Arterial Disorders NCLEX Review

Arterial Disorders "Think of a Dying Garden"

When your patient suffers from arterial disease, blood return is not the issue. Instead, we have a problem with the flow – blood that can’t get down to the area in question. As a result, the surface will look more like a “barren wasteland.” Think of it as a garden: if you can’t transport water and nutrients to the plants (in this case, tissues), everything will dry up and die.

Causes: partial stenosis or complete occlusion (Atherosclerosis)

Reynaud disease
Buerger disease

Signs and symptoms:

Intermittent claudication
Dusky, purplish (grayish-blue) discoloration of feet (dependent)
White/pale (elevated)
Lower back, buttock discomfort
Loss of hair, shiny skin (lower ex)
Low BP on lower ex
Thickened toenails
Ulcers on legs

Deep, pale (common: toes, feet, other skin areas)

Venous refiling (dependent)
Decreased or absent pedal pulse
Numbness, cold, tingling in extremity

Interventions:

Elevate the feet at rest (not at the level of the heart)
Monitor peripheral pulses
Smoking cessation
Administer anticoagulants, vasodilators and anti-platelet medications
Individualized exercise program
Avoid crossing legs
Avoid exposure to cold
NEVER apply direct heat

Procedures:

Percutaneous transluminal angioplasty
Endarterectomy
Amputation

Venous Disorders "It’s About Pooling Blood"

Varicose veins

When your patient has venous insufficiency, what’s going on? It’s not a problem with blood flow, it’s a problem with blood return. When the blood can’t get back up to the heart, it pools in the lower leg.

Causes: Thromboembolism, varicose, chronic venous insufficiency

Signs and symptoms:

Discoloration of the lower extremity, stasis dermatitis
Edema over the tibia
Ulcers
Tenderness in legs
Positive Homan’s sign

Arterial vs. Venous

	Arterial	Venous
Pain	Intermittent claudication	Aching: cramping
Pulse Assessment	Diminished	Normal or diminished
Ulcer	Deep, pale (toes, feet, other skin areas)	Superficial, pink (inner/outer ankle)
Skin	Dependent rubor/dusky red; pallor upon elevation; dry, shiny, skin; cool or cold temperature, mild edema	Thick and tough, brown pigment, cool, may have edema

Risk reduction:

Monitor peripheral pulses
Administer anticoagulants
Management of body weight
Physical exercise
Smoking cessation
Avoid extreme temperatures
SCDs, TED hose
Elevate the legs
Educate patient regarding thrombectomy

Aortic Aneurysm

An aortic aneurysm is an abnormal dilation of the arterial wall caused by localized weakness
and stretching in the medial layer or wall of the aorta.
Located anywhere along the abdominal aorta.
Goal of treatment: limit the progression of the disease by modifying risk factors, controlling
the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture.

Assessment:

Thoracic aneurysm

Pain extending to neck, shoulders, lower back, or abdomen
Syncope
Dyspnea
Increased pulse
Cyanosis
Hoarseness, difficulty swallowing (pressure from the aneurysm)

Abdominal aneurysm

Prominent, pulsating mass in the abdomen, at or above the umbilicus
Systolic bruit over the aorta
Tenderness on deep palpation
Abdominal or lower back pain

Rupturing aneurysm

Severe abdominal or back pain
Lumbar pain radiating to the flank and groin
Hypotension
Increased pulse rate
Signs of shock
Hematoma at flank area

Interventions:

Monitor vital signs.
Obtain information regarding back or abdominal pain
Question the client of the pulsation in the abdomen.
Check peripheral circulation, including pulses, temperature, and color.
Observe for signs of rupture
Note any tenderness over the abdomen.
Monitor for abdominal distention
Nonsurgical interventions
Modify risk factors.
Instruct the client regarding the procedure for monitoring BP.
Regular HCP visits to follow the size of the aneurysm.
Severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent
elevation of BP? notify the HCP immediately.

Instruct the client with an aortic aneurysm to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness.

