the cardiovascular system nrs 108-ecc majuvy l. sulse rn, msn, ccrn lola oyedele rn, msn, ctn

The Cardiovascular System

NRS 108-ECCMajuvy L. Sulse RN, MSN, CCRN

Lola Oyedele RN, MSN, CTN

SITES FOR PALPATING PERIPHERAL PULSES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

VEINS IN THE LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

VENOUS THROMBOSIS DESCRIPTION

Thrombus can be associated with an inflammatory process

When a thrombus develops, inflammation occurs that thickens the vein wall leading to embolization

TYPES OF VENOUS THROMBOSIS

THROMBOPHLEBITIS A thrombus associated with inflammation

PHLEBOTHROMBUS A thrombus without inflammation

PHLEBITIS Vein inflammation associated with invasive

procedures such as IVs DEEP VEIN THROMBOPHLEBITIS (DVT)

More serious than a superficial thrombophlebitis because of the risk for pulmonary embolism

RISKS FACTORS FOR VENOUS THROMBOSIS

Venous stasis from varicose veins, heart failure, immobility

Hypercoagulability disorders Injury to the venous wall from IV

injections, fractures, trauma Following surgery, particularly hip surgery

and open prostate surgery Pregnancy Ulcerative colitis Use of oral contraceptives

PHLEBITIS ASSESSMENT

Red, warm area radiating up an extremity Pain and soreness Swelling

IMPLEMENTATION Apply warm, moist soaks as prescribed to

dilate the vein and promote circulation Assess temperature of soak prior to applying Assess for signs of complications such as tissue

necrosis, infection, or pulmonary embolus

DEEP VEIN THROMBOPHLEBITIS (DVT)

ASSESSMENT Calf or groin tenderness or pain with or without

swelling Positive Homans’ sign Warm skin that is tender to touch


IMPLEMENTATION Provide bed rest Elevate the affected extremity above the level

of the heart as prescribed Avoid using the knee gatch or a pillow under

the knees Do not massage the extremity Provide thigh-high compression or

antiembolism stockings as prescribed to reduce venous stasis and to assist in the venous return of blood to the heart


IMPLEMENTATION Administer intermittent or continuous warm,

moist compresses as prescribed Palpate the site gently, monitoring for warmth

and edema Measure and record the circumference of the

thighs and calves Monitor for shortness of breath and chest pain,

which can indicate pulmonary emboli


IMPLEMENTATION Administer thrombolytic therapy (t-PA,

tissue plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms

Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots

Monitor APTT during heparin therapy Administer warfarin (Coumadin) therapy as

prescribed when the symptoms of DVT have resolved


IMPLEMENTATION Monitor PT and INR during warfarin (Coumadin)

therapy Monitor for the hazards and side effects

associated with anticoagulant therapy Administer analgesics as prescribed to reduce

pain Administer diuretics as prescribed to reduce

lower extremity edema Provide client teaching

ASSESSING FOR PERIPHERAL EDEMA

From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders


CLIENT EDUCATION Hazards of anticoagulation therapy Signs and symptoms of bleeding Avoid prolonged sitting or standing,

constrictive clothing, or crossing legs when seated

Elevate the legs for 10 to 20 minutes every few hours each day

Plan a progressive walking program


CLIENT EDUCATION Inspect the legs for edema and how to

measure the circumference of the legs Antiembolism stockings (hose) as prescribed Avoid smoking Avoid any medications unless prescribed by

the physician Importance of follow-up physician visits and

laboratory studies Obtain and wear a Medic Alert bracelet

ANTIEMBOLISM HOSE

From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

VENOUS INSUFFICIENCY

DESCRIPTION Results from prolonged venous hypertension

that stretches the veins and damages the valves

The resultant edema and venous stasis causes venous stasis ulcers, swelling, and cellulitis

Treatment focuses on decreasing edema and promoting venous return from the affected extremity

Treatment for venous stasis ulcers focuses on healing the ulcer and preventing stasis and ulcer recurrence


ASSESSMENT Stasis dermatitis or discoloration along the

ankles extending up to the calf Edema The presence of ulcer formation

PERIPHERAL VASCULAR DISEASE

From Bryant RA (1992): Acute and chronic wounds: nursing management, St. Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.


