Unit 2 Diseases of Blood Vessels. Hypertension High Blood Pressure Most common CV problem in US...
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Transcript of Unit 2 Diseases of Blood Vessels. Hypertension High Blood Pressure Most common CV problem in US...
Unit 2Diseases of Blood
Vessels
Hypertension
•High Blood Pressure•Most common CV problem in US today
•Persistent BP readings > or = 140/90
HTN
•Silent killer – why?•Incidence – men vs. women; African American
•Increasing in children
HTN•2 factors determine BP
–Cardiac Output–Peripheral Vascular Resistance
–BP = CO X PVR
HTN Complications:
•Damage to:–Heart–Blood Vessels–Kidneys–Brain–Eyes
Types of HTN
•Primary (Essential)•Secondary•Malignant
Primary or Essential
•90-95% of cases•Cause unknown
Secondary•Known cause•Kidney disease, tumors, malformed blood vessels, endocrine problems
•Pregnancy
Malignant
•Sudden•Rapid progression•Inc in black males < 40•Usually fatal within 2 years
Risk Factors HTN
•Dyslipidemia•Atherosclerosis•Diabetes•Smoking•> 60 y.o.•Male
Risk Factors HTN
•Postmenopausal female
•Family History •Sedentary Lifestyle•Obesity•Others
Signs and Symptoms
•Usually no early s/s - “silent killer”•Occipital headaches•Lightheadedness•Epistaxis
Signs and Symptoms
•Fatigue•Dyspnea•Edema•Nocturia•Organ Damage
Treatment Goal
•Reduce PVR and BP•Treat Underlying Conditons
Lifestyle Modification
•Weight loss•Smoking Cessation•Na and Alcohol restriction
•Exercise•Relaxation
Pharmacologic•Stepped Care Approach
–Step 1 – start 1 drug•Thiazide diuretic•Betablocker•ACE inhibitor•Calcium Channel Blockers
Pharmacologic–Step 2
•Increase dose of first drug or add 2nd
–Step 3•Increased dose, add 3rd drug, try different drug from step 1
Pt Education
•Lifelong treatment•Meds•Lifestyle changes
(CVA) Cerebrovascular
Accident
•Interruption of blood flow to part of brain
•What happens then?
CVA
•3rd leading cause of death in U.S.
•Leading cause of adult disability
Types of Stokes
•Hemorrhagic•Ischemic
Hemorrhagic Stroke•20% of all strokes•Blood vessel ruptures or bleeds
•Classified by location–Intracerebral–Subarachnoid
Ischemic Stroke•80% of all strokes•Caused by obstruction of blood vessel
•Classified as:–Embolic–Thrombotic
NonmodifiableRisk factors
•Age•Race•Gender •Heredity
ModifiableRisk factors
•Refer to Table 27-1–Page 410
Diagnosis•H & P•Brain Imaging Studies
–Angiography–Doppler Studies–CT / MRI–EEG
Stages of a Stroke•TIA
–Transient Ischemic Attack
•SIE–Stroke In Evolution
•CS–Complete Stroke
Transient Ischemic Attack (TIA)
•Temporary Neurological Deficit
•Last few minutes to 24 hours
•No permanent effects
TIA Treatment•Platelet Aggregatin Inhibitors–Examples?
•Anticoagulants–Examples?
TIA Treatment
•Carotid Endarterectomy
•Angioplasty
Complete Stroke (CS)
•When neuro deficits do not change for 2 – 3 days
CVA•Recovery is uncertain at first
•Brain cells do not regenerate
•If damaged but not dead, do have potential
CVA•Collateral circ plays role•Cell damage also d/t edema in brain
•Quick functional return = better prognosis
As Health Care Professional:
•Recognize impending CVA warning signs
•Get help ASAP•New therapies can prevent/dec damage
- TPA or Amicar
Signs and Symptoms
•Depend on: - Cause - Area of brain affected
Hemorrhagic Stroke
•Sx. Generally sudden•Severe headache•Stiff neck•Loss of consciousness•Vomiting•Seizures
Embolic Stroke•Sx. usually occur without warning
•May see hx. of heart or blood vessel disease
•Many possible S & S–WHY?
