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Vascular System

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B. Physiologicalcontrol. 1. Autoregulation:theabilityoftissuetocontrolits ownbloodflow.Autoregulatorysystemenables bloodsupplytovitalorgans(brain,kidney,heart)to remainrelativelyconstant,eventhoughblood pressuremayfluctuatewithinnormalranges. 2. Nervoussystemcontrol. a. Parasympatheticnervoussystem:influenceon bloodflowistheregulationoftheheartrateby thevagusnerve. b. Sympatheticnervoussystem. (1)Primaryinfluenceofsympatheticsystem isonarteriolesfordilationandconstriction ofthevesselsinordertomaintainperipheral resistanceandvasomotortone. (2) Peripheralresistanceisresistanceof arteriolestoflowofblood. (3) Dilationdecreasesperipheralresistance, therebydecreasingbloodpressure; vasoconstrictionincreasesperipheral resistance,therebyincreasingbloodpressure.

Blood PressureA. Systolicbloodpressureisthearterialpressureatthe peakofventricularcontraction.Thesystolicpressureis determinedprimarilybytheamountofbloodejected.B. Diastolicpressurerepresentsthepressureexertedin thearteriesattheendofsystole;itistherestingventri- cularpressure.Diastolicpressuredependsontheability ofthearteriestostretchandhandlethebloodflow.C. Pulsepressureisthedifferencebetweenthesystolicand diastolicpressures.

DISORDERS OF THE VASCULAR SYSTEM

Atherosclerosis

Atherosclerosis is the most common disease of the arteries. The word means “hardening of the arteries.”A. Atherosclerosis:mostcommonclassificationofarterio- sclerosis;characterizedbystenosisandobstructionin thelumenofthevessel(Figure11-1). 1. Processisslow;generallynoevidenceofproblems untilamajorarteryisaffectedandthereissevere decreaseinbloodsupplytotissuesuppliedbyartery involved.

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PHYSIOLOGY OF THE VASCULAR SYSTEM

VesselsA. Arteries. 1. Primaryfunctionistotransportnutrientsand oxygentothecellularlevel. 2. Arterialvascularsystemisahigh-pressuresystem witharapidbloodflow.B. Capillaries. 1. Microscopicvesselsatthecellularlevel. 2. Capillarybedistheareaofcirculationwherethe arteriolesbranchintocapillariesandexchange betweenthecirculatingbloodvolumeandthe interstitialfluidoccurs.C. Veins. 1. Primaryfunctionoftheveinsistoreturnbloodto theheart. 2. Veinscontainvalvestomaintaindirectionofblood flowandtopreventthebackflowofblood. 3. Venoussystemisalow-pressuresystem.D. Circulatorysystems. 1. Systemiccirculation:theflowofbloodfromthe leftventricleintotheaortaandthroughthearteries tothecapillarybeds,wherecellularnutritionand oxygenationoccur;thenbloodreturnstotheright atriumoftheheartviatheveins. 2. Pulmonarycirculation:theflowofbloodfromthe rightventricleintothepulmonaryarteryandthen intothelungs;inthecapillarybedsofthelungs, thebloodpicksupoxygenandreleasescarbondiox- ideandthenreturnstotheleftatriumthroughthe pulmonaryveins. 3. Hepatic-portalcirculation:theflowofblood fromthevenoussystemofthestomach,intestines, spleen,andpancreasintotheportalveinand throughtheliverforabsorptionofnutrientsand removaloftoxins.Venousbloodleavestheliver throughthehepaticveinandflowsintotheinferior venacavaforreturntotherightatrium.E. Lymphaticsystem:primaryfunctionistoreturnfluid andproteintothebloodfromtheinterstitialfluid.

Mechanics of Blood FlowA. Bloodflowiscontrolledby: 1. Thediameterofthevessel. 2. Thelengthofthevessel. 3. Thepressureateitherendofthevessel. 4. Theviscosityoftheblood.

224 CHAPTER 11 Vascular System

2. Arteriescommonlyaffectedbyatherosclerosis: a. Coronaryarteries. b. Cerebrovasculararteries. c. Aorta:mayleadtoaorticaneurysm. d. Peripheralarteries.

Data CollectionA. Modifiableriskfactors. 1. Diethighinsaturatedfats(cholesterol). 2. Smoking. 3. Obesity. 4. Decreasedactivity. 5. Stress.B. Nonmodifiableriskfactors. 1. Familialtendencies. 2. Age.C. Conditionsacceleratingatheroscleroticdevelopment. 1. Diabetesmellitus. 2. Hypertension. 3. Highcholesterol/triglyceridelevels.D. Clinicalmanifestations:dependonarteryinvolved.E. Diagnostics. 1. Clinicalmanifestationofspecificareainvolved. 2. Increasedlevelsofserumtriglycerides,lipids,and cholesterol.

TreatmentA. Low-cholesteroldiet.B. Decreaseriskfactors.C. Antihyperlipidemicmedications(seeAppendix11-2).D. Peripheralvasodilatingmedications.E. Vascularsurgery.

Nursing InterventionsSeeNursingInterventionforspecificareasinvolved.

Hypertension

Hypertension is a consistent increase in blood pressure.A. Classification. 1. Essential(primary,benign,idiopathic):etiologyun- known;accountsforapproximately85%to95%of hypertensiveclients. 2. Secondary:accountsforapproximately10%to15% ofhypertensioncases;thesustainedelevationisdue toanidentifiablecause. a. Increasedintracranialpressure. b. Renaldisease. c. Pregnancy-inducedhypertension(toxemia). d. Cushing’ssyndrome. e. Thyrotoxicosis. 3. Malignanthypertension:asustainedincreaseinthe diastolicpressurethatisunresponsivetotreatment. 4. Hypertensivecrisis:whenthedegreeofhyperten- sionisalife-threateningsituation.

Data CollectionA. Riskfactorsinessentialhypertension(Table11-1).B. Clinicalmanifestationsofessentialhypertension.

NURSING PRIORITY – Encourage blood pressure monitoring in clients with increased risk, hypertension is most often asymptomatic.

1. Increaseinbloodpressure. 2. Headache. 3. Dizziness. 4. Palpitations. 5. Increaseintherateofatherosclerosis. 6. Heartfailure. 7. Leftventricularhypertrophy. 8. Visualdisturbances.C. Diagnostics. 1. Increaseinbloodpressure,especiallydiastolicpres- sureontwoseparateoccasionsatleast2weeks apart(Box11-1). a. Diastolicpressureof80mmHgorhigher. b. Systolicpressureof125mmHgorhigher.

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FIGURE 11-1 Pathophysiology of Atherosclerosis From Ignatavicius, DD, Workman, ML: Medical Surgical Nursing Patient-Centered Collaborative Care, ed 6, St Louis, 2010, Saunders.

CHAPTER 11 Vascular System 225

TABLE 11-1 RISK FACTORS IN ESSENTIAL HYPERTENSION

Nonmodifi able Factors Modifi able FactorsAge:B/Pprogressivelyincreaseswithage,commonlyincreases Obesity:centralabdominalobesity.betweenages30-50years. Stress:repeated,prolongedstress.prevalentinwoman.Gender:moreprevalentinmenuntilage55,andthenmore Excesssodiumintake:causesfluidretentionandcontributestoEthnicgroup:higherinAfricanAmericansthaninwhites. increasedbloodpressure.Familyhistory:especiallyifcloserelativehashypertension. Elevatedlipidlevels:hyperlipidemiaiscommoninclientswith highB/P. Substanceabuse:excessivealcoholintake,tobaccouse. Sedentarylifestyle:regularphysicalactivityhelpstodecreaserisk.

TEST ALERT: Review with client understanding of health promotion behaviors.

2. Diagnosticstoruleoutproblemofsecondaryhyper- tension.D. Complications. 1. Coronaryarterydisease. 2. Cerebralvasculardisease(seeChapter15). a. Reversibleischemicneurologicdeficit(RIND). b. Stroke(brainattack). 3. Nephrosclerosis:ischemiaoftheintrarenalvessels. 4. Retinaldamage:ischemiaofthearteriolesinthe retina. 5. Hypertensivecrisis. 6. Peripheralvasculardisease.

TEST ALERT: Compare current data to client baseline data (e.g., vital signs). Determine if vital

signs are abnormal.

TreatmentA. Diet. 1. Lowsodium. 2. Weightreduction. 3. Decreasedcholesterolandsaturatedfats.B. Regularexercise.C. Antihypertensivemedications(seeAppendix11-4).D. Diureticstodecreasecirculatingvolume(seeAppendix 11-5).E. Limitalcoholintaketo1to2ouncesperday.F. Stressmanagement.G. Stopsmoking.

Nursing Interventionsv Goal: Toidentifyandeducatehigh-riskindividuals.A. Encourageclienttoparticipateincommunityblood pressurescreeningprograms.B. Educatepublicregardingriskfactors.C. Identifyhealth-promotingbehaviorforhigh-riskindividuals(Box11-2).v Goal: Toreducebloodpressureandassistclienttomaintaincontrol.(Figure11-3).A. Assessresponsetomedication. 1. Antihypertensives(seeAppendix11-4). 2. Diuretics(seeAppendix11-5).B. Evaluatebloodpressuremeasurement(Box11-1)

OLDER ADULT PRIORITY: Older adults are more sensitive to blood pressure changes. A drop in blood pressure to less than 120 mm Hg systolic may cause orthostatic hypotension.

