ARTERIAL AND VENOUS DISORDERS

MAIN POINTS

Raynaud’s disease
Buerger’s disease
Assessment of aortic aneurysms
Hypertension
Client instructions related to arterial and venous
disorders
SITES FOR PALPATING PERIPHERAL
PULSES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders
 VEINS IN THE LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3,

Philadelphia: W.B. Saunders
 VENOUS THROMBOSIS

DESCRIPTION
 Thrombus can be associated with an inflammatory process
 When a thrombus develops, inflammation occurs that thickens
the vein wall leading to embolization
 TYPES OF VENOUS THROMBOSIS
THROMBOPHLEBITIS
 A thrombus associated with inflammation
PHLEBOTHROMBUS
 A thrombus without inflammation
PHLEBITIS
 Vein inflammation associated with invasive procedures such as
IVs
DEEP VEIN THROMBOPHLEBITIS (DVT)
 More serious than a superficial thrombophlebitis because of
the risk for pulmonary embolism
 RISKS FACTORS FOR VENOUS
THROMBOSIS
Venous stasis from varicose veins, heart failure,
immobility
Hypercoagulability disorders
Injury to the venous wall from IV injections,
fractures, trauma
Following surgery, particularly hip surgery and open
prostate surgery
Pregnancy
Ulcerative colitis
Use of oral contraceptives
 PHLEBITIS
ASSESSMENT
 Red, warm area radiating up an extremity
 Pain and soreness
 Swelling
IMPLEMENTATION
 Apply warm, moist soaks as prescribed to dilate the vein and
promote circulation
 Assess temperature of soak prior to applying
 Assess for signs of complications such as tissue necrosis,
infection, or pulmonary embolus
 DEEP VEIN THROMBOPHLEBITIS (DVT)
ASSESSMENT
 Calf or groin tenderness or pain with or without swelling
 Positive Homans’ sign
 Warm skin that is tender to touch
 DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION
 Provide bed rest
 Elevate the affected extremity above the level of the heart as
prescribed
 Avoid using the knee gatch or a pillow under the knees
 Do not massage the extremity
 Provide thigh-high compression or antiembolism stockings as
prescribed to reduce venous stasis and to assist in the venous
return of blood to the heart
 DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION
 Administer intermittent or continuous warm, moist
compresses as prescribed
 Palpate the site gently, monitoring for warmth and edema
 Measure and record the circumference of the thighs and calves
 Monitor for shortness of breath and chest pain, which can
indicate pulmonary emboli
DEEP VEIN THROMBOPHLEBITIS (DVT)

IMPLEMENTATION
 Administer thrombolytic therapy (t-PA, tissue
plasminogen activator) if prescribed, which must be
initiated within 5 days after the onset of symptoms
 Administer heparin therapy as prescribed to prevent
enlargement of the existing clot and prevent the
formation of new clots
 Monitor APTT during heparin therapy
 Administer warfarin (Coumadin) therapy as prescribed
when the symptoms of DVT have resolved
 DEEP VEIN THROMBOPHLEBITIS (DVT)
IMPLEMENTATION
 Monitor PT and INR during warfarin (Coumadin) therapy
 Monitor for the hazards and side effects associated with
anticoagulant therapy
 Administer analgesics as prescribed to reduce pain
 Administer diuretics as prescribed to reduce lower extremity
edema
 Provide client teaching
ASSESSING FOR PERIPHERAL EDEMA

From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders
 DEEP VEIN THROMBOPHLEBITIS
(DVT)
CLIENT EDUCATION
 Hazards of anticoagulation therapy
 Signs and symptoms of bleeding
 Avoid prolonged sitting or standing, constrictive clothing, or
crossing legs when seated
 Elevate the legs for 10 to 20 minutes every few hours each day
 Plan a progressive walking program
 DEEP VEIN THROMBOPHLEBITIS (DVT)

CLIENT EDUCATION
 Inspect the legs for edema and how to measure the
circumference of the legs
 Antiembolism stockings (hose) as prescribed
 Avoid smoking
 Avoid any medications unless prescribed by the physician
 Importance of follow-up physician visits and laboratory studies
 Obtain and wear a Medic Alert bracelet
 ANTIEMBOLISM HOSE

