Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3: Arterial disorders such as Arterial occlusive disease, Arterial embolism, Arterial thrombosis, Thromboangiitis obliterans (Buerger’s disease), Aortitis, Aortoiliac disease, Aneurysms, Raynaud’s disease, and Thoracic outlet syndrome

1. Nursing Care of Clients with
Peripheral Vascular Disorders

2. Overview of Disorders

3. PERIPHERAL ARTERIAL OCCLUSIVE
DISEASE
Upper extremity arterial occlusive disease
Arterial embolism; Arterial thrombosis
Thromboangiitis obliterans (buerger’s disease)
Aortitis
Aortoiliac disease
Aneurysms
Aortic aneurysm
Thoracic aortic aneurysm
Abdominal aortic aneurysm
Dissecting aorta
Other aneurysms
Raynaud’s disease
Thoracic outlet syndrome

4. VENOUS DISORDERS
Venous Thrombosis, Deep Vein Thrombosis (DVT),
Thrombophlebitis, and Phlebothrombosis
Chronic Venous Insufficiency
Leg Ulcers
Varicose Veins
Cellulitis

5. LYMPHATIC DISORDERS
Lymphangitis and Lymphadenitis
Lymphedema and Elephantiasis

6. Peripheral vascular disease (PVD)
includes disorders that alter the natural flow of blood
through the arteries and veins of the peripheral circulation.
affects the lower extremities much more frequently than the
upper extremities.
Generally, a client with a diagnosis of PVD has arterial
disease (peripheral arterial disease [PAD]) rather than venous
involvement.
Some clients have both arterial and venous disease.

7. Peripheral Arterial/ Venous Disease
A chronic disorder in which partial or total occlusion
deprives the lower extremities of oxygen and nutrients
Tissue damage occurs below the level of the arterial
occlusion
Atherosclerosis - most common cause of peripheral arterial
disease

8. PERIPHERAL ARTERIAL OCCLUSIVE
DISEASE

9. Peripheral Arterial Disorders (PAD)
Aka: Peripheral arterial occlusive disease
Arterial Occlusive Disorders
Lower extremity arterial disease (LEAD)
Is the arterial insufficiency of the extremities
most common cause is Arteriosclerosis Obliterans (ASO)
lower extremities are more commonly affected.
More prevalent among men 50-70 years old

10. Assessment
intermittent claudication: hallmark of the disease
rest pain: severe
is a numbness or burning, often described as feeling like a
toothache, that is severe enough to awaken clients at night.
it may be so excruciating that it is unrelieved by opioids.
elevating the extremity or placing it in a horizontal position
increases the pain, whereas placing the extremity in a
dependent position reduces the pain.
In bed, some sleep with affected leg hanging over the side of the
bed.
Some patients sleep in a reclining chair in an attempt to relieve
the pain.

11. Assessment
Coldness or cold sensitivity – Coldness in the feet with
exposure to a cold environment, associated with blanching or
cyanosis due to ischemia
extremity
Cold and pale when elevated
or ruddy and cyanotic when placed in a dependent position
nails : thickened and opaque
Skin: shiny, atrophic, and dry, with sparse hair growth.
comparison of the right and left extremities.
Bruits may be auscultated with a stethoscope

12. Assessment
Ulceration and gangrene. May be due to ischemia ot
trauma. Impaired tissue perfusion inhibits healing
process
Edema. Due to severe obstruction
Sexual dysfunction. Occlusion of terminal aorta
decreases blood supply to the penile arteries
Gangrene
muscle atrophy

13. Assessment
peripheral pulses: important part of assessing arterial
occlusive disease.
Unequal pulses between extremities or the absence
of a normally palpable pulse is a sign of peripheral
arterial disease.
The femoral pulse in the groin and the posterior tibial
pulse beside the medial malleolus are most easily palpated.

17. Diagnostic Findings
CW Doppler and ankle-brachial indices (ABIs)
Treadmill testing for claudication
duplex ultrasonography

18. Medical Management
Control hypertension
Reduce risk factors:
Control serum lipids
Weight reduction
Low fat low cholesterol diet
Daily walking
Cessation of tobacco use
Note: Patients should not be promised that their symptoms will
be relieved if they stop tobacco use, because claudication may
persist, and they may lose their motivation to stop using
tobacco
Skin and foot care

19. PHARMACOLOGIC THERAPY
hemorheologic and antiplatelet agents
Vasodilators
Antihyperlipidemics

20. hemorheologic agent
Pentoxifylline (Trental)
Increase flexibility of RBCs
decreases blood viscosity by inhibiting platelet aggregation and
decreasing fibrinogen and thus increases blood flow in the
extremities.

22. Antiplatelet agents
aspirin (acetylsalicylic acid, Ancasal) : 325 or 81
mg/day
clopidogrel (Plavix)
ticlopidine (Ticlid)
Cilostazol (Pletal) : inhibit platelet aggregation, inhibit
smooth muscle cell proliferation, and increase vasodilation.

23. Surgical Management
Percutaneous transluminal angioplasty
Balloon angioplasty
Laser angioplasty
Stent insertion
Atherectomy
Arterial revascularization : Arterial bypass; vascular grafting
Endarterectomy
Endovascular surgery
Amputation

24. SURGICAL MANAGEMENT
choice of the surgical procedure depends on the
degree and location of the stenosis or occlusion.
overall health of patient and length of procedure that can be
tolerated.

25. vascular grafting or endarterectomy
For patients, severe intermittent claudication and disabling or
when the limb is at risk for amputation because of tissue loss
palliative therapy of primary amputation rather than an
arterial bypass.

