chapter 19 care of patients with hypertension and peripheral vascular disease

79
Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Upload: janis-flynn

Post on 31-Dec-2015

227 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Chapter 19CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Page 2: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Hypertension

▪ Persistently high blood pressure

▪ Ages 30-59▪ Systolic ≥ 140 mm Hg▪ Diastolic ≥ 90 mm Hg

▪ Ages ≥ 60▪ Systolic ≥ 150 mm Hg ▪ Diastolic ≥ 90 mm Hg

▪ Taken twice on 2 separate occasions

▪ Untreated can lead to end organ damage▪ Brain, heart, kidneys and eyes

▪ Death is associated with MI, cerebral hemorrhage and heart failure

▪ Known as the “silent killer” 2

Page 3: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Hypertension

▪ Primary hypertension▪ Idiopathic or essential ▪ 90-95% are this type (hereditary)

▪ Secondary hypertension ▪ Stress, excess alcohol, sickle cell, arteriosclerosis, coarctation of the

aorta, eclampsia, renal disease, endocrine and neurological disorders

▪ Drug use, HRT, and nicotine can also contribute

▪ If an underlying cause can be detected and eliminated- Secondary HTN

3

Page 4: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Risk Factors for Primary Hypertension

▪ Nonmodifiable risk factors▪ Age▪ Gender▪ Ethnicity/race▪ Family history

▪ Modifiable risk factors▪ Alcohol▪ Cigarette smoking▪ Diabetes▪ Obesity▪ Stress▪ Elevated serum lipids▪ Excess dietary sodium▪ Lower socioeconomic status

4

Page 5: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Cultural Considerations

▪ Hypertension and African Americans▪ African Americans tend to have a higher incidence of

hypertension than do other minority groups and Caucasians▪ African-Americans also have higher noncompliance,

complication, and mortality rates▪ Economic issues, access to health care, dietary practices,

and weight have been identified as possible reasons for the disparities

5

Page 6: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Pathophysiology

▪ Blood pressure equals the amount of blood pumped out of the heart multiplied by the systemic vascular resistance

▪ If diameter changes – BP changes▪ Vasoconstriction or vasodilation

▪ Increase in volume – BP changes ▪ Hypovolemia or hypervolemia

▪ Increase in viscosity – BP changes▪ Thinner or thicker blood

▪ Can be related to SNS involvement or RAAM

Page 7: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE
Page 8: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Signs and Symptoms

▪ No signs/symptoms in early stages

▪ Target organ damage signs and symptoms ▪ Brain▪ Aorta▪ Eyes▪ Heart ▪ Kidneys

▪ Develop coronary heart disease at a rate 2-3x as quickly

▪ Diagnosis▪ BP readings elevated on 2 occassions; 2 weeks apart▪ May have an ECG or stress test

Page 9: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Goals of Treatment

▪ Reduction of high blood pressure

▪ Long-term control to decrease the risk of stroke, heart attack, loss of vision, and kidney disease

9

Page 10: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Stepped-Care Approach

▪ First step▪ Smoking cessation▪ Weight reduction▪ Sodium restriction▪ Alcohol restriction▪ Exercise▪ Low-fat diet▪ Stress control

▪ Second step▪ Antihypertensive

▪ Third step▪ More medications

10

Page 11: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

JNC 8 guidelines

▪ Treat to goal BP ▪ ≥ 60 years old▪ <150/90 mm Hg

▪ < 60 years old▪ All ages with diabetes, NO CKD▪ All ages CKD with or without diabetes ▪ < 140/90 mm Hg

▪ Reinforce medications and lifestyle adherence

Page 12: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Antihypertensive Therapy

▪ Diuretics▪ Thiazide-type

▪ ACE inhibitors

▪ Angiotensin Receptor Blockers (ARBs)

▪ Calcium Channel Blockers

▪ During therapy: Measure heart rate and BP at beginning of therapy and periodically throughout. Ortho BP’s will show if BP reduces too much.

