CARDIO VASCULAR SYSTEM

VENOUS DISORDERS

Venous Thromboembolism (VTE)

Deep vein thrombosis (DVT) and pulmonary

embolism (PE) collectively make up the
condition known as (VTE)
:DVT

Is a blood clot in a major vein that usually develops in the

.legs and/or pelvis

:PE
is an obstruction of a blood vessel in the lungs, usually
.due to a blood clot, which blocks a coronary artery

The incidence of VTE

to 20% in general medical patients 10%to 50% in patients who have had a stroke 20%up to 80% in critically ill patientsof patients hospitalized with VTE develop long-term 30%
post thrombotic complications

Risk Factors for (DVT) &(PE)

Endothelial Damage- 1
Trauma
Pacing wires
Dialysis access catheters
Repetitive motion injury

Surgery
Central venous catheter
Local vein damage

Venous Stasis- 2
Bed rest or immobilization
History of varicosities
Age (greater than 65 years)

Obesity
Spinal cord injury

Altered Coagulation- 3
Cancer
Pregnancy
Oral contraceptive use
Protein C deficiency
Protein S deficiency
Antiphospholipid antibody syndrome
Factor V Leiden defect
Prothrombin 20210A defect
Hyperhomocysteinemia
Elevated factors II, VIII, IX, XI
Antithrombin III deficiency
Polycythemia
Septicemia

Clinical Manifestations
Un common, phlegmasia cerulea dolens (massive iliofemoral
venous thrombosis), in which the entire extremity becomes
massively swollen, tense, painful, and cool to the touch

:Deep Veins obstruction- 1

Edema and swelling of the extremityThe amount of swelling can be determined by measuring
the another extremity size
If both extremities are swollen, a size difference may be
difficult to detect

The affected extremity may feel warmer, and thesuperficial veins may appear more prominent

Tenderness, which usually occurs later, can be detected by. gently palpating the affected extremity
Homans sign (pain in the calf after the foot is sharplydorsiflexed) , but it is not a reliable sign for DVT

Superficial Veinspain or tenderness, redness, and warmth in the involvedarea

The risk of the superficial venous thrombi becomingdislodged or fragmenting into emboli is very low because
most of them dissolve spontaneously

So
treated at home with bed rest, elevation of the leg, analgesic
agents, and possibly anti-inflammatory medication

Assessment and Diagnostic Findings

Assess Patients with a history of high risk factors-

:key concerns during nursing assessment includelimb pain, a feeling of heaviness, functional - 1
impairment, ankle engorgement, and edema
differences in leg circumference bilaterally from thigh - 2
to ankle
increase in the surface temperature of the leg, - 3
particularly the calf or ankle
areas of tenderness or superficial thrombosis (ie, cord- 4

.like venous segment)

Complications of VenousThrombosis
Valvular destruction
Chronic venous insufficiency
Increased venous pressure
Varicosities
Venous ulcers

Venous obstruction
Increased distal pressure
Fluid stasis
Edema
Venous gangrene

Prevention
Application of graduated compression stockings -1
Use of intermittent pneumatic compression devices - 2
Encouragement of early mobilization and leg exercises -3
For surgical patients, administration of subcutaneous - 4
un fractionated or low-molecular- weight heparin
(LMWH)
lifestyle changes as appropriate, which may include - 5
weight loss, smoking cessation, and regular exercise

Medical Management
:A- Pharmacologic Therapy
Unfractionated Heparin- 1
Subcutaneously to prevent development of DVTIntermittent or continuous IV infusion for 5 days toprevent the extension of a thrombus and the
development of new thrombi
Oral anticoagulants, such as warfarin, are administered with heparin therapy

Low-Molecular-Weight Heparin (LMWHs)- 2

Subcutaneous ,such as (dalteparin and enoxaparin)One or two SC injections each dayfewer bleeding complications and lower risks of heparin-induced thrombocytopenia (HIT) than unfractionated
heparin
Used safely in pregnant womenExpensive-

Oral Anticoagulants- 3
Warfarin is a vitamin K antagonist that is indicated for
extended anticoagulant therapy , and have a slow
onset of action
Factor Xa Inhibitor- 4
given daily SC at a fixed dose, as Fondaparinuxhas a half-life of 17 hoursMust be used with caution in patients with renal insufficiency
Also effective in conjunction with warfarin-

