Vascular System - NCLEX® Review Courses by Nursing ... 11 WEB-COLOR.pdf · E. Vascular surgery. Nursing Interventions See Nursing Intervention for specific areas involved. Hypertension

Vascular System

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B. Physiological control. 1. Autoregulation: the ability of tissue to control its ownbloodflow.Autoregulatorysystemenables blood supply to vital organs (brain, kidney, heart) to remainrelativelyconstant,eventhoughblood pressuremayfluctuatewithinnormalranges. 2. Nervoussystemcontrol. a. Parasympatheticnervoussystem:influenceon bloodflowistheregulationoftheheartrateby the vagus nerve. b. Sympatheticnervoussystem. (1)Primaryinfluenceofsympatheticsystem is on arterioles for dilation and constriction ofthevesselsinordertomaintainperipheral resistanceandvasomotortone. (2) Peripheral resistance is resistance of arteriolestoflowofblood. (3) Dilation decreases peripheral resistance, thereby decreasing blood pressure; vasoconstriction increases peripheral resistance, thereby increasing blood pressure.

Blood PressureA. Systolic blood pressure is the arterial pressure at the peak of ventricular contraction. The systolic pressure is determinedprimarilybytheamountofbloodejected.B. Diastolic pressure represents the pressure exerted in the arteries at the end of systole; it is the resting ventricular pressure. Diastolic pressure depends on the ability ofthearteriestostretchandhandlethebloodflow.C. Pulse pressure is the difference between the systolic and diastolic pressures.

DISORDERS OF THE VASCULAR SYSTEM

AtherosclerosisAtherosclerosis is the most common disease of the ✽

arteries. The word means “hardening of the arteries.”A. Atherosclerosis:mostcommonclassificationofarterio- sclerosis; characterized by stenosis and obstruction in thelumenofthevessel(Figure11-1). 1. Processisslow;generallynoevidenceofproblems untilamajorarteryisaffectedandthereissevere decrease in blood supply to tissue supplied by artery involved.

PHYSIOLOGY OF THE VASCULAR SYSTEM

VesselsA. Arteries. 1. Primaryfunctionistotransportnutrientsand oxygen to the cellular level. 2. Arterialvascularsystemisahigh-pressuresystem witharapidbloodflow.B. Capillaries. 1. Microscopic vessels at the cellular level. 2. Capillary bed is the area of circulation where the arterioles branch into capillaries and exchange betweenthecirculatingbloodvolumeandthe interstitialfluidoccurs.C. Veins. 1. Primaryfunctionoftheveinsistoreturnbloodto the heart. 2. Veinscontainvalvestomaintaindirectionofblood flowandtopreventthebackflowofblood. 3. Venoussystemisalow-pressuresystem.D. Circulatorysystems. 1. Systemiccirculation:theflowofbloodfromthe left ventricle into the aorta and through the arteries to the capillary beds, where cellular nutrition and oxygenation occur; then blood returns to the right atriumoftheheartviatheveins. 2. Pulmonarycirculation:theflowofbloodfromthe rightventricleintothepulmonaryarteryandthen into the lungs; in the capillary beds of the lungs, the blood picks up oxygen and releases carbon diox- ideandthenreturnstotheleftatriumthroughthe pulmonaryveins. 3. Hepatic-portalcirculation:theflowofblood fromthevenoussystemofthestomach,intestines, spleen, and pancreas into the portal vein and through the liver for absorption of nutrients and removaloftoxins.Venousbloodleavestheliver throughthehepaticveinandflowsintotheinferior venacavaforreturntotherightatrium.E. Lymphaticsystem:primaryfunctionistoreturnfluid andproteintothebloodfromtheinterstitialfluid.

Mechanics of Blood FlowA. Bloodflowiscontrolledby: 1. Thediameterofthevessel. 2. The length of the vessel. 3. The pressure at either end of the vessel. 4. The viscosity of the blood.

224 CHAPTER 11 Vascular System

2. Arteriescommonlyaffectedbyatherosclerosis: a. Coronary arteries. b. Cerebrovascular arteries. c. Aorta:mayleadtoaorticaneurysm. d. Peripheral arteries.

Data CollectionA. Modifiableriskfactors. 1. Diet high in saturated fats (cholesterol). 2. Smoking. 3. Obesity. 4. Decreased activity. 5. Stress.B. Nonmodifiableriskfactors. 1. Familialtendencies. 2. Age.C. Conditionsacceleratingatheroscleroticdevelopment. 1. Diabetesmellitus. 2. Hypertension. 3. High cholesterol/triglyceride levels.D. Clinicalmanifestations:dependonarteryinvolved.E. Diagnostics. 1. Clinicalmanifestationofspecificareainvolved. 2. Increasedlevelsofserumtriglycerides,lipids,and cholesterol.

TreatmentA. Low-cholesterol diet.B. Decrease risk factors.C. Antihyperlipidemicmedications(seeAppendix11-2).D. Peripheralvasodilatingmedications.E. Vascular surgery.

Nursing InterventionsSeeNursingInterventionforspecificareasinvolved.

HypertensionHypertension is a consistent increase in blood ✽

pressure.A. Classification. 1. Essential(primary,benign,idiopathic):etiologyun- known;accountsforapproximately85%to95%of hypertensive clients. 2. Secondary:accountsforapproximately10%to15% of hypertension cases; the sustained elevation is due toanidentifiablecause. a. Increased intracranial pressure. b. Renal disease. c. Pregnancy-inducedhypertension(eclampsia). d. Cushing’ssyndrome. e. Thyrotoxicosis. 3. Malignant hypertension: a sustained increase in the diastolicpressurethatisunresponsivetotreatment. 4. Hypertensive crisis: when the degree of hypertension is a life-threatening situation.

Data CollectionA. Risk factors in essential hypertension (Table 11-1).B. Clinicalmanifestationsofessentialhypertension.

NURSING PRIORITY ✔ – Encourage blood pressure monitoring in clients with increased risk, hypertension is most often asymptomatic.

1. Increase in blood pressure. 2. Headache. 3. Dizziness. 4. Palpitations. 5. Increase in the rate of atherosclerosis. 6. Heart failure. 7. Left ventricular hypertrophy. 8. Visualdisturbances.C. Diagnostics. 1. Increase in blood pressure, especially diastolic pressure on two separate occasions at least 2 weeks apart (Box 11-1). a. Diastolicpressureof80mmHgorhigher. b. Systolicpressureof125mmHgorhigher.

FIGURE 11-1 Pathophysiology of Atherosclerosis - (From Ignatavicius, DD, Workman, ML: Medical Surgical Nursing Patient-Centered Collaborative Care, ed 6, St Louis, 2010, Saunders.)

CHAPTER 11 Vascular System 225

2. Diagnosticstoruleoutproblemofsecondaryhyper- tension.D. Complications. 1. Coronary artery disease. 2. Cerebral vascular disease (see Chapter 15). a. Reversibleischemicneurologicdeficit(RIND). b. Stroke (brain attack). 3. Nephrosclerosis:ischemiaoftheintrarenalvessels. 4. Retinaldamage:ischemiaofthearteriolesinthe retina. 5. Hypertensive crisis. 6. Peripheral vascular disease.

TEST ALERT: Compare current data to client baseline data (e.g., vital signs). Determine if vital

signs are abnormal.

TreatmentA. Diet. 1. Lowsodium. 2. Weight reduction. 3. Decreased cholesterol and saturated fats.B. Regular exercise.C. Antihypertensivemedications(seeAppendix11-4).D. Diureticstodecreasecirculatingvolume(seeAppendix 11-5).E. Limitalcoholintaketo1to2ouncesperday.F. Stressmanagement.G. Stopsmoking.

Nursing Interventionsv Goal: To identify and educate high-risk individuals.A. Encourageclienttoparticipateincommunityblood pressurescreeningprograms.B. Educate public regarding risk factors.C. Identifyhealth-promotingbehaviorforhigh-riskindi- viduals (Box 11-2).v Goal: To reduce blood pressure and assist client to maintaincontrol.(Figure11-2).A. Assessresponsetomedication. 1. Antihypertensives (see Appendix 11-4). 2. Diuretics (see Appendix 11-5).B. Evaluatebloodpressuremeasurement(Box11-1)

OLDER ADULT PRIORITY: ✔ Older adults are more sensitive to blood pressure changes. A drop in blood pressure to less than 120 mm Hg systolic may cause orthostatic hypotension.

C. Maintainlow-sodiumdiet.D. Assesschangesinweightwithregardtolow-sodium intake and use of diuretics.E. When blood pressure (BP) is initially decreased, evaluate client’s tolerance to drop in BP.