C. Maintainlow-sodiumdiet.D. Assesschangesinweightwithregardtolow-sodium intakeanduseofdiuretics.E. Whenbloodpressure(BP)isinitiallydecreased,evaluateclient’stolerancetodropinBP.

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• Ifaclienthasbeenhypertensiveforalongperiodoftime, theclient’s“normal”systolicbloodpressuremayneedtobe greaterthan120mmHgtomaintainadequatebloodflowand allowclienttoperformADLs.• Teachclienthowtoavoidincreasedproblemswithortho- statichypotension.• Obtainbloodpressurereadingswithclientstanding,lying, andsittingandinbotharms.• Makesureclienthasnothadanynicotineorcoffeefor aboutanhourbeforetakingbloodpressuremeasurements.• Donotallowclienttocrosslegsduringbloodpressure measurement.• Complianceproblemsoccurwhentheclienthastotake severalmedicationsforBPaswellascopewithother chronichealthproblems.

BOX 11-1 OLDER ADULT CARE FOCUS Evaluation of Blood Pressure


F. Sideeffectsofmedicationarefrequentlytemporary.G. AvoiddrugsthatinteractwithBPmedications(e.g., antacids,cold/sinusmedications).H. Ifsexualproblemsorimpotencedevelops,contactHCP; donotstoptakingmedication.I. Takemeasurestocontroleffectsoforthostatichypo- tension. 1. Getupslowly,sitatthebedsidetoregainequilib- rium,andthenstandslowly. 2. Wearelasticsupporthose. 3. Lieorsitdownwhendizzinessoccurs. 4. Donotstandorsitforprolongedperiodsoftime.J. Lifestylemodifications(Box11-2)

Peripheral Arterial Disease (Peripheral Vascular Disease)

Also known as peripheral vascular disease (PVD), this disorder primarily involves narrowing and obstruction of the of the extremities, especially the lower extremities. The atherosclerotic lesions cause chronic arterial obstruction that progressively leads to decreased oxygen delivery to the tissues.A. Lesionsarepredominantlyfoundintheloweraorta, frombelowtherenalarteriesextendingthroughthe poplitealarea.B. Bythetimesymptomsoccur,thearteryisapproximate- ly85%to95%occluded.C. Therenal,femoral,popliteal,andaorticiliacarteries arethemostcommonlyaffectedsites.

Data CollectionA. Riskfactors(sameasforhypertension–Table11-1).B. Clinicalmanifestations.

TEST ALERT: Recognize the client with conditions resulting in inadequate circulation of

lower extremities.

1. Intermittentclaudication(painwithactivity,re- lievedbyrest). 2. Ischemicpainatrest,orpainatnightindicatesad- vancedstagesofPVD. 3. Paresthesiaofthefeet. 4. Decreasedorabsentperipheralpulses(Figure11-2). a. Dorsalaspedis,posteriortibial. b. Popliteal. c. Femoral. 5. ArterialUlcers. a. Commonlyfoundonmetatarsalheadsandtips oftoes. b. Painful,sharpedges,palecolorbase,frequently occursonthelargetoe. c. Poorhealingofinjuriesontheextremitiesdueto lackofcirculation. 6. Changesintheskin. a. Cooltotouch.

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1. Presenceofposturalhypotension. 2. Changeinurinaryoutput. 3. Changeinenergylevel. 4. Changesinlevelofconsciousness.F. Report signifi cant changes in BP to the charge nurse.

NURSING PRIORITY: Obtain hemodynamic mea-surements: the BP of a hypertensive person should be measured lying down, sitting and standing; measure the BP in both arms.

Home Care

A. Continuelow-cholesterol,low-sodiumdiet.B. Decreaseweightifappropriate.C. Assisttoidentifyanappropriate,consistent,regular exerciseprogram. 1. Agraduallyincreasingexerciseprogram. 2. Episodicstrenuousactivityshouldbeavoided. 3. Walking,swimming,slowjogging. 4. Avoidweightliftingandheavyisometricexercises.D. Takemedicationsasprescribed. 1. Takemedicationatregulartimes. 2. Knowthenamesandcommonsideeffectsofthe medications. 3. Informhealthcareprovider(HCP)ifunabletoaf- fordmedications. 4. Donotstoptakingmedicationsunlessadvisedtoby HCP.

TEST ALERT: Identify side effects and adverse reactions of medications.

E. Avoidhotbaths,steamrooms,spas(increasevasodilat- ingeffectofmedications).

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• Loseweightifindicated.• Limitalcoholandcaffeineintake.• Followaregularprogramofaerobicexercise (30to45-minutes;3to4daysaweek).• Limitsodiumintake.• Maintainadequatepotassiumintake.• Maintainadequateintakeofdietarycalcium,magnesium, andfiber.• Stopsmoking.• Reduceintakeofdietarysaturatedfatandcholesterol.

BOX 11-2 LIFESTYLE MODIFICATIONS FOR HYPERTENSION PREVENTION AND CONTROL

TEST ALERT: Review client/family understanding of health promotion behaviors.


b. Shiny,fragile,poorturgor. c. Dry,scaly. d. Lossofhaironthelowerleg. 7. Brittle,thicktoenails. 8. Dependentrubor(duskyredness)whenlegsarein- dependentposition,pallorwithelevationofthelegs.C. Diagnostics- seeAppendix11-1.

Treatment A. Medical. 1. Vasodilatingmedications. 2. Decreaseprogressionofatherosclerosis. a. Decreasedietarycholesterolintake. b. Initiateanexerciseprogramastolerated. c. Stopalltobaccouse. d. Decreaseweightifappropriate. 3. Preventandcontrolinfections. 4.Treatmentofdiabetes.B. Surgical:Proceduresareperformedwhenintermittent claudicationinterfereswiththeclient’sactivitiesof dailylivingorwhenthecirculationmustberestored inordertosalvagethelimb. 1. Peripheralatherectomy:removalofplaquewithin theartery. 2. Bypassgraft:bypassofanobstructionbysuturinga graftproximallyanddistallytotheobstruction. 3. Patchgraftangioplasty:arteryisopened,plaqueis removed,andapatchissuturedintheopening towidenthelumen. 4. Amputation:usedasalastresortwhenother therapieshavefailedandgangreneorinfectionis extensive.C.Nonsurgical. 1. Percutaneoustransluminalangioplasty:useofa ballooncathetertocompresstheplaqueagainstthe arterialwall. 2. Laser-assistedangioplasty:aprobeisadvanced throughacannulatotheareaofocclusion;alaseris usedtovaporizetheatheroscleroticplaque. 3. Intravascularstent:placementofastentwithina narrowedvesseltomaintainpatency.

Nursing Interventionsv Goal: Toevaluatelevelofinvolvementoftheextremity.A. Assessperipheralpulses;comparequalityofpulsesin thelowerextremities.B. Evaluateskinontheaffectedextremity. 1. Color,skintemperature. 2. Capillaryrefill. 3. Conditionoftheskinandnailbeds. 4. Presenceofulcersorlesions,stagesofhealing. 5. Assesstolerancetoactivity;atwhatpointdoespain occur.

TEST ALERT: Review assessment of peripheral pulses, report signs of potential complications.

v Goal: Topreventinjuryandinfection.A. Avoidvigorousrubbingoftheextremity.B. Preventpressuretoheels,ankles,toes.C. Useheelcoversandbedcradletopreventpressureon thetoesandheels.D. Maintaingoodskinhygieneandpropercareoftoenails. 1. Donottrimthetoenails. 2. Donottrimcallusesorcorns. 3. Advise RN or HCP if client has ingrown toenails. 4. Keepfeetcleananddry,donotsoakfeet,use lubricatinglotiontopreventskincracks. 5. Teachclienttoalwayswearshoes;avoidshoesor socksthataretootight.

TEST ALERT: Identify methods for preventing complications associated with illness. Identify

factors that affect wound healing.

Figure 11-2 Pulse Points for assessment of arterial pulse, From: Ignatavicius, DD, Workman, ML: Medical Surgical Nursing Patient-Centered Collaborative Care, ed 6, St Louis, 2010, Saunders. Page 717, Fig 35-6.


v Goal: Toincreasearterialsupplyanddecreasevenouscongestiontotheextremity.A. Encouragemoderateexercise(e.g.,walking).B. Performactiveposturalexercises(Buerger-Allen exercises).C. Maintainconstantwarmtemperature;donotusehot waterbottlesorheatingpadsonlowerextremities.D. Avoidpressureintheposteriorpoplitealarea. 1. Donotraisekneegatchofthebedwithoutraising thefootofthebedtoeliminatepressurebehindthe knee. 2. Whentheclientissittinginachair,makesurethe feetareflatonthefloortodecreasethepressure fromtheedgeofthechairbehindtheknee. 3. Teachclienttoavoidclothingthatistightandre- strictscirculationtothelowerextremities(e.g., kneehighhose,girdles).E. Elevateextremitieswhileatrest.F. Promotebloodflowtolegs. 1. Avoidstandinginonepositionforprolonged periods. 2. Avoidcrossinglegsatthekneesorankleswhilein bed.F. Preventvasoconstriction. 1. Decreasecaffeineintake. 2. Stopalltobaccouse. 3. Avoidbecomingchilled,keeplowerextremities warm.G. Controldiseasesprecipitatingarterialproblems. 1. Diabetes. 2. Hypertension.

