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MedicalMedical--Surgical Surgical Nursing CareNursing Care

Second EditionSecond Edition

Karen Burke

Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown

Copyright ©2007 by Pearson Education, Inc.

Chapter 28Chapter 28Caring for Clients withCaring for Clients withPeripheral Vascular DisordersPeripheral Vascular Disorders

Priscilla LeMoneElaine Mohn-Brown

HypertensionHypertension

Blood pressure higher than 140 mm Hg systolic or 90 Blood pressure higher than 140 mm Hg systolic or 90 mm Hg diastolic on three separate readings several mm Hg diastolic on three separate readings several weeks apartweeks apartCommon in people over age 40Common in people over age 40



p p gp p gHypertension in the elderlyHypertension in the elderly

HypertensionHypertension

Often called the silent killerOften called the silent killerClassified by cause and courseClassified by cause and coursePrimary hypertensionPrimary hypertension

No identified causeNo identified cause



No identified causeNo identified causeRisk factorsRisk factors

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BOX 28BOX 28--22 Risk Factors for Hypertension.Risk Factors for Hypertension.



HypertensionHypertensionSecondary HypertensionSecondary Hypertension

Elevated blood pressure related to another disorderElevated blood pressure related to another disorderKidney diseaseKidney diseaseCoarctation of the aortaCoarctation of the aortaPregnancyPregnancy



g yg yEndocrineEndocrineNeurologic disorderNeurologic disorderUse of stimulantsUse of stimulants

Diagnostic tests: blood, urine testsDiagnostic tests: blood, urine tests

Hypertension Hypertension -- PathophysiologyPathophysiologyPeripheral vascular resistance primary factor Peripheral vascular resistance primary factor determining blood pressuredetermining blood pressureHypertensionHypertension

Increased resistance to blood flowIncreased resistance to blood flow



Disrupted physiologic mechanismsDisrupted physiologic mechanismsOveractive sympathetic nervous systemOveractive sympathetic nervous systemOveractive reninOveractive renin––angiotensinangiotensin––aldosterone systemaldosterone systemAtrial natriuretic peptide participatesAtrial natriuretic peptide participatesInsulin resistance plays a roleInsulin resistance plays a role

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Hypertension Hypertension -- PathophysiologyPathophysiology

Blood volume and peripheral vascular resistance Blood volume and peripheral vascular resistance increaseincreaseWorkload of left ventricle increasesWorkload of left ventricle increasesLeft ventricular muscle mass increasesLeft ventricular muscle mass increases



Left ventricular muscle mass increasesLeft ventricular muscle mass increases

HypertensionHypertensionManifestations and ComplicationsManifestations and Complications

Usually no symptoms other than increased blood pressureUsually no symptoms other than increased blood pressureComplaints of vague headache or dizzinessComplaints of vague headache or dizzinessMorning headacheMorning headacheBl d i iBl d i i



Blurred visionBlurred visionUnsteadinessUnsteadinessDepressionDepressionNocturiaNocturia

Hypertensive CrisisHypertensive Crisis

Rapid increase in systolic pressure 240 mm Hg or Rapid increase in systolic pressure 240 mm Hg or diastolic pressure 120 mm Hgdiastolic pressure 120 mm HgMalignant hypertension: diastolic pressure > 130 mm Malignant hypertension: diastolic pressure > 130 mm HgHg



ggImmediate treatmentImmediate treatmentHeadache, confusion, blurred vision, restlessness, Headache, confusion, blurred vision, restlessness, motor/sensory deficitsmotor/sensory deficits

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Hypertension Hypertension -- TreatmentTreatment

No specific diagnostic testsNo specific diagnostic testsLab tests done to diagnose secondary hypertensionLab tests done to diagnose secondary hypertensionTreatment to lower blood pressureTreatment to lower blood pressureReduce the risk of damage to CV system and otherReduce the risk of damage to CV system and other



