Chapter 23 - MANAGEMENT OF PATIENT WITH CORONARY VASCULAR

DISORDERS

Coronary Atherosclerosis

. Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within
arterial walls and lumen
. In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce
blood flow to the myocardium
. Coronary artery disease (CAD) is the most prevalent cardiovascular disease in adults
Clinical Manifestations of Atherosclerosis

. Symptoms and complications are related to the location and degree of vessel obstruction
. Angina pectoris (most common manifestation)
. Other symptoms: epigastric distress, pain that radiates to jaw or left arm, SOB, atypical
symptoms in women

* Myocardial infarction
* Heart failure
* Sudden cardiac death

Risk Factors for Coronary Artery Disease (CAD)

* Refer to Chart 23-1

→Four modifiable risk factors cited as major (cholesterol abnormalities, tobacco use,
HTN, and diabetes)

* Elevated LDL: primary target for cholesterol- lowering medication

* Framingham risk calculator
* Metabolic syndrome
* hs-CRP (high-sensitivity C-reactive protein)

Prevention of CAD
* Control cholesterol
* Dietary measures
* Physical activity
* Medications
* Cessation of tobacco use
* Manage HTN
* Control diabetes

Cholesterol Medications

* Six types of lipid-lowering agents: affect the lipid components somewhat differently
(Table 23-1)

→3-Hydroxy-3-methylglutaryl coenzyme A (HMG- COA) (or statins)

→Nicotinic acids
→ Fibric acids (or fibrates)
→ Bile acid sequestrants (or resins)
→ Cholesterol absorption inhibitors
→ Omega-3 acid-ethyl esters

Question #1

The nurse is caring for a patient with hypercholesterolemia who has been prescribed
atorvastatin (Lipitor). What serum levels should be monitored in this patient?

A. Complete blood count (CBC)

B. Blood cultures
C. Na and K levels
D. Liver enzymes – Correct answer

Angina Pectoris

* A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior

chest caused by insufficient coronary blood flow
* Physical exertion or emotional stress increases myocardial oxygen demand, and the
coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand
* Types of angina Refer to Chart 23-2

Assessment and Findings for Angina

* Anxiety frequently accompanies the pain

 * Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and
vomiting
* The pain of typical angina subsides with rest or NTG

* Unstable angina is characterized by increased frequency and severity and is not

relieved by rest and NTG. Requires medical intervention!

Gerontologic Considerations for Angina

* Diminished pain transition that occurs with aging may affect presentation of symptoms
* "Silent" CAD
* Teach older adults to recognize their "chest pain- like" symptoms (i.e., weakness)
* Pharmacologic stress testing; cardiac catheterization
* Medications should be used cautiously!

Treatment of Angina Pectoris

❖Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply

* Medications
* Oxygen
* Reduce and control risk factors
* Reperfusion therapy may also be done

Medications for Angina

* Nitroglycerin
* Beta-adrenergic blocking agents
* Calcium channel blocking agents
* Antiplatelet and anticoagulant medications
* Aspirin
* Clopidogrel and ticlopidine
* Heparin
* Glycoprotein IIb/IIIa agents

Question #2

The nurse is caring for a patient who has severe chest pain after working outside on a hot
day and is brought to the emergency center. The nurse administers nitroglycerin to help
alleviate chest pain. Which side effect should concern the nurse the most?

A. Dry mucous membranes

B. Heart rate of 88 bpm
C. Blood pressure of 86/58 mm Hg – correct answer
D. Complaints of headache

Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI)

* Emergent situation
* Characterized by an acute onset of myocardial ischemia that results in myocardial
death (i.e., MI) if definitive interventions do not occur promptly
* Although the terms coronary occlusion, heart attack, and MI are used synonymously,
the preferred term is MI

Assessment of the Patient with Angina Pectoris

* Symptoms and activities, especially those that precede and precipitate attacks (Chart
23-4)
* Risk factors, lifestyle, and health promotion activities
* Patient and family knowledge
* Adherence to the plan of care

