VALAS present

Darmawan Ismail
Bedah Thoraks Kardiak & Vaskuler
 Vein
• Thrombosis
• Phlebitis
• Varices
 Deep Vein Thrombosis (DVT)

• Most likely to occur in deep veins

of the calf (80%)
• 25% of thrombi that occur in calf
will extend to the popliteal &
femoral veins
• PE may be the first sign of DVT
 DVT Manifestations

• When clot is in formative stage, may notice no symptoms

• Usually profound tenderness; affected extremity may be
larger (unilateral edema)
• Dull aching esp when walking: Most common
• Severe pain, esp when walking
• Cyanosis of extremity
• Slightly elevated temp
• General malaise
 Homan’s Sign
• Was long considered classic manifestation—this
is no longer true

• Sign is not specific to DVT & can be elicited by

any condition of the calf

• As calf muscles contract, there is risk of

detaching thrombus from the wall
 Superficial Vein Thrombosis (SVT)

• Thrombi form primarily in upper extremities

• Primary cause: trauma to venous wall assoc
w/venous catheters, repeated venous punctures,
use of strong IV solutions the produce
inflammatory response  Thrombophlebitis
 SVT Manifestations

• Dull, aching pain over affected area: KEY

• Marked redness along vein
• Increased warmth over area of inflammation
• Palpable cordlike structure
• More immediate attention is required if edema,
chills, high fever; suggests complications of
inflammation
 Collaborative Care:
Thrombophlebitis
1. Tx focus: inflammatory process, prevention
of further clotting, extension & restoration of
blood flow
2. Must be differentiated from cellulitis, calf
strain, contusion, lymphatic obstruction
3. Med tx: use of meds, treat
inflammation/infection, dissolve clots
 Lab & Diagnostics

• Doppler ultrasound Vascular

• Magnetic Resonance Imaging
• Ascending contrast venography (most accurate)
 Conservative Therapy: SVT
• Prophylaxis: LMW Heparin
• Prevention is Key!: post op clients –leg exercises, TED’s,
ambulate asap, no leg crossing, loose fitting clothes, exercise
• Focus: relief of symptoms and reversal of inflammatory
process
• Apply warm, moist compresses over affected area &
administer anti-inflammatory agents as prescribed
• Some clients may require antibiotics (therapeutic or
prophylactic)
 Conservative Therapy: DVT

• Anticoagulants may be prescribed for severe cases

• Strict bedrest until symptoms of tenderness & edema
resolve
• Legs elevated, knees slightly flexed, above heart level to
promote venous return & discourage venous pooling
• TED’s or pneumatic compression devices
 Chronic Venous Insufficiency

1. Disorder involving stasis of blood in lower

extremities as result of obstruction & reflux
of venous valves
2. Assoc w/changes in venous circulation
resulting from thrombophlebitis & valvular
incompetence, varicose veins
 Clinical Manifestions
• Lower leg edema
• Itching
• Brown pigmentation/Cyanosis of skin of lower leg/foot
• Fibrosis/hardness of subcutaneous tissues
• Stasis ulcers over ankle, most often medial
 Complication: Ulcer development
• Blood pools in lower limb and peripheral circulation slows;
insufficient oxygen & nutrients to cells
• Cells die causing formation of venous stasis ulcers
• In attempt to heal stasis ulcer, body increases supply of
oxygen, nutrients, and energy to area; but it does not reach
the diseased tissues due to impaired circulation = enlarged
ulcers
 Complication: Ulcer development
• Congested venous circulation prevents biochemicals from
immune system to diseased tissues, interfering w/normal
inflammatory response. Increases risk for wound infection
• Area around stasis ulcers appear shiny, atrophic, & cyanotic,
w/brownish pigmentation. May have eczema or stasis
dermatitis, scar tissue
• Slight trauma will result in serious tissue breakdown
 Assessment: Lab & Diagnostics
• No specific labs or diagnostic tests
• Diagnosis is usually based on clinical findings
– Interview data
– Family Hx
– Past medical Hx
– Physical exam
 Nursing Interventions/Teaching
• BR, w/feet elevated above heart level
• Avoid long periods of standing –walk as much as possible
• Avoid anything that pinches skin (knee-highs)
• While sitting, do not cross legs & avoid pressure behind knees
• Elastic support hose
• Follow guidelines for care of legs & feet
 Evaluation…the client

• Verbalizes s/s infection; remains free of infection

• Verbalizes understanding of disease process, tx,
regimen, limitations & is compliant
• Demonstrates improved perfusion AEB skin color
& reduction/absence of edema
• Displays increasing tolerance to activity
• Pain/discomfort relieved
 Varicose Veins