Thrombolytic Therapy-5
catheter-directed thrombolytic (fibrinolytic) therapy lyses and.dissolves thrombi in at least 50% of patients
is given within the first 3 days after acute) eg, alteplase- (
thrombosis, if initiated more than 14 days it will be less
.effective
:The advantages
less long-term damage to the venous valves and a reducedincidence of post thrombotic syndrome and chronic
venous insufficiency
incidence of bleeding than heparin, so if bleeding can not
stopped, the thrombolytic agent is discontinued

:B- Endovascular Management

is necessary for DVT when anticoagulant or thrombolytic
therapy is contraindicated

A thrombectomy may be necessary. This mechanical

method of clot removal may involve using intraluminal
.catheters with a balloon or other devices

Nursing Management
:A-Assessing and Monitoring Anticoagulant Therapy
unfractionated heparin is administered by continuous IV- 1
infusion using an electronic infusion device
Dosage calculations are based on the patients weight- 2
possible bleeding tendencies are detected by a- 3
pretreatment clotting profile
If renal insufficiency exists, lower doses of heparin are- 4
.required

Periodic coagulation tests and hematocrit levels are- 5

obtained
Oral anticoagulants are monitored by the PT or the INR- 6
Oral anticoagulants administered with heparin until- 7
desired anticoagulation has been achieved

B- Monitoring and Managing Potential Complications

Bleeding
Microscopic examination of the urine- 1
Bruises, nosebleeds, and bleeding gums -2
IV injections of protamine sulfate may be effective with- 3
heparin
Risks of protamine administration include bradycardia and
hypotension, can be minimized by slow administration
Administration of vitamin K and/or infusion of fresh-frozen -4
plasma or prothrombin concentrate are effective with
anticoagulant agent

Oral and low-dose IV vitamin K significantly reduces-5

the INR within 24 hours

Thrombocytopenia
A complication of heparin therapy may be heparin induced
thrombocytopenia (HIT)
It is a sudden decrease in the platelet count by at least30% of baseline levels
it is preferable not to use unfractionated heparin over the- 1
long term for the greatest risks
The administration of LMWH is less frequently associated- 2
with HIT
Beginning warfarin with unfractionated heparin can- 3
provide a stable INR or PT by day 5 of heparin treatment,
.at which time the heparin may be discontinued

Regular monitoring of platelet counts - 4

: Early signs include- 5
appearance of skin necrosis, either at the site of injection or at distal sites where thromboses occur
skin discoloration consisting of large hemorrhagic areas hematomasPurpura ,and blisteringIf thrombocytopenia does occur, platelet aggregation - 6
studies are performed, the heparin is discontinued,
and alternate anticoagulant therapy is rapidly initiated

:Drug Interactions
close monitoring of the patients medication schedule - 1
. is necessary
Check if any medications or supplements are - 2
contraindicated with warfarin, Many medications and
supplements inhibit oral anticoagulants

C- Providing Comfort
Elevation of the affected extremity- 1
graduated compression stockings, and analgesic- 2
.agents
Warm, moist packs applied to the affected extremity- 3
encouraged to walk once anticoagulation therapy has- 4
been initiated
instruct the patient that walking is better than - 5
standing or sitting for long periods
Bed exercises, such as repetitive dorsiflexion of the - 6
foot

:D- Compression Therapy

Stockings
Graduated compression stockings usually are prescribed - 1
The amount of pressure gradient is determined by the- 2
amount and severity of venous disease
Are designed to apply 100% of the prescribed pressure- 3
gradient at the ankle and pressure that decreases as the
stocking approaches the thigh, reducing the caliber of the
superficial veins in the leg and increasing flow in the deep
. veins

These stockings may be knee high, thigh high, or- 4

pantyhose
When the stockings are off, the skin is inspected for-5
signs of irritation, and the calves are examined for
.tenderness
.Any skin changes or signs of tenderness are reported-6
Stockings are contraindicated in patients with severe - 7
pitting edema because they can produce severe pitting
at the knee

NB
For ambulatory patients
graduated compression stockings are removed at
night and reapplied before the legs are
lowered from the bed to the floor in the
.morning

External Compression Devices and Wraps

Short stretch elastic wraps may be applied from the toes- 1
.to the knee in a 50% spiral overlap

:The Unna boot-2

consists of a paste bandage impregnated with zinc oxide,glycerin, gelatin, and sometimes calamine, is applied
without tension in a circular fashion from the base of the
. toes to the tibial tuberosity with a 50% spiral overlap

It is important to keep the foot dorsiflexed at a 90degree angle, thus avoiding excess pressure or
trauma to the anterior ankle area
Once the bandage dries, it provides a constant and consistent compression of the venous system, remain
in place for as long as 1 week