Thrombotic Stroke
•Sx. can be gradual or sudden onset
•Sx. related to area affected
Brain Damage S/S
•AphasiaAphasia•DysarthriaDysarthria•DysphagiaDysphagia•DyspraxiaDyspraxia•HemiplegiaHemiplegia
–Most common result
•Sensory ImpairmentSensory Impairment•Unilateral NeglectUnilateral Neglect•Homonymous Homonymous HemianopsiaHemianopsia
•Intellectual/EmotionalIntellectual/Emotional•EliminationElimination
CVA Nursing Implications
L.O.C.•Neuro Check q1h - Glasgow Coma Scale•Get baseline assess•Report and document change in LOC ASAP
Motor & Sensory Functions
•Compare bilaterally
The Acute PhaseThe Acute Phase
Medical Tx of CVA
•Depends on symptoms•Treat HTN•Treat increased ICP
Airway / OxygenAirway / Oxygen•Position on unaffected side•Monitor O2 Sat. (pulse ox.)•Oral airway available•Suction equip in room•O2 in room
Frequent Vitals and Frequent Vitals and Neuro checksNeuro checks
•Check for s/s of inc ICP•If see s/s of inc ICP, elevate HOB 30º
S/S of Inc. ICP(Intracranial pressure)
•Change in LOC•Change in Sensory, Motor Function
•Pulse <60, >100•Resp Distress•Widened pulse press.•Pupil changes
Drug TherapyDrug Therapy•tPA if ischemic
–Within 3 hours•Treat Cerebral Edema
–Diuretics–Corticosteroids
•Treat Hypertension
Rehabilitation Phase
•Affected by acute Nursing care
•Prevent contractures•Prevent decubs and joint deformities
•B & B training
Goal of Rehab
•Return > independence•As much self care as possible
•Eval ability to perform self care first
Rehab disciplines
•Nursing•Physicians•P.T., O.T., S.T.•Social service•Dietician
Ms. Sandusky is an 82yo female brought into ER forcomplaints of right sided weakness and visual disturbances.
Past History: Multiple TIA’s, HTN, and NIDDM.Surgical History: RTHA, Laminectomy.Social History: No smoking, occasional ETOH use. Lives
alone. No family in area. NKDAMeds: Lotrel 10mg daily, ASA 81mg daily, Glucophage
1000mg 2xday, Percocet PRN, Xanax PRN
Current: 178/92, 102, 18, 98.9, 98%. Begin Heparin dripper protocol NOW, Clonodine 1mg po NOWPt flaccid right side. Dyspraxia noted. ST to evalfor dysphagia. Pt aphasic. Continue home meds.May crush in thickened liquids
Diseases of the Arteries
Arterial Embolism•Blood clot carried through circulation
•Often arise from chambers of heart
•Esp with atrial fib, MI, CHF, endocarditis
S/S:•Severe, acute Pain•Gradual loss of sensory and motor function
•Pain with movement•Absent Pulses•Pallor or mottling•Temp Change
Management•Anticoagulants•Thrombolytics•Embolectomy - surgical removal of clot•Patient Education
Peripheral Arterial Occlusive Disease
•Atherosclerosis obliterans
•Arterial Insufficiency•Peripheral Vascular Disease (PVD)
Peripheral Arterial Occlusive Disease
•Increased in men •Cause:
–Atherosclerosis–Embolism–Trauma–Vasospasm
Risk Factors:
•Cigs•Hyperlipidemia•HTN•DM•Stress
Hallmark symptom:•Intermittent claudicationIntermittent claudication–pain in lower extrem.