26. Endarterectomy
an incision is made into the artery
atheromatous obstruction is removed.
artery is then sutured closed to restore vascular integrity

28. Bypass grafts
are performed to reroute the blood flow around the stenosis
or occlusion.
Before bypass grafting, the surgeon determines where the
distal anastomosis (site where the vessels are surgically
joined) will be placed.
The distal outflow vessel must be at least 50% patent for the
graft to remain patent.
A higher bypass graft patency rate is associated with keeping
the length of the bypass as short as possible.

29. femoral-to-popliteal graft
surgical procedure of choice if atherosclerotic occlusion is
below the inguinal ligament in the superficial femoral artery
Class. based on location of distal anastomosis
above-knee
below-knee grafts

30. Bypass grafts may be synthetic or autologous vein.
Native vein or autologous vein
greater or lesser saphenous vein or a combination of one of the saphenous
veins and an upper extremity vein such as the cephalic vein are used to
meet the required length.
woven or knitted Dacron, expanded polytetrafluoroethylene
(ePTFE, such as Gore- Tex or Impra), collagen-impregnated,
and umbilical vein.

31. Nursing Management
Maintaining circulation
Maintain skin integrity and prevent infection
Monitoring and managing potential complications
Promoting home and community-based care

32. Maintaining circulation: Post op care
Monitor the ff q hour for first 8 hours and then every 2 hours
for 24 hours
Pulses
color and temperature of the extremity
capillary refill
Sensory and motor function of the affected extremities
Note: Compare extremities
Doppler evaluation
ABI : at least once q 8 hrs for 1st 24 hrs and then OD until
discharge (not usually assessed for pedal artery bypasses).

33. Disappearance of a pulse that was present may
indicate thrombotic occlusion of the graft
Notify surgeon STAT

34. Maintain circulation
Warm environmental temperature
Place legs in slight dependency to promote arterial flow
Avoid pressure on affected extremity; use padding for support
Avoid vigorous massage of extremities
Avoid
Chilling and exposure to cold
Avoid contrictive clothing
Crossing legs
Quit smoking
Do not go barefootd
Trim toenails straight
Avoid scratching or rubbing feet

35. Exercise
may improve arterial blood flow to the affected limb through
buildup of the collateral circulation.
is individualized for each client
Contrindicated: severe rest pain, venous ulcers, or gangrene
Initiate gradually and is slowly increased
nurse instructs the client to walk until the point of
claudication, stop and rest, and then walk a little farther.
Eventually, clients are able to walk longer distances as
collateral circulation develops.

36. Positioning
To promote circulation
Still controversial
Some have swelling in extremities
Because swelling prevents arterial flow, should elevate feet at rest,
but shld be taught to refrain raising legs above heart level.
Extreme elevation slows arterial blood flow to the feet.
In severe cases, clients with PAD and swelling may sleep with the
affected limb hanging from the bed, or they may sit upright in a
chair for comfort.
avoid crossing their legs, which may interfere with blood flow.

37. Maintain skin integrity and prevent
infection
Examine skin on a daily basis
Take daily bath and dry the skin gently
Apply moisturizing cream/lotion in the skin. Avoid using
alcohol
Foot care
Wear comfortable, well fitted pair of shoes
Avoid direct heat application over the extremities

38. Monitoring and managing potential
complications
UO
central venous pressure
mental status
pulse rate and volume
permit early recognition and treatment of fluid imbalances.

39. Monitoring and managing potential
complications
Bleeding / Hematoma
can result from the heparin administered during surgery or from an
anastomotic leak.
Avoid leg crossing and prolonged extremity dependency
to prevent thrombosis.
Edema
normal postoperative finding
elevating the extremities and encouraging the patient to exercise the
extremities while in bed reduces edema.
Elastic compression stockings
care must be taken to avoid compressing distal vessel bypass grafts.
Severe edema of the extremity, pain, and decreased sensation of
toes or fingers can be an indication of compartment syndrome.

40. Promoting home and community-based
care
Assess patient’s ability to manage independently.
Determine if patient has a network of family and friends to
assist with ADL
Encourage to make the lifestyle changes necessary with a
chronic disease, including pain management and
modifications in diet, activity, and hygiene (skin care).
Ensure has knowledge and ability to assess for any postop
complications such as infection, occlusion of the artery or
graft, and decreased blood flow.
Assists in developing a plan to stop using tobacco.

41. Promote activity
Regular aerobic exercises such as walking, swimming,
jogging , bicycling
Do exercises 30-45 minutes 3-4 times a week

42. Prevention
Primary – provide info on the effects of the following:
Cigarrete smoking. Nicotene causes vaso-constriction, spasms
of the arteries, reduced circulation to the extremities. CO2
reduces O2 transport to the tissues
Hypertension. Cause elastic tissue in the arteries to be replaced
by fibrous collagen tissue reducing arterial elasticity and
increases resistance.

43. Hyperlipidemia. Contribute to atherosclerotic plaques in vessels
Obesity. Added burden on the heart and blood vessels
Physical inactivity. Compromises circulation
Emotional stress. Stimulates the sympathetic response which
results to vasocontriction
DM. Changes in glucose and fat metabolism enhances
atherosclerosis

44. Secondary prevention
Encourage clients with early symptoms to seek medical care to
prevent complications
Tertiary prevention
Rehabilitation . Exercises to develop collateral circulation.