NURSING PRIORITY: In planning and caring for the diabetic client, problems of peripheral vascular disease must be considered. Poor peripheral circulation is a common complication.

v Goal:ToprovideappropriatepreoperativecareA. SeeChapter3.v Goal:Toevaluateandpromotecirculationintheaffectedextremityfollowingvascularsurgery.A. Performextremitycirculationchecks:initiallyevery 15minutes,thenhourly,thenevery4hours.Report immediatelyanychangesinqualityofpulses.B. Encouragemovementoftheextremityassoonasclient isawake.Avoidflexionintheareaofthegraft(femoral orpoplitealareas).C. Encourageclienttobeoutofbedandambulateassoon asindicated;performpulsecheckswhenclientreturns tobed.D. Donotallowtheraisedkneegatchofthebedtoput pressureonthepoplitealarea.E. Assessclient’sresponsetoanticoagulants;maintain bleedingprecautions(seeChapter14).F. Continuemeasurestoprotectthefeet.

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G. Assessfordevelopmentofdependentedema;may requirecompressiondressingsoruseofdiuretics.H. Monitorforpotentialcomplicationsofbleeding(e.g., clotformation,compartmentsyndrome).I. Assesstypeofpain–painfromincreasedperfusionis differentthanpainofischemiapriortosurgery.J. NotifysurgeonorHCPimmediatelyofanysymptoms suggestiveofafurtherdecreaseincirculationorof occlusionofgraft.v Goal:Toprovidegeneralpostoperativecareasindicated(seeChapter3).

Home CareA. Loseweightifappropriatethroughalow-fat,low- cholesterol,high-fiberdiet.B. Avoid: 1. Standingorsittingforprolongedperiodsoftime. 2. Avoidtightsocks,constrictiveclothing,stockings. 3. Smoking.C. Avoidtraumatotheextremities.D. Careofextremities: 1. Visuallyinspectfeetdaily 2. Avoidbathwaterthatistoohot. 3. Drywellbetweentoes. 4. Preventdryingofskin;nolotionbetweentoes. 5. Clipnailsstraightacross. 6. Seekcarepromptlyforulcerationsorblisters. 7. Alwayswearwell-fitting/protectiveshoes;donotgo barefoot. 8. Elevatefeetiftheyareswelling. 9. Evaluatebruisesanddiscoloredareas. 10. Assessforanybreaksintheskin.

Figure 11-3 Hypertensive Nursing Care From: Zerwekh, JA, Claborn, JC, Miller, CJ, Memory Notebook of Nursing, Vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.


E. Donotapplydirectheattothelegs.F. Exerciseastolerated;stopifpainoccurs.G. Maintaingoodnutrition.H. Teachclientmethodstoincreasecirculationduring normalworkday(donotcrosslegs;useagoodchair; getupandwalkeveryhourifworkingatadesk).

TEST ALERT: Review client adaptations to illness and/or disease. Assist client in identifying

behaviors that could impact health.

Thromboangiitis Obliterans (Buerger’s Disease)

Thromboangiitis obliterans is a condition that causes vasculitis of the small and medium-size arteries and veins of the extremities.

Data CollectionA. Intermittentclaudication.B. Painispredominantsymptom.C. Cyanosisandrednessoftheextremity.D. Increasedsensitivitytocoldintheextremity.E. Ischemiculcerationsmaydevelopinfingers,toes,and thenmayprogressupward.F. Decreasedsensation.G. Peripheralpulsesmaybediminishedorabsent(see Figure11-2).H. Closelyassociatedwithtobaccouse,especiallyyoung menwhosmoke.

TreatmentNocure;treatmentisbasedonsymptoms;cessationofalltobaccousefrequentlystopsdiseaseprogress.

Nursing Interventionsv Goal:Toevaluatelevelofinvolvementoftheextremityandincreasecirculationtotheextremity.A. Encourageclienttodecreaseorstopalltobaccouse.B. Evaluatetolerancetoactivity.C. Inspectfeetforvascularchanges.D. Haveclientperformposturalexercisestodecrease venouscongestion.E. Performcirculatorychecksoftheaffectedextremity.F. Protectextremitiesfromexposuretocold.v Goal:Toassistclienttounderstandimplicationsofthediseaseandmeasurestomaintainhealth.A. SeePVDgoalsaboutassistingclienttounderstand implicationsofthedisease.

NURSING PRIORITY: The vascular problem has a direct relationship to cigarette smoking. The client should understand that in order for the condition to be controlled, he must quit smoking.

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Raynaud’s Disease

A disease characterized by episodic spasms of the small cutaneous arteries. It occurs primarily in the fingers.

Raynaud’s Phenomena

A. Intermittentepisodicspasmsofthearteriolesofthe fingers,toes,nose,andears.Spasmsarenotnecessarily correlatedwithotherperipheralvascularproblems.B. Conditionusuallyoccursinthehandsandisbilateral andsymmetrical.

Data CollectionA. Increasedincidenceinfemales20to49yearsold.B. Symptomsareprecipitatedby: 1. Exposuretocold. 2. Emotionalstress. 3. Smoking. 4. Caffeineconsumption.C. Associatedwithconnectivetissuediseasessuchas systemiclupuserythematosus,scleroderma,and rheumatoidarthritis.D. Initiallythereispallororcyanosisduetothevaso spasm,causingnumbnessandtingling.Asdigitswarm, thereisredness,warmth,andthrobbingashyperemia occurs.E. Involvementgenerallyisbilateral.F. Pulsesmayremainadequate.G. Attacksareusuallyintermittentandonlylastafew minutes.

TreatmentA. Nocure;diagnosisandtreatmentarebasedon symptoms.B. Vasodilatingmedications.

Nursing Interventionsv Goal:Toassistclienttounderstanddiseaseimplica-tionsandmeasurestoincreasearterialcirculation.A. Stopalltobaccouse,especiallysmoking.B. Evaluateclient’sresponsetoactivities.C. Performcirculatorychecksoftheaffectedextremity.D. Performvisualinspectionoftheskinoftheaffected extremity.E. Protectextremitiesfromexposuretocold.F. Limitcaffeineintake.G. Avoidvasoconstrictivedrugs.

Aneurysm

An aneurysm is a dilation or sac formed within the wall of an arterial vessel. The aneurysm may involve one layer or all layers of the arterial wall.

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A. Typesofaneurysms. 1. Berryaneurysm(seeChapter15). 2. Abdominalaorticaneurysm:occursprimarilyinthe abdominalaortabelowtherenalarteries. 3. Thoracicaorticaneurysm:locatedintheaortain thethoracicarea. 4. Dissectinganeurysm:bleedingoccursbetweenthe layersofthevesselwall.B. Commonlocations. 1. Abdominalaorticaneurysm(AAA):occursmost oftenintheabdominalaortabelowtherenal arteries. 2. Thoracicaorticaneurysm:locatedontheaortain thethoracicarea. 3. Femoralaneurysm. 4. Poplitealaneurysm.

Data Collection A. Abdominalaorticaneurysm(AAA). 1. Maybeasymptomatic. 2. Epigastric,back,flankorabdominalpain. 3. Pulsatingabdominalmassmaybepalpable. 4. Signsofrupture. a.Severebackpain. b.Rapidhypotensionandshock. c.Abdominaldistentionandtenderness. d.Hematomaformationintheflankregion.B. Thoracicaorticaneurysm. 1. Frequentlyasymptomatic. 2. Compressionofstructuresintheadjacentarea. a.Dysphagiaduetopressureontheesophagus. b.Hoarsenessduetopressureonthelaryngeal nerve. c. Pressureonthevenacavamaycauseedemaof headandarms. 3. Signsofdissectionandrupture. a.Suddenconstant,excruciatingbackand/orchest pain. b.Rapidhypotensionprogressingtoshock.C. Diagnostics(seeAppendix11-1). 1. Chestx-ray. 2. Aortography. 3. Abdominalultrasound.

TreatmentDirectedtowardpreventionofrupture(e.g.,surgicalresectionoftheaneurysm).

Nursing Interventionsv Goal:Toprepareclientandfamilyforanticipatedsurgery.A. Provideappropriatepreoperativecare(seeChapter3).B. Identifyotherchronichealthproblemsthatwillhave implicationspostoperatively(hypertension,diabetes, PVD).

C. Evaluatecharacteristicsofpulsesinthelowerextremi- ties;marklocationsanddocumentstatusforevaluation postoperatively.v Goal:Tomonitor,prevent,andrecognizecomplica-tionsbeforesurgicalintervention.A. Controlhypertension. 1. Administerantihypertensives. 2. Decreaseriskfactors.B. Observecloselyforsignsofrupture/dissection.C. Donotvigorouslypalpateabdomen.