• Ifaclienthasbeenhypertensiveforalongperiodoftime, theclient’s“normal”systolicbloodpressuremayneedtobe greaterthan120mmHgtomaintainadequatebloodflowand allowclienttoperformADLs.• Teachclienthowtoavoidincreasedproblemswithortho- static hypotension.• Obtainbloodpressurereadingswithclientstanding,lying, andsittingandinbotharms.• Makesureclienthasnothadanynicotineorcoffeefor aboutanhourbeforetakingbloodpressuremeasurements.• Donotallowclienttocrosslegsduringbloodpressure measurement.• Complianceproblemsoccurwhentheclienthastotake severalmedicationsforBPaswellascopewithother chronichealthproblems.

BOX 11-1 OLDER ADULT CARE FOCUS Evaluation of Blood Pressure

TABLE 11-1 RISK FACTORS IN ESSENTIAL HYPERTENSION

Nonmodifiable Factors Modifiable FactorsAge:B/Pprogressivelyincreaseswithage,commonlyincreases Obesity:centralabdominalobesity.betweenages30-50years. Stress:repeated,prolongedstress.prevalentinwoman.Gender:moreprevalentinmenuntilage55,andthenmore Excesssodiumintake:causesfluidretentionandcontributestoprevalentinwomen. increasedbloodpressure.Ethnicgroup:higherinAfricanAmericansthaninwhites. Elevatedlipidlevels:hyperlipidemiaiscommoninclientswithFamilyhistory:especiallyifcloserelativehashypertension. highB/P. Substance abuse: excessive alcohol intake, tobacco use. Sedentary life style: regular physical activity helps to decrease risk.

TEST ALERT: Review with client understanding of health promotion behaviors.


Home CareA. Continuelow-cholesterol,low-sodiumdiet.B. Decrease weight if appropriate.C. Assist to identify an appropriate, consistent, regular exerciseprogram. 1. Agraduallyincreasingexerciseprogram. 2. Episodic strenuous activity should be avoided. 3. Walking,swimming,slowjogging. 4. Avoidweightliftingandheavyisometricexercises.D. Takemedicationsasprescribed. 1. Takemedicationatregulartimes. 2. Knowthenamesandcommonsideeffectsofthe medications. 3. Informhealthcareprovider(HCP)ifunabletoaf- fordmedications. 4. Donotstoptakingmedicationsunlessadvisedtoby HCP.

TEST ALERT: Identify side effects and adverse reactions of medications.

E. Avoidhotbaths,steamrooms,spas(increasevasodilat- ingeffectofmedications).F. Sideeffectsofmedicationarefrequentlytemporary.G. AvoiddrugsthatinteractwithBPmedications(e.g., antacids,cold/sinusmedications).H. Ifsexualproblemsorimpotencedevelops,contactHCP; donotstoptakingmedication.I. Takemeasurestocontroleffectsoforthostatichypo- tension. 1. Getupslowly,sitatthebedsidetoregainequilib- rium,andthenstandslowly. 2. Wear elastic support hose. 3. Lie or sit down when dizziness occurs. 4. Donotstandorsitforprolongedperiodsoftime.J. Lifestylemodifications(Box11-2)

Peripheral Arterial Disease (Peripheral Vascular Disease)

Also known as peripheral vascular disease (PVD), this ✽disorder primarily involves narrowing and obstruction of the of the extremities, especially the lower extremities. The atherosclerotic lesions cause chronic arterial obstruction that progressively leads to decreased oxygen delivery to the tissues.A. Lesionsarepredominantlyfoundintheloweraorta, frombelowtherenalarteriesextendingthroughthe popliteal area.B. Bythetimesymptomsoccur,thearteryisapproximate- ly85%to95%occluded.C. Therenal,femoral,popliteal,andaorticiliacarteries arethemostcommonlyaffectedsites.

1. Presence of postural hypotension. 2. Change in urinary output. 3. Change in energy level. 4. Changes in level of consciousness.F. Report significant changes in BP to the charge nurse.

NURSING PRIORITY: ✔ Obtain hemodynamic mea-surements: the BP of a hypertensive person should be measured lying down, sitting and standing; measure the BP in both arms.

• Loseweightifindicated.• Limitalcoholandcaffeineintake.• Followaregularprogramofaerobicexercise (30to45-minutes;3to4daysaweek).• Limitsodiumintake.• Maintainadequatepotassiumintake.• Maintainadequateintakeofdietarycalcium,magnesium, andfiber.• Stopsmoking.• Reduceintakeofdietarysaturatedfatandcholesterol.

BOX 11-2 LIFESTYLE MODIFICATIONS FOR HYPERTENSION PREVENTION AND CONTROL

TEST ALERT: Review client/family understanding of health promotion behaviors.

FIGURE 11-2 Hypertensive Nursing Care - (From: Zerwekh, JA, Claborn, JC, Miller, CJ, Memory Notebook of Nursing, Vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.)


Data CollectionA. Riskfactors(sameasforhypertension–Table11-1).B. Clinicalmanifestations.

TEST ALERT: Recognize the client with conditions resulting in inadequate circulation of

lower extremities.

1. Intermittentclaudication(painwithactivity,re- lieved by rest). 2. Ischemicpainatrest,orpainatnightindicatesad- vanced stages of PVD. 3. Paresthesia of the feet. 4. Decreasedorabsentperipheralpulses(Figure11-3). a. Dorsalas pedis, posterior tibial. b. Popliteal. c. Femoral. 5. Arterial ulcers. a. Commonlyfoundonmetatarsalheadsandtips of toes. b. Painful,sharpedges,palecolorbase,frequently occurs on the large toe. c. Poorhealingofinjuriesontheextremitiesdueto lack of circulation. 6. Changes in the skin. a. Cool to touch. b. Shiny, fragile, poor turgor. c. Dry, scaly. d. Loss of hair on the lower leg. 7. Brittle, thick toenails. 8. Dependentrubor(duskyredness)whenlegsareina dependent position, pallor with elevation of the legs.C. Diagnostics - see Appendix 11-1.

Treatment A. Medical. 1. Vasodilatingmedications. 2. Decrease progression of atherosclerosis. a. Decrease dietary cholesterol intake. b. Initiateanexerciseprogramastolerated. c. Stop all tobacco use. d. Decrease weight if appropriate. 3. Prevent and control infections. 4.Treatmentofdiabetes.B. Surgical:Proceduresareperformedwhenintermittent claudication interferes with the client’s activities of dailylivingorwhenthecirculationmustberestored inordertosalvagethelimb. 1. Peripheralatherectomy:removalofplaquewithin the artery. 2. Bypass graft: bypass of an obstruction by suturing a graftproximallyanddistallytotheobstruction. 3. Patchgraftangioplasty:arteryisopened,plaqueis removed,andapatchissuturedintheopening towidenthelumen.

4. Amputation:usedasalastresortwhenother therapies have failed and gangrene or infection is extensive.C. Nonsurgical. 1. Percutaneoustransluminalangioplasty:useofa ballooncathetertocompresstheplaqueagainstthe arterial wall. 2. Laser-assisted angioplasty: a probe is advanced through a cannula to the area of occlusion; a laser is usedtovaporizetheatheroscleroticplaque. 3. Intravascularstent:placementofastentwithina narrowedvesseltomaintainpatency.

Nursing Interventionsv Goal: Toevaluatelevelofinvolvementoftheextremity.A. Assessperipheralpulses;comparequalityofpulsesin thelowerextremities.B. Evaluateskinontheaffectedextremity. 1. Color,skintemperature. 2. Capillaryrefill. 3. Condition of the skin and nail beds. 4. Presence of ulcers or lesions, stages of healing. 5. Assess tolerance to activity; at what point does pain occur.

FIGURE 11-3 Pulse Points for assessment of arterial pulse, (From: Ignatavicius, DD, Workman, ML: Medical Surgical Nursing Patient-Centered Collaborative Care, ed 6, St Louis, 2010, Saunders.)


TEST ALERT: Review assessment of peripheral pulses, report signs of potential complications.

v Goal: Topreventinjuryandinfection.A. Avoidvigorousrubbingoftheextremity.B. Prevent pressure to heels, ankles, toes.C. Use heel covers and bed cradle to prevent pressure on the toes and heels.D. Maintain good skin hygiene and proper care of toenails. 1. Donottrimthetoenails,reportproblemstoRNor encourage client to see podiatrist. 2. Donottrimcallusesorcorns. 3. Advise RN or HCP if client has ingrown toenails. 4. Keep feet clean and dry, do not soak feet, use lubricating lotion to prevent skin cracks. 5. Teach client to always wear shoes; avoid shoes or socks that are too tight.

