Vascular Problems, Stroke, Aneurysms, and HTN Crisis

By Diana Blum MSN MCC NURS 2140

Vascular Disorders
Common disorders in America: hypertension atherosclerosis arterial occlusive disease abdominal aortic aneurysms (AAA) deep vein thrombosis (DVT) venous insufficiency

 C reactive protein is a marker for cardiac inflammation

Increases mean: risk of damage

hormones

Homocysteine: protein that promotes coagulation by increasing factor 5 and factor 11 while depressing activation of protein C and increasing thrombus formation risk
Vitamin b6 and b12 and folate lowers homocysteine levels

PAD

Arterial diseases:
Arteriosclerosis (atherosclerosis) Aneurysm formation Arteriosclerosis obliterans Raynauds phenomenon Arterial embolism Thromboangiitis obliterans Diabetic arteriosclerotic disease hypertension

Manifestations :ARTERIAL (50% occulsion before symptoms) Ischemia (reduced oxygenation) - leads to pain Paresthesia (decreased sensation in extremities = tingling/numbing) Pain (in feet/leg muscles = burning, throbbing, cramping) -usually from exercise BUT also with elevation of lower extremities
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(continued): Hallmark sign: Intermittent claudication (pain in exercising muscles usually in calf - directly related to decreased blood supply during activity & recedes with rest Temperature: (COLD) Skin color changes: skin pale on elevation but red dependent
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(continued) Reactive hyperemia: (reduced blood flow to extremity results in arteriolar dilation so when the blood supply is restored, the affected area becomes warm/red from congestion Pulse changes: Peripheral diminished or absent

(continued) Prolonged capillary refill: - 3 seconds or more Ulcers: - open lesions on feet from diminished distal perfusion

Arteriosclerosis -describes arterial disorders in which degenerative changes result in decreased blood flow Atherosclerosis: - most common form of arteriosclerosis, excessive accumulation of lipids

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Major risk factors of arteriosclerosis:

Hypertension (MOST SIGNIFICANT) Cigarette smoking (nicotine has DIRECT vasoconstricting effect) Elevated serum cholesterol (fat causes obstructive plaques) Obesity (increased work to heart) Diabetes (hyperglycemia causes damage to vessel wall) Other: increase age, inactivity, family hx

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Heart: coronary arteries (angina, MI, death) Brain (transient ischemic attacks =TIAs CVA, death) Kidneys (renal arterial stenosis lead to chronic renal failure) Extremities (gangrene of digits & intermittent claudication)

Most common affected areas from arteriosclerosis:

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Pathophysiology of atherosclerosis
-inflammatory process, begins as fatty streaks that are deposited in the intima of the arterial wall Genetics and environment play a factor in the progression Elastic arteries: aorta, carotid, lg & med. sized muscular arteries (popliteals) most susceptible arteries. Endothelial injury: may be initiated by smoking, hypertension, diabetes, hyperlipidemia,

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 Inflammatory cells(including macrophages) become attracted to the wall Macrophages infiltrate wall and ingest lipid which turns them into foam cells They then release biochemical substances that cause further damage and attract platelets which then causes clots to form

Ankle-brachial index of blood pressure: Used to diagnose peripheral vascular disease

-compares the blood pressure at ankle with that of the arm. -normally these should be the same (with a ratio of 1) -lesser number than 1 shows decreased blood pressure at the ankle compared to upper extremity = = which indicates peripheral vascular disease to lower extremities
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 Indications for fem-pop bypass: diabetes hypertension vasculitis collagen disease Buegers disease Also, Embolectomy (surgical removal)

SURGERY

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Fem-pop bypass

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MEDICAL MANAGEMENT
ANTIPLATELET THERAPY Aspirin, ticlid, plavix, pletal, trental Beta blockers ARBs Statins Radiation therapy Angioplasty with stents

Nursing Interventions
Monitor BP for difference between arms
Could be indicative of aortic coarctation
Narrowing of aorta lumen

