BLOOD VESSEL DISORDERS
Inflammatory Disorders and Complications
Thrombophlebitis
Thrombophlebitis is inflammation of the wall of a vein, in which one or more clots form. Deep vein thrombosis (DVT) defines the condition wherein a blood clot (thrombus) has formed inside a deep blood vessel. The blood clot forms in response to the initial inflammation. Phlebitis is the inflammation of a blood vessel without clot formation.
In some situations (e.g., following trauma, childbirth, MI, CVA, CHF, or cancer surgery), excessive coagulability of the blood causes thrombophlebitis and thrombosis. Obesity is also a predisposing factor. Women who use birth control pills may have a higher than average risk of developing blood clots.
Nursing Alert Never massage or rub a client’s leg. Rationale: Rubbing could dislodge a clot and cause embolism.
Pressure or prolonged inactivity may cause venous thrombosis. It may occur after surgery or any illness in which a person remains in one position for long periods, or when sitting in a car or airplane for an extended length of time. The legs are most likely to be affected because venous blood does not return quickly enough, a condition known as venous stasis or venous standstill. Prevention of venous stasis is a major reason for early ambulation in illness. Clients with any condition that requires prolonged immobilization often receive low-dose prophylactic anticoagulants. (Some physicians recommend that all adults take aspirin daily, as a preventive measure.)
IN PRACTICE :EDUCATING THE CLIENT 81-3
MYOCARDIAL INFARCTION:WHEN TO SEEK MEDICAL HELP
♦ Chest pain unrelieved with sublingual nitroglycerin
♦ Left or right arm pain
♦ Severe shortness of breath
♦ Faintness or dizziness
♦ Unusual fatigue or weakness
♦ Palpitations or irregular or rapid heartbeat
♦ Back pain or jaw pain
♦ Symptoms presenting as severe indigestion
Note:There are times when no symptoms may be present.
Special Considerations : LIFESPAN
Thrombophlebitis
Older adults and those with heart disease or varicose veins are most susceptible to thrombophlebitis. Prolonged sitting may be a contributing factor. Inform older adults of the importance of frequent position changing. A rocking chair provides some exercise for people who find walking difficult.
Most thrombi form in veins because venous blood moves more slowly than arterial blood. However, a thrombus may form in an artery (arterial thrombosis); this condition is usually related to arteriosclerosis, but it may result from infection, injury, or diabetes mellitus.
Signs and Symptoms. Signs and symptoms of thrombophlebitis include pain in the affected leg, redness, swelling, fever, fatigue, and loss of appetite. A positive Homans’ sign can indicate thrombophlebitis. (This test is considered positive when calf pain greatly increases with dorsiflexion of the foot.)
Medical Treatment. Imaging studies are performed to differentiate between superficial thrombosis and DVT because each is treated differently. Clients with DVT only in the calf can be treated with outpatient therapy, receiving low-molecular-weight heparin. Those who must be admitted to the hospital require IV heparinization for 3 to 5 days, in conjunction with overlapping oral anticoagulant therapy, until adequate anticoagulation is achieved. Frequent blood tests to monitor clotting times are used to regulate the dosage of anticoagulants. The client may remain on oral anticoagulants for 3 to 6 months. In addition, clients are usually placed on bed rest for 1 to 5 days, gradually resuming their normal activities.
Nursing Considerations. All clients who are confined to bed should begin an exercise plan as soon as possible. The simplest exercises include periodic contraction and relaxation of the leg muscles and moving of the toes and feet. The bedcovers must be sufficiently loose to permit free movement. Most clients who must remain on bed rest wear antiembolism stockings and may have the foot of the bed elevated to help prevent venous stasis. Passive range-of-motion (PROM) exercises or the continuous passive motion (CPM) device may be used for clients who are unable to exercise actively. When caring for the client with thrombophlebitis, include the following:
• If exercise is ordered, encourage the client to wiggle the toes, bend the knees, and turn the ankle back and forth.
• In deep thrombophlebitis, immobilize the affected part.