46. Acute Peripheral Arterial Occlusion

47. ACUTE PERIPHERAL ARTERIAL
OCCLUSION
Aka: Arterial embolism and arterial thrombosis
arterial occlusions : sudden and dramatic.
Occlusion may affect the upper extremities, but it is more
common in the lower extremities.
most common cause : embolus or local thrombus
Emboli originating from heart: are most common
Risk factors
AMI within the preceding weeks
atrial fibrillation
infective endocarditis
chronic heart failure

48. Assessment
severe pain below level of the occlusion
occurs even at rest.
affected extremity : cool or cold, pulseless, and mottled.
Minute areas on the toes may be blackened or gangrenous.
"six P's" of ischemia:
pain, pallor, pulselessness, paresthesia, paralysis, and
poikilothermia (coolness) of the involved extremity.

49. Interventions
initiate treatment promptly to avoid permanent damage or
loss of an extremity.
Anticoagulant therapy with unfractionated heparin (UFH;
Hepalean*) is usually the first intervention to prevent further
clot formation.
bolus of up to 10,000 units
angiography

50. Surgical treatment
Emergencysurgical thrombectomy or embolectomy
with local anesthesia
to remove the occlusion.
physician makes an incision, which is followed by an
arteriotomy (a surgical opening into an artery).
then inserts a Fogarty catheter into artery and retrieves
embolus.
may be necessary to close artery with patch graft.

51. Fogarty catheter

52. Preop nursing care
bed rest with extremity level or slightly dependent (15
degrees).
affected part is kept at room temperature and
protected from trauma.
Heating and cooling pads are contraindicated
ischemic extremities are easily traumatized by alterations in
temperature.
If possible, tape and electrocardiogram electrodes should not
be used on the extremity
sheepskin and foot cradles are used to protect the leg
from mechanical trauma.

53. PostopNursing care
Monitor affected extremity for improvement in color,
temperature, and pulse, other extremities for s/s of new thrombi
or emboli.
mild incisional pain is normal
Watch closely for complications caused by reperfusing the artery
after thrombectomy or embolectomy
spasms and swelling of the skeletal muscle.
Swelling of the skeletal muscles is characterized by edema, pain on
passive movement, poor capillary refill, numbness, and muscle
tenseness.
Fasciotomy (surgical opening into the tissues) may be necessary to
prevent further injury and save the limb.

54. Buerger’s disease

55. Buerger’s disease
Inflammatory, non-lipid occlusive condition of small to medium
arteries followed by vein that impairs circulation to the legs, feet
and occasionally hands
Rare, occurs most often in men, ages of 20 and 35 years, all
races

56. Cause
Unknown
believed to be autoimmune disease (autoimmune vasculitis)
Linked to smoking or chewing of tobacco (suggesting a
hypersensitivity reaction to nicotine)

57. Pathophy
characterized by recurring inflammation of the intermediate and
small arteries and veins of the lower and (in rare cases) upper
extremities.
Polymorphonuclear leukocytes infiltrate the walls of small and
medium sized arteries and veins
Thrombus formation and occlusion of vessels
Diminished blood flow produces ulceration and later on gangrene
lower extremities; upper extremities or viscera can also be
involved
Generally bilateral and symmetric with focal lesions.
Superficial thrombophlebitis may be present.

59. Clinical Manifestations
intermittent claudication
Most characteristic manifestation
foot cramps, especially of the arch (instep claudication), after
exercise.
relieved by rest
often, a burning pain is aggravated by emotional disturbances,
nicotine, or chilling.
Cold sensitivity of the Raynaud type is found in one half the
patients and is frequently confined to the hands.
Digital rest pain is constant, and the characteristics of the pain
do not change between activity and rest.

60. Clinical Manifestations
intense rubor (reddish blue discoloration) of the foot
absence of pedal pulse but normal femoral and popliteal
pulses.
absent or diminished radial and ulnar artery pulses
Various types of paresthesia may develop.
As the disease progresses, definite redness or cyanosis of the
part appears when the extremity is in a dependent position.
generally bilateral, but color changes may affect only one
extremity or only certain digits.
Color changes may progress to ulceration, and ulceration with
gangrene eventually occurs.

61. The feet of a patient with Buerger
disease.
Note the ischemic ulcers
on the distal portion of the
left great, second, and fifth
toes.
Though the patient's right
foot is normal in gross
appearance, angiography
demonstrated
compromised arterial flow
to both feet.
http://emedicine.medscape.com/article/460027-
overview#showall

62. Superficial
thrombophlebitis of the
great toe in a patient with
Buerger disease.
http://emedicine.medscape.com/article/460027-
overview#showall

63. The tobacco smoke–
stained fingers of this
patient suggested the man's
diagnosis (Buerger disease).
The patient presented with
small, painful ulcers on the
tips of his thumb and ring
finger.
http://emedicine.medscape.com/article/460027-
overview#showall

64. This lower extremity
arteriogram of the
peroneal and tibial arteries
of a patient with Buerger
disease demonstrates the
classic findings of multiple
small- and medium-sized
arterial occlusions with
formation of compensatory
"corkscrew collaterals."
http://emedicine.medscape.com/article/460027-
overview#showall

65. Diagnostic Findings
Allen's test
Segmental limb blood pressures
Demonstrate distal location of the lesions or occlusions.
Duplex ultrasonography/ Doppler ultrasonography
used to document patency of the proximal vessels and to
visualize the extent of distal disease.
Contrast angiography
Demonstrate diseased portion of anatomy.
Arteriography
Plethysmography
Venography

66. Management
main objectives: improve circulation to extremities,
prevent progression of disease, and protect extremities
from trauma and infection.
Treatment same as that for atherosclerotic peripheral
arterial disease.

