Beth Campos MSN RN

Instructor
2016

Beth Campos MSN RN

Instructor
April 2016

Identify specific anatomic and physiologic factors that

affect the vascular system and tissue oxygenation
Indicate appropriate parameters for assessing a
patient with peripheral vascular disease, aneurysm,
and aortic dissection
Discuss tests and procedures used to diagnose
selected vascular disorders and the nursing
considerations for each.
State pathophysiology, signs and symptoms,
complications, and medical/surgical treatments for
selected vascular disorders.
Assist in developing a plan of care for patients with
selected vascular disorders.
Assist in developing a plan of care for patients with
selected vascular disorders.

 Function is to maintain blood flow to supply

adequate oxygen and nutrients to all tissues
Delivery of oxygen and nutrients to the tissues
depends on adequate perfusion (blood flow)
which requires a functionally intact
cardiovascular system
When the vascular system is compromised by
vascular disease, homeostasis of the body is
affected
Any interruption of the blood flow results in
tissue hypoxia which can lead to tissue
necrosis if untreated
Vascular diseases can affect the arterial and
venous components of the circulation

Artery

Vein

Capillary

Vessels that carry blood

away from the heart
toward the tissues
Thick-walled
structures with three
layers:
1. Intima
2. Media
3. Adventitia
Smooth muscles encircle
and control the diameter
Contraction of
muscles constrict
arteries
Relaxation of muscles
dilate arteries

 Arterioles

branch into
progressively smaller
vessels to form
capillaries (single layer
of endothelial cells) that:
1. allow efficient
delivery of
nutrients and
oxygen into the
tissues
2. removal of
metabolic wastes
from the tissues
Tiny vessels that receive
blood from the
capillaries are venules,
the smallest veins

The vessels that return

blood to the heart
Composed of the same
layers as the arteries and
arterioles, but layers are
less defined, thinner and
less muscular but
stretched more than
those of the arteries. Can
store large volume of
blood
Veins have valves to:
1.allow blood to move in
only one direction
2.prevent backflow of
blood in the
extremities

1. Resistance within the vessels is controlled by

the diameter of the vessels:
When vascular diameter increases
(vasodilatation), peripheral resistance falls and
blood flow increases
Sympathetic nervous system stimulation causes
release of epinephrine and norepinephrine,
kidneys release angiotensin II which can cause
vasoconstriction
When vascular diameter decreases
(vasoconstriction), peripheral resistance increases,
reducing blood flow
Vasodilatation is due to release of kinins,
histamine, serotonins and prostaglandin
The diameter of peripheral blood vessels is regulated
by the vasomotor center in the medulla and pons

2. Blood viscosity: thickness of the

blood
An increase in RBC or decrease in the
body water produces
hemoconcentration which increases
blood viscosity
When blood is concentrated, kidneys
begin to retain water.
Important factor: capillary permeability
Hydrostatic presure and osmotic
(oncotic) pressure maintain balanced
movement of fluids in and out of the
capillaries

Primary age-related change is

Arteriosclerosis
Stiffening of the vessel walls: delivery of
oxygen and nutrients to tissues is
compromised; buildup of waste products in
tissue
Loss of elasticity: increases peripheral
resistance which impairs blood flow which
increases ventricular workload
Decrease of hemoglobin: produces a decline
in the oxygen-carrying capacity of the blood
Slowing heart rate and decrease in stroke
volume: may result in 30 to 40% decrease in
cardiac output

Focuses on the Six classic Ps of

peripheral vascular disease: Six Ps
1. Pain
2. Pulselessness
3. Paralysis
4. Pallor
5. Paresthesia
6. Poikilothermia (warm, cold)

Pain: location (calf, thigh, hip or buttocks),

nature (throbbing, continuous, intermittent),
duration, precipitating factors (exercise,
lying down) and alleviating factors .