Collaborative Problems of the Patient wit Angina Pectoris

* ACS, MI, or both

* Arrhythmias and cardiac arrest (see Chapters 22 and 25)
* Heart failure (see Chapter 25)
* Cardiogenic shock (see Chapter 11)
Planning and Goals for the Patient with Angina Pectoris

* Goals

→Immediate and appropriate treatment of angina

→Prevention of angina
→Reduction of anxiety
→Awareness of the disease process
→Understanding of prescribed care and adherence to the self-care program
→Absence of complications

Nursing Interventions for the Patient wit Angina Pectoris

* Treat angina
* Reduce anxiety
* Prevent pain
* Educate patients about self-care
* Continuing care

Nursing Intervention: Treat Angina

* Priority
* Patient is to stop all activities and sit or rest in bed (semi-Fowler positioning)
* Administer medications as ordered or by protocol, usually NTG. Reassess pain and
administer NTG up to three doses
* Administer oxygen 2 L/min by nasal cannula

Nursing Intervention: Reduce Anxiety

* Use a calm manner

* Stress-reduction techniques
* Patient teaching
* Addressing patient's spiritual needs may assist in allaying anxieties
* Address both patient and family needs

Nursing Intervention: Preventing Pain

* Identify level of activity that causes patient's prodromal S&S

* Plan activities accordingly
* Alternate activities with rest periods
* Educate patient and family

Nursing Intervention: Patient Teaching #1

* Balance activity with rest
* Follow prescribed exercise regimen
* Avoid exercising in extreme temperatures
* Use resources for emotional support (counselor)
* Avoid over-the-counter medications that may increase HR or BP before consulting
with health care provider
* Stop using tobacco products (nicotine increases HR and BP)
* Diet low in fat and high in fiber

Nursing Intervention: Patient Teaching #2

* Medication teaching (carry NTG at all times!)

* Follow up with health care provider
* Report increase in S&S to provider
* Maintain normal BP and blood glucose levels

Assessment of the Patient with ACS

* Chest pain

→Occurs suddenly and continues despite rest and medication

→Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR

* ECG changes

→Elevation in the ST segment in two contiguous leads is a key diagnostic indicator for
MI

* Lab studies: cardiac enzymes, troponin, creatine kinase, myoglobin

Collaborative Problems of the Patient wit ACS

* Acute pulmonary edema (see Chapter 25)

* Heart failure (see Chapter 25)
* Cardiogenic shock (see Chapter 11)
* Arrhythmias and cardiac arrest (see Chapters 22 and 25)
* Pericardial effusion and cardiac tamponade (see Chapter 25)

Planning and Goals for the Patient with ACS

* Goals:
→Relief of pain or ischemic signs (e.g., ST- segment changes) and symptoms
→Prevention of myocardial damage
→Maintenance of effective respiratory function, adequate tissue perfusion
→Reduction of anxiety
→Adherence to the self-care program
→Early recognition of complications

Nursing Interventions for the Patient wit ACS

* Relieve pain and S&S of ischemia

* Improve respiratory function
* Promote adequate tissue perfusion
* Reduce anxiety
* Monitor and manage potential complications
* Educate patient and family
* Provide continuing care

Nursing Management of the Patient with ACS

* Oxygen and medication therapy

* requent VS assessment
* Physical rest in bed with head of bed elevated
* Relief of pain helps decrease workload of heart
* Monitor I&O and tissue perfusion
* Frequent position changes to prevent respiratory complications
* Report changes in patient's condition
* Evaluate interventions!

Question #3
The nurse is caring for a patient after cardiac surgery. Which nursing intervention is
appropriate to help prevent complications arising from venous stasis?