▪ Assess for dizziness, confusion, restlessness, and drowsiness

Page 13: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

JNC RECOMENDATIONS

▪ Non black community thiazide, ACEi, ARB or CCB alone or combo

▪ Black Community thiazide or CCB alone or combo

▪ All races with CKD with or withoug Diabetes ACEi or ARB alone or in combo

Page 14: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Preventing Falls for Patients with Orthostatic Hypotension

▪ Rise slowly from a lying to a sitting position; do not hold your breath as you arise. Sit for 1 minute before standing; stand slowly holding onto a stable object. Stand for 1 minute before walking

▪ While seated, flex and rotate the feet several times before attempting to stand; have feet firmly planted on the floor before standing

14

Page 15: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Preventing Falls for Patients with Orthostatic Hypotension (cont.)

▪ When walking, do not turn your head or body abruptly

▪ When feeling unsteady while standing, call for assistance before walking

▪ Report lightheadedness or sudden dizziness Use the bathroom before meals and try to avoid getting up for

30 to 60 minutes after meals.

15

Page 16: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Complications

▪ Malignant hypertension▪ Rapidly progressive moderate to severe hypertension, difficult to

control▪ Diastolic BP ranges from 140-170 mm Hg▪ May suffer end organ damage

▪ Hypertensive crisis▪ Hypertensive emergency▪ BP rises >180/120 mmHg, target organ damage▪ ICU for treatment to lower BP ▪ Reduce to 160/100 mmHg over 2 hours

▪ Hypertensive urgency▪ BP rises >180/120 mmHg, no evidence of target organ damage

16

Page 17: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

HYPERTENSION

▪ Hypertensive emergencies: Headache, blurred vision, seizures, nausea, and change in LOC

▪ Goal is to prevent ischemia to heart renal and cerebral arteries

Page 18: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Assessment (Data Collection)

▪ Modifiable and nonmodifiable risk factors

▪ Elder care considerations▪ BP lower after a meal, take BP in between meals

▪ Physical Assessment▪ Vital signs- sitting and standing BP▪ Cardiovascular assessment▪ Laboratory values▪ BMP – especially BUN and creatinine

18

Page 19: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Nursing Diagnosis

▪ Risk for injury

▪ Deficient knowledge

▪ Imbalance nutrition

▪ Anxiety

Page 20: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Expected Outcomes

▪ The patient will not experience retinopathy

▪ The patient’s blood pressure will return to normal limits

▪ The patient will verbalize understanding of medications and disease process

▪ The patient will lose 10% of body weight in a designated period

▪ The patient will be able to choose low-fat and low-sodium items from a variety of menus

20

Page 21: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Implementation

▪ Diet▪ Cultural variations▪ Reduction of sodium intake▪ Weight loss- 7-12 pounds can reduce BP▪ Caffeine reduction

▪ Stress reduction

▪ Smoking cessation

▪ Exercise regimen

▪ The goal is a weight that is within 15% of ideal body weight

▪ Grapeseed extract is an alternative medicine treatment for hypertension that also helps decrease cholesterol

21

Page 22: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Complications of Uncontrolled Hypertension

▪ Hypertension can cause damage to arteries, making them less elastic. This places an increased workload on the heart. This may cause myocardial infarction, left ventricular hypertrophy, and congestive heart failure

▪ Small vessel damage to the brain disrupts circulation and may lead to transient ischemic attacks (TIAs) and stroke

▪ Hypertension may cause damage to the small vessels of the kidney and may lead to kidney failure

▪ Hypertension damages the arteries of the eye, causing the formation of clots or occurrence of hemorrhage that may lead to blurred vision or blindness

22

Page 23: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Evaluation

▪ Effect on blood pressure

▪ Patient knowledge—medications, diet, exercise, stress management, and smoking cessation

▪ Patient compliance

▪ Sudden discontinuation of BP meds can cause rebound hypertension

▪ Consistent measurements within normal limits is an indicator of compliance

23

Page 24: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arteriosclerosis and Atherosclerosis

▪ Arteriosclerosis- hardening of the arteries▪ Thickening of arterial wall, Loss of musculature and

accumulation of calcium

▪ Atherosclerosis- accumulation of plaque along vessels▪ Cells, fibrin and cell debris also accumulate, may cause a

clot

▪ Uncontrolled diabetes and hypertension may be a major factor in the development of these both.

