Disorders In Tissue Perfusion Disorders Of The Peripheral Vascular System Liz Mathewson.
Disorders In Tissue Perfusion
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Transcript of Disorders In Tissue Perfusion
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Disorders In Tissue Perfusion
Disorders Of The Peripheral Vascular System
Liz Mathewson
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Summary• normal A&P of peripheral vasc. system
• risk factors and causes
• prevention and health teaching
• assessments
• nsg. diagnosis
• medical/surgical/pharmatherapeutic
• nursing measures
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Categories of Disorders
• Obstruction: thrombus, embolus, lymphedema
• Inflammation: phlebitis, thrombophlebitis
• Degeneration: arteriosclerosis, atherosclerosis, aneurysm, varicose veins, stasis ulcer
• Unknown causes: Buerger’s disease, Raynauds Disease
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Pharmacology
Classifications:
• anticoagulants (and their reversal agents)
• antilipidemics (antihyperlipidemic)
• platelet inhibitors
• thrombolytics
• peripheral vasodilators
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Obstructive Disease
• Can affect both venous and arterial circulation as well as lymph system
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To the Brain
To the stomachTo the liver
To the Kidneys
Iliac Artery
Femoral Artery
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Arterial Obstructive Disease
• (degenerative condition leading to obstructive condition)
• Arteriosclerosis: “hardening of the arteries”– muscle fibers and the endothelial lining of the
walls of small arteries and arterioles become thickened
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Obstructive Arterial Disease
Atherosclerosis: affects the intima of the large and medium-sized arteries– caused by an accumulation of lipids, calcium,
blood components, carbohydrates, and fibrous tissue on the intima layer = plaque
Direct effects:
Indirect effects:
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Atherosclerosis
• Risk factors:– diet - age– high blood pressure - gender– diabetes - family hx– stress– sedentary lifestyle– smoking
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Assessment• Health history and clinical manifestations• Pain (where)• Skin appearance and temperature
– Rubor
– cyanosis
– brittle nails,
– dry scaling skin, atrophy, decrease hair growth, ulceration
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Signs and Symptoms
• Occur when vessel is 60% occluded
• Early include pain, changed appearance, or changed sensation
• Pain or “intermittent claudication”
• Pain on exertion or pain at rest?
• Chronic = collateral circulation
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Assessment
• Pulses– present or absent, volume, quality, symmetry
“pedal pulses present bilaterally”– Posterior tibial; dorsalis pedis; popliteal;
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Assessment
• Mental status
• Edema (Pitting or non-pitting)
• Risk factors:– controllable (modifiable)– not controllable (non-modifiable)
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Arterial Assessment Tools• Doppler U/S flow Studies
• Ankle blood pressures
• Exersize tests
• CT
• CT Angiography
• MRI
• Angiography
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Progression of Disease
• Decreased oxygen leads to ischemia
• Ischemia leads to infarction
• Infarction leads to necrosis
• Ischemia Infarction Necrosis
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Arterial ulcers
Ischemia Infarction Necrosis
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Venous Ulcers (characteristics)
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Nsg. Diagnosis
• Alteration in peripheral tissue perfusion related to compromised circulation
• Pain related to impaired ability of peripheral vessels to supply tissues with oxygen
• Risk for impaired skin integrity related to compromised circulation
• Knowledge deficit regarding self-care activities
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Nursing Diagnosis
• Alteration in peripheral tissue perfusion related to compromised circulation
– Goal: Increase arterial blood supply to extremities
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Medical Management
• Medical: modification of risk factors; a controlled exercise program to increase circulation; and medication
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Surgical Management
• Surgical: Inflow procedures and outflow procedures– Bypass (artificial graft/insitu graft)– Endarterectomy
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Grafts
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Endarterectomy
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Post-op Care• Maintaining circulation – how?
• Assessment: pulses, colour, temperature, capillary refill, sensory and motor functions
• use doppler (at PRCH, use doppler on Dr.Thompson pts.)