TEST ALERT: Identify methods for preventing complications associated with illness. Identify

factors that affect wound healing.

v Goal: To increase arterial supply and decrease venous congestiontotheextremity.A. Encouragemoderateexercise(e.g.,walking).B. Performactiveposturalexercises(Buerger-Allen exercises).C. Maintainconstantwarmtemperature;donotusehot waterbottlesorheatingpadsonlowerextremities.D. Avoid pressure in the posterior popliteal area. 1. Do not raise knee gatch of the bed without raising thefootofthebedtoeliminatepressurebehindthe knee. 2. Whentheclientissittinginachair,makesurethe feetareflatonthefloortodecreasethepressure fromtheedgeofthechairbehindtheknee. 3. Teach client to avoid clothing that is tight and re- strictscirculationtothelowerextremities(e.g., knee high hose, girdles).E. Elevateextremitieswhileatrest.F. Promotebloodflowtolegs. 1. Avoid standing in one position for prolonged periods. 2. Avoid crossing legs at the knees or ankles while in bed.F. Preventvasoconstriction. 1. Decrease caffeine intake. 2. Stop all tobacco use. 3. Avoidbecomingchilled,keeplowerextremities warm.G. Controldiseasesprecipitatingarterialproblems. 1. Diabetes. 2. Hypertension.

NURSING PRIORITY: ✔ In planning and caring for the diabetic client, problems of peripheral vascular disease must be considered. Poor peripheral circulation is a common complication.

v Goal: To provide appropriate preoperative care.A. See Chapter 3.v Goal: Toevaluateandpromotecirculationintheaffectedextremityfollowingvascularsurgery.A. Performextremitycirculationchecks:initiallyevery 15minutes,thenhourly,thenevery4hours.Report immediatelyanychangesinqualityofpulses.B. Encouragemovementoftheextremityassoonasclient isawake.Avoidflexionintheareaofthegraft(femoral or popliteal areas).C. Encourageclienttobeoutofbedandambulateassoon asindicated;performpulsecheckswhenclientreturns to bed.D. Do not allow the raised knee gatch of the bed to put pressure on the popliteal area.E. Assessclient’sresponsetoanticoagulants;maintain bleeding precautions (see Chapter 14).F. Continuemeasurestoprotectthefeet.G. Assessfordevelopmentofdependentedema;may requirecompressiondressingsoruseofdiuretics.H. Monitorforpotentialcomplicationsofbleeding(e.g., clotformation,compartmentsyndrome).I. Assesstypeofpain–painfromincreasedperfusionis differentthanpainofischemiapriortosurgery.J. NotifysurgeonorHCPimmediatelyofanysymptoms suggestive of a further decrease in circulation or of occlusion of graft. v Goal: To provide general postoperative care as indicated (see Chapter 3).

Home CareA. Lose weight if appropriate through a low-fat, low- cholesterol,high-fiberdiet.B. Avoid: 1. Standingorsittingforprolongedperiodsoftime. 2. Avoid tight socks, constrictive clothing, stockings. 3. Smoking.C. Avoidtraumatotheextremities.D. Careofextremities: 1. Visually inspect feet daily 2. Avoid bath water that is too hot. 3. Dry well between toes. 4. Prevent drying of skin; no lotion between toes. 5. Clip nails straight across. 6. Seekcarepromptlyforulcerationsorblisters. 7. Alwayswearwell-fitting/protectiveshoes;donotgo barefoot. 8. Elevatefeetiftheyareswelling. 9. Evaluatebruisesanddiscoloredareas. 10. Assessforanybreaksintheskin.


E. Do not apply direct heat to the legs.F. Exerciseastolerated;stopifpainoccurs.G. Maintain good nutrition.H. Teachclientmethodstoincreasecirculationduring normalworkday(donotcrosslegs;useagoodchair; get up and walk every hour if working at a desk).

TEST ALERT: Review client adaptations to illness and/or disease. Assist client in identifying

behaviors that could impact health.

Thromboangiitis Obliterans (Buerger’s Disease)

Thromboangiitis obliterans is a condition that causes ✽vasculitis of the small and medium-size arteries and veins of the extremities.

Data CollectionA. Intermittentclaudication.B. Painispredominantsymptom.C. Cyanosisandrednessoftheextremity.D. Increasedsensitivitytocoldintheextremity.E. Ischemiculcerationsmaydevelopinfingers,toes,and thenmayprogressupward.F. Decreasedsensation.G. Peripheralpulsesmaybediminishedorabsent(see Figure11-3).H. Closely associated with tobacco use, especially young menwhosmoke.

TreatmentNocure;treatmentisbasedonsymptoms;cessationofalltobaccousefrequentlystopsdiseaseprogress.

Nursing Interventionsv Goal: Toevaluatelevelofinvolvementoftheextremityandincreasecirculationtotheextremity.A. Encourage client to decrease or stop all tobacco use. B. Evaluate tolerance to activity.C. Inspect feet for vascular changes.D. Haveclientperformposturalexercisestodecrease venous congestion.E. Performcirculatorychecksoftheaffectedextremity.F. Protectextremitiesfromexposuretocold.v Goal: Toassistclienttounderstandimplicationsofthediseaseandmeasurestomaintainhealth.A. See PVD goals about assisting client to understand implicationsofthedisease.

NURSING PRIORITY: ✔ The vascular problem has a direct relationship to cigarette smoking. The client should understand that in order for the condition to be controlled, he must quit smoking.

Raynaud’s DiseaseA disease characterized by episodic spasms of ✽

the small cutaneous arteries. It occurs primarily in the fingers.

Raynaud’s Phenomena

A. Intermittentepisodicspasmsofthearteriolesofthe fingers,toes,nose,andears.Spasmsarenotnecessarily correlatedwithotherperipheralvascularproblems.B. Condition usually occurs in the hands and is bilateral andsymmetrical.

Data CollectionA. Increasedincidenceinfemales20to49yearsold.B. Symptomsareprecipitatedby: 1. Exposure to cold. 2. Emotionalstress. 3. Smoking. 4. Caffeineconsumption.C. Associated with connective tissue diseases such as systemiclupuserythematosus,scleroderma,and rheumatoidarthritis.D. Initially there is pallor or cyanosis due to the vaso spasm,causingnumbnessandtingling.Asdigitswarm, thereisredness,warmth,andthrobbingashyperemia occurs.E. Involvementgenerallyisbilateral.F. Pulsesmayremainadequate.G. Attacksareusuallyintermittentandonlylastafew minutes.

TreatmentA. Nocure;diagnosisandtreatmentarebasedon symptoms.B. Vasodilatingmedications.

Nursing Interventionsv Goal: Toassistclienttounderstanddiseaseimplica-tionsandmeasurestoincreasearterialcirculation.A. Stopalltobaccouse,especiallysmoking.B. Evaluate client’s response to activities.C. Performcirculatorychecksoftheaffectedextremity.D. Performvisualinspectionoftheskinoftheaffected extremity.E. Protectextremitiesfromexposuretocold.F. Limitcaffeineintake.G. Avoid vasoconstrictive drugs.

AneurysmAn aneurysm is a dilation or sac formed within the ✽

wall of an arterial vessel. The aneurysm may involve one layer or all layers of the arterial wall.


A. Typesofaneurysms. 1. Berryaneurysm(seeChapter15). 2. Abdominalaorticaneurysm:occursprimarilyinthe abdominalaortabelowtherenalarteries. 3. Thoracicaorticaneurysm:locatedintheaortain the thoracic area. 4. Dissectinganeurysm:bleedingoccursbetweenthe layers of the vessel wall. B. Commonlocations. 1. Abdominalaorticaneurysm(AAA):occursmost oftenintheabdominalaortabelowtherenal arteries. 2. Thoracicaorticaneurysm:locatedontheaortain the thoracic area. 3. Femoralaneurysm. 4. Poplitealaneurysm.

Data Collection A. Abdominalaorticaneurysm(AAA). 1. Maybeasymptomatic. 2. Epigastric,back,flankorabdominalpain. 3. Pulsatingabdominalmassmaybepalpable. 4. Signs of rupture. a. Severe back pain. b. Rapid hypotension and shock. c.Abdominaldistentionandtenderness. d.Hematomaformationintheflankregion.B. Thoracicaorticaneurysm. 1. Frequentlyasymptomatic. 2. Compressionofstructuresintheadjacentarea. a. Dysphagia due to pressure on the esophagus. b. Hoarseness due to pressure on the laryngeal nerve. c. Pressureonthevenacavamaycauseedemaof headandarms. 3. Signs of dissection and rupture. a. Sudden constant, excruciating back and/or chest pain. b. Rapid hypotension progressing to shock.C. Diagnostics (see Appendix 11-1). 1. Chest x-ray. 2. Aortography. 3. Abdominalultrasound.

TreatmentDirected toward prevention of rupture (e.g., surgical resection oftheaneurysm).

Nursing Interventionsv Goal: Toprepareclientandfamilyforanticipatedsurgery.A. Provide appropriate preoperative care (see Chapter 3).B. Identifyotherchronichealthproblemsthatwillhave implicationspostoperatively(hypertension,diabetes, PVD).

