Vascular System

Review of Anatomy and Physiology Vascular Segments •Arteries •Veins •Capillaries/

Capillary beds •Lymphatics – network of endothelial tubes that drains in your vena cava

Blood Vessel Structure  Blood Vessel Structure  tunica intima – innermost layer – Endothelial cells  tunica media – middle layer – Elastic Conn tse and Smooth muscle cells  tunica adventitia – outermost layer

Functions of the Vascular System  

Pressure, Flow and Resistance Capillary Exchange  Diffusion – movt of solute from ↑ to ↓ concentration  Filtration – passive movt of fluids from arterial end to interstitial tissues (↑ to ↓ concentration)  Pinocytosis – cell drinking – Osmosis – movt of particles or fluid from (↑ to ↓ concentration) • Oncotic Pressure (albumin) • Hydrostatic Pressure- vessels to cells

PERIPHERAL VASCULAR DISEASES – characterized by disturbances of blood flow through the peripheral vessels. - disturbances usually damage tissues as a result of ischemia, excessive accumulation of waste, and fluids or both.

HISTORY TAKING  BIOGRAPHICAL

and DEMOGRAPHIC DATA

Age Occupation  PAST

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HEALTH HISTORY Vascular impairment (vasospastic changes in color and temp of digits) Hypertension, DM, stroke, transient ischemic attacks, changes in vision, leg pain during activity, leg cramps, phlebitis, blood clots, pulmonary emboli, edema, varicose veins, leg ulcers or extremities that are cold, pale or blue Medications and Herbal medicine Allergy to iodine

 FAMILY

HEALTH HISTORY Note any history of DM, hypertension, CAD, collagen diseases, and PVD  PSYCHOSOCIAL

HISTORY

Occupational history Smoking or use of any tobacco products Diet Clinical manifestations

CURRENT HEALTH ARTERIAL DISORDERS  Intermittent claudication - cramping leg pain in the calf muscles during ambulation that disappears within 1 to 2 minutes of rest.  It result from inadequate tissue perfusion due to arterial stenosis secondary to atherosclerosis.  Intermittent claudication is predictable and reproducible.  Rest pain - Distal forefoot burning, numbness or tingling, pain at rest, pain that awakens them during the night  Elevation of the extremities causes pain; standing and extremities in dependent position can relieve pain  Claudication distance – distance the client can walk

Risk factors: A – ge R – T smoking T – hrombosis/ embolus E – levated lipids R – T DM I – ncreased BP A – therosclerosis L – ink to family of PVD

VENOUS DISORDERS – has insidious onset    

Pain has slow onset; not associated with rest or activity Exercise and elevation generally relieve discomfort and swelling Edema may be the initial complaint Skin changes: erythema lipodermatosclerosis drying and flaking status dermatitis ulceration

Venous Disorders 

RISK FACTORS:  Family history for venous disease Job history involving many hours of standing in one place  Multiple pregnancy  Obesity 1. Increased pressure in leg veins 2. Vein walls distention

3. Distended walls prevent valve leaflets from meeting each other when they close 4. Incompetent veins 5. Back flow of blood 6. Increased hydrostatic pressure in the venous end of capillary 7. Fluid from intravascular will shift into the interstitial space 8. Edema 9. Blood flow slows 10. Decreased oxygen supply 11. Hypoxia

CLINICAL MANIFESTATIONS OF LOWER EXTREMITY DISORDER

MANIFESTATION

ARTERIAL

VENOUS

Pain

Intermittent claudication. Aching, heaviness Rest pain may be Exercise and elevation present, or pain may decrease pain worsen with elevation Nocturnal cramping Heaviness in the legs at the end of the day

Skin

Absence of hair in chronic Brown discoloration. condition. Thin and Normal toenails shiny. Thick toenails (fungal infxn)

Color

Pale with dependent rubor Brown discoloration. Dependent cyanosis

Temperature

Cool

Sensation

Decreased; numbness present

No change or may be warmer than unaffected area tingling, Pruritus may be present may be

CLINICAL MANIFESTATIONS OF LOWER EXTREMITY DISORDER MANIFESTATION

ARTERIAL

VENOUS

Pulses

Decreased to absent

Present, but may be difficult to palpate because of edema

Edema

May be present but usually Present, worse at end absent of day, improved with elevation

Muscle mass

Reduced in chronic disease Unaffected

Ulcers

Small, painful ulcers on pressure points, points of trauma, between toes, or distal most point, especially lateral malleolus and toes

Broad, shallow, slightly painful ulcers of the ankle and lower leg. Surrounding skin is brown and fibrotic.

