NUR 326_Perfusion_Su23_Student Copy_744171586

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Perfusion & CV Disorders

Assessment of the
Cardiovascular System
 Health history
 Demographic information
 Family/genetic history
 Cultural/social factors
 Risk factors
 Modifiable
 Nonmodifiable
Health History
 Common symptoms
 Chest pain/discomfort
 Pain/discomfort in other areas of the upper body
 SOB/dyspnea
 Peripheral edema, weight gain, abdominal distention
 Palpitations
 Unusual fatigue, dizziness, syncope, change in LOC

Past Health, Family, and
Social History
 Medications
 Nutrition
 Elimination
 Activity, exercise
 Sleep, rest
 Self-perception/self-concept
 Roles and relationships
 Sexuality and reproduction
 Coping and stress tolerance
Physical Assessment of the
Cardiovascular System
 General appearance
 Skin and extremities
 Pulse pressure
 Blood pressure; orthostatic changes
 Arterial pulses
 Jugular venous pulsations
 Heart inspection, palpation, auscultation
 Assessment of other systems

Laboratory Tests
 Cardiac biomarkers
 Substances that are released into the blood when the heart is damaged or stressed.
 Measurements of these biomarkers are used to help diagnose acute coronary syndrome
(ACS) and cardiac ischemia, conditions associated with insufficient blood flow to the
heart.
 Blood chemistry, hematology, coagulation
 Lipid profile
 Brain (B-type) natriuretic peptide
 Levels are higher than normal with heart failure.
 C-reactive protein
 Indicates inflammation
 Homocysteine
 Elevated homocysteine increases risk for dementia, heart disease and
stroke
 Refer to Table 21-4, Especially blood chemistries
Electrocardiography
 12-lead ECG
 Continuous monitoring
 Hardwire
 Telemetry
 Lead systems
 Ambulatory
monitoring
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 Exercise stress test
 Patient walks on treadmill with
intensity progressing according
Cardiac 
to protocols
ECG, V/S, symptoms monitored
Stress  Terminated when target HR is
Testing achieved
 Pharmacologic stress testing
 Vasodilating agents given to
mimic exercise

 Radionuclide imaging:
 Myocardial perfusion imaging
 Positron emission tomography
Diagnostic  Test of ventricular function, wall
Tests 
motion
Computed tomography (CT)
 Magnetic resonance angiography

Echocardiography
 Noninvasive
ultrasound test that is
used to:
 Measure the
ejection fraction
 Examine the size,
shape, and motion
of cardiac structures
 Transthoracic
 Transesophageal

Cardiac
Catheterization
 Invasive procedure used to

diagnose structural and
functional diseases of the heart
and great vessels
 Right heart catheterization
 Pulmonary artery pressure

and oxygen saturations
may be obtained; biopsy of
myocardial tissue may be
obtained
 Left heart catheterization
 Involves use of contrast

agent

Nursing Interventions
Observe cath site for Assess peripheral Evaluate temperature, Screen for arrhythmias
bleeding, hematoma pulses color, and capillary
refill of affected
extremity
Maintain bed rest 2 to 6 Instruct patient to Monitor for contrast- Ensure patient safety
hours report chest pain, induced nephropathy
bleeding

 Central venous pressure
 Pulmonary artery pressure
Hemodynamic  Intra-arterial B/P monitoring
Monitoring  Minimally invasive cardiac output
monitoring devices

Pulmonary Artery Catheter and
Pressure Monitoring System
Assessment and Management of
Patients with Hypertension
Hypertension
High blood pressure
Most common chronic disease among U.S. adults
Dx: SBP > 130 or DBP > 80 for two or more BP

assessments (ATI, p. 233)
Normal Blood Pressure
• Systolic <120 mm Hg and Diastolic <80 mm Hg
Elevated Blood Pressure