A. Encourage crossing of legs

B. Use pillows in the popliteal space to elevate the knees in the bed
C. Discourage exercising
D. Apply sequential pneumatic compression devices as prescribed – correct answer

Invasive Coronary Artery Procedures

* Percutaneous transluminal coronary angioplasty (PTCA) or PCI

* Coronary artery stent
* Coronary artery bypass graft (CABG)
* Cardiac surgery
Nursing Management: Patient Requiring Invasive Cardiac Intervention #1

* Assessment of patient
* Reduce fear and anxiety
* Monitor and manage potential complications
* Provide patient education
* Maintain cardiac output
* Promote adequate gas exchange
* Maintain fluid and electrolyte balance
* Minimize sensory – perception imbalance

Nursing Management: Patient Requiring Invasive Cardiac Intervention #2

* Relieve pain
* Maintain adequate tissue perfusion
* Maintain body temperature
* Promote health and community-based care

Chapter 24 MANAGEMENT OF PATIENTS WITH STRUCTURAL,

INFECTIOUS, AND INFLAMMATORY CARDIAC DISORDERS

Valvular Disorders

* Regurgitation: The valve does not close properly, and blood backflows through the
valve
* Stenosis: The valve does not open completely, and blood flow through the valve are
reduced
* Valve prolapse: The stretching of the valve leaflet into the atrium during systole

Specific Valvular Disorders

* Mitral valve prolapse
* Mitral regurgitation
* Mitral stenosis
* Aortic regurgitation
* Aortic stenosis

Nursing Management of Patients with Valvular Heart Disorders

→ Patient education
→ Monitor VS trends, heart and lung sounds, peripheral pulses

* Monitor for complications

→ Heart failure
→ Arrhythmias
→ Other symptoms: dizziness, syncope, angina pectoris

* Medication schedule: plan and education

* Daily weights: monitor for weight gain
* Plan activity with rest periods

Question #1

The nurse is providing education for a client diagnosed with mitral valve prolapse
(MVP). Which of the following should be included in the teaching plan? (Select all that
apply.)

A. MVP is not hereditary

B. Caffeine is tolerated in small amounts
Correct Answers
C. Avoid alcohol
D. Stop use of tobacco products
E. Prophylactic antibiotics are not prescribed before dental procedures

Surgical Management of Valvular Heart Disorders

* Valvuloplasty

→ Commissurotomy
→ Balloon valvuloplasty
→ Annuloplasty
→ Leaflet repair
→ Chordoplasty
* Valve Replacement

→ Mechanical
→ Tissue
→ Bioprosthesis
→ Homografts
→ Autografts
Nursing Management of the Patient with Valvuloplasty or Valve Replacement #1

* Balloon valvuloplasty

→ Monitor for heart failure and emboli

→ Assess heart sounds every 4 hours
→ Same care as after cardiac catheterization
* Surgical valvuloplasty or valve replacements

→ Focus is hemodynamic stability and recovery from anesthesia

→ Frequent assessments with attention to neurologic, respiratory, and cardiovascular
systems

Nursing Management of the Patient with Valvuloplasty or Valve Replacement #2

* Patient education

→ Anticoagulation therapy
→ Prevention of infective endocarditis
→ Follow-up
→ Repeat echocardiograms

Cardiomyopathy

* Cardiomyopathy is a series of progressive events that culminates in impaired cardiac

output

* Types

→ Dilated cardiomyopathy (DCM)

→ Hypertrophic cardiomyopathy (HCM)
→ Restrictive/constrictive cardiomyopathy (RCM)
→ Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)
→ Unclassified cardiomyopathy
Question #2

What is the main electrolyte involved in cardiomyopathy?

A. Calcium
B. Phosphorus
C. Potassium
D. Sodium – correct answer

Assessment of the Patient with Cardiomyopathy

* History (predisposing factors, family history)

* Chest pain
* Review of systems: presence of orthopnea, syncope
* Review of diet (Na reduction, vitamin supplements)
* Psychosocial history: impact on family, stressors, depression
* Physical assessment: VS, pulse pressure; pulsus paradoxus; weight gain or loss; PMI;
murmurs; S3 or S4; pulmonary auscultation for crackles, JVD, and edema