From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2,
St. Louis, 2000, Mosby.
 VENOUS INSUFFICIENCY

DESCRIPTION
 Results from prolonged venous hypertension that stretches the
veins and damages the valves
 The resultant edema and venous stasis causes venous stasis
ulcers, swelling, and cellulitis
 Treatment focuses on decreasing edema and promoting venous
return from the affected extremity
 Treatment for venous stasis ulcers focuses on healing the ulcer
and preventing stasis and ulcer recurrence
 VENOUS INSUFFICIENCY
ASSESSMENT
 Stasis dermatitis or discoloration along the ankles extending
up to the calf
 Edema
 The presence of ulcer formation
PERIPHERAL VASCULAR DISEASE

From Bryant RA (1992): Acute and chronic wounds: nursing management, St.
Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.
 VENOUS INSUFFICIENCY
WOUND CARE
 Provide care to the wound as prescribed by the physician
 Assess the client’s ability to care for the wound, and initiate
home care resources as necessary
 If an Unna boot (a dressing constructed of gauze moistened
with zinc oxide) is prescribed, it will be changed by the
physician weekly
 VENOUS INSUFFICIENCY
WOUND CARE
 The wound is cleansed with normal saline prior to application
of the Unna boot; providone-iodine (Betadine) or hydrogen
peroxide is not used because they destroy granulation tissue
 The Unna boot is covered with an elastic wrap that hardens, to
promote venous return and prevent stasis
 Monitor for signs of arterial occlusion from an Unna boot that
may be too tight
 Keep tape off of the client’s skin
 VENOUS INSUFFICIENCY
MEDICATIONS
 Apply topical agents to wound as prescribed to debride the
ulcer, eliminate necrotic tissue, and promote healing
 When applying topical agents, apply an oil-based agent as
petroleum jelly (Vaseline) on surrounding skin, because
debriding agents can injure healthy tissue
 Administer antibiotics as prescribed if infection or cellulitis
occur
 VENOUS INSUFFICIENCY
CLIENT EDUCATION
 Wear elastic or compression stockings during the day and
evening as prescribed
 Put on elastic stockings upon awakening before getting out of
bed
 Put a clean pair of elastic stockings on each day and that it will
probably be necessary to wear the stockings for the remainder
of life
 VENOUS INSUFFICIENCY

CLIENT EDUCATION
 Avoid prolonged sitting or standing, constrictive clothing, or
crossing legs when seated
 Elevate the legs for 10 to 20 minutes every few hours each day
 Elevate legs above the level of the heart when in bed
 VENOUS INSUFFICIENCY

CLIENT EDUCATION
 The use of an intermittent sequential pneumatic compression
system, if prescribed; instruct the client to apply the
compression system twice daily for 1 hour in the morning and
evening
 Advise the client with an open ulcer that the compression
system is applied over a dressing
 VARICOSE VEINS
DESCRIPTION
 Distended protruding veins that appear darkened and tortuous
 Vein walls weaken and dilate, and valves become incompetent
ASSESSMENT
 Pain in the legs with dull aching after standing
 A feeling of fullness in the legs
 Ankle edema
NORMAL VEINS AND VARICOSITIES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

for clinical practice, ed 2, Philadelphia: W.B. Saunders
 VARICOSE VEINS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby
 VARICOSE VEINS
TRENDELENBURG TEST
 Place the client in a supine position with the legs elevated
 When the client sits up, if varicosities are present, veins fill
from the proximal end; veins normally fill from the distal end
 TRENDELENBURG TEST

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders
 VARICOSE VEINS
IMPLEMENTATION
 Assist with the Trendelenburg test
 Emphasize the importance of antiembolism stockings as
prescribed
 Instruct the client to elevate the legs as much as possible
 Instruct the client to avoid constrictive clothing and pressure
on the legs
 Prepare the client for sclerotherapy or vein stripping, as
prescribed
 SCLEROTHERAPY
DESCRIPTION
 A solution is injected into the vein followed by the application
of a pressure dressing
 An incision and drainage of the trapped blood in the sclerosed
vein is performed 14 to 21 days after the injection, followed by
the application of a pressure dressing for 12 to 18 hours
 VEIN STRIPPING