Monitor for carotid bruits Assess cap refill, pulses,skin

Acute arterial stenosis

Monitor for the 5 Ps pain, sudden pallor pulselessness paresthesias paralysis

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Acute peripheral arterial occlusion

may result from rupture and thrombosis of an atherosclerotic plaque, an embolus from the heart or thoracic or abdominal aorta, an aortic dissection, or acute compartment syndrome Symptoms and signs are sudden

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Buerger Disease
Autoimmune disease Recurrent inflammation of small arteries and veins of the extremities resulting in thrombus formation and occlusion. Unknown cause Men 20-35 years old All races Link to heavy smoking/chewing tobacco s/s: rubor (reddish blue) color to foot, no Pedal pulse, discolored legs when dangled, eventually gangrene sets in

Aneurysms of Central Arteries

Enlargement of artery to @ least 2X its normal Aortic dissection
Medial & intimal layers separate

Risk Factors: -hypertension -cocaine use - Marfan syndrome

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Thoracic Aortic Aneurysm

85% are caused by atherosclerosis More frequent in men b/w 40-70 years old Most common site for dissection 1/3 of pts with this die from rupture

Asymptomatic Pain is primary symptomconstant Dyspnea Cough Hoarseness Stridor Aphonia (weakness or complete loss of voice) Unequal pupils

S/S

Diagnostics
Chest x-ray TEE CT

Aortic dissection

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Aortic Dissections: Type III most common type

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Abdominal Aortic Aneurysm Size and Rupture Risk*

AAA Diameter (cm) Rupture Risk (%/yr)

<4 44.9

0 1%

55.9*
66.9 77.9 >8

510%
1020% 2040% 3050%

*Elective surgical repair should be considered for aneurysms > 5.05.5 cm.

Signs/symptoms of aortic dissection:

n/v, diaphoresis with pain tearing pain Sudden onset not relieved with change of position Dissection of ascending aorta: anterior CP with radiation to neck, throat, jaw Dissection of descending: interscapular back pain radiation to lower back or abdomen
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Treatment of hypertension for aortic dissection:

IV propranolol Nitropresside drip after beta blocker ( nitropresside by itself causes tachycardia AND left vent. contractility that is why a beta-blocker should be given first, then start nitropresside drip) Diagnosis: CXR (but 10% normal) see medialstinal widening Contrast CT MRI
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 GOAL: to keep blood pressure to lowest possible but yet allows tissue perfusion
Per physican recommendations

Surgery for distal dissections:

Mortality in 1st 48 hrs if unrepaired proximal aortic dissections is 40% Usually distal dissections treated medically unless: rapid expansion saccular formation persistent pain hemodynamic compromised blood leakage impending rupture

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Dacron tube

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Abdominal Aortic Aneurysm (AAA)

75% of all aneurysms Located between renal arteries & aortic bifurcation Symptoms from pressure exerted in surrounding structures. Many nonsymtomatic until ruptures Look for pulsating abdominal mass With rupture: hypovolemic shock & mortality around 90%
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Nonsurgical management of AAA

Monitor growth: freq. CT scans Antihypertensives SURGICAL: graft

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Aortic aneurysm with graft inserted by endovascular surgery:

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Post-op nursing interventions for graft:

Vitals Pulses distal to graft Report: changes in pulse cool extremities distal to graft white/blue to extremities distal to graft severe pain abd. distention decreased UO

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Post-op nursing intervention (continued) Post graft Elevation of head to 45 or less Renal function lab Respiratory status Paralytic ileus (NG tube) Assess for dysrhythmias post thoracic

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Venous diseases:
Venous thrombosis (thrombophlebitis) known as DVT Varicose veins Venous stasis ulcers

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Venous manifestations: Pain: - in feet/ leg muscles; aching/throbbing - results from venous stasis & increases as day progresses (esp with sitting or standing) Temperature changes: - warm to touch since blood can enter but cannot leave affected parts