Planning and Goals for the Patient with Cardiomyopathy

* Goals
→ Improvement of cardiac output and peripheral blood flow
→ Increased activity tolerance
→ Reduction of anxiety
→ Decreased sense of powerlessness
→ Effective management of self-care
Nursing Interventions for the Patient with Cardiomyopathy #1

* Improve cardiac output and peripheral blood flow

→ Rest, positioning (legs down), supplemental 02, medications, low Na diet, avoid
dehydration

* Increase activity tolerance and improve gas exchange

→ Cycle rest and activity, ensure patient recognizes symptoms that indicate the need for
rest

* Reduce anxiety

→ Eradicate or alleviate perceived stressors, educate family about diagnosis, assist with
anticipatory grieving

Nursing Interventions for the Patient with Cardiomyopathy #2

* Decrease the sense of powerlessness

→ Assist patients in identifying things that have been lost (i.e., ability to play sports),
assist patients in identifying amount of control they still have left

* Promote home and community-based care

→ Educate patients about ways to balance lifestyle and work while accomplishing
therapeutic activities
→ Assess patient, family and their adjustment to lifestyle change educate family about
CPR and AEDS, establish trust

Evaluation of the Patient with Cardiomyopathy #1

* Maintains or improves cardiac function

→ HR and RR WNL, decreased dyspnea and increased comfort, maintain or improve

gas exchange, absence of weight gain, maintain or improve peripheral blood flow

* Maintains or increases activity tolerance

→ Carries out activities of daily living (e.g., brush teeth, feed self), reports increased
tolerance to activity
Evaluation of the Patient with Cardiomyopathy #2

* Is less anxious

→ Discusses prognosis, verbalizes fears and concerns, participates in support groups,

demonstrates appropriate coping mechanisms

* Decreases sense of powerlessness

→ Identifies emotional response to diagnosis, discusses control that they have

* Effectively manages self-care program

→ Takes medications as prescribed, modifies diet to accommodate sodium and fluid

recommendations, modifies lifestyle, identifies S&S to be reported

Infectious Diseases of the Heart

* Any of the three layers of the heart may be affected by an infectious process
* Diseases are named by the layer of the heart that is affected
* Diagnosis is made by patient symptoms and echocardiogram
* Management for all infectious diseases is prevention
* IV antibiotics usually are necessary once an infection has developed in the heart

Types of Infectious Disease of the Heart #1

* Rheumatic endocarditis

→ Occurs most often in school-age children after group A beta-hemolytic streptococcal

pharyngitis; need to promptly recognize and treat "strep" throat to prevent rheumatic
fever

* Infective endocarditis

→ Usually develops in people with prosthetic heart valves or structural cardiac defects;
also occurs in patients who are IV drug abusers and in those with debilitating diseases,
indwelling catheters, or prolonged IV therapy

Clinical Manifestations of Infectious Diseases of the Heart

* Fever
* New heart murmur, friction rub at left lower sternal border (pericarditis)
 * Osler nodes, Janeway lesions, Roth spots, and splinter hemorrhages in nailbeds
(rheumatic)
* Cardiomegaly, heart failure, tachycardia, splenomegaly
* Fatigue, dyspnea, syncope, palpitations, chest pain (myocarditis)
* Diagnostic tools: blood cultures, echocardiogram, CBC, rheumatoid factor, ESR, CRP,
ECG, cardiac catheterization, TEE, CT scan

Prevention of Infectious Diseases of the Heart

* Antibiotic prophylaxis before certain procedures

* Ongoing oral hygiene
* Female patients are advised NOT to use IUDs
* Meticulous care should be taken in patients "at risk" who have catheters
* Catheters should be removed as soon as they are no longer needed
* Immunizations

Question #3

A patient with restrictive cardiomyopathy taking digoxin presents with symptoms of

anorexia, nausea, vomiting, headache, and malaise. What should the nurse expect to be
included in the plan of care for this patient?

