- Email: [email protected]
Vascular nursing scope of practice
PAGE 106
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
SEPTEMBER 2003
Vascular nursing scope of practice The Society for Vascular Nursing
The Society for Vascular Nursing (SVN), an international association, was founded in 1982 for the purpose of promoting excellence in the compassionate and comprehensive management of individuals and their families who suffer from vascular disease. SVN members, the Board of Directors, and expert consultants facilitated the development of this document. The purpose of this document is to define the patient population, provide a framework for professional growth and development for vascular nurses, and outline the scope of practice and standards of vascular nursing care by vascular nurses. Vascular nursing practice refers to the care of patients who have known or predicted physiological alterations of the vascular system. Vascular nursing promotes and protects the health of individuals, and seeks to educate individuals and their families at risk for vascular disease using knowledge from the fields of nursing, medicine, and the social sciences. The practice of vascular nursing is dynamic in response to the needs of individuals with vascular disease, as well as to the advancements in the fields of vascular medicine, interventional radiology, and vascular surgery. Its focus includes health promotion, assessment for alterations of function and implementation of strategies to assist clients to maintain, regain, or improve function and prevent disability.
WHAT IS VASCULAR DISEASE? Vascular diseases encompass a wide array of arterial, venous, and lymphatic problems and may be acute or chronic in nature. The epidemiology of vascular disease provides an overview of the magnitude of the disease and serves to define the patient population.
Arterial disease Causes of arterial disease are extremely varied; however, atherosclerosis is the underlying mechanism responsible for peripheral arterial disease (PAD). PAD encompasses those entities that result in arterial occlusions in vessels other than those of the coronary and intracranial vascular beds. Although PAD includes the extracranial, carotid, upper extremity, visceral, and renal circulation, the term is usually applied to disease involving the circulation of the lower extremity.1 Among those with lower extremity PAD, approximately two thirds are asymptomatic.2 It Address reprint requests to The Society for Vascular Nursing, 7794 Grow Drive, Pensacola, FL 32514. J Vasc Nurs 2003;21:106-9. Copyright © 2003 by the Society for Vascular Nursing, Inc. 1062-0303/2003/$30.00 ⫹ 0 doi:doi:10.1016/S1062-0303(03)00014-1
is important to identify these patients since PAD is a marker of generalized atherosclerosis, thereby placing the individual at increased risk of concomitant coronary and cerebrovascular disease. This is because atherosclerosis is diffuse in nature and thus, the process may affect various segments of the arterial tree. Individuals with lower extremity PAD often present for treatment because of symptoms of intermittent claudication or critical limb ischemia. Critical limb ischemia may take the form of rest pain, minor tissue loss (ulceration), or gangrene. The prevalence of PAD increases dramatically with age, from only 3% for ages 40 to 59 years to nearly 20% for those ages 70 years or older.3 The aging of the baby boom generation and increasing life span yield a projected 40% increase in the total number of Americans with PAD by the year 2020.3,4. Since there is such significant overlap in patients with PAD and concomitant coronary and cerebrovascular disease, treatment goals should focus on both the effects of atherosclerosis in the peripheral circulation, and the systemic nature of the disease. As indicated above, PAD is recognized as a marker of generalized atherosclerosis, and those with PAD are at significantly increased risk of death from myocardial infarction and stroke.5 As such, it accounts for nearly three fourths of all deaths from cardiovascular disease.6 The focus now on the prevention of vascular disease provides generalist and advanced practice vascular nurses with a new opportunity to influence patient care. All patients presenting for treatment of their extremity problems should have their risk factors rigorously assessed, and appropriate therapies instituted to decrease the risks of both peripheral progression and cardiovascular mortality. Major risk factors for PAD include male gender, advanced age (⬎50 