24

Page 25: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Peripheral Vascular Disease

▪ Narrowing or obstruction of peripheral blood vessels and loss of function

▪ May be due to spasms (Raynaud’s) structural defects (aneurysms) or emboli

▪ Also valvular dysfunction in veins, thrombus formation in veins, or thrombophlebitis (inflammation of the wall of a vein associated with thrombosis)

▪ Prevention▪ Decrease atherosclerosis and arteriosclerosis▪ Control diabetes mellitus and hypertension▪ Prevent smoking

25

Page 26: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Diagram of the Peripheral Vascular System

26

Page 27: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Peripheral Arterial Disease (PAD) (Arterial Insufficiency)

▪ Most commonly caused by atherosclerosis ▪ Leads to ischemia and tissue necrosis▪ Acute occlusion is caused by an emboli ▪ Common in carotid arteries

▪ Signs, symptoms, and diagnosis▪ Intermittent claudication – pain with ambulation, declines with rest▪ Rubor especially when dependent ( cardinal sign of inflammation)▪ Tight shiny skin▪ Diminished or absent pulses▪ Temperature change especially distal to occlusion ▪ Leg wounds that are difficult to heal

27

Page 28: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Peripheral Arterial Disease (PAD) (Arterial Insufficiency)

▪ Arterial ulcers ▪ Lack of blood flow▪ Sharp edges and pale base, painful ▪ Slow and difficult to heal

▪ Arterial embolism ▪ Thrombus near atheromatous plaque (accumulation of lipid containing plaques on

the innermost layer of artery wall) ruptures

S/S▪ Six Ps▪ Pain, pulselessness, paresthesia ( pins and needles caused chiefly by pressure on

or damage to the peripheral nerves), paralysis, poikilothermia ( coldness), pallor

▪ Diagnosis▪ ABI (normal value is 1= systolic pressure is the same at the ankle and

brachial art sites), Xray or Radiographic Ultrasound

Page 29: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial Ulcers

Page 30: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Cellulitis of the Legs

30

Page 31: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Cellulitis of the Legs

▪ A common and potentially serious bacterial skin infection

▪ Edema & rubor

▪ Size of wound may vary

▪ May develop gangrene-amputation

Page 32: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Gangrene of Toes

32

Page 33: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Treatment for Arterial Occlusive Disease

▪ Exercise is the best treatment for arterial occlusive disease▪ Walking vigorously for 20 minutes twice a day will encourage

growth of collateral circulation and reduce the severity of claudication in the majority of patients

▪ The exercise program is started slowly, working up to a faster pace and the full 20 minutes

▪ Some dietary supplements have proven helpful in increasing circulation

▪ Keep ulcers clean and free from pressure ▪ Moist dressings, debridement only by a qualified health

professional

▪ Medications 33

Page 34: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

MEDICATIONS

• Anti-platelet agents and platelet inhibitors may be used alone or in combination with other drugs. Aspirin is the most commonly used antiplatelet agent. It prevents the aggregation of platelets in the arteries.

• Platelet inhibitors, such as clopidogrel (Plavix), may be prescribed. Patients experiencing intermittent claudication may achieve relief of symptoms when prescribed pentoxifylline (Trental) or cilostazol (Pietal). Research has shown cilostazol to be more effective than clopidogrel These drugs increase blood flow by inhibiting clot formation in the vessel.

• Patients experiencing acute ischemia may receive thrombolytic therapy. Urokinase, tPA, or tNK are the drugs of choice for thrombolysis.

• Cholesterol-lowering drugs (e.g., atorvastatin [Lipitor], simvastatin [Zocor]), ezetimibe [Zetia]) have been shown to be effective by decreasing low-density lipoprotein (LDL) and increasing high-density lipoprotein (HDL) levels, thus reducing plaque deposits in the arteries.

