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Flashcards in Week 7 Deck (31):
1

The vascular system is comprised of

Arteries and arterioles
Capillaries
Veins and venules
Lymphatic vessels

2

The vascular system depends on

Cardiovascular system
Systemic blood vessels
Circulating blood (volume/viscosity)
Nervous & endocrine system activity
Metabolic tissues needs
Lymphatic system

3

Vascular system

Function:
To meet the circulatory needs of the tissues
Constantly changing according to metabolic requirements
When supply doesn’t meet demand = ischaemia

How?
Blood flow (from high pressure to low pressure)
(from arterial [~100mmHg] venous [~4mmHg])
Flow rate = ΔP/R (pressure difference ÷ resistance)
Capillary Fluid exchange
Hydrostatic (blood pressure)/osmotic pressures (proteins)
Any extra between arterial supply & venous reabsorption lymph

Imbalance = oedema

4

Peripheral blood flow

Flow rate = ΔP/R! Affected by:-
Hemodynamic resistance
Blood viscosity
Vessel diameter
Regulation of peripheral vascular resistance
CNS (sympathetic = vasoconstriction)
Hormonal (noradrenaline/adrenaline/angiotensin)
Chemicals/proteins/hypoxia/pH
Movement of fluid across the capillary wall:
To meet metabolic needs
Hydrostatic & osmotic force

5

Pathophysiology heart failure

Left:
Pulmonary congestion & reduced cardiac output
Poor arterial blood supply
Right:
Venous congestion & ? reduced cardiac output

6

Pathophysiology alteration in vessel supply

Lymph/arterial/venous
Intact
Rupture – aneurysm/trauma
Patent
Atherosclerosis/thrombus/valve issues
Responsive
Vasospasm/arteriosclerosis/aging changes

7

Clinical manifestations of peripheral arterial disorders

Intermittent claudication
Pulses diminished or absent
Oedema – None/minimal
Skin changes: Trophic – cold/dry/shiny/hairless/thick opaque toe nails
Pallor when elevated
Red when dangling (dependent rubor)
Ulcers – tips of extremities/ painful/deep/circular/pale to black base or dry gangrene

8

Clinical manifestations of peripheral venous disorders

Pain: aching to cramp like, relieved by activity/elevation
Pulses usually present
Oedema – present/increases at the end of day
Skin changes: warm/thick/ tough/darkened/? dermatitis
Ulcers – medial malleolus/ pain variable/ superficial/irregular border/granulation base

9

Assessment of intermittent claudication

Muscular/cramping (ischaemic) type pain
Precipitated by exercise
Resolves within 10 mins of rest
Reproducible
Area depend on which vessel affected
Lack of blood supply of oxygen/nutrients when increase in demand
Caused by arterial supply failure
Anaerobic cellular metabolism

10

Common sites of Atherosclerotic Obstruction

Coronary arteries
Carotid arteries
Aortic bifurcation
Iliac and common femoral arteries
Distal popliteal artery

11

Modifiable risk factors for peripheral arterial disease

Smoking
Diet
Hypertension
Hyperlipidaemia
Diabetes
Obesity
Stress
Sedentary lifestyle
C-reactive protein (inflammation)
Hyperhomocysteinemia (clotting factor)

12

Non-modifiable risk factors for peripheral arterial disease

Age
Gender
Familial predisposition/genetics

13

Nursing assessment of PAD

Health history
Medications
Risk factors
Clinical manifestations of arterial insufficiency
Claudication and rest pain
Colour changes
Weak or absent pulses
Skin changes and skin breakdown
Arterial/venous/lymphatic (medical) diagnosis made

14

Diagnosis of PAD

Altered peripheral tissue perfusion
Chronic pain
Risk for impaired skin integrity
Knowledge deficient

15

Planning of PAD

Major goals include:
Increased arterial blood supply
Promotion of vasodilatation
Prevention of vascular compression
Relief of pain
Attainment or maintenance of tissue integrity
Adherence to self-care programme

16

Implementation of PAD

Exercises and activities:
Walking (stop with pain – gradually increase tolerance)
Graded isometric exercises.
Promote circulation & development of collateral circulation
Specialist advice before commencement
Contraindications include leg ulcers/cellulitis/thrombotic occlusions
Positioning strategies
Temperature
Effects of heat (vasodilation) & cold (avoid)
Stop smoking
Stress reduction (counselling)
Due to poor nutrition & oxygen supply the extremities are susceptible to injury/infection/poor healing
Protection of extremities and avoidance of trauma
Good hygiene/gentle soap/moisturisers
Regular inspection of extremities (infection/inflammation)
Podiatric care (foot wear/nail care)
No constricting clothing
Good nutrition/stop smoking
Weight reduction as necessary
Nurse - Patient education essential

17

Complications of PAD

Atrophy of skin/nerves /muscles
Delayed healing/wound necrosis/infection/gangrene