years), diabetes mellitus, tobacco use, sedentary lifestyle, uncontrolled hypertension, and dyslipidemia. These risk factors are highly concordant with the risk factors for coronary and cerebrovascular disease; thus, nurses in many disciplines are likely to encounter a client population with similar systemic effects of atherosclerosis. Diabetes mellitus deserves special consideration, since 15.7 million people (that is, 5.9% of the population) have diabetes.7 Atherosclerosis is more common in individuals with diabetes than in those who do not have diabetes, and occurs at a younger age. The effects of atherosclerosis may be manifested in the coronary, cerebral, and peripheral arterial circulation. Heart disease is the leading cause of diabetes-related deaths, and the risk of stoke is 2 to 4 times higher in individuals with diabetes.7 In the lower extremities, the more distal distribution of peripheral arterial disease, diminished sensation due to diabetic neuropathy, and decreased resistance to infection in poorly controlled diabetes, the more likely incidence of gangrenous changes of the feet in patients with diabetes. More than half of lower limb amputations in the United States occur in people with diabetes. From 1993 to 1995, approximately 67,000 amputations were performed each year in people with diabetes.7
Vol. XXI No. 3
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
Vascular nurses are in a prime position to educate the individual with diabetes so as to increase knowledge regarding the disease process and thereby decreasing the risk of limb amputation. Generalist and advanced practice vascular nurses are also knowledgeable in wound management and can institute measures aimed at managing diabetic foot ulcers. Each year 200,000 people are diagnosed with abdominal aortic aneurysms (AAA).8 In the United States, half of all patients with untreated AAAs die of an aortic rupture within 5 years. AAAs are the nation’s 13th leading cause of death, killing close to 17,000 Americans each year.6 The condition is more common in men, with approximately 5% of men over the age of 60 developing an AAA.8 Seventy-five percent of those diagnosed with AAA will be asymptomatic.9 For most of these patients, management is directed toward early detection and appropriate surgical intervention by preventing aneurysm rupture. Vascular nurses must be familiar with this disease process to effectively counsel and educate patients and their families regarding treatment options. Cerebrovascular disease dramatically affects the lives of millions of Americans, their families, communities in which they reside, health care delivery systems treating those affected, health promotion organizations fighting the battle against stroke, and health policy makers who influence the national agenda.10 According to the American Heart Association,5 stroke ranks third among the leading causes of death in the United States. Furthermore, causes of death surpassing stroke are diseases of the heart and all forms of cancer. In 1998, 1 out of 14 deaths was due to stroke. The report further estimates that more than 700,000 incident strokes occur every year, adding to the number of approximately 4.4 million stroke survivors. It is the leading cause of serious, long-term disability.10 Prevention and risk factor modification are ways to positively affect these statistics. Surgical intervention such as carotid endarterectomy may be performed on those who are asymptomatic but where impaired blood flow is detected. However, the risk for surgery should be less than a combined stroke/death rate of 3% in this cohort of people.11,12 Vascular nurses may also focus on the overall assessment, treatment, and evaluation of individuals requiring surgical or interventional strategies to manage their arterial problem. These procedures include, but are not limited to, carotid artery surgery, lower extremity revascularization by either surgical or endovascular approaches, surgery for aneurysmal disease, renal/mesenteric disease, limb amputation, and the creation of vascular access for hemodialysis.
Nonatherosclerotic arterial disease A variety of nonatherosclerotic arterial diseases exists. Vascular nurses require a familiarity with these diseases to effectively evaluate patient outcomes. Nonatherosclerotic arterial diseases include, but are not limited to, Buerger’s disease, Raynaud’s syndrome, fibromuscular dysplasia, trauma, compartment syndrome, arterial infection, compression syndromes, congenital conditions, and hyperviscosity syndromes.