67. Management
Exercise programs that Avoid injury to the
us gravity to fill and drain extremities
the blood vessels to Antibiotics , analgesics
promote adequate débridement of necrotic
circulation tissue: Minimize infection
Monitor pulses Regional sympathetic
Stop smoking block or
Absolute discontinuation ganglionectomy
of tobacco use is the only produce vasodilation and
strategy proven to prevent increase blood flow.
the progression of Buerger
disease. Amputation

68. Other treatments
Other treatment approaches exist but are less effective.
Intermittent compression of the arms and legs to
increase blood flow to extremities
Spinal cord stimulation
therapeutic angiogenesis
Medications to stimulate growth of new blood vessels
Vasodilators: rarely prescribed
Lumbar sympathetectomy
cut nerves to affected area to control pain and increase blood
flow; controversial

69. SURGICAL MANAGEMENT OF
COMPLICATIONS
Amputations
If gangrene of a toe develops as a result of arterial occlusive
disease in the leg,
below-knee amputation (BKA) or above-knee amputation
toe amputation or even transmetatarsal amputation
Indications
worsening gangrene, especially if the infected area is moist,
severe rest pain, or fulminating sepsis.

70. NURSING MANAGEMENT OF
COMPLICATIONS
Postop care amputation
Elevate stump for first 24 hours to promote venous return and
minimize edema.
The incision is monitored for signs of hematoma (unapproximated
suture line, discoloration or ruddy color changes of the skin along the
suture line, tenderness with palpation, or oozing of dark blood from
the suture line).
Assess fit of elastic bandages and ensures integrity of wrap and
continued ability to fit two fingers between layers of wrap.
Distal skin color and warmth are assessed, if accessible, and recorded.
Elastic bandages are removed and reapplied as prescribed by the
surgeon (eg, every 6 hours using figure-of-eight turns).

71. NURSING MANAGEMENT
grief, fear, or anxiety r/t loss of limb.
Encourage discuss his or her feelings.
Spiritual advisors and other health care team members are
consulted
Recovery and rehabilitation require multidisciplinary care
(e.g., physicians, physical and occupational therapists,
prosthetists, dietitians, nurses, discharge coordinators).
prosthetic device fitting

72. Discharge planning
Assess ability to manage independently.
Assist in developing a plan to stop using tobacco and to
manage pain.
Encourage to make the lifestyle changes necessary with a
chronic disease, including modifications in diet, activity, and
hygiene (skin care).
Determine whether patient has a network of family and
friends to assist with ADL.
Ensure that patient has knowledge and ability to assess for
any postoperative complications such as infection and
decreased blood flow.

73. Lifestyle and home remedies
Take care of fingers and toes
Check the skin on arms and legs daily for cuts and scrapes,
keep in mind that if lost feeling to a finger or toe may not feel, for
example, a cut when it happens.
Keep your fingers and toes protected and avoid exposing them to cold.
Low blood flow to extremities means body can't resist infection as easily.
Small cuts and scrapes can easily turn into serious infections.
Clean any cut with water, apply antibiotic ointment and cover it with a clean
bandage.
Keep an eye on any cuts or scrapes to make sure they're healing.
If they get worse or heal slowly, see doctor promptly.
Visit your dentist regularly to keep gums and teeth in good health and
avoid gum disease, which in its chronic form is associated with Buerger's
disease.
http://www.mayoclinic.com/health/buergers-
disease/DS00807/METHOD=print&DSECTION=all

75. AORTIC ANEURYSM

76. AORTIC ANEURYSM
Abnormal dilatation of
the arterial wall caused
by localized weakness
and stretching in the
medial layer or wall of an
artery
An aneurysm is a localized
sac or dilation formed at a
weak point in wall of aorta
Can be located anywhere
along the aorta

77. Classification
classified by shape or form
saccular aneurysm
projects from one side of
the vessel only
fusiform aneurysm
If an entire arterial
segment becomes dilated
mycotic aneurysms
very small aneurysms due
to localized infection

78. What is the diference between true
and false aneurysm?
True anuerysm false aneurysms
all three tunica layers are or pseudoaneurysm
one in which the entire wall is
involved injured blood escapes between
tunica layers and they separate.
the blood is contained by the
surrounding tissues, with
eventual formation of a sac
communicating with the artery
(or heart).
If the separation continues, a
clot may form, resulting in a
dissecting aneurysm.

79. Classification
By location
Abdominal
Thoracic
Cerebral , etc

80. Etiologic Classification of Arterial
Aneurysms
atherosclerotic changes in the aorta
Congenital: Primary connective tissue disorders (Marfan’s
syndrome, Ehlers-Danlos syndrome) and other diseases (focal
medial agenesis, tuberous sclerosis, Turner’s syndrome, Menkes’
syndrome)
Mechanical (hemodynamic): Poststenotic and arteriovenous
fistula and amputation-related
Traumatic (pseudoaneurysms): Penetrating arterial injuries,
blunt arterial injuries, pseudoaneurysms
Inflammatory (noninfectious): Associated with arteritis
(Takayasu’s disease, giant cell arteritis, systemic lupus
erythematosus, Behçet’s syndrome, Kawasaki’s disease) and
periarterial inflammation (ie, pancreatitis)

81. Etiologic Classification of Arterial
Aneurysms
Infectious (mycotic): Bacterial, fungal, spirochetal
infections
Pregnancy-related degenerative: Nonspecific,
inflammatory variant
Anastomotic (postarteriotomy) and graft aneurysms:
Infection, arterial wall failure, suture failure, graft failure

82. Risk factors
Genetic predisposition
smoking (or other tobacco use)
Hypertension
Obesity
Stress
Hypercholesterolemia

83. Aortitis

84. Aortitis
is inflammation of the aorta, particularly of the aortic arch.
Two types
Takayasu’s disease
occlusive thromboaortopathy
is uncommon
syphilitic aortitis
Rare

85. Aorta
main trunk of arterial system
divided into
(1) ascending aorta (5 cm [2 inches] in diameter, contained in
the pericardium)
(2) aortic arch (extending upward, backward, and downward)
(3) descending aorta

87. Thoracic aorta is above diaphragm
Abdominal aorta is below the diaphragm.
further divided as
suprarenal (above renal artery level)
perirenal level (at renal artery level)
infrarenal (below renal artery level).

