FUNCTIONS OF THE VASCULAR SYSTEM :FUNCTIONS OF THE VASCULAR SYSTEM Circulatory needs of tissues > when metabolic needs increase – blodd vessels dilate to increase the flow of oxygen & nutrients to the tissues. > when metabolic needs decrease – vessels constrict & bld. Flow to the tissues decreases. Capillary filtration & reabsorption Hemodynamic Resistance > vessel radius – most impt.factor that determines resistance


Slide 2:Peripheral Vascular Regulating Mechanisms - Sympathetic nervous system activity – is the most impt. factor in regulating the caliber & blood flow of peripheral blood vessels. - All vessels are innervated by the SNS except the capillary & precapillary sphincters. Stimulation of the SNS causes ___________. The neurotransmitter responsible for vasoconstriction is ______________. EPINEPHRINE – in low conc.causes vasodilation in skeletal muscles, heart & brain.


DIAGNOSTIC TESTS :DIAGNOSTIC TESTS 1. Doppler ultrasound flow studies2. Exercise Testing 3. Duplex Ultrasonography 4. Computed Tomography 5. Computed Tomography Angiography 6. Magnetic Resonance Angiography 7. Angiographys


ARTERIAL DISORDERS :ARTERIAL DISORDERS ARTERIOSCLEROSIS – most common disease of the arteries.Means “ hardening of the arteries.” RISK FACTORS for Atherosclerosis & peripheral arterial disease. MODIFIABLE RISK FACTORS - nicotine use - diet ( contributing to hyperlipidemia ) - hypertension


Slide 5:Diabetes mellitus Obesity Stress Sedentary lifestyle Elevated C- reactive protein – sensitive marker of cardiovascular inflammation. Hyperhomocysteinemia – homocysteine is a protein that promotes coagulation by increasing factor V & factor XI activity Vitamins B6 , B12, FOLATE – may lower homocysteine levels


Nonmodifiable Risk Factors :Nonmodifiable Risk Factors Age Gender Familial predisposition / genetics ASSESSMENT Claudication pain ; rest pain in the forefoot; pallor;rubor , or cyanosis;weak or absent peripheral pulses; skin breakdown or ulcerations;


NURSING DIAGNOSES :NURSING DIAGNOSES Altered peripheral tissue perfusion r/t compromised circulation Chronic pain r/t impaired ability of peripheral vessels to supply tissues with oxygen Risk for impaired skin integrity r/t compromised circulation Deficient knowledge regarding self – care activities


NURSING INTERVENTIONS :NURSING INTERVENTIONS Improving Peripheral Arterial Circulation > lower extremities – elevating the head of the bed on 15 – cm. ( 6 inch) blocks or by having the patient use a reclining chair or sit with the feet resting on the floor. Promoting Vasolidation & preventing Vascular compression > applications of warmth > instruct patient to avoid exposure to cold temperatures.


Slide 9:Adequate clothing & warm temperatures protect the patient from chilling. NURSING ALERT ! Patients are instructed to test the temperature of bath water & to avoid using hot water bottles & heating pads on the extremities. Applying a hot water bottle or a heating pad to the abdomen can cause reflex vasodilation in the extremities & is safer than direct application of heat to affected extremities.


Slide 10:Instruct patient to avoid smoking – nicotine causes vasopasm & thereby reduce circulation to the extremities. Avoiding stressful situations & emotional stress – stimulate SNS resulting in peripheral_________________. > counseling services or relaxation training Avoid constrictive clothing such as tight socks,panty girdles,sholaces Instruct client to avoid crossing the legs because it compresses vessels in the legs.


Slide 11:RELIEVING PAIN > Analgesics such as oxycodone plus acetylsalicylic acid ( Percodan) oxycodone plus acetaminophen ( Percocet ) MAINTAINING TISSUE INTEGRITY > wear sturdy, well- fitting shoes or slippers > eating a well – balanced diet – contains adequate protein & vitamins > vitamin C – essential for collagen synthesis & capillary developoment.