1. Pain:
Intermittent claudication: is pain due to
decreased perfusion aggravated by exercise and
relieved by rest
It is a feeling of tightness, burning, fatigue,
aching or cramping.
When blood supply to the muscle group is decreased,
the muscles are unable to receive adequate
blood flow to supply nutrients and oxygen and
remove metabolic waste, ischemia develops
causing pain. When activity stops, pain subsides
Rest pain: indicates severe arterial occlusion
Can cause tissue ischemia in the extremity with
severe, burning pain in the legs and feet after lying
flat for a period of time
Pain is relieved when legs dangled in
dependent position that promotes blood flow by
gravity

2. Pulselessness: palpate peripheral pulses for

rate, rhythm and quality. Compare pulses
bilaterally to determine differences
3. Paralysis: impairment of motor function
(impaired conduction of nerve impulses)
4. Pallor: due to reduced blood supply.
Detected by inspecting site and compare skin
color with other skin areas
5. Paresthesia: abnormal sensation
(numbness, tingling, pins and needles
sensation or crawling sensation)
6. Poikilothermia: is decreased temperature
at the ischemic site detected by palpating the
affected and surrounding areas. Feels cooler
than the rest

Past Medical History: cardiovascular history, CAD, MI,

hypertension, atherosclerosis, DM
Family History: relevant diseases: hypertension, CAD,
MI, atherosclerosis, aneurysm, and diabetes
Functional assessment: determines the effect of the
disease on the patients life: pain, inactivity, amputation
Smoking history, dietary habits (high fat intake),

exercise
Review of systems:
Changes associated with PVD: thick, brittle nails;
shiny, taut, scaly, dry skin; skin temperature; skin
ulcers; muscle atrophy; localized redness and
hardness; hair loss on extremities
Assess for chest pain and dyspnea (PE)
Assess for symptoms of aneurysms: hoarseness,
dysphagia, dyspnea, abdominal or back pain, or
swelling of the head and arms

Physical examination: determine whether it is

arterial or venous in nature. Arterial
complications involve multiple areas. Venous
complications are more localized
Inspect the skin for color and lesions:
Pallor is vasoconstriction (inadequate blood flow)
Reddish brown rubor in lower extremities is
arterial occlusion
Brownish discoloration is venous disorders
Open ulcers, scars around ankles, stasis
dermatitis (brown pigmentation with flaky skin over
edematous areas)
Arterial stasis: begins with ulcers in the toes,
painful pale and crusty
Venous stasis: ulcers in the ankle areas, develop
slowly, painless, difficult to heal

Capillary refill time to determine adequacy of

peripheral perfusion: >3 seconds is reduction in
peripheral perfusion
Palpate affected areas to evaluate temperature
(cool limb is arterial problem; warm limb is venous
disorder)
Pulsating mass in the abdomen maybe an
aneurysm
Detect edema: press thumb in the edematous area
for 5 seconds. Severity is graded as:
less than 1/4 inch is 1
to inch is 2
to 1 inch is 3
more than 1 inch is 4
If depression remains, it is pitting edema

Evaluation of peripheral pulses: for presence,

symmetry, volume and rhythm
Upper extremities: brachial, ulnar and radial
Lower extremities: femoral, popliteal, dorsalis pedis,
and posterior tibial arteries
Sclerotic vessel feels stiff and cordlike
Normal vessel is soft and springy
+ Homans sign: pain in the calf area or behind the
knee after dorsiflexing the foot while the knee is
slightly flexed
Allen test: to determine the adequacy or arterial
circulation in the hand when the palm return to
normal color when pressure is released from ulnar
artery
Bruit sounds: turbulent, fast moving fluid when
vessel is auscultated

Femoral

Popliteal

Pedal

Tibial

 Buerger-Allen

exercises allow gravity to

fill and empty the blood vessel.
Stress management: emotional stress
causes vasoconstriction
Pain management: when intermittent
claudication occurs, stops exercise, once pain
goes away, activity is resumed
Smoking cessation: vasoconstriction
occurs for up to 1 hour after a cigarette
has been smoked. Smoking causes
vasospasm
Elastic stockings: proper size, applied in
the morning. Remove 10-20min twice a
day, check skin for irritation

 Surgical

procedures:
Embolectomy: removal of blood clot in a
large vessel
Percutaneous transluminal
angioplasty: dilate lumen of artery by
inflated balloon to improve blood flow
Endarterectomy: plaque are stripped from
the intima of vessel
Sympathectomy: excision of sympathetic
ganglia to promote vascular dilation
Vein ligation and stripping for varicose
veins
Sclerotherapy: injection of chemical
irritants to close a vessel