WOUND CARE Provide care to the wound as prescribed by the

physician Assess the client’s ability to care for the

wound, and initiate home care resources as necessary

If an Unna boot (a dressing constructed of gauze moistened with zinc oxide) is prescribed, it will be changed by the physician weekly


WOUND CARE The wound is cleansed with normal saline prior

to application of the Unna boot; providone-iodine (Betadine) or hydrogen peroxide is not used because they destroy granulation tissue

The Unna boot is covered with an elastic wrap that hardens, to promote venous return and prevent stasis

Monitor for signs of arterial occlusion from an Unna boot that may be too tight

Keep tape off of the client’s skin


MEDICATIONS Apply topical agents to wound as prescribed to

debride the ulcer, eliminate necrotic tissue, and promote healing

When applying topical agents, apply an oil-based agent as petroleum jelly (Vaseline) on surrounding skin, because debriding agents can injure healthy tissue

Administer antibiotics as prescribed if infection or cellulitis occur


CLIENT EDUCATION Wear elastic or compression stockings during

the day and evening as prescribed Put on elastic stockings upon awakening before

getting out of bed Put a clean pair of elastic stockings on each

day and that it will probably be necessary to wear the stockings for the remainder of life

VENOUS INSUFFICIENCY CLIENT EDUCATION

Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated

Elevate the legs for 10 to 20 minutes every few hours each day

Elevate legs above the level of the heart when in bed

VENOUS INSUFFICIENCY CLIENT EDUCATION

The use of an intermittent sequential pneumatic compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening

Advise the client with an open ulcer that the compression system is applied over a dressing

VARICOSE VEINS DESCRIPTION

Distended protruding veins that appear darkened and tortuous

Vein walls weaken and dilate, and valves become incompetent

ASSESSMENT Pain in the legs with dull aching after standing A feeling of fullness in the legs Ankle edema

NORMAL VEINS AND VARICOSITIES


VARICOSE VEINS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby

VARICOSE VEINS TRENDELENBURG TEST

Place the client in a supine position with the legs elevated

When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end

TRENDELENBURG TEST


VARICOSE VEINS IMPLEMENTATION

Assist with the Trendelenburg test Emphasize the importance of antiembolism

stockings as prescribed Instruct the client to elevate the legs as much

as possible Instruct the client to avoid constrictive clothing

and pressure on the legs Prepare the client for sclerotherapy or vein

stripping, as prescribed

SCLEROTHERAPY DESCRIPTION

A solution is injected into the vein followed by the application of a pressure dressing

An incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours

VEIN STRIPPING DESCRIPTION

Varicose veins are removed if they are larger than 4 mm in diameter or if they are in clusters

PREOPERATIVE Assist the physician with vein marking Evaluate pulses as a baseline for comparison

postoperatively

VEIN STRIPPING

POSTOPERATIVE Maintain elastic (Ace) bandages on the

client’s legs Monitor the groin and leg for bleeding through

the elastic bandages Monitor the extremity for edema, warmth,

color, and pulses Elevate the legs above the level of the heart

VEIN STRIPPING POSTOPERATIVE

Encourage range-of-motion exercises of the legs

Instruct the client to avoid leg dangling or chair sitting

Instruct the client to elevate the legs when sitting

Emphasize the importance of wearing elastic stockings after bandage removal

PERIPHERAL ARTERIAL DISEASE (PAD)

DESCRIPTION A chronic disorder in which partial or total

arterial occlusion deprives the lower extremities of oxygen and nutrients

Tissue damage occurs below the level of the arterial occlusion

Atherosclerosis is the most common cause of PAD

ARTERIES IN THE LEG



ASSESSMENT Intermittent claudication (pain in the muscles

resulting from an inadequate blood supply) Rest pain, characterized by numbness, burning

or aching in the distal portion of the lower extremities, that awakens the client at night and is relieved by placing the extremity in a dependent position