• Systolic 120–129 mm Hg and Diastolic <80 mm Hg
Stage 1 hypertension
• Systolic 130–129 mm Hg or Diastolic 80–89 mm Hg
• Systolic >140 mm Hg or Diastolic >90 mm Hg
Classification of Blood Pressure

for Adults Age 18 Years and Older

Normal Blood Pressure
• Systolic <120 mm Hg and Diastolic <80 mm Hg
Elevated Blood Pressure

• Systolic 120–129 mm Hg and Diastolic <80 mm Hg
• Systolic 130–129 mm Hg or Diastolic 80–89 mm Hg What if the SBP & DBP
fall into different
Stage 2 hypertension categories?
• Systolic >140 mm Hg or Diastolic >90 mm Hg
Classification of Blood Pressure

for Adults Age 18 Years and Older

Incidence of
Hypertension—“The
Silent Killer”
Primary/essential Secondary
hypertension hypertension About 33% of the
adult population of
• 90–95% of patients; • 5–10% of patients; renal
unidentifiable cause disease, sleep apnea,
the United States
pregnancy related has hypertension
About 46% do not Highest prevalence

have it under control in African Americans

Manifestations of Hypertension
May have few or no symptoms other than elevated blood pressure
• Headache (particularly in AM)
• Facial flushing
• Dizziness
• Fainting
• Visual disturbances
• Nocturia
Symptoms related to organ damage are seen late and are serious
• Retinal and other eye changes
• Renal damage
• Myocardial infarction
• Cardiac hypertrophy
• Stroke
Pathophysiologic Processes
Can result from increases in cardiac output, peripheral
resistance, or both
May also be a problem with the body’s control system
Dysfunction of the autonomic nervous system
Increased renin–angiotensin–aldosterone system
Resistance to insulin action
Activation of the immune system

Alternative Manifestations
 Masked hypertension
 Blood pressure that is suggestive of hypertension that is
paradoxically normal in health care settings
 White coat hypertension

 Hypertensive blood pressure readings in the health care
setting that is paradoxically normal ranges in other
settings

 Smoking
 Obesity
 Decreased physical activity
 Hyperlipidemia
 Diabetes mellitus
Major Risk  Microalbuminuria or GFR <60 mL/min
Factors  Older age (60+ or postmenopausal)
 Positive family history
 Stress
 African American
 High alcohol consumptions
 Excessive sodium intake

 Kidney disease
 Cushing’s disease
Risk  Primary aldosteronism
Factors:  Pheochromocytoma
Secondary  Brain tumors, encephalitis
HTN  Medications
 Pregnancy

Patient Assessment
History and physical Retinal exam

examination
Urinalysis (BUN, Creatinine)

Laboratory tests Blood chemistry (blood corticoids, blood
glucose, cholesterol studies)
ECG
Chest X-ray
Abnormal Physical
Examination Findings
 Additional cardiac sounds
 Retinal hemorrhages (EOD)
 Distended jugular veins
 Renal artery bruit (EOD)
 Facial flushing

 Maintain blood pressure (“controlled”)
 <130/80 mm Hg
 Lifestyle modifications
 Weight reduction
Medical
 DASH diet, decreased sodium intake (<2.3g)
Management
 Regular physical activity (2-3x/wk)
 Reduced alcohol consumption
 Smoking cessation
 Stress reduction

 Pharmacologic therapy
 Decrease peripheral resistance, blood
volume
Medical  Decrease strength and rate of myocardial

contraction
Management
 Diuretics, beta-blockers, alpha1-blockers,
combined alpha- and beta-blockers,
vasodilators, ACE inhibitors, ARBs,
calcium channel blockers,
dihydropyridines, and direct renin
inhibitors

Medication Treatment
 Stage I hypertension:
 African American and patients >60 years: calcium
channel blocker or thiazide diuretic
 Non African American and patients <60 years: ACE-I or

ARB
 Low doses are initiated, and the medication dosage is

increased gradually if blood pressure does not reach
target goal (<130/80)
 Multiple medications may be needed to control blood

pressure

Assessment
 History and risk factors
 Assess potential symptoms of target organ damage