C. Evaluatecharacteristicsofpulsesinthelowerextremi- ties;marklocationsanddocumentstatusforevaluation postoperatively.v Goal: Tomonitor,prevent,andrecognizecomplica-tions before surgical intervention.A. Control hypertension. 1. Administerantihypertensives. 2. Decrease risk factors.B. Observe closely for signs of rupture/dissection.C. Donotvigorouslypalpateabdomen.

TEST ALERT: Determine if client is prepared for surgery. Monitor client after surgery.

v Goal: Topromotegraftpatencyandoptimalcircula-tionpostoperativeaneurysmresection.A. Followgeneralpostoperativecareasindicated(see Chapter 3).B. Maintainadequatebloodpressuretofacilitatetissue perfusionandfillingofthegraft.C. Monitorclientresponseto(IV)fluidsandbloodcompo- nents.D. Initiallyperformhourlychecksofperipheralcircula- tion;monitorcharacteristicsofpulsesinlowerextremi- ties(seeFigure11-3).Symptomsofgraftocclusion include: 1. Changesordecreaseinqualityofpulse. 2. Extremitycoolbelowlevelofgraft. 3. Changeincolorofextremity. 4. Increaseinabdominaldistentionandincreased severityofpaininextremities.E. Evaluate urine output hourly.F. Evaluatebloodureanitrogen(BUN)andserum creatinine levels to assess renal function.G. Maintainadequatebodywarmthtopreventtempera- ture-induced vasoconstriction.H. Immediatelyreportanychangesinthestatusof circulationofaclient’sextremity.

TEST ALERT: Recognize client conditions that result in insufficient vascular perfusion; review

assessment of peripheral pulses of client. Pulse checks are critical in vascular surgery client. The nurse should compare the peripheral pulses in the lower extremities and initiate protective and preventative actions.

v Goal: Tomaintainhomeostasisandpreventpostopera-tivecomplications.A. Maintainadequatebodywarmth.B. Assessandmaintainadequatehydration.C. Assessforelevationoftemperature.D. Evaluate for return of GI function. 1. Bowel sounds. 2. Distention. 3. Passageofflatus. 4. Diarrhea.


E. Nasogastricsuctionisfrequentlyusedintheimmediate postoperativeperiodtopreventgastricdistentionfrom causing increased pressure around area of the graft.

Home CareA. Activity restrictions. 1. No heavy lifting for 6-12 weeks. 2. Avoid activities that involve pushing, pulling, or straining.B. Report any signs of infection, redness, swelling, drainage, or fever.

Shock (Severe Hypotension)Shock is characterized by inadequate blood flow and ✽

tissue perfusion.A. Foradequatecirculationtooccur,allpartsofthecircu- latorysystemmustfunctioneffectivelytogether. 1. Adequatevasculartonetomaintainnormal resistance of the vessels. 2. Abilityofthehearttomaintaincardiacoutput. 3. Adequateamountoftotalbloodvolume.B. Theinitialproblemsprecipitatingshockandthespe- cifictreatmentfortheproblemsareverydifferent. However, regardless of the precipitating cause of shock, theunderlyingproblemisinadequatetissueperfusion.C. Classificationsofshock. 1. Hypovolemicshock:sizeofvascularcompartment remainsthesamewhilethevolumeofbloodor plasmadecreases;mayberelativeorabsolute. a. Hemorrhage. b. Burns. c. Severefluidloss. 2. Cardiogenic shock: heart is unable to effectively circulatetheintravascularvolume. a. Dysrhythmias. b. Myocardial infarction (MI). c. Heart failure. 3. Distributiveshock:anincreaseinthebloodvolume on the venous side with a decrease in the venous return to the heart. a. Neurogenic: spinal cord shock; loss of nerve supply to blood vessels. b. Septic:vasodilationfromsevereinfection. c. Anaphylactic: vasodilation secondary to histaminerelease(allergicreactions). 4. Obstructiveshock:physicalimpedimenttoblood flow. a. Pulmonaryembolism. b. Venacavacompression. c. Tensionpneumothorax.

Data CollectionSignsandsymptomsofshockareessentiallythesameregardless of the precipitating cause.

TEST ALERT: Implement interventions to man-age potential client circulatory complications. Be

able to recognize clients at increased risk; know the early symptoms of shock and initiate protective and pre-ventive actions.

A. Risk factors. 1. Increased incidence in the very young and in the very old. 2. Increased incidence in clients with chronic progressive disease states. 3. Trauma. 4. Postoperativehemorrhage.B. Clinicalmanifestations. 1. Compensatorystage(early). a.Clientisorientedtotime,place,anddatebut mayberestlessorapprehensivewithincreased anxiety. b.BP—lownormal;pulse—increasedornormal; respirations—increased;temperature—normal orsubnormal. c.Urineoutputmaybeslightlydecreased,but withinnormalrange. d.Complaintsofthirstandfeelingcool;skinpale and cool. e.Nausea/vomitingcommonasBPdecreases. 2. Progressivestage(intermediate). a. Decreasing sensory perception; decreased responsivenesstostimuli. b. Vital signs. (1) BP continues to decrease. (2) Pulse rate increased with weak or thready peripheral pulses. (3) Respirations—rate is increased with dyspnea. c. Cold,moistskin;pallor. d. Decrease in urine to oliguric levels. e.Developmentofacidosis 3. Refractory (irreversible, late). a. Progressively decreasing level of consciousness to unresponsiveness. b.BP—notmeasurable(unabletoperfusevital organs); pulse—slow and irregular; respirations—irregular, shallow, labored. c. Anuria. d.Clientbecomeshypoxicwithskinpallor, cyanosisandmottling. 4. Diagnostics:basedontheclinicalmanifestations andhistoryofunderlyingproblems.

TreatmentDependsontheunderlyingproblem.


Nursing Interventionsv Goal: Toidentifyandmonitorprogress.A. Maintain bed rest.B. Position supine to increase venous return but not compromisepulmonarystatus.C. Maintainairway;providesupplementaloxygen.D. Keepwarm;nochilling.E. Protectfromfallsandinjury.F. Evaluateforprogressionofshock—compensatingto noncompensating.v Goal: Tomaintainventilationandpreventhypoxia(seeChapter10).A. Monitorlevelsofpulseoximetry,ABGs.B. Determinequalityandchangesinbreathsounds, characteristics of respirations.C. Monitor changes in orientation and presence of confusion.D. Maintain airway patency.v Goal: Tocorrectacid-baseimbalance(seeChapter5).v Goal: To assess and support the cardiovascular and respiratorysystems.A. Monitor blood pressure closely in individuals at increased risk.B. Evaluatetissueperfusioninresponsetodysrhythmias.C. Protect integrity of venous access lines. D. Hypovolemicshockrequiresanincreaseinthe circulatingvolume;monitorclientresponsetofluid resuscitation.v Goal: To evaluate renal response to decrease in cardiac output.

TEST ALERT: Identify client factors that could interfere with elimination. Decreased urinary

output is often an early observable sign of decreased renal perfusion secondary to decrease in cardiac output.

A. Evaluate urine output hourly.B. CarefullyassessrenalresponsetoincreaseinIVfluids.C. MonitorBUNandcreatinineforevidenceofrenalcom- plications.v Goal: Tomaintainhomeostasisanddecreaseeffectsofshock.A. Monitorclientresponsetomedicationstocounteract effects of shock (see Appendix 11-6).B. Continue to orient client.C. Decreaseunnecessarysensorystimuli.D. Maintain NPO; provide oral hygiene.E. Evaluate for bowel sounds and distention due to intestinalischemia.F. Keepclientcomfortablywarm;donotallowchilling.F. DonotadministermedicationsPO,IM,or subcutaneously because of decreased tissue perfusion. (RN or HCP will administer medications IV push.)

G. Provideemotionalsupport;continuetotalkwithclient and describe procedures before they are done.H. Avoid unnecessary nursing procedures.

Chronic Venous Insufficiency and Venous Stasis Ulcers

Chronic venous insufficiency (CVI) results from ✽damage to the valves of the veins in the legs. A. Theprimarycauseofchronicvenousinsufficiencyis incompetentvalvesofthedeepveins,primarilyin thelowerextremities.B. Compressionandreliefofvenouscongestionarethe keyfactorstotreatmentandpreventionofCVI.C. Thisvalvularincompetenceleadstoregurgitationof blood,venouspooling,andedemainthelower extremities;eventuallyresultingindevelopmentof venous stasis ulcers.

Data CollectionA. Risk factors. 1. Valveincompetence. 2. Chronic disease (diabetes). 3. Previous episode of DVT.B. Clinicalmanifestations. 1. Brownor“brawny”skinonlowerlegs. 2. Edema. 3. Stasisdermatitisorstasiseczemaisoftenthefirst indication. 4. Ulcers occur above the outer ankle. 5. Ulcerstypicallyhaveirregularlyshapedmargins and red in color. 6. Copiousserosanguineousdrainagefromulcers. 7. Ulcerations are very painful.C. Diagnostics:historyandclinicalmanifestations.D. Complications. 1. Infectionandcellulitisarecommon. 2. Delayed or poor healing.