A. The patient's digoxin will be changed to nifedipine

B. The patient's digoxin dose will be decreased – correct answer
C. Nothing; these are signs of restrictive cardiomyopathy that are expected
D. The patient will be admitted to an ICU

Chapter 25 Management of Patients with Complications from Heart Disease

Heart Failure #1

* Heart failure (HF) is a clinical syndrome resulting from structural or functional cardiac
disorders that impair the ability of a ventricle to fill or eject blood; the heart is unable to
pump enough blood to meet the body's metabolic demands or needs.
 * The term heart failure indicates myocardial disease, in which there is a problem with
the contraction of the heart (systolic dysfunction) or filling of the heart (diastolic
dysfunction) may cause pulmonary or systemic congestion

Chronic Heart Failure

* The incidence of HF increases with age

* Approximately 6 million people in the United States have HF, and 870,000 new cases
are diagnosed each year
* Most common reason for hospitalization of people older than 65 years and the second
most common reason for visits to a provider's office
* Approximately 20% of patients discharged after treatment for HF are readmitted to the
hospital within 30 days and nearly 50% are readmitted to the hospital within 6 months

Clinical Manifestations of Heart Failure

* Right Sided

→ Viscera and peripheral congestion

→ Jugular venous distention (JVD)
→ Dependent edema
→ Hepatomegaly
→ Ascites
→ Weight gain

* Left Sided

→ Pulmonary congestion, crackles

→ S3 or "ventricular gallop"
→ Dyspnea on exertion (DOE)
→ Low O₂ sat
→ Dry, nonproductive cough initially
→ Oliguria

Medical Management of the Patient with Heart Failure

* Treatment may include

→ Oral and IV medications

→ Lifestyle modifications
→ Supplemental O₂
→ Surgical interventions: ICD and heart transplant

* Comprehensive education and counseling to patient and family is needed

Medications Used to Treat HF #1

* Diuretics: decreases fluid volume, monitor serum electrolytes

* Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases
afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
* Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work
similarly
* Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before
effects seen; use with caution in patients with asthma

Medications Used to Treat HF #2

* Ivabradine: decreases rate of conduction through the SA node; observe for decrease
HR and BP
* Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors; observe for
decreased BP
* Digitalis: improves contractility; monitor for digitalis toxicity especially if patient is
hypokalemic

Gerontologic Considerations
 * May present with atypical signs and symptoms such as fatigue, weakness, and
somnolence.
* Decreased renal function can make older patients resistant to diuretics and more
sensitive to changes in volume.
* Administration of diuretics to older men requires nursing surveillance for bladder
distention caused by urethral obstruction from an enlarged prostate gland.

Question #1

Which classification of medications play a pivotal role in the management of HF caused

by systolic dysfunction?

A. ACE inhibitors – correct answer

B. Beta-blockers
C. Diuretics
D. Digitalis

Assessment of the Patient with Heart Failure

* Focus

→ Effectiveness of therapy
→ Patient's self-management
→ S&S of increased HF
→ Emotional or psychosocial response

* Health History

* Physical Examination

→ Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or
signs of fluid overload; daily weight and I&O; assess responses to medications

Collaborative Problems and Potential Complications of the Patient with HF

* Pulmonary edema
* Hypotension, poor perfusion, and cardiogenic shock (see Chapter 11)
* Arrhythmias (see Chapter 22)
* Thromboembolism (see Chapter 26)
* Pericardial effusion
Planning and Goals for the Patient with Heart Failure

* Goals

→ Promote activity and reduce fatigue

→ Relieve fluid overload symptoms
→ Decrease anxiety or increase the patient's ability to manage anxiety

→ Encourage the patient to verbalize his or her ability to make decisions and influence
outcomes
→ Educate the patient and family about management of the therapeutic regimen

Nursing Interventions for the Patient with Heart Failure #2

* Manage fluid volume

→ Assess for symptoms of fluid overload

→ Daily weight
→ I&O
→ Diuretic therapy; timing of meds
→ Fluid intake; fluid restriction
→ Maintenance of sodium restriction