PAGE 107
Venous disease Venous disease encompasses a wide spectrum of disorders, ranging from those with benign, primarily cosmetic concerns, such as spider telangiectasias and superficial varicose veins, to those with potentially life- and limb-threatening consequences, such as acute deep vein thrombosis and pulmonary emboli. Other manifestations of venous pathology include superficial venous thrombophlebitis, variceal bleeding, and chronic venous insufficiency. In spite of the broad spectrum of disease states, the basic underlying pathology behind venous disease is derived from 2 primary pathologic processes: obstruction of flow and venous valvular incompetence, which ultimately results in venous hypertension. Vascular nurses must be familiar with the risk factors for venous disease to effectively assess for and manage care for those at risk. An estimated 500,000 to 600,000 people in the United States have chronic venous insufficiency (CVI), which is the most common venous disorder. The term CVI refers to a constellation of limb symptoms including edema, pain, and pigmentation changes and disability, which can progress to chronic ulceration. CVI is responsible for 90% of lower extremity ulcerations.13 The goals of therapy are twofold: to heal the ulcer and to prevent ulcer recurrence. The advanced practice vascular nurse who is an expert in venous ulcer care may provide supervision or direction for ulcer management (eg, topical agents, dressing techniques), assist with the implementation of medical therapies when appropriate, and provide patient education and support.
Lymphatic disease The lymphatic system consists of an extensive network that collects lymph from the various organs and tissues and connects to an elaborate system of collecting vessels that transport the lymph to the blood stream. Lymphedema results from a malformation or obstruction of the lymphatic vessels and/or nodes. Lymphedema may be acquired or congenital, and it often develops secondary to another event, such as trauma. Lymphedema has various definitions, but in all types there is impaired transcapillary fluid exchange and impaired transport of lymph.14 Lymphedema can be localized or generalized with the lower extremities more commonly affected. Physical examination often reveals an edematous extremity, noticeable asymmetry, and skin that is pale and oily in appearance. The advanced practice vascular nurse may play a role in the differential diagnosis of lymphedema through history taking and a comprehensive physical examination. However, both generalist and advanced practice vascular nursing interventions are aimed at reducing edema, maintaining the edema-free state, control of infection, and providing education and emotional support.
LEVELS OF VASCULAR NURSING PRACTICE
Generalist practice Registered nurses at the generalist level have completed a nursing program and met state licensure examination requirements. Registered nurses who practice in vascular nursing set-
PAGE 108
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
tings may work as staff nurses, case managers, and nurse managers, and in other roles in the field of vascular nursing. Because of the dynamic nature of today’s health care environment, vascular nurse generalists practice in a variety of settings. These settings vary in purpose, type, location, acuity, and the auspices under which they operate. Practice setting include, but are not limited to, acute and subacute care facilities, home care agencies, ambulatory care clinics, outpatient services, residential facilities, skilled nursing facilities, private practice, physicians’ offices, and wound care clinics. Educational preparation for the vascular nurse generalist ranges from a 2-year associate degree to a 4-year baccalaureate degree.
Advanced practice The advanced practice registered nurse in vascular nursing is a licensed registered nurse who is educationally prepared as a clinical nurse specialist or a nurse practitioner at least at the master’s degree level. Advanced practice vascular nurses have acquired an in-depth knowledge base and clinical skills to prepare them for expansion and advancement in practice. Consistent with a broadened knowledge base, advanced practice vascular nursing is characterized by both increased complexity of clinical decision-making and greater skill in managing organizations and environments. Preparation for any of the advanced practice roles in vascular nursing occurs during graduate education, which includes a common base of knowledge in nursing and an expanded core of knowledge specific to the assessment and management of individuals with vascular disease. Because of the dynamic nature of today’s health care environment, advanced practice vascular nurses also practice in a variety of settings. These settings vary in purpose, type, location, acuity, and the auspices under which they operate. Practice settings include, but are not limited to, acute and subacute care facilities, home care agencies, ambulatory care clinics, outpatient services, residential facilities, skilled nursing facilities, private practice, physicians’ offices, and wound care clinics. Nurses in advanced practice vascular nursing roles may provide comprehensive physical assessment and demonstrate a high level of autonomy and expert skill in the diagnosis and treatment of the complex human responses of individuals, families, or communities to actual or potential health problems. They formulate clinical decisions to manage acute and chronic illness and promote wellness. They provide and deliver health care that is accessible to clients in various settings and throughout the life cycle. Advanced practice vascular nurses integrate education, research, management, leadership, and consultation into clinical roles, and they function in collegial relationships with nursing peers and other professionals and individuals to influence the health care environment. The advanced practice vascular nurse is responsible for identifying the scope of practice permitted by state and federal laws and regulations, the professional code of ethics, and professional practice standards. In addition, the advanced practice nurse’s experience, education, knowledge, and abilities circumscribe the nurse’s competence. Both generalist and advanced practice level vascular nursing practice are characterized by interventions that promote health,
SEPTEMBER 2003
assess for alterations in function, assist patients to regain or improve their function, and prevent further disability. The vascular nurse generalist collaborates with the care team to influence client and family outcomes. They may practice under the direction of the advanced practice vascular nurse. The Standards of Care and Standards of Professional Performance for the generalist and the advanced practice vascular nurse further serve to differentiate generalist and advanced practice.