• Prevent vigorous coughing or deep breathing (because of the danger of embolism; see next section). Try to keep the client from straining when defecating; administer stool softeners, as ordered.
• Use warm, moist packs (low temperature). Rationale: Gently stimulate circulation and dissolution of the clot, but avoid overdilation of blood vessels.
• Enforce bed rest. Rationale: Moving could cause embolism. Elevate the affected leg on soft pillows. Rationale: Promote comfort and enhance venous return from the leg.
While the client is on anticoagulant therapy, follow the general nursing precautions and procedures to reduce the risks of injury and bleeding. The client usually receives IV heparin during the acute phase and warfarin (Coumadin) as a prophylactic measure later. Routine prothrombin times (PT) for monitoring of Coumadin and partial thromboplastin time (PTT) clotting tests are done to monitor anticoagulant therapy. The dosage is based on daily blood tests. If clotting time is too high, the medication is temporarily discontinued. Provide education to the client and family about anticoagulants and when to contact the physician if problems occur (e.g., in cases of increased bruising, bleeding).
If the client is to wear an antiembolism stocking or an elastic bandage, apply it with even pressure from the toes to the thigh. Rationale: Uneven pressure could cause another clot to form. Remove elastic stockings or bandages at least once per shift for a short time. Gently cleanse the extremity and apply lotion, if necessary. Inspect the extremity carefully for any skin changes.
If the client is required to stay in bed for some time, help him or her to progress gradually from complete bed rest to ambulation, according to physician’s orders. Constantly observe for any signs of embolism.
Embolism
Embolism is a severe complication of thrombophlebitis. An embolus is a blood clot that is carried through the circulation to some vital organ; it can lodge in a blood vessel and cause death. Urgent treatment is vital; refer to the earlier section on thrombolytic therapy.
Types. A pulmonary embolism is the result of a blood clot that travels to the lungs. If the obstruction occurs in a large pulmonary blood vessel (the most common site for the lodging of an embolus originating in the leg), it may cause sudden death. The obstruction of a small vessel may not be so damaging. A pulmonary embolism may cause sudden, sharp chest pain; breathing difficulty; violent cough; and bloody sputum. The client will become cyanotic, and symptoms of shock can develop rapidly. The immediate treatment is to administer oxygen and to provide for complete bed rest in a high semi-Fowler’s position. Continuous IV anticoagulation therapy with heparin is a widely used treatment. Pain relief with the use of IV morphine is also indicated.
A coronary embolus is a blood clot that travels to a blood vessel in the heart. If the embolus lodges in a blood vessel within the heart, the heart tissue distal to the blockage will necrose. Depending on how large the vessel is, the necrosed area may cause instant death. Symptoms of a lesser blockage are sudden, severe chest pain and other characteristic symptoms of an MI, which were discussed earlier.
In cerebral embolism, the clot blocks one of the brain’s blood vessels, causing a cerebrovascular accident (CVA). The amount of brain damage depends on the vessel’s size and location. This situation is commonly known as an ischemic CVA.
Peripheral embolism and thrombosis in a limb involves an embolus that lodges in a blood vessel leading to an extremity. In this case, the first symptom is severe pain at the site of the blockage. The extremity becomes pale and cold to the touch; pulses distal to the blockage are lost. The limb becomes white and cold. Other symptoms of shock are seen if a large blood vessel is obstructed. Amputation below the level of the blockage may be necessary if a clot in a large vessel is not dissolved quickly or surgically removed. Without circulation, gangrene will occur.
Surgical Treatment. Certain surgical procedures may be performed to combat the danger of embolism. Emboli can be removed from pulmonary arteries, although this procedure is rare. If a thrombus is located in the femoral vein, the blood vessel can be ligated (tied off) at the blockage site in a procedure called femoral ligation. Sometimes, the vena cava is made smaller (vena cava ligation) or a filter is inserted in the vein to prevent clots from traveling to the heart.
