Peripheral Artery Disease (Occlusive, Aneurysms, Vasospastic) 2. Venous disease (Thrombosis, Chronic venal insufficiency)
Demographics of AtherosclerosisAge 60 – 80 (earlier if diabetic), Men > women, Blacks (3x more likely)
Subjective Data (also RF) for PADsmoking, hyperlipidemia, HTN, DM (also - obesity, ↑uricemia, family history, sedentary, stress)
Objective Data (also classic s/s) for PADIntermittent claudication (resolves within 10 minutes or less with rest), Paresthesia, Pallor on ↑, Rubor dangling, Thin, shiny, taut, hairless skin, Diminished or absent peripheral pulses, Rest pain and/or skin ulcers (later signs)
Where does PAD commonly occur?Segments of arterial system (aortoiliac, femoral, popliteal, tibial, peroneal) - Most common: BTK in DM, Non-DM at femoral-popliteal
Complications of PADAtrophy, Delayed healing, Wound infection, Tissue necrosis, Arterial ulcers (most serious can lead to gangrene -> amputation)
Diagnostic Studies PADH&P, Doppler US, ABIs (BP pre/post exercise using handheld Doppler), Dulplex imaging, Angiography, MRA

Peripheral Artery Disease Therapeutics

Question Answer
PAD PreventionModify RF: Quit smoking, Tx hyperlipidemia, Control HTN and/or DM (BP <130/80, A1C <7.0% in DM)
PAD Drug Therapy-Antiplatelet (ASA, adenosine diphosphate receptor inhibitors {ticlopidine, clopidogrel})
-ACE-I (ramipril) used even if no ↑ BP, EBP shows ↓ Mortality & Cardiovascular morbidity, ↑Peripheral blood flow & ABIs, ↑ Walking distance
-Vasodilators to tx Intermittent claudication (pentoxifylline, cilostazol)
PAD TLC-Exercise: improves O2 extraction in legs and skeletal metabolism, walking is most effective (30-60 min/day)
-Nutrition: Dietary chol <200 mg/day, Decreased intake of saturated fat, Soy may replace animal protein
PAD Complementary TxGinkgo biloba (↑ walking distance), Folate, Vitamin B6, Cobalamin (B12) (↓ homocysteine levels -high levels are believed to >chance of heart disease)
Critical Limb Ischemia ManagementProtect from trauma, Reduce vasospasm, Prevent/control infection, Maximize arterial perfusion
Indications for Intervention Radiologic ProceduresIncapacitating Intermittent claudication; Pain at rest; Ulceration/gangrene that threatens limb
(May be candidate tPA if within 3 hours of onset OR may nick skin at femoral artery put tPA directly on clot – then can be 6 hours)
Intervention Radiologic ProceduresAlternative to open surgical approach - usually done in cath lab; Includes PTA, Stents, Atherectomy, Cyroplasty
Percutaneous transluminal balloon angioplasty (PTA)Insertion of a catheter (contains cylindrical balloon) through the femoral artery - Balloon inflates to dilating the vessel (works best in vessels with < 4 inches (10CM) of occlusion, but high rate of recurrence within 1 year)
Common Surgical for PAD-Peripheral arterial bypass operation (autogenous vein or synthetic - synthetic typically for long bypasses)
-Balloon angioplasty with stenting used in combination with bypass surgery
-Endarterectomy (cut artery & remove plaque)

Peripheral Artery Disease Nursing Process

Question Answer
PAD NDIneffective tissue perfusion, Impaired skin integrity, Activity intolerance, Ineffective therapeutic regimen management, Pain (acute or chronic)
PAD NI-Assess- frequent monitoring of skin color/temp, cap refill, pulses distal to op site, CMS checks
-Positioning, padding, OOB, Avoid prolonged sitting, Avoid knee flexion, ↑legs when not amublating
-BOLO: bleeding, thrombosis/emboli, compartment syndrome, 5 Ps, delayed healing
PAD Ambulatory and Home CareManagement of risk factors; Importance of meticulous foot care (especially if diabetic); Importance of gradual physical activity after surgery
Nursing goals for PAD-Adequate tissue perfusion/promote circulation
-Increased exercise tolerance/plans for walking
-Intact, healthy skin/free from infection on extremities
-Verbalize key elements of therapeutic regimen, knowledge of disease, treatment plan, reduction of risk factors, and proper ulcer/foot care

Acute Arterial Ischemic Disorders

Question Answer
Arterial Ischemiasudden interruption in the arterial blood supply to a tissue that, if left untreated, can result in tissue death (check the 6 Ps)
Treatment of arterial ischemiaanticoagulants to prevent growth; surgical thrombectomy; if surgery not possible maybe percutaneous catheter-directed thrombolytic therapy using tPA alteplase or urokinase
Thromboangitis (Buerger's disease)nonatherosclerotic, segmental, recurrent inflammatory disorder of the small- and medium-sized arteries and veins of the extremities (same RF as athereosclerosis)
Treatment of thromboangitiscomplete cessation of tobacco/marijuana in any form; severe cases may require amputation
Raynaud'sepisodic vasospastic disorder of small cutaneous arteries, most often involving the fingers and toes (cold/numb during vasoconstriction, throbbing/aching/swelling in hyperemic phase)
Treatment of Raynaud'sloose clothing, protect from cold; stop using all tobacco products and avoid caffeine/vasoconstrictive drugs