89. Takayasu’s disease
chronic inflammatory disease of the aortic arch and its branches
affects young or middle-aged women; Asian descent
Cause
nonatherosclerotic
exact pathologic mechanism is unknown
thought to be immune complex mediated
progresses from a systemic inflammation with localized arteritis to
end-organ ischemia bcoz of large vessel stenosis or obstruction.
Lesions are typically long, smooth areas of narrowing with or
without aneurysms

90. Takayasu’s disease: Diagnostic exams
diagnose and evaluate the lesions
Magnetic resonance angiography
CT
Duplex ultrasonography
Arteriography

91. Takayasu’s disease Management
early stage
Corticosteroids
cytotoxic immunosuppressive agents.
Selective PTA & Surgical revascularization
performed after suppression of the systemic vascular
inflammation.

92. Aortoiliac disease

93. AORTOILIAC DISEASE
If collateral circulation has developed, patients with a stenosis
or occlusion of the aortoiliac segment may be asymptomatic,
or they may complain of buttock or low back discomfort
associated with walking.
Men may experience impotence.
decreased or absent femoral pulses.

94. Medical Management
Treatment same as that for atherosclerotic peripheral arterial
occlusive disease.
aortobi iliac graft
distal anastomosis is made to iliac artery, and entire surgical
procedure can be performed within abdomen.
aortobifemoral graft
if iliac vessels are diseased
distal anastomosis is made to femoral arteries
Bifurcated woven or knitted Dacron grafts are preferred for this
surgical procedure.

95. Nursing Management
Preoperative assessment
brachial, radial, ulnar, femoral, posterior tibial, and dorsalis
pedis pulses ; establish baseline for follow-up after arterial
lines are placed

96. Nursing Management
Postoperative care
monitoring for signs of thrombosis in arteries distal to the
surgical site.
Assess color and temperature of the extremity, capillary refill
time, sensory and motor function, and pulses by palpation and
Doppler q 1 hr for 1st first 8 hrs and then q 2 hrs for 1st 24 hrs.
Report STAT to physician
Any dusky or bluish discoloration, coolness, capillary refill time greater
than 3 seconds, decrease in sensory or motor function, or decrease in
pulse quality

97. Nursing Management
Postoperative care
Monitor UO
Renal function may be impaired as a result of hypoperfusion
from hypotension, involvement of the renal arteries during the
surgical procedure, hypovolemia, or embolization of the renal
artery or renal parenchyma. V
VS, pain, and intake and output are monitored with the pulse
and extremity assessments.
Lab results monitored and reported
Ischemic bowel usually causes increased pain and elevated white
blood cell count (20,000 to 30,000 cells/mm3).

98. Nursing Management
Abdominal assessment
bowel sounds and paralytic ileus is performed at least q 8 hrs.
BS may not return b4 third postop day (normal)
(-) bowel sounds, (-) flatus, and (+) abdominal distention: indicates of
paralytic ileus.
Manual manipulation of the bowel during surgery may have caused
bruising, resulting in decreased peristalsis.
Nasogastric suction
may be necessary to decompress bowel until peristalsis returns.
liquid bowel movement b4 3rd postop day
may indicate bowel ischemia
may occur when mesenteric blood supply (celiac, superior
mesenteric, or inferior mesenteric arteries) is occluded.

99. THORACIC AORTIC ANEURYSM

100. THORACIC AORTIC ANEURYSM
Atherosclerosis: most
common cause
occur most frequently in
men, 40 and 70 years.
thoracic area - most
common site for a
dissecting aneurysm.
About one third of patients
with thoracic aneurysms
die of rupture of the
aneurysm

101. Clinical Manifestations
Symptoms are variable and depend on how rapidly the
aneurysm dilates and how the pulsating mass affects
surrounding intrathoracic structures.
Some :asymptomatic.
chest pain- most prominent symptom
usually constant and boring but may occur only when the
person is supine
unequal pulses and arterial pressure in upper extremities,
tracheal deviation, cyanosis, weakness

102. Clinical Manifestations
1. Dyspnea 1. result of pressure of the
sac against the trachea, a
main bronchus, or the
lung itself
2. Cough 2. frequently paroxysmal
and with a brassy quality
3. Hoarseness, stridor, 3. resulting from pressure
or weakness or against the left recurrent
complete aphonia laryngeal nerve

103. Clinical Manifestations
4. Dysphagia 4. due to impingement on
the esophagus by the
aneurysm.
5. Dilated superficial 5. when large veins in chest
veins of the chest, are compressed by the
neck, or arms aneurysm
6. Unequal pupils 6. Pressure against the
cervical sympathetic
chain

104. Diagnostic Findings
chest x-ray
transesophageal echocardiography
CT

105. ABDOMINAL AORTIC ANEURYSM
(AAA)

106. ABDOMINAL AORTIC ANEURYSM
Atherosclerosis: most common cause
common among Caucasians; affects men four times more
often than women; most prevalent in elderly patients
Most occur below the renal arteries (infrarenal aneurysms).
Untreated, the eventual outcome may be rupture and death.