Page 35: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Peripheral Arterial Disease

▪ Goals of treatment▪ Increase blood flow through the peripheral arteries▪ Decrease the risk of clot formation in the vessels

35

Page 36: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Peripheral Arterial Disease (cont.)

▪ Percutaneous transluminal angioplasty (PTA)▪ Stents may be used

▪ Laser angioplasty

▪ Surgical treatment ▪ Aorto-iliac bypass or a femoro-popliteal bypass▪ Postoperative care:▪ Vital signs▪ Distal pulses▪ Parasthesia▪ s/s bleeding, hematoma▪ Temperature▪ infection

36

Page 37: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Femoro-Popliteal Bypass Graft

37

Page 38: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Nursing Management- PAD

▪ Assessment (data collection)▪ Q 4 hour assessment of affected extremity▪ 6 P’s ▪ Early detection and intervention for complications

▪ Nursing diagnosis and planning▪ Maintain arterial blood flow to the lower extremities ▪ Protect tissues from further injury from pressure and

constriction of blood flow – hopefully increase collateral circulation

▪ Prevent wound infection▪ Ineffective tissue perfusion, Impaired skin integrity, Injury (risk),

Acute pain.

38

Page 39: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Implementation

▪ Keep patient and environment warm

▪ Avoid constrictive clothing

▪ Allow lower extremities to dangle

▪ Change position frequently

▪ Exercise – walking, swimming, and leg exercises when at rest

▪ Smoking cessation

39

Page 40: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Evaluation

▪ Changes in peripheral pulses and skin integrity

▪ Improvement or extension of vascular ulcers

▪ Changes in color, sensation, and temperature of the lower extremities

▪ Patient’s perception of pain

▪ Level of compliance

▪ Tolerance of exercise activities

▪ Photograph of wounds weekly show improvement

40

Page 41: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Aneurysm

▪ Outpouching of the wall of the artery, from a structural defect

▪ Atherosclerosis and hypertension play a key role as well as smoking

▪ Three types: fusiform, saccular, or dissecting ▪ Can occur at area of plaque, from a genetic predisposition or hypertension

▪ May occur in any artery

▪ Clots may form along wall of aneurysm ▪ Can break off and become an emboli

▪ Will continue to grow larger

▪ May rupture if not detected or treated. ▪ Dissection

41

Page 42: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Types of Aneurysms

Page 43: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Types

▪ (A) Fusiform. The entire circumference of the artery is dilated.

▪ (B) Saccular. One side of artery is dilated.

▪ (C) Dissecting. A tear in the inner layer causes a cavity to form between the layers of the artery and fill with blood. The cavity expands with each heartbeat

Page 44: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Aneurysm

▪ Signs and symptoms▪ No obvious symptoms▪ May experience pain or pressure ▪ Visible pulsation in abdomen

▪ Diagnosis ▪ Usually found incidentally ▪ Xray, US, MRI, CT scans

▪ Treatment▪ Surgery – depends on area involved▪ May wait until 6-8 cm to perform surgery

▪ Focus: Lower blood pressure and treat the pain▪ Medications – beta blockers▪ Post-op 24-48 hours in ICU

Page 46: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Nursing Management of Aneurysms

▪ Assessment (data collection)▪ Complete H & P – medical surgical history ▪ Signs and symptoms experienced if any▪ Especially pain

▪ Medications

▪ Expected outcomes▪ The patient will not experience rupture or dissection of the

aneurysm▪ The patient will report absence of pain▪ The patient will verbalize understanding of management of

medical condition

46

Page 47: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Nursing Management of Aneurysms (cont.)

▪ Implementation ▪ Patient teaching ▪ Monitoring of cardiac function▪ Pain management

▪ Evaluation▪ Evaluate patient’s understanding of teaching related to the

disease process, potential complications, follow-up appointments, medications, and recommended lifestyle changes

47

Page 48: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial Insufficiency

▪ Carotid occlusion▪ Atherosclerosis narrows the carotid artery ▪ Bruit heard ▪ Confusion, visual abnormalities in one eye, fainting, weakness or

paralysis, or other signs of decreased blood flow to brain.