Peripheral Vascular Disorders
Most peripheral vascular disorders are evidenced at one time or another by the following symptoms:
• Intermittent claudication: The person experiences no pain at rest; but exercise, particularly walking, causes excruciating pain in the limb, which disappears when the limb is again at rest. Smoking, vascular spasm, and atherosclerosis aggravate this condition. Intermittent claudication caused by venous stasis is called venous claudication.
• Tingling and numbness: The extremity or part of the extremity becomes numb, or the person feels a persistent tingling sensation, caused by poor circulation.
• Coldness and difference in size: The extremities may feel cold to the touch or the person may sense that the hands and feet are cold. One leg may be markedly different in size, color, and temperature from the other.
• Lack of new tissue growth: The skin may become paper thin, shiny, and easily subject to breakdown. Blood vessels are visible.
Simple changes to lifestyle can prevent or arrest peripheral vascular diseases. In Practice: Nursing Care Guidelines 81-2 lists general nursing measures for peripheral vascular disease.
Buerger Disease
Buerger disease (thromboangiitis obliterans) results from inflammation that causes obstruction of blood vessels in the extremities, especially the legs. It is more common in men than in women, primarily affecting persons who are heavy smokers. Chilling aggravates the condition. Buerger disease is less common today than in the past.
Usually, the first sign is cramps in the calf muscles, brought on by exercise, which disappear with rest. Other symptoms include tingling, burning, numbness, and edema, which may develop into pitting or brawny (hard) edema. Hardened, painful areas develop along the course of blood vessels. When the feet and legs hang down, they take on a mottled purplish-red hue; when raised, they become abnormally pale. Ulcers may develop that, if infected, could result in gangrene, necessitating amputation. As the disease progresses, pain continues even during rest.
IN PRACTICE :NURSING CARE GUIDELINES 81-2
CARING FOR CLIENTS WITH PERIPHERAL VASCULAR DISEASE
♦ Protect the client’s feet and legs from undue pressure of linens. Rationale: Doing so prevents discomfort and skin breakdown.
♦ Take great care in trimming the toenails. Rationale: Cuts or abrasions on the feet are difficult to heal.
♦ Be sure to dry carefully between the toes after washing them. Rationale: Moisture promotes skin breakdown. Any break in the skin or subsequent infection heals much more slowly when circulation is poor.
♦ Be very careful about application of heat. Use extra clothing rather than external heat to warm the extremities. Rationale: This person is easily burned.
♦ Report skin breakdown immediately Rationale: Ambitious therapy will be needed.
♦ Use warm baths to help increase the circulation; be sure the water is not hot. Rationale: Heat helps dilate blood vessels. This client is very susceptible to burns. Use a bath thermometer; the maximum temperature is I00°F or 37.8°C.
♦ Do not attempt to treat corns or calluses. Rationale: The client may be accidentally cut or injured, predisposing the client to infection.
Medical and Surgical Treatment. Affected individuals must avoid anything that worsens this condition, especially chilling of hands and feet. Tobacco in any form is dangerous because nicotine constricts blood vessels. Advise clients to stop smoking or stop using smokeless tobacco immediately.
Mild exercise is recommended if it is not painful. For this purpose, Buerger-Allen exercises are prescribed. They consist of alternately raising, lowering, and resting the legs. Sometimes, cramps occur with exercise (intermittent claudication). Clients may use an electrically operated rocking bed (oscillating bed) if they cannot exercise actively. Antibiotics, anti-inflammatory agents, and analgesics may be necessary to treat infection and pain. External heat is not used. Rather, clients are encouraged to wear extra clothing. Encourage fluid intake and advise clients to avoid constrictive clothing.
Sometimes, a sympathectomy is performed, whereby the sympathetic nerves, which innervate the smooth muscles, are cut to relieve vasospasms and increase blood flow to the lower extremities.
Raynaud Phenomenon
Raynaud phenomenon is a condition that is characterized by spasmodic constriction of arteries supplying the extremities. It especially affects fingers and toes; often it involves only the fingers. It affects women more frequently than men, especially young women. Cold and emotional stress can precipitate the condition. However, the cause is unknown.