108. Pathophysiology
All aneurysms involve a
damaged media layer of the
vessel.
After an aneurysm
develops, it tends to
enlarge.

109. Clinical Manifestations
feel heart beating in their If associated with
abdomen when lying down thrombus, a major vessel
feel abdominal mass or may be occluded or smaller
abdominal throbbing distal occlusions may result
pulsatile mass in from emboli.
middle and upper A small cholesterol,
abdomen platelet, or fibrin emboli
most important diagnostic may lodge in the
indication interosseous or digital
systolic bruit over mass arteries, causing blue
toes

110. Atheroemboli from small
AAAA produce livedo
reticularis of the feet (ie,
blue toe syndrome).
http://emedicine.medscape.com/article/756735-
overview#showall

111. Diagnostic Findings
Duplex ultrasonography or CT
used to determine the size, length, and location of the aneurysm
Ultrasonography
Watchful Waiting Period
For sml aneurysm
conducted at 6-month intervals until aneurysm reaches a size at
which surgery to prevent rupture is of more benefit than the
possible complications of a surgical procedure.
Some aneurysms remain stable over many years of
observation.

112. Conventional angiography
Angiography is used to diagnose the renal area. In this
instance, an endoleak represented continued pressurization of
the sac.

114. Gerontologic Considerations
Most occur ages of 60 and 90 years.
Rupture is likely with coexisting hypertension and with
aneurysms wider than 6 cm.
In most cases at this point, the chances of rupture are greater
than the chance of death during surgical repair.
If the elderly patient is considered at moderate risk for
complications related to surgery or anesthesia, the aneurysm
is not repaired until it is at least 5 cm (2 inches) wide.

115. MANAGEMENT: Aneursyms

116. MANAGEMENT: Aneursyms
Goals
Limit progression
Control BP
Recognizing early symptoms
Prevent rupture

117. Management
Size- <5cm and asymptomatic- follow up with serial
ultrasound every 3-12 months
>5cm elective repair
Growth rate- normally 2-8mm/year, if > 4mm/year consider
elective surgery
Symptomatic – mandates repair
control blood pressure
Systolic pressure is maintained at about 100 to 120 mm Hg with
antihypertensive medications
Correct risk factors
Pulsatile flow is reduced by medications that reduce cardiac
contractility (eg, propranolol [Inderal]).

118. SURGICAL MANAGEMENT
Surgery : treatment of choice for abdominal aneurysms wider than
5 cm (2 inches) wide or those that are enlarging
Endoaneurysmorrhaphy- opening the sac and suturing a prosthetic
graft to the normal aorta within the aneurysm
(Teflon/Dacron/Gortex)
Endovascular repair
Elective aneurysm repair
Via traditional open laparotomy
standard treatment
open surgical repair of the aneurysm by resecting the vessel and
sewing a bypass graft in place.

119. standard preoperative care
Type and crossmatch blood
Administer prophylactic antibiotics (cefazolin, 1 g intravenous
piggyback)
Insert a Foley catheter
Establish large-bore intravenous access
Monitor central venous pressure or establish Swan-Ganz
catheterization (if indicated)
Prepare the skin from the nipples to the mid thigh
Administer general anesthesia (with or without epidural
anesthesia)
Cell Saver use has become popular
Insert a nasogastric tube
http://emedicine.medscape.com/article/756735-overview#a11

120. Post Surgical Complications
Post op Renal failure
Ischemic colitis
Acute leg ischemia
Spinal cord ischemia- ligation of the artery of
Adamkiewicz which supplies the spinal cord
anterior spinal artery syndrome-paraplegia, rectal and
urinary incontinence, loss of pain and vibratory sense with
preservation of vibratory and proprioception
Aortic Graft infection
Sexual Dysfunction

121. Post Op Nursing Interventions
Thoracic Aneurysm Repair
Thoracotomy or median sternotomy approach is used
Aneurysm is exposed and excised and a graft or prosthesis is
sewn onto the aorta
Total cardiopulmonary bypass is necessary for excision of
aneurysms in the ascending and arch of the aorta
Partial cardiopulmonary bypass for descending aneurysms

122. Monitor for signs of hemorrhage
Monitor chest tubes for an increase in chest drainage
Assess sensation and motion of all extremities and notify
physician for deficits
Monitor serum creatinine, BUN and hourly outputs

123. Monitor for dysrhythmias
Monitor respiratory status
Encourage coughing and deep breathing
No lifting of heavy objects for 6-12 weeks
Avoid straining

124. SURGICAL MANAGEMENT:
Endovascular grafting
placement of endovascular stents
alternative for treating an infrarenal abdominal aortic aneurysm
Involves transluminal placement and attachment of a sutureless
aortic graft prosthesis across an aneurysm
can be performed under local or regional anesthesia.
performed if abdominal aorta and iliac arteries are not
extremely tortuous and if the aneurysm does not begin at the
level of the renal arteries.

126. SURGICAL MANAGEMENT:
Endovascular grafting
Potential complications
bleeding
hematoma, or wound infection at the femoral insertion site
Distal ischemia or embolization
dissection or perforation of the aorta
graft thrombosis
graft infection
break of the attachment system
graft migration
proximal or distal graft leaks
delayed rupture
bowel ischemia

127. Nursing Management
Preop
Anticipate rupture
Recognize that patient may have cardiovascular,
cerebral, pulmonary, and renal impairment from
atherosclerosis.
Assess functional capacity of all organ systems
Medical therapies designed to stabilize physiologic
function should be promptly implemented.