TEST ALERT: Determine if client is prepared for surgery. Monitor client after surgery.

v Goal:Topromotegraftpatencyandoptimalcircula-tionpostoperativeaneurysmresection.A. Followgeneralpostoperativecareasindicated(see Chapter3).B. Maintainadequatebloodpressuretofacilitatetissue perfusionandfillingofthegraft.C. Monitorclientresponseto(IV)fluidsandbloodcompo- nents.D. Initiallyperformhourlychecksofperipheralcircula- tion;monitorcharacteristicsofpulsesinlowerextremi- ties(seeFigure11-2).Symptomsofgraftocclusion include: 1. Changesordecreaseinqualityofpulse. 2. Extremitycoolbelowlevelofgraft. 3. Changeincolorofextremity. 4. Increaseinabdominaldistentionandincreased severityofpaininextremities.E. Evaluateurineoutputhourly.F. Evaluatebloodureanitrogen(BUN)andserum creatininelevelstoassessrenalfunction.G. Maintainadequatebodywarmthtopreventtempera- ture-inducedvasoconstriction.H. Immediatelyreportanychangesinthestatusof circulationofaclient’sextremity.

TEST ALERT: Recognize client conditions that result in insufficient vascular perfusion; review

assessment of peripheral pulses of client. Pulse checks are critical in vascular surgery client. The nurse should compare the peripheral pulses in the lower extremities and initiate protective and preventative actions.

v Goal:Tomaintainhomeostasisandpreventpostopera-tivecomplications.A. Maintainadequatebodywarmth.B. Assessandmaintainadequatehydration.C. Assessforelevationoftemperature.D. EvaluateforreturnofGIfunction. 1. Bowelsounds. 2. Distention. 3. Passageofflatus. 4. Diarrhea.


E. Nasogastricsuctionisfrequentlyusedintheimmediate postoperativeperiodtopreventgastricdistentionfrom causingincreasedpressurearoundareaofthegraft.

Home CareA. Activityrestrictions. 1. Noheavyliftingfor6-12weeks. 2. Avoidactivitiesthatinvolvepushing,pulling,or straining.B. Reportanysignsofinfection,redness,swelling,drainage,orfever.

Shock (Severe Hypotension)

Shock is characterized by inadequate blood flow and tissue perfusion.A. Foradequatecirculationtooccur,allpartsofthecircu- latorysystemmustfunctioneffectivelytogether. 1. Adequatevasculartonetomaintainnormal resistanceofthevessels. 2. Abilityofthehearttomaintaincardiacoutput. 3. Adequateamountoftotalbloodvolume.B. Theinitialproblemsprecipitatingshockandthespe- cifictreatmentfortheproblemsareverydifferent. However,regardlessoftheprecipitatingcauseofshock, theunderlyingproblemisinadequatetissueperfusion.C. Classificationsofshock. 1. Hypovolemicshock:sizeofvascularcompartment remainsthesamewhilethevolumeofbloodor plasmadecreases;mayberelativeorabsolute. a. Hemorrhage. b. Burns. c. Severefluidloss. 2. Cardiogenicshock:heartisunabletoeffectively circulatetheintravascularvolume. a. Dysrhythmias. b. Myocardialinfarction(MI). c. Heartfailure. 3. Distributiveshock:anincreaseinthebloodvolume onthevenoussidewithadecreaseinthevenous returntotheheart. a. Neurogenic:spinalcordshock;lossofnerve supplytobloodvessels. b. Septic:vasodilationfromsevereinfection. c. Anaphylactic:vasodilationsecondaryto histaminerelease(allergicreactions). 4. Obstructiveshock:physicalimpedimenttoblood flow. a. Pulmonaryembolism. b. Venacavacompression. c. Tensionpneumothorax.

Data CollectionSignsandsymptomsofshockareessentiallythesameregardlessoftheprecipitatingcause.

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TEST ALERT: Implement interventions to man-age potential client circulatory complications. Be

able to recognize clients at increased risk; know the early symptoms of shock and initiate protective and preventive actions.

A. Riskfactors. 1. Increasedincidenceintheveryyoungandinthe veryold. 2. Increasedincidenceinclientswithchronic progressivediseasestates. 3. Trauma. 4. Postoperativehemorrhage.B. Clinicalmanifestations. 1. Compensatorystage(early). a.Clientisorientedtotime,place,anddatebut mayberestlessorapprehensivewithincreased anxiety. b.BP—lownormal;pulse—increasedornormal; respirations—increased;temperature—normal orsubnormal. c.Urineoutputmaybeslightlydecreased,but withinnormalrange. d.Complaintsofthirstandfeelingcool;skinpale andcool. e.Nausea/vomitingcommonasBPdecreases. 2. Progressivestage(intermediate). a.Decreasingsensoryperception;decreased responsivenesstostimuli. b.Vitalsigns. (1) BPcontinuestodecrease. (2) Pulserateincreasedwithweakorthready peripheralpulses. (3) Respirations—rateisincreasedwith dyspnea. c. Cold,moistskin;pallor. d.Decreaseinurinetooliguriclevels. e.Developmentofacidosis 3. Refractory(irreversible,late). a.Progressivelydecreasinglevelofconsciousness tounresponsiveness. b.BP—notmeasurable(unabletoperfusevital organs);pulse—slowandirregular; respirations—irregular,shallow,labored. c. Anuria. d.Clientbecomeshypoxicwithskinpallor, cyanosisandmottling. 4. Diagnostics:basedontheclinicalmanifestations andhistoryofunderlyingproblems.

TreatmentDependsontheunderlyingproblem.


Nursing Interventionsv Goal:Toidentifyandmonitorprogress.A. Maintainbedrest.B. Positionsupinetoincreasevenousreturnbutnot compromisepulmonarystatus.C. Maintainairway;providesupplementaloxygen.D. Keepwarm;nochilling.E. Protectfromfallsandinjury.F. Evaluateforprogressionofshock—compensatingto noncompensating.v Goal:Tomaintainventilationandpreventhypoxia(seeChapter10).A. Monitorlevelsofpulseoximetry,ABGs.B. Determinequalityandchangesinbreathsounds, characteristicsofrespirations.C. Monitorchangesinorientationandpresenceof confusion.D. Maintainairwaypatency.v Goal:Tocorrectacid-baseimbalance(seeChapter5).v Goal:Toassessandsupportthecardiovascularandrespiratorysystems.A. Monitorbloodpressurecloselyinindividualsat increasedrisk.B. Evaluatetissueperfusioninresponsetodysrhythmias.C. Protectintegrityofvenousaccesslines.D. Hypovolemicshockrequiresanincreaseinthe circulatingvolume;monitorclientresponsetofluid resuscitation.v Goal:Toevaluaterenalresponsetodecreaseincardiacoutput.

TEST ALERT: Identify client factors that could interfere with elimination. Decreased urinary

output is often an early observable sign of decreased renal perfusion secondary to decrease in cardiac output.

A. Evaluateurineoutputhourly.B. CarefullyassessrenalresponsetoincreaseinIVfluids.C. MonitorBUNandcreatinineforevidenceofrenalcom- plications.v Goal:Tomaintainhomeostasisanddecreaseeffectsofshock.A. Monitorclientresponsetomedicationstocounteract effectsofshock(seeAppendix11-6).B. Continuetoorientclient.C. Decreaseunnecessarysensorystimuli.D. MaintainNPO;provideoralhygiene.E. Evaluateforbowelsoundsanddistentiondueto intestinalischemia.F. Keepclientcomfortablywarm;donotallowchilling.F. DonotadministermedicationsPO,IM,or subcutaneouslybecauseofdecreasedtissueperfusion. (RN or HCP will administer medications IV push.)

G. Provideemotionalsupport;continuetotalkwithclient anddescribeproceduresbeforetheyaredone.H. Avoidunnecessarynursingprocedures.

Chronic Venous Insufficiency and Venous Stasis Ulcers

Chronic venous insufficiency (CVI) results from damage to the valves of the veins in the legs. A. Theprimarycauseofchronicvenousinsufficiencyis incompetentvalvesofthedeepveins,primarilyin thelowerextremities.B. Compressionandreliefofvenouscongestionarethe keyfactorstotreatmentandpreventionofCVI.C. Thisvalvularincompetenceleadstoregurgitationof blood,venouspooling,andedemainthelower extremities;eventuallyresultingindevelopmentof venousstasisulcers.

Data CollectionA. Riskfactors. 1. Valveincompetence. 2. Chronicdisease(diabetes). 3. PreviousepisodeofDVT.B. Clinicalmanifestations. 1. Brownor“brawny”skinonlowerlegs. 2. Edema. 3. Stasisdermatitisorstasiseczemaisoftenthefirst indication. 4. Ulcersoccurabovetheouterankle. 5. Ulcerstypicallyhaveirregularlyshapedmargins andredincolor. 6. Copiousserosanguineousdrainagefromulcers. 7. Ulcerationsareverypainful.C. Diagnostics:historyandclinicalmanifestations.D. Complications. 1. Infectionandcellulitisarecommon. 2. Delayedorpoorhealing.