•Aching, cramping,•Tiredness, weaknesss
with exercise, rest
Other S/S:•Diminished / Absent Peripheral Pulses
•Rest pain•Numbness / Tingling•Coolness•Muscle Atrophy
Other S/S:•Skin Changes
–Pale when up–Red with dependency–Hairlessness
•Nail Changes
Diagnosis
•Doppler studies•Plethymography•Angiography
Treatment
•Decrease risk factors•Drug therapy•Surgery
Types of surgery
•Sympathectomy•Vascular grafting•Endarterectomy•PTA (Percutaneous Transluminal Angioplasty)
•Amputation
Nursing Care•Assess: - peripheral pulses - color - temp - mobility- sensation (peripheral
neuropathy ?)
Nursing Care•Protect from Injury
–no pressure–foot care–shoes/socks–careful w/ temp. extremes
–no leg crossing
Nursing Interventions:
•Activity Intolerance•Pain•Impaired Skin Integrity•Ineffective Tissue Perfusion
•Risk for Infection
Buergers Disease•Thromboangiitis Obliterans•Inflammatory thrombotic disorder of arteries and veins in LE and UE
•Results in obstruction/occlusion
Buergers Disease•Not atherosclerotic process
•Cause Unknown•Occurs only in smokers
Symptoms•Intermittent claudication
•Rest Pain•Skin color & temp changes
Symptoms
•Cold Sensitivity•Abnormal sensation•Ulceration•Gangrene
Treatment•Smoking Cessation•Buerger-Allen Exercises
–See pg. 617-618•Vasodilators•Antibiotics
Treatment•Anticoagulants •Platelet Aggregation Inhibitors
•Protection of Affected Extremities
•Sympathectomy
Raynaud’s Disease
•Intermittent arteriolar vasoconstriction
•Affects Hands Primarily•Inc in women 16 - 40
S/S:•Chronically Cold hands, Numbness, Tingling and Pallor.
•Not symmetric•Skin Changes:
–Pallor to cyanosis to redness
Treatment
•Prevent Pain–Avoid stimuli that causes vasoconstriction
–Ideas???
Treatment:
•Promote Vasodilation–Ca Channel Blockers–ACE inhibitors–Alpha Blockers–Sympatholytics
Aneurysms•Dilated segment of an artery
•Due to weakness and stretching of arterial wall
http://www.healthline.com/channel/abdominal-aortic-aneurysm-aaa_videos
Causes:•Congenital•Aquired
–Arteriosclerosis (athero)–Trauma–Infection–Hypertension
Location
•Aorta–Abdominal
•Most common site•Thoracic
S/S:•Vary with location•Thoracic
–Often without sx.–Chest pain–Hoarseness–Dysphagia
S/S:•Abdominal
–Most asymptomatic –Usually detected on Routine PE and X-Ray
–Back/Flank PainBack/Flank Pain–Epigastric Pain–Constipation
Complications•Rupture•Thrombus Formation•Emboli•Pressure on Surrounding Structures
Treatment•Control systolic BP - i.e.- Captopril•Surgery (~ 5 cm.) - synthetic graft
Postop Care•Impaired Urinary Elimination
•Risk for Injury•Ineffective Breathing Pattern
Postop Care•Decreased Cardiac Output
•Ineffective Tissue Perfusion
Cerebral Aneurysm•Localized vascular dilatations
•Most result from congenital defects
•Also from head injury•Bifurcation of major art
Rupture of cerebral aneurysm
•Hemorrhagic CVA•May be fatal•Most have hx of HTN•Activity often precedes
Nursing Care:•Prevent rebleeding•Keep quiet as possible•Look for change in LOC - Glasgow coma scale•Inc ICP or BP > inc rebleed
Glasgow Coma Scale
•Eye opening response
•Speech•Motor ability
Surgical Tx of Cerebral Aneurysm
•Tx of choice•Clipping•Reinforce with muscle fascia or acrylic
Diseases of the VeinsDiseases of the Veins
VenousVenous ThrombosisThrombosis•Includes:
–PhlebitisPhlebitis–ThrombophlebitisThrombophlebitis–PhlebothrombosisPhlebothrombosis–Deep Vein Deep Vein Thrombosis (DVT)Thrombosis (DVT)
3 Contributing Factors•Called Virchow’s Triad
–Stasis of blood–Damage to the vessel walls