 Angina, shortness of breath, altered speech, altered
vision, nosebleeds, headaches, dizziness, balance
problems, nocturia
 Cardiovascular assessment: apical and peripheral pulses
 Personal, social, and financial factors that will influence

the condition or its treatment

Collaborative Problems and
Potential Complications
 Left ventricular hypertrophy
 Myocardial infarction
 Heart failure
 Transient ischemic attack (TIA)
 Cerebrovascular disease (CVA, stroke, or brain

attack)
 Renal insufficiency and chronic kidney disease
 Retinal hemorrhage
Planning and Goals
Understanding of the disease process

and its treatment
Participation in a self-care program
Absence of complications

Interventions
Discuss with pt factors that increase risk of HTN & how to manage them
Support and educate the patient about the treatment regimen
Reinforce and support lifestyle changes
Administer medications as prescribed
Follow-up care
Monitoring for potential complications
Monitor blood pressure and other VS
Monitor labs (kidney function, triglycerides, Na, K+)

Evaluation and Outcomes
 Reports knowledge of disease management sufficient to

maintain adequate tissue perfusion
 Maintains blood pressure at less than 130/80 mm Hg with
lifestyle modifications, medications, or both
 Demonstrates no symptoms of angina, palpitations, or vision

changes
 Has stable BUN and serum creatinine levels
 Has palpable peripheral pulses

 Effectively manages health program

 Adheres to the dietary regimen as prescribed: reduces calorie,
sodium, and fat intake; increases fruit and vegetable intake
 Exercises regularly
 Takes medications as prescribed and reports side effects
 Measures BP routinely
 Abstains from tobacco and excessive alcohol intake
 Keeps follow‐up appointments

 Has no complications
 Reports no changes in vision; exhibits no retinal damage on vision
testing
 Maintains pulse rate and rhythm and respiratory rate within normal
ranges; reports no dyspnea or edema
 Maintains urine output consistent with intake; has renal function test
results within normal range
 Demonstrates no motor, speech, or sensory deficits
 Reports no headaches, dizziness, weakness, changes in gait, or falls

 Medication regimen can be difficult to remember
 Expense can be a challenge
 Monotherapy, if appropriate, may simplify the medication regimen

and make it less expensive
 Ensure that older adult patients understand the regimen and can see
and read instructions, open medication containers, and get
prescriptions refilled
 Include family and caregivers in educational program
Gerontologic Considerations

Question
The nurse is preparing an education plan for a patient

newly diagnosed with hypertension. Which of the following
should be included in the education plan?
A. Engage in regular aerobic physical activity such as brisk
walking (at least 30 min/day most days of the week)
B. Eliminate alcoholic beverages from the diet
C. Reduce sodium intake to no more than 2 g/day
D. Maintain a normal body weight with BMI between 18
and 30 kg/m2
Answer to Question
A. Engage in regular aerobic physical activity such as brisk
walking (at least 30 min/day most days of the week).
Rationale: The nurse assists the patient to develop and

adhere to an appropriate exercise regimen (as described
above), because regular activity is a significant factor in
reducing blood pressure. Alcoholic beverages can be
consumed in moderation. Sodium should be reduced to no
more than 2.3g/day, and the patient should maintain a
normal body weight with a BMI between 18.5 and 24.9
kg/m2
 Often occurs when clients do not follow
the HTN medication therapy regimen
 Hypertensive urgency
Hypertensive  Blood pressure >180/120 mm Hg but no
Crises evidence of immediate or progressive
target organ damage
 Hypertensive emergency
 Blood pressure >180/120 mm Hg and
must be lowered immediately to prevent
further damage to target organs

Hypertensive
Crises
 Manifestations:
 Severe headache
 Extremely high BP
 Blurred vision
 Dizziness
 Disorientation
 Epistaxis

Nursing Actions
 Recognize manifestations
 Administer IV antihypertensive therapies
 Monitor BP q5-15 minutes before, during, and after crisis
 Assess neurologic status
 Monitor for cerebrovascular change
 Monitor ECG to assess cardiac status