▪ Carotid endarterectomy or stent may be placed

▪ Post operative care ▪ Assess for excessive bleeding, changes in airway or neurological deficits

▪ May need to be medically managed rather than have surgery▪ Reinforce signs of complications and medication regimen-antiplatelet

regimen and anticoagulants▪ Call 911 for sensory or motor deficits

48

Page 49: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial Insufficiency

▪ Buerger’s disease (thromboangiitis obliterans)▪ Small and medium arteries ▪ Inflammation and thickening of arterial walls, occlusion in hands or feet may occur▪ Direct link to cigarette smoking

▪ Signs and symptoms ▪ Numbness and tingling in toes or fingers especially in cold weather▪ Pain in feet ▪ Intermittent claudication progressively worsens ▪ Ulceration and gangrene may occur

▪ Nursing management ▪ Smoking cessation ▪ Exercise regimen ▪ Skin Assessment

Page 50: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial Insufficiency

▪ Raynaud’s disease and Raynaud phenomenon▪ Spasms of arteries in upper and lower extremities ▪ Exaggerated response to cold and stress, leads to vasospasm ▪ Mostly young women ▪ Affects fingers and toes ▪ May be a primary or secondary to Lupus, RA or scleroderma ▪ Occurs in unilateral areas

▪ Signs and symptoms ▪ Constriction of small vessels in response to cold or stress ▪ Body parts change color (blanching, cyanosis and then

redness/erythema)▪ May progress to ischemic changes and gangrene

Page 51: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE
Page 52: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial Insufficiency - Raynaud’s (continued)

▪ Diagnosis ▪ Patient history of symptoms ▪ ESR or ANA

▪ Treatment and Nursing management ▪ Conservative treatment ▪ Stress control▪ Avoiding cold (wear gloves, layer clothes▪ Smoking cessation ▪ Limit caffeine intake ▪ Evaluate progression of symptoms especially skin integrity ▪ May be prescribed Calcium channel blockers or alpha blockers

Page 53: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Raynaud’s Disease

53

Page 54: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Venous Thrombosis

▪ Associated with inflammation of the vein

▪ DVT most commonly affects iliac and femoral veins ▪ Virchow’s triad for venous thrombosis: (1) venous stasis; (2)

damage of the inner lining of the vein (endothelium); and (3) hypercoagulability of the blood

▪ Immobility is leading cause ▪ Surgery (orthopedics especially), injury, paralysis ▪ Smoking, female hormone replacement, estrogen contraceptives,

corticosteroids, and various blood disorders may also contribute ▪ Diabetes, PVD, sepsis, obesity and dehydration contribute also.

▪ Aggregation of blood leads to clot formation

54

Page 55: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

VENOUS THROMBUS

▪ A venous thrombus is made up of platelets, red blood cells, white blood cells, and fibrin.

▪ Platelets attach to a vein wall and then a tail forms as a moiré blood cells and fibrin collect.

▪ As the tail grows, it drifts in the blood flowing past it.

▪ The turbulence of the blood flow can cause parts of the drifting thrombus to break off and become emboli that travel to the lungs.

Page 56: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Normal venous blood flow. Formation of a blood clot.

Formation of a thrombus.

Page 57: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Venous Thrombosis

▪ If DVT is not resolved it can lead to venous insufficiency ▪ Chronic

▪ May become an embolus, most commonly will travel to the lungs ▪ Life threatening emergency▪ High- Fowlers▪ Oxygen ▪ Notify Physician or Health care provider▪ Stay with the patient ▪ Medication for pain and anxiety ▪ Follow up diagnostic testing- US, VQ Scan, D-Dimer

Page 58: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Superficial Thrombophlebitis

▪ Constinuous IV therapy or contaminated drug needles may lead to development

▪ Swelling, redness, warmth, tenderness and pain

▪ Diagnosed by ultrasound or venography ▪ Physical exam performed, patient history and evaluation of signs and

symptoms

▪ Treatment and nursing management ▪ D/C source of irritation ▪ Warm moist heat ▪ Elevate extremity ▪ Change IV catheter