TreatmentA. Medical therapy. 1. Compressiontherapy. a.Elasticcompressionstockings. b.Sequentialcompressiondevices. c. Unna boot (a paste bandage). 2. Moist dressings for open wound care. 3. Good nutritional status. 4. Treatmentofvaricoseveins.B. Surgical therapy: excision of ulcer with skin grafting.

Nursing Interventionsv Goal: To prevent/relieve venous congestion; this is the keytoulcermanagement(Box11-3).


B. Change dressings as necessary due to excessive wound drainage.C. Dressingmaybeusedincombinationwithcompression devices.D. Encourageincreaseinproteinandvitaminstopromote healing.v Goal: To teach clients about self-care as recurrence of CVI is high.A. Avoidtraumatolimbs.B. Usemoisturizinglotionstopreventskinfromcracking; do not use fragrant products.C. Seekmedicalcareatfirstsignofwoundinfection 1. Pain 2. Purulent drainage 3. Offensive odor.

TEST ALERT: Implement measures to promote venous return, to manage potential circulatory

complications, and to monitor wounds for signs and symptoms of infection.

Varicose VeinsVaricose veins occur when veins in the lower trunk ✽

and extremities become congested and dilated because of incompetent valves in the vessels, as well as loss of elasticity of the vessel wall. As venous pressure increases, the-muscle around the vein fails to constrict effectively, and there is increased congestion and decreased venous return.

Data CollectionA. Risk factors. 1. Congenital weakness of the vein walls. 2. Obesity. 3. Pregnancy. 4. Worksettingsrequiringprolongedsittingor standing.B. Clinicalmanifestations. 1. Dilated, tortuous subcutaneous veins. 2. Objectionablecosmeticappearance. 3. Aching or pain after prolonged standing. 4. Paingenerallyrelievedbyelevatingtheextremity. 5. Nocturnallegcramps.

TreatmentA. Medical. 1. Rest with feet elevated. 2. Elastic support hose.B. Surgical. 1. Scleropathy:injectionofsclerosingagentsinto affected vein. 2. Surgicalligationoftheveins;maybecombined with vein stripping as well.

A. Compressiondevices:preventionofvenousstasisisthe key to healing. 1. Compressionboots/stockings:extremitymaybe coveredwithcontinuouscompressionbandage, boot, or stocking. 2. Intermittentorsequentialpneumaticcompression devices: always check arterial circulation with any typeofcompressiondevice. 3. Assessadequacyofarterialcirculationpriorto initiatingcompressiontherapy.B. Keepfeetcleananddry;assessfordevelopmentof venous ulcers.C. Keep feet/legs elevated.D. Avoid prolonged sitting/standing.E. Instituteadailywalkingprogramonceulcershave healed.v Goal:Promotehealingofvenousstasisulcers.A. Applymoistoxygenpermeabledressings(e.g.,hydro- colloids,foams).

• Encouragemobility;evenstandingatthebedsidepromotes venous tone.• Elasticsupportstockings: 1. Hospitalizedclientsshouldwearthemallthetime. 2. Homeclientsgenerallywearthemduringtheday;they should put stockings on before getting out of bed and removethemwhengoingtobed. 3. Make sure the stockings are not causing increased pressure behind the knee, and do not allow stockings to bunch up and cause constriction behind the knee. 4. Toe hole should be under the toes and heel patch over the heel. 5. Do not hang feet dependent when putting stockings on; elevateorplacethemparallelonthebed.• Pneumaticsequentialcompressiondevices(SCDs)may be used in the hospital on clients at increased risk for complicationssecondarytovenousstasis. 1. Removeevery8hourstoinspectskin. 2. Ifclientisathighriskfordevelopmentofthrombophle- bitis,measureareatodetermineifthereisanincreasein size of calf or thigh. 3. Assesslegsforareasofwarmth,tenderness,orinflam- mation.• Teachclienttoelevatelegsforabout20minutesevery4to 5 hours.• Avoidprolongedsitting;getupanwalkfor5minutesevery 1 to 2 hours.• Donotcrosslegswhensittingorlyinginbed.• Donotwearclothingthatrestrictscirculationtolower extremities.• Maintaingoodfluidintake;avoiddehydration.

TEST ALERT: Implement interventions to promote venous return. Plan interventions to

prevent complications of cardiovascular system.

BOX 11-3 NURSING MEASURES TO DECREASE VENOUS STASIS


Nursing Interventionsv Goal: To identify client at high risk and prevent developmentofvaricosities.A. Encourage client to avoid sitting or standing for prolongedperiodsoftime.B. Preventinjuriestoextremities.C. Encourage client to avoid constrictive clothing.D. Teachclienttoavoidrubbingextremities.v Goal: Toassistclienttounderstandimplicationsofthediseaseandmeasurestomaintainhealth.A. Elastic stockings should be put on before getting out of bedinthemorning.B. Maintaingoodskincareoflowerextremities.C. Decrease weight if appropriate.D. Avoid prolonged standing or sitting in the work environment.E. Avoid constrictive clothing.

ThrombophlebitisProblem begins with an inflammation of the ✽ vein.

The inflammatory process may initiate a clot formation and the development of deep vein thrombosis (DVT). Thrombi occurring in the deep veins of the pelvis, legs, and abdomen are of particular concern because there is increased incidence of embolus formation.

TEST ALERT: Identify complications of im-mobility. Monitor client responses to interventions

for preventing complications from immobility. With any condition that causes an increase in venous stasis or inflammation to a vein, there is a significant increased risk for the development of thrombophlebitis and DVT.

Data CollectionA. Risk factors (Virchow’s Triad). 1. Venous stasis. a. Surgery (hip, pelvic and orthopedic surgery are associated with high risk). b. Pregnancy, obesity. c. Prolongedimmobility(bedrest,longtrips, prolonged sitting). d.Heartdisease(atrialfibrillation,congestiveheart failure). 2. Hypercoagulability. a. Malignancies, dehydration. b. Blood dyscrasias. c.Oralcontraceptives,hormonereplacement therapy. d.Pregnancyandpostpartum. 3. Endothelialdamage. a. IVfluidsanddrugs(IVcatheterization,drug abuse, caustic solutions or drugs) b.Abdominalandpelvicsurgery.

c. Fracturesanddislocations(especiallyofthepelvis, hip, or leg). d. History of DVT.B. Clinicalmanifestations. 1. Redness,warmth,andtendernessalongvein. 2. Crampingcalfpain. 3. Swollenextremity. 4. Warm,cyanoticskin. 5. Increasedtemperature. 6. Homans’sign:thisisnolongerconsideredan accurateindicatorofthrombophlebitis.

NURSING PRIORITY: ✔ Do not attempt to check Homans’ sign on a client with a diagnosis of thrombo-phlebitis. This can cause embolization of a thrombus that is present.

C. Diagnostics (Appendix 11-1).D. Complications. 1. DVTassociatedwithhighriskforpulmonary emboli. 2. Chronicvenousinsufficiencyandvenousstasis ulcers.

TEST ALERT: Implement measures to manage potential circulatory complications. Due to the

multiple types of conditions that precipitate circulatory complications, questions may be incorporated into the care of the surgical client, the obstetric client, or any client with problems of circulation or immobility.

TreatmentA. Medical(primarymethodoftreatment). 1. Bedrestwithelevationofaffectedextremity. 2. Warm,moistheat. 3. Anticoagulants,anti-inflammatoryandfibrinolytic medications(seeAppendix11-3,and5-7). 4. Elasticstockingsifedemaispresentafterclientis ambulatory. 5. Elastic stocking on unaffected leg during period of bed rest. 6. Range-of-motionexercisesonunaffected leg during bed rest.B. Surgicalintervention:donetopreventpulmonary emboli. 1. Venousthrombectomy. 2. Vena cava ligation. 3. Umbrellafilterdeviceinthevenacava.


