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Flashcards in Vascular Problems Deck (12):
1

Acute Arterial
Ischemic Disorders

Buerger’s and Raynaud’s

2

Buerger’s Disease

- Affects small and medium arteries in arms and legs
- Inflamed vessels that may subsequently block blood flow
- Eventually damages tissue, which becomes infected and may become gangrenous (Turn black/fall off)

- Usually in young male smokers (20-40)
- Becoming prevalent in women
- Chemicals in tobacco irritate inside of vessels can start building up plaque

Can be confused with PAD- peripheral aretery disease
- Intermittent claudication- walk, pain in legs, stop, pain goes away, walk again and more pain, etc. Never goes away
- Fingers/toes turn pale when cold
- Painful open sores
- Chronic gum disease

Diagnostics:
Blood test to rule out other diseases
Allen’s test- press on both sides to block the circulation, release on one side, see blood come back to hands
U/S, Angiogram

Treatment:
***Delete tobacco use
Vasodilators
Possibly heparin/coumadin
Intermittent compression
Sympathectomy- cut the nerve
Amputation

Prevention
Stay out of the cold
Protection of fingers/toes
Meticulous wound care
Dental visits
NO tobacco
No use of vasocontrictors

3

Raynaud’s Disease

Condition that causes vasospasms of small arteries in areas that stick out – fingers/toes/nose/ears

Occurs mostly in females (15-40)
Stimulation to the sympathetic nervous system
Overreaction to cold and /or stress
- When body is cold, it slows blood supply to extremities to preserve core temp
- Skin turns pale first then dusky blue
- When spasm is over, turns red then normal

4

Raynaud’s Phenomenon

- Worse than Raynaud’s disease
- Caused by varied conditions or reactions to drugs that confine or constrict the vessels
- Other disorders that can occur with this –migraines, angina, pulmonary HTN

Treatment almost the same as Buerger’s with the addition of meds to prevent vasospasms- make sure we don’t’ have any kind of vasoconstrictors on board

5

Venous Disorders

Thrombophlebtis: superficial and DVT

6

Venous physiology

- Veins return blood from all body parts back to the heart

- Large veins and arteries run parallel and often share a name

- Venous pathways are more difficult to trace

- Deep veins have major role in propelling blood against gravity back to heart: Many have one-way valves
Muscle contractions surrounding veins help with this role
Thrombi (clots )can happen in the deep veins (usually in legs) called deep vein thrombosis (DVT)

- Superficial veins are smaller and slower but feed back into the large vessels: Main problems involve inflammation
If clot occurs in superficial vessel –superficial thrombophlebitis



7

Thrombophlebtis

Formation of blood clots (thrombosis) and inflammation of the vessel(phebitis) occurring together.

Superficial thrombophebitis is painful but is fairly harmless compared to Deep Vein Thrombosis: Located in the small vessels, Don’t usually break loose as emboli

DVT causes less inflammation usually lower leg
- The less inflammation around the clot, the less tightly the clot adheres to the vein wall and more apt to break loose.
- Even the squeezing muscle action of walking can cause it to break loose
- ***This is the dangerous one!!!!!!!!!- BED REST
- The embolus travels through the heart and get trapped in the lungs, blocking circulation to the area. (Pulmonary Embolus)
- Prophylactic: get them up and move them after they are stable



8

Deep Vein Thrombosis (DVT)

Three main factors (Virchow’s Triad):
- 1. An increased tendency for blood to clot: oral contraceptive, pregnancy and postpartum, polycythemia, inherited feature from parent
- 2. Injury to the vein's lining: ”vasculitis”- due to injury, lupus, IV drug use, cancer therapy, previous DVT and phlebitis, leg fractures, sepsis
- 3. Slowing blood flow: venoustasis- immobile, MI, CHF, Stroke

Risk Factors:
- Immobilization – long periods of sitting, bedrest
- Recent surgery (especially hip, knee, or female reproductive organ surgery),
- Fractures
- Hyper coagulability
- Medications such as estrogen and birth control pills
- Childbirth within the last 6 months
- Overproduction of red blood cells in bone marrow (polycythemia vera)
- Malignant tumor
- Deep venous thrombosis is most common in adults over age 60, but it can occur in any age group.

Prevention:
- Ankle pumps while in bed so that they use the calf muscles to pump blood back, walking on trips
- Support hose: flow more rapid – Careful!
- Pneumatic stockings: Pre, intra and post op surgery until up walking, ***Remove regularly to assess skin integrity, ***Don't use on patients with an acute DVT, significant peripheral vascular ischemia, large open wounds or skin grafts, or cancer of the extremity, If the devices weren't applied at onset of bed rest or during surgery, ***ask for a venous/arterial doppler exam before applying them, to rule out a DVT. For prevention not treatment!
- Anticoagulant Therapy

Clinical Manifestations:
- Pain, purple redness and edema are usually minimal, occurring in one extremity
- Some people have no symptoms at all until the PE
- When the clot blocks a large vessel, the calf swells and may be very painful (does not correlate to size, location, or severity of DVT), tender and warm to touch
- Some clots heal by converting to scar tissue which may damage the valves in the vessel so backflow can happen causing edema especially at the end of the day. This can be a chronic condition -Totally bad circulation.