58

Page 59: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Superficial Thrombophlebitis

▪ Treatment and nursing management ▪ D/C source of irritation ▪ Warm moist heat ▪ Elevate extremity ▪ Change IV catheter ▪ Bedrest ▪ Support stockings after acute phase▪ Assess and document – color, warmth, circumference and pulses ▪ Medications ▪ Education ▪ Avoid sitting for long periods, standing in one place for long periods,

NSAIDS, TEDs application, activity limits, and preventative measures. ▪ Evaluate resolution of s/s

Page 60: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Deep Vein Thrombosis

▪ Deep veins of leg affected – clot formation

▪ Evident with edema in one extremity▪ May be bilateral

▪ Warmth over area

▪ Diagnosis▪ Ultrasound (Duplex Sonography), MRI may be done ▪ ACT ( activated clotting time), PT/INR, PTT, H/H and D-dimer▪ Possible venography ▪ NEVER vigorously rub affected extremity

60

Page 61: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Patient with DVT

61

Page 62: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Deep Vein Thrombosis

▪ Treatment▪ Compression ▪ SCDs or TEDs – only removed for bathing and laundered daily ▪ Only apply to non affected extremity for 24-48 hours

▪ Ambulation – following acute phase ▪ IV Heparin▪ Lovenox SQ or Coumadin▪ Factor Xa inhibitors (Arixtra)▪ Coumadin therapy initiated at about day 3

▪ Depending on extent of DVT may be candidate for tPA, urokinase, Retavase

(Clot busting medications)

Page 63: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

DEEP VEIN THROMBOSIS

▪ No effect on existing clot- prevents new formation

▪ Coumadin for 3-6 months

▪ Replace Teds q 6 months

▪ Heparin Induced Thrombocytopenia – decreased platelet count

▪ PTT monitored and CBC every 3 days

▪ Patients at risk for more PE- IVC filter

Page 64: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Vena Cava Filter

Page 65: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Deep Vein Thrombosis

▪ Postthrombotic syndrome▪ Some blockage remains ▪ Increased swelling, pain, hyperpigmentation, possible skin ulcers ▪ Treated with anticoagulants, compression stockings, extremity

▪ Venous Thrombophlebitis Prophylaxis ▪ Prescribed orders for surgical patients and those deemed at risk▪ SCDs or Teds▪ Low Molecular weight Heparin (Lovenox)

Page 66: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Deep Vein Thrombosis

▪ Observe site – compare side to side▪ Redness, edema

▪ Palpate for warmth

▪ Measure circumference bilaterally

▪ Monitor VS- Temperature >100.4

▪ Nursing education ▪ Early ambulation, leg exercises, change positions, hydration ▪ Especially those who sit or stand for long periods, plane flights, etc.

▪ Evaluation ▪ Resolution of symptoms, decrease edema, return to normal color and

temperature

Page 67: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Varicose Veins

▪ Enlarged, dilated, tortuous veins

▪ Incompetent valves in veins

▪ Occur in saphenous veins or perforator in ankle

▪ May be congenital or familial▪ May be due to chronic thrombophlebitis or DVT▪ Obesity, pregnancy or standing for long periods

▪ Signs and symptoms ▪ Dilated, twisted veins on legs▪ Edema in feet or ankles ▪ Dull ache, heavy or full feeling in legs▪ May have pain, itching or both 67

Page 68: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE
Page 69: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

VericoseVeins

▪ In varicose veins, the valves do not work properly -- allowing blood to pool in the vein and making it difficult for the muscles to push the blood "uphill." Instead of flowing from one valve to the next, the blood continues to pool in the vein, increasing venous pressure and the likelihood of congestion while causing the vein to bulge and twist. Because superficial veins have less muscle support than deep veins, they are more likely to become varicose.