TreatmentA. Medicaltherapy. 1. Compressiontherapy. a.Elasticcompressionstockings. b.Sequentialcompressiondevices. c. Unnaboot(apastebandage). 2. Moistdressingsforopenwoundcare. 3. Goodnutritionalstatus. 4. Treatmentofvaricoseveins.B. Surgicaltherapy:excisionofulcerwithskingrafting.

Nursing Interventionsv Goal:Toprevent/relievevenouscongestion;thisisthekeytoulcermanagement(Box11-3).

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B. Changedressingsasnecessaryduetoexcessivewound drainage.C. Dressingmaybeusedincombinationwithcompression devices.D. Encourageincreaseinproteinandvitaminstopromote healing.v Goal:Toteachclientsaboutself-careasrecurrenceofCVIishigh.A. Avoidtraumatolimbs.B. Usemoisturizinglotionstopreventskinfromcracking; donotusefragrantproducts.C. Seekmedicalcareatfirstsignofwoundinfection 1.Pain 2.Purulentdrainage 3.Offensiveodor.

TEST ALERT: Implement measures to promote venous return, to manage potential circulatory

complications, and to monitor wounds for signs and symptoms of infection.

Varicose Veins

Varicose veins occur when veins in the lower trunk and extremities become congested and dilated because of incompetent valves in the vessels, as well as loss of elasticity of the vessel wall. As venous pressure increases, the-muscle around the vein fails to constrict effectively, and there is increased congestion and decreased venous return.

Data CollectionA. Riskfactors. 1. Congenitalweaknessoftheveinwalls. 2. Obesity. 3. Pregnancy. 4. Worksettingsrequiringprolongedsittingor standing.B. Clinicalmanifestations. 1. Dilated,tortuoussubcutaneousveins. 2. Objectionablecosmeticappearance. 3. Achingorpainafterprolongedstanding. 4. Paingenerallyrelievedbyelevatingtheextremity. 5. Nocturnallegcramps.

TreatmentA. Medical. 1. Restwithfeetelevated. 2. Elasticsupporthose.B. Surgical. 1. Scleropathy:injectionofsclerosingagentsinto affectedvein. 2. Surgicalligationoftheveins;maybecombined withveinstrippingaswell.

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A. Compressiondevices:preventionofvenousstasisisthe keytohealing. 1. Compressionboots/stockings:extremitymaybe coveredwithcontinuouscompressionbandage, boot,orstocking. 2. Intermittentorsequentialpneumaticcompression devices:alwayscheckarterialcirculationwithany typeofcompressiondevice. 3. Assessadequacyofarterialcirculationpriorto initiatingcompressiontherapy.B. Keepfeetcleananddry;assessfordevelopmentof venousulcers.C. Keepfeet/legselevated.D. Avoidprolongedsitting/standing.E. Instituteadailywalkingprogramonceulcershave healed.v Goal:Promotehealingofvenousstasisulcers.A. Applymoistoxygenpermeabledressings(e.g.,hydro- colloids,foams).

• Encouragemobility;evenstandingatthebedsidepromotes venoustone.• Elasticsupportstockings: 1. Hospitalizedclientsshouldwearthemallthetime. 2. Homeclientsgenerallywearthemduringtheday;they shouldputstockingsonbeforegettingoutofbedand removethemwhengoingtobed. 3. Makesurethestockingsarenotcausingincreased pressurebehindtheknee,anddonotallowstockingsto bunchupandcauseconstrictionbehindtheknee. 4.Toeholeshouldbeunderthetoesandheelpatchover theheel. 5. Donothangfeetdependentwhenputtingstockingson; elevateorplacethemparallelonthebed.• Pneumaticsequentialcompressiondevices(SCDs)may beusedinthehospitalonclientsatincreasedriskfor complicationssecondarytovenousstasis. 1. Removeevery8hourstoinspectskin. 2. Ifclientisathighriskfordevelopmentofthrombophle- bitis,measureareatodetermineifthereisanincreasein sizeofcalforthigh. 3. Assesslegsforareasofwarmth,tenderness,orinflam- mation.• Teachclienttoelevatelegsforabout20minutesevery4to 5hours.• Avoidprolongedsitting;getupanwalkfor5minutesevery 1to2hours.• Donotcrosslegswhensittingorlyinginbed.• Donotwearclothingthatrestrictscirculationtolower extremities.• Maintaingoodfluidintake;avoiddehydration.

TEST ALERT: Implement interventions to promote venous return. Plan interventions to

prevent complications of cardiovascular system.

BOX 11-3 NURSING MEASURES TO DECREASE VENOUS STASIS


Nursing Interventionsv Goal:Toidentifyclientathighriskandpreventdevelopmentofvaricosities.A. Encourageclienttoavoidsittingorstandingfor prolongedperiodsoftime.B. Preventinjuriestoextremities.C. Encourageclienttoavoidconstrictiveclothing.D. Teachclienttoavoidrubbingextremities.v Goal:Toassistclienttounderstandimplicationsofthediseaseandmeasurestomaintainhealth.A. Elasticstockingsshouldbeputonbeforegettingoutof bedinthemorning.B. Maintaingoodskincareoflowerextremities.C. Decreaseweightifappropriate.D. Avoidprolongedstandingorsittinginthework environment.E. Avoidconstrictiveclothing.

Thrombophlebitis

Problem begins with an inflammation of the vein. The inflammatory process may initiate a clot formation and the development of deep vein thrombosis (DVT). Thrombi occurring in the deep veins of the pelvis, legs, and abdomen are of particular concern because there is increased incidence of embolus formation.

TEST ALERT: Identify complications of im-mobility. Monitor client responses to interventions

for preventing complications from immobility. With any condition that causes an increase in venous stasis or inflammation to a vein, there is a significant increased risk for the development of thrombophlebitis and DVT.

Data CollectionA. Riskfactors(Virchow’sTriad). 1. Venousstasis. a.Surgery(hip,pelvicandorthopedicsurgeryare associatedwithhighrisk). b.Pregnancy,obesity. c. Prolongedimmobility(bedrest,longtrips, prolongedsitting). d.Heartdisease(atrialfibrillation,congestiveheart failure). 2. Hypercoagulability. a. Malignancies,dehydration. b.Blooddyscrasias. c.Oralcontraceptives,hormonereplacement therapy. d.Pregnancyandpostpartum. 3. Endothelialdamage. a. IVfluidsanddrugs(IVcatheterization,drug abuse,causticsolutionsordrugs) b.Abdominalandpelvicsurgery.

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c. Fracturesanddislocations(especiallyofthepelvis, hip,orleg). d. HistoryofDVT.B. Clinicalmanifestations. 1. Redness,warmth,andtendernessalongvein. 2. Crampingcalfpain. 3. Swollenextremity. 4. Warm,cyanoticskin. 5. Increasedtemperature. 6. Homans’sign:thisisnolongerconsideredan accurateindicatorofthrombophlebitis.

NURSING PRIORITY: Do not attempt to check Homans’ sign on a client with a diagnosis of thrombo-phlebitis. This can cause embolization of a thrombus that is present.

C. Diagnostics(Appendix11-1).D. Complications. 1. DVTassociatedwithhighriskforpulmonary emboli. 2. Chronicvenousinsufficiencyandvenousstasis ulcers.

TEST ALERT: Implement measures to manage potential circulatory complications. Due to the

multiple types of conditions that precipitate circulatory complications, questions may be incorporated into the care of the surgical client, the obstetric client, or any client with problems of circulation or immobility.

TreatmentA. Medical(primarymethodoftreatment). 1. Bedrestwithelevationofaffectedextremity. 2. Warm,moistheat. 3. Anticoagulants,anti-inflammatoryandfibrinolytic medications(seeAppendix11-3,and5-7). 4. Elasticstockingsifedemaispresentafterclientis ambulatory. 5. Elasticstockingonunaffected legduringperiodof bedrest. 6. Range-of-motionexercisesonunaffected legduring bedrest.B. Surgicalintervention:donetopreventpulmonary emboli. 1. Venousthrombectomy. 2. Venacavaligation. 3. Umbrellafilterdeviceinthevenacava.

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Nursing Interventions

NURSING PRIORITY: The best way to prevent the development of a pulmonary emboli is to prevent the development of DVT or thrombophlebitis. It is much easier to prevent the problem than it is to treat it.

v Goal:Topreventproblemofthrombophlebitisinclientsathighrisk.A. Useprophylacticmeasuresforthesurgicalclient(see Chapter3).B. Preventcomplicationsofimmobility(seeChapter3).C. Provideprophylacticanticoagulationmedicationsfor- thehigh-riskclient(e.g.,hipandprostatesurgery clients).D. Implementnursingmeasurestodecreasevenousstasis (seeBox11-3). 1. Donotcrosslegsinthebedorwhilesitting. 2. Donotplaceapillowundertheknees. 3. Donotstandorsitinonepositionforaprolonged periodoftime. 4. Performisometricexercisesofthecalfandthigh muscles. 5. Intermittentpneumaticcompressiondevicesmaybe usedtofacilitatevenousreturn.