Aortic Aneurysms

Question Answer
DefinitionOutpouchings or dilations of the arterial wall; may involve aortic arch, thoracic aorta, and/or abdominal aorta; Dilated aortic wall becomes lined with thrombi that can embolize (growth rate is unpredictable)
DistributionMost (75%) are in abdominal aorta below renal arteries; 25% in thoracic region (often asymptomatic, may have deep diffuse chest or interscapular pain)
Possibly s/s of ascending aortic aneurysmangina, hoarseness, JVD & head/arm edema, but usually asymptomatic
CausesAtherosclerosis (most common), but may be degenerative, congenital, mechanical, inflammatory, infectious, or from trauma
Two main classifications1. True aneurysm (entire wall of aneurysm, at least 1 vessel wall intact, can be fusiform or sacculated) 2. False aneurysm (rupture contained by surrounding tissue)
Since often asymptomatic, how are they dx?-During a physical as a pulsatile mass
-Imaging for unrelated problems (CT is most accurate to determine size)
-Auscuatated bruits; S/S of aortic compression
-"Blue-toe syndrome" (patchy mottling in feet & toes in the presence of palpable pedal pulses)
Treatment of small aneurysm (<4 cm)RF mods (↓BP), Monitor with US, MRI, CT q 6 months; threshold for repair 5.5 cm (<5.5 cm in women with AAA)
Possible Tx for older or high-risk patientsEndovascular repair (must meet strict eligibility criteria, is alternative to conventional surgical tx)

Aortic Aneurysms Repair & Nursing Considerations

Question Answer
Surgical repair-required if ruptured (= EMERGENCY - btwn 33%-94% mortality w/ AAA)
-Pre-op reuirements: hydration, stabilize lytes, coag, & HCT
-may be done earlier in younger, low-risk patients or with rapidly expanding/symptomatic/high rupture risk
Surgical TechniqueClamp & Incise diseased segment, Remove thrombus/plaque, Insert synthetic graft & suture native aortic wall around it (acts as a protective cover)
Risks associated with clamping?adequate perfusion (esp renal if clamped above renal arteries - ↑post-op risk), make sure good kidney perfusion before incision closure
Endovascular graft procedureInvolves placement of non sutured aortic graft into abdominal aorta inside aneurysm through femoral artery “cutdown”
Benefits of endovascular graft↓anesthesia & operative time, ↓blood loss; ↓morbidity and mortality & quicker recovery; shorter hospital stay & faster resumption of physical activity; higher patient satisfaction & reduction in overall costs
Possible complications of endovascular graftPerigraft leaks (most common comp - blood seeps from new endograft into old aneurysm site); Aneurysm growth or rupture; Aortic dissection; Bleeding, Graft thrombosis; Graft dislocation and embolization; Incisional site hematoma, Site infection
AA repair Pre-op NIH&P (establish baseline; quality & character of peripheral pulses & neurologic status), Teaching, S/S cardiac, pulmonary, cerebral, lower extremity vascular problems
AA repair Post-op NI-Monitor for indications of rupture (s/s hypovolemic shock; Abdominal, back, groin or periumbilical pain, Pulsating abdominal mass)
-Maintain graft patency (avoid severe HTN)
-Monitor Cardiovascular status (EKG, lytes, ABGs, O2, antidysrhythmic/pain meds)
-Infection control (abx, temp, WBCs) & GI status (NG tube, abd assessment/flatus, s/s of bowel ischemia)
Post Tx Home Care NITeaching (Increase activity gradually, No heavy lifting, S/S infection or neuro changes) & Support (Encourage patient to express concerns)

Aortic Dissection

Question Answer
Is it a type of aneurysm?No!!! Often misnamed “dissecting aneurysm”
What is it?An acute & life threatening (90% mortality if not surgically tx) tear in the intimal lining of arterial wall (most commonly in thoracic aorta)
PathoTear in lining allows blood to “track” between intima and media, creating a false lumen of blood flow; As heart contracts, each systolic pulsation ↑ pressure on damaged area causing further ↑ dissection (May occlude major branches of aorta & blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities)
Demographic affectedOlder people with chronic HTN; ↑ incidence in those w/ Marfan syndrome; Blunt trauma and/or pregnancy can precipitate
Manis (depend on location)Sudden, severe (ripping/tearing) pain in anterior chest (mimics MI) radiating down spine to abd or legs; May also have Cardio, neuro, & Respiratory signs; If Aortic Arch: ↓cerebral flow may cause neuro deficiencies
ComplicationsCardiac tamponade (blood escapes into pericardial sac); Aortic rupture (exsanguination and/or hemorrhage in mediastinal, plerual, or abd cavities); Occlusion of arterial supply to vital organs
Diagnostic studiesH&P, EKG, Echo, CXR, TEE, MRI or enhanced CT, angiography (to assess extent of dissection)
What drugs may be used to ↓ BP and myocardial contractility?IV β-adrenergic blocker (esmolol); CCB, Sodium nitroprusside, ACE-I
When is conservative tx used?If no symptoms; success is judged by pain relief (but emergency sx required if involving ascending aorta)
Surgical techniqueResection damaged segment and replace with synthetic graft
Why is surgery delayed as long as possible?Give time for blood in false lumen to clot and for edema to decrease in the area of the dissection (even w/ surgery 30-day mortality is btwn 10%-28%)
AD Pre-op NIKeep in Semi-Fowler's, Maintain quiet environment, Manage meds (anxiety, pain, HTN), EKG & interarterial pressure monitoring, Monitor VS and changes in quality of peripheral pulses
AD Post-op & Home care NISame as AA repair (similar surgical procedure)

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