▪ Any condition that puts excessive pressure on the legs or abdomen can lead to varicosity. The most common pressure inducers are pregnancy, obesity, and standing for long periods. Being sedentary likewise may contribute to varicosity, because muscles that are out of condition offer poor blood-pumping action. The likelihood of varicosity also increases as veins weaken with age. Contrary to popular belief, sitting with crossed legs will not cause varicose veins, although it can aggravate an existing condition.

Page 70: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE
Page 71: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Varicose Veins

▪ Diagnosis▪ Physical assessment and patient history

▪ Treatment ▪ Elastic stockings ▪ Exercising legs and feet▪ Elevation of lower extremities throughout day ▪ Avoid prolonged standing, sitting or crossing legs▪ Weight reduction ▪ Exercise- walking or swimming ▪ May be a surgical candidate ▪ Sclerotherapy, closure procedure, vein stripping

Page 72: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Chronic Venous Insufficiency

▪ Common in elderly

▪ Occurs when there is damage to valve- allows blood to pool

▪ Increase in venous pressure – leads to leakage of RBCs into the tissues▪ Brown discoloration in skin

▪ Signs and symptoms ▪ Chronically swollen legs, thick brownish skin at ankles and itchy scaly

skin ▪ Venous stasis ulcers commonly occur

▪ Diagnosis ▪ Patient history and physical

72

Page 73: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Characteristic Skin Changes in the Patient with Venous Insufficiency

73

Page 74: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Chronic Venous Insufficiency

▪ Treatment and Nursing Management ▪ Knee high TEDs ▪ Elevate legs 8 out of 24 hours ▪ Avoid prolonged standing, sitting ▪ Elevate legs above level of heart when possible ▪ Sleep with foot of bed elevated 6 inches ▪ No crossing legs▪ No tight constrictive clothing, garters, girdles▪ No vigorous rubbing of area with varicose veins

Page 75: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Venous Stasis Ulcers

▪ Diabetes mellitus patient at risk

▪ Chronic venous insuffiency

▪ Begins as small tender inflamed area, and becomes quite painful ▪ Difficult to heal due to congestion in underlying tissue- lack of nutrients

▪ Treatment▪ Leg elevation, moist dressing and compression ▪ Unna boots (changed weekly), TEDs, SCDs

▪ Wound vacs for extreme cases ▪ Keep skin dry and lubricated ▪ May need a skin graft if severe

75

Page 76: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Venous Stasis Ulcer

76

Page 77: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Venous Stasis Ulcers

▪ Nursing management▪ Assessment ▪ History and physical ▪ Thorough skin assessment – size, location, exudate in any wounds ▪ Pain assessment ▪ Pulses bilaterally

▪ Nursing Diagnosis and Planning ▪ Low self esteem, knowledge deficit, pain

▪ Implementation ▪ Evaluate skin integrity, improvement or deterioration of wounds

▪ Evaluation ▪ Compliance with treatment, verbalizing knowledge of disease and care,

improvement in symptoms, pictures of wounds along with measurements, decreased pain, preventative measures, skin care, and when to seek medical care.

Page 78: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Arterial versus venous disorders

Characteristics Arterial disease Venous disease

Pulses Diminished, weak or absent Strong and symmetrical, may be difficult to feel with edema

Skin Pallor, dependent rubor, thin, dry, shiny, cool

Mottling with brown pigmentation at ankles, veins may be visible; legs or feet bluish when dependent, dermatitis, warm at ankle

Edema Absent or mild Present, particularly at ankle and foot

Ulceration On toes or pressure points At bones of ankle

Necrosis and gangrene

Likely Unlikely

Pain Intermittent claudication when walking

Aching, crampy, nocturnal cramps

Nails Thick, brittle (normal in elderly) Normal

Hair Hair loss (normal in elderly) Normal

Page 79: Chapter 19 CARE OF PATIENTS WITH HYPERTENSION AND PERIPHERAL VASCULAR DISEASE

Community Care

▪ Ongoing assessment

▪ Coordination of care with other members of the health care team

▪ Monitoring progress and compliance with treatment

▪ Patient education ▪ Lifestyle changes, medication and follow up care

79