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Venous manifestations: Skin color changes: reddened or cyanotic Edema: pooling of fluid results in edema Venous stasis ulcers: skin breakdown due to increased pressure from chronic pooling of blood Decreased mobility: may result from the edema
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 DVT risk for pulmonary embolism - legs - seen post hip surgery, knee replacement pregnancy, ulcerative colitis, hrt failure, immobility

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DVT :
Groin tenderness/pain Unilateral sudden onset edema leg Homans sign (appears in only 10% of pt with DVT) Ultrasonography

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DVT interventions:
Rest (do NOT massage area) Low-molecular weight heparin Coumadin TPA ****Contraindications to anticoagulant therapy
Pt compliance, bleeding, aneurysms, trauma, alcohol, recent surgery, liver or kidney disease, hazard jobs, pregnancy

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Nursing cares
Monitor for hemorrhage Monitor PT/PTT

Heparin is therapeutic b/w 60-92 on ptt Coumadin is therapeutic b/w 2-3 on PT/INR
Monitor for Thrombocytopenia Monitor Platelets s/s; purpura, bruising, hematomas Provide bedrest Ted Hose or ace wraps for prevention of DVT SCDs for prevention of DVT Pain meds

Hypertension
- excessive tension exerted on arterial walls which places pts at increased risk for target organ damage -asymptomatic until complications develop - elevation may be systolic or diastolic or both - normal <120 mmHg systolic <80 mmHg diastolic
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S/S
Often none Occipital headache more severe on rising Lightheadedness Epistaxis Known as the Silent Killer

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Factors that determine arterial pressure

Cardiac output which is the volume of blood pumped by the heart in 1 minute Peripheral vascular resistance which is the force in the peripheral blood vessels that the left ventricular must overcome to eject blood out of the heart

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Pathophysiologic processes for hypertension: BP=CO X peripheral resistance Elevated BP is direct result of increased peripheral resistance, increased CO or both Renin-angiotensin-aldosterone system Aldosterone: increased water/Na+ retention thus increasing ECF volume which leads to increased CO with subsequent increase BP
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Possible Causes of PVR

Narrowing of blood vessels, PVD, CAD, kidney disease: > renin/angiotensin =vasoconstriction Release of catecholamine (epinephrine and adrenalin) = vasoconstriction > blood volume= more work to pump > Blood viscosity=harder to pump Ability of blood vessel to stretch

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 95% of cases of hypertension are 1st degree (essential) 2nd degree hypertension: CHAPS Cushings syndome Hyperaldosteronism Aortic coarctation Pheochromocytoma Stenosis of renal arteries
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Complications
Damage to blood vessels of the eyes, heart, kidney, brain resulting in: Stroke CHF AMI Renal failure Blindness

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 Large vessels: aneurysmal dilation accelerated atherosclerosis aortic dissection Cardiac: acute= pulm edema, MI chronic= LVH

Target Organ Disease from hypertension

Cerebrovascular: acute= Intracranial bleed, coma, seizure mental status changes, TIA, stroke chronic=TIA, stroke

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Target organ disease from hypertension: Renal: acute=hematuria, azotemia chronic=elevated creatinine proteinuria Retinopathy: acute=papilledema, hemorrhages chronic=hemorrhages,exudates,
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Treatment of hypertension:
Lifestyle modification ABCD: ACE inhibitors; ARB B-blockers Calcium channel blockers Diuretics

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HTN CRISIS
Sometimes rare sometimes fatal Diastolic BP 120-130
Causes vascular damage

Can be caused by renal failure, HTN, Med withdrawal

Hypertensive Crisis: Treatment

Parenteral agents for immediate redux of BP In ICU for monitoring Arterial line Drug of choice: sodium nitroprusside =direct acting arterial & venous vasodilator = reduces BP rapidly but lower mean arterial pressure no more than 25% over 1st 2 hours = easily titratable = monitor closely for hypotension = shield this drip from light
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STROKE: occlusion of cerebral vasculature