Management: Hypertensive
Urgency
 Oral agents can be administered with the goal of
normalizing blood pressure within 24 to 48 hours
 Fast-acting oral agents:
 Beta-adrenergic blocker—labetalol
 Angiotensin-converting enzyme inhibitor—captopril
 Alpha2-agonist—clonidine
 Patient requires close monitoring of blood pressure and
cardiovascular status
 Assess for potential evidence of target organ damage

Management: Hypertensive
Emergency
Reduce blood pressure by 20-25% in first hour (not below 140/90)
Reduce to 160/100 mm Hg within 2 to 6 hours
Then gradual reduction to normal 24 to 48 hours of treatment

• Exceptions are ischemic stroke and aortic dissection
Medications
• IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate,
enalaprilat, nitroglycerin
Need very frequent monitoring of BP and cardiovascular status
Question
Which of the following is a

priority nursing assessment
when caring for the
patient in a hypertensive
crisis receiving intravenous
vasodilators?
A. Pain
B. I&O
C. Vision
D. Family history

Answer to Question
B. I&O
Rationale: Assessing the individual’s fluid volume status is

recommended because if there is volume depletion
secondary to natriuresis caused by the elevated blood
pressure, then volume replacement with normal saline can
prevent large sudden drops in blood pressure when
antihypertensive medications are administered.
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
 Cardiovascular disease is the leading cause of death in the
United States for men and women of all racial and ethnic groups
 Goal: Improve blood flow to the heart, avoid vasoconstriction

Pathophysiology of
Atherosclerosis
The Coronary Arteries
Clinical Manifestations of
Atherosclerosis
 Symptoms are caused by myocardial ischemia
 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
 Diabetes
 High total cholesterol
 Elevated LDL (primary target for cholesterol-lowering medication)
 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

Angina
Insufficient cardiac blood flow; oxygen demand is greater than supply
Stable (exertional) angina

• Occurs with exercise and is relieved by rest or nitroglycerine
Unstable (preinfarction) angina

• Occurs with exercise or rest, but increases in occurrence, severity, and
duration over time
Variant (Prinzmetal’s) angina
• Due to coronary artery spasm, often occurring during periods of rest
Assessment and Findings for
Angina
 May be described as tightness, choking, or a heavy/pressure sensation
 Frequently retrosternal and may radiate to neck, jaw, shoulders, back
or arms (usually left)
 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!
 Pain unrelieved by rest or NTG and lasting more than 15 min
differentiates angina from MI (ATI, p. 199).
PQRST Textbook p. 735

Mr. Simpson
• Instructed to place one nitroglycerin tablet under his tongue when

experiencing chest pain/angina. He should have the medication
with him at all times.
• May take tablets, 5 minutes apart, up to three doses.
• If the pain persists, emergency transfer to the nearest level
trauma facility is encouraged.
• Mr. Simpson should be advised that he may take the medication
prior to an activity that is known to produce chest pain.
• The nitroglycerin is environmentally sensitive so it should be
stored in its original container and replaced every 6 months.

for Angina
 Diminished pain transition that occurs with aging may affect
presentation of symptoms
 “Silent” CAD
 Increased risk of CAD for older adults who are physically inactive, have
one or more chronic diseases, or have lifestyle habits contributing to
atherosclerosis
 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
 Rest
 Medications
 Oxygen
 Reduce and control risk factors
 Reperfusion therapy may also be done
 Managing at home: Chart 23-5

Medications for Angina
Vasodilators Analgesics Beta-adrenergic

• Nitroglycerin • Morphine sulfate blocking agents
• Metoprolol
Thrombolytic Antiplatelet
Calcium channel medications agents
blocking agents • Aleteplase and • Aspirin
reteplase • Clopidogrel
Anticoagulant Glycoprotein
agents IIb/IIIa agents
• Heparin • Eptifibatide
• Enoxaparin

Chapter 26
Assessment and Management of Patients with
Vascular Disorders and Problems of Peripheral
Circulation
Vascular System
 Consists of two interdependent systems
 Right side of the heart pumps blood through the lungs to the pulmonary
circulation
 Left side of the heart pumps blood to all other body tissues through the
systemic circulation
 Arteries and arterioles
 Capillaries
 Veins and venules
For vascular diseases, you
 Lymphatic vessels want to increase vasodilation
and decrease
vasoconstriction.
Help the blood get where it

needs to go. Use gravity.
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

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 Increased left
Impaired blood flow
resistance 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)

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
Photograph courtesy of Kim Cantwell-Gab, MN, ACNP, ANP.