PROMOTION OF HEALTH The vascular nurse stresses health promotion, reflecting nursing’s long-standing commitment to the well being of the individual, family, group, and community. The vascular nurse performs assessments, targets individuals at risk for vascular disease, and initiates interventions aimed at promoting or maintaining vascular health. These assessments focus on the identification of risk factors for arterial, venous, and lymphatic disease and education of the individual/family regarding these risk factors, which include, but are not limited to, hypertension, smoking, diabetes mellitus, and hyperlipidemia.
ASSESSMENT FOR ALTERATIONS IN FUNCTION The vascular nurse performs assessments and collects data regarding the health status of the individual with vascular disease in a systematic and ongoing manner. Collected data include not only the physical needs of the individual but also the psychosocial and spiritual needs. Out of data collection, nursing diagnoses are formulated, measurable goals are determined, and a plan of care is developed, implemented, and evaluated. Information obtained from the individual or family is communicated to other members of the care team as well.
MEASURES TO MAINTAIN, REGAIN, OR IMPROVE FUNCTION AND PREVENT DISABILITY A major focus of direct nursing care involves teaching the individual/family ways to maintain, regain, or to improve function, as well as to prevent disability. The patient education includes information relative to the individual’s specific vascular problem, as well as instruction on health-promoting behaviors including, but not limited to, diet, exercise, blood glucose control/monitoring, smoking cessation, and hypertension management. Teaching must take into consideration the capabilities and limitations of the individual/family and collaboration with other professional and specialists such as dieticians.
CERTIFICATION Certification is a process that national professional nursing organizations use to recognize advanced practice. Certification requires: graduation from an accredited or approved educational program that provides necessary course work and clinical experience, and a certification examination, recognized nationally by the advanced practice specialty’s professional organization. The American Nurses Credentialing Center offers cardiac/vascular nursing certification examination and recertification. Candidates sitting for the cardiac/vascular examination must meet the fol-
Vol. XXI No. 3
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
lowing guidelines: 1) hold a currently active registered nurse license in the United States or its territories; 2) have practiced the equivalent of 2 years full time as a registered nurse in the United States; 3) hold either an associate’s degree/diploma or a baccalaureate or higher degree in nursing, depending on the examination; 4) have a minimum of 2000 hours of clinical practice in the specialty within the last 3 years; and 5) have had 30 contact hours of continuing education in the specialty within the last 3 years. Faculty may use up to 500 hours of faculty teaching or clinical supervision in the specialty area of practice toward the practice requirement. Students may use up to 500 hours of time spent in an academic program of nursing study toward their clinical practice requirement. Recertification involves completing 1500 clinical practice hours and 150 contact hours of continuing education over the previous 5 years.15
ETHICS The practice of generalist and advanced practice vascular nurse is guided by the Code of Ethics for Nurses established by the American Nurse Association.5 The vascular nurse operating under this code acknowledges the patient’s rights to privacy and confidentiality and the patient’s right to be informed and to be treated with dignity. The vascular nurse recognizes the patient not only as a unique individual but also as part of a broader structure encompassing family or other significant relationship(s). The generalist and advanced practice vascular nurse acknowledge the client’s cultural beliefs, diversity, and individual uniqueness. Vascular nursing care that is provided is nonjudgmental and non-discriminatory. The vascular nurse serves as a client advocate, works to facilitate client decision-making, and promotes an ethical practice environment and professional integrity. In addition, the advanced practice vascular nurse acknowledges the patient’s rights to be informed, of self-determination, and truthful disclosure. The advanced practice vascular nurse considers the client’s cultural beliefs, diversity, and individual uniqueness when diagnosing, prescribing, and planning therapeutic intervention.
