Most not active enough to show symptoms; is a result of SYSTEMIC ARTHEROSCLEROSIS.

RF:

• CAD
• Cerebral Vascular Disease
• Stroke
• Men
• HTN
• Dyslipidemia
• Smoking
• Diabetes
• Family hx
• Obesity
• High homocysteine levels

ABRUPT

• Embolus = most common cause; other causes are thrombus (fm plaque), aortic dissection, compartment syndrome

Acute Arterial Occlusion

S/S

• Severe pain below the level of the occlusion that occurs even at ret
• Extremity is cool or cold, pulseless, mottled
• Small areas on toes may be blackened or gangrenous
• 5 P's
• Pain
• Pallor - may occur only when elevated
• Pulselesness
• Parasthesia
• Paralysis
• Poikilothermia (coolness)

PAD

S/S

• Claudication - cramping, burning muscle discomfort or pain; stops after rest. (Distance becomes shorter as condition worsens)
• Diminished pulses
• Rubor - dusky red when extremity in dependent pos (below heart)
• Ulcers - toes, between toes
  
• Hair thinning or gone
• Dry, scaly, dusky, pale or mottled skin
• Thickened toenails

PAD

Diagnostics

• Ankle-brachial index (ABI) - measures BP in same side arm and ankle; should be = < 0.9 is diagnostic of PAD (think about it, pressure with PAD higher in lower extremity bc overcoming thrombus)
• Doppler ultrasound - locates the occlusion
• Angiography - EXACT location
• Pre-req for surgery
• Non-invasive if done by CT
• Contrast
• Serious complications - hemorrhage, thrombosis, embolus, death

PAD

Treatment

• Risk factor modification
• Keep legs below heart level
• Elevate HOB
• Avoid vasoconstrictors (Sinus - Sudafed, phenylehrine)
• Foot care
• Anti-platelets lessen symtpoms

PAD

Medications

• Antiplatelets!!
• Aspirin
• Persantine
• Plavix
• Ticlid
• For claudication (decrease viscocity):
• Pletal
• Trental
• Anti-hypertensives (watch pt on beta blockers - can have drug related claudication)

PAD

Treatment/Surgery

• Percutaneous Transluminal Angioplasty (PTA) - dilates the vessel with balloon catheter
• Reocclusion rate is high
• Thromboendarterectomy - pt who don't respond to PTA
• Bypass revascularization -
• Goal = relieve sx, induce healing for ulcers, avoid complications
• Thrombolytic Therapy (clot busters):
• Urokinase
• Tissue plasminogen activator (tPA)

PAD

Teaching

• RF's - using Wellbutrin, Chantix for smoking cessation
• Hydration
• Exercise
• Heart friendly diet (low sodium, low fat)
• Screening for HTN, DM
• Avoid stasis - freq pos changes, no leg crossing, no pillows under knees, no elastic support hose
• Avoid exposure to the cold and direct heat application

Acute Arterial Occlusion

Nursing Care

• Assess:
• 6 P's
• Recent invasive procedures
• Ulcers, skin
• Position legs lower than the heart
• Use linen cradle, sheepskin
• Post surgery:
• No pillows under knees
• Mon. blood values
• Notify physician:
• Hypotension, tachycardia
• Decreased UO
• Pain

PAD

NDx

1. Ineffective Tissue Perfusion
2. Pain
3. Impaired skin integrity
4. Knowledge deficit
5. Anxiety

Raynaud's Phenomenon/Disease

"Blue, white, red disease"

• Caused by vasospasm of superficial vessels - arterioles blood flow to tissue has been decreased temporarily
• Triggered by stress and cold
• S/S:
• Cold in extremity
• Pain (burning)
• Paresthesia (tingling)
• Color change
• Can be reversed upon removing stimulus

Reynaud's

Treatments

• Ca Channel Blockers:
• nifedipine (Procardia)
• Nursing care:
• Keeping warm -lessens severity
• Manage stress
• Stop smoking
• Exercise
• Avoid meds that affect blood flow:
• Caffeine, nicotine
• Sinus meds & other vasoconstrictors

