VASCULAR DISORDERS

NR 240

Revised 2/09 JBorrero

ANATOMY & PHYSIOLOGY

ARTERIES WALLS ARE THICKER
DUE TO GREATER SMOOTH
MUSCLE, HENCE STRONGER &
CAN WITHSTAND HIGH
PRESSURE

ANATOMY & PHYSIOLOGY

PHYSICAL PRINCIPLES THAT
DETERMINE BLOOD FLOW
1.
2.

PRESSURE CREATED BY
PUMPING OF HEART
RESISTANCE OF BLOOD
PUMPED (PVR) PERIPHERAL
VASCULAR RESISTANCE
(CHANGE IN VESSEL RADIUS)

ARTERIAL DISORDERS
SUSTAINED HIGH ARTERIAL PRESSURE
INCREASES THE EFFECTS OF INJURY AND
DISEASE
EFFECTS OF ARTERIAL DISEASE CAUSES
TISSUE ISCHEMIA DEATH OF TISSUE
SEVERITY OF SYMPTOMS IS DEPENDENT
UPON METABOLIC RATE & TISSUE NEEDS
SURGERY MAY RE-ESTABLISH CIRCULATION

ARTERIAL ASSESSMENT
PURPOSE: TO DETERMINE
ADEQUATE TISSUE PERFUSION
GUIDE LINES
1. COMPARE UPPER & LOWER
2. COMPARE BILATERALLY
3. COMPARE DISTAL & PROXIMAL
4. SUPINE (VS) DEPENDENT
CHANGES

ARTERIAL ASSESSMENT

1.
2.
3.

MAJOR AREAS OF ASSESSMENT

CIRCULATION PULSE MEANS
PERFUSION
MOTION MUSCLES NEED
OXYGEN
SENSATION PAIN, BURNING,
PROPRIOCEPTION, NUMBNESS

ARTERIAL ASSESSMENT

CIRCULATION

CHECK PULSE POINTS

CAROTID
RADIAL
FEMORAL
DORSALIS PEDIS
POSTERIOR TIBIAL
CAPILLARY REFILL

ARTERIAL ASSESSMENT
PULSES ARE BASED ON A SCALE
0 to 4+
0 = NO PULSE
1+ = THREADY PULSE
2+ = NORMAL PULSE
3+ = BOUNDING PULSE
4+ = ANEURYSM

ARTERIAL ASSESSMENT

1.
2.

3.
4.
5.
6.
7.

ARTERIAL INSUFFICIENCY

SKIN COOL, SHINY THIN, ONION

LIKE
PAIN /W COLD
PALE /W ELEVATION
DISTAL PULSES OR ABSENT
DECREASED OR ABSENT HAIR
ISCHEMIC ULCERS
THICK NAILS

COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
DUPLEX ULTRASOUND
HELPS Dx NARROWING OR
OCCULUSION OF INTERNAL
CAROTIDS or DVT
FALSE (+) DUE TO
NO PATIENT PREP
CALCIFICATION
OF VESSELS
PAINLESS & SAFE
SUPINE POSITION

COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
SEGMENTED ARTERIAL PRESSURE
MONITORING
MEASURES PRESSURE DIFFERENCE
BETWEEN EXTREMITIES AT DIFFERENT
LEVELS
USES B/P MONITOR & DOPPLER

ANKLE/BRACHIAL INDEX
EXAMPLE:
BRACHIAL PRESSURE =120mmHg
ANKLE PRESSURE = 96mmHg

ABI = 96 / 120 = 0.8

NORMAL

0.9 - 1.2

RISK IS LOW

VASCULAR
DISEASE

0.6 0.9

SEVERE
DISEASE

< 0.5

MODERATE
RISK EXISTS
VERY HIGH
RISK EXISTS

ARTERIAL ASSESSMENT

CLAUDICATION
INTERMITTANT CRAMPING OF
SKELETAL MUSCLES WITH EXERCISE
STANDARD ABLE TO WALK ONE
CITY BLOCK W/O PAIN
(+) = PAIN WITH AMBULATION, PAIN
WITH ELEVATION, RELIEF WITH
DEPENDENT POSITION
Tx: pentoxyphylline (Trental)
cilostazol (Pletal)

ACUTE ARTERIAL
INSUFFICIENCY
THE 5

Ps

WHEN PRESENT = SURGICAL EMERGENCY!

PAIN
2. PALLOR
3. PULSELESSNESS
4. PARALYSIS
5. PARESTHESIA
1.

