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Nursing Care of Patients with Vascular

Disorders
Part I

Miami University Hamilton


Campus
Debbie Beyer RN MSN
Associate Professor
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Review
Blood pressure (BP) control
Baroreceptors, also called pressoreceptors, are located in the walls of the
aortic arch and carotid sinuses.
Baroreceptors are specialized nerve endings affected by changes in the
arterial BP.
Increases in arterial pressure stimulate baroreceptors, and the heart rate and
arterial pressure decrease.
Decreases in arterial pressure reduce stimulation of the baroreceptors and
vasoconstriction occurs, as does an increase in heart rate.
Stretch receptors, located in the vena cava and the right atrium, respond to
pressure changes that affect circulatory blood volume.
When the BP decreases as a result of hypovolemia, a sympathetic response
occurs, causing an increased heart rate and blood vessel constriction; when
the BP increases as a result of hypervolemia, an opposite effect occurs.
Antidiuretic hormone (vasopressin) influences BP indirectly by regulating
vascular volume. (Silvestri, Linda Anne. Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition.
W.B. Saunders Company, 102010. pp. 786 - 787).

Review
Blood pressure (BP) control
Increases in blood volume result in decreased antidiuretic hormone
release, increasing diuresis, decreasing blood volume, and thus
decreasing BP.
Decreases in blood volume result in increased antidiuretic hormone
release; this promotes an increase in blood volume and therefore BP.
Renin, a potent vasoconstrictor, causes the BP to increase.
Renin converts angiotensinogen to angiotensin I; angiotensin I is
then converted to angiotensin II in the lungs.
Angiotensin II stimulates the release of aldosterone, which promotes
water and sodium retention by the kidneys; this action increases
blood volume and BP.
(Silvestri, Linda Anne. Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition. W.B.
Saunders Company, 102010. pp. 786 - 787).

Review
The vascular system
Arteries are vessels through which the blood passes away from the
heart to various parts of the body; they convey highly oxygenated
blood from the left side of heart to the tissues.
Arterioles control the blood flow into the capillaries.
Capillaries allow the exchange of fluid and nutrients between the
blood and the interstitial spaces.
Venules receive blood from the capillary bed and move blood into
the veins.
Veins transport deoxygenated blood from the tissues back to the
right heart and then to the lungs for oxygenation.
Valves help return blood to the heart against the force of gravity.
The lymphatics drain the tissues and return the tissue fluid to the
blood.

(Silvestri, Linda Anne. Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition. W.B.
Saunders Company, 102010. pp. 786 - 787).

Review
Blood pressure
tension or pressure exerted by blood against arterial walls

Minimum Required
maintain open vessels
capillary perfusion
oxygenation

Excess Pressureharmful
increase workload of heart
altering the vessel structure
affecting sensitive body tissues

Eyes
Kidneys
Heart
Central nervous system
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Primary Hypertension
Also known as: Essential hypertension
1 in 3 person in the United States
90% have no identified cause
30% of hypertensive adults remain unaware of
their condition
Systolic blood pressure > 140 or diastolic >90
Important health issue
Rarely causes symptoms or limitations

Major Risk Factor


Coronary heart disease, heart failure, stroke and
renal failure.
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Primary Hypertension
Manifestations
Asymptomatic
Blood pressure elevations initially are
transient but then become permanent.
When symptoms appear often vague
Headache upon awakening
Depend upon target organ damage
Nocturia, confusion, nausea and vomiting, visual
disturbances

Primary Hypertension
Complications
Atherosclerosis rate accelerates
Increases risk of stroke and coronary heart disease

Workload of left ventricle increases


Ventricular hypertrophyincreases risk for coronary heart disease,
dysrhythmias and heart failure

Increased pressure in cerebral vessels


Microaneurysms and increased risk for cerebral hemorrhage

Hypertensive Encephalopathy
Syndrome characterized by extreme high blood pressure, altered level
of consciousness, increased intracranial pressure, papilledema and
seizures

Nephrosclerosis and renal insufficiency


Proteinuria and microscopic hematuria
African Americans more often than caucasians
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Primary Hypertension
Age related increase in systolic pressure
Diastolic pressure gradually rises until about age 50
Systolic pressure continues to rise as we age

Risk factorsnonmodifiable
Race
Genetic and Family history
Age

Risk factorsmodifiable
Mineral Intake
High sodium intake
Low potassium, calcium and magnesium intakes

Obesity
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Primary Hypertension
Risk factorsmodifiable
Mineral Intake
High sodium intake
Low potassium, calcium and magnesium
intakes