Nursing Interventions

NURSING PRIORITY: ✔ The best way to prevent the development of a pulmonary emboli is to prevent the development of DVT or thrombophlebitis. It is much easier to prevent the problem than it is to treat it.

v Goal: Topreventproblemofthrombophlebitisinclients at high risk.A. Useprophylacticmeasuresforthesurgicalclient(see Chapter 3).B. Preventcomplicationsofimmobility(seeChapter3).C. Provideprophylacticanticoagulationmedicationsfor- the high-risk client (e.g., hip and prostate surgery clients).D. Implementnursingmeasurestodecreasevenousstasis (see Box 11-3). 1. Do not cross legs in the bed or while sitting. 2. Do not place a pillow under the knees. 3. Do not stand or sit in one position for a prolonged periodoftime. 4. Performisometricexercisesofthecalfandthigh muscles. 5. Intermittentpneumaticcompressiondevicesmaybe used to facilitate venous return.

v Goal: Todecreaseinflammatoryresponseandpreventemboliformation.A. Maintain bed rest with the feet elevated.B. Warm,moistsoaksmaybeusedtodilatearteriesand veinsandtodecreaselymphaticcongestionandpro- motehealing.C. Observe client for adverse reactions to anticoagulants (see Appendix 11-3).D. Elasticstockingsmaybeusedifclient’slegsbecome edematousafterambulating.E. Do not use pillow under the knees or elevate the knee gatch of the bed.F. Measurecircumferenceofclient’scalfdailytodeter minechanges.

Home CareA. Avoid oral contraceptives.B. Decrease/stopsmoking.C. Avoidconstrictiveclothingonlowerextremities.D. Stand and walk every hour if working at a desk or sedentary activity. E. Lose weight if indicated.F. Decreasesodiumindietifedemaispresent.G. Followinstructionsregardinganticoagulationtherapy at-home.H. Followmeasurestopreventvenousstasisandpromote venous return (see Box 11-3).I. Report increased pain, swelling, redness, or skin changes.

Study Questions: Vascular System

1. Aclienthadanaorticfemoralbypassgraft.Thenurse assiststheclientbacktobedafterhehasambulated. Whatwillbeaprioritynursingassessment? 1 Determinefluctuationsinclient’sbloodpressure. 2 Assesspulseratetodeterminetoleranceofactivity. 3 Evaluatethetemperatureoftheclient’saffected extremity. 4 Determinequalityofpulseintheclient’saffected extremity.2. Thenurseisteachingaclientabouthomecareand treatmentofthevenousstasisulcersonhisleg.What wouldbeincludedinthenurse’sinstructions? Select all that apply.____ 1 Dressingsdonotneedtobechangedfrequentlybe-

causethereisminimaldrainage.____ 2 Healingwillbefacilitatedbywearinglegcompres-

sion devices.____ 3 When in the sitting position, legs should be kept

elevated.____ 4 Claudicationpainmayberelievedbystoppingall

activity.____ 5 Cool packs can be applied to the ulcers to decrease

inflammation.

3. The nurse is told in report that a hypertensive client has beenstartedonmedicationsandhasbeenexperiencing orthostatic hypotension. What considerations will thenursemakeincaringforthisclient? 1 Assisttheclienttoasittingpositionandallowhim to sit on the side of the bed before standing. 2 Whenambulatingtheclient,observeforthe presence of tachycardia and decreased blood pressure. 3 Assesstheclient’sbloodpressurewithhimina sitting and in a lying position. 4 Obtainassistancewhenambulatingtheclientdueto his tendency toward syncope.4. Thenurseisadministeringheparin.Whatisthecorrect procedureforadministrationofthismedication? 1 Checktheprothrombintimeandadministerthe medicationifitisbelow30seconds. 2 Use a 22-gauge, 1⁄2-inchneedleandinjectthe medicationsubcutaneously. 3 Injectthemedicationintothedeltoidandrub carefullytodispersemedication. 4 With a 25-gauge, 5⁄8-inchneedle,injectthe medicationintotheabdomen.


5. Whatwouldthenurseidentifyasmodifiablerisk factorstopreventthedevelopmentofessential hypertension? 1 Obesity,drugabuse,smoking. 2 Obesity,smoking,historyofcancerinthefamily. 3 Sedentary lifestyle, obesity, vegetarian diet. 4 Sedentarylifestyle,obesity,smoking.6. A hypertensive client is concerned about her medications.Sheasksthenursehowlongshewillhave totakemedication.Whatisthebestnursingresponse? 1 When the client returns to see her doctor in 2 months,themedicationsmaybediscontinuedat thattime. 2 Whentheclient’sbloodpressurereturnstonormal foraperiodof6months,hermedicationwillbe discontinued. 3 Tomaintainstablecontrolofherbloodpressure,the clientwillremainonthemedicationindefinitely. 4 Themedicationmaybeadjustedeverymonth;the client needs to talk with the doctor.7. The nurse is caring for a client with venous blood poolinginthelowerextremitiessecondaryto chronicvenousinsufficiency.Thenursewould identifywhatassessmentdatathatwouldcorrelatewith thisdiagnosis?Selectallthatapply.____ 1 Stasisdermatitis.____ 2 Diminishedperipheralpulses.____ 3 Peripheraledema.____ 4 Gangrenous wounds.____ 5 Venous stasis ulcers.____ 6 Skinhyperpigmentation.8. Aclienthasperipheralvasculardiseasewith compromisedcirculationinthelowerextremities.What wouldthenursingassessmentreveal? 1 Diminishedpedalpulses. 2 3+edemabilaterally. 3 Dusky gray color of the feet. 4 Musclespasmsinthefeet.9. Thenurseisassessingaclientwhois4hours postoperativeforarepairofhisaorticaneurysm.The nursewouldimmediatelyreportwhichfindings? 1 Totalurinaryoutputof80mLsincesurgery. 2 Nobowelsoundsinanyofthefourquadrants. 3 Legs and feet cool to touch bilaterally. 4 Pulsesweakandequalinbothextremities.10. Whatisincludedinthenursingmanagementofaclient withdeepveinthrombosis? 1 Ambulatetheclientintheroomtodecreasevenous stasis. 2 Assisttheclientwithactiverangeofmotionto affectedextremity. 3 Maintain the client on bed rest and elevate the foot of the bed. 4 Elevate the legs when the client is out of bed. 11. A client has been diagnosed with left leg thrombophlebitis.Whichfindingswouldnot be typical ofthiscondition?

1 Pain and tenderness in the left leg. 2 Warmthoverinfectedarea. 3 Redness over infected area. 4 Decreasedqualityofpulseinleftleg.12. An older adult client has peripheral vascular disease and the nurse is advised that the client also experiences intermittentclaudication.Whatarethecharacteristics ofintermittentclaudication? 1 Pain in the client’s hands being aggravated by smokingandcoldtemperatures. 2 Painoccurringinthelowerpartoftheextremity when the client is sitting down. 3 The need for analgesics prior to walking due to increased pain. 4 Presenceofpainonambulation,painisrelievedby sitting down.13. Whatclientprofileindicatesahighriskforthe developmentofperipheralvasculardisease? 1 A 76-year-old client with hypertension and diabetes mellitus. 2 A 65-year-old client with a history of hypertension and alcohol abuse. 3 A35-year-oldathletewithafamilyhistoryof diabetes. 4 A35-year-oldclientwithafamilyhistoryof cardiovascular disease.14. Aclienthasadiagnosisofdeepveinthrombosis. Whatwouldbetypicalassessmentfindings? 1 Extremityiscooltotouchandedematous. 2 Bilateral,swollen,redextremities. 3 Thready pulse and slow capillary return. 4 Pain with swelling in affected part of leg.15. A client is to be discharged and the physician has changedtheanticoagulantfromheparintowarfarin sodium(Coumadin).Whyisthemedicationbeing changedfromheparintoCoumadin when the client is discharged? 1 The client cannot safely take heparin when he gets home. 2 Coumadinmaybetakenbymouthandheparin cannot. 3 Coumadin doesnotrequiremonitoringof coagulation studies. 4 Astheclientbecomesmoremobile,theCoumadin ismoreeffective.16. Thenurseiscaringforaclientfollowingathoracotomy. Whatassessmentfindingwouldbepresentiftheclient isexperiencinghypovolemicshockfromexcessive bleeding? 1 Urineoutputbelow30mLperhour. 2 Jugular vein distention with head elevated. 3 Chesttubedrainageof50mLperhourfor4hours. 4 Bloodpressure110/70mmHg,pulserate120beats perminute.17. Whichofthefollowingwouldcausethemostproblems foraclientwithhypertension? 1 Caffeine,sugar,milkproducts. 2 Chocolate, tea, nicotine.


3 Caffeine,amphetamines,nicotine. 4 Fruits,sugar,amphetamines.18. Aclientistakingadiureticfortreatmentofhis hypertension. What foods would the nurse encourage theclienttoeat? 1 Orangejuiceandapricots. 2 Cranberryjuiceanddairyproducts. 3 Leafy,greenvegetablesandapplejuice. 4 Grains,legumes,andfish.19. Whatwouldthenurseexpecttofindontheassessment ofaclientwithadiagnosisofarterialinsufficiency? 1 Thin, fragile toenails. 2 Dependent rubor.