COMMON DIAGNOSTIC
VASCULAR TESTS

ANGIOGRAPHY (ANGIOGRAM)
INVASIVE TECHNIQUE USED WHEN
SURGICAL INTERVENTION IS BEING
CONSIDERED
USED TO DIAGNOSE
EMBOLI, THROMBOSIS, TRAUMA,
ANEURYSM, BUERGERS DISEASE,
ARTERIOSCLEROSIS

ARTERIAL DISORDERS
ARTERIAL SYSTEM PROBLEMS
CAN BE CONTROLLED BY
MODIFYING RISK FACTORS:
SMOKING
DIET
GLUCOSE CONTROL
ACTIVITY LEVEL
HYPERLIPIDEMIA
BP (DOUBLES RISK)

WHEN ARTERIES BECOME

OCCLUDED
HEALTHY ARTERIES ARE BLOOD
VESSELS WHICH ARE FLEXIBLE,
STRONG & ELASTIC

THEIR INSIDE LINING IS

SMOOTH SO BLOOD CAN FLOW
WITHOUT RESTRICTION
Risk Factors cause arteries to become
occluded.

Progression of Occlusion

PLAQUE DEPOSIT
ORIGINAL DIAMETER

ARTERIAL DISORDERS
PERIPHERAL ARTERIAL
INSUFFICIENCY / OCCLUSION
ASSESSMENT:
WEAK/ ABSENT PULSES
PAIN /W LEG ELEVATION
SKIN COOL TO TOUCH
PALE SKIN COLOR
THICKENED TOENAILS

ARTERIAL DISORDERS
GOALS:
1. IMPROVE PERIPHERAL ARTERIAL
CIRCULATION WITH EXERCISE
REGULAR EXERCISE SUCH AS
WALKING INCREASES
CIRCULATION

ARTERIAL DISORDERS
GOALS:
2. PREVENT VASCULAR COMPRESSION

AVOID RESTRICTIVE CLOTHING,

CROSSING LEGS, SITTING FOR
PROLONGED PERIODS

ARTERIAL DISORDERS
GOALS:
3. RELIEVE PAIN

CONSIDER ANALGESICS SO
PATIENT CAN PARTICIPATE IN
ACTIVITIES

ARTERIAL DISORDERS
GOALS:
4. MAINTAIN TISSUE INTEGRITY

AVOID TRAUMA, WEAR CORRECT

SHOE GEAR (NO BARE FEET!)
TEST WATER TEMP WITH HAND
NOT FOOT!
REGULAR PODIATRY CARE
GOOD NUTRITION

ANGIOPLASTY

BALLOON
ANGIOPLASTY
CATHETER
INSERTED
THROUGH AN
ARTERY
BALLOON IS
INFLATED AND
COMPRESSES
LESION

USED FOR
INSERTION OF
STENTS

ANGIOPLASTY

MEDICAL MANAGEMENT
THROMBOLYTIC THERAPY
USED TO DISSOLVE CLOTS:
Retavase, streptokinase, tPa
SURGICAL MANAGEMENT
1. GRAFTING BYPASS SURGERY
2. ENDARTERECTOMY REMOVAL OF
ATHEROSCLEROTIC PLAQUE
3. AORTO/FEMORAL/TIBIAL BYPASS

INTERVENTIONS
1.

RISK FACTOR MODIFICATION

SMOKING (Most significant RISK FACTOR)
NICOTINE CAUSES VASOSPASMS
WEIGHT LOSS
REDUCES WORKLOAD IN
EXTREMITIES
LOW FAT DIET WILL RETARD
PROGRESSION OF ATHEROSCLEROSIS
CONTROL HTN

INTERVENTIONS
2.

PAIN MANAGEMENT
INTENSITY IS VARIABLE
MANAGEMENT- RTC
PAIN MEDICATION
(MAY NOT BE EFFECTIVE)
DEPENDENT POSITION MAY
COMFORT

INTERVENTIONS
3.

MAINTAIN FLUID VOLUME

IN SEVERE STENOSIS PATIENT MUST
MAINTAIN SUFFICIENT BLOOD PRESSURE
TO AVOID COMPLETE OCCLUSION

INTERVENTIONS
4.

ACTIVITY
MONITOR CLAUDICATION
TEACH PATIENT PAIN IS NOT
HARMFUL, BUT A BODY SIGNAL
FOR NEED TO REST
EMPHASIZE: EXERCISE INCREASES
COLLATERAL CIRCULATION
CHECK WITH DOCTOR ABOUT ANY
EXERCISE
PROGRESSION SHOULD BE GRADUAL

INTERVENTIONS
5.