Obesity
Central obesity

Insulin Resistance
Excess Alcohol Consumption
Stress
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Primary Hypertension
Interdisciplinary Care
Reduction of blood pressure to < 140/90
With diabetes or renal disease goal is
<130/80
Goal: reduce cardiovascular and renal
mortality and morbidity
No cure but can be controlled
Usually combination of 2 or more drugs
and lifestyle changes
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Primary Hypertension
Interdisciplinary Care
Diagnosis
Evaluate for identifiable causes
Presence or absence of target organ damage
Tests

Electrocardiogram (ECG)
Urinalysis
Blood Glucose
Hematocrit
Serum potassium, creatinine, calcium
Cholesterol and lipoprotein profile
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Primary Hypertension
Interdisciplinary Care
Lifestyle Modifications
Diet
Reduce sodium intake, maintain adequate calcium and
potassium intake, reduce total and saturated fat intake
Dietary Approaches to Stop Hypertension (DASH) diet
Whole foods focus; rich in fruits and vegetables and low
in total and saturated fats
Weight loss diet (even 10 pounds can decrease BP)

Physical Activity
Regular exercise (aerobic) 30-45 minutes/day/5-6
days/week
Isometric exercises (weight lifting) can increase Systolic BP

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Primary Hypertension
Interdisciplinary Care
Lifestyle Modifications
Alcohol and Tobacco Use
No more than one ounce of ethanol or 2
drinks/day

Nicotine is a vasoconstrictor
Smoking and heart disease link
Smoking cessation highly recommended

Stress Reduction
Regular exercise is treatment of choice

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Primary Hypertension
Interdisciplinary Care
Medications
Use of one or more of the following classifications
Most patients require treatment with at least 2
or more from different classifications:

Diuretics
Beta adrenergic blockers
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers (ARB)
Vasodilators
Calcium channel blockers
Centrally acting sympatholytics

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Primary Hypertension
Medications
Diuretics
Preferred treatment for systolic HTN in older adults
Prevent tubular reabsorption of sodium, thus
promote sodium and water excretion and reduce
blood volume
Thiazide diuretics
Hydrochlorothiazide (HydroDIURIL) (HCTZ)

Loop diuretics
Furosemide (Lasix)

NI: Monitor Blood pressure and potassium levels

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Primary Hypertension
Medications
Beta Adrenergic Blockers (-lol)
If patient also has diabetes, heart failure or
coronary artery disease may be used initially
Reduce peripheral vascular resistance and decrease
renin secretion
Contraindicated in patients with asthma or COPD as
they promote bronchial constriction
Carvedilol (Coreg)
Metoprolol tartrate (Lopressor)

NI: monitor blood pressure and heart rate, give


carvedilol with food, monitor for orthostatic changes
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Primary Hypertension
Medications
ACE inhibitors (-pril) or ARBs
If patient also has diabetes, heart failure or history of myocardial
infarction (MI) or chronic renal disease may be used initially
ACE inhibitorsblock formation of antiotensin II by inhibiting the action
of the angiotensin-converting enzyme. Angiotensin II is a potent
vasoconstrictor tha also stimulates aldosterone release; blocking its
action prevents vasoconstriction and sodium and water retention.
Enalapril (Vasotec)
Lisinopril (Prinivil, Zestril)

ARBsimilar effect although they block angiotensin II receptors.


Losartan (Cozaar)

NI: monitor blood pressure, monitor for hyperkalemia or changes in


BUN and creatinine, monitor for angioedema. May need to be
discontinued if persistent cough develops.
Classification less effective for most African-Americans

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Primary Hypertension
Medications
Drug classes that promote vasodilation and reduce peripheral vascular
resistance
Alpha blockers
Dilate both arterioles and veinscan cause significant orthostatic hypotension
Doxazosin (Cardura)
NI: May cause first-dose syncopebest to take at night; monitor BP and heart rate

Calcium channel blockers


Diltiazem (Cardizem)
Amlodipine (Norvasc)
Can cause reflex tachycardia

NI: monitor BP and heart rate

Direct Acting Vasodilators


Hydralazine (Apresoline)
Oral and intravenous

Associated with reflex tachycardia and fluid retention; rarely administered as


single-drug treatments NI: monitor BP, heart rate and edema.