DESCRIPTION
 Varicose veins are removed if they are larger than 4 mm in
diameter or if they are in clusters
PREOPERATIVE
 Assist the physician with vein marking
 Evaluate pulses as a baseline for comparison postoperatively
 VEIN STRIPPING

POSTOPERATIVE
 Maintain elastic (Ace) bandages on the client’s legs
 Monitor the groin and leg for bleeding through the elastic
bandages
 Monitor the extremity for edema, warmth, color, and
pulses
 Elevate the legs above the level of the heart
 VEIN STRIPPING
POSTOPERATIVE
 Encourage range-of-motion exercises of the legs
 Instruct the client to avoid leg dangling or chair sitting
 Instruct the client to elevate the legs when sitting
 Emphasize the importance of wearing elastic stockings after
bandage removal
 PERIPHERAL ARTERIAL DISEASE (PAD)

DESCRIPTION
 A chronic disorder in which partial or total arterial occlusion
deprives the lower extremities of oxygen and nutrients
 Tissue damage occurs below the level of the arterial occlusion
 Atherosclerosis is the most common cause of PAD
 ARTERIES IN THE
LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3,

Philadelphia: W.B. Saunders
 PERIPHERAL ARTERIAL DISEASE (PAD)
ASSESSMENT
 Intermittent claudication (pain in the muscles resulting from
an inadequate blood supply)
 Rest pain, characterized by numbness, burning or aching in the
distal portion of the lower extremities, that awakens the client
at night and is relieved by placing the extremity in a dependent
position
 Lower back or buttock discomfort
PERIPHERAL ARTERIAL DISEASE (PAD)
ASSESSMENT
 Loss of hair and dry scaly skin on the lower extremities
 Thickened toenails
 Cold and gray-blue color of skin in the lower extremities
 Elevational pallor and dependent rubor in the lower
extremities
 Decreased or absent peripheral pulses
 PERIPHERAL ARTERIAL DISEASE (PAD)

ASSESSMENT
 Signs of arterial ulcer formation occurring on or between the
toes, or on the upper aspect of the foot, that are characterized
as painful
 Blood pressure measurements at the thigh, calf, and ankle are
lower than the brachial pressure (normally BP readings in the
thigh and calf are higher than those in the upper extremities)
 ARTERIAL OBSTRUCTIONS AND
CORRESPONDING AREAS OF CLAUDICATION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders
 ARTERIAL INSUFFICIENCY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia,
2000, W.B. Saunders.
 GANGRENE

From Auerbach PS: Wilderness Medicine: Management of wilderness and

environmental emergencies, ed. 3, St. Louis, 1995, Mosby.
 PERIPHERAL ARTERIAL DISEASE (PAD)

IMPLEMENTATION
 Assess pain
 Monitor the extremities for color, motion and sensation, and
pulses
 Obtain BP measurements
 Assess for signs of ulcer formation or signs of gangrene
 Assist in developing an individualized exercise program that is
initiated gradually and slowly increased
 PERIPHERAL ARTERIAL DISEASE (PAD)

IMPLEMENTATION
 Encourage prescribed exercise, which will improve arterial
flow through the development of collateral circulation
 Instruct the client to walk to the point of claudication, stop and
rest, then walk a little further
 PERIPHERAL ARTERIAL DISEASE (PAD)