–Hypercoagulability
Risk Factors
BedrestSurgery (general anesthesia) > 40
Leg Trauma and Immobiization
Risk Factors contPrevious Venous Insufficiency
ObesityOral ContraceptivesMalignancy
SymptomsOften AsymptomaticEdemaWarmthTenderness / PainWith DVT: + Homan’s Sign+ Homan’s Sign
Diagnosis
VenographyPlethysmographyDoppler Ultrasound
Treatment Goal:
Prevent thrombosisPrevent PEPrevent recurrenceReduce Discomfort
Treatment cont:•Anticoagulant Therapy:
–IV Heparin–Oral Coumadin
•Thrombolytic therapy•Surgical thrombectomy
Nursing Care:•Ongoing assess for PE•Bedrest•Elevation of extremity•Antiembolism Hose•Warm, Moist soaks
Nursing Care
Compare extremitiesProtect from pressureAnalgesics as prescribedPt. Education
Pt Education re: anticoagulants
Take daily - same timeWear medical ID bandBl testing importanceDrug interactionsS/S of bleedingAvoiding injury
Chronic Venous Insufficiency
•Culmination of long standing venous hypertension
•Veins and Valves are damaged
Symptoms:•Edema (ankles)•Stasis dermatitis•Stasis ulceration
–Medial Malleolus•Pain with dependency and ambulation
Symptoms:Pain in Calf or thigh
–Heaviness/Dull acheSkin CoolPulses present
–May be difficult to palpate – WHY?
Treatment Goal
•Promote venous return
•Prevent / Treat Ulceration
Nursing Interventions•Ineffective Tissue PerfusionIneffective Tissue Perfusion
–Elevate legs–Avoid
•Standing still•Crossing legs•Restrictive clothing
Nursing Interventions
•Disturbed Body Image•Risk for Infection
–Monitor for infection–Handwashing–Wound care
Nursing Interventions
•Impaired Skin Integrity–Checking / Treating ulcerations
–Teaching home care
Leg Ulcers:
•Major complication with PVD
•Prevention is key•Good nursing assess•Good pt education
Varicose Veins
•Dilated, tortuous superficial veins
•D/T incompetent valves•Usually in LE•Affects 1 in 5 people
Result of:•Hereditary weakness•Aging•Pregnancy•Obesity•Prolonged Standing
Symptoms:•Oversized, Discolored, Tortuous Veins
•Dull aching •Heaviness•Muscle Cramps
–Increased at night
Symptoms:•Muscular Fatigue•Ankle Edema•Over time
–Postphlebotic Syndrome
Diagnosis•Plethysmography•Venogram•Doppler Ultrasound•Brodie-Trendelenberg
Treatment•Medical
–Avoid •Restrictive garments•Prolonged standing or sitting
•Crossing Legs
Treatment–Elevate Extremity–Weight Reduction–Support Stockings
•Surgery–Sclerotherapy–Ligation and Stripping
Surgical management
•Vein ligation (tied off) and stripping (removal)
•Other veins take over work of those removed
Nursing care after ligation and stripping
•Pt education•Elastic compression•Exercise legs•Elevate foot of bed•Early ambulation•Discharge teaching
A woman, calling Mount Sinai Hospital, said, "Hello, I want to know if a patient is getting better."The voice on the other end of the line said, "Do you know the patient's name and room number?"She said, "Yes, darling! She's Sarah Finkel, in Room 302."He said, "Oh, yes. Mrs. Finkel is doing very well. In fact, she's had two full meals, her blood pressure is fine, she's going to be taken off the heart monitor in a couple of hours and if she continues this improvement, Dr. Cohen is going to send her home Tuesday."The woman said, "Thank God! That's wonderful! Oh! That's fantastic! That's wonderful news!"The man on the phone said, "From your enthusiasm, I take it you must be a close family member or a very close friend!"She said, "I'm Sarah Finkel in 302! Cohen, my doctor, doesn't tell me a word!"