DUE TO: 1. emboli that lodges in cerebral vasculature (from a-fib, vegetations on an infect valve) 2. atherosclerotic plaque (occludes carotid arteries) 3. venous occlusion (secondary to thrombosis) 4. arterial dissection (in carotid or vertebrobasilar system) 5. severe hypotension ( infarct in cerebral areas) 6. hemorrhage :occurs during activity

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 Sudden loss of function resulting from disrupted blood supply to area in brain 5 types:
Large artery
Caused by atherosclerosis

TIA

Small penetrating artery

Most common Also called lacunar strokes because it creates a cavity

Cardiogenic emboli
Usually from afib

Cryptogenic
No known cause

Other
Caused from Drug use, migraines,spontaneous

Hemorrhagic stroke
Bleeding into brain tissue or ventricles, subdural, or subarachnoid spaces due to ruptured aneurysm or from severe hypertension VASOSPASM (after a bleed)
4-14 days post hemorrhage Management is difficult

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manifestations
Severe headache LOC Tinnitus Dizziness Hemiparesis

Prognosis: variable

diagnostics
CT Lumbar puncture Angiography

Prevention
Manage HTN Avoid alcohol Increase public awareness

Assessment Tools
Neurological assessment upon admission or change in client status, including:
Level of consciousness Orientation Motor ability Pupils Speech/language Vital signs Blood glucose

 Risk assessment for complications including fall, pressure ulcer, painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis

Pain assessment Administration and interpretation of dysphagia screen Nutrition and hydration screening Screening for alterations in cognition, perception, and language using validated tools Assessment of activities of daily living (ADL) using validated tools Assessment of bowel and bladder function Depression screening using a validated tool

 Assessment/screening of caregiver burden using a validated tool Screening of stroke clients and their partners for sexual concerns Assessment of stroke client and their caregivers' learning needs, abilities, learning preferences and readiness to learn Referral for further assessment and management, as indicated Documentation of all assessments and screenings

Treatment for stroke: (Note similar to measures for myocardial ischemia/MI)

Thrombolysis (who is not a candidate?) Lower BP Quit smoking Decrease cholesterol Antiplatelet (ASA)

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Stroke treatment (continued)

ASA Heparin (SQ or IV contin infusion) Low-molecular wt heparin (lovenox) Warfarin (coumadin) ------------------------------------------------------Obtain PT, PTT prior to therapy PT: monitor oral anticoag : goal=1.5 to 2 times pt baseline PTT: monitor heparin: goal=1.5 to 2 times pt baseline INR: monitor Warfarin: goal=2 to 3
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More stroke treatment:

Carotid artery angioplasty Arteriovenous Malformation (gamma radiation through Gamma knife) Aneurysms (coils) Craniotomy for clot removal

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Nursing assessment with anticoagulant therapy: Observe for bleeding Also, antiplatelet meds (Plavix, Persantine) cause bruising, hemorrhage, liver disease (need liver function tests) GIVE clopidogrel (Plavix) with food

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Nursing Diagnosis
Impaired physical mobility: -flaccid, spasticity Disturbed sensory perception: -vision, proprioception, sensation Unilateral neglect: - use both sides of body (dress affected side first) Impaired verbal communication:: -expressive, receptive, both Impaired swallowing: must be evaluated, must prevent aspiration !!! But yet meet caloric needs Urinary and/or bowel incontinence

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Complications
Rebleed Vasospasm Hydrocephalus Hypoxia of brain

Nursing interventions
Administer oxygen Provide adequate hydration Evaluate swallow function Frequent neuro checks Strict I/O Seizure precautions Monitor ICP Monitor BP closely Teach stress reduction techniques Manage agitation

 Evacuation of blood via craniotomy Goal of surgery is to prevent further rupture/bleed Post op complications

Surgery and complications

Disoriented Amnesia Korsaffs syndrome (psychosis caused by lack of thiamine) Personality changes Intraop emboli Electrolyte disturbances GI bleed

QUESTIONS???