ARTERIAL LEG DISORDER

PHYSICAL EXAMINATION Inspection, palpation, auscultation Nursing Responsibilities: Prepare the environment Provide natural lighting Warm the environment Provide a quiet environment

INSPECTION     

   

SKIN HAIR DISTRIBUTION CAPILLARY REFILL – Blanch Test MUSCLE ATROPHY EDEMA – grade 0= no edema; 1= barely detectable; 2= <5mm; 3= 5 to 10 mm; 4= >1cm VENOUS PATTERN ULCERS ELEVATION PALLOR – arterial insufficiency; perform only when needed; note the degree of pallor at rest TRENDELENBURG’S TEST – help detect abnormal venous filling time; reveals valvular incompetence of the deep veins

TRENDELENBURG TEST

PALPATION TEMPERATURE  PULSES • ALLEN’S TEST 

HOMAN’S SIGN

AUSCULTATION Limb BP  Bruit 

DIAGNOSTIC PROCEDURES NON-INVASIVE I. DOPPLER ULTRASONOGRAPHY – permit assessment of arterial diseases through: 1) Evaluation of audible arterial signals; 2) Limb BP measurement II. ANKLE – BRACHIAL INDEX – commonly used parameter for overall evaluation of extremity status ABI = higher systolic ankle pressure higher systolic brachial pressure - 1 or more – normal; 0.5 to 0.8 – claudication, <0.4 – rest pain

III. ULTRASONIC DUPLEX SCANNING – are used to 1) localize vascular obstruction; 2) evaluate the degree of stenosis; 3) determine the presence or absence of vascular reflux Most sensitive and specific non-invasive modality for detecting DVT

IV. AIR PLETHYSMOGRAPHY - measure volume changes in the legs; venous volume, ejection fraction and residual volume fractions are also measured

IV.

IMPEDANCE PLETHYSMOGRAPHY – used to measure venous blood volume changes in the extremities

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VI. EXERCISE TESTING – provides an objective measurement of the severity of intermittent claudication. NI: PRE-PROCEDURE • Inform client about the purpose and risks of exercise testing. Informed consent. • Instruct client not to eat or smoke 2 to 3 hours before the test and dress appropriately for exercise. • No strenuous activities should be made at least 12 hours before the test • Obtain a resting ECG • Prepare skin for electrode placement PROCEDURE: • Obtain baseline VS and ECG strip

• •

Observe ECG monitor constantly for changes Monitor the client for chest pain, dysrhythmias, ST segment changes, unexpected changes in BP and other cardiac manifestations.

VII. COMPUTED TOMOGRAPHY – provides a cross-section of vessel walls and other structures. VIII. MAGNETIC RESONANCE IMAGING – tissue changes, tumors, aneurysm, and DVT

VIII. MAGNETIC RESONANCE ANGIOGRAPHY – uses magnetic imaging techniques to access blood vessels (3-dimensional-angiogram. -images are not obscured by bone, bowel, gas, fat or vascular calcification

Magnetic Resonance Angiography

INVASIVE ANGIOGRAPHY – most invasive of the diagnostic procedures for arterial disorders and poses the greatest risk for the client Injecting contrast agent to arterial system and performing radiographic studies. Preprocedure: Explain procedure NPO 2-6 hours before procedure Postprocedure: V/S, NVS, Distal pulse checks Assess puncture site for hematoma Bed rest 6-8 hrs. with extremity kept in straight alignment if transfemoral approach Continous IV hydratio 6-8 hrs. to assist contrast excretion BUN and Crea levels monitored the next day Watch out for Pseudoaneurysm (significant complication) - blood leaking outside the vessel wall but within a contained area adjacent to artery. - Provide site for infection, source of emboli, cause intravascular thrombosis

II. VENOGRAPHY – performed in a manner similar to angiography, used to examine the venous system; ca detect DVT and other abnormalities (incompetent valves) PROCEDURE:  Ascending – to record valvular patency  Descending – to determine valve reflux and competence PREPROCEDURE: 1. Document the presence and quality of peripheral pulses 2. Clear liquids for 3 to 4 hours before the procedure to maintain hydration POSTPROCEDURE: 1. Place a pressure dressing on the injection site 2. Bed rest for 2 hours if the femoral vein was punctured 3. Monitor pulses for the next 4 to 6 hours 4. Continue IV fluids for 8 to 24 hours 5. Assess fluid balance

 III.

VASCULAR ENDOSCOPY (ANGIOSCOPY) –permits imaging of intra-arterial disease with the use of fiberoptic technology. Images are in color and in three dimensions.  Flexible fiberoptic angioscope, light source, irrigation system, camera, video recorder and monitor  Allows internal visualization of vessel lumen; can identify thrombus & plaque,  Post procedure care same as angiography

IV.INTRAVASCULAR UTZ – provides information about the atherosclerotic intima beneath the luminal surface. It can determine the thickness of the arterial wall and can distinguish thrombus and calcium from vascular tissues

END of PRESENTATION!