MAINTAINING TISSUE INTEGRITY

CHANGE POSITION FREQUENTLY
AVOID CROSSING LEGS
& CONSTRICTIVE CLOTHING
METICULOUS FOOT CARE (PODIATRIST)
PROTECT FROM INJURY
KEEP EXTREMITIES WARM
(NO HEATING BLANKET OR HOT WATER
BOTTLES!)

SURGICAL MANAGEMENT
S/P BYPASS SURGERY- Postop
NEUROVASCULAR ASSESSMENT
COMPLICATIONS

GRAFT OCCLUSION:THROMBOSIS
COMPARTMENT SYNDROME
GRAFT INFECTIONS
FISTULA/ULCER FORMATION

EDUCATE PATIENT TO

REPORT PAIN UNRELIEVED BY MEDS

STOP SMOKING
ID NORMAL HEALING PROCESS

ARTERIAL DISEASES
BUERGERS DISEASE [TAO]
(aka: Thromboangiitis Obliterans)
1. DISEASE IS LINKED DIRECTLY TO
SMOKING (REQUIRED HX FOR DX)
2. POSSIBLE IMMUNOPATHOGENESIS
3. INFLAMMATION PRODUCES CRITICAL
LIMB ISCHEMIA
4. DISEASE CAN PROGRESS PROXIMALLY

Raynauds Disease
VASOSPASTIC DISORDERS:
1. BLOOD VESSELS (FINGERS & TOES) GO
INTO SPASM
2. EXTREME SENSITIVITY TO TEMP
CHANGES (ESPECIALLY COLD)
3. MORE COMMON FEMALE > MALE
4. Color changes are Red/White/Blue

RAYNAUDS
CLASSIFIED:
1. RAYNAUDS DISEASE = WHEN
SYMPTOMS ARE THE ONLY PRESENTING
FACTOR
2. RAYNAUDS PHENOMENON = WHEN
SYMPTOMS ARE SECONDARY TO
ANOTHER CONDITION
EX: RA, SCLERODERMA, LUPUS, CARPAL
TUNNEL SYDROME, THORACIC OUTLET
SYNDROME

RAYNAUDS
DX:
1. BILATERAL
2. OCCURS X 2 YEARS
3. NO OTHER CAUSE
Prevention:
1. PROTECT FROM COLD EXPOSURE
2. AVOID EXCESSIVE EMOTIONAL STRESS
3. DO NOT USE VIBRATING TOOLS

ANEURYSM
ANEURYSM = AN
LOCALIZED
ABNORMAL
DILATION OF A
BLOOD VESSEL
HIGH RISK
IN
MARFANS
SYNDROME

Abdominal Aortic
Aneurysm:Pathophysiology
Aneurysm-permanent localized dilation
of an artery
-enlarges to 2x normal
diameter
-middle layer of artery is
weakened
-HTN produces more tension
and enlargement within the artery

AORTIC ANEURYSMS
Location: Thoracic
Abdominal aortic aneurysms
Etiology:
Atherosclerosis (+HTN & smoking)
Syphillis
Marfan Syndrome
Ehlers-Danlos syndrome

AAA Assessment
Upper abdomen pulsation, left of
midline
+ bruit over mass
Abdominal, flank or back pain- if
leaking or ruptured
Abd Xray- Eggshell Calcification
Cat scan
Aortic angiography
Ultrasonography

Interventions
Nonsurgical
Surgical- AAA Resection
- Endovascular stent graft

Post-op care of the AAA patient:

VENOUS
ANATOMY & PHYSIOLOGY
VEINS HAVE THIN WALLS
(LESS SMOOTH MUSCLE)
ALLOW VESSELS TO DISTEND
MORE THAN ARTERIES

Venous System
ANATOMY & PHYSIOLOGY
BLOOD FLOWS AGAINST
GRAVITY BECAUSE:
VALVES ONE WAY VALVES
PREVENT BACKFLOW. (VALVE
COMPETENCY DEPENDS UPON
INTEGRITY OF VEIN WALL)

MUSCLE CONTRACTION MILKS

BLOOD THROUGH VESSELS

VENOUS ASSESSMENT

1.
2.
3.
4.
5.
6.

