1 Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN.

1

Nursing Care & Interventions for Clients with Vascular

ProblemsKeith Rischer RN, MA, CEN

2

Today’s Objectives…

Review the pathophysiology of arteriosclerosis, including the factors that cause arterial injury

Discuss drug therapy for hypertension Evaluate the effectiveness of interdisciplinary

interventions to improve hypertension Prioritize nursing care for the patient

experiencing vascular disorders Develop a continuing care plan for a client who

has hypertension Prioritize postoperative care for clients who have

undergone peripheral bypass surgery.

3

Serum Lipids:Cholesterol

One of the several types of fats (lipids) Important component of cell membranes, and bile

acidsBuilding blocks in certain types of hormonesPredominant substance in atherosclerotic

plaques Circulates in the blood in combination with

triglycerides, encapsulated by special fat-carrying proteins called lipoproteins

<200 is desirable for total cholesterol

4

Lipoproteins

LDL = Low Density Lipoproteins - “bad cholesterol” <130 is desirable

HDL = High Density Lipoproteins - “good cholesterol” >30 is desirable- the higher the HDL, the lower the

risk of CAD

Triglycerides- combination of glycerol with 3 fatty acids Transportable fuel- energy source Strongly influenced by diet

5

Cholesterol Levels

LDL Cholesterol <100 Optimal 100-129 Near optimal/above optimal 130-159 Borderline High 160-189 High >190 Very high

Total Cholesterol <200 Desirable 200-239 Borderline High >240 High

HDL Cholesterol <40 Low >60 High

6

Hypertension

“Vascular Disease” Affects 1 in every 4 adults in the US Major risk factor for cardiovascular disease (CVD)

Stroke, MI, Heart Failure Other Target Organ Damage

LV hypertrophyNephropathyVascular DisordersPVD Retinopathy

7

Categories

Primary (Essential)- without identified cause 90-95% of all hypertension Pathophysiology: (exact cause unknown)

Heredity H2O & Na+ retention Altered renin-angiotensin mechanism Stress and increase sympathetic nervous system activity Insulin resistance and hyperinsulinemia Endothelial cell dysfunction

Secondary- results from identifiable cause renal disease, endocrine disorders, neuro disorders, meds, PIH

8

Stages of Hypertension

Category SBP(mmHg) DBP(mmHg)

Normal <120 <80 Prehypertension 120-139 80-89 Hypertension, Stage 1: 140-159 90-99 Hypertension, Stage 2: 160-179 100-

109 Hypertension, Stage 3: >180 >110

9

Clinical Manifestations

EarlyElevated BPAsymptomatic (silent killer)

LaterSymptoms secondary to effects on blood

vessels in various organs or tissuesFatigue, reduced activity tolerance, dizziness,

palpitations, angina, dyspnea

10

Risk Factors for Primary Hypertension

Age Alcohol use Cigarette smoking DM Elevated serum lipids Excess dietary

sodium Gender

Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

11

Knowledge Deficit

Encourage healthy lifestyles Lifestyle modifications for all patients with

prehypertension and hypertension Components of lifestyle modifications include:

weight reduction, DASH eating plan dietary sodium reduction aerobic physical activity moderation of alcohol consumption Stress reduction

12

Risk for Ineffective Therapeutic Regimen Management

Interventions:Teach medication compliance, usually for the

rest of life.goals of therapy potential side effects

Assist client to understand therapeutic regimen.Discuss consequence of noncomplianceMost African American clients will need at least 2

medications to achieve blood pressure controlACE inhibitor and calcium channel blocker

.

13

Diuretics

LoopBumetanide (Bumex)Furosemide (Lasix)

Thiazide-TypeChlorothiazideHydrochlorothiazide

(HCTZ)

Potassium-SparingSpironolactone

(aldactone)

14

Pharmacologic: Diuretics

Mechanism of Action: Thiazides, Loop,

Potassium Sparing S/E:

fluid and electrolyte imbalances

– K+, Mg++ CNS effects GI effects

Nursing Considerations: Monitor for orthostatic

hypotension– dehydration

Hypokalemia

15

Adrenergic Inhibitors:Beta Blockers

Cardioselective (β1)Atenolol (Tenormin)Metoprolol (Lopressor)

Non-cardioselective (β1, β2) Propranolol (Inderal)

Mechanism of ActionBlocks beta actions causing:

decreased heart rate decreased BPdecreased contractility

16

Adrenergic Inhibitors:Beta Blockers

S/E: Orthostatic hypotensionBradycardiaHypotensionFatigueWeakness

Nursing considerations Use in caution with heart failure

Diabetes who take BB may not have sx of hypoglycemia monitor pulse regularly

17

ACE Inhibitors

Drug Interactions:NSAIDS (decrease BP control)Diuretics (excessive hypotensive effect) Potassium supplements, potassium-sparing diuretics

(increased risk of hyperkalemia) Lithium (increased lithium serum levels)

Precautions: “First dose effect “– severe hypotension. Remain in bed

for 3 to 4 to prevent falls. Obtain BP before giving - hold if hypotensiveChange positions slowly due to orthostatic hypotensionMonitor liver and kidney function

18

Angiotensin Receptor Antagonists (Blockers)

Losartan (Cozaar) Mechanism:

Inhibit binding of angiotensin II receptors in blood vessels and other tissues

vascular smooth muscle relaxation increased salt and water excretion reduced plasma volume

Side Effects: Hypotension Dizziness Cough, Heart failure Angioedema

Drug Interactions: Potassium-sparing diuretics ( serum K+)