Irregular, tortuous veins with

incompetent valves
 Varicose Veins

• May develop anywhere in body, but most develop in lower

extremities
• Vein in legs most often affected: Long Saphenous
• Occur in 1 out of 5 people; more common females > 35;
Whites > Blacks; familial tendency
• Causes
– Severe damage or trauma to saphenous vein
– Effects of gravity produced by long periods of standing
• Types
– Primary: no deep veins involved
– Secondary: caused by obstruction of deep veins (Most Common)
 Pathophysiology

• Major cause: sustained stretching of vascular wall die to

long-standing increased intravenous pressure
• Valves become incompetent because they cannot close
properly due to stretching
• Prolonged standing, the force of gravity, lack of lower limb
exercise, & incompetent venous valves all weaken muscle-
pumping mechanism, & return of venous blood to heart
decreases
• As client stands for long time, blood pools and vessel wall
continues to stretch, and valves become increasingly
incompetent
Normal vs Abnormal
 Clinical Manifestations
• Severe, aching pain in leg
• Leg fatigue &/or heaviness
• Itching over affected leg (stasis dermatitis)
• Feelings of heat in the leg
• Visibly dilated veins
• Thin, discolored skin above ankles
• Complications: insufficiency, stasis ulcers, chronic
stasis dermatitis, thrombophlebitis
 Assessment: Labs & Diagnostics
• No specfic labs
• Diagnostics
– Doppler ultrasound flow tests & angiographic
studies or Duplex Doppler ultrasound
– Trendelenburg tests assists w/diagnosis
 Collaborative Interventions

• Conservative measures include

antiembolism stockings and regular
walking & leg elevation
• Mild analgesics may relieve pain
• Compression sclerotherapy & vein
stripping are surgical techniques that
may alleviate the major symptoms of
varicose veins, however there is no
cure
 Nursing Process

Focus:
Restore venous circulation
Relieve symptoms
Prevent complications
Promote behaviors that minimize symptoms
 Arterial diseases
• Thrombo-embolism
• Arteriosclerosis
• Raynaud disease
• Burger disease
• Claudication intermitten
• Subclavian steal syndrome
 Arterial Thrombo-embolism

• Sudden interruption of blood flow to an organ or

body part due to a clot (thrombus) travel from other
organ (embolus).
 Acute Limb Ischemia
Pathophysiology
Metabolic syndrome and reperfusion injury,
Thrombo-embolism (dysritmia)
Clinical classification
I. Viable
II. Threatened
a. Marginally
b. Immediately
III. Irreversible

Clinical diagnosis ( Five P’s) or 6 P’s

Pain, pulselessness,pallor,paresthesia and paralysis (+)
poikilothermia
 Etiology of Acute Limb Ischemia
1.Embolic Occlusion
Origin of arterial emboli
* Arterial fibrillation
* Rheumatic MS(90% from heart)
* Myocardial infarction
Less common causes
* Debris from aneurysm * Prosthetic heart valves
* Debris from ateriosclerotic plaques
* Left atrial myxoma * Ventricular aneurysm
* Bacterial endocarditis * other

2.Acute Arterial Thromboembolism

3.Bypass Graft Thrombosis
4. Other
 Arteriosclerosis
• Any hardening (and loss of elasticity)
of medium or large arteries
• Atherosclerosis, a specific form of
arteriosclerosis  fatty plaques
 Raynaud disease
• Condition that affects the blood supply to the
fingers, toes and occasionally the ears and
nose.
• Raynaud’s attack, or episode, the blood vessels
constrict (narrow) and the blood supply to
these areas is reduced.
• Skin color changes which are often
accompanied by a throbbing or burning
sensation, cold, and numbness.
• Type:
– Primary Raynaud’s or Raynaud’s disease
no other medical problem
– Secondary Raynaud’s or Raynaud’s
phenomenon  other medical problem
 Burger disease
• Buerger's disease  thromboangiitis obliterans
• Blood vessels become inflamed, swell and blocked with blood
clots (thrombi)  infection and gangrene.
• Usually in the hands and feet  arms and legs.
• Quitting all forms of tobacco is the only way to stop Buerger's
disease.
 Claudication intermitten
• a clinical diagnosis given for muscle pain (ache,
cramp, numbness or sense of fatigue),[1] classically in
the calf muscle, which occurs during exercise, such as
walking, and is relieved by a short period of rest.
 Subclavian steal syndrome
• Retrograde blood flow in the vertebral artery
associated with proximal ipsilateral subclavian artery
stenosis or occlusion.
• Patients who develop neurological symptoms as a
consequence of brain ischemia that occurs during or
immediately following exercise of the ipsilateral arm
Fontaine Classification of Peripheral Arterial Occlusive Disease