Venous Thrombosis

Thrombophlebitis: inflammation
Phlebothrombosis: without inflammation
Phlebitis: associated with invasive procedures
Deep vein thrombophlebitis: more serious due to respiratory compromise
Venus stasis, HF, immobility
Hypercoagulability disorders
Injury to the venous wall
Post ortho and abdominal surgery
Pregnancy
Ulcerative colitis
Use of contraceptives
Certain malignancies
Fractures, injuries of the pelvis or lower ext

Risk factors:

Venus stasis, HF, immobility
Hypercoagulability disorders
Injury to the venous wall
Post ortho and abdominal surgery
Pregnancy
Ulcerative colitis
Use of contraceptives
Certain malignancies
Fractures, injuries of the pelvis or lower ext

Phlebitis

Red, warm area radiating up the vein and extremity
Pain
Swelling

Interventions:

Apply warm, moist soaks
Assess for signs of complications such as tissue necrosis, infection, or pulmonary embolus.

Deep Vein Thrombosis

Calf or groin tenderness, pain with/without swelling
Positive Homan’s sign
Warm skin, tender to touch

Interventions:

Bed rest
Leg elevation 10 to 20 minutes every few hours
AVOID using knee gatch or pillow under the knees
Do not massage
Ant embolic stockings (knee-knee, thigh-thigh)
Moist compress (intermittent or continuous)
Monitor for warmth and edema
Measure/record circumference of thighs and calves\
Monitor for shortness of breath and chest pain
Thrombolytic therapy - initiated within 5 days after the onset
Heparin therapy – monitor APTT
warfarin when DVT resolves – monitor PT and INR

Client education:

Hazards of anticoagulation therapy
Recognize bleeding
Avoid constrictive activities
Elevate extremity 10-20 mins every few hours
Progressive exercise program
Inspect legs for edema, measure
Antiembolism stockings
Avoid smoking
Avoid OTC
Medic-Alert bracelet

Embolectomy

Removal of an embolus from an artery, using a catheter. Patch graft may be required to close the artery.

Preoperative Interventions:

Obtain a baseline vascular assessment.
Anticoagulants as prescribed.
Thrombolytics as prescribed.
Place a bed cradle on the bed.
Avoid bumping or jarring the bed.
Maintain the extremity in a slightly dependent position.

Postoperative Interventions:

Assess cardiac, respiratory, and neurological status.
Monitor affected extremity for color, temperature, and pulse.
Assess sensory and motor function of the affected extremity.
Monitor for signs and symptoms of new thrombi or emboli.
Administer oxygen as prescribed.
Monitor pulse oximetry.
Monitor for complications caused by reperfusion of the artery, such as spasms and swelling
of the skeletal muscles.
Monitor for signs of swollen skeletal muscles: as edema, pain on passive movement, poor
capillary refill, numbness, and muscle tenseness.
Maintain bed rest initially, with the client in a semi-Fowler’s position.
Place a bed cradle on the bed.
Check the incision site for bleeding or hematoma.
Administer anticoagulants as prescribed
Monitor laboratory values related to anticoagulant therapy.
Instruct the client to recognize the signs and symptoms of infection and edema.
Instruct the client to avoid prolonged sitting or crossing the legs when sitting.
Instruct the client to elevate the legs when sitting.
Instruct the client to wear antiembolism stockings as prescribed and how to remove and reapply the stockings.
Instruct the client to ambulate daily.
Instruct the client about anticoagulant therapy and the hazards associated with anticoagulants.

Vena Cava Filter and Ligation of Inferior Vena Cava

Insertion of an intracaval filter (umbrella) that partially occludes the inferior vena
cava and traps emboli to prevent pulmonary emboli

Ligation: Suturing or placing clips on the inferior vena cava to prevent pulmonary emboli; done
via abdominal laparotomy

Preoperative Intervention:

D/C anticoagulant (may cause bleeding)

Postoperative interventions:

Administer oxygen as prescribed.
Maintain a semi-Fowler’s position.
Avoid hip flexion.
Provide activity as prescribed.
Check the insertion site for bleeding or hematoma and signs or symptoms of infection.
Assess for peripheral edema.
Maintain antiembolism stockings as prescribed.
Monitor laboratory values related to anticoagulant therapy.
Instruct the client to recognize the signs and symptoms of infection and edema.
Instruct the client to avoid prolonged sitting or crossing the legs when sitting.
Instruct the client to elevate the legs when sitting.
Instruct the client to wear antiembolism stockings as prescribed and how to remove and reapply the stockings.
Instruct the client to ambulate daily.
Instruct the client about anticoagulant therapy and the hazards associated with anticoagulants.