Symptoms of Raynaud phenomenon include blanched and cold extremities. They perspire and feel numb and prickly. Later they become blue—especially the fingernails—and are painful. As heat restores blood flow, the hands become red and warm. In the early stages, these symptoms disappear after an episode, and the hands seem normal again. But as the disease progresses, cyanosis persists between attacks, and ulcers, which are slow to heal, may develop on the fingertips.
The skin looks tight and shiny, and the nails become deformed. The fingertips may develop gangrene.
Clients must avoid chilling at all times. They must always wear warm clothing outdoors in winter (e.g., wool gloves and socks, and insulated boots). A goose down or other comforter at night provides steady warmth. Electric blankets may be dangerous because they may be too hot and could burn the client. Clients should avoid emotional upsets and tension of any kind. Smoking is contraindicated. Drugs to relieve spasm of arteries and dilate blood vessels provide considerable relief. A sympathectomy may be necessary.
Varicose Veins
Varicose veins result from weakening of the valves of the veins so that blood pools in the legs or another dependent area. Normal veins fill from below because of valvular action. With varicose veins, the veins fill abnormally. (Hemorrhoids and esophageal varices are also varicose veins.) Predisposing factors include heredity, and weakening of the vein walls resulting from prolonged standing, poor posture, repeated pregnancies, round garters, obesity, tumors, HTN, and chronic diseases of the liver or kidneys. Varicose veins may also result from thrombophlebitis. Women are more commonly affected with varicosities of the legs than men, especially if they have had several pregnancies.
Signs and Symptoms. The main sign of varicose veins in the legs is the appearance of dark, tortuous superficial veins that become more prominent when the person stands and appear as dark protrusions. These superficial veins can sometimes rupture, causing a varicose ulcer. Internal or deep varicose veins cause symptoms such as pain, fatigue, a feeling of heaviness, and muscle cramps. Symptoms are much more severe in hot weather and at high altitudes. A diagnostic test involves putting the client into the Trendelenburg position to test blood drainage. Leg veins that do not fill normally on standing signify varicose veins.
Medical and Surgical Treatment. Treatment includes elevating the legs for a few minutes at 2- to 3-hour intervals throughout the day. It also includes avoiding constriction, standing for long periods, or restrictive clothing. The client should wear support hose. All measures aim at promoting venous return from the legs.
In severe cases, surgical ligation and stripping of varicose veins is done. The larger veins are surgically ligated, and smaller ones are stripped. Occasionally, sclerosing solutions are used for small varicosities: The solution is injected into the vessel that causes irritation and eventually fibrosis.
Nursing Considerations. The client needs teaching about measures that promote venous drainage, to avoid the need for possible surgery. If surgery is necessary, apply antiembolism stockings to the leg postoperatively, and elevate the foot of the bed to encourage venous return. Analgesics may be ordered. Aspirin is often the drug of choice because of its anticoagulant action.
Early ambulation is important after surgical treatment. Often, the client must ambulate as soon as he or she recovers from anesthesia. The client may be alarmed at the idea of walking so soon after the operation, while the legs are stiff and sore, and they will most likely need reassurance and an explanation of the need for moving about. The order is often written for the client to walk 5 to 10 minutes each hour during the day and several times at night. Assist and encourage the client to follow this regimen.
IN PRACTICE :EDUCATING THE CLIENT 81-4
DISCHARGE TEACHING AFTER VENOUS STRIPPING
• Elevate the legs while sitting.
• Be sure to walk and to avoid standing still in one place for any length of time.
• Avoid sitting for a lengthy time.
• Learn how to apply antiembolism stockings correctly.
• If possible, lose weight.
• Do not use tobacco.
In Practice: Educating the Client 81-4 includes ideas for client teaching after venous stripping. Instruct the client how to apply antiembolism stockings correctly. Teach him or her to avoid knee-high stockings and socks with elastic tops. If weight reduction is suggested, the clinical dietitian will give instructions.
Telangiectasia (Spider Veins)
Telangiectasia is a group of small dilated blood vessels. It is treated by scleropathy, the injection of a weak sodium chloride solution into nonfunctioning veins. Pressure is applied at specific points, and the veins stick together and are gradually absorbed. The lines almost disappear. The treatment is relatively painless.