Reduce the risk of damage to CV system and other Reduce the risk of damage to CV system and other target organstarget organsControl lifestyle variables and medicationControl lifestyle variables and medication

Hypertension Hypertension –– TreatmentTreatmentLifestyle ModificationsLifestyle Modifications

Restrict alcohol use, restrict cigarette smoking, increase Restrict alcohol use, restrict cigarette smoking, increase physical activity, stress reductionphysical activity, stress reductionWeight lossWeight lossDietDiet



DietDietReduce sodium and fatReduce sodium and fatPromote weight lossPromote weight lossDASH dietDASH diet

Hypertension Hypertension –– Nursing CareNursing CareIneffective Health MaintenanceIneffective Health Maintenance

TeachingTeachingPrescribed treatmentPrescribed treatmentLifestyle changesLifestyle changesS di i t kS di i t k



Sodium intakeSodium intakeWeight loss strategiesWeight loss strategies

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Hypertension Hypertension –– Nursing CareNursing CareEvaluationEvaluation

Client informationClient informationResponse to treatmentResponse to treatmentTeachingTeaching



Hypertension Hypertension –– Nursing CareNursing Care

TeachingTeachingPrimary care providerPrimary care providerNeed for home careNeed for home careDaily medicationDaily medication



Realistic exercise planRealistic exercise planStress reductionStress reductionRegular followRegular follow--up careup care

AneurysmAneurysm

Weakness and localized dilation of blood Weakness and localized dilation of blood vessel wallvessel wallClassified by shape and locationClassified by shape and location



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Figure 28Figure 28--1.1. Aortic aneurysms. (A) Fusiform aneurysm of the abdominal aorta. (B) Saccular aneurysm of the descending Aortic aneurysms. (A) Fusiform aneurysm of the abdominal aorta. (B) Saccular aneurysm of the descending thoracic aorta. (C) Dissecting aneurysm of the ascending thoracic aorta.thoracic aorta. (C) Dissecting aneurysm of the ascending thoracic aorta.



AneurysmAneurysmOften are asymptomaticOften are asymptomaticPressure on adjacent tissues and organs causes Pressure on adjacent tissues and organs causes manifestationsmanifestations



AneurysmAneurysmThoracic AorticThoracic Aortic

Often asymptomaticOften asymptomaticMight have substernal (anginal), neck, or back painMight have substernal (anginal), neck, or back painPressure on thoracic structures might cause SOB, stridor, Pressure on thoracic structures might cause SOB, stridor, cough swallowing difficulties facial edema JVDcough swallowing difficulties facial edema JVD



cough, swallowing difficulties, facial edema, JVDcough, swallowing difficulties, facial edema, JVDEnlarge, rupture, leading to deathEnlarge, rupture, leading to death

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AneurysmAneurysmAbdominal AorticAbdominal Aortic

Associated with HTN, smoking, advancing ageAssociated with HTN, smoking, advancing ageFound in adults over age 70Found in adults over age 70Asymptomatic; might have a pulsating mass in the Asymptomatic; might have a pulsating mass in the mid/upper abdomen with a bruitmid/upper abdomen with a bruit



mid/upper abdomen with a bruitmid/upper abdomen with a bruitComplaints of mild to severe midComplaints of mild to severe mid--abdominal/lower back abdominal/lower back painpainPain an indication of pending rupturePain an indication of pending rupture

AneurysmAneurysmAortic DissectionAortic Dissection

LifeLife--threatening emergencythreatening emergencyTear in the inner layer of aorta with bleeding into middle Tear in the inner layer of aorta with bleeding into middle layerlayerVessel wall splitsVessel wall splits



Vessel wall splitsVessel wall splitsCommon in the ascending aortaCommon in the ascending aortaHTN, Marfan syndrome at higher riskHTN, Marfan syndrome at higher risk

Aortic DissectionAortic DissectionManifestationsManifestations

Ripping painRipping painHigh blood pressure followed by a sudden dropHigh blood pressure followed by a sudden dropAbsent peripheral pulsesAbsent peripheral pulses