VENOUS INSUFFICIENCY

DRY, FLAKY
(BROWN & BLOTCHY)
PURPLE DEPENDENT
ELEVATION s DEPENDENT EDEMA
EDEMA MAY OBLITERATE PULSES
VENOUS STASIS ULCERS
PARESTHESIAS

Disorders of Venous
Circulation

PHLEBITIS-Vein
inflammation

THROMBOPHLEBITIS
INFLAMMATION OF
WALLS OF VEINS WITH
CLOT FORMATION

PHLEBOTHROMBOSIS
CLOT DEVELOPS DUE
TO VENOUS STASIS OR
THICK BLOOD
HYPERCOAGUABILITY
& INFLAMMATION
DVT- Deep Vein
Thrombosis

VENOUS DISORDERS
VIRCHOWS TRIAD
PREDISPOSING FACTORS
a)
b)
c)

VENOUS STASIS Bedrest, BP,

HYPOVOLEMIA,
HYPERCOAGULABILITY CANCER,SMOKING,
POLYCYTHEMIA, SURGERY, SEPSIS, OC
ENDOTHELIAL DAMAGE STIMULATES
PLATELET AGGREGATION, VENOUS
INFLAMMATION

VENOUS DISORDERS
Other Risk Factors
d)
e)

f)
g)
h)
i)
j)
k)

IMMOBILIZATION PARALYSIS, PROLONGED

BEDREST, LONG PLANE OR CAR RIDES
DISEASE PROCESSES SEPSIS,
SLE,HEMATOLOGICAL DISORDERS, MS,MALIGNANCY,
CHF, MI, ULCERATIVE COLITIS
PRESSURE OBESITY, PREGNANCY, TUMOR
TRAUMA FRACTURES, VENIPUNCTURE
CLOTTING DYSFUNCTION
SURGICAL PROCEDURES HIP, GYN & UROLOGICAL
& in age >40
OC use- especially in women who smoke
OTHER DEHYDRATION, ADVANCED AGE

VENOUS DISORDERS
DEEP VENOUS THROMBOSIS (DVT)
1. PATHOPHYSIOLOGY DEEP VEIN CLOT
MOST COMMON IN LOWER LEG (CALF)
UNDIAGNOSED DVT OCCURS IN 50% OF
PATIENTS WITH PULMONARY EMBOLI

Assessment of DVT
S&S
-Calf or groin tenderness
-Pain that can be dull or aching, especially when walking
-Sudden onset of unilateral swelling of the leg
-Cyanosis of the affected extremity
-Slightly elevated temp
-General malaise

Assessment of DVT
Homans Sign-pain on dorsiflexion of foot
NO LONGER ADVISED-can increase the risk of
detaching the thrombus as the calf muscle
contract
Coag studies
D Dimer-increased values with venous thrombosis,
PE, DIC and Malignancy
Duplex Scan

INTERVENTIONS
*Bedrest and leg elevation
*Warm moist soaks may be ordered
*Evaluate for PE
*Anti-inflammatory drugs for superficial
thrombophlebitis ASA or NSAIDS
*Heparin therapy
*Warfarin (Coumadin)

Heparin Therapy
1.Prior to initiation of therapy:
Hx of bleeding disorders
CBC w/ platelet count
UA
Stool for occult blood
Creatinine level
PTT,PT, INR baseline

2. Heparin bolus is given IVP (100u/kg) followed by

continuous infusion and protocol
3. Goal is to attain aPTT level 1.5-2.5x normal

Heparin therapy
4. Assess for signs and symptoms of bleeding
5. Monitor platelet counts- can lead to heparin induced
thrombocytopenia.
6. Antidote available- protamine sulfate

Other Options:
LMWH-Longer half-life and more predictable
Lovenox- 1mg/kg Adjust for renal pts
Fragmin
Coumadin- started while pt is on heparin
-takes 3-4 days to be therapeutic
-monitor INR/PT
-antidote-Vitamin K

VENOUS DISORDERS
TREATMENT
a)

PREVENTIVE
i.
ii.
iii.

EARLY AMBULATION
EXTERNAL COMPRESSION (VCB)
PROPHYLACTIC ANTICOAGULANTS
LOW DOSE HEPARIN
LOW MOLECULAR WT. HEPARIN (FRAGMIN)

b)

WHEN DVT EXISTS

i.
ii.
iii.

BR TO CHANCE OF EMBOLI
ELEVATION TO VENOUS RETURN & EDEMA
ANTICOAGULANTS PREVENT CLOTS FROM
INCREASING (THEY DO NOT DISSOLVE THEM!)