18

Medical treatment for PAD

Medical (relieve symptoms/improve arterial supply)
Risk factor modification (smoking/diet/exercise)
Drugs (aspirin …/prostaglandin)
Management of diabetes/hypertension/obesity
Refer to podiatrist/physio/rehab. speciallist

Surgical (relieve symptoms/improve arterial supply)
PTBA (balloon angioplasty/stent)
Peripheral arterial bypass graft (femoral-popliteal)
Endarterectomy/patch graft
Amputation (last resort)

19

Nursing Management – Peripheral arterial bypass graft

Vital signs/neurovascular observations (pulses)
Graft patency obs (doppler)
Ankle brachial index (8hrly)
IDC 1hrly measures
Complex invasive line care
Wound care (bleeding/haematoma)
Elevate extremity/gently exercise
Graduated compression stockings(?)
Analgesia
Discharge advice/patient education
Care of co-morbidities

20

Aortic aneurysm

An aneurysm is a localised sac or dilation formed at a weak point in the wall of the aorta.

Type:
True – wall of artery forms the aneurysm
False – disruption of all artery layers (trauma/infection)
Shape
Position (thoracic 85%)

21

Risk factors for aortic aneurysm

Atherosclerosis in most cases
Genetic link/congenital vessel wall weakness
Trauma/disease/inflammation
After formation - tends to enlarge
Smoking/hypertension

22

Clinical manifestations of aortic aneurysm

(often asymptomatic/varied)
Pain/throbbing/”beating”
Ascending – voice hoarseness/dysphagia/venous return interruption (distended neck vessels/oedema)
Thoracic – deep spreading chest pain
Abdominal –back pain/bowel pressure/bruit/palpable
From thrombosis of smaller vessels

23

Diagnosis of aortic aneurysm

Routine examination
Pulsatile mass in 80% cases/bruit
Chest x-ray – calcification/widening of aorta
ECG to rule out MI
Echocardiology – aortic insufficiency
Ultrasound/ CT scan/MRI scan
Angiography – useful to assess other vessel involvement

24

Medical management for aortic aneurysm

Depends on symptoms/prognosis/position/ patient co-morbidities
High rate of surgical death/complications
Prevent rupture/early detection essential
Conservative (small aneurysm/poor surgical risk)
Risk factor/behaviour modification (hypertension/smoking/sedentary lifestyle)
Manage co-morbidities & other atherosclerosis

Operative
Surgical - graft or primary closure
Endovascular – femoral/iliac artery catheter accessed
minimally invasive/strict criteria

25

Post op nursing care for an ascending aortic aneurysm

Complex major surgery/surgical ICU/HDU area
Patient may have complex co-morbidities
Vital signs/neurovascular – frequent/regular
Monitoring for signs of occlusion/thrombosis/emboli
Monitor all systems (respiratory/renal – IDC 1 hrly)
Monitor T° 4 hrly (graft rejection)
Assess site/wound – haematoma/ooze/inflammation
Often first or second day post op walking
Surgeon/facility dependent

26

Risk factors for deep vein thrombosis

over 35 years
smoker
family history
oral contraceptive
obesity

27

Clinical manifestations of DVT

Maybe nil or non specific
Unilateral pain/warm/erythema
Systemic T°/tender/Homan’s sign

28

DVT prevention/prophylaxis

Early mobility/ambulation/SOOB
Bed exercises/deep breathing & coughing/alter position
Compression stockings/(good for distal DVT but what about proximal)? – Fit correctly!!!!
Pneumatic compression devices - SCDs/ICDs
Drugs
Anticoagulants - Heparin(LMWH)/enoxaparin/warfarin (phasing out)/others

No prophylaxis – 26% patients developed DVT
Stockings alone – 13% patients developed DVTs (50% )
Stockings and anticoagulants – only 4% patients developed DVTs

29

DVT treatment

Prevent further growth & fragmentation (into PE)
Bed rest with limb elevation
Anticoagulants (prevent further thrombi)
Thrombi resolves naturally (not through anticoags)
Then mobilise with quality stockings (not the cheapies)
Drug Therapy
Heparin – IV infusion/SCI/Warfarin/more modern types
Thrombolytics
Previously (with DVTs) only for limb threatening situations
Now being trialled to ascertain treatment as more routine

Surgery (uncommon):
Vena cava filter
Open thrombolectomy

30

Contraindications of Pneumatic Compression Devices/stockings

The obese (can’t fit them correctly/tourniquet the limb!)
Heart failure
Assess your patient/history
Certain conditions/diseases of the lower limbs
Diabetic neuropathy
Severe oedema of the lower limb

31

Adverse events of pneumatic compression devices

Nerve palsies
Common peroneal nerve palsy
Paraesthesia of legs/feet
Compartment syndrome
Pressure ulcers
Slipping while walking (wear shoes/slippers!)