19

Calcium Channel Blockers

Amlodipine (Norvasc)

Diltiazem (Cardizem)

Nifedipine (Procardia)

Mechanism of Action Blocks slow channels of

Calcium Decreases contractility Vasodilation AV node slows

20

Calcium Channel Blockers S/E:

Hypotension Bradycardia AV block Nausea H/A Peripheral edema

Monitor I&O closely

Nursing considerations: Always obtain BP-HR before giving use with caution in patients with heart failure Orthostatic changes

Change position slowly contraindicated in patients with 2nd or 3rd degree heart block Concurrent use w/b-blockers incr risk of CHF

21

HTN Case Study

45yr African American maleComplaint: new onset severe global HAVS: P-88 R-20 BP-210/142 sats 96% RA

Slightly confused to place, timePMH: HTN x10 yrs-unable to afford meds, not

taking the last weekLabs: K+ 4.2, Na+ 138, creat 2.5, trop neg, 12 lead EKG no acute changes

Nursing/medical priorities…

22

HTN Case Study

MD orders:Metoprolol 5mg IV push q5” x3 for SBP 160-

1805mg/5cc….administer over 2”…how much

every 15-30 seconds???Nursing priorities/considerations…

Admit to ICUVS before transfer: P-68 R-20 BP-192/118

23

In ICU…

Started on Nipride gttStarted at 0.5mcgBP 180/90….in 2 hours Next am 140/90

Started on po:LisinoprilDiltiazemMetoprololConcerns to address upon DC???

24

Peripheral Arterial Disease

Altered flow of blood through arteries/veins of peripheral circulation

Manifestation of systemic atherosclerosis a chronic condition in

which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

25

Physical Assessment Intermittent claudication

Pain that occurs even while at rest; numbness and burning Inflow disease affecting the lower back, buttocks, or thighs

Distal aorta Outflow disease causing cramping in calves, ankles, and feet

Superficial femoral artery (knee and down) Hair loss and dry, scaly, mottled skin and thickened toenails Ulcers

arterial ulcers diabetic ulcers venous stasis ulcers

.

26

Nonsurgical Management

Exercise Positioning

avoid extreme raising legs above heart, do elevate for edema

Promoting vasodilation warmth and avoid cold temp, stop smoking

Drug therapy clopidogrel (Plavix), Pentoxifylline (Trental), ASA

Percutaneous transluminal angioplasty Atherectomy

.

27

Surgical Management

Preoperative care Documentation of distal

pulses

Postoperative care Assessment for graft

occlusion Promotion of graft patency Treatment of graft

occlusion Monitoring for compartment

syndrome Assessment for infection

.

28

Acute Peripheral Arterial Occlusion Embolus

most common cause of occlusions, although local thrombus may be the cause

Assessment pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia

(coolness) Surgical therapy

arteriotomy Nursing care

CMS Pain assessment Spasms/swelling

Compartment syndrome

.

29

Anticoagulation Therapy:Heparin

Inhibits (does not dissolve) thrombus and clot formation

Given IV/SQ Never given IM D/T risk of hematoma

Does not cross placental barrierAntidote

Protamine sulfate: Fast acting, short ½ life

Note: If sx’s of bleeding stop infusion, be prepared to give antidote

Aneurysms of Central Arteries

30

Patho Middle layer weakened Stretching of intima

Fusiform aneurysm Saccular aneurysm Dissecting aneurysm

(aortic dissections) Thoracic aortic

aneurysms Abdominal aortic

aneurysms

.

31

Thoracic & Abdominal Aortic Aneurysm

Thoracic Back pain shortness of breath hoarseness,

and difficulty swallowing Sudden excruciating back or

chest pain is symptomatic of thoracic rupture

Abdominal Pain steady with a gnawing

quality unaffected by movement-may

last for hours or days abdomen, flank, or back.

Abdominal mass is pulsatile Rupture is the most frequent

complication and is life threatening.

Aortic Dissection

32

Patho Pain Emergency care goals include:

Elimination of pain Reduction of blood pressure Immediate OR

Surgical treatment

Abdominal Aortic Aneurysm Repair

33

Preoperative care Assess peripheral pulses

Operative procedure Postoperative care

Monitor vital signs Assess for complications

Paralytic ileus Assess for graft occlusion

or rupture Change in CMS Severe pain Decreased u/o

.

34

Thoracic Aortic Aneurysm Repair

Preoperative care Operative procedure Postoperative care

assessments:Vital signsCMS changesComplications

Respiratory distressCardiac

dysrhythmiasHemorrhageParaplegia

.

35

Raynaud’s Phenomenon

Patho Sx

Blanching >cyanosis Pain

Aggravated by cold/stress

Treatment Procardia

Side effects

Education Cold exposure Stop smoking Stress reduction

.

Venous Thromboembolism

36

Thrombus Virchows Triad

Venous blood stasis Endothelial injury hypercoagubility

Thrombophlebitis Thrombus w/inflammation

Deep vein thrombosis (DVT) Pulmonary embolism

Phlebitis Inflammation of superficial veins

Assessment: Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Localized edema Venous flow studies-US Lab:D-Dimer

.

37

Nonsurgical Management

Treatment PrioritiesPrevent complications

Rest Drug therapy includes:

Heparin IV therapyLow–molecular weight heparin-Subq

Lovenox q 12 hoursWarfarin therapyThrombolytic therapy

TPA

38

Venous Insufficiency

Patho Sx

Edema TEDS

Stasis dermatitis Stasis ulcers

Occlusive dressings

.