Slide 12:Vitamin A – enhances epithelialization Zinc – necessary for cell mitosis & cell proliferation. PERIPHERAL ARTERIAL OCCLUSIVE DISEASE > Hallmark – intermittent claudication - elevating the extremity or placing it in a horizontal position increases the pain, placing the extremity in a dependent position reduces the pain.


Slide 13:Assessment findings; MEDICAL MANAGEMENT > pharmacologic therapy – Pentoxifylline ( Trental) > cilostazol ( Pletal ) – these two are the only medications indicated for the treatment of claudication. > Antiplatelet agents – aspirin or clopidogrel ( Plavix )


Slide 14:SURGICAL MANAGEMENT > vascular grafting or endarterectomy – THROMBOANGIITIS OBLITERANS ( Buerger’s disease ) – it results in thrombus formation & occlusion of the vessels. > is believed to be an autoimmune disease that results in occlusion of distal vessels. > occurs most often in men b/n 20 & 35 years of age > heavy smoking or chewing of tobacco is a causative or aggravating factor.


Slide 15:Clinical manifestations; > pain – is the outstanding symptom – the patient complains of foot cramps after exercise & is relieved by rest.


ANEURYSM :ANEURYSM Is a localized sac or dilation formed at weak point in the wall of the artery. Types – saccular – aneurysm projects from one side of the vessel only. > fusiform – an entire arterial segment becomes dilated.


ABDOMINAL AORTIC ANEURYSM :ABDOMINAL AORTIC ANEURYSM The most common cause is atherosclerosis. RISK FACTORS: > genetic predisposition > tobacco use > hypertension – accounts for more than 50 %


ASSESSMENT :ASSESSMENT Only about 40 % of patients have symptoms. Some patients complain that they can feel their heart beating in their abdomen when lying down; May report a “ heatbeat” in the abdomen;prominent,pulsating mass in the abdomen ( most impt.diagnostic indication ) Systolic bruit may be heard Moderate to severe abdominal or lumbar back pain ( sign of impending rupture )


DIAGNOSTICS :DIAGNOSTICS Abdominal ultrasound, CT scan, arteriography to confirm the presence ,size, & location of aneurysm. MEDICATIONS : a. Antihypertensive therapy – diuretics, beta blockers, ACE inhibitors, calcium channel blockers b. Anticoagulant therapy – postop ( Heparin while in the hospital ; Coumadin when discharged )


SURGICAL MANAGEMENT :SURGICAL MANAGEMENT a. Surgical resection or excision of the aneurysm ( excised section is replaced with a graft that is sewn end to end ) – not usually performed on aneurysms less than 4 to 5 cm. in size. “ emergency surgery “ is the only intervention for clients with a ruptured aneurysm. Postoperative :Assess for graft occlusion ( changes in pulse, cool to cold extremities below the graft,white or blue extremities or flanks, severe pain )s


Slide 21:Hypovolemia,renal failure, respiratory distress, cardiac dysrhythmias, paralytic ileus, paraplegia,paralysis INSTRUCTIONS : > teach the client signs of impending rupture. > teach the client to monitor BP & report any increases immediately. > do limited lifting for 4 to 6 weeks after surgery ( no heavy lifting at all : > 15 to 20 lbs.) > clients who receive a synthetic graft may require prophylactic antibiotics.