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AneurysmAneurysmDiagnostic testsDiagnostic tests

Abdominal or chest xAbdominal or chest x--rayrayAbdominal ultrasoundAbdominal ultrasoundCT scan/MRICT scan/MRI



Aneurysm Aneurysm -- TreatmentTreatmentMedicationsMedications

AntihypertensivesAntihypertensivesAnticoagulantsAnticoagulants



Aneurysm Aneurysm -- TreatmentTreatment

SurgerySurgeryRepair those that are tender or enlargingRepair those that are tender or enlargingExcise the aneurysm and replace with graftExcise the aneurysm and replace with graft



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Figure 28Figure 28--2. 2. Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.(B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.



Figure 28Figure 28--2. (continued) 2. (continued) Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft. vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.



Aneurysm Aneurysm -- TreatmentTreatment

Surgery Surgery –– Preop Nursing CarePreop Nursing CareRoutine careRoutine careICU environmentICU environmentReport changes in medical conditionReport changes in medical condition



Bed restBed restAvoid Valsalva maneuverAvoid Valsalva maneuver

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AneurysmAneurysmSurgery Surgery –– Postop Nursing CarePostop Nursing Care

General careGeneral careChest tubeChest tubeAssess for bleedingAssess for bleedingFl id/bl d t f iFl id/bl d t f i



Fluid/blood transfusionsFluid/blood transfusionsComplicationsComplications

Aneurysm Aneurysm –– Nursing CareNursing Care

AnxietyAnxietyPainPainIneffective Tissue PerfusionIneffective Tissue Perfusion



AneurysmAneurysm

Continuing CareContinuing CareControl HTN, diet, stress reduction, alcohol, smoking, Control HTN, diet, stress reduction, alcohol, smoking, medicationsmedicationsPrevent complicationsPrevent complications



Postop teachingPostop teachingRestRestPrevent constipationPrevent constipationFollow up appointmentsFollow up appointments

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Peripheral AtherosclerosisPeripheral AtherosclerosisPathophysiologyPathophysiology

Thick peripheral arteries, plaque deposits, lumen narrowsThick peripheral arteries, plaque deposits, lumen narrowsDecreased blood flow and oxygen to distal tissuesDecreased blood flow and oxygen to distal tissuesSymptoms after 60% vessel occludedSymptoms after 60% vessel occluded



Peripheral AtherosclerosisPeripheral Atherosclerosis

ManifestationsManifestationsPainPainIntermittent claudicationIntermittent claudicationSkin color changesSkin color changes



Pulse changesPulse changesBruitBruitComplications: gangrene, amputationComplications: gangrene, amputation

Peripheral Atherosclerosis Peripheral Atherosclerosis ––TreatmentTreatment

Improve/maintain blood supply and relieve symptomsImprove/maintain blood supply and relieve symptoms



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Peripheral AtherosclerosisPeripheral Atherosclerosis

Diagnostic testsDiagnostic testsSegmented blood pressuresSegmented blood pressuresExercise stress testingExercise stress testingDoppler ultrasoundsDoppler ultrasounds



Transcutaneous oximetryTranscutaneous oximetryAngiographyAngiography

Peripheral Atherosclerosis Peripheral Atherosclerosis --TreatmentTreatment

MedicationsMedicationsAspirinAspirinPlavixPlavixPletalPletal



VasodilatorsVasodilators

Peripheral AtherosclerosisPeripheral AtherosclerosisTreatmentTreatment

Smoking cessationSmoking cessationExerciseExerciseWeight reductionWeight reductionC l t th iC l t th i



Complementary therapiesComplementary therapies

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Percutaneous transluminal angioplastyPercutaneous transluminal angioplastyStentStentAtherectomyAtherectomy




SurgerySurgeryRevascularizationRevascularizationEndarterectomyEndarterectomy



Peripheral Atherosclerosis Peripheral Atherosclerosis ––Nursing CareNursing Care

Ineffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralPulsesPulsesWarmthWarmthFrequent position changesFrequent position changes