IMPLEMENTATION
 As swelling in the extremities prevents arterial blood flow,
instruct the client to elevate his or her feet at rest, but to
refrain from elevating them above the level of the heart,
because extreme elevation slows arterial blood flow to the feet
 In severe cases of PAD, clients with edema may sleep with the
affected limb hanging from the bed or they may sit upright in a
chair for comfort
 PERIPHERAL ARTERIAL DISEASE (PAD)
CLIENT EDUCATION
 Avoid crossing the legs, which interferes with blood flow
 Avoid exposure to cold (causes vasoconstriction) to the
extremities and to wear socks or insulated shoes for warmth at
all times
 Never to apply direct heat to the limb such as with a heating
pad or hot water, because the decreased sensitivity in the limb
may result in burning
 PERIPHERAL ARTERIAL DISEASE (PAD)
CLIENT EDUCATION
 Inspect the skin on the extremities daily and to report any
signs of skin breakdown
 Avoid tobacco and caffeine because of their vasoconstrictive
effects
 Use of hemorrheologic and antiplatelet medications as
prescribed
 Importance of taking all medications prescribed by the
physician
 PERIPHERAL ARTERIAL DISEASE (PAD)
PROCEDURES TO IMPROVE ARTERIAL BLOOD
FLOW
 Percutaneous transluminal angioplasty
 Laser-assisted angioplasty
 Atherectomy
 Bypass surgery (aortofemoral or femoral-popliteal)
 RAYNAUD’S DISEASE
DESCRIPTION
 Vasospasms of the arterioles and arteries of the upper and
lower extremities
 Vasospasm causes constriction of the cutaneous vessels
 Attacks are intermittent and occur with exposure to cold or
stress
 Affects primarily fingers, toes, ears, and cheeks
 RAYNAUD’S DISEASE

ASSESSMENT
 Blanching of the extremity, followed by cyanosis during
vasoconstriction
 Reddened tissue when the vasospasm is relieved
 Numbness, tingling, swelling, and a cold temperature at the
affected body part
 RAYNAUD’S PHENOMENON

From Barkauskas VH et al (1998) Health and physical assessment (2nd ed.). St. Louis: Mosby.
 RAYNAUD’S DISEASE

IMPLEMENTATION
 Monitor pulses
 Administer vasodilators as prescribed
 Assist the client to identify and avoid precipitating factors such
as cold and stress
CLIENT EDUCATION
 Medication therapy
 Avoid smoking
 Wear warm clothing, socks, and gloves in cold weather
 Avoid injuries to fingers and hands
 BUERGER'S DISEASE

DESCRIPTION
 An occlusive disease of the median and small arteries and veins
 The distal upper and lower limbs are most commonly affected
 Also known as thromboangiitis obliterans
 BUERGER'S DISEASE

ASSESSMENT
 Intermittent claudication
 Ischemic pain occurring in the digits while at rest
 Aching pain that is more severe at night
 Cool, numb, or tingling sensation
 Diminished pulses in the distal extremities
 Extremities are cool and red in the dependent position
 Development of ulcerations in the extremities
 BUERGER'S DISEASE

IMPLEMENTATION
 Instruct the client to stop smoking
 Monitor pulses
 Instruct the client to avoid injury to the upper and lower
extremities
 Administer vasodilators as prescribed
 Instruct the client regarding medication therapy
 AORTIC ANEURYSMS

DESCRIPTION
 Abnormal dilation of the arterial wall, caused by localized
weakness and stretching in the medial layer or wall of an artery
 The aneurysm can be located anywhere along the abdominal
aorta
 The goal of treatment is to limit the progression of the disease
by modifying risk factors, controlling the BP to prevent strain
on the aneurysm, recognizing symptoms early, and preventing
rupture
 ARTERIAL OCCLUSION AND
ANEURYSMS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

for clinical practice, ed 2, Philadelphia: W.B. Saunders
 TYPES OF ANEURYSMS

FUSIFORM
 Diffuse dilation that involves the entire circumference of the
arterial segment
SACCULAR
 Distinct localized outpouching of the artery wall
 TYPES OF ANEURYSMS

DISSECTING
 Created when blood separates the layers of the artery wall
forming a cavity between them
FALSE (PSEUDOANEURYSM)
 Occurs when the clot and connective tissue are outside the
arterial wall
 Formed after complete rupture and subsequent formation of a
scar sac
 TYPES OF ANEURYSMS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders
 THORACIC AORTIC ANEURYSM

ASSESSMENT
 Pain extending to neck, shoulders, lower back, or abdomen
 Syncope
 Dyspnea
 Increased pulse
 Cyanosis
 Weakness
 ABDOMINAL AORTIC ANEURYSM