VENOUS DISORDERS :VENOUS DISORDERS Venous thrombosis, deep vein thrombosis ( DVT), thrombophlebitis, phlebothrombosis RISK FACTORS: ENDOTHELIAL DAMAGE - trauma, surgery,pacing wires - central venous catheters - dialysis access catheters - local vein damage - repetitive motion injury


Slide 23:B. VENOUS STASIS - bed rest or immobilization - obesity - history of varicosities - spinal cord injury - age ( greater than 65 years ) C. ALTERED COAGULATION - cancer, pregnancy, oral contraceptive use - polycythemia, septicemia, hyperhomocysteinemia


THROMBOPHLEBITIS :THROMBOPHLEBITIS The formation of a thrombus in association with inflammation of the vein. 1.Superficial - palpable, firm,cord – like vein - surrounding area warm, red, tender to touch - edema may or may not be present 2. Deep - unilateral edema, pain


Slide 25:Warm skin & elevated temperature If inferior vena cava is involved, both legs will be edematous If superior vena cava is involved,both upper extremities, neck, back, & face may become edematous or cyanotic. If the calf is involved – positive homan’s sign ( pain on dorsiflexion of the foot,esp.when the leg is raised ) DIAGNOSTICS Venous doppler ultrasonic flowmeter or duplex scanning


Slide 26:Lung scan Venography or pletysmography THERAPEUTIC MANAGEMENT 1. Priority Nursing Diagnoses: pain, ineffective tissue perfusion, risk for impaired skin integrity 2. Medications a. Anticoagulant therapy Heparin – while in the hospital Enoxaparin – low-molecular weight heparin Coumadin – maintenance therapy at home for 2 – 4 months.


Slide 27:B. Thrombolytics – dissolve blood clots: effective less than 72 hours. Streptokinase ( Streptase), Alteptase ( Activase ) C.Analgesics – NSAIDs are usually prescribed. 3. measure & record the circumferences of the thighs & calves. 4.Elevate the affected extremity above the level of the heart (________________ ) 5. Apply warm,moist compresses to affected extremity


Slide 28:6. Keep bed covers from touching affected limb by using an overbed cradle.No restrictive clothing. 7. Never massage affected extremity.Instruct client to report any pink- tinged sputum,shortness of breath, & chest pain. ( ____________) 8. Instructions a. early ambulation b.avoid prolonged standing or sitting c.stop smoking, use of antiembolism stockings ( prevent venous stasis )


VENOUS INSUFFICIENCYS :VENOUS INSUFFICIENCYS Prolonged venous hypertension ( inadequate venous return ) w/c stretches the veins & damages the valves. PATHOPHYSIOLOGY/ASSESSMENT prolonged sitting/standing: teachers, waitresses, nurses, office workers pregnancy / obesity thrombus formation


Slide 30:Damaged valves Stretched veins Edema venous stasis decreased venous return venous stasis ulcers


Slide 31:CLINICAL MANIFESTATIONS > edema of the lower legs > stasis dermatitis – thick, coarse, brownish skin around the ankles & feet > stasis ulcers THERAPEUTIC MANAGEMENT 1.Priority Nursing Diagnoses Impaired Skin Integrity, Risk for Infection r/t skin ulcerations, Disturbed Body Image, Ineffective Tissue Perfusion


Slide 32:2.MEDICATIONS :S a.topical agents ( for skin ulcers ) – hydrocortisone, antifungals, or zinc oxide - apply petroleum jelly on surrounding skin. b.Oral or IV antibiotics – infected ulcers or cellulitis occurs. c. Sclerosing agents – sclerotherapy – to occlude blood flow in a vein causing disappearance of the varicosity. hypertonic saline, polidocanol


Slide 33:3. Increase Venous Return a. keep legs elevated above heart level b. avoid long periods of standing. c. Wear elastic support or compression stockings. > apply stockings before getting out of bed & place leg in a dependent position. > Wear stocking during the day & evening, remove at night. d. Use of an intermittent sequential pneumatic compression system – apply system twice daily for 1 hour in the morning & evening.


Slide 34:4. Trwat venous stasis ulcer a. Treated with hydrocolloid dressing & compression wraps,Unna boot ( dressing with gauze moistened with zinc oxide ) b. Cleansed with normal saline. NO BETAdine or hydrogen peroxide – destroy granulation tissue. 5. Instructions Elevate legs for at least 20 minutes a day.Keep legs above the level of the heart when in bed.No prolonged standing/sitting.No restrictive clothing.