P iP i



PainPainPain scalePain scaleWarmthWarmthSmoking cessationSmoking cessationStress reductionStress reduction

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Impaired Skin IntegrityImpaired Skin IntegrityAssess every 8 hoursAssess every 8 hoursFoot and leg careFoot and leg careFoot cradleFoot cradle




EvaluationEvaluationStrength/equality of pulsesStrength/equality of pulsesCapillary refillCapillary refillSkin colorSkin color



TemperatureTemperaturePainPainBleedingBleeding


TeachingTeachingExerciseExerciseSmoking cessationSmoking cessationLegs/foot careLegs/foot care



Stress reductionStress reductionMedicationsMedicationsSurgical teachingSurgical teaching

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Arterial Thrombus/EmbolismArterial Thrombus/EmbolismOcclusion of blood flow through an arteryOcclusion of blood flow through an arteryAtherosclerotic changes can cause a thrombus or Atherosclerotic changes can cause a thrombus or blood clotblood clotBlood clot breaks away, becomes an embolusBlood clot breaks away, becomes an embolus



Lodges in small vesselsLodges in small vesselsLeads to tissue necrosis, gangreneLeads to tissue necrosis, gangrene

BOX 28BOX 28--1212 Manifestations of Arterial Thrombosis or Embolus.Manifestations of Arterial Thrombosis or Embolus.



Acute Arterial OcclusionAcute Arterial Occlusion

Diagnosis and treatmentDiagnosis and treatmentPhysical examinationPhysical examinationAngiographyAngiographyThrombolytic therapyThrombolytic therapy



Anticoagulant therapyAnticoagulant therapySurgerySurgery

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Acute Arterial Occlusion Acute Arterial Occlusion ––Nursing CareNursing Care

AssessmentAssessmentChief complainChief complainComplains of painComplains of painPulsesPulses



TeachingTeaching

Acute Arterial Occlusion Acute Arterial Occlusion ––Nursing CareNursing Care

Ineffective ProtectionIneffective ProtectionThrombolytic drugsThrombolytic drugsReport bleedingReport bleedingH&H levelsH&H levelsPT tiPT ti



PT timesPT times

Buerger’s DiseaseBuerger’s DiseaseManifestationsManifestations

Pain in the involved extremityPain in the involved extremityCramping in the instep of the foot or leg calves, relieved by Cramping in the instep of the foot or leg calves, relieved by restrestRest pain in fingers and toesRest pain in fingers and toes



Rest pain in fingers and toesRest pain in fingers and toesSmoking, cold, emotional distress trigger burning painSmoking, cold, emotional distress trigger burning painPale, cool/cold to touchPale, cool/cold to touchSkin shiny, thin; nails thick and malformedSkin shiny, thin; nails thick and malformedPulses difficult to obtain or absentPulses difficult to obtain or absent

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Raynaud’s PhenomenonRaynaud’s PhenomenonSpasms of the small arteries of extremitiesSpasms of the small arteries of extremitiesSpasms limit blood flowSpasms limit blood flowManifestationsManifestations

S/S occur after exposure to cold or workS/S occur after exposure to cold or work--related vibrationrelated vibration



BlueBlue--whitewhite--red syndromered syndromeNumbness, stiffness, decreased sensation, aching painNumbness, stiffness, decreased sensation, aching pain

Venous ThrombosisVenous ThrombosisSmall clots develop in veinsSmall clots develop in veinsThree pathologic factors: Virchow’s triadThree pathologic factors: Virchow’s triad

Venous stasisVenous stasisIncreased blood coagulabilityIncreased blood coagulability

l ll i jl ll i j



Vessel wall injuryVessel wall injuryDeep venous thrombosis (DVT)Deep venous thrombosis (DVT)

Figure 28Figure 28--4. 4. Common locations of deep venous thrombosis.Common locations of deep venous thrombosis.