ASSESSMENT
 Prominent, pulsating mass in abdomen, at or above the
umbilicus
 Systolic bruit over the aorta
 Tenderness on deep palpation
 Abdominal or lower back pain
 RUPTURING ANEURYSM
ASSESSMENT
 Severe abdominal or back pain
 Lumbar pain radiating to the flank and groin
 Hypotension
 Increased pulse rate
 Signs of shock
RUPTURED ABDOMINAL AORTIC ANEURYSM

From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6,
Philadelphia, 1999, W.B. Saunders.
 AORTIC ANEURYSMS

DIAGNOSTIC TESTS
 Done to confirm the presence, size, and location of the
aneurysm
 Includes abdominal ultrasound, CT scan, and arteriography
 AORTIC ANEURYSMS

IMPLEMENTATION
 Monitor vital signs
 Obtain information regarding back or abdominal pain
 Question the client regarding the sensation of palpation in the
abdomen
 Inspect the skin for the presence of vascular disease or
breakdown
 AORTIC ANEURYSMS

IMPLEMENTATION
 Check peripheral circulation including pulses, temperature,
and color
 Observe for signs of rupture
 Note any tenderness over the abdomen
 Monitor for abdominal distention
 AORTIC ANEURYSMS

NONSURGICAL IMPLEMENTATION
 Modify risk factors
 Instruct the client regarding the procedure for monitoring BP
 Instruct the client on the importance of regular physician visits
to follow the size of the aneurysm
 AORTIC ANEURYSMS

NONSURGICAL IMPLEMENTATION
 Instruct the client that if severe back or abdominal pain or
fullness, soreness over the umbilicus, sudden development of
discoloration in the extremities, or a persistent elevation of BP
occurs, to notify the physician immediately
 Instruct the client with a thoracic aneurysm to immediately
report the occurrence of chest or back pain, shortness of
breath, difficulty swallowing, or hoarseness
 AORTIC ANEURYSMS

PHARMACOLOGICAL IMPLEMENTATION
 Administer antihypertensives to maintain the BP within
normal limits and to prevent strain on the aneurysm
 Instruct the client in the purpose of the medications
 Instruct the client about the side effects and schedule of the
medication
 ABDOMINAL AORTIC ANEURYSM
RESECTION
DESCRIPTION
 Surgical resection or excision of the aneurysm
 The excised section is replaced with a graft that is sewn end-to-
end
ANEURYSM RESECTION WITH
GRAFT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders
 ABDOMINAL AORTIC ANEURYSM
RESECTION
PREOPERATIVE
 Assess all peripheral pulses as a baseline for postoperative
comparison
 Instruct the client on coughing and deep-breathing exercises
 Administer bowel preparation as prescribed
 ABDOMINAL AORTIC ANEURYSM
RESECTION

POSTOPERATIVE
 Monitor vital signs
 Monitor peripheral pulses distal to the graft site
 Monitor for signs of graft occlusion, including changes in
pulses, cool to cold extremities below the graft, white or blue
extremities or flanks, severe pain, or abdominal distention
 Limit elevation of the head of the bed to 45 degrees to prevent
flexion of the graft
 ABDOMINAL AORTIC ANEURYSM
RESECTION

POSTOPERATIVE
 Monitor for hypovolemia and renal failure due to significant
blood loss during surgery
 Monitor urine output hourly, and notify the physician if it is
less than 50 ml per hour
 Monitor serum creatinine and BUN daily
 Monitor respiratory status and auscultate breath sounds to
identify respiratory complications
 ABDOMINAL AORTIC ANEURYSM
RESECTION

POSTOPERATIVE
 Encourage turning, coughing and deep breathing, and
splinting the incision; ambulate as prescribed
 Maintain nasogastric tube to low suction until bowel sounds
return
 Assess for bowel sounds and report their return to the
physician
 Monitor for pain and administer medication as prescribed
 Assess incision site for bleeding or signs of infection
 ABDOMINAL AORTIC ANEURYSM
RESECTION

