Lewis: Medical-Surgical Nursing, 9

th
Edition
Chapter 38
Nursing Management: Vascular Disorders
KEY POIN!
PE"IP#E"$% $"E"Y DI!E$!E
Peripheral artery disease (PAD) is a progressive narrowing and degeneration of the
arteries of the upper and lower extremities. In most ases! it is a result of atheroslerosis.
"ignifiant ris# fators for PAD are to$ao use (most important)! h%perlipidemia!
elevated high&sensitivit% '&reative protein! dia$etes! and unontrolled h%pertension.
PE"IP#E"$% $"E"Y DI!E$!E O& #E %O'E" E("EMIIE!
PAD of the lower extremities affets the aortoilia! femoral! popliteal! ti$ial! or peroneal
arteries.
(he severit% of linial manifestations depends on the site and extent of $lo#age and the
amount of ollateral irulation.
o (he lassi s%mptom of PAD of the lower extremities is intermittent laudiation.
)ther s%mptoms inlude paresthesia! num$ness or tingling in the toes or feet! rest
pain! and the loss of $oth pressure and deep pain sensations.
o Ph%sial findings inlude thin! shin%! and taut s#in with loss of hair on the lower
legs* diminished or a$sent pedal! popliteal! or femoral pulses* elevation pallor*
and reative h%peremia when the lim$ is in a dependent position.
'ompliations of PAD inlude nonhealing ulers over $on% prominenes on the toes!
feet! and lower leg! and gangrene. Amputation ma% $e re+uired if $lood flow is not
restored.
,arious tests are used to diagnose PAD! inluding Doppler ultrasound with segmental
$lood pressures! alulating the an#le&$rahial index (A-I)! and angiograph%.
(he overall goals for the patient with lower&extremit% PAD inlude ade+uate tissue
perfusion! relief of pain! inreased exerise tolerane! and intat! health% s#in on
extremities.
o (he first treatment goal for patients with PAD is to aggressivel% modif% all
ardiovasular ris# fators. All to$ao use must $e stopped.
o Drug therap% inludes statins! antiplatelet agents! and angiotensin&onverting
en.%me (A'E) inhi$itors. (wo drugs approved to treat intermittent laudiation
are ilosta.ol (Pletal) and pentoxif%lline ((rental).
o (he primar% nondrug treatment for laudiation is to$ao essation and a formal
exerise&training program! with wal#ing $eing the most effetive exerise.
o Interventional radiologi proedures for PAD inlude perutaneous transluminal
$alloon angioplast% with stenting or atheretom%.
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Key Points 38-2
o (he most ommon surgial proedure for PAD is a peripheral arterial $%pass
operation with autogenous vein or s%ntheti graft material to $%pass or arr%
$lood around the lesion.
o All patients with PAD should $e taught the importane of metiulous foot are.
Critical limb ischemia is a hroni ondition harateri.ed $% ishemi rest pain! arterial
leg ulers! and5or gangrene of the leg aused $% advaned PAD.
$C)E $"E"I$% I!C#EMIC DI!O"DE"!
Acute arterial ischemia is a sudden interruption in the arterial $lood suppl% to a tissue!
organ! or extremit% that! if untreated! results in tissue death.
'ommon auses inlude em$olism! throm$osis! or trauma.
"peifi manifestations depend on the area affeted of the $od%. "igns and s%mptoms of
an aute arterial ishemia usuall% have an a$rupt onset and inlude the 6six Ps7: pain!
pallor! pulselessness! paresthesia! paral%sis! and poi#ilothermia.
(reatment options inlude antioagulation! throm$ol%sis! em$oletom%! surgial
revasulari.ation! or amputation.
#"OM*O$N+III! O*%IE"$N!
Thromboangiitis obliterans (-uerger8s disease) is a rare nonatherosleroti! segmental!
reurrent inflammator% disorder of the small and medium&si.ed arteries! veins! and
nerves of the upper and lower extremities.
Patients ma% have intermittent laudiation of the feet! hands! or arms. As the disease
progresses! rest pain and ishemi ulerations develop.