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REFERENCES 1. Ouriel K. Detection of peripheral arterial disease in primary care. JAMA 2001;286:1380-1. 2. Hiatt RF. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344:1608-21. 3. Criqui MH, Langer RD, Fronek A. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992;326:381-6. 4. U.S. Census Bureau. 1999. Available at: http://www.census. gov. 5. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas: American Heart Association; 2001. 6. National Institutes of Health. Morbidity and Mortality: 2000 Chart Book on Cardiovascular, Lung, and Blood Diseases. Bethesda (MD): US Department of Health and Human Services; 2000. 7. National Diabetes Information Clearinghouse. Diabetes Statistics in the United States. NIH Publication No. 99-3892. Bethesda (MD): National Institutes of Health; 1999. 8. Gillum RF. Epidemiology of aortic aneurysm in the United States. J Clin Epidemiol 1995;48:1289-98. 9. Mitchell MB, Rutherford RB, Krupski WC. Infrarenal aortic aneurysms. In: Rutherford RB, Gloviczki P, Cronenwett JL, editors. Vascular surgery. 5th ed. Philadelphia: Harcourt Brace & Company; 1999. 10. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas: American Heart Association; 1999. 11. Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke. Circulation 2001;103:163-82. 12. Goldstein LB, Samsa GP, Matchar DB, Oddone EZ. Multicenter review of preoperative risk factors for endarterectomy for asymptomatic carotid artery stenosis. Stroke 1998;297: 50-3. 13. Burton C. Venous ulcers. Am J Surg 1994;167:37S-41S. 14. Bergen JJ. Lymphedema. In: Fahey VA, editor. Vascular nursing. 3rd edition. Philadelphia: W.B. Saunders; 1999. 15. US Department of Health and Human Services. Morbidity & Mortality: 2000 Chart Book on Cardiovascular, Lung, and Blood Diseases. Bethesda (MD): National Institutes of Health, National Heart, Lung, and Blood Institute.
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
SEPTEMBER 2003
Vascular nursing scope of practice The Society for Vascular Nursing
The Society for Vascular Nursing (SVN), an international association, was founded in 1982 for the purpose of promoting excellence in the compassionate and comprehensive management of individuals and their families who suffer from vascular disease. SVN members, the Board of Directors, and expert consultants facilitated the development of this document. The purpose of this document is to define the patient population, provide a framework for professional growth and development for vascular nurses, and outline the scope of practice and standards of vascular nursing care by vascular nurses. Vascular nursing practice refers to the care of patients who have known or predicted physiological alterations of the vascular system. Vascular nursing promotes and protects the health of individuals, and seeks to educate individuals and their families at risk for vascular disease using knowledge from the fields of nursing, medicine, and the social sciences. The practice of vascular nursing is dynamic in response to the needs of individuals with vascular disease, as well as to the advancements in the fields of vascular medicine, interventional radiology, and vascular surgery. Its focus includes health promotion, assessment for alterations of function and implementation of strategies to assist clients to maintain, regain, or improve function and prevent disability.
WHAT IS VASCULAR DISEASE? Vascular diseases encompass a wide array of arterial, venous, and lymphatic problems and may be acute or chronic in nature. The epidemiology of vascular disease provides an overview of the magnitude of the disease and serves to define the patient population.