POSTOPERATIVE
 Prepare the client for discharge by providing instructions
regarding pain management, wound care, and activity
restrictions
 Instruct the client not to lift objects greater than 15 to 20
pounds for 6 to 12 weeks
 Advise the client to avoid activities requiring pushing, pulling,
or straining
 Instruct the client not to drive a vehicle until approved by the
physician
 THORACIC AORTIC ANEURYSM
REPAIR
DESCRIPTION
 A thoracotomy or median sternotomy approach is used to
enter the thoracic cavity
 The aneurysm is exposed, excised, and a graft or prosthesis is
sewn onto the aorta
 Total cardiopulmonary bypass is necessary for excision of
aneurysms in the ascending aorta
 Partial cardiopulmonary bypass is used for clients with an
aneurysm in the descending aorta
THORACIC AORTIC ANEURYSM REPAIR

POSTOPERATIVE
 Monitor vital signs
 Monitor for signs of hemorrhage such as a drop in BP,
increased pulse rate and respirations, and report to the
physician immediately
 Monitor chest tubes for an increase in chest drainage, which
may indicate bleeding or separation at the graft site
THORACIC AORTIC ANEURYSM REPAIR

POSTOPERATIVE
 Assess sensation and motion of all extremities and notify the
physician if deficits occur, which can be due to a lack of blood
supply during surgery
 Monitor respiratory status and auscultate breath sounds to
identify respiratory complications
 Encourage turning, coughing, and deep breathing, splinting
the incision
 Monitor cardiac status for dysrhythmias
THORACIC AORTIC ANEURYSM REPAIR

POSTOPERATIVE
 Monitor for pain and administer medication as prescribed
 Assess the incision site for bleeding or signs of infection
 Prepare the client for discharge by providing instructions
regarding pain management, wound care, and activity
restrictions
THORACIC AORTIC ANEURYSM REPAIR

POSTOPERATIVE
 Instruct the client not to lift objects greater than 15 to 20
pounds for 6 to 12 weeks
 Advise the client to avoid activities requiring pushing, pulling,
or straining
 Instruct the client not to drive a vehicle until approved by the
physician
 EMBOLECTOMY

DESCRIPTION
 Removal of an embolus from an artery using a catheter
 A patch graft may be required to close the artery
 EMBOLECTOMY

PREOPERATIVE
 Obtain a baseline vascular assessment
 Administer anticoagulants as prescribed
 Administer thrombolytics as prescribed
 Place a bed cradle on the bed
 Avoid bumping or jarring the bed
 Maintain the extremity in slightly dependent position
 EMBOLECTOMY

POSTOPERATIVE
 Assess cardiac, respiratory, and neurological status
 Monitor affected extremity for color, temperature, and pulse
 Assess sensory and motor function of the affected extremity
 Monitor for signs and symptoms of new thrombi or emboli
 Administer oxygen as prescribed
 Monitor pulse oximetry
 EMBOLECTOMY

POSTOPERATIVE
 Monitor for complications caused by reperfusion of the artery,
such as spasms and swelling of the skeletal muscles
 Monitor for signs of swollen skeletal muscles, such as edema,
pain on passive movement, poor capillary refill, numbness, and
muscle tenseness
 Maintain bed rest initially, with the client in semi-Fowler’s
position
 Place a bed cradle on the bed
 EMBOLECTOMY

POSTOPERATIVE
 Check the incision site for bleeding or hematoma
 Administer anticoagulants as prescribed
 Monitor laboratory values related to anticoagulant therapy
 Instruct the client to recognize the signs and symptoms of
infection and edema
 Instruct the client to avoid prolonged sitting or crossing the
legs when sitting
VENA CAVAL FILTER AND LIGATION OF
INFERIOR VENA CAVA

VENA CAVAL FILTER

 Insertion of an intracaval filter (umbrella) that partially
occludes the inferior vena cava and traps emboli to prevent
pulmonary emboli
LIGATION
 Suturing or placing clips on the inferior vena cava to prevent
pulmonary emboli
 VENA CAVAL FILTERS

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical
management for positive outcomes, ed 6, Philadelphia: W.B. Saunders
VENA CAVAL FILTER AND LIGATION OF
INFERIOR VENA CAVA

PREOPERATIVE
 If the client has been taking an anticoagulant, consult with the
physician regarding discontinuation of the medication to
prevent hemorrhage
VENA CAVAL FILTER AND LIGATION OF
INFERIOR VENA CAVA