(here are no la$orator% or diagnosti tests speifi to -uerger8s disease.
(reatment inludes omplete essation of to$ao use in ever% form. 'onservative
management inludes the use of anti$iotis to treat an% infeted ulers and analgesis to
manage the ishemi pain.
"urgial options inlude revasulari.ation! implantation of a spinal ord stimulator! and
s%mpathetom%.
"$YN$)D,! P#ENOMENON
Raynauds phenomenon is an episodi vasospasti disorder of small utaneous arteries!
most fre+uentl% involving the fingers and toes. (he exat etiolog% is un#nown.
'linial s%mptoms inlude vasospasm&indued olor hanges of the fingers! toes! ears!
and nose (white! $lue! and red). An episode usuall% lasts onl% minutes $ut in severe ases
ma% persist for several hours.
"%mptoms usuall% are preipitated $% exposure to old! emotional upsets! affeine! and
to$ao use.
Diagnosis is $ased on persistent s%mptoms for at least 0 %ears. (here is no diagnosti test.
Patient teahing should $e direted toward prevention of reurrent episodes. (emperature
extremes and all to$ao produts should $e avoided.
'alium hannel $lo#ers are the first&line drug therap%.
$O"IC $NE)"Y!M!
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Key Points 38-3
Aortic aneurysms are outpouhings or dilations of the arterial wall.
(he primar% auses of aorti aneur%sms an $e lassified as degenerative! ongenital!
mehanial! inflammator%! or infetious.
Aorti aneur%sms ma% involve the aorti arh and thorai aorta. 4ost are found in the
a$dominal aorta $elow the level of the renal arteries.
o (horai aorta aneur%sms are often as%mptomati. (he most ommon
manifestations are deep! diffuse hest pain that ma% extend to the intersapular
area* hoarseness* and d%sphagia.
o A$dominal aorti aneur%sms (AAAs) are often as%mptomati! $ut s%mptoms ma%
mimi pain assoiated with a$dominal or $a# disorders.
(he most serious ompliation related to an untreated aneur%sm is rupture and $leeding.
Diagnosti tests for AAAs inlude hest x&ra%! eletroardiogram (to rule out m%oardial
infartion)! ehoardiograph%! omputed tomograph% ('() san! and magneti resonane
imaging (49I) san.
(he goal of management is to prevent the aneur%sm from rupturing.
o "urgial repair therap% is done for aneur%sms greater that are than : m in si.e!
are rapidl% expanding or have a high ris# for rupture! and in those patients who
are s%mptomati.
o 4inimall% invasive endovasular aneur%sm repair is an alternative to
onventional surgial repair and involves the plaement of a sutureless aorti graft
into the a$dominal aorta inside the aneur%sm.
(he overall goals for a patient undergoing aorti surger% inlude normal tissue perfusion!
intat motor and sensor% funtion! and no ompliations related to surgial repair! suh as
throm$osis or infetion.
o Postoperativel%! the patient t%piall% re+uires lose monitoring in an I'; setting.
o 4onitoring for graft paten% and ade+uate renal perfusion are priorities.
4aintenane of an ade+uate $lood pressure (-P) is extremel% important.
o Anti$iotis are given to prevent infetion.
o Peripheral pulses! s#in temperature and olor! apillar% refill time! and sensation
and movement of the extremities are assessed and reorded per hospital poli%.
o <ourl% urine outputs and dail% weights are reorded.
)n disharge! teah the patient to graduall% inrease ativities $ut to avoid heav% lifting
for = wee#s.
$O"IC DI!!ECION
Aortic dissection is the result of a tear in the intimal (innermost) lining of the arterial
wall! reating a false lumen through whih $lood flows.
Degeneration of the elasti fi$ers in the medial la%er and hroni h%pertension are the
most li#el% auses of aorti dissetion.
Patients with an aute asending aorti dissetion report sudden! severe onset of
exruiating hest and5or $a# pain radiating to the ne# or shoulders.