Diagnostics:
- Difficult to detect especially if minimal pain or swelling
- D-Dimer blood test, Coag studies. A negative D-dimer rules out DVT in patients with low-to-moderate risk. All patients with a positive D-dimer require a further studies
- Venous compression U/S and Color Duplex Doppler U/S can confirm
- Venogram with and without contrast
- If PE suspected, scan using radioactive marker is done with the Doppler of the legs
- If patient collapses, no need for these right away - need emergency treatment
- If you suspect a DVT: MEASURE BOTH LEGS
- If you squeeze the leg and they have pain- Pratts sign
- Temperature of 100 or more

Treatment
- The primary objectives for the treatment of deep venous thrombosis (DVT) are to: ***prevent pulmonary embolism (PE), reduce morbidity, and prevent/minimize the risk of developing the postphlebitic syndrome. (Chronic pain, swelling, cramps, itching, sores) 
- Initial treatment with Heparin or LMWH, should continue for at least 5 days while warfarin therapy is commenced.
- Heparin and warfarin are continued simultaneously until the INR is >2 for 24 hours
- Antidote to heparin- protamine sulfate; antidote to Coumadin- Vitamin K
- Repeat Ultrasounds are performed about every six weeks
- Hospitalized at first
- Bedrest with foot of bed elevated (6 inches)
- Elevation and compression (applied only by provider or nurse with special training) – will not be done until we know the clot won’t move
- One pillow under thigh and 2 under calf
- Clotbusters can be used if less than 48 hrs old
- Filter can be surgically placed

Nursing Care:
Monitor closely for:
- ***Bleeding especially in the urine, stool, skin or nose
- Change in level of consciousness (Intracranial bleed).
- If on heparin, protamine sulfate should be on hand
- If on warfarin, Vitamin K should be on hand
- Monitor CBC, ***particularly platelet count, coagulation studies (PT, aPTT, INR, etc.)

Educate
- on proper technique for sub-q injections if on heparin or LMWH (safer than heparin)
- Need to check in with the doctor regularly
- Take meds as ordered
- Labs as ordered
Teach patient prevention:
- Need to wear compression hose if ordered every day!
- Ambulation and leg exercises
- Adequate fluid intake
Teach to Avoid:
- Sitting with knees bent or crossed for long periods
- Stretch during long car or plane trips
- Standing for long periods

If Pulmonary Embolism occurs:
- Chest pain on inhalation
- Cough up blood
- SOB
- 1/5 die within the first hour

Diagnostics:
- CT
- Pulmonary angiogram
- D-Dimer

Treatment is emergent!:
- O2
- Heparin
- Pain relief
- Surgical removal of embolus

9

Superficial Venous Problems

Inflammation and clotting of superficial vessels

Varicosities and Chronic Venous Insufficiency

10

Superficial vessels: 
inflammation and clotting

- Most often in the leg vessels and perhaps the groin
- Slight injury can be the cause of the inflammation
- Sudden acute inflammatory reaction causes a thrombus to form and adhere firmly the vein wall lessening the likelihood of an embolus
- There are no surrounding muscles to squeeze and dislodge the clot
- May indicate a more serious condition (e.g., Hypercoagulability due to Cancer)

Symptoms and Diagnosis:
- Localized pain and swelling develop rapidly
- Reddened area over vein
- Warm and very tender to touch
- Vein feels like a hard cord
- May be confused with a cellulitis

Treatment:
- Most often will subside by itself within days
- May be weeks before the lumps/tenderness goes away completely
- Treated with analgesics and NSAIDs: Sometime a local can be injected and the thrombus removed. Compression dressing.
- If in the groin, may extend to deep vein: May break loose, may need to be tied off to prevent extension


11

Varicosities

- Weakness in the walls of the vessel
- Over time they become enlarged and don’t fit in the space they normally occupied so become elongated and convoluted
- Valves now separate and the pull of gravity cause the blood to flow backward causing more pressure and stretching

- Can be inherited
- Can be hormonal- pregnancy, menopause
- Old age, obesity, smoking, job- on your feet all day

Types:
Primary
Secondary
Reticular
Telangiectasias

S/S:
Unsightly
Commonly ach, especially when just forming
Legs feel restless, tired
Lower leg may itch especially if warm
Leads to scratching > Redness/rash
Though usually no complications, superficial phlebitis can occur

Treatment:
Goal: Relieve symptoms, improve appearance and prevent complications
- Walk at least an hour a day
- If sedentary, walk every hour
- Elevation
- Stockings- apply before you get out of bed
- Surgery
- Injection therapy
- Laser



12

Chronic Venous Insufficiency

Prone to infection
Could end up getting some skin grafting
Usually inside the ankle and around the back
Starts with edema and then gets brownish and leathery
Pain with walking
Cannot get shoes on at the end of the day

Treatment:
Herbs
Topical antibiotics
Wet to dry dressing
Vacuum
Moist dressing
Compression
Radiant heat
Debris the area
Skin grafts