Assessment of the Patient with Peripheral
Vascular Problems
 Health history
 Medications
 Risk factors
 HTN, Hyperlipidemia, DM, smoking, obesity, sedentary lifestyle, familial disposition,
female, age > 65, elevated CRP, hyperhomocysteinemia
 Signs and symptoms of arterial insufficiency
 Claudication (burning, cramping, and pain in legs during exercise)
 Rest pain
 Capillary refill in toes > 3 sec
 Color changes
 Cold and cyanotic extremity
 Pallor of extremity w/ elevation
 Dependent redness of extremity
 Weak or absent pulses
 Skin changes and skin breakdown
 Loss of hair in lower calf, ankle, and foot
 Dry, scaly, mottled skin
 Thick toenails
 Ulcers and possible gangrene of toes
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—body part below the level of the heart
 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
 Arteriosclerosis and atherosclerosis
 Peripheral artery disease
 Upper extremity arterial disease
 Aortoiliac disease
Arterial  Aneurysms (thoracic, abdominal, other)
Disorders  Aortic dissection
 Arterial embolism and arterial
thrombosis
 Raynaud’s phenomenon and other
acrosyndromes

Arteriosclerosis and
Atherosclerosis
 Arteriosclerosis
 Hardening of the arteries
 Diffuse process whereby the muscle fibers and the endothelial lining
of the walls of small arteries and arterioles become thickened
 Atherosclerosis
 Type of arteriosclerosis (ATI, p. 223)
 Different process, affecting the intima of large and medium-sized
arteries
 Accumulation of lipids, calcium, blood components, carbohydrates,
and fibrous tissue on the intimal layer of the artery
 Atheromas or plaques

Progression of Atherosclerosis
Risk Factors for Atherosclerosis and PAD
Modifiable Nonmodifiable
  Increasing age
Nicotine use
  Familial
Diabetes
predisposition/genetics
 Hypertension
 Hyperlipidemia
 Diet
 Stress
 Sedentary lifestyle
 C-reactive protein
Peripheral Artery Disease (PAD)
 Tissue damage occurs below arterial obstruction (distal to occlusion)
 Characterized by inadequate blood flow away from the heart.
 Hallmark symptom is intermittent claudication described as aching,
cramping, or inducing fatigue or weakness
 Occurs with some degree of exercise or activity
 Relieved with rest
 Pain is associated with critical ischemia of the distal extremity and is
described as persistent, aching, or boring (rest pain)
 Ischemic rest pain is usually worse at night and often wakes the patient
 Examples of PAD:
 Buerger’s disease, subclavian steal syndrome, thoracic outlet
syndrome, Raynaud’s disease, and popliteal entrapment

Common Sites of
Atherosclerotic Obstruction
 Phosphodiesterase III inhibitor
 Cilostazol
Pharmacologic  Antiplatelet agents

Therapy for PAD  Aspirin
 Clopidogrel
 Statins

Nursing Actions for PAD
 Encourage client to exercise to build up collateral circulation