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BOX 28BOX 28--1313 Risk Factors for Venous Thrombosis.Risk Factors for Venous Thrombosis.



Venous ThrombosisVenous ThrombosisCalf pain, muscle tendernessCalf pain, muscle tendernessDull, aching pain with walkingDull, aching pain with walkingEnlarged calf, cyanoticEnlarged calf, cyanoticPositive Homan’s signPositive Homan’s sign



ggPulmonary embolismPulmonary embolismSuperficial vein thrombophlebitisSuperficial vein thrombophlebitis

Trauma to vein wallTrauma to vein wall

BOX 28BOX 28--1414 Manifestations of Deep and Superficial Venous Thrombosis.Manifestations of Deep and Superficial Venous Thrombosis.



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Venous InsufficiencyVenous Insufficiency

Large veins of legs occludedLarge veins of legs occludedDistends veinsDistends veinsValves damagedValves damagedValves fail to closeValves fail to close



Valves fail to closeValves fail to closeBlood collects and pools in lower extremitiesBlood collects and pools in lower extremitiesCongestion and edema of leg tissueCongestion and edema of leg tissueVenous stasis ulcers developVenous stasis ulcers develop

Figure 28Figure 28--5.5. Chronic venous insufficiency. Note the discoloration of the ankle and the stasis ulcer. (Source: Camera M.D. Chronic venous insufficiency. Note the discoloration of the ankle and the stasis ulcer. (Source: Camera M.D. Studios, Carroll H. Weiss, Director, 8290 N.W. 26th Place, Sunrise, FL 33322.)Studios, Carroll H. Weiss, Director, 8290 N.W. 26th Place, Sunrise, FL 33322.)



Varicose VeinsVaricose VeinsIrregular, tortuous vein with incompetent valvesIrregular, tortuous vein with incompetent valvesCommonly affect lower extremitiesCommonly affect lower extremities



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Figure 28Figure 28--7. 7. (A) Normal leg veins. (B) Varicose veins(A) Normal leg veins. (B) Varicose veins



Varicose VeinsVaricose VeinsPathophysiologyPathophysiology

Increased pressure stretches the vessel wallIncreased pressure stretches the vessel wallStanding increases pressure in the leg veinsStanding increases pressure in the leg veinsDecreases venous return to the heartDecreases venous return to the heartBl d ll t i th l iBl d ll t i th l i



Blood collects in the leg veinsBlood collects in the leg veins

Varicose VeinsVaricose VeinsManifestationsManifestations

Severe, aching leg painSevere, aching leg painLeg fatigue/heavinessLeg fatigue/heavinessItchingItchingH t ft l d t diH t ft l d t di



Heat after prolonged standingHeat after prolonged standingVisibly dilated veinsVisibly dilated veins

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Varicose VeinsVaricose VeinsComplicationsComplications

Venous insufficiencyVenous insufficiencyStasis dermatitisStasis dermatitisStasis ulcersStasis ulcersSki b kl thi d di l dSki b kl thi d di l d



Skin above ankles thin and discoloredSkin above ankles thin and discoloredVenous thrombosisVenous thrombosis

Varicose Veins Varicose Veins

Diagnostic testsDiagnostic testsDoppler ultrasoundDoppler ultrasoundTrendelenburg testTrendelenburg test



Figure 28Figure 28--3.3. A Doppler (ultrasound) stethoscope. Photographer: Elena Dorfman.)A Doppler (ultrasound) stethoscope. Photographer: Elena Dorfman.)