3 Bounding arterial pulses. 4 Warm,erythematouslegs.20. ThenurseiscaringforaclientwithBuerger’sdisease. Whatwouldbethemostimportantinformationto discusswiththisclientregardinghiscondition? 1 Elevateextremitiesseveraltimesaday. 2 Protecttheextremitiesfromcold. 3 Stopsmoking. 4 Stop activity when pain occurs.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

Appendix 11-1 VASCULAR DIAGNOSTICS Normal Value Therapeutic Value Nursing Implications

Activatedcoagulation 70-120sec 150-210sec 1. Usedtoevaluateheparinlevelchanges. time(ACT) 2. CorrelateresultswithAPTT.FragmentD-dimer lessthan250ng/mL lessthan250ng/mL 1. Confirmsthrombinandplasmingeneration (D-dimertest) haveoccurred. 2. Usedindiagnosisofdisseminatedintravascular coagulation(DIC)andtoscreenforthrombosis and acute MI.Prothrombintime(PT) 10-13-secrange 11⁄2 to 21⁄2times 1. Usedtoevaluateliverfunctionandmonitor controllevel warfarin(Coumadin)medications.Activatedprothrombin Activated:30-45sec 11⁄2 to 21⁄2times 1. Indicatorofadequacyofanticoagulationwithtime(APTT) normal heparin. 2. Donotdrawsamplefromextremitywith a heparin lock or infusion.Internationalnormalized Mathematicallycalculated 1.5-2.0(anticoagulation) 1. CalculatedlevelbasedonPT;methodofratio(INR) tomaintainconsistency (0.7-1.8) standardizingvalues.

INVASIVE STUDIES

Peripheralarteriography Involvesinjectionofaradiopaquedyeinto 1. Explainprocedurestoclient;mildsedative(angiography) eitherthearteryorthevein;x-raysare maybeindicated.Venogram takentoidentifyatheroscleroticplaques, 2. Afterprocedure: presenceofaneurysms a. Circulatorychecksdistaltothepuncturesite. b. Observe client for allergic reactions to the dye. c. Pressure dressings to arterial puncture sites.

NONINVASIVE STUDIES

Doppler ultrasonography: Hand-heldDopplerdeviceusedtodetectflowofbloodinperipheralarterialdisease.Isnotsensitiveto-early disease changes.Venous /arterial duplex scan: Usesultrasoundtoassessveinsforflowandpressure.HasbecometheprimarydiagnostictoolforDVTbecause itpermitsvisualizationofthevein.Ankle-brachial index (ABI): Calculated index using a handheld Doppler; divide the ankle systolic blood pressure (SBP) by the highest brachialSBP;normal=0.91to1.30;moderatePAD=0.41to0.70.Computerized tomography (CT):Allowsforvisualizationofthearterialwallandadjacentstructures.Usedfordiagnosisofabdominalaortic aneurysmorgraftocclusions.Trendelenburg’s test: Clientliessupinewithlegelevatedtodraintheveins.Atourniquetisthenappliedatmidthighandtheclientisaskedto stand.Veinsnormallyfillfrombelow(ordistally);avaricoseveinwillfillfromabove(orproximally)becauseofthe incompetentvalves.Donotleavetourniquetinplacelongerthan1minute.

SERUM STUDIES


Appendix 11-2 ANTIHYPERLIPIDEMIC MEDICATIONSMedications Side Effects Nursing ImplicationsAntihyperlipidemics:DecreaseLDLcholesterol,butpreferablydonotdecreasetheHDLcholesterol.Usedincombinationwithdietaryrestrictions,exercise,andsmokingcessationtoreducebloodlipidlevels.

General Nursing Implications• Adviseclientthatserumliverenzymesshouldbemonitoredthroughouttherapy.• Medicationsshouldbetakenwiththeeveningmealoratbedtime.• Medicationsshouldbeusedinconjunctionwithotherlipid-loweringtherapies(exercise,low-cholesteroldiet,smokingcessation).• Serumcholesterolandtriglyceridelevelsshouldbemonitoredperiodicallythroughouttherapy.Medications Side Effects Nursing ImplicationsCholestyramine(Questran): POColestipol (Colestid): PO

Colesevelam(Welchol): PO

Nicotinic acid (Niacin, Nicolar): PO

Gemfibrozil(Lopid): PO

Lovastatin (Mevacor): POSimvastatin(Zocor): POFluvastatin(Lescol): POAtorvastatin (Lipitor): POPravastatin (Pravachol): POCrestor (Rosuvastatin) PO

GI disturbancesConstipation

IntenseflushingGI disturbancesHyperglycemia

DiarrheaGI disturbancesAbdominalpain

Muscle breakdownHepatotoxicGI disturbances

1. Supplementalfat-solublevitaminsinlong-termtherapy.2. Mix powder or granules with several ouncesoffluidforadministration,donottakethemedicationdry.3. Use with caution in presence of consti-pation;increasefiberandfluidintaketo prevent constipation.

1. Take all tablets with food and water2. Does not have side effects of Questran or Colestid.

1. Immediatelyreportsignsofhepatotox- icity (darkening of urine, light colored stools, anorexia).2.Flushingoccursinalmostallclients;willdiminishoverseveralweeks.

1. Assessforincreaseinmusclepain.2. Will potentiate warfarin-derivative anticoagulants (Coumadin).3.Donotconfusewithhyoscyamine (Levbid).

1. Should not be given to clients with pre- existing liver disease.2. Advise client to report any increase in musclepain.3. Do not confuse pravastatin (Pravachol) with lansoprazole (Prevacid).

GI, Gastrointestinal; HDL, high-density lipoprotein; LDL, low-density lipoprotein; PO,bymouth(orally).


Appendix 11-3 ANTICOAGULANTS/ANTIPLATELETSMedications Side Effects Nursing ImplicationsGeneral Nursing Implications• Increasedriskforbleedingwhenusedconcurrentlywithotherdrugs,herbalremedies,orfoodsaffectingcoagulation.• Initiatebleedingprecautions(Box9-1).• Donotautomaticallydiscontinueaccordingtoautomaticstoppolicies(procedures,surgery)withoutverifyingtheorder;reevaluateall clients whose anticoagulants are being held for procedures and assess the need to reorder the anticoagulant therapy.

NURSING PRIORITY: ✔ If heparin is discontinued, within hours the client is not adequately anticoagulated and is at increased risk for complications.

Medications Side Effects Nursing Implications

Heparin: IV, subQMay not be given PO.Short-termanticoagulation

Low-Molecular Weight-HeparinEnoxaparin (Lovenox): subQDalteparinsodium(Fragmin): subQ

Warfarinsodium(Coumadin): POLong-termanticoagulation

Bleedingtendencies:hematuria,bleedinggums,orfrankhemorrhageHeparin-inducedthrombocytopenia:associatedwithincreaseinthrombosis

1. Check the APTT for therapeutic levels.2.Protaminesulfateistheantidote.3. Will not dissolve established clots.4. Evaluate client for decreased platelets. 5. Effectiveimmediatelyafteradministration;anticoagulation effect has a half life of 1.5 hours. 6.Donotstoreinsameareaasinsulin;botharegivenby units.7.ProphylacticusedoesnotrequiredailyAPTTlevels.8.Determineifheparinisbeingusedtotreatthromboem-bolicproblemorasprophylaxisforthromboembolicproblems.

1. Use:prophylaxisforthromboembolicproblemsinhigh-riskclients(immobility,hiporkneereplacement).2. Dosage is not interchangeable with heparin.3. Leavetheairlockintheprefilledsyringetoprevent leakage.4.Lovenoxshouldbeinjectedintothe“lovehandles”oftheabdomen.

1. Check the PT and INR to evaluate level of anticoagulation.2.VitaminKistheantidote.3. Half-life is 3-5 days; discontinue 3 days before any invasive procedure. 4. Client teaching:•Bleedingprecautions(Box9-1).•Adviseallhealthcareprovidersofmedication–druginteractionsarecommon.•Maintainroutinechecksoncoagulationstudies.•Donotstoptakingmedicationunlesstoldtodoso by health care provider.

Antiplatelet MedicationsAspirin: PO

Clopidogrel (Plavix): PO

Cilostazol (Pletal): PO

Ticlopidine (Ticlid): PO

GIbleeding,hemorrhagicstroke

Abdominalpain,dyspepsia,diarrheaBlood dyscrasias

Headache, dizziness, G I bleeding

Diarrhea,bleeding,aplasticanemia

1. Giveninsmalldoses(e.g.,81mgdaily).2.ProphylactictherapyforpreventionofMIandthrom- botic stroke in clients with TIAs.

1. ProphylactictreatmentforpreventionofMI,strokesin clients with established peripheral artery disease.2.Expensiveandslightlymoreeffectivethanaspirin.3. Monitor for bleeding tendencies.

1.Monitorforreliefofintermittentclaudication.2.Grapefruitjuiceinhibitsmetabolism.3.Administeronanemptystomach.