Patient Education for the Patient with Heart Failure

* Medications
* Diet: low-sodium diet and fluid restriction
* Monitor for signs of excess fluid, hypotension, and symptoms of disease exacerbation,
including daily weight
* Exercise and activity program
* Stress management
* Prevention of infection
* Know how and when to contact health care provider
* Include family in education

Patient Education for the Patient with Heart Failure

* Medications
* Diet: low-sodium diet and fluid restriction
* Monitor for signs of excess fluid, hypotension, and symptoms of disease exacerbation,
including daily weight
* Exercise and activity program
* Stress management
* Prevention of infection
* Know how and when to contact health care provider
* Include family in education

Question #2

Which of the following is not an appropriate recommendation for an exercise program for
the patient with HF?

A. Follow the exercise period with a cool-down activity

B. High-intensity training will provide the most benefit
C. Wait 2 hours after eating a meal before performing the physical activity
D. Begin with low-impact activities such as walking

Pulmonary Edema

* Acute event reflecting a breakdown of physiologic compensatory mechanisms

* Results in hypoxemia, often severe
* Clinical manifestations: restlessness, anxiety, tachypnea, dyspnea, cool and clammy
skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations),
increased sputum production (sputum may be frothy and blood tinged), decreased level of
consciousness

Nursing Interventions for the Patient with Pulmonary Edema

* Positioning the patient to promote circulation

* Providing psychological support
→ Reassure patient and provide anticipatory care

* Monitoring medications
→ I&O

End-of-Life Considerations

* HF is a chronic and often progressive condition

→ Need to consider issues related to the end of life

→ When palliative or hospice care should be considered

Cardiogenic Shock
 * Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome
* Commonly occurs following acute MI when a large area of myocardium becomes
ischemic and hypokinetic
* Can occur as a result of end-stage HF, cardiac tamponade, pulmonary embolism (PE),
cardiomyopathy, and arrhythmias

Thromboembolism

* Patients with cardiovascular disorders are at risk for the development of arterial
thromboemboli and venous thromboemboli (VTE)
* Decreased mobility and circulation increase the risk for thromboembolism in patients
with cardiac disorders, including those with HF
* Intra-cardiac thrombi can form in patients with atrial fibrillation because the atria do
not contract forcefully, and increasing the likelihood of thrombus formation

Pericardial Effusion and Cardiac Tamponade

* Pericardial effusion is the accumulation of fluid in the pericardial sac.

* Cardiac tamponade is the restriction of heart function because of this fluid, resulting
in decreased venous return and decreased CO
* Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged
neck veins, labile or low BP, shortness of breath
* Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure,
rising venous pressure, distant heart sounds
Medical Management of Pericardial Effusion and Cardiac Tamponade

* Pericardiocentesis

→ Puncture of the pericardial sac to aspirate pericardial fluid

* Pericardiotomy

→ Under general anesthesia, a portion of the pericardium is excised to permit the

exudative pericardial fluid to drain into the lymphatic system

Medical Management of Pericardial Effusion and Cardiac Tamponade

* Pericardiocentesis

→ Puncture of the pericardial sac to aspirate pericardial fluid

* Pericardiotomy

→ Under general anesthesia, a portion of the pericardium is excised to permit the

exudative pericardial fluid to drain into the lymphatic system

Sudden Cardiac Death or Cardiac Arrest

* Emergency management: cardiopulmonary resuscitation

→ A: airway
→ B: breathing
→ C: circulation
→ D: defibrillation for VT and VF

Sudden Cardiac Death or Cardiac Arrest

* Emergency management: cardiopulmonary resuscitation

→ A: airway
→ B: breathing
→ C: circulation
→ D: defibrillation for VT and VF

Question #3
What is the most reliable sign of cardiac arrest in an adult and child?