• Blockage of veins or arteries of the extremities
• Produces inflammation and occlusive thrombi in smaller arteries
• RF - SMOKING, tobacco use, men (20-40)
• S/S:
• Pain, cramping, numbness
• Claudication
• Gangrene poss
• Coldness
• Pulses diminished or absent
• Pallor with elevation
• Rubor in dependent position

Buerger's Disease

Treatments

Nursing care:

• Teach smoking cessation
• Keep extremities warm
• Keep in dependent position
• Regular exercise
• Proper footwear

• Abnormal dilation in the wall of an artery = result in weakening of the arterial wall
• Fusiform - involves whole circumference
• Saccular - outpouching
• TRUE aneurysms affect all 3 layers of wall
• Pseudoaneurysm - connection between lumen and C.T., there is a rupture which leads to a blood filled cavity = thrombus.
• Aortic Aneurysms:
• Thoracic AA
• Abdominal AA
• MOST HAVE NO SX!!

• More common
• Causes:
•  Trauma
• Vesselitis

AAA

Physical Assessment

If not asymptomatic...:

• Abdominal, flank, or back pain
• Gnawing
• Unaffected by mvmt
• Lasting for hours or days
• Pulsation - between umbilicus & xiphoid (slightly left of midline)
• Auscultate for bruit, but DO NOT PALPATE

If expansion & rupture suspected...

• Severe pain with sudden onset in back or lower abdomen that may radiate to groin, butt, or legs
• Hypovolemic shock - hypotension, diaphoresis, decreased LOC, oliguria, pulselessness distal to rupture, dysrhythmias
• Poss distention or hematomas in flanks

TAA

Physical Manifestations

• Back pain

Manifestations of compression of the aneurysm on adjacent structures:

• SOB
• Hoarseness
• Difficulty swallowing
• Mass possibly visible above suprasternal notch

Rupture:

• Sudden and excruciating back or chest pain
• Hypovolemic shock

Aortic Aneurysms

Imaging Assessment

• AAA -abdominal or lat spine xray shows "eggshell" appearance
• CT scan -size and location of AAA or TAA
• TAA - CXR
• Aortic arteriography - before surgery for TAA
• Ultrasonography - for acurate diagnosis, size and location of AAA

Aortic Aneurysm

Nonsurgical Mgmt

Antihypertensives

Frequent ultrasound or CT - pt with small or asymptomatic aneurysms

AAA

Surgical Mgmt

• Graft (replacement)
• Endograft - stent in artery
• Percutaneous

TAA

Surgical Mgmt

Median sternotomy or thoracotomy - to enter thoracic cavity

Synthetic graft is placed  - walls of the aneurysm are wrapped around it

• Anatomic compression of popliteal artery
• Young people
• Intermittent claudication in one or both legs
• Ischemic sysmtoms

At rest:

• Diminished distal pulses (rare)

Diagnosis - history, exam, arteriography
Mgmt - surgical repair - reconstruction of the artery

Post-Op Care

Aneurysms

• Check peripheral pulses
• Cold extremities = graft occlusion
• Tachycardia, hypotension
• Increasing pain
• Decreased UO = obstruction, hemorrhage
• Mental status change
• Parasthesia

Report:

• Increasing hematoma
• Increased abdominal girth
• Paralytic illeus for 2-3 days (report return of bowel sounds)

Blood surging through tear in aortic intima with separation of layers, which creates another region for blood to flow in to.

Causes - HTN!

Aortic Dissection

S/S

• Most common= PAIN
• "Tearing," "ripping," and "stabbing"
• Tends to move from site of origin
• Diaphoresis
• N/V
• Faintness
• Apprehension
• BP elevated or limb BP may differ (BAD)
• Diminished or absent peripheral pulses
• Aortic regurgitation - musical murmur
• Altered LOC
• Paraparesis
• Stroke

Aortic Dissection

Diagnostic Imaging

TEE

CTA or MRA

CXR

Transthoracic Echocardiograph (TTE) - most beneficial

Aortic Dissection

Treatment

• Maintain BP < 110 mmHg (Intra-arterial BP monitoring)
• B blocker (propanolol)
• Nitroprusside - if beta blockers don't work; given IV
• Surgery - graft

Aortic Dissection

NDx

• Risk for altered tissue perfusion
• Decreased CO
• Pain
• Anxiety