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v Goal:Todecreaseinflammatoryresponseandpreventemboliformation.A. Maintainbedrestwiththefeetelevated.B. Warm,moistsoaksmaybeusedtodilatearteriesand veinsandtodecreaselymphaticcongestionandpro- motehealing.C. Observeclientforadversereactionstoanticoagulants (seeAppendix11-3).D. Elasticstockingsmaybeusedifclient’slegsbecome edematousafterambulating.E. Donotusepillowunderthekneesorelevatetheknee gatchofthebed.F. Measurecircumferenceofclient’scalfdailytodeter minechanges.

Home CareA. Avoidoralcontraceptives.B. Decrease/stopsmoking.C. Avoidconstrictiveclothingonlowerextremities.D. Standandwalkeveryhourifworkingatadeskor sedentaryactivity.E. Loseweightifindicated.F. Decreasesodiumindietifedemaispresent.G. Followinstructionsregardinganticoagulationtherapy at-home.H. Followmeasurestopreventvenousstasisandpromote venousreturn(seeBox11-3).I. Reportincreasedpain,swelling,redness,orskin changes.

Study Questions: Vascular System

1. Aclienthadanaorticfemoralbypassgraft.Thenurse assiststheclientbacktobedafterhehasambulated. Whatwillbeaprioritynursingassessment? 1 Determinefluctuationsinclient’sbloodpressure. 2 Assesspulseratetodeterminetoleranceofactivity. 3 Evaluatethetemperatureoftheclient’saffected extremity. 4 Determinequalityofpulseintheclient’saffected extremity.2. Thenurseisteachingaclientabouthomecareand treatmentofthevenousstasisulcersonhisleg.What wouldbeincludedinthenurse’sinstructions?Select allthatapply.____ 1 Dressingsdonotneedtobechangedfrequentlybe-

causethereisminimaldrainage.____ 2 Healingwillbefacilitatedbywearinglegcompres-

siondevices.____ 3 Wheninthesittingposition,legsshouldbekept

elevated.____ 4 Claudicationpainmayberelievedbystoppingall

activity.____ 5 Coolpackscanbeappliedtotheulcerstodecrease

inflammation.

3. Thenurseistoldinreportthatahypertensiveclienthas beenstartedonmedicationsandhasbeenexperiencing orthostatichypotension.Whatconsiderationswill thenursemakeincaringforthisclient? 1 Assisttheclienttoasittingpositionandallowhim tositonthesideofthebedbeforestanding. 2 Whenambulatingtheclient,observeforthe presenceoftachycardiaanddecreasedblood pressure. 3 Assesstheclient’sbloodpressurewithhimina sittingandinalyingposition. 4 Obtainassistancewhenambulatingtheclientdueto histendencytowardsyncope.4. Thenurseisadministeringheparin.Whatisthecorrect procedureforadministrationofthismedication? 1 Checktheprothrombintimeandadministerthe medicationifitisbelow30seconds. 2 Usea22-gauge,1⁄2-inchneedleandinjectthe medicationsubcutaneously. 3 Injectthemedicationintothedeltoidandrub carefullytodispersemedication. 4 Witha25-gauge,5⁄8-inchneedle,injectthe medicationintotheabdomen.


5. Whatwouldthenurseidentifyasmodifiablerisk factorstopreventthedevelopmentofessential hypertension? 1 Obesity,drugabuse,smoking. 2 Obesity,smoking,historyofcancerinthefamily. 3 Sedentarylifestyle,obesity,vegetariandiet. 4 Sedentarylifestyle,obesity,smoking.6. Ahypertensiveclientisconcernedabouther medications.Sheasksthenursehowlongshewillhave totakemedication.Whatisthebestnursingresponse? 1 Whentheclientreturnstoseeherdoctorin2 months,themedicationsmaybediscontinuedat thattime. 2 Whentheclient’sbloodpressurereturnstonormal foraperiodof6months,hermedicationwillbe discontinued. 3 Tomaintainstablecontrolofherbloodpressure,the clientwillremainonthemedicationindefinitely. 4 Themedicationmaybeadjustedeverymonth;the clientneedstotalkwiththedoctor.7. Thenurseiscaringforaclientwithvenousblood poolinginthelowerextremitiessecondaryto chronicvenousinsufficiency.Thenursewould identifywhatassessmentdatathatwouldcorrelatewith thisdiagnosis?Selectallthatapply.____ 1 Stasisdermatitis.____ 2 Diminishedperipheralpulses.____ 3 Peripheraledema.____ 4 Gangrenouswounds.____ 5 Venousstasisulcers.____ 6 Skinhyperpigmentation.8. Aclienthasperipheralvasculardiseasewith compromisedcirculationinthelowerextremities.What wouldthenursingassessmentreveal? 1 Diminishedpedalpulses. 2 3+edemabilaterally. 3 Duskygraycolorofthefeet. 4 Musclespasmsinthefeet.9. Thenurseisassessingaclientwhois4hours postoperativeforarepairofhisaorticaneurysm.The nursewouldimmediatelyreportwhichfindings? 1 Totalurinaryoutputof80mlsincesurgery. 2 Nobowelsoundsinanyofthefourquadrants. 3 Legsandfeetcooltotouchbilaterally. 4 Pulsesweakandequalinbothextremities.10. Whatisincludedinthenursingmanagementofaclient withdeepveinthrombosis? 1 Ambulatetheclientintheroomtodecreasevenous stasis. 2 Assisttheclientwithactiverangeofmotionto affectedextremity. 3 Maintaintheclientonbedrestandelevatethefoot ofthebed. 4 Elevatethelegswhentheclientisoutofbed.11. Aclienthasbeendiagnosedwithleftleg thrombophlebitis.Whichfindingswouldnotbetypical ofthiscondition?

1 Painandtendernessintheleftleg. 2 Warmthoverinfectedarea. 3 Rednessoverinfectedarea. 4 Decreasedqualityofpulseinleftleg.12. Anolderadultclienthasperipheralvasculardisease andthenurseisadvisedthattheclientalsoexperiences intermittentclaudication.Whatarethecharacteristics ofintermittentclaudication? 1 Painintheclient’shandsbeingaggravatedby smokingandcoldtemperatures. 2 Painoccurringinthelowerpartoftheextremity whentheclientissittingdown. 3 Theneedforanalgesicspriortowalkingdueto increasedpain. 4 Presenceofpainonambulation,painisrelievedby sittingdown.13. Whatclientprofileindicatesahighriskforthe developmentofperipheralvasculardisease? 1 A76-year-oldclientwithhypertensionanddiabetes mellitus. 2 A65-year-oldclientwithahistoryofhypertension andalcoholabuse. 3 A35-year-oldathletewithafamilyhistoryof diabetes. 4 A35-year-oldclientwithafamilyhistoryof cardiovasculardisease.14. Aclienthasadiagnosisofdeepveinthrombosis. Whatwouldbetypicalassessmentfindings? 1 Extremityiscooltotouchandedematous. 2 Bilateral,swollen,redextremities. 3 Threadypulseandslowcapillaryreturn. 4 Painwithswellinginaffectedpartofleg.15. Aclientistobedischargedandthephysicianhas changedtheanticoagulantfromheparintowarfarin sodium(Coumadin).Whyisthemedicationbeing changedfromheparintoCoumadinwhentheclientis discharged? 1 Theclientcannotsafelytakeheparinwhenhegets home. 2 Coumadinmaybetakenbymouthandheparin cannot. 3 Coumadindoesnotrequiremonitoringof coagulationstudies. 4 Astheclientbecomesmoremobile,theCoumadin ismoreeffective.16. Thenurseiscaringforaclientfollowingathoracotomy. Whatassessmentfindingwouldbepresentiftheclient isexperiencinghypovolemicshockfromexcessive bleeding? 1 Urineoutputbelow30mlperhour. 2 Jugularveindistentionwithheadelevated. 3 Chesttubedrainageof50mlperhourfor4hours. 4 Bloodpressure110/70mmHg,pulserate120beats perminute.17. Whichofthefollowingwouldcausethemostproblems foraclientwithhypertension? 1 Caffeine,sugar,milkproducts. 2 Chocolate,tea,nicotine.


3 Caffeine,amphetamines,nicotine. 4 Fruits,sugar,amphetamines.18. Aclientistakingadiureticfortreatmentofhis hypertension.Whatfoodswouldthenurseencourage theclientto-eat? 1 Orangejuiceandapricots. 2 Cranberryjuiceanddairyproducts. 3 Leafy,greenvegetablesandapplejuice. 4 Grains,legumes,andfish.19. Whatwouldthenurseexpecttofindontheassessment ofaclientwithadiagnosisofarterialinsufficiency? 1 Thin,fragiletoenails. 2 Dependentrubor.