A. Decrease in blood pressure

B. Absence of brachial pulse
C. Absence of breathing
D. Absence of carotid pulse

Chapter 26
Assessment and Management of Patients with Vascular Disorders and Problems of
Peripheral Circulation
Function of the Vascular System

* Circulatory needs of tissues

* Blood flow
* Blood pressure
* Capillary filtration and reabsorption
* Hemodynamic resistance
* Peripheral vascular regulating mechanisms

Pathophysiology of the Vascular System

* Pump failure
* Alterations in blood and lymphatic vessels
* Circulatory insufficiency of the extremities

Gerontologic Considerations

* Aging produces changes in the walls of the blood vessels that affect the transport of
oxygen and nutrients to the tissues
* Changes cause vessels to stiffen and results in:

→ Increased peripheral resistance

→ Impaired blood flow
→ Increased left ventricular workload

Assessment of the Vascular System

 * Health history

→ Intermittent claudication,
→ "Rest pain"
→ Location of the pain

* Physical assessment

→ Skin (cool, pale, pallor, rubor, loss of hair, brittle nails, dry or scaling skin, atrophy,
and ulcerations)
→ Pulses

Diagnostic Evaluation

* Doppler ultrasound flow studies

→ Ankle-brachial index (ABI)

* Exercise testing
* Duplex ultrasonography

* Computed tomography scanning

* Angiography and magnetic resonance angiography

* Contrast phlebography (venography)

* Lymphoscintigraphy

Continuous Wave (CW) Doppler Ultrasound

* Handheld ultrasound device that detects blood flow, combined with computation of
ankle or arm pressures
* Signals are reflected by the moving blood cells
* Diagnostic technique helps characterize the nature of peripheral vascular disease

Assessment of the Patient with Peripheral Vascular Problems

* Health history
* Medications
* Risk factors
* Signs and symptoms of arterial insufficiency
* Claudication and rest pain
* Color changes
* Weak or absent pulses
* Skin changes and skin breakdown

Assessment of the Patient with Peripheral Vascular Problems

* Health history
* Medications
* Risk factors
* Signs and symptoms of arterial insufficiency
* Claudication and rest pain
* Color changes
* Weak or absent pulses
* Skin changes and skin breakdown

Planning and Goals for the Patient with Peripheral Vascular Problems

* Major goals include:

 → Increased arterial blood supply
→ Decrease in venous congestion
→ Promotion of vasodilatation and prevention of vascular compression
→ Relief of pain
→ Attainment/maintenance of tissue integrity
→ Adherence to the self-care program

Improving Peripheral Arterial Circulation

* Positioning strategies
* Exercise program and activities: walking, graded isometric exercises

→ Consult primary provider before engaging in an exercise routine

* Temperature; effects of heat and cold

* Discourage use of nicotine
* Stress reduction

Improving Peripheral Arterial Circulation

* Positioning strategies
* Exercise program and activities: walking, graded isometric exercises

→ Consult primary provider before engaging in an exercise routine

* Temperature; effects of heat and cold

* Discourage use of nicotine
* Stress reduction

Arterial Disorders

* Arteriosclerosis and atherosclerosis

* Peripheral artery disease
* Upper extremity arterial disease
* Aortoiliac disease
* Aneurysms (thoracic, abdominal, other)
* Aortic dissection
* Arterial embolism and arterial thrombosis
* Raynaud's phenomenon and other acrosyndromes
Risk Factors for Atherosclerosis and PAD

* Modifiable

→ Nicotine use
→ Diabetes
→ Hypertension
→ Hyperlipidemia
→ Diet
→ Stress
→ Sedentary lifestyle
→ C-reactive protein
→ Hyper-homocysteinemia

* Nonmodifiable

→ Increasing age
→ Familial (Pre-disposition/genetics)
Pharmacologic Therapy for PAD

* Phosphodiesterase III inhibitor

→ Cilostazol

* Antiplatelet agents

→ Aspirin
→ Clopidogrel

* Statins

Question #1

The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What
should be included in the teaching plan?