• Complications: decreased urinary output, CVP, mental status, pulse rate and volume = fluid imbalance
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Post-op Care
• Bleeding, hematoma
• Edema
• Infection
• Discharge planning
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Upper extremity Obstruction
• Arm fatigue and pain with exercise and inability to hold or grasp objects.
• Avoid venopuncture, injury, using tape, taking BP, protect from cold. Assess frequently
• May need bypass
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Arterial Embolism
• Usually originate in the chamber of the heart as a result of atrial fibrillation, or CHF, infective endocarditis or MI.
• Carried to left side of heart and into arterial system
• May be caused by catheters, stents, intra-aortic balloon pump.
• Trauma, crush injury, penetrating wound
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Signs and Symptoms
• 6 “P”s– pain– pallor– pulselessness– paresthesia– paralysis– poikothermia
X
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Treatment
• FAST to prevent tissue infarction
• heparin
• surgery (embolectomy)
• ? Thrombolytic therapy if no contraindications
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Venous Obstruction
• Venous Thrombosis
• Deep Vein Thrombosis
• Thrombophlebitis
• Phlebothrombosis
• * not identical disease processes but for clinical purposes used interchangeably
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Pathophysiology
Stasis of Blood
Vessel Wall InjuryAltered Blood Coagulation
Virchow’s Triad
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Venous Stasis
• Reduced Blood Flow due to :– heart failure or shock– dilated veins due to medications– decreased skeletal muscle contractions due to
paralysis, anesthesia, and bed rest
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Vessel Wall Injury
• Damage to the Intima Due to:– direct trauma (fractures, dislocations)– diseases of the veins, (infection/inflammation)– chemical irritation (IV meds and solutions
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Increased blood coaguability
• Due to:– abrupt withdrawal of anticoagulants– oral contraceptives– blood dyscrasias (abnormalities)
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Clinical ManifestationsOften Non-Specific:
• inflammation or redness along a superficial vein
• limb pain, feeling of heaviness
• functional impairment
• ankle engorgement, edema
• unilateral increase in leg circumference
• increased warmth to touch of leg/foot
• tenderness to touch, rosy colour
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Thrombus to Embolus
• Platelets attach to vein wall with a tail-like appendage containing fibrin, RBC, WBC
• grows in direction of blood flow
• elevation in venous pressure (sudden movement, increased muscle movement) cause fragment to break off and travel
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Deep Vein Thrombosis
• Sign and symptoms are non specific, sometimes PE is the first sign
• deep veins have thinner walls and less muscle mass in the media than superficial veins
• run parallel to arteries and have the names
• have valves as do the superficial veins
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Deep Vein Obstruction
• Creates swelling and edema in extremity because the outflow of venous blood is inhibited
• limb may be warm and superficial veins appear more prominent
• tenderness
• Howman’s sign
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Superficial thrombosis
• Pain or tenderness, redness and warmth in involved area
• embolus rare as these thrombi usually dissolve spontaneously
• treated with bed rest at home, elevation of leg, analgesics, and sometimes anti inflammatory
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Medical Management for DVT
• Medication
• Surgery: only if anticoagulant or thrombolytic therapy is contraindicated, the danger of PE is extreme, and the venous drainage is so severely compromised that permanent damage to the extremity will result.