1. Monitor coagulation studies throughout therapy.2. Monitor cholesterol/triglyceride levels.

GI, Gastrointestinal; MI,myocardialinfarction;PO,bymouth(orally);TIA,transientischemicattack

TEST ALERT: Observe for effects of medications. Review the nursing implications associated with administration of anticoagulants.

HIGH

ALERT


Appendix 11-4 ANTIHYPERTENSIVE MEDICATIONSMedications Side Effects Nursing Implications

General Nursing Implications• Adviseclientthatpostural(orthostatic)hypotensionmayoccurandhowtodecreaseeffects: Sitonsideofbedbeforestanding,makesureclientisstablebeforestanding. Donotstandforprolongedperiodsoftime. Older client is at increased risk Mayoccurwithfirstdoseorsubsequentdoses. Problemismostoftentemporary.• Hypotensionmaybeincreasedbyhotweather,hotshowers,hottubs,andalcoholingestion.• Clientshouldnotabruptlydiscontinuemedicationorchangedosagewithoutconsultinghealthcareprovider.Abruptwithdrawalcancause rebound hypertension.• Encouragealow-sodiumdietandweightmaintenanceorreduction.• Discourageuseofalltobaccoproducts.• Haveclientreportunpleasantsideeffectsrelatedtosexualdysfunction.• Adviseclientnottotakeover-the-countercoughmedicationsordecongestantsthatcontainpseudoephedrine;thesemedicationscausean increase in BP.

TEST ALERT: Observe for effects of medications. Evaluate client’s use of medications.


Vasodilator:Actsdirectlyonvascularsmoothmuscletoproducevasodilation.

Hydralazine HCl (Apresoline): PO, IM, IV

Minoxidil (Loniten): PO

Tachycardia,headache,sodiumretention,drug-inducedlupussyndrome

Tachycardia,sodiumandwaterretention

1. Adviseclientthatposturalhypotensionmayoccur.2.Maybeusedincombinationwithotherantihyperten-sivemedications.

1. Used in clients with severe hypertension that is not respondingtoothermedications.2.Requiresveryclosemonitoringofbloodpressure.

Centrally Acting Inhibitors (antiadrenergics):Decreasesympatheticeffect(norepinephrine),resultingindecreasedBPandperipheralresis-tance, decrease in heart rate, and no change in cardiac output.

Methyldopa: POMethyldopate: IV

Hepatotoxicity,hemolyticanemiasexual dysfunction, orthostatic hypo-tension

1. Ifwithdrawnabruptly,mayprecipitateahypertensive crisis.2.DonotconfusemethyldopawithlevodopaorL-dopa3.Monitorfordepressionoralteredmentalstatusinolder adults.

ACE Inhibitors: Reduce peripheral vasculature resistance without increasing cardiac output, rate, or contractility; angiotension antagonists.

Captopril (Capoten): POEnalapril (Vasotec): POLisinopril (Zestril): PORamipril(Altace): POMoexipril (Univase): POBenazepril (Lotensin): PO

Posturalhypotension,hyperkalemia,insomnia,nonproductivecough,lossoftaste

1.Monitorcloselyonfirstdose;hypotensionandfirst-dosesyncopefrequentlyoccurs.2.Conservepotassium;maynotneedapotassiumsupple-mentwhengivenwithadiuretic.3.Skippingdosesorstoppingdrugmayresultinrebound hypertension.

Beta-Adrenergic Blockers and Calcium Channel Blockers See Appendix 12-2.

ACE,Angiotensin-convertingenzyme;BP, blood pressure; ECG,electrocardiogram;GI, gastrointestinal; IM,intramuscularly; IV, intravenously; PO,bymouth(orally).


Loop Diuretics: Blocksodiumandchloridereabsorption.Preventreabsorptionofwaterbackintothecirculationcausinganincreasein excretion of the water, and produces diuresis.

Furosemide(Lasix): PO, IM, IVBumetanide(Bumex): PO, IM, IVTorsemide(Demadex): PO, IV

Dehydration, hypotension; excessive loss ofpotassium,sodium,chloride;hypergly-cemia,hyperuricemia;muscleweakness

1. Strong diuretic that provides rapid diuresis.2.Usewithcautioninolderadults;CNSproblemsof confusion, headache.3. Monitor closely for tinnitus/hearing loss.4.DonotconfuseBumexwithbuprenorphine(Buprenex).

Thiazide Diuretics: InhibitNaClreabsorption,whichcausesanincreaseintheexcretionofwater,sodium,andchloride.

Chlorothiazide (Diuril): IV, POChlorthalidone (Hygroton): POHydrochlorothiazide(HydroDIURIL, Esidrix): POMetolazone (Zaroxolyn): PO(a thiazide-like diuretic)

Dehydration, hypotension; excessive loss ofpotassium,hyperglycemia,hyperurice-mia;muscleweakness

1.Frequentlyusedasfirst-linedrugtocontrolessential hypertension.2. Increased risk for digitalis toxicity if taking digoxin products.

Potassium-Sparing Diuretics: Block the effect of aldosterone on renal tubules

Spironolactone (Aldactone): POTriamterene(Dyrenium): PO

Hyperkalemia,hyponatremia,impotence,hypotension

1.Maybeusedincombinationwithotherdiureticstoreducepotassiumloss.2.Potassium-sparingeffectsmayresultinhyperkalemia.3. Clientshouldnottakepotassiumsupplements.4. Avoid salt substitutes and foods containing large amountsofsodiumorpotassium.

Osmotic Diuretic:Increasesosmoticpressureofthefluidintherenaltubules,preventingreabsorptionofsodiumandwater.

Mannitol (Osmitrol): IV Pulmonaryedema,CHF,tissuedehydration,nausea,vomiting

1. Stopinfusionifclientbeginstoshowsymptomsofrespiratorycomplications.2.Monitorinfusionsitecloselyforinfiltrationand/or extravasation.3. May be used to decrease intracranial pressure.

BP, Blood pressure; CHF, congestive heart failure; CNS,centralnervoussystem; IM,intramuscularly;IV, intravenously; PO,bymouth(orally).

FIGURE 11-4 Diuretic Water Slide - (From: Zerwekh, JA, Claborn, JC, Miller, CJ, Memory Notebook of Nursing: Pharmacology and Diagnostics, ed 2, Ingram, Texas, 2009,

Nursing Education Consultants.)

Appendix 11-5 DIURETICS

General Nursing Implications

• Inhospitalizedclients,evaluatedailyweightsforfluidlossorgain.

• Evaluateintakeandoutputrecordsandcomparetoweightgainorloss.

ª Monitorforhypokalemia,anorexia,muscleweakness,numbness,tingling, paresthesia, confusion, and excessive thirst.

• Adviseclientoffoodsthatarerichinpotassium(Table2-2).

• Administermedicationsinthemorningtoallowdiuresistooccurduringtheday.

• Teachclienthowtodecreaseeffectsofposturalhypotension.

• MonitorBPresponsetomedication.



Appendix 11-6 MEDICATIONS USED FOR TREATMENT OF SHOCK

General Nursing Implications• Mostoftenlimitedtocriticalcaresettings;constantmonitoringisrequired.• AdministeredIVindilutedsolutionbyinfusionpump.• MonitorIVinfusionsiteclosely;leakageintotissuemaycausetissuesloughing.• ContinuousECGmonitoring;observeclientcloselyforcardiacdysrhythmias.• Monitorurinaryoutputeveryhour.• MedicationsshouldnotbeadministeredtoclientsreceivingMAOIsortricyclicantidepressants.• PrimaryresponsibilityofPNistomonitorclientandkeepRNandHCPcloselyadvisedofclient’sresponse.


Adrenergics:Increasesmyocardialcontractility,therebyimprovingcardiacoutput,BP,andurineoutput.

Dopamine(Intropin):IV Dysrhythmias(tachycardia),angina, 1.Shouldnotbegiventoclientswithtachydysrhythmiasor hypertension,headaches ventricularfibrillation 2. High Alert Medication–consequencesofamedication error can be fatal, always check with RN and HCP. 3. If extravasation occurs, stop infusion immediately and notify RN or HCP. 4.CloslymonitorVS,cardiacrhythm,andurinaryoutput duringadministration.

Dobutamine(Dobutrex):IV Tachycardia,dysrhythmias,hypertension 1. Closely observe client for development of angina, notifiy RN or HCP. 2. If extravasation occurs, stop infusion and notify RN or HCP.

Epinephrinehydrochloride Nervousness,restlessness,tremors, 1.Besuretoreadlabelcorrectlyandusecorrectstrength/(Adrenalin):IV angina,dysrhythmias,tachycardia, concentration. hypertension. 2. High-Alert Medication - dosages are easily confused and mistakesaremade. 3.Useintreatmentofanaphylacticshockandcardiacarrest.

HIGH

ALERT

ECG,Electrocardiogram;IV, intravenous; MAOIs,monoamineoxidaseinhibitors;VS, vital signs.

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