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Primary Hypertension
Medications
Centrally Acting Sympatholytics
Stimulate alpha2 receptors in CNS result in fall in cardiac
output and vasodilation
Dry mouth and sedation common side effects
Clonodine (catapres)
Can be given in oral or transdermal delivery

NI: monitor BP and heart rate

Medication regime usually include 2 or more drugs


with all blood pressure medical management,
monitor for orthostatic blood pressure and instruct
patient to not discontinue therapy due to rebound
hypertension and serious medical consequences.
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Primary Hypertension
Nursing Care
Complementary and alternate therapies
Education
Nursing Diagnoses:
Ineffective health maintenance
Risk for noncompliance
Imbalance nutrition: more than body
requirements
Deficient knowledge
Excess fluid volume
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Secondary Hypertension
Blood pressure increase with a known cause
Kidney disease
Endocrine disorders
Cushings syndrome
Primary aldosteronism
Pheochromocytomarare tumor of adrenal medulla
Hyperthyroidism
Pituitary disorders

Coarctation of the aorta


Neurological diosorders
Sleep apnea
Drug use
Pregnancy
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Hypertensive Crisis
Rapid, significant elevations in systolic pressure
Also known as: Hypertensive emergency or malignant
hypertension
>180/120
Immediate treatment (within one hour)
Prevent cardiac, renal and vascular damage
Reduce morbidity and mortality

Cerebral edema can develop


Prolong hypertension can lead to intravascular coagulation and
acute renal failure due to damage to the walls of the arterioles
and renal blood vessels
Manifestations:
headache, confusion, restlessness, papilledema, blurred vision, motor
and sensory deficits.
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Hypertensive Crisis
Causestop taking medication or hypertension poorly
controlled
Most susceptibleyounger patients (30-50), African American
males, pregnant women with pre-eclampsia, and people with
collagen and or renal disease.
Goal is reduce BP by 25% in first hour then toward 160/100 in
2-6 hours, avoid rapid or excessive blood pressure decreases
which may lead to renal, cerebral or cardiac ischemia
Blood pressure measured every 5-30 minutes
Monitor renal status and detect underlying cause
Drug used:
Sodium nitroprusside (Nipride) potent vasodilator

Nursing care focuses on monitoring blood pressure, drug


management, emotional and psychological support. Teaching
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Aneurysm
Abnormal dilation of a blood vessel often at a
site of weakness or a tear in vessel wall.
Common sites:
Aorta
Peripheral arteries
Ventricular wall especially left ventricle

Causes or precursors
Hypertension
Arteriosclerosis or atherosclerosis
Trauma
Smoking history
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Aneurysm
Types of aneurysms
True
Affect all three layers of the vessel
Grow slowly but progressively

False
Traumatic break in vessel wall
Saccular in nature (look like small sacs)
Berry aneurysm
Small and commonly found in brain

Dissecting aneurysms
Blood invades or dissects the layers of the vessel wall
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Aneurysm
Aortic Aneurysms
Thoracic
Manifestations:

May be asymptomatic
Back,neck or substernal pain
Dyspnea, stridor or brassy cough if press on trachea
Hoarseness or dysphagia if pressing on esophagus or
laryngeal nerve
Edema of face and neck
Distented neck veins

Complications
Rupture and hemorrhage
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Aneurysm
Aortic Aneurysms
Abdominal
Manifestations

Pulsating abdominal mass


Aortic calcification on xray
Mild to severe midabdominal or lumbar back pain
Cool, cyanotic extremities if iliac arteries are involved
Claudication (ischemic pain with exercise, relieved with rest)

Complications
Peripheral emboli to lower extremities
Rupture and hemorrhage

Aortic Dissection
Blood invades or dissects the layers of the vessel wall
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Aneurysm
Aortic Aneurysms
Aortic Dissection
Manifestations

Abrupt, severe, ripping or tearing pain in area of aneurysm


Mild or marked hypertension early
Weak or absent pulses and blood pressure in upper extremities
Syncope
Life threatening emergency

Complications

Hemorrhage
Renal failure
MI, heart failure, cardiac tamponade
Sepsis
Weakness or paralysis of lower extremities
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Aneurysm
Interdisciplinary Care
Diagnosis
Chest xray, ultrasound, CT or MRI
Angiography
Most asymptomatic and found on routine
physical examination or thru diagnostics for
other issues
May monitor size of aneurysm and medically
manage
>5 cm associated with increase rupture and
may be surgically repaired.
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Aneurysm
Interdisciplinary Care
Medications
Antihypertensive drugs to control heart rate
and blood pressure

Surgical management
Anticoagulation may be instituted (Heparin
with transfer to warfarin (Coumadin)
Others may use lifelong low-dose aspirin
therapy
Grafts are used to treat aneurysms
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Aneurysm
Nursing Care
Surgical
Preopas much education as time permits; many
surgeries may be emergent
Postoproutine post op care
Maintain fluid replacement
Monitor blood pressure and pulses in all extremities
Monitor temperature, sensation and numbness in all
extremities
Monitor abdomen, bowel sounds, pain and distention
Monitor renal status and urine output
Monitor for lower extremity weakness or paraplegia
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Aneurysm
Nursing Care
Nursing diagnoses
Ineffective tissue perfusion: peripheral,
renal, cardiovascular
Risk of injury
Anxiety

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