POSTOPERATIVE
 Monitor vital signs
 Assess cardiac and respiratory status
 Administer oxygen as prescribed
 Monitor pulse oximetry
 Maintain semi-Fowler’s position
 Avoid hip flexion
 Maintain antiembolism stockings as prescribed
VENA CAVAL FILTER AND LIGATION OF
INFERIOR VENA CAVA

POSTOPERATIVE
 Provide activity as prescribed
 Check the insertion site for bleeding and hematoma
 Assess for peripheral edema
 Monitor laboratory values related to anticoagulant therapy
VENA CAVAL FILTER AND LIGATION OF
INFERIOR VENA CAVA

CLIENT EDUCATION
 Signs and symptoms of infection and edema
 Avoid prolonged sitting or crossing legs when sitting
 Elevate the legs when sitting
 Wear antiembolism stockings as prescribed and how to remove
and reapply the stockings
 Ambulate daily
 About anticoagulant therapy and the hazards associated with
anticoagulants
 HYPERTENSION

DESCRIPTION
 Persistent elevation of the systolic blood pressure above 140
mmHg and the diastolic blood pressure above 90 mmHg
 Most significant predictor of developing coronary artery
disease and a major risk factor for coronary, cerebral, renal,
and peripheral vascular disease
 The disease is initially asymptomatic
 HYPERTENSION

DESCRIPTION
 The goals of treatment include to reduce the blood pressure
and to prevent or lessen the extent of organ damage
 Nonpharmacological approaches, such as lifestyle changes,
may be initially prescribed and if the BP cannot be decreased
after a reasonable time period (1 to 3 months), then the client
may require pharmacological treatment
 HYPERTENSION
ORGAN INVOLVEMENT

EYES
 Visual changes
BRAIN
 Cerebrovascular accident (CVA)
CARDIOVASCULAR SYSTEM
 Congestive heart failure (CHF), hypertensive crisis
KIDNEYS
 Renal failure
HYPERTENSIVE RETINOPATHY

From Michelson JB, Friedlaender MH (1996) The eye in clinical medicine. London:
Times Mirror International Publishers.
 HYPERTROPHY OF THE LEFT
VENTRICLE IN HYPERTENSION

From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6,
Philadelphia, 1999, W.B. Saunders.
 HYPERTENSION

TYPES
 Primary or essential
 Secondary
 PRIMARY OR ESSENTIAL
HYPERTENSION

DESCRIPTION
 No known etiology
RISK FACTORS
 Aging
 Family history
 Black race with higher prevalence in males
 Obesity
 Smoking
 Stress
 SECONDARY HYPERTENSION
DESCRIPTION
 Occurs as a result of other disorders or conditions
 Treatment depends on the cause and the organs involved
PRECIPITATING CONDITIONS
 Cardiovascular disorders
 Renal disorders
 Endocrine system disorders
 Pregnancy
 Medications
 HYPERTENSION

ASSESSMENT
 May be asymptomatic
 Headache
 Visual disturbances
 Dizziness
 Chest pain
 Tinnitus
 Flushed face
 Epistaxis
 HYPERTENSION

IMPLEMENTATION: GOALS
 To reduce the blood pressure
 To prevent or lessen the extent of organ damage
 HYPERTENSION

IMPLEMENTATION
 Question the client regarding the signs and symptoms
indicative of hypertension
 Obtain the blood pressure (BP) two or more times on
both arms with the client supine and standing; compare
the BP with prior documentation
 Determine family history of hypertension
 Identify current medication therapy
 Obtain weight
 Evaluate dietary patterns and sodium intake
 HYPERTENSION

IMPLEMENTATION
 Assess for visual changes or retinal damage
 Assess for cardiovascular changes, such as distended neck
veins, increased heart rate, dysrhythmias
 Evaluate chest x-ray for heart enlargement
 Assess neurological system
 Evaluate renal function
 Evaluate results of diagnostic and laboratory studies
 HYPERTENSION