Preoperative nursing care

Patient with severe cardiovascular disease have
activity restrictions to reduce demands on circulatory
system until the surgical procedure is done
Optimize peripheral circulation: keep extremity warm
Protect the limb from further injury
Postoperative nursing care
Primary goal: to stimulate circulation by
encouraging movement and preventing stasis within
the extremity
Evaluate tissue perfusion: color, temperature, pain,
tenderness, cap refill, edema, quality of peripheral
pulses, exercise tolerance
Do not cross legs, avoid keeping legs in dependent
position for long periods of time. Elevate legs

Thrombus is a clot that adheres to the

vessel wall
Thrombi tends to develop in areas where:
injury to an arterial wall intravascular
factors stimulate coagulation sluggish
flow vessel lumen partially obstructed, wall
damaged and rough by atherosclerosis
Other causes:
Polycythemia, dehydration, repeated arterial
sticks, Infection or inflammation of the vessel
Developing thrombus can occlude arterial
blood flow thru the vessel leading to
ischemia of tissues supplied by the artery

If a thrombus breaks up and travel, it

becomes an embolus (thromboembolism)
traveling in the circulatory system until it
lodges in a vessel blocking blood flow
distal to the occlusion.
Embolism: sudden obstruction of a blood
vessel by a debris. Effects of arterial occlusion
depend on the size of embolus and organs
involved
Substances that can become an embolus:
Atherosclerotic plaque, masses of bacteria,
cancer cells, amniotic fluid, bone marrow fat
Foreign bodies such as air bubble, broken IV
catheter

 Signs

and symptoms: abrupt onset with acute

arterial occlusion with severe pain (intermittent
claudication), pain aggravated by movement or
pressure, gradual loss of sensory and motor function
in the affected areas
absent distal pulses, pallor and mottling
(irregular discoloration), can be sharp line of color.
temperature demarcation: tissue beyond the
obstruction is pale and cool
Six clinical signs of acute arterial occlusion (6
Ps):
1.P-ain (severe, acute)
2.P- allor (mottling, irregular discoloration)
3.P- ulselessness, (absent distal pulses)
4.P- aresthesia (numbness)
5.P- aralysis ( gradual loss of function)
6.P- oikilothermia (feels cold)

Diagnostics:
Arteriography: injection of dye in the vascular
system to examine the arteries.
Side effects: hemorrhage, allergic reactions
to dye, thrombosis at insertion site, embolus,
infection, exposure to high doses of radiation
Doppler ultrasound: low intensity, high
frequency sound waves are directed toward the
artery
Management: Goal is to protect and save
the affected extremity. If treatment not
initiated immediately, can progress to tissue
necrosis and gangrene within hours
Anticoagulant therapy: IV heparin, coumadin
Thrombolytic agents
Surgery: Thrombectomy, embolectomy

Ineffective Tissue perfusion related to

compromised circulation: administer meds, ROM
exercise as ordered
Fear related to risk of death: encourage
expression of feelings of helplessness and
anxiety, identify coping mechanisms
Impaired physical mobility related to surgery,
compromised circulation: develop progressive
exercise plan impaired skin integrity related to
ischemic changes: protect extremities from
pressure, trauma, extreme heat and cold
Impaired skin integrity: protect skin of limb
from trauma, pressure and extreme hot or cold
especially edematous area
Ineffective therapeutic regimen
management: medication compliance and
discharge planning

Chronic progressive narrowing of arterial

vessels that leads to obstruction or occlusion.
Usually affects the lower extremities resulting
from atherosclerosis.
Atherosclerosis is the leading cause of
occlusive disease
Common in men older than 50 years
Also called: Atherosclerosis obliterans,
arterial insufficiency, and peripheral
vascular disease, lower extremity arterial
disease (LEAD)
Etiology:
Organic: caused by structural changes from
plaque or inflammation of vessel
Functional: short-term localized spasm in the
blood vessel such as in Raynauds disease