VENOUS DISORDERS
AMBULATION PERMITTED WHEN EDEMA .
BELOW KNEE TEDS USED IF NO ARTERIAL
DISEASE
(TEDS MAY INTERFERE WITH ARTERIAL FLOW)
THROMBECTOMY SURGICAL TREATMENT OF
CHOICE WHEN ARTERIAL FLOW IS AFFECTED
BY DVT
(GREENFIELD FILTER PREVENTS SHOWER OF
PULMONARY EMBOLI) INSERTED IN INFERIOR
VENA CAVA

GREENFIELD FILTER

Inserted into
Inferior Vena
Cava
Filters out clots
as blood returns
to the right side
of the heart

GREENFIELD FILTER

READILY
IDENTIFIED ON
X-RAY

CHRONIC VENOUS
INSUFFICIENCY
1.

PATHOPHYSIOLOGY & EPIDEMIOLOGY

OCCURS IN 10% OF POPULATION /W DVT

Stasis of blood in lower extremity-due to

prolonged standing, sitting in one position,
pregnancy, and obesity

INCOMPETENT VALVES IN DEEP VEINS

VENOUS PRESSURE IMPEDES CAPILLARY

PERFUSION

PROTEINS LEAK INTO INTERSTITIAL TISSUES

EDEMA IS CHRONIC ULCERS & SCARRING

CHRONIC VENOUS INSUFFICIENCY

Venous Stasis Ulcers

SIGNS & SYMPTOMS INDURATION
HYPERPIGMENTATION, STASIS DERMATITIS &
ULCERATIONS, EDEMA
GOALS: Decrease edema and Promote venous return
INTERVENTIONS:

2.

3.
4.

a)
b)
c)
d)
e)
f)
g)

COMPRESSION STOCKINGS OR DRESSINGS

ULCERS TREATED WITH TOPICAL AGENTS-Unna,Accuzyme
AVOID TRAUMA
AVOID SITTING FOR LONG PERIODS
EXERCISE TO MUSCLE ACTIVITY
Platelet derivative growth factor ointments-Regranex
Apligraf-type of skin graft

Varicose Veins

Protruding veins that are

darkened/tortuous are caused by weak
vein walls, increased venous pressure &
incompetent valves
Common in patients that stand for long
periods
Pregnancy
Obesity
Family hx of varicose veins
Systemic problems-heart disease

Assessment- S & O Data

Severe, aching pain in leg

Leg fatigue and heaviness
Itching over the affected leg (statis
dermatitis)
Feelings of heat in the leg
Visibly dilated veins
Thin, discolored skin above the ankles
Increased incidence of PE and
thrombophlebitis

Diagnostic Tests
Tourniquet test
Trendelenberg test
Doppler ultrasound/ angiography

Medical and Surgical Interventions

for Varicose Veins

Elevate extremity
Elastic Stockings
Sclerotherapy-for
small/limited # of
veins

Vein stripping or
ligation
EndoVenous Laser
tx
RF (radio
frequency)
-vein is heated from
inside

Lymphatic System
ANATOMY & PHYSIOLOGY
LYMPHATIC SYSTEM WORKS WITH
CIRCULATORY SYSTEM
a)
b)

THORACIC DUCT
b
RIGHT LYMPHATIC DUCT

DRAINAGE:
THORACIC DRAINS ABDOMEN
(R) DRAINS HEAD, NECK & THORAX

ANATOMY & PHYSIOLOGY

LYMPHATIC FLUID COLLECTS &
RETURNS TO VENOUS CIRCULATION BY
EMPTYING INTO SUBCLAVIAN VEINS

WHEN INTERSTITIAL FLUID PRESSURE

INCREASES LYMPHATIC FLOW
INCREASES
WHEN DRAINAGE IS IMPAIRED EDEMA
ENSUES (FLUID COLLECTS)

ANATOMY & PHYSIOLOGY

CAUSES OF LYMPHEDEMA INCLUDE:

LYMPHANGITIS
CELLULITIS
INSUFFICIENT NUMBER OF VESSELS
SECONDARY FACTORS
MALIGNANCY
TRAUMA
SURGICAL REMOVAL

Assessment

Pain at site of injury

Redness of skin
Fever and chills
Red streak on skin extending toward the
lymph nodes
Lymph nodes enlarged
WBC, Blood & Wound cultures
Lymphangiography-IV dye, Xrays
Lymphoscintigraphy-simple,no SE

INTERVENTIONS

Moist heat
Elevation and immobilization of the extremity
Elastic stockings
Na restriction
Antibiotics/antifungals for infection
Diuretics
Analgesics

THANK YOU