 Promote vasodilation and avoid vasoconstriction
• Provide warm environment
 Never apply direct heat, such as a heating pad, to the extremity
• Wear insulated socks
• Avoid exposure to cold
• Avoid stress, caffeine, and nicotine
 Promote proper positioning
 Avoid crossing legs
 Refrain from wearing restrictive garments
 Elevate legs to reduce swelling (not above level of heart)
Question
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 above the heart
B. Exercise is discouraged
C. Keep the lower extremities in a neutral or dependent
position
D. PAD should not cause pain
Answer to Question
C. Keep the lower extremities in a neutral or dependent
position
Rationale: For patients with PAD, blood flow to the lower
extremities needs to be enhanced; therefore, the nurse
encourages keeping the lower extremities in a neutral or
dependent position. In contrast, for patients with venous
insufficiency, blood return to the heart needs to be
enhanced, so the lower extremities are elevated. Exercise
can be prescribed to aid in the development of collateral
circulation. Some pain is associated with PAD.
Peripheral Venous Disorders
 Venous thromboembolism (VTE) condition
 DVT
 Thrombophlebitis
 PE
 Chronic venous insufficiency/post-thrombotic
syndrome
 Leg ulcers
 Varicose veins
Problems with the veins that interfere with adequate return of

blood flow from the extremities to the heart. Can result in stasis.
How would positioning for venous insufficiency
differ from arterial insufficiency?
HELP GET BLOOD WHERE IT NEEDS TO GO by
elevating lower extremities.
vs
Venous Thromboembolism
Pathophysiology
• Associated with Virchow’s triad
Risk factors
• Hip surgery, total knee replacement, open prostate surgery

• Heart failure
• Immobility (such as post-op)
• Pregnancy
• OCP
• Active cancer
• Ulcerative colitis
• CVLs and dialysis catheters
• Factor V Leiden defect
Endothelial damage
• Venous stasis
• Altered coagulation
Manifestations
• Deep veins
• Superficial veins

Assessment findings:
 May be asymptomatic
 Calf or groin pain, tenderness, and sudden onset of edema of the
extremity
 Warmth, edema, and induration and hardness over involved blood
vessel
 Changes in circumferences of right and left calf and thigh over time
 Localized edema over affected area
 SOB and chest pain may indicate embolus has moved to the lungs
Nursing Care
 Encourage early ambulation following initiation of anticoagulant therapy
 Encourage dorsiflexion and plantarflexion exercises while in bed
 Occasionally elevate legs above level of heart
 Administer anticoagulant therapy as prescribed
 IV Unfractionated Heparain
 SQ Heparin or LMWH
 Warfarin
 Factor Xa Inhibitors
 Direct Thrombin Inhibitors
 Do not massage affected limb
 Provide compression or anti-embolism stockings
 Prepare client for inferior vena cava filter
Medical Management
 Medications
Venous  Anticoagulants
Thromboembolism
 Thromboembolic therapy
 Inferior Vena Cava Filter

 Early ambulation and leg exercises
 Graduated compression stockings
 Intermittent pneumatic compression
devices
Preventive  Subcutaneous heparin or LMWH
Measures  Lifestyle changes
 Weight loss
 Smoking cessation
 Regular exercise

Question
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
Answer to Question
B. A 25-year-old patient with a central venous catheter in
place to treat septicemia
Rationale: Some risk factors for venous thromboembolism
include but are not limited to age older than 65 years,
patients undergoing surgery, central venous catheter
placement, septicemia, and pregnancy. The client in this
question with two risk factors is the 25-year-old with a
central venous catheter in place to treat septicemia. All
other patients only have one risk factor.
Chronic Venous Insufficiency
 Occurs secondary to incompetent valves in the deeper veins of LE
 Allows pooling of blood and dilation of veins
 Veins unable to carry fluid and wastes from LE leads to:
 Swelling
 Venous Stasis Ulcers
 Cellulitis (in advanced cases)
Risk Factors
 Periods of prolonged venous hypertension → damage to valve → backup of
blood, edema, damage to deep tissue
 Sitting or standing in one position for long period of time
 Obesity
 Pregnancy
 Thrombophlebitis
Assessment Findings:
 Limbic pain
 Stasis dermatitis
 Edema
Chronic  Stasis ulcers
Venous
Nursing Care:
Insufficiency  Elevate legs for at least 20 min (4-5x/day)
 Elevate legs above heart while in bed
 Educate pt to avoid crossing legs
 Apply compression stockings
 Educate pt to apply after legs have
been elevated and swelling as at
minimum