I. Sense of cold,numbness,Raynaud’s syndromes

II. Intermittent claudication

III. Rest pain

IV. Ulcer, gangrene

 Physical Examination

1. Inspection
a. Trophic change
b. Color change
c. Ischemic ulcer
d. Gangrene
2. Palpation
a. Temperature
b. Pulse
3. Auscultation : Bruit
Noninvasive Vascular Laboratory Examination

1. Doppler arterial signal analysis

2. Resting ankle blood pressure
3. Doppler segmental limb pressure measurement
(Three or four segmental)
4. Hyperemia test
a. Treadmill exercise testing
b. Reative hyperemia test
5. Pulse volume recorder
6. Strain-gauge plethysmography
7. Photoplethysmography
 Lymphatic diseases
• Lymphangitis
• Lymphadenitis
• Lymphedema
 Lymphangitis
• inflammation of lymphatic channels due to infectious or
noninfectious causes. Potential pathogens include bacteria,
mycobacteria, viruses, fungi, and parasites.
• Lymphangitis most commonly develops after cutaneous
inoculation of microorganisms into the lymphatic vessels
through a skin wound or as a complication of a distal infection
 Lymphadenitis
• Infection of the lymph nodes (also called
lymph glands). It is a common complication
of certain bacterial infections.

• Lymphadenopathy  swollen/enlarged
lymph nodes". It could be due
toinfection, auto-immune disease,
or malignancy.
 Lymphedema
• Swelling that generally occurs in one arms or legs. Sometimes
both arms or both legs may be swollen.
• Lymphedema is caused by a blockage in lymphatic system
• The blockage prevents lymph fluid from draining well, and as
the fluid builds up, the swelling continues.
• Lymphedema is most commonly caused by the removal of or
damage to lymph nodes as a part of cancer development
 Aortic Diseases
• Coarctatio
• Aneurysm
 Coarctation Aorta
• congenital condition whereby the aorta narrows in the area
where the ductus arteriosus (ligamentum arteriosum after
regression) inserts.
• Symptoms include: difficulty breathing, poor appetite or
trouble feeding, failure to thrive or nosebleeds. They may
have cold legs and feet or have pain in their legs with exercise
(intermittent claudication).
• In more severe cases, Arterial hypertension in the arms with
normal to low blood pressure in the lower extremities is
classic. Poor peripheral pulses in the legs and a weak femoral
artery pulse may be found in severe cases.
Coarctation Aorta
 Aortic Aneurysm
Classification of Aortic Aneurysm
(According to Location)

1. Ascending Aortic Aneurysm(Annuloaortic ectasia

2. Aortic Arch aneurysm
3. Descending Aortic Aneurysm
4. Thoracoabdominal Aortic Aneurysm
5. Abdominal aortic Aneurysm

Shape of Aneurysm

* Sacuclar type
* Fusiform type
* Dissecting aortic aneurysm
 Clinical Presentation and Diagnosis
Hemodynamic State
*Sudden death *Hypovolemic shock
*Cardiogenic shock(acute AR 35-60%)

Symptomes and Signs

* Sudden severe pain and feeling of impending death
(Often interscapular pain,precordial and radiate into
neck or arm)
* Painless * Ischemic sypmtomes of occlusion of a major
vessels.
Diagnosis
1. Chest x-ray
2. Ecchocardiography
3. CT Angiography
4. Aortography or MRA
 Symptoms for A.A.Ab.
• Usually a symptomatic
• Incidental finding
• Palpable mass in mid abdomen
• Back pain
• Abdominal fullness, abdominal pain
Etiologic Classification

1. Congenital aneurysm
2. Acquired aneurysm

* Atherosclerotic aneurysm
* Traumatic aneurysm
* Syphilitic aneurysm
* Mycotic aneurysm
* Dissecting aneurysm
 Aortic Dissection