NONPHARMACOLOGICAL
 Weight reduction, if necessary, or maintenance of ideal weight
 Dietary sodium restriction to 2 g daily as prescribed
 Moderate intake of alcohol and caffeine-containing products
 Initiation of a regular exercise program
 HYPERTENSION

NONPHARMACOLOGICAL
 Avoidance of smoking
 Relaxation techniques and biofeedback therapy
 Elimination of unnecessary medications that may contribute to
the hypertension
 HYPERTENSION: STEPPED CARE
APPROACH
DESCRIPTION
 If a pharmacological approach to treating hypertension is
required, a single medication is prescribed and monitored for
its effectiveness
 Medications are added to the treatment regimen until the BP is
controlled
 Refer to the module entitled Cardiovascular Medications, for
information regarding medications to treat hypertension
 HYPERTENSION: STEPPED CARE
APPROACH

STEP 1
 A single medication is prescribed, which may be a
diuretic, beta blocker, calcium channel blocker, or
angiotensin-converting enzyme (ACE) inhibitor
STEP 2
 Step 1 therapy is evaluated after 1 to 3 months
 If the response is not adequate, compliance is evaluated
 The medication may be increased or a new medication is
prescribed, or a second medication is added to the
treatment plan
 HYPERTENSION: STEPPED CARE
APPROACH
STEP 3
 Compliance is evaluated
 Further evaluation of Step 2
 If a therapeutic response is not adequate, a second medication
is substituted or a third medication is added to the treatment
plan
STEP 4
 Compliance is evaluated
 Careful assessment of factors limiting the antihypertensive
response is done
 A third or fourth medication may be added to the treatment
plan
 HYPERTENSION: CLIENT EDUCATION

Importance of compliance with the treatment plan

The disease process, explaining that symptoms
usually do not develop until organs have suffered
damage
Planning a regular exercise program, avoiding heavy
weight lifting and isometric exercises
Importance of beginning the exercise program
gradually
Express feelings about daily stress
Identify ways to reduce stress
 HYPERTENSION: CLIENT EDUCATION

Relaxation techniques
Incorporate relaxation techniques into the daily
living pattern
Technique for monitoring blood pressure
Maintain a diary of blood pressure readings
Importance of lifelong medication and the need for
follow-up treatment
Dietary restriction, which may include sodium, fat,
calories, and cholesterol
 HYPERTENSION: CLIENT EDUCATION

How to shop and prepare low-sodium meals

List of products that contain sodium
Read labels of products to determine sodium content
focusing on substance listed as sodium, NaCl, and
MSG
Bake, roast, or boil foods, avoid salt in preparation of
foods, and avoid using salt at the table
Fresh foods are best to consume and to avoid canned
foods
 HYPERTENSION: CLIENT EDUCATION

The action, side effects, and scheduling of

medications
If uncomfortable side effects occur, to contact the
physician and not to stop the medication
Avoid over-the-counter medication
Importance of follow-up care
 HYPERTENSIVE CRISIS

DESCRIPTION
 Any clinical condition requiring immediate reduction in blood
pressure
 An acute and life-threatening condition
 The accelerated hypertension requires emergency treatment,
since target organ damage (brain, heart, kidneys, retina of the
eye) can occur quickly
 Death can be caused by stroke, renal failure, or cardiac disease
 HYPERTENSIVE CRISIS

ASSESSMENT
 A diastolic pressure above 120 mmHg
 Headache
 Drowsiness
 Confusion
 Changes in neurological status
 Tachycardia and tachypnea
 Dyspnea
 Cyanosis
 Seizures
 HYPERTENSIVE CRISIS

IMPLEMENTATION
 Maintain a patent airway
 Administer IV antihypertensive medications as prescribed
 Monitor vital signs assessing BP every 5 minutes
 Assess for hypotension during the administration of
antihypertensives
 Place the client in a supine position if hypotension occurs
 HYPERTENSIVE CRISIS

IMPLEMENTATION
 Have emergency medications and resuscitation equipment
readily available
 Maintain bed rest, with the head of the bed elevated at 45
degrees
 Monitor IV therapy assessing for fluid overload
 Monitor I&O
 Insert Foley catheter as prescribed
 Monitor urinary output, and if oliguria or anuria occurs, notify
the physician