Lower back or buttock discomfort


ASSESSMENT Loss of hair and dry scaly skin on the lower

extremities Thickened toenails Cold and gray-blue color of skin in the lower

extremities Elevational pallor and dependent rubor in

the lower extremities Decreased or absent peripheral pulses


ASSESSMENT Signs of arterial ulcer formation occurring on or

between the toes, or on the upper aspect of the foot, that are characterized as painful

Blood pressure measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally BP readings in the thigh and calf are higher than those in the upper extremities)

ARTERIAL OBSTRUCTIONS AND CORRESPONDING AREAS OF CLAUDICATION


ARTERIAL INSUFFICIENCY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

GANGRENE

From Auerbach PS: Wilderness Medicine: Management of wilderness and environmental emergencies, ed. 3, St. Louis, 1995, Mosby.


IMPLEMENTATION Assess pain Monitor the extremities for color, motion and

sensation, and pulses Obtain BP measurements Assess for signs of ulcer formation or signs of

gangrene Assist in developing an individualized exercise

program that is initiated gradually and slowly increased


IMPLEMENTATION Encourage prescribed exercise, which will

improve arterial flow through the development of collateral circulation

Instruct the client to walk to the point of claudication, stop and rest, then walk a little further


IMPLEMENTATION As swelling in the extremities prevents arterial

blood flow, instruct the client to elevate his or her feet at rest, but to refrain from elevating them above the level of the heart, because extreme elevation slows arterial blood flow to the feet

In severe cases of PAD, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright in a chair for comfort


CLIENT EDUCATION Avoid crossing the legs, which interferes with

blood flow Avoid exposure to cold (causes

vasoconstriction) to the extremities and to wear socks or insulated shoes for warmth at all times

Never to apply direct heat to the limb such as with a heating pad or hot water, because the decreased sensitivity in the limb may result in burning


CLIENT EDUCATION Inspect the skin on the extremities daily and to

report any signs of skin breakdown Avoid tobacco and caffeine because of their

vasoconstrictive effects Use of hemorrheologic and antiplatelet

medications as prescribed Importance of taking all medications

prescribed by the physician


PROCEDURES TO IMPROVE ARTERIAL BLOOD FLOW Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy Bypass surgery (aortofemoral or femoral-

popliteal)

RAYNAUD’S DISEASE DESCRIPTION

Vasospasms of the arterioles and arteries of the upper and lower extremities

Vasospasm causes constriction of the cutaneous vessels

Attacks are intermittent and occur with exposure to cold or stress

Affects primarily fingers, toes, ears, and cheeks

RAYNAUD’S DISEASE ASSESSMENT

Blanching of the extremity, followed by cyanosis during vasoconstriction

Reddened tissue when the vasospasm is relieved

Numbness, tingling, swelling, and a cold temperature at the affected body part

RAYNAUD’S PHENOMENON

From Barkauskas VH et al (1998) Health and physical assessment (2nd ed.). St. Louis: Mosby.

RAYNAUD’S DISEASE IMPLEMENTATION

Monitor pulses Administer vasodilators as prescribed Assist the client to identify and avoid

precipitating factors such as cold and stress CLIENT EDUCATION

Medication therapy Avoid smoking Wear warm clothing, socks, and gloves in cold

weather Avoid injuries to fingers and hands

BUERGER'S DISEASE DESCRIPTION

An occlusive disease of the median and small arteries and veins

The distal upper and lower limbs are most commonly affected

Also known as thromboangiitis obliterans

BUERGER'S DISEASE ASSESSMENT

Intermittent claudication Ischemic pain occurring in the digits while at

rest Aching pain that is more severe at night Cool, numb, or tingling sensation Diminished pulses in the distal extremities Extremities are cool and red in the dependent

position Development of ulcerations in the extremities

BUERGER'S DISEASE IMPLEMENTATION

Instruct the client to stop smoking Monitor pulses Instruct the client to avoid injury to the upper

and lower extremities Administer vasodilators as prescribed Instruct the client regarding medication

therapy

AORTIC ANEURYSMS DESCRIPTION

Abnormal dilation of the arterial wall, caused by localized weakness and stretching in the medial layer or wall of an artery