Comparison of arterial & venous disease :Comparison of arterial & venous disease


VARICOSE VEINS :VARICOSE VEINS A vein or veins in w/c blood has pooled, producing distended,tortuous, palpable vessels. ASSESSMENT 1. Pain in the legs with dull aching after standing. 2. Dilated, tortuous superficial veins will be seen along the upper & lower legs. 3. Positive Trendelenburg test – evaluate valve competence.


Slide 37:a.Client is placed in a position with elevated legs. b. If there are varicosities, the veins fill from the proximal end. THERAPEUTIC MANAGEMENT 1. Priority Nursing Diagnoses Pain, Ineffective Tissue Perfusion, Risk for Impaired Skin Integrity, Risk for Peripheral Neurovascular Dysfunction TREATMENT a. Sclerotherapy – palliative procedure


Slide 38:b. Vein Stripping – involves ligation ( tying off) of the entire vein & dissection & removal of the vein.Varicose veins larger than 4 mm. in diameter or if in clusters – removed > perform hourly circulation checks postop. > maintain elastic ( ace ) bandage on the legs. > apply compression gradient stockings from foot to groin. > elevate the legs above the level of the heart postop.


Slide 39:INSTRUCTIONS instruct client to avoid leg dangling or prolonged sitting or standing. Change position often. Maintain ideal body weight.


HYPERTENSION :HYPERTENSION Disorder characterized by BP that consistently exceeds 140/90: confirmed on at least 2 visits several weeks apart. PATHOPHYSIOLOGY Risk Factors: > positive family history > high sodium intake > obesity, inactivity, excessive alcohol intake > cardiovascular/ renal disorders (secondary)


: Increase cardiac output Systemic vascular resistance (thickened arterial beds, increase blood viscosity) HYPERTENSION Organ involvement: Eyes; visual changes Brain; CVA : CV : heart failure,hypertensive crisis: Kidneys : renal failure


Slide 42:TYPES OF HYPERTENSION: 1.Pre-hypertension: systolic BP b/n 120 & 139 mmHg. Or a diastolic pressure b/n 80 & 89 mmHg. 2. Primary hypertension (essential HPN) –most common, develops without apparent cause 3. Secondary HPN – rfesults from another source ( renal failure ) 4.Malignant HPN – either primary or secondary HPN that is severe.


Slide 43:B. ASSESSMENT 1. subjective – occipital headache ( early morning), blurred vision, weight gain, ,dyspnea on exertion, dizziness, chest pain 2. Objective – BP consistently 140/90 mmHg,peripheral edema,retinal vessel changes, S3 & S4 heart sounds,epistaxis C. DIAGNOSTICS 1. Serial BP measurements 2. creatinine, BUN,potassium 3. Urinalysis – check for protein in the urine


Slide 44:D. THERAPEUTIC MANAGEMENT 1. Priority Nursing Diagnoses Ineffective Health Maintenance, Risk for noncompliance, Decreased Cardiac Output 2. MEDICATIONS > DIURETICS > BETA BLOCKERS, CALCIUM CHANNEL BLOCKERS, ACE INHIBITORS, ANGIOTENSIN RECEPTOR BLOCKERS


Slide 45:INSTRUCTIONS a. Teach lifestyle modification: > sodium restriction – 2 grams daily as prescribed; > weight reduction/maintenance ideal weight > moderate intake of alcohol & caffeine – containing products > exercise – avoid heavy lifting & isometric exercises


Slide 46:> Relaxation techniques > NO SMOKING DASH (dietary approaches to stop HPN):grain & grain products, vegetables, fruits, low fat,nonfat dairy foods, meats, poultry, fish,nuts, legumes, sweets,( prescribed number of servings ) C. DESCRIBE THE IMPORTANCE OF COMPLIANCE