Contributory factors: atherosclerosis, thrombosis,

embolism, hyperlipidemia, DM, HTN, cigarette
smoking, stress, obesity, familial disposition, age,
trauma, vasospasm, inflammation, autoimmune
responses
Common sites for arterial occlusion are the distal
superficial femoral and the popliteal arteries.
Tissue damage occurs below the arterial obstruction
Pathophysiology: arteries deliver oxygen rich blood
to the tissues. Anything that impedes flow causes
imbalance in supply and demand. Hypoxia affects all
tissues distal to the occlusion
Pathologic changes in the arteries, typically plaque
formations causing occlusions prevent delivery of
oxygen and nutrients to the tissues
Severe oxygen deprivation lead to ischemia and
necrosis (tissue death)

 Signs

and Symptoms: no early symptoms

Intermittent claudication: (classic sign) pain in
the calves of the lower extremities associated with
activity or exercise. It is aching, cramping,
tiredness, weakness in the legs that occur
with walking, relieved by rest
Diminished/Absence of peripheral pulses
below occlusive area
Rest pain: persistent and aching pain that occurs
during inactivity, increases when leg is elevated and
decreases when dependent. Rest pain is severe
arterial occlusion
Tingling or numbness of toes, cool to touch
and numb, muscle atrophy
Skin color: extremity is pale when elevated,
reddish purple when dependent, toenails are
thickened
Shiny, thin scaly, dry flaky skin, subcutaneous
tissue loss, hairlessness on the affected extremity,
and ulcers with a pale gray or yellowish hue.
Edema may develop

Diagnostics: ankle/brachial pressure index (ABPI):

<0.8 is suggestive of arterial occlusion; doppler
ultrasound, arteriography
Complications: gangrene with extremity
amputation, infection, sepsis, aneurysm, rupture
Management: make lifestyle changes including
Smoking cessation (high priority): nicotine
(patch, spray, gum, inhalers), varenicline
(Chantix), bupropion
Exercise: 3 sessions each week for at least 6
months
Weight management, low-fat, low-cholesterol,
low-calorie diet
Treatments for hypertension,
hyperlipidemia or diabetes if present

Nursing interventions:
Assess/monitor peripheral circulation (pulses, color,
temperature, cap refill, edema, skin breakdown)
fluid status, coagulation status, pain exercise tolerance,
intermittent claudication
Encourage exercise to build up collateral
circulation- initiate gradually, increase slowly: walk
until point of pain (claudication), stop and rest
until pain subsides and walk a little farther (this
builds collateral circulation)
Positioning: avoid crossing legs, no pillows under knees,
avoid prolonged sitting, both feet on floor when sitting,
refrain from wearing restrictive clothings, elevate legs
to reduce swelling but not above level of the heart
Explain healthy lifestyle, daily foot care, drug
regimen

Promote vasodilatation and avoid

vasoconstriction:
provide warm environment, wear warm insulated
socks, no direct heat to skin (sensitivity is
decreased), avoid exposure to cold
(vasoconstriction)
Avoid stress nicotine and caffeine.
Vasoconstriction effects last for 1 hour after each
cigarette smoked
Administer medications as prescribed:
pentoxyfyline (Trental) increase flexibility of RBC
and decrease blood viscosity can increase blood flow
to extremities (prevent claudication)
Antiplatelet agents such as ASA, clopidogrel
(Plavix), cilostazol (Pletal)
Anticholesterol drugs and vasodilators
Antihypertensives to improve tissue perfusion

Surgical interventions :
Percutaneous transluminal angioplasty: intraarterial procedure using a balloon and
intravasular stent to open and maintain the
patency of a vessel
Atherectomy: use of high speed rotary metal burr
to scrape out affected arteries to improve blood flow
Endarterectomy with bypass grafts: use of graft
materials, can be autogenous (harvested) or
synthetic
Post op care:
assess distal pulses to surgical site, palpate
or use a doppler, compare with unaffected
extremity
Assess 6Ps, cap refill, edema, redness, VS, I&O,
fluid status
Limit ROM to prevent clot formation