3 Boundingarterialpulses. 4 Warm,erythematouslegs.20. ThenurseiscaringforaclientwithBuerger’sdisease. Whatwouldbethemostimportantinformationto discusswiththisclientregardinghiscondition? 1 Elevateextremitiesseveraltimesaday. 2 Protecttheextremitiesfromcold. 3 Stopsmoking. 4 Stopactivitywhenpainoccurs.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

Appendix 11-1 VASCULAR DIAGNOSTICS Normal Value Therapeutic Value Nursing Implications

Activatedcoagulation 70-120sec 150-210sec 1. Usedtoevaluateheparinlevelchanges. time(ACT) 2. CorrelateresultswithAPTT.FragmentD-dimer lessthan250ng/ml lessthan250ng/ml 1. Confirmsthrombinandplasmingeneration (D-dimertest) haveoccurred. 2. Usedindiagnosisofdisseminatedintravascular coagulation(DIC)andtoscreenforthrombosis andacuteMI.Prothrombintime(PT) 10-13-secrange 11⁄2to21⁄2times 1. Usedtoevaluateliverfunctionandmonitor controllevel warfarin(Coumadin)medications.Activatedprothrombin Activated:30-45sec 11⁄2to21⁄2times 1. Indicatorofadequacyofanticoagulationwithtime(APTT) normal heparin. 2. Donotdrawsamplefromextremitywith aheparinlockorinfusion.Internationalnormalized Mathematicallycalculated 1.5-2.0(anticoagulation) 1. CalculatedlevelbasedonPT;methodofratio(INR) tomaintainconsistency (0.7-1.8) standardizingvalues.

INVASIVE STUDIES

Peripheralarteriography Involvesinjectionofaradiopaquedyeinto 1. Explainprocedurestoclient;mildsedative(angiography) eitherthearteryorthevein;x-raysare maybeindicated.Venogram takentoidentifyatheroscleroticplaques, 2. Afterprocedure: presenceofaneurysms a. Circulatorychecksdistaltothepuncturesite. b. Observeclientforallergicreactionsto thedye. c. Pressuredressingstoarterialpuncturesites.

NONINVASIVE STUDIES

Doppler ultrasonography: Hand-heldDopplerdeviceusedtodetectflowofbloodinperipheralarterialdisease.Isnotsensitiveto-early diseasechanges.Venous /arterial duplex scan: Usesultrasoundtoassessveinsforflowandpressure.HasbecometheprimarydiagnostictoolforDVTbecause itpermitsvisualizationofthevein.Ankle-brachial index (ABI):CalculatedindexusingahandheldDoppler;dividetheankleSBPbythehighestbrachialSBP;normal=0.91to 1.30;moderatePAD=0.41to0.70.Computerized tomography (CT):Allowsforvisualizationofthearterialwallandadjacentstructures.Usedfordiagnosisofabdominalaortic aneurysmorgraftocclusions.Trendelenburg’s test: Clientliessupinewithlegelevatedtodraintheveins.Atourniquetisthenappliedatmidthighandtheclientisaskedto stand.Veinsnormallyfillfrombelow(ordistally);avaricoseveinwillfillfromabove(orproximally)becauseofthe incompetentvalves.Donotleavetourniquetinplacelongerthan1minute.

SERUM STUDIES


Appendix 11-2 ANTIHYPERLIPIDEMIC MEDICATIONSMedications Side Effects Nursing ImplicationsAntihyperlipidemics:DecreaseLDLcholesterol,butpreferablydonotdecreasetheHDLcholesterol.Usedincombinationwithdietaryrestrictions,exercise,andsmokingcessationtoreducebloodlipidlevels.

General Nursing Implications—Adviseclientthatserumliverenzymesshouldbemonitoredthroughouttherapy.—Medicationsshouldbetakenwiththeeveningmealoratbedtime.—Medicationsshouldbeusedinconjunctionwithotherlipid-loweringtherapies(exercise,low-cholesteroldiet,smokingcessation).—Serumcholesterolandtriglyceridelevelsshouldbemonitoredperiodicallythroughouttherapy.Medications Side Effects Nursing ImplicationsCholestyramine(Questran):POColestipol(Colestid):PO

Colesevelam(Welchol):PO

Nicotinicacid(Niacin, Nicolar):PO

Gemfibrozil(Lopid):PO

Lovastatin(Mevacor):POSimvastatin(Zocor):POFluvastatin(Lescol):POAtorvastatin(Lipitor):POPravastatin(Pravachol):POCrestor(Rosuvastatin)PO

GIdisturbancesConstipation

IntenseflushingGIdisturbancesHyperglycemia

DiarrheaGIdisturbancesAbdominalpain

MusclebreakdownHepatotoxicGIdisturbances

1. Supplementalfat-solublevitaminsinlong-termtherapy.2.Mixpowderorgranuleswithseveralouncesoffluidforadministration,donottakethemedicationdry.3. Usewithcautioninpresenceofconsti-pation;increasefiberandfluidintaketopreventconstipation.

1.Takealltabletswithfoodandwater2.DoesnothavesideeffectsofQuestranorColestid.

1. Immediatelyreportsignsofhepatotox-icity(darkeningofurine,lightcoloredstools,anorexia).2.Flushingoccursinalmostallclients;willdiminishoverseveralweeks.

1. Assessforincreaseinmusclepain.2.Willpotentiatewarfarin-derivativeanti-coagulants(Coumadin).3.Donotconfusewithhyoscyamine(Lev-bid).

1. Shouldnotbegiventoclientswithpre-existingliverdisease.2.Adviseclienttoreportanyincreaseinmusclepain.3.Donotconfusepravastatin(Pravachol)withlansoprazole(Prevacid).

GI,Gastrointestinal;HDL,high-densitylipoprotein;LDL,low-densitylipoprotein;PO,bymouth(orally).


Appendix 11-3 ANTICOAGULANTS/ANTIPLATELETSMedications Side Effects Nursing ImplicationsGeneral Nursing Implications—Increasedriskforbleedingwhenusedconcurrentlywithotherdrugs,herbalremedies,orfoodsaffectingcoagulation.—Initiatebleedingprecautions(Box9-1).—Donotautomaticallydiscontinueaccordingtoautomaticstoppolicies(procedures,surgery)withoutverifyingtheorder;reevaluateallclientswhoseanticoagulantsarebeingheldforproceduresandassesstheneedtoreordertheanticoagulanttherapy.

NURSING PRIORITY If heparin is discontinued, within hours the client is not adequately anticoagulated and is at increased risk for complications.

Medications Side Effects Nursing Implications

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Heparin:IV,subQMaynotbegivenPO.Short-termanticoagulation

Low-Molecular Weight-HeparinEnoxaparin(Lovenox):subQDalteparinsodium(Fragmin):subQ

Warfarinsodium(Coumadin):POLong-termanticoagulation

Bleedingtendencies:hematuria,bleedinggums,orfrankhemorrhageHeparin-inducedthrombocytopenia:associatedwithincreaseinthrombosis

1. ChecktheAPTTfortherapeuticlevels.2.Protaminesulfateistheantidote.3. Willnotdissolveestablishedclots.4. Evaluateclientfordecreasedplatelets.5. Effectiveimmediatelyafteradministration;anticoagu-lationeffecthasahalflifeof1.5hours.6.Donotstoreinsameareaasinsulin;botharegivenbyunits.7.ProphylacticusedoesnotrequiredailyAPTTlevels.8.Determineifheparinisbeingusedtotreatthromboem-bolicproblemorasprophylaxisforthromboembolicproblems.

1. Use:prophylaxisforthromboembolicproblemsinhigh-riskclients(immobility,hiporkneereplacement).2.Dosageisnotinterchangeablewithheparin.3. Leavetheairlockintheprefilledsyringetopreventleakage.4.Lovenoxshouldbeinjectedintothe“lovehandles”oftheabdomen.

1. CheckthePTandINRtoevaluatelevelofanticoagula-tion.2.VitaminKistheantidote.3.Half-lifeis3-5days;discontinue3daysbeforeanyinvasiveprocedure.4.Clientteaching:•Bleedingprecautions(Box9-1).•Adviseallhealthcareprovidersofmedication–druginteractionsarecommon.•Maintainroutinechecksoncoagulationstudies.•Donotstoptakingmedicationunlesstoldtodosobyhealthcareprovider.

Antiplatelet MedicationsAspirin:PO

Clopidogrel(Plavix):PO

Cilostazol(Pletal):PO

Ticlopidine(Ticlid):PO

GIbleeding,hemorrhagicstroke

Abdominalpain,dyspepsia,diarrheaBlooddyscrasias

Headache,dizziness,GIbleeding

Diarrhea,bleeding,aplasticanemia

1. Giveninsmalldoses(e.g.,81mgdaily).2.ProphylactictherapyforpreventionofMIandthrom-boticstrokeinclientswithTIAs.

1. ProphylactictreatmentforpreventionofMI,strokesinclientswithestablishedperipheralarterydisease.2.Expensiveandslightlymoreeffectivethanaspirin.3. Monitorforbleedingtendencies.

1.Monitorforreliefofintermittentclaudication.2.Grapefruitjuiceinhibitsmetabolism.3.Administeronanemptystomach.

1.Monitorcoagulationstudiesthroughouttherapy.2.Monitorcholesterol/triglyceridelevels.

GI,Gastrointestinal;MI,myocardialinfarction;PO,bymouth(orally);TIA,transientischemicattack

TEST ALERT: Observe for effects of medications. Review the nursing implications associated with administration of anticoagulants.