 Often form over medial malleolus
 Chronic
Venous  Difficult to heal
Stasis  Often recurrent
Ulcers  Can lead to amputation or death
 Neuropathy → discomfort
disproportionate to ulcer severity

Assessment of the Patient with Venus Stasis Ulcers
 History of the condition
 Assess pain, peripheral pulses, edema
 Treatment depends on the type of ulcer
 Assess for presence of infection
 Assess nutrition
Collaborative Problems and Potential
Complications of the Patient with Leg Ulcers
 Infection
 Gangrene
 Anti-infective therapy depends on the
infecting agent
Medical  Oral antibiotics are usually prescribed
Management  Compression therapy
of the  Débridement of wound

 Dressings
Patient with  Long-term management
Leg Ulcers  Dietician
 Would care specialist

Nursing Care: Venous Stasis Ulcers
 Administer and assist with tx to improve circulation
 Wound vac
 Hyperbaric chamber
 Assess and treat pain PRN
 Apply oxygen-permeable polyethylene films to superficial ulcers
 Apply occlusive hydrocolloid dressings to deeper ulcers
 Promote granulation and re-epithelialization
 Leave a dressing on 3-7 days
 Apply chemical debridement agents as prescribed
 Topical enzymatic agents to: debride ulcer, eliminate necrotic
tissue, & promote healing
 Administer abx as prescribed
 Prepare for oxygen therapy

Nursing Care: Venous Stasis
Ulcers, Cont.
 Obtain ABG as ordered
 Assess for complications
 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
 Enlarged, twisted, and
superficial veins
 Can occur in any part of body
 Commonly in LE and in
esophagus
Risk Factors:
 Female
 Age > 30 yr and in occupation
requiring prolonged standing
 Pregnancy
 Obesity
 Heart disease
 Family history

Varicose Veins
Assessment Findings:
 Distended, superficial veins visible just below skin
 Tortuous in nature
 Client reports:
 Muscle cramping and aches
 Pain after sitting
 Pruritis
Therapeutic Procedures (ATI, p. 229):
 Sclerotherapy
 Vein Stripping
 Endovenous laser treatment
 Radio frequency energy
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
 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
10
minute
break
Case Studies
• Divide into groups of 5-6
• Complete the study guide assigned to your group
• Include names of group members
• Use textbooks, notes, internet, etc.
• Type answers in a fun color
• Submit case and answers to discussion board when finished
• 6 Cases Total – Reference DB when studying

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Perfusion & CV Disorders

 Pain/discomfort in other areas of the upper body

 Peripheral edema, weight gain, abdominal distention

 Unusual fatigue, dizziness, syncope, change in LOC

 Skin and extremities

 Blood pressure; orthostatic changes

 Jugular venous pulsations

 Heart inspection, palpation, auscultation

 Assessment of other systems

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 Invasive procedure used to

 Right heart catheterization

 Pulmonary artery pressure

 Left heart catheterization

 Involves use of contrast

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High blood pressure

Most common chronic disease among U.S. adults

Dx: SBP > 130 or DBP > 80 for two or more BP

Elevated Blood Pressure

Classification of Blood Pressure

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Elevated Blood Pressure

Classification of Blood Pressure

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About 46% do not Highest prevalence

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Dysfunction of the autonomic nervous system

Increased renin–angiotensin–aldosterone system

Resistance to insulin action

Activation of the immune system

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 White coat hypertension

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 Decreased physical activity

 Positive family history

 High alcohol consumptions

 Excessive sodium intake

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History and physical Retinal exam

Urinalysis (BUN, Creatinine)

 Retinal hemorrhages (EOD)

 Distended jugular veins

 Renal artery bruit (EOD)

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 Reduced alcohol consumption

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Medical  Decrease strength and rate of myocardial

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 Non African American and patients <60 years: ACE-I or

 Low doses are initiated, and the medication dosage is

 Multiple medications may be needed to control blood

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 Assess potential symptoms of target organ damage

 Cardiovascular assessment: apical and peripheral pulses

 Personal, social, and financial factors that will influence

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 Transient ischemic attack (TIA)