 Nursing

Diagnosis: Read pp 487-489

Ineffective Tissue Perfusion related to vascular
occlusion: administer vasodilator agents to improve
blood flow, encourage exercise, discourage smoking.
Elevation of extremities is not recommended
with arterial diseases
Acute pain related to impaired circulation:
administer analgesics, vasodilators, calciumchannel blockers
Decreased Cardiac Output: monitor for signs and
symptoms of deficient fluid volume (tachycardia,
restlessness, decreases urine output, pallor,
hypotension) and bleeding. Monitor daily weights
Ineffective Self-Health management: to cope,
patient must understand the disease process
and treatment. Fears and concerns have enormous
effects on patients perception of situation. Lifestyle
changes is important to management

Nursing Diagnosis:
Activity Intolerance related to impaired blood
flow to extremities: monitor tolerance to planned
activities and exercise regimen (Read pp 489)
Chronic Pain related to ischemia: rest
extremities, administer analgesics, relaxation
techniques
Impaired Skin Integrity related to inadequate
circulation: avoid tissue trauma, avoid infections of
the ulcers. Foot care (no barefoot, fitted
shoes, inspect feet daily, toenails cut
straight across)
Risk for Infection: of the surgical incision and the
grafts. Monitor temperature, report fever to
surgeon. Inspect site for redness, edema and
drainage. Administer antibiotics
Disturbed Body Image related to muscle
atrophy, stasis ulcers, skin discoloration: identify
coping strategies to deal with feelings

Also called Thromboangitis Obliterans

Recurring inflammation and thrombosis of
small and medium arteries and veins of
lower and upper extremities
arteries and veins inflamed and spastic causing
clots to form resulting in occlusion or total
obstruction of blood vessels of hands and
feet.
With the degree of ischemia, ulcers and
gangrene may be present
Cause unknown, can be autoimmune
disorder
Almost always affects men, age 25-40 with
history of smoking or chewing tobacco
Occurs only in smokers
Cigarette smoking is the single most
significant cause

Signs and Symptoms

affected extremity pain: Intermittent
claudication, rest pain
Six Ps: extremities pale, abnormal sensation
(numbness, decreased sensation), ulcers,
gangrene, pulses diminished
skin color and temperature changes in
affected areas: red or cyanotic, cool
extremities, cold sensitivity
shiny, nail thickened and malformed, skin is
thin

 Diagnostics:

physical findings, arteriography

Management: no cure or effective treatment
Stop smoking: participate in cessation program
Administer aspirin, prostaglandin iloprost,
vasodilators (calcium-channel blockers),
antibiotics, anticoagulant
Avoid activities that impede blood flow: avoid
crossing legs and pillows under knees, prolonged
sitting. Place extremities below level of heart
Avoid alcohol, caffeine
Care of the feet, protect extremity from
trauma. Shoes that fit well. Inspect skin.
Keep extremities warm with socks and blanket
If gangrene develops: amputation (40% who
continue tobacco use require amputations).
Medic alert bracelet

Vasoconstrictive response causing ischemia from

exposure to cold and stress. Mainly affects hands
Two types:
1. Primary (Raynauds Disease)
2. Secondary ((Raynauds Phenomenon)
Pathophysiology: characterized by episodes of intense
vasospasm in small arteries of the fingers and
sometimes toes, ears and nose. Prevents arterial
blood from perfusing fingertips (ischemia). Can
progress overtime. If remain constricted, can lead to
gangrenous and necrotic fingers
Cause is unknown, related to hypersensitivity to cold
or serotonin. Young women ages 16 to 40 are
affected especially during winter months. Stress can
aggravate
Cardinal signs: chronically cold hands, numb,
tingling.
Phases: blanching, ischemic pain then reddening
Decreased sensation, stiffness, fingertips thicken, nail
brittle. Asymmetric finger involvement, thumb not
affected

 During

arterial
spasm color
changes from
pallor to cyanosis
to redness
White: pallor
(blanching) is
sudden
vasoconstriction
Blue: cyanosis is
inadequate
oxygenation
Redness: due to
vasodilatation
(hyperemia)
allowing blood flow
to return