Arterial disease Causes of arterial disease are extremely varied; however, atherosclerosis is the underlying mechanism responsible for peripheral arterial disease (PAD). PAD encompasses those entities that result in arterial occlusions in vessels other than those of the coronary and intracranial vascular beds. Although PAD includes the extracranial, carotid, upper extremity, visceral, and renal circulation, the term is usually applied to disease involving the circulation of the lower extremity.1 Among those with lower extremity PAD, approximately two thirds are asymptomatic.2 It Address reprint requests to The Society for Vascular Nursing, 7794 Grow Drive, Pensacola, FL 32514. J Vasc Nurs 2003;21:106-9. Copyright © 2003 by the Society for Vascular Nursing, Inc. 1062-0303/2003/$30.00 ⫹ 0 doi:doi:10.1016/S1062-0303(03)00014-1
is important to identify these patients since PAD is a marker of generalized atherosclerosis, thereby placing the individual at increased risk of concomitant coronary and cerebrovascular disease. This is because atherosclerosis is diffuse in nature and thus, the process may affect various segments of the arterial tree. Individuals with lower extremity PAD often present for treatment because of symptoms of intermittent claudication or critical limb ischemia. Critical limb ischemia may take the form of rest pain, minor tissue loss (ulceration), or gangrene. The prevalence of PAD increases dramatically with age, from only 3% for ages 40 to 59 years to nearly 20% for those ages 70 years or older.3 The aging of the baby boom generation and increasing life span yield a projected 40% increase in the total number of Americans with PAD by the year 2020.3,4. Since there is such significant overlap in patients with PAD and concomitant coronary and cerebrovascular disease, treatment goals should focus on both the effects of atherosclerosis in the peripheral circulation, and the systemic nature of the disease. As indicated above, PAD is recognized as a marker of generalized atherosclerosis, and those with PAD are at significantly increased risk of death from myocardial infarction and stroke.5 As such, it accounts for nearly three fourths of all deaths from cardiovascular disease.6 The focus now on the prevention of vascular disease provides generalist and advanced practice vascular nurses with a new opportunity to influence patient care. All patients presenting for treatment of their extremity problems should have their risk factors rigorously assessed, and appropriate therapies instituted to decrease the risks of both peripheral progression and cardiovascular mortality. Major risk factors for PAD include male gender, advanced age (⬎50 years), diabetes mellitus, tobacco use, sedentary lifestyle, uncontrolled hypertension, and dyslipidemia. These risk factors are highly concordant with the risk factors for coronary and cerebrovascular disease; thus, nurses in many disciplines are likely to encounter a client population with similar systemic effects of atherosclerosis. Diabetes mellitus deserves special consideration, since 15.7 million people (that is, 5.9% of the population) have diabetes.7 Atherosclerosis is more common in individuals with diabetes than in those who do not have diabetes, and occurs at a younger age. The effects of atherosclerosis may be manifested in the coronary, cerebral, and peripheral arterial circulation. Heart disease is the leading cause of diabetes-related deaths, and the risk of stoke is 2 to 4 times higher in individuals with diabetes.7 In the lower extremities, the more distal distribution of peripheral arterial disease, diminished sensation due to diabetic neuropathy, and decreased resistance to infection in poorly controlled diabetes, the more likely incidence of gangrenous changes of the feet in patients with diabetes. More than half of lower limb amputations in the United States occur in people with diabetes. From 1993 to 1995, approximately 67,000 amputations were performed each year in people with diabetes.7
Vol. XXI No. 3
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