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Varicose Veins Varicose Veins -- TreatmentTreatment

ConservativeConservativeAntiembolic stockingsAntiembolic stockingsDaily walkingDaily walkingAvoid prolonged sitting/standingAvoid prolonged sitting/standing



Elevate legsElevate legs

Reduce discomfortReduce discomfortNo real cureNo real cure

Varicose Veins Varicose Veins -- TreatmentTreatmentSurgerySurgery

SclerotherapySclerotherapyVein strippingVein stripping



Varicose Veins Varicose Veins –– Nursing CareNursing CareIneffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralAssess pulses, capillary refill, skin temperature, Assess pulses, capillary refill, skin temperature, edemaedemaAntiembolic hoseAntiembolic hose



Leg wraps as prescribedLeg wraps as prescribedLeg exercisesLeg exercisesLeg positioningLeg positioning

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Varicose Veins Varicose Veins –– Nursing CareNursing CareTeachingTeachingDaily walksDaily walksAntiembolic hoseAntiembolic hoseElevate legsElevate legs



ggAvoid sitting/standingAvoid sitting/standingCalf/thigh muscle exercisesCalf/thigh muscle exercises

Venous Conditions Venous Conditions -- TreatmentTreatmentMedicationsMedications

NSAIDsNSAIDsAnticoagulantsAnticoagulantsHeparinHeparinO l f iO l f i



Oral warfarinOral warfarinThrombolyticsThrombolytics

Venous Conditions Venous Conditions -- TreatmentTreatmentSurgerySurgery

Venous thrombectomyVenous thrombectomyInsertion of filtering deviceInsertion of filtering device



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Figure 28Figure 28--6. 6. A vena caval filter to trap emboli from the pelvis and lower extremities.A vena caval filter to trap emboli from the pelvis and lower extremities.



Venous ConditionsVenous ConditionsDiagnostic testsDiagnostic tests

Duplex venous ultrasoundDuplex venous ultrasoundPlethysmographyPlethysmographyMRIMRIA di t t hl b h hA di t t hl b h h



Ascending contrast phlebography or venographyAscending contrast phlebography or venography

Venous Conditions Venous Conditions -- TreatmentTreatmentPreventionPreventionElastic stockingsElastic stockingsPneumatic compression devicesPneumatic compression devicesLeg exercisesLeg exercisesE l b l tiE l b l ti



Early ambulationEarly ambulationNo leg crossingNo leg crossingCompresses to relieve symptomsCompresses to relieve symptomsBed restBed restElevate legsElevate legsTED hoseTED hose

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Venous Conditions Venous Conditions –– Nursing CareNursing Care

Assess all clients who may be at riskAssess all clients who may be at risk



TABLE 28TABLE 28--66 Evaluating Edema.Evaluating Edema.



Venous Conditions Venous Conditions –– Nursing Nursing CareCare

Stasis dermatitis and stasis ulcer careStasis dermatitis and stasis ulcer careWet compresses, boric acid, Burrow’s solution, isotonic Wet compresses, boric acid, Burrow’s solution, isotonic salinesalineTopical ointmentsTopical ointmentsUnna bootUnna boot



Unna bootUnna boot

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Ineffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralPeripheral pulsesPeripheral pulsesCalf and thigh diameterCalf and thigh diameterElevate legsElevate legsA ti b li h / t kiA ti b li h / t ki



Antiembolic hose/stockingsAntiembolic hose/stockingsFrequent position changesFrequent position changesAnticoagulants/thrombolyticsAnticoagulants/thrombolyticsLab valuesLab values


PainPainPain scalePain scaleWarm, moist heatWarm, moist heatBed restBed rest




Impaired Skin IntegrityImpaired Skin IntegrityAssess every 8 hoursAssess every 8 hoursMild soap, solutions, lotionsMild soap, solutions, lotionsMattressMattressA ti / i ROMA ti / i ROM



Active/passive ROMActive/passive ROMProgressive ambulationProgressive ambulation

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EvaluationEvaluationComfort levelComfort levelPeripheral circulationPeripheral circulationBruising/bleedingBruising/bleeding



Lab resultsLab results


TeachingTeachingDisease processDisease processCourse of treatmentCourse of treatmentLab testsLab testsM di tiM di ti



MedicationsMedicationsWound careWound careActivityActivityMeasures to prevent recurrenceMeasures to prevent recurrenceFollowFollow--up visitsup visitsEfforts to avoid complicationsEfforts to avoid complications

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