The aneurysm can be located anywhere along the abdominal aorta

The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture

ARTERIAL OCCLUSION AND ANEURYSMS


TYPES OF ANEURYSMS FUSIFORM

Diffuse dilation that involves the entire circumference of the arterial segment

SACCULAR Distinct localized outpouching of the artery

wall

TYPES OF ANEURYSMS DISSECTING

Created when blood separates the layers of the artery wall forming a cavity between them

FALSE (PSEUDOANEURYSM) Occurs when the clot and connective tissue are

outside the arterial wall Formed after complete rupture and subsequent

formation of a scar sac

TYPES OF ANEURYSMS


THORACIC AORTIC ANEURYSM ASSESSMENT

Pain extending to neck, shoulders, lower back, or abdomen

Syncope Dyspnea Increased pulse Cyanosis Weakness

ABDOMINAL AORTIC ANEURYSM ASSESSMENT

Prominent, pulsating mass in abdomen, at or above the umbilicus

Systolic bruit over the aorta Tenderness on deep palpation Abdominal or lower back pain

RUPTURING ANEURYSM ASSESSMENT

Severe abdominal or back pain Lumbar pain radiating to the flank and groin Hypotension Increased pulse rate Signs of shock

RUPTURED ABDOMINAL AORTIC ANEURYSM

From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

AORTIC ANEURYSMS DIAGNOSTIC TESTS

Done to confirm the presence, size, and location of the aneurysm

Includes abdominal ultrasound, CT scan, and arteriography

AORTIC ANEURYSMS IMPLEMENTATION

Monitor vital signs Obtain information regarding back or

abdominal pain Question the client regarding the sensation of

palpation in the abdomen Inspect the skin for the presence of vascular

disease or breakdown

AORTIC ANEURYSMS IMPLEMENTATION

Check peripheral circulation including pulses, temperature, and color

Observe for signs of rupture Note any tenderness over the abdomen Monitor for abdominal distention

AORTIC ANEURYSMS NONSURGICAL IMPLEMENTATION

Modify risk factors Instruct the client regarding the procedure for

monitoring BP Instruct the client on the importance of regular

physician visits to follow the size of the aneurysm

AORTIC ANEURYSMS NONSURGICAL IMPLEMENTATION

Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs, to notify the physician immediately

Instruct the client with a thoracic aneurysm to immediately report the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness

AORTIC ANEURYSMS PHARMACOLOGICAL IMPLEMENTATION

Administer antihypertensives to maintain the BP within normal limits and to prevent strain on the aneurysm

Instruct the client in the purpose of the medications

Instruct the client about the side effects and schedule of the medication

ABDOMINAL AORTIC ANEURYSM RESECTION

DESCRIPTION Surgical resection or excision of the aneurysm The excised section is replaced with a graft

that is sewn end-to-end

ANEURYSM RESECTION WITH GRAFT


ABDOMINAL AORTIC ANEURYSM RESECTION

PREOPERATIVE Assess all peripheral pulses as a baseline for

postoperative comparison Instruct the client on coughing and deep-

breathing exercises Administer bowel preparation as prescribed

ABDOMINAL AORTIC ANEURYSM RESECTION POSTOPERATIVE

Monitor vital signs Monitor peripheral pulses distal to the graft site Monitor for signs of graft occlusion, including

changes in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention

Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft


Monitor for hypovolemia and renal failure due to significant blood loss during surgery

Monitor urine output hourly, and notify the physician if it is less than 50 ml per hour

Monitor serum creatinine and BUN daily Monitor respiratory status and auscultate

breath sounds to identify respiratory complications


Encourage turning, coughing and deep breathing, and splinting the incision; ambulate as prescribed

Maintain nasogastric tube to low suction until bowel sounds return

Assess for bowel sounds and report their return to the physician

Monitor for pain and administer medication as prescribed

Assess incision site for bleeding or signs of infection


Prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions

Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks

Advise the client to avoid activities requiring pushing, pulling, or straining

Instruct the client not to drive a vehicle until approved by the physician

THORACIC AORTIC ANEURYSM REPAIR

DESCRIPTION A thoracotomy or median sternotomy approach

is used to enter the thoracic cavity The aneurysm is exposed, excised, and a graft

or prosthesis is sewn onto the aorta Total cardiopulmonary bypass is necessary for

excision of aneurysms in the ascending aorta Partial cardiopulmonary bypass is used for

clients with an aneurysm in the descending aorta

THORACIC AORTIC ANEURYSM REPAIR POSTOPERATIVE

Monitor vital signs Monitor for signs of hemorrhage such as a drop

in BP, increased pulse rate and respirations, and report to the physician immediately

