Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology and risk factors for vascular disease
- Identify the common laboratory and diagnostic tests for vascular disease
- Apply nursing concepts and plan associated nursing care for the patient with a vascular disease
- Evaluate the efficacy of nursing care for the patient with a vascular disease
- Discuss the medical therapies that apply to the care of vascular disease
The two most commonly occurring forms of vascular disease are carotid artery disease and abdominal aortic aneurysm (AAA). Also referred to as carotid artery stenosis, carotid artery disease is a condition that occurs when the carotid arteries, which supply blood to the brain, become narrowed or blocked by the presence of plaque. An abdominal aortic aneurysm (AAA) develops when plaque clogs the aorta in the abdomen, causing it to balloon out in an attempt to keep blood flowing through it. Currently, 3 percent of Americans are diagnosed with carotid artery disease (Dossahboy & Ayra, 2021), and 4 to 8 percent of Americans have AAA (Chung, 2021). Individuals with carotid artery stenosis are at high risk for stroke.
When carotid artery disease is identified, it is presumed that vascular disease is also present in the aortic and renal arteries, leading to the risk of AAA and renal disease. Untreated carotid artery disease with significant occlusion can lead to a cerebral vascular accident. A lifestyle of active nicotine use, a diet high in saturated fats, and physical inactivity all add risk to vascular disease. While the majority of AAAs remain stable, AAA dissection, in which the vessel wall tears and hemorrhages blood, occurs annually in approximately 5 to 30 cases per 1 million people (Mancini, 2022).
Pathophysiology
It is important to understand the fundamental terminology and pathophysiology associated with vascular disease. A widespread hardening of the arteries is called arteriosclerosis, and atherosclerosis is a form of arteriosclerosis in which there is narrowing and reduced blood flow through the arterial wall due to plaque formations (Mayo Clinic, 2022).
An aneurysm is an enlargement of an artery, due to a weakened wall from high-velocity flows of blood. An AAA will occur with an endothelial stretching of the aorta due to a stiff and sclerotic arterial narrowing. Eventually, the vessel wall out-pouches and the continued pressures from the high-pressure left ventricle will compromise the vessel wall, and it dissects with blood leaking or, in lethal cases, fully tears through the intima (Figure 12.26).
Clinical Manifestations
Vascular disease may not be easily identifiable, as some patients may be asymptomatic. Patients with small aneurysms may not even know they have one. Larger aneurysms will cause diaphoresis, dizziness, fainting, tachycardia, nausea and vomiting, shortness of breath, and severe, sudden abdominal pain. A ruptured AAA will manifest as a pulsation in the stomach with pain. In severe cases when it tears, the patient will experience intra-abdominal bleeding. It is important that the nurse asks about the onset of new symptoms and when they began.
Carotid artery disease may or may not cause symptoms depending on the severity of the blockage, or if it is one vessel or both. The patient may report visual changes, experience confusion, memory impairment, “brain fog,” or experience numbness or weakness on the side with severe disease (Qaja et al., 2024). With more severe blockages, syncope and passing out may ensue.
Diagnostics and Laboratory Values
The first step in diagnosing carotid artery disease is an ultrasound of the great neck vessels to assess for blood flow velocity abnormalities. Carotid artery blockage greater than 50 percent will likely require pharmacological or surgical intervention. An abdominal or pelvic ultrasound or abdominal computed tomography (CT) is typically sensitive to detect AAA. Diagnostic angiography may be utilized in dual workup of coronary artery disease and AAA. While laboratory values do not directly detect the presence of vascular disease, their abnormal values may suggest its presence. Elevated calcium levels and high lipid levels will lead to diagnostic suspicion of calcium deposits and plaque formation in the arterial intima. An elevated hemoglobin A1C will suggest a background diagnosis of diabetes mellitus, which further increases the risk of vascular disease.
Nursing Care of the Patient with Vascular Disease
While clinical judgment and interventions have similarities of pertinent cardiovascular assessments, brief focused assessments centralize around the diseased vessel. Perfusion alterations may change slowly over time if the diseased vessel has persisted but will normalize if an interventional approach has been taken.
Recognizing and Analyzing Cues
The nurse will begin by performing a focused heart and lung assessment. While assessing the carotid pulse, do not occlude the diseased artery, as this will advance to a syncopal episode. Utilizing the bell of a stethoscope, gently press against the carotid arteries to listen for a bruit, which is a “swooshing” sound. Note the presence of the bruit and if it is soft or harsh. For AAA, assess for a non-tender pulsatile mass. Avoid pressing down firmly as this can advance a rupture. A bruit can be heard over the epigastric region as well.