Medical Diagnosis: signs and symptoms and on the

absence of evidence of occlusive vascular disease
Management: Goals are to prevent pain, promote
vasodilatation in the extremities
Drugs: Vasodilators (Calcium channel blockers such
as diltiazem (Cardizem), transdermal nitroglycerin, an
endothelin receptor antagonist (bosentan),
phosphodiesterase inhibitors (sildenafil), and intravenous
prostaglandins (iloprost)
Surgery: sympathectomy to interrupt sympathetic
nerves

Nursing Interventions:
Acute Pain and Ineffective tissue perfusion related
to vasospasm: Reduce pain and improve tissue
perfusion by avoiding stimuli that causes vasoconstriction
(exposure to cold, smoking, and excessive stress)

Nursing Interventions:
Keep hands warm, use mittens than gloves,
warming devices (warm water, warm hair-dryer)
during attacks.
Check pulses, cap refill, color, temperature edema

Protect from trauma and injury due to lack of

sensation during periods of vasoconstriction that
results in serious burns. Check skin for ulcers,
infection. Avoid activities that impede blood flow
Cessation of smoking, avoid alcohol and
caffeine, OTC cold remedies that contain
vasoconstrictor
Stress reduction: exercise, massage therapy,
maintain normal body weight
Wear medical alert bracelet

Dilated segment of an artery caused by weakness

and stretching of the arterial wall
Bulging, ballooning or dilatation at a
weakened point of an artery, diameter increased
to 50% the normal size
Can be: Cause unknown. Can be:
1. Congenital: congenital aneurysms are Marfan
syndrome (inherited connective tissue disease)
and Ehlers-Danlos syndrome (inherited collagen
disease)
2. Acquired: arteriosclerosis, smoking,
hypertension trauma, infection

Classic symptom: back pain, flank pain

caused by aneurysm pressing against
nerves of vertebrae

Risk factors:
Atherosclerosis (most common cause),
uncontrolled hypertension, Marfan
Syndrome (connective tissue disorder),
cigarette smoking, trauma, infections
(syphilis), Congenital abnormalities, heredity,
men older than age 50 (highest risk of death
from AAA)
Risk for rupture
Aneurysms greater than 6cm (2.4 in diameter)
have a 50% chance of rupture within one year)
Aneurysms less than 6cm have a 15-20%
chance of rupture in one year
Aneurysm <4cm is usually silent
Abdominal aorta most common site of
aneurysm formation!!

1.Fusiform:
dilatation of entire
circumference of
the artery
2.Saccular: bulging
on only one side
3.Dissecting: when
a cavity is formed
from a tear in the
artery wall (intima)
fill with blood.
Prone to rupture

 Signs

and Symptoms vary with location

Thoracic AA: usually no symptom, can be deep

diffuse chest pain
Aneurysm that press on laryngeal nerve:
hoarseness, on esophagus: dysphagia
If SVC is compressed: edema of arms and legs
Compression of pulmonary structures: airway
obstruction
Abdominal AA can be palpated as a pulsating
mass abdominal mass slightly left of the umbilicus.
Often silent if <4cm. Men over 50 yrs old has highest
risk of death of AAA
Gnawing constant abdominal, back or flank pain
(classic) caused by aneurysm pressing
against nerves of vertebrae
Common symptom: Abdominal pain, feeling of
fullness, nausea, constipation, elevated BP, bruit
over the abdominal aneurysm. Lower back pain
suggests rapid expansion and impending
rupture

 AAA

rupture: severe sudden onset of tearing,

ripping and stabbing back, flank, abdominal pain.
When signs and symptoms come suddenly,
aneurysm is about to rupture
With rupture: hypovolemic shock (tachycardia,
hypotension); diaphoresis, nausea, vomiting,
faintness, apprehension, decreased or absent
peripheral pulses, neuro deficits. Mortality is high
Rupturing aneurysm is an emergency surgery!!
Complications: rupture, thrombus formation,
emboli, pressure on surrounding structures
Medical diagnosis: physical findings, ultrasound,
MRA, CT scan, echocardiography, aortography.
Monitor small AA
Medical treatment: antihypertensives lower BP
to prevent arterial wall to rupture
Avoid lifting heavy objects

Surgical repair and grafts:

AAA resection: excision of aneurysm and placement of
a Dacron graft
Percutaneous insertion of endothelial stent
grafts: placement of a stent graft via femoral artery,
blood flow thru the stent to reduce pressure
Preop care: document chronic conditions like
emphysema or heart disease, that increase risk of
postoperative complications
Priority: keep systolic BP between 100 and 120mm
Hg
Postop care: Admit to ICU/CCU for 24 to 48hrs
Monitor VS, hemodynamic status, cap refill, renal
function and fluid balance. IV fluids to maintain
hydration and renal perfusion
Monitor BP. Prolonged hypotension can cause thrombus
formation within the graft, severe hypertension can
cause leakage or rupture of the anastomosis suture line.
Avoid flexion of the graft, Keep HOB at 45 degrees

 Postoperative

Nursing Care

Impaired Urinary Elimination: aorta is clamped for a

period of time, there is risk for renal damage (renal
failure). Monitor I&O, report less than 5ml/hr, daily
weights, BUN and creatinine to detect signs of
altered renal perfusion
Nursing Diagnosis:
Risk for Injury: NGT attached to suction to avoid gastric
and bowel distention (stress the incision)
Ineffective Breathing Patterns: high risk for
atelectasis and pneumonia. Use of incentive spirometers,
CBDE, analgesics, monitor lung sounds
Decreased Cardiac Output: risk for hemorrhage.
Monitor VS, wound dressings. Early signs: restlessness
and tachycardia. Late signs: hypotension, cyanosis,
decreased alertness
Ineffective Tissue Perfusion: Inspect and palpate the
extremities for color, warmth, and peripheral pulses,
sensation and movement of extremities, increased pain
level

Small tear in the intima that permits blood to

escape into the space between the intima and
the media usually due to hypertension.
Blood accumulates between layers, causing
the media to split lengthwise. The split may
extend up and down the aorta, where it can
occlude major arteries
Management:
If no complications, patient managed with
antihypertensives to decrease the strength of
cardiac contractions
Replacement with a synthetic graft
Postop- care: keep blood pressure at
lowest possible level
Nursing care is similar to that of a patient who
has had an aneurysm repair

Disease of the veins that interferes with

adequate flow of blood from the extremities
Disorders:
1. Venous thromboembolism (VTE):
deep vein thrombosis (DVT)
pulmonary embolism (PE)
2. Venous insufficiency
3. Varicose veins
Three causes: thrombus formation, defective
valves, lack of skeletal muscle contractility
Risk factors: sitting or standing for long
periods, obesity, pregnancy, thrombophlebitis,
systemic diseases, family history, heart failure,
immobility, hip/knee surgery, aging

 Varicosities

are elongated, tortuous, dilated superficial

veins often the saphenous veins in the lower extremities
Dilatation results from incompetent valves in the
veins: valves cannot prevent backflow of blood
(reflux)
Causes: unknown, hereditary weakness, aging,
pregnancy, obesity, occupations requiring prolonged
standing. Restrictive clothings aggravates the condition
Classified as:
1.Primary: only superficial veins affected, caused by
structural defect in the vessel wall
2.Secondary: acquired or congenital, characterized by
deep vein obstruction, causing dilation of collateral and
superficial veins stasis and pooling of deep veins
Can also occur in the esophagus (esophageal varices
in portal hypertension and hemorrhoidal veins)

 Signs

and Symptoms: onset is gradual and

progressive
Telangiectasies (spider veins) are minor chronic
venous diseases. In advanced stage, dilated veins
are oversized, discolored (purplish), tortuous,
dull aching sensations when standing or walking, ankle
edema
Feeling of heaviness and increased muscle fatigue in
the affected leg, muscle cramps especially at night
sometimes relieved with walking or elevating extremity.
Overtime will develop postphlebitic syndrome:
persistent edema, brownish skin discoloration and
ulcers commonly on the inner aspect of the ankles
Medical diagnosis: appearance, duplex
ultrasonography, trendelenburg test (+ when
patient sits up, veins fills up)
Management: goals are to improve circulation,
relieve pain and avoid complications.
Exercise, elevation, elastic compression