Intermittent Pneumatic Compression Devices

can be used with elastic or graduated compression- 1
stockings
consist of an electric controller that is attached by air hoses - 2
to plastic knee high or thigh-high sleeves
The leg sleeves are divided into compartments, which-3
sequentially fill to apply pressure to the ankle, calf, and thigh
at 35 to 55 mm Hg of pressure
increase blood velocity beyond that produced by the- 4
. stockings
Ensuring that prescribed pressures are not exceeded,- 5
assessing for patient comfort, and ensuring compliance to
therapy

E- Positioning the Body and Encouraging

Exercise
The feet and lower legs should be elevated - 1
periodically above the level of the heart
Active and passive leg exercises, particularly those - 2
involving calf muscles
Early ambulation is most effective- 3
Deep-breathing exercises- 4
avoid sitting for more than an hour at a time - 5
.Walk at least 10 minutes every 1 to 2 hours - 6

It
results from
obstruction
of the venous
Chronic
Venous
Insufficiency/
- valves3in the legs.or a reflux of blood through
valves
( Postthe
thrombotic
Syndrome)
Superficial and deep leg veins can be involved-

Gravity

Blood
pressure

Competent valves showing blood flow patterns when the valve is open (A) and
. closed (B), allowing blood to flow against gravity
C, With faulty or incompetent valves, the blood cannot move toward the heart

INFECTIOUS DISEASES OF THE HEART

Endocarditis- 1
A- Rheumatic Endocarditis

Patients with rheumatic fever may develop rheumatic

heart disease
Acute rheumatic fever, which occurs most often in
school age children, may develop after an episode of
group A beta hemolytic streptococcal pharyngitis

B- Infective Endocarditis
is a microbial infection of the endothelial surface of the
heart. It usually develops in people with prosthetic
heart valves or structural cardiac defects

Myocarditis- 2
inflammatory process involving the myocardium, can
cause heart dilation, thrombi on the heart wall (mural
thrombi), infiltration of circulating blood cells around
,the coronary vessels and between the muscle fibers
and degeneration of the muscle fibers themselves

Pericarditis- 3
inflammation of the pericardium, the membranous sac
. enveloping the heart
Primary illnessSecondary, it may develop during various medical and. surgical disorders
For example
After pericardectomy (opening of the pericardium) following
. cardiac surgery
also may occur 10 days to 2 months after acute myocardial
infarction (MI)

ARTERIAL DISORDERS
Arteriosclerosis and Atherosclerosis - 1
: Arteriosclerosis
is the most common disease of the arteries; the term
. means hardening of the arteries
It is a diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened

:Atherosclerosis
A different process, affecting the intima of the large and
.medium-sized arteries
These changes consist of the accumulation of lipids,
calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery. These
accumulations are referred to as atheromas or
.plaques
: It may be complicated by
hemorrhage, ulcerationcalcification, or thrombosisMyocardial infarction-

.stroke, or gangrene-

Peripheral Arterial Occlusive Disease - 2

Arterial insufficiency of the extremities occurs most . often in men and is a common cause of disability
The legs are most frequently affected; however, the upper extremities may be involved. The age of onset
and the severity are influenced by the type and
number of atherosclerotic risk factors
In PAD, obstructive lesions are predominantly confined to segments of the arterial system extending from the
. aorta below the renal arteries to the popliteal artery
frequently seen in patients with diabetes mellitus and in elderly patients

pain may be described as aching, cramping, or inducing fatigue or weakness that occurs with the same degree
.of exercise or activity and is relieved with rest
The pain commonly occurs in muscle groups distal to .the area of stenosis or occlusion
Elevating the extremity or placing it in a horizontal position increases the pain, whereas placing the
extremity in a dependent position reduces the pain

Thromboangiitis Obliterans (Buergers Disease)

It is characterized by recurring inflammation of the
intermediate and small arteries,veins, and valves of
the lower and upper extremities
It results in thrombus formation and segmental occlusion
of the vessels
There is considerable evidence that heavy smoking or
chewing of tobacco is a causative or an aggravating
factor

Raynauds Phenomenon
Is a form of intermittent arteriolar vasoconstrictionthat results in coldness, pain, and pallor of the
fingertips or toes
.There are two forms of this disorderPrimary or idiopathic (Raynauds disease) occurs in - 1
the absence of an underlying disease
Secondary Raynauds occurs in association with an - 2
underlying disease, usually a connective tissue disorder,
such as systemic lupus erythematosus, rheumatoid
arthritis, or scleroderma; trauma; or obstructive arterial
.lesions

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