Aneurysms
An aneurysm is an outpouching of a blood vessel. Although it may occur in any vessel, the most common site is the aorta. Figure 81-11 shows several types of aneurysms.
An aneurysm in the aorta or in a cerebral vessel represents an extreme emergency. If it ruptures, surgical intervention may be done if the aneurysm is in an operable site. However, if surgery is not done immediately, the vessel may hemorrhage and the person may die. If the aneurysm is discovered before it ruptures, it is treated by surgical repair, such as clamping or removal. Usually, a synthetic graft is substituted for the portion of the vessel affected.
Aneurysms may be congenital, occur after trauma, or develop as a result of the increased pressure of arteriosclerosis. Unknown cerebral aneurysm rupture is often the cause of sudden death in healthy athletes.
Cerebrovascular Accident
A sudden or gradual interruption of blood supply to a vital center in the brain is a cerebrovascular accident (CVA), also known as a stroke, brain attack, or central vascular accident. A CVA can cause complete or partial paralysis or death. CVAs are the third leading cause of death in America.
FIGURE 81-11 · Three forms of aneurysms: A. Berry aneurysm in the circle of Willis, B. fusiform-type aneurysm of the abdominal aorta, and C. a dissecting aortic aneurysm.
Risk factors for CVAs include hypertension, smoking, diabetes mellitus, sickle cell disease, cardiac dysrhythmias, substance abuse, and atherosclerosis. Smoking increases the risk of developing a CVA by two to six times. The risk also increases for smokers who use birth control pills over an extended period of time. Postmenopausal women are more likely to have CVAs than are younger women. There is a higher incidence of death from CVA in women, although men and women are equally afflicted with the condition.
Types of CVAs
• Transient ischemic attack (TIA) is a sudden, short-lived attack. The person recovers within 24 hours. TIA is often a warning that another, more serious, stroke will occur later. Reversible ischemic neurologic deficit (RIND) is similar to a TIA, except that the symptoms last for as long as a week. A brain scan may reveal that a brain infarction has occurred.
• Cerebral thrombosis: In this most frequent cause of CVA, a blood clot or piece of plaque blocks an artery that supplies a vital brain center, usually as a result of arteriosclerosis.
• Cerebral embolism: A blood clot breaks off from a thrombus elsewhere in the body and is carried to the brain, where it lodges in a blood vessel and shuts off blood supply to part of the brain. Cerebral thrombosis and cerebral embolism cause decreased blood (oxygen) flow to the brain and may be referred to as ischemic CVAs.
• Cerebral hemorrhage or aneurysm (hemorrhagic CVA): An artery in the brain bursts because of arteriosclerosis, continuing weakening of the aneurysm wall, hypertension, or an acute severe rise in blood pressure. The results are blood vessel rupture and hemorrhage.
Signs and Symptoms. Symptoms of CVA depend on its cause. In some cases of thrombosis and ischemia, the person has had dizzy spells or sudden memory loss for some time before the actual CVA. No pain accompanies these symptoms, so the client may ignore them. A cerebral hemorrhage may give warning. It causes dizziness and ringing in the ears (tinnitus), as well as a violent headache, often with nausea and vomiting. A hemorrhage may follow unusual exertion, such as shoveling snow, heavy eating, or vigorous exercise. Embolism usually occurs without warning, although the person often has a history of cardiovascular disease.
A sudden-onset CVA is usually the most severe. The victim loses consciousness; the face becomes red; breathing is noisy and strained. The pulse is slow but full and bounding. Blood pressure is elevated, and the person may be in a deep coma. Stroke in evolution (SIE) is a gradual worsening of symptoms of brain ischemia. The coma may deepen progressively until death occurs, or the person may gradually regain consciousness and eventually recover. The longer the time period that the person remains unresponsive, the less likely it is that the person will recover. The first few days after onset are critical. The responsive person may show signs of memory loss or inconsistent behavior; he or she may be easily fatigued, lose bowel and bladder control, or have poor balance.