A. Elevate the lower extremities

B. Exercise is discouraged
C. Keep the lower extremities in a neutral or dependent position
D. PAD should not cause pain
Raynaud's Phenomenon

* Intermittent arterial vasoocclusion, usually of the fingertips or toes

→ Raynaud's disease: primary or idiopathic

→ Raynaud's syndrome: associated with other underlying disease such as scleroderma

* Manifestations: sudden vasoconstriction results in color changes, numbness, tingling,

and burning pain
* Episodes brought on by a trigger such as cold or stress
* Occurs most frequently in young women
* Protect from cold and other triggers. Avoid injury to hands and fingers

Venous Thromboembolism

* Pathophysiology
* Risk factors
* Endothelial damage

→ Venous stasis
→ Altered coagulation

* Manifestations

→ Deep veins
→ Superficial veins

Preventive Measures

* Early ambulation and leg exercises

* Graduated compression stockings
* Intermittent pneumatic compression devices
* Subcutaneous heparin or LMWH
* Lifestyle changes

→ Weight loss
→ Smoking cessation
→ Regular exercise

Question #2

Which patient is at highest risk for venous thromboembolism?

A. A 50-year-old postoperative patient

B. A 25-year-old patient with a central venous catheter in place to treat septicemia

C. A 71-year-old otherwise healthy older adult

D. A pregnant 30-year-old woman due in 2 weeks

Medical Management of the Patient with Leg Ulcers

* Anti-infective therapy depends on the infecting agent

→ Oral antibiotics are usually prescribed

* Compression therapy
* Débridement of wound
* Dressings
* Other

Assessment of the Patient with Leg Ulcers

* History of the condition

* Assess pain, peripheral pulses, edema
* Treatment depends on the type of ulcer
* Assess for presence of infection
* Assess nutrition

Medical Management of the Patient with Leg Ulcers

* Anti-infective therapy depends on the infecting agent

→ Oral antibiotics are usually prescribed

* Compression therapy
* Débridement of wound
* Dressings
* Other

Collaborative Problems and Potential Complications of the Patient with Leg Ulcers

* Infection
* Gangrene
Nursing Interventions for the Patient with Leg Ulcers

* Restoring skin integrity

→ Cleansing wound; positioning; avoiding trauma; avoid heat sources

* Improving physical mobility

→ Physical activity initially restricted to promote healing; gradual progression of

activity
→ Activity to promote blood flow; encourage patient to move about in bed and
exercise upper extremities
→ Diversional activities
→ Analgesic agents before scheduled activities

* Promoting adequate nutrition

→ Protein; Vitamins C and A; Iron; Zinc

Varicose Veins

* Prevention

→ Avoid activities that cause venous stasis (wearing socks that are too tight at the top
or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for
long periods)
→ Elevate the legs 3 to 6 inches higher than heart level
→ Encourage to walk 30 minutes each day if there are no contraindications
→ Wear graduated compression stockings
→ Querweight patients should begin weight reduction plans

Varicose Veins

* Prevention

→ Avoid activities that cause venous stasis (wearing socks that are too tight at the top
or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for
long periods)
→ Elevate the legs 3 to 6 inches higher than heart level
→ Encourage to walk 30 minutes each day if there are no contraindications
→ Wear graduated compression stockings
→ Overweight patients should be encouraged to begin weight reduction plans
Lymphatic Disorders

* Lymphangitis: inflammation or infection of the lymphatic channels

* Lymphadenitis: inflammation or infection of the lymph nodes
* Lymphedema: tissue swelling related to obstruction of lymphatic flow

→ Primary: congenital
→ Secondary: acquired obstruction

Question #3

Which of the following is an effective strategy used to promote lymphatic drainage and
prevent edema in clients with lymphedema?

A. Antibiotic therapy for 14 days

B. Constant elevation of the affected extremity
C. Application of heat therapy twice per day
D. Daily exposure to the sun

Cellulitis

* S&S: localized swelling or redness, fever, chills, sweating

* Treat with oral or IV antibiotics based on severity
* Nursing

→ Elevate affected area 3 to 6 inches above heart level

→ Warm, moist packs to site every 2 to 4 hours
→ Educate regarding prevention of recurrence
→ Reinforce education about skin and foot care