HIGH

ALERT


Appendix 11-4 ANTIHYPERTENSIVE MEDICATIONSMedications Side Effects Nursing Implications

General Nursing Implications—Adviseclientthatpostural(orthostatic)hypotensionmayoccurandhowtodecreaseeffects.Sitonsideofbedbeforestanding,makesureclientisstablebeforestanding.Donotstandforprolongedperiodsoftime.OlderclientisatincreasedriskMayoccurwithfirstdoseorsubsequentdoses.Problemismostoftentemporary.—Hypotensionmaybeincreasedbyhotweather,hotshowers,hottubs,andalcoholingestion.—Clientshouldnotabruptlydiscontinuemedicationorchangedosagewithoutconsultinghealthcareprovider.Abruptwithdrawalcancausereboundhypertension.—Encouragealow-sodiumdietandweightmaintenanceorreduction.—Discourageuseofalltobaccoproducts.—Haveclientreportunpleasantsideeffectsrelatedtosexualdysfunction.—Adviseclientnottotakeover-the-countercoughmedicationsordecongestantsthatcontainpseudoephedrine;thesemedicationscauseanincreaseinBP.

TEST ALERT: Observe for effects of medications. Evaluate client’s use of medications.

Medications Side Effects Nursing Implications

Vasodilator:Actsdirectlyonvascularsmoothmuscletoproducevasodilation.

HydralazineHCl(Apresoline):PO,IM,IV

Minioxidil(Loniten):PO

Tachycardia,headache,sodiumretention,drug-inducedlupussyndrome

Tachycardia,sodiumandwaterretention

1. Adviseclientthatposturalhypotensionmayoccur.2.Maybeusedincombinationwithotherantihyperten-sivemedications.

1. Usedinclientswithseverehypertensionthatisnotrespondingtoothermedications.2.Requiresveryclosemonitoringofbloodpressure.

Centrally Acting Inhibitors (antiadrenergics):Decreasesympatheticeffect(norepinephrine),resultingindecreasedBPandperipheralresis-tance,decreaseinheartrate,andnochangeincardiacoutput.

Methyldopa:POMethyldopate:IV

Hepatotoxicity,hemolyticanemiasexualdysfunction,orthostatichypo-tension

1. Ifwithdrawnabruptly,mayprecipitateahypertensivecrisis.2.DonotconfusemethyldopawithlevodopaorL-dopa3.Monitorfordepressionoralteredmentalstatusinolderadults.

ACE Inhibitors:Reduceperipheralvasculatureresistancewithoutincreasingcardiacoutput,rate,orcontractility;angiotensionantagonists.

Captopril(Capoten):POEnalapril(Vasotec):POLisinopril(Zestril):PORamipril(Altace):POMoexipril(Univase):POBenazepril(Lotensin):PO

Posturalhypotension,hyperkalemia,insomnia,nonproductivecough,lossoftaste

1.Monitorcloselyonfirstdose;hypotensionandfirst-dosesyncopefrequentlyoccurs.2.Conservepotassium;maynotneedapotassiumsupple-mentwhengivenwithadiuretic.3.Skippingdosesorstoppingdrugmayresultinreboundhypertension.

Beta-Adrenergic BlockersandCalcium Channel BlockersSeeAppendix12-2.

ACE,Angiotensin-convertingenzyme;BP,bloodpressure;ECG,electrocardiogram;GI,gastrointestinal;IM,intramuscularly; IV,intravenously;PO,bymouth(orally).


Appendix 11-5 DIURETICS

General Nursing Implications

—Inhospitalizedclients,evaluatedailyweightsforfluidlossorgain.

—Evaluateintakeandoutputrecordsandcomparetoweightgainorloss.

—Monitorforhypokalemia,anorexia,muscleweakness,numbness,tingling,paresthesia,confusion,andexcessivethirst.

—Adviseclientoffoodsthatarerichinpotassium(Table2-2).

—Administermedicationsinthemorningtoallowdiuresistooccurduringtheday.

—Teachclienthowtodecreaseeffectsofposturalhypotension.

—MonitorBPresponsetomedication.

MEdICaTIoNS SIdE EFFECTS NurSINg IMPlICaTIoNS

Loop Diuretics: Blocksodiumandchloridereabsorption.Preventreabsorptionofwaterbackintothecirculationcausinganincreaseinexcretionofthewater,andproducesdiuresis.

Furosemide(Lasix):PO,IM,IVBumetanide(Bumex):PO,IM,IVTorsemide(Demadex):PO,IV

Dehydration,hypotension;excessivelossofpotassium,sodium,chloride;hypergly-cemia,hyperuricemia;muscleweakness

1. Strongdiureticthatprovidesrapiddiuresis.2.Usewithcautioninolderadults;CNSproblemsofconfusion,headache.3.Monitorcloselyfortinnitus/hearingloss.4.DonotconfuseBumexwithbuprenorphine(Buprenex).

Thiazide Diuretics: InhibitNaClreabsorption,whichcausesanincreaseintheexcretionofwater,sodium,andchloride.

Chlorothiazide(Diuril):IV,POChlorthalidone(Hygroton):POHydrochlorothiazide(HydrodIurIl, Esidrix):POMetolazone(Zaroxolyn):PO(athiazide-likediuretic)

Dehydration,hypotension;excessivelossofpotassium,hyperglycemia,hyperurice-mia;muscleweakness

1.Frequentlyusedasfirst-linedrugtocontrolessentialhypertension.2.Increasedriskfordigitalistoxicityiftakingdigoxinproducts.

Potassium-Sparing Diuretics:Blocktheeffectofaldosteroneonrenaltubules

Spironolactone(Aldactone):POTriamterene(Dyrenium):PO

Hyperkalemia,hyponatremia,impotence,hypotension

1.Maybeusedincombinationwithotherdiureticstoreducepotassiumloss.2.Potassium-sparingeffectsmayresultinhyperkalemia.3. Clientshouldnottakepotassiumsupplements.4.Avoidsaltsubstitutesandfoodscontaininglargeamountsofsodiumorpotassium.

Osmotic Diuretic:Increasesosmoticpressureofthefluidintherenaltubules,preventingreabsorptionofsodiumandwater.

Mannitol(osmitrol):IV Pulmonaryedema,CHF,tissuedehydration,nausea,vomiting

1. Stopinfusionifclientbeginstoshowsymptomsofrespiratorycomplications.2.Monitorinfusionsitecloselyforinfiltrationand/orextravasation.3.Maybeusedtodecreaseintracranialpressure.

BP,Bloodpressure;CHF,congestiveheartfailure;CNS,centralnervoussystem; IM,intramuscularly;IV,intravenously;PO,bymouth(orally).

Figure 11-4 Diuretic Water Slide - From: Zerwekh, JA, Claborn, JC, Miller, CJ,

Memory Notebook of Nursing: Pharmacology and Diagnostics, ed 2, Ingram, Texas, 2009,

Nursing Education Consultants.


Appendix 11-6 MEDICATIONS USED FOR TREATMENT OF SHOCK

General Nursing Implications—Mostoftenlimitedtocriticalcaresettings;constantmonitoringisrequired.—AdministeredIVindilutedsolutionbyinfusionpump.—MonitorIVinfusionsiteclosely;leakageintotissuemaycausetissuesloughing.—ContinuousECGmonitoring;observeclientcloselyforcardiacdysrhythmias.—Monitorurinaryoutputeveryhour.—MedicationsshouldnotbeadministeredtoclientsreceivingMAOIsortricyclicantidepressants.—PrimaryresponsibilityofPNistomonitorclientandkeepRNandHCPcloselyadvisedofclient’sresponse.

MEdICaTIoNS SIdE EFFECTS NurSINg IMPlICaTIoNS

Adrenergics:Increasesmyocardialcontractility,therebyimprovingcardiacoutput,BP,andurineoutput.

Dopamine(Intropin):IV Dysrhythmias(tachycardia),angina, 1.Shouldnotbegiventoclientswithtachydysrhythmiasor hypertension,headaches ventricularfibrillation 2. High alert Medication–consequencesofamedication errorcanbefatal,alwayscheckwithRNandHCP. 3.Ifextravasationoccurs,stopinfusionimmediatelyand notifyRNorHCP. 4.CloslymonitorVS,cardiacrhythm,andurinaryoutput duringadministration.

Dobutamine(Dobutrex):IV Tachycardia,dysrhythmias,hypertension 1.Closelyobserveclientfordevelopmentofangina,notifiyRN orHCP. 2.Ifextravasationoccurs,stopinfusionandnotifyRNorHCP.

Epinephrinehydrochloride Nervousness,restlessness,tremors, 1.Besuretoreadlabelcorrectlyandusecorrectstrength/(Adrenalin):IV angina,dysrhythmias,tachycardia, concentration. hypertension. 2.High-alert Medication -dosagesareeasilyconfusedand mistakesaremade. 3.Useintreatmentofanaphylacticshockandcardiacarrest.

HIGH

ALERT

ECG,Electrocardiogram;IV,intravenous;MAOIs,monoamineoxidaseinhibitors;VS,vitalsigns.

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