128. Nursing Management
Indications of a rupturing
Signs of impending rupture AAA
severe back pain or abdominal constant, intense back pain
pain
may be persistent or falling BP
intermittent localized in the
middle or lower abdomen to left decreasing hematocrit
of midline
Low back pain
because of pressure of the
aneurysm on the lumbar nerves.
a serious symptom, usually
indicating that the aneurysm is
expanding rapidly and is about
to rupture.

129. Rupture into peritoneal cavity : rapidly fatal
Retroperitoneal rupture of an aneurysm
May result in hematomas in the scrotum, perineum, flank, or penis.
Rupture into vena cava
Signs of heart failure or a loud bruit
results in higher-pressure arterial blood entering the lower-pressure
venous system and causing turbulence, which is heard as a bruit.
high BP and increased blood volume returning to right heart from
vena cava may cause R heart to fail.
The overall surgical mortality rate associated with a ruptured
aneurysm is 50% to 75%.

130. Possible complications of
Postoperative care surgery
intense monitoring of arterial occlusion
pulmonary, cardiovascular, hemorrhage
renal, and neurologic Infection
status. ischemic bowel
renal failure
impotence

131. DISSECTING AORTA

132. DISSECTING AORTA
Occasionally, in an aorta diseased by arteriosclerosis, a tear
develops in the intima or the media degenerates, resulting in
a dissection

133. Pathophysiology
Arterial dissections (separations) are commonly associated with poorly
controlled hypertension;
three times more common in men than in women
occur most commonly in the 50- to 70-year-old age group
Dissection is caused by rupture in the intimal layer.
A rupture may occur through adventitia or into the lumen through the intima,
allowing blood to reenter the main channel and resulting in chronic dissection
or occlusion of branches of the aorta.
As the separation progresses, the arteries branching from the involved area of
the aorta shear and occlude. The tear occurs most commonly in the region of
the aortic arch, with the highest mortality rate associated with ascending aortic
dissection. The dissection of the aorta may progress backward in the direction
of the heart, obstructing the openings to the coronary arteries or producing
hemopericardium (effusion of blood into the pericardial sac) or aortic
insufficiency, or it may extend in the opposite direction, causing occlusion of
the arteries supplying the gastrointestinal tract, kidneys, spinal cord, and legs.

134. Clinical Manifestations
Onset of symptoms - usually sudden.
Severe and persistent pain
tearing or ripping
anterior chest or back
extends to shoulders, epigastric area, or abdomen.
May be mistaken for an AMI

135. Clinical Manifestations
Cardiovascular, neurologic, and gastrointestinal symptoms are
responsible for other clinical manifestations, depending on the
location and extent of the dissection.
may appear pale
Sweating and tachycardia
elevated BP
BP markedly different from one arm to the other
if dissection involves the orifice of the subclavian artery on one side.
early diagnosis is usually difficult
because of the variable clinical picture associated with this condition

136. Diagnostic Findings
Arteriography
CT
transesophageal echocardiography
Duplex ultrasonography
magnetic resonance imaging

137. Management
Medical Management Nursing Management
Medical or surgical same nursing care with an
treatment depends on the aortic aneurysm requiring
type of dissection present surgical intervention
and follows the general
principles outlined for the
treatment of thoracic
aortic aneurysms.

138. OTHER ANEURYSMS

139. OTHER ANEURYSMS
peripheral vessels: subclavian artery, renal artery, femoral
artery, or popliteal artery
most often result of atherosclerosis
s/s
pulsating mass
disturbs peripheral circulation distal to it.
Pain and swelling develop because of pressure on adjacent
nerves and veins.

141. OTHER ANEURYSMS
Diagnostic exam
Duplex ultrasonography and CT to determine the size, length,
and extent of the aneurysm.
Arteriography may be performed to evaluate the level of
proximal and distal involvement.

142. OTHER ANEURYSMS
Surgical repair
replacement grafts or endovascular repair using a stent-graft or
wall graft, which is a Dacron or PTFE (polytetrafluroethylene)
graft with external structures made from a variety of materials
(nitinol, titanium, stainless steel) for additional support.

143. Nursing Management: endovascular
repair postop care
Supine 6 hours; head of bed elevated up to 45 degrees after 2
hours.
needs to use bedpan or urinal while on bed rest, or a Foley
catheter may be used.
VS and Doppler assessment of peripheral q 15 min four
times, then q 30 min for four times, then q hour for four
times, and then as directed by the physician or unit standards.
catheterization site is assessed when vital signs and pulses are
monitored.

144. Nursing Management: endovascular
repair postop care
Assess bleeding, swelling, pain, and hematoma formation.
Any changes in vital signs, pulse quality, bleeding, swelling, pain,
or hematoma are reported to the physician.
also notify if persistent coughing, sneezing, vomiting, or systolic
blood pressure above 180 mm Hg
Coz of increased risk hemorrhage.
If able to resume preprocedure diet encouraged drink fluids.
IV infusion may be continued until able drink normally.
Fluids are important to maintain blood flow through arterial repair
site and assist kidneys excreting IV contrast agent and other
medications used during procedure.
6 hrs post procedure
may able roll side to side and may ambulate with assistance to
bathroom.