Patients with aute
desending aorti dissetion are more li#el% to report pain in their $a#! a$domen! or legs
and desri$e the pain as 6sharp7 and 6worst ever7 followed less fre+uentl% $% 6tearing7
or 6ripping.7
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Key Points 38-4
Diagnosti studies used to assess aorti dissetion are similar to those performed for
AAA.
(he initial goal of therap% for aorti dissetion without ompliations is to lower the heart
rate and -P and manage pain.
"urger% is indiated when drug therap% is ineffetive or when ompliations of aorti
dissetion are present.
VENO)! #"OM*O!I!
Phlebitis is the inflammation of the walls of the small! annulated veins of the hand or
arm and presents with two or more of the following s%mptoms: pain! tenderness! warmth!
er%thema! swelling! and a palpa$le ord.
Venous thrombosis is the most ommon disorder of the veins and involves the formation
of a throm$us (lot) in assoiation with inflammation of the vein. Venous
thromboembolism (,(E) represents the spetrum of patholog% from deep vein
throm$osis (D,() to pulmonar% em$olus.
D,( involves a throm$us in a deep vein! most ommonl% the ilia and femoral veins! and
an result in em$oli.ation of throm$i to the lungs.
(hree important fators (alled Virchos triad) in the etiolog% of venous throm$osis are
(2) venous stasis! (0) damage of the endothelium! and (>) h%peroagula$ilit% of the $lood.
Super!icial "enous thrombosis (",() involves a throm$us in a superfiial vein!
presenting as a palpa$le! firm! su$utaneous ordli#e vein. (he surrounding area ma% $e
tender to the touh! reddened! and warm. A mild s%stemi temperature elevation and
leu#o%tosis ma% $e present.
o (reatment for lower leg ",( onsists of low&moleular&weight heparin (L4?<)
for 3: da%s or a proph%lati dose of fondaparinux (Arixtra).
o Elasti ompression sto#ings! oral and topial nonsteroidal antiinflammator%
drugs! and exerise suh as wal#ing are also reommended for s%mptom relief.
(he patient with lower extremit% ,(E ma% or ma% not have unilateral leg edema! pain!
tenderness with palpation! dilated superfiial veins! a sense of fullness in the thigh or alf!
paresthesias! warm s#in! er%thema! and5or a s%stemi temperature greater than 211.3 @
(>A ').
(he most serious ompliations of ,(E are PE! post&throm$oti s%ndrome (P(")! and
phlegmasia erulea dolens.
o Post-thrombotic syndrome (P(") results from hroni venous h%pertension aused
$% valvular destrution! stiff nonompliant vein walls! and persistent venous
o$strution.
o "%mptoms inlude pain! ahing! heaviness! swelling! ramps! ithing! and
tingling. 'linial signs inlude persistent edema! inreased pigmentation! e.ema!
seondar% variosities! and lipodermatoslerosis.
,(E proph%laxis for hospitali.ed patients depends on individual patient ris# and ma%
involve earl% am$ulation! elasti ompression sto#ings! se+uential ompression devies!
and antioagulation.
(he goals in the treatment of ,(E are to prevent propagation of the lot! development of
an% new throm$i! and em$oli.ation. Antioagulation therap% is routinel% used.
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Key Points 38-5
(hree maBor lasses of antioagulants are availa$le: (2) vitamin C antagonists! (0)
throm$in inhi$itors (diret and indiret)! and (>) fator Da inhi$itors! suh as
fondaparinux.
o ?arfarin! a vitamin C antagonist, inhi$its ativation of the vitamin CEdependent
oagulation fators.
o Indiret throm$in inhi$itors inlude unfrationated heparin (;<) and low&
moleular&weight heparin (L4?<).
o Diret throm$in inhi$itors inlude lepirudin (9efludan) and $ivalirudin
(Angiomax) and are administered $% ontinuous I, infusion.
"ome ,(E patients re+uire surgial therap%! inluding throm$etom% and plaement of
vena ava interruption devies! suh as the Freenfield filter.