Splitting of the medial layer of the

Aortic wall,associated with intimal

Flap---Inlet—develope false and true

lumen
Shock
 Overview
• Shock occurs when a diminished amount of
blood is available to the circulatory system
• The vascular system fails to hold the fluid
portion of the blood
• Vasodilation of the blood vessels occurs and
disrupts the osmotic fluid balance in the body
 Overview
• Plasma cells leave the blood and enter the
interstitial spaces
• The formed elements remain in the blood
– Blood viscosity increases
– The rate of blood flow decreases
• Insufficient amounts of O2 are being
transported in the blood
 Predisposing Factors
• Extreme fatigue
• Extreme exposure to heat or cold
• Extreme dehydration
• Illness
• Severe injury
 General Signs and Symptoms
• Low Blood Pressure
– Systolic BP is usually below 90 mmHg
• Pulse is rapid and weak
• Respiration is rapid and shallow
• Skin is pale, cool, and clammy
• Drowsiness
 Types of Shock
• Hypovolemic
• Cardiogenic
• Distributive
• Obstructive
 Hypovolemic Shock
• Results from trauma in which
there is blood loss
• Decreased blood volume causes
a decrease in blood pressure
• Insufficient amounts of O2 is
being transported to body
tissues and organs
 Distributive shock
Neurogenic Shock
• Results due to the overall
dilation of the blood vessels
within the cardiovascular
system
• Decreased blood pressure
• Insufficient amounts of O2 is
being transported to body
tissues and organs
• Decrease BP & HR
(Bradycardia)
 Distributive shock
Psychogenic Shock
• Commonly known as “fainting” (syncope)
• Results due to a temporary dilation of the
blood vessels in the body causing a decrease
in the blood flow to the brain
 Distributive shock
Septic Shock
• Results due to a severe infection
– Usually a bacterial infection
• Toxins released by the bacteria cause dilation of the
blood vessels within the cardiovascular system
• Decreased blood pressure
• Insufficient amounts of O2 is being transported to
body tissues and organs
 Distributive shock
Anaphylactic Shock
• Results due to a severe allergic reaction
• Allergic reaction may be caused by:
– Foods
– Insect bites
– Drugs
– Inhaling dusts, pollens, etc…
 Distributive shock
Metabolic Shock
• Results due to a severe illness that goes untreated
– For example, untreated diabetes
• Results due to an extreme loss of bodily fluid
– For example, excessive urination, diarrhea, or vomiting
 Cardiogenic Shock
• Results due to the inability of the heart to
pump enough blood to the body
• Decreased cardiac output
• Decreased blood pressure
• Insufficient amounts of O2 is being
transported to body tissues and organs
 Cardiogenic Shock
• Cause  heart failure
– AMI
– Valve disease
– Congenital heart disease
– Sepsis
 Obstructive Shock
• caused by a mechanical impediment that
prevents diastolic filling of the ventricles
leading to a significant fall in cardiac
output.
• Causes
– Tension pneumothorax.
– Cardiac tamponade
– Massive pulmonary thromboembolism
– Other obstructive rare causes: Aortic
stenosis, valvular stenosis, cardiac tumor,
Pulmonary hypertension, coarctation of the
aorta.
Immediate Management
 Immediate Management
• Maintain normal body temperature
• In most cases, elevate the feet and legs above the
level of the heart
• Exceptions include:
– Neck injury – immobilize in the position found
– Head injury – elevate the head and shoulders
– Leg fracture – splint and elevate
Secondary Management
 Secondary Management
Vital Signs
• Pulse • Pupils
• Respiration • Level of consciousness
• Blood pressure • Movement
• Temperature • Abnormal nerve
• Skin color response
 Abnormal Pulse
• Rapid and weak • Slow and strong
– Shock – Skull fracture
– Bleeding – Stroke
– Diabetic coma • No pulse
– Heat exhaustion – Cardiac arrest
• Rapid and strong – Death
– Heatstroke
– Severe fright
 Respiration
• Normal respiration rate for adults
– ~ 12 breaths per minute
• Normal respiration rate for children
– ~ 20 breaths per minute
• Rapid and shallow respiration is indicative of
shock
 Blood Pressure

• Normal systolic blood

pressure in adults
– Males: 115 – 120 mm Hg
– Females: 105 – 110 mm Hg
• Normal diastolic blood
pressure in adults
– Males: 75 – 80 mm Hg
– Females: 65 – 70 mm Hg
 Temperature

• Normal body temperature

– ~ 98.6°F (~ 37°C)
• Core temperature is most accurately measured at
the tympanic membrane of the ear
• Changes in body temperature are reflected in the
skin
 Skin: Temperature
• Cool, clammy skin
– Shock
– Trauma
– Heat exhaustion
• Cool, dry skin
– Overexposure to cold
• Hot, dry skin
– Disease
– Infection
– Overexposure to environmental heat
 Skin: Color
• Three skin colors are • Red skin color
commonly identified in – Heatstroke
medical emergencies: – High blood pressure
– Red – Elevated body
– White temperature
– Blue
 Skin: Color
• White skin color • Blue skin color
– Shock – Airway obstruction
– Insufficient circulation – Respiratory insufficiency
– Fright
– Hemorrhage
– Heat exhaustion
– Insulin shock
 Pupils
• Pupils are extremely sensitive to changes in the
nervous system
• If one or both pupils are dilated…
– Shock
– Head injury
– Heatstroke
– Hemorrhage
– CNS stimulant drug
• One constricted pupil…
– CNS depressant drug
 Pupils
• If one or both pupils fail to respond to light…
– Brain injury
– Alcohol
– Drug poisoning
• Pupil response to light is more critical than the
evaluation of pupil size
 Level of Consciousness
• In normal conditions, the athlete is…
– Alert
– Aware of the surrounding environment
– Responds quickly to vocal stimulation
• Abnormal levels of consciousness may result due to…
– Shock
– Head injury
– Heatstroke