A set of vital signs will identify any episodes of uncontrolled high blood pressure, as this may make a ruptured aneurysm worse. If the AAA ruptures, the patient will manifest with hypotension and tachycardia. The patient must maintain bed rest, and the nurse must call for help by alerting the rapid response team if the patient is hemodynamically unstable. It is likely the patient will be sent to the operating room for intervention. Once the AAA has been repaired, a peripheral vascular assessment will change after a revascularization; if perfusion is restored after correction of a tight vessel or a compromised artery in AAA, it is expected pulses will improve. The nurse must note the quality and character of distal pulses. Blockages from carotid artery stenosis may affect blood flow to the affected limb. Radial pulses and pulses in the feet need to be monitored for post-procedure evaluation so that the blood is not compromised in the limbs.
For safety, patients with occlusions in the carotid artery should change position slowly to avoid dizziness, dangle feet before standing up, or maintain bed rest if unable to safely ambulate. The patient will receive a statin, antiplatelets, antihypertensives, and anti-diabetic agents as necessary. Reinforce lifestyle modification with smoking cessation and healthy eating.
Evaluation of Nursing Care of the Patient with Vascular Disease
Disease stability and improvement in circulation are the main outcomes when evaluating the efficacy of nursing care. The following goals should be incorporated:
- Circulation goals for patients with stable disease are to maintain hemodynamic stability with blood pressures less than 120/90 mm Hg.
- In cases of AAA dissection or carotid artery occlusion, the patient will receive appropriate revascularization therapies.
- The patient’s pulses will remain unchanged or improve following revascularization therapies.
- For skin integrity, if the patient is to have a CEA, the incision will remain open to air and will be free of redness, edema, and discharge. Endovascular repair access sites may require the patient to keep the limb straight or remain flat dependent on the access site.
Evaluating Outcomes
Following stabilization, secondary prevention strategies are created to avert further vasculopathy events. The Joint Task Force from the European Atherosclerosis Society and European Society of Vascular Medicine (2023) recommend the patient’s low-density lipoprotein target levels less than 70 mg/dL, controlled diabetes with an A1C less than 7 percent, and blood pressure will remain within normal parameters. Patients with vascular disease are likely to have knowledge gaps. Teaching about lifestyle modifications may center around the patient’s understanding of the effects of nicotine on vascular health and making healthy nutrition choices.
Vascular disease is a very preventable disease; however, the nurse’s role in the care of the patient with these illnesses is influenced by secondary and tertiary preventive strategies. The medical emergent implications with AAA and the progressive features of carotid artery disease require astute physical assessment, knowledge of the vascular system, and the wellness requirements to delay disease. Disease management can be successful with nursing support and informed education.
Link to Learning
This article discusses the relationship between cigarette smoking and carotid artery disease in Hispanic, Black, and White patients.
Medical Therapies and Related Care
The degree of intervention for AAA will depend on the measurement of the endovascular aneurysm size. The Society for Vascular Surgery recommends annual monitoring for AAAs measuring 4 to 4.9 cm in diameter. For AAAs measuring larger than 5.5 cm, elective (planned) endovascular surgery is indicated; in severe cases with rupture, an open approach is necessary (Chiakof et al., 2018) (Figure 12.27). Similar to the 90-minute door-to-angioplasty time (or “door-to-balloon” time) for coronary reperfusion, the Society for Vascular Surgery recommends the same timeframe for vascular repair of a ruptured AAA (Chiakof, 2018).
Endovascular intervention is similar in procedure to angiography. A guidewire is inserted into the femoral artery and an expandable stent graft is threaded through the guidewire. The stent permits blood flow and creates stability in the arterial wall, avoiding continued strain on the outpouching (Schanzer, n.d.).
Carotid artery stenosis with less than 50 percent blockage requires medical monitoring. Revascularization with a surgical carotid endarterectomy (CEA) (Figure 12.28) is indicated for symptomatic blockages of 50 to 99 percent and asymptomatic blockages of 70 to 99 percent.
Pharmacological therapies for both carotid artery disease and AAA are similar in that patients will receive lipid-lowering therapies with statins (e.g. atorvastatin), antihypertensive therapy, and antiplatelet therapy (i.e., chronic aspirin therapy) as necessary. Diabetes control, when applicable, is also important. Lifestyle modifications such as smoking cessation, a low fat/low cholesterol diet, limiting or omitting alcohol, and exercise are also recommended to reduce the risk of further plaque formation.