Monitor chest tubes for an increase in chest drainage, which may indicate bleeding or separation at the graft site


Assess sensation and motion of all extremities and notify the physician if deficits occur, which can be due to a lack of blood supply during surgery

Monitor respiratory status and auscultate breath sounds to identify respiratory complications

Encourage turning, coughing, and deep breathing, splinting the incision

Monitor cardiac status for dysrhythmias

THORACIC AORTIC ANEURYSM REPAIR

POSTOPERATIVE Monitor for pain and administer medication as

prescribed Assess the incision site for bleeding or signs of

infection Prepare the client for discharge by providing

instructions regarding pain management, wound care, and activity restrictions


Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks

Advise the client to avoid activities requiring pushing, pulling, or straining

Instruct the client not to drive a vehicle until approved by the physician

EMBOLECTOMY DESCRIPTION

Removal of an embolus from an artery using a catheter

A patch graft may be required to close the artery

EMBOLECTOMY PREOPERATIVE

Obtain a baseline vascular assessment Administer anticoagulants as prescribed Administer thrombolytics as prescribed Place a bed cradle on the bed Avoid bumping or jarring the bed Maintain the extremity in slightly dependent

position

EMBOLECTOMY POSTOPERATIVE

Assess cardiac, respiratory, and neurological status

Monitor affected extremity for color, temperature, and pulse

Assess sensory and motor function of the affected extremity

Monitor for signs and symptoms of new thrombi or emboli

Administer oxygen as prescribed Monitor pulse oximetry


Monitor for complications caused by reperfusion of the artery, such as spasms and swelling of the skeletal muscles

Monitor for signs of swollen skeletal muscles, such as edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness

Maintain bed rest initially, with the client in semi-Fowler’s position

Place a bed cradle on the bed


Check the incision site for bleeding or hematoma

Administer anticoagulants as prescribed Monitor laboratory values related to

anticoagulant therapy Instruct the client to recognize the signs and

symptoms of infection and edema Instruct the client to avoid prolonged sitting or

crossing the legs when sitting


Instruct the client to elevate the legs when sitting

Instruct the client to wear antiembolism stockings as prescribed and how to remove and reapply the stockings

Instruct the client to ambulate daily Instruct the client about anticoagulant therapy

and the hazards associated with anticoagulants

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA VENA CAVAL FILTER

Insertion of an intracaval filter (umbrella) that partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli

LIGATION Suturing or placing clips on the inferior vena

cava to prevent pulmonary emboli

VENA CAVAL FILTERS

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA POSTOPERATIVE

Monitor vital signs Assess cardiac and respiratory status Administer oxygen as prescribed Monitor pulse oximetry Maintain semi-Fowler’s position Avoid hip flexion Maintain antiembolism stockings as prescribed

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA PREOPERATIVE

If the client has been taking an anticoagulant, consult with the physician regarding discontinuation of the medication to prevent hemorrhage

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA POSTOPERATIVE

Provide activity as prescribed Check the insertion site for bleeding and

hematoma Assess for peripheral edema Monitor laboratory values related to

anticoagulant therapy

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA CLIENT EDUCATION

Signs and symptoms of infection and edema Avoid prolonged sitting or crossing legs when

sitting Elevate the legs when sitting Wear antiembolism stockings as prescribed

and how to remove and reapply the stockings Ambulate daily About anticoagulant therapy and the hazards

associated with anticoagulants

the cardiovascular system nrs 108-ecc majuvy l. sulse rn, msn, ccrn lola oyedele rn, msn, ctn

Documents

heart slide

saunders slide

ctn slide

embolization slide

vein wall

pulmonary embolus slide

pulmonary embolism slide

superficial thrombophlebitis