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Nursing Interventions
• Assessing and monitoring meds
• observing for complications
• providing comfort
• applying elastic stockings
• positioning pt and encouraging exercise
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Venous Ulcers (characteristics)
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Anticoagulants
• Heparin: two types– fractionated, low-molecular - weight heparin– fractionated heparin is given IV 5 to 7 days and
coumadin (orally) started concurrently– sometimes given prophylactically SC– regulated by monitoring the partial
thromboplastin time, the INR, and the platelet count
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Heparin
• LMWH, more $
• SC
• longer 1/2 life
• does are adjusted by wt, does not bind with plasma proteins
• fewer bleeding complications
• can be given to pregnant women
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Heparin
Nursing responsibilities:
• monitor blood work
• observe for bleeding
• to reverse heparin = protamine sulfate
• to reverse warfarin = vit K
• drug interactions
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Thrombolytic Agents
• i.e. Streptokinase
• lyses thrombi and emboli
• observe for bleeding
• contraindicated: recent bleed, trauma,
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Lymphedema
• Primary or secondary
• results from an obstruction of lymph vessels and an accumulation of lymph
• noticed in dependent position
• starts of as soft, pitting and treatable
• progresses to firm, non pitting and does not respond to treatment
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Lymphedema
• Obstruction may be in the node or vessel• often seen in the arm following a mastectomy• treatment may include bedrest, elevation,
active and passive exercise, custom fitted stockings
• Pharm: diuretic, antibiotics, • Surgery: excision of tissue and fascia
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Venous insufficiency
• Chronic venous insufficiency:• results from venous valve obstruction and a
result of venous hypertension• wall of the vein become distended resulting
in reflux• post thrombotic syndrome• edema altered pigmentation, pain and stasis
dermatitis
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Leg ulcers
• 75% of leg ulcers from CVI
• inflamed necrotic tissue sloughs off
• arterial insufficiency ulcers account for approx.. 20% the remaining 5% from SSE, burns and other factors
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Arterial Ulcers
• Small circular, deep ulcerations on the tips of toes or in the web spaces between toes
• medial side of hallux or lateral 5th toe
• may result in gangrene of toe
• gangrene usually left alone
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Venous Ulcers
• Ulcers are usually in the area of the medial or lateral malleolus and are large, superficial, and highly exudative.
• See pictures on pg 710 of Brunner
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Nursing Diagnosis
• Impairment of skin integrity related to vascular insufficiency
• Impaired physical mobility related to activity restrictions of he therapeutic regimen and plan
• Altered nutrition, less than body requirements, related to increased need for nutrients that promote wound healing
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Goals
• Demonstrates restored skin integrity
• Increases physical mobility
• Attains adequate nutrition
• How????
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Patient Teaching
• venus ulceration from CVI
• antigravity activities
• elevate legs during the day
• sleep with foot of bed elevated
• no prolonged standing
• no cross legs, no trauma
• foot care, stockings
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Varicose veins
• Abnormally dilated, tortuous superficial veins caused by incompetent venous valves
• predisposing factors– hereditary– occupation/lifestyle– gender (female)
May be primary or secondary
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Varicose Veins
• May result in chronic venous insufficiency: edema, pain, pigmentation and ulceration
• susceptibility to injury and infection is increased
• treatment: surgical, sclerotherapy, stockings
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Degeneration of the Vascular System
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Aneurysm• A localized sac or dilation involving an
artery formed at a weak point in a vessel wall
• classified by its shape or form
• most common saccular or fusiform
• saccular projects from one side of the vessel only
• fusiform is when entire arterial segment dilates
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Aneurysm
• Small aneurysm caused by localized infection is called mycotic aneurysms
• most common is the abdominal aortic (AAA)
• serious because they can rupture leading to hemorrhage and death
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Thoracic Aneurysm
• Most common site for a dissecting aneurysm
• common in men between age 40-70
• 1/3 of pts with thoracic aneurysms die from rupture
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Signs and symptoms
• Depends on how rapid the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures.
• Usually pain is the prominent symptom
• shortness of breath, dysphasia, loss of voice
• hoarseness, stridor
• dx by chest xray, ct, mri
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S & S of AAA• Common in whites, 4:1 men to women
• most occur below the renal arteries
• c/o “heart beating in stomach”
• abd mass
• “blue toe” syndrome as a result of embolus
• 80% can be palpated
• impending rupture include sever pain
• 50 to 75% mortality rate for ruptured AAA
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AAA
• surgical repair
• put in a graft
• may be bifurcated
• better if it is below renal arteries
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Dissecting Aorta
• A tear develops in the intima or the media degenerates, resulting in dissection
• onset sudden, severe persistent pain, tearing feeling, pain in shoulders, chest, epigastric or abd.
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Raynauds Disease
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Buerger’s Disease