 Management

:
Sclerotherapy:
solution is injected
into the vein,
followed by pressure
dressing. Incision
and drainage of the
trapped blood in the
sclerosed veins are
performed 14 to 21
days after injection,
followed by pressure
dressings for 1218hrs
Endovenous laser
Vein ligation and
stripping: clustered treatment: uses laser fiber
or large veins >4mm
to heat and close main
diameter are
vessel that contributes to
removed
the varicosity

Nursing Interventions:
Preop care: assist with vein markings, evaluate
pulses for comparison
Post op care: inspect the legs for color, edema,
turgor, and capillary refill, pulses, maintain
elastic bandages, monitor groin and leg for
bleeding, elevate legs above level of heart,
encourage ROM, avoid leg dangling or chair
sitting, emphasize wearing elastic stocking
Activity restrictions and positioning of the legs
(usually 15 to 30 degrees for the 1 st 24 hours)
Patient teachings: Avoid restrictive garments,
prolong standing or sitting, crossing legs or
knees. Elevate extremities. No injury to the
compromised areas. Weight reduction reduces
pressure on the lower extremities. Support
stocking as recommended by PMD

Venous insufficiency is a chronic condition

damaged or aging valves within the veins
interfere or reduce venous blood return to the
heart causing pooling of blood in the lower
extremities.
With increased pressure, venous stasis occurs
leading to edema, brownish discoloration of the
legs and feet, skin hardened, leathery
Veins rupture releasing RBC in the tissues
staining skin tissue brown. Ulcer develop from
increased pressure and rupture of small veins
Treatment goals: to decrease edema and heal
ulcers
Compression wraps and stockings, elevation of legs
for at least 20 minutes 4 to 5X a day above level of
heart, foot of the bed elevated 5 to 6 inches
No crossing of legs
Bed rest, treat infection of ulcers with antibiotics
Unna boot: gauze dressing with zinc oxide,
calamine and glycerin. Change every 2 to 7 days
Skin grafting

end result of chronic venous insufficiency.

Dyfunctional valves reduce venous blood return
to the heart.
Due to long-standing pressure that stretches the veins
and damages the valves. Veins rupture releasing
RBC in the tissues staining skin tissue brown.
Ulcer develop from increased pressure and rupture
of small veins
Signs and symptoms
Edema around lower legs, pain, brownish skin
(stasis dermatitis), and stasis ulcerations (medial
malleolus)
Heaviness or dull ache in the calf or thigh
Cool skin temperature, nails are normal, feet and
ankles often cyanotic when in a dependent position
Diagnosis: Physical examination, C/S for draining
wounds

Medical and surgical treatment

Compression: Elastic or compression stockings
and pneumatic compression device
If patient has an ulcer, special dressings, systemic
antibiotics, topical dbriding agents such as Elase,
and Unna boots. Use of Hyperbaric oxygen
therapy. Skin ulcers are cultured and treated
Assessment: Inspect the lower extremities for
rubor and stasis dermatitis, palpate skin
temperature, and determine the presence of pain in
the affected extremity

Nursing Diagnosis:
Ineffective Tissue Perfusion
Disturbed Body Image
Risk for Infection
Impaired Skin Integrity

Acute bacterial infection of the lymphatic channels

The inflammation is the result of an infectious
process, commonly caused by staphylococcus or
streptococcus
Can cause sepsis and can be fatal
Signs and symptoms
Enlargement of the lymph nodes along the
lymphatic channel. Tenderness as these nodes are
assessed. Nodes can be palpated along groin, axilla,
cervical regions
painful red streak from the infected wound extends
up the extremity along the path of the lymphatics.
Can localize into abscess with pus
Elevated temperature and chills
Medical diagnosis:
Classic signs and symptoms, supported by wound
culture results, Lymphangiography

Assessment
Inspect skin for open wounds, inflammation, and
red streaks along the paths of lymphatic channels
Monitor for increase in size of extremitiy, pain
level, fever
Palpate lymph nodes in groin and underarm areas
for enlargement
Management:
Broad spectrum antibiotics, Analgesics,
Abscess is incised to drain the suppurative
material
Rest and elevation of the limb to reduce
lymphedema; and elastic support hose
Inspect skin for open wounds, S/S of inflammation,
streakings and enlarged nodes
Warm moist soaks to improve circulation