Gursing diagnoses and olla$orative pro$lems for the patient with ,(E revolve around
the pro$lems of aute pain! ineffetive health maintenane! ris# for impaired s#in
integrit%! and the potential ompliations of $leeding related to antioagulant therap% and
pulmonar% em$olism.
(he overall goals for the patient with ,(E inlude pain relief! dereased edema! no s#in
uleration! no $leeding ompliations! and no evidene of pulmonar% em$oli.
Disharge teahing should fous on elimination of modifia$le ris# fators for ,(E! the
importane of elasti ompression sto#ings and monitoring of la$orator% values!
mediation instrutions! and guidelines for follow&up.
V$"ICO!E VEIN!
Varicose "eins! or variosities! are dilated! tortuous su$utaneous veins most fre+uentl%
found in the saphenous s%stem.
(he etiolog% of variose veins is un#nown! and ris# fators inlude ongenital wea#ness
of the vein struture! female gender! use of hormones (oral ontraeptives or <()!
inreasing age! o$esit%! pregnan%! venous o$strution resulting from throm$osis or
extrinsi pressure $% tumors! or oupations that re+uire prolonged standing.
(he most ommon s%mptom is an ahe or pain after prolonged standing! whih is
relieved $% wal#ing or $% elevating the lim$. Goturnal leg ramps in the alf ma% our.
'olla$orative are involves rest with the affeted lim$ elevated! ompression sto#ings!
and exerise! suh as wal#ing.
A num$er of treatment options exist! inluding slerotherap%! laser therap%! high&intensit%
pulsed&light therap%! and surgial proedures! suh as phle$etom% and vein ligation.
(reatment is optional if variose veins are onl% a osmeti pro$lem.
Prevention is a #e% fator related to variose veins. (eah the patient measures to
promote venous irulation.
C#"ONIC VENO)! IN!)&&ICIENCY $ND VENO)! %E+ )%CE"!
Chronic "enous insu!!iciency (',I)! a ommon medial pro$lem in women and older
adults! results in inreased am$ulator% venous h%pertension.
',I an result from long&standing variose veins or post&throm$oti s%ndrome and an
lead to venous leg ulers.
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Key Points 38-6
'linial manifestations inlude the s#in of the lower leg appearing leather%! with a
harateristi $rownish or 6$rawn%7 appearane! edema and e.ema! and pruritus.
,enous ulers lassiall% are loated a$ove the medial malleolus. (he wound margins are
irregularl% shaped! and the tissue is t%piall% a rudd% olor. ;ler drainage ma% $e
extensive. Pain is present and ma% $e worse when the leg is in a dependent position.
'ompression is essential to the management of ',I! venous uler healing! and
prevention of uler reurrene.
o 'ompression options inlude elasti wraps! ustom&fitted elasti ompression
sto#ings! elasti tu$ular support $andages! a ,elro wrap! se+uential
ompression devies! a paste $andage with an elasti wrap! and multila%er (three
or four) $andage s%stems.
o 4oist environment dressings are the $asis of wound are and inlude transparent
film dressings! h%droolloids! h%drogels! foams! impregnated gau.e! and
om$ination dressings.
o Assess nutritional status.
o 4onitor wounds for signs of infetion. (he usual treatment for infetion is
de$ridement! wound exision! and s%stemi anti$iotis.
Alternative treatments ma% inlude overage with a split&thi#ness s#in graft! ultured
epithelial autograft! allograft! or $ioengineered s#in.
Long&term management of venous leg ulers should fous on teahing the patient a$out
self&are measures $eause the inidene of reurrene is high.
o Proper foot and leg are is essential to avoid additional trauma to the s#in.
o (he patient with ',I should avoid standing or sitting with the feet dependent for
long periods.
o (eah patients with venous ulers to elevate their legs a$ove the level of the heart
to redue edema.
o )ne an uler is healed! enourage a dail% wal#ing program.
o Presription elasti ompression sto#ings should $e worn dail% and replaed
ever% 3 to = months to redue the ourrene of ',I.
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