145. RAYNAUD’S DISEASE

146. Raynaud’s disease
is a form of intermittent arteriolar vasoconstriction that
results in coldness, pain, and pallor of the fingertips or toes.
Vasospasm of the arterioles and arteries of the upper and
lower extremities; causes constriction of the cutaneous
vessels
occurs more frequently in cold climates and during winter

147. Raynaud's phenomenon Raynaud's disease
usually unilaterally. occurs bilaterally.
occurs in people older than occur between the ages of
30 years of age 17 and 50 years
can occur in either sex more common in women

148. The pathophysiology is the same for
both entities.
Clients often have an associated systemic connective tissue
disease, such as systemic lupus erythematosus or progressive
systemic sclerosis.
As a result of vasospasm, the cutaneous vessels are
constricted and blanching of the extremity occurs, followed
by cyanosis. When the vasospasm is relieved, the tissue
becomes reddened or hyperemic. The client's extremities are
numb and cold, and he or she may complain of pain and
swelling.
Ulcers may also be present. These attacks are intermittent
and can be aggravated by cold or stress. In severe cases, the
attack lasts longer and gangrene of the digits can occur.

150. Cause
The etiology is unknown.
many have immunologic disorders (scleroderma, systemic
lupus erythematosus, rheumatoid arthritis), obstructive
arterial disease, or trauma
associated with smoking
Rarely leads to gangrene

151. Prognosis
Varies
some patients slowly improve, some become progressively
worse, and others show no change.
Ulceration and gangrene are rare
however, chronic disease may cause atrophy of the skin and
muscles.
With appropriate patient teaching and lifestyle modifications,
the disorder is generally benign and self-limiting.

152. Clinical Manifestations
Classic clinical picture - Triphasic color changes in the
hands
Blanching (pallor or white) of the fingers after exposure to
cold or stress due to vasoconstriction and spasm
Cyanosis (blue) follows because of oxygen deprivation of the
tissues
Red skin as exaggerated reflow (hyperemia) when oxygenated
blood returns to the digits after the vasospasm stops.
The characteristic sequence of color change of Raynaud’s phenomenon is described as
white, blue, and red.

155. Symptoms
Numbness, tingling, and burning pain occur as the color change
bilateral and symmetric
may result from defect in basal heat production that eventually
decreases the ability of cutaneous vessels to dilate.
Episodes may be triggered by emotional factors or by unusual
sensitivity to cold.
Generally unilateral and affecting only one or two digits, the
phenomenon is always associated with underlying systemic disease.
Attacks are intermittent and can occur with exposure to cold or
stress
Affects primarily the hands less commonly the feet

156. Diagnostics
ANA titer
Arteriography
Doppler ultrasound

157. Medical Management
Avoid trigggers (e.g., cold, tobacco, stress) that provoke
vasoconstriction
Medications
Sympathectomy
Amputation

158. Vasodilating agents
Commonly prescribed drugs are
nifedipine (Procardia)
cyclandelate (Cyclospasmol)
phenoxybenzamine (Dibenzyline)
help to relieve the symptoms
can cause uncomfortable S/E (facial flushing, headaches,
hypotension, and dizziness)

159. Sympathectomy
For severe symptoms that cannot be alleviated by drugs
lumbar sympathectomy
physician cuts sympathetic nerve fibers that cause
vasoconstriction of blood vessels in the lower extremities.
effective when experiencing foot symptoms.
sympathetic ganglionectomy
for upper extremities, a similar procedure
may provide symptom relief.
long-term effectiveness is questionable.

160. Education of client is important in
prevention of complications.
Minimize exposure to cold
remain indoors as much as possible during cold weather
wear layers of clothing when outdoors
hats and mittens or gloves should be worn at all times when
outside.
Use fabrics specially designed for cold climates (e.g., Thinsulate)
warm up vehicles before getting in
To avoid touching cold steering wheel or door handle, which could elicit
an attack.
during summer, a sweater should be available when entering air-
conditioned rooms.
Maintain warm body temperature

162. Methods to prevent vasoconstriction
Avoid all forms of nicotine; Smoking cessation, nicotine gum
or patches used to help people quit smoking may induce
attacks
Avoid decongestants and caffeine

163. Nursing Management
decrease stress
help the client to identify stressors and provides suggestions for
reducing them.
Stress management classes
Avoid situations that may be stressful or unsafe.
Safety
Handle sharp objects carefully to avoid injuring the fingers.
Inform abt postural hypotension that may result from
medications (ex: calcium channel blockers)
safety precautions related to alcohol, exercise, and hot weather.

164. Complications
serious but uncommon
Gangrene
Amputation

165. THORACIC OUTLET SYNDROME

166. Thoracic outlet syndrome
is a compression of the subclavian artery at thoracic outlet by
anatomic structures, such as a rib or muscle.
arterial wall may be damaged, producing thrombosis or
embolization to distal arteries of the arms.
three common sites of compression in the thoracic outlet
• The interscalene triangle
• Between the coracoid process of the scapula and the pectoralis
minor tendon
• Most commonly, the costoclavicular space

168. more common in females
people whose occupations require holding their arms up or
leaning over, such as baseball players, golfers, or swimmers.
trauma (whiplash or after clavicular fracture)

169. s/s
neck, shoulder, and arm pain : may be intermittent.
numbness and moderate edema of extremity.
pain and numbness worse when arm is placed in certain
positions, such as over head or out to side.
Clients may have overdeveloped neck and shoulder muscles,
and the affected arm may appear cyanotic.

170. COLLABORATIVE MANAGEMENT
PT
Exercises
Avoiding aggravating positions, such as elevating the arms.
Surgical treatment
resection of anatomic structure that is compressing the artery.
performed only if has severe pain, has lost hand function, or is
responding poorly to conservative treatment.

171. References
Brunner
Ignatavicius
http://www.mayoclinic.com/health/buergers-
disease/DS00807/METHOD=print&DSECTION=all