Vascular nurses are in a prime position to educate the individual with diabetes so as to increase knowledge regarding the disease process and thereby decreasing the risk of limb amputation. Generalist and advanced practice vascular nurses are also knowledgeable in wound management and can institute measures aimed at managing diabetic foot ulcers. Each year 200,000 people are diagnosed with abdominal aortic aneurysms (AAA).8 In the United States, half of all patients with untreated AAAs die of an aortic rupture within 5 years. AAAs are the nation’s 13th leading cause of death, killing close to 17,000 Americans each year.6 The condition is more common in men, with approximately 5% of men over the age of 60 developing an AAA.8 Seventy-five percent of those diagnosed with AAA will be asymptomatic.9 For most of these patients, management is directed toward early detection and appropriate surgical intervention by preventing aneurysm rupture. Vascular nurses must be familiar with this disease process to effectively counsel and educate patients and their families regarding treatment options. Cerebrovascular disease dramatically affects the lives of millions of Americans, their families, communities in which they reside, health care delivery systems treating those affected, health promotion organizations fighting the battle against stroke, and health policy makers who influence the national agenda.10 According to the American Heart Association,5 stroke ranks third among the leading causes of death in the United States. Furthermore, causes of death surpassing stroke are diseases of the heart and all forms of cancer. In 1998, 1 out of 14 deaths was due to stroke. The report further estimates that more than 700,000 incident strokes occur every year, adding to the number of approximately 4.4 million stroke survivors. It is the leading cause of serious, long-term disability.10 Prevention and risk factor modification are ways to positively affect these statistics. Surgical intervention such as carotid endarterectomy may be performed on those who are asymptomatic but where impaired blood flow is detected. However, the risk for surgery should be less than a combined stroke/death rate of 3% in this cohort of people.11,12 Vascular nurses may also focus on the overall assessment, treatment, and evaluation of individuals requiring surgical or interventional strategies to manage their arterial problem. These procedures include, but are not limited to, carotid artery surgery, lower extremity revascularization by either surgical or endovascular approaches, surgery for aneurysmal disease, renal/mesenteric disease, limb amputation, and the creation of vascular access for hemodialysis.
Nonatherosclerotic arterial disease A variety of nonatherosclerotic arterial diseases exists. Vascular nurses require a familiarity with these diseases to effectively evaluate patient outcomes. Nonatherosclerotic arterial diseases include, but are not limited to, Buerger’s disease, Raynaud’s syndrome, fibromuscular dysplasia, trauma, compartment syndrome, arterial infection, compression syndromes, congenital conditions, and hyperviscosity syndromes.
PAGE 107
Venous disease Venous disease encompasses a wide spectrum of disorders, ranging from those with benign, primarily cosmetic concerns, such as spider telangiectasias and superficial varicose veins, to those with potentially life- and limb-threatening consequences, such as acute deep vein thrombosis and pulmonary emboli. Other manifestations of venous pathology include superficial venous thrombophlebitis, variceal bleeding, and chronic venous insufficiency. In spite of the broad spectrum of disease states, the basic underlying pathology behind venous disease is derived from 2 primary pathologic processes: obstruction of flow and venous valvular incompetence, which ultimately results in venous hypertension. Vascular nurses must be familiar with the risk factors for venous disease to effectively assess for and manage care for those at risk. An estimated 500,000 to 600,000 people in the United States have chronic venous insufficiency (CVI), which is the most common venous disorder. The term CVI refers to a constellation of limb symptoms including edema, pain, and pigmentation changes and disability, which can progress to chronic ulceration. CVI is responsible for 90% of lower extremity ulcerations.13 The goals of therapy are twofold: to heal the ulcer and to prevent ulcer recurrence. The advanced practice vascular nurse who is an expert in venous ulcer care may provide supervision or direction for ulcer management (eg, topical agents, dressing techniques), assist with the implementation of medical therapies when appropriate, and provide patient education and support.
Lymphatic disease The lymphatic system consists of an extensive network that collects lymph from the various organs and tissues and connects to an elaborate system of collecting vessels that transport the lymph to the blood stream. Lymphedema results from a malformation or obstruction of the lymphatic vessels and/or nodes. Lymphedema may be acquired or congenital, and it often develops secondary to another event, such as trauma. Lymphedema has various definitions, but in all types there is impaired transcapillary fluid exchange and impaired transport of lymph.14 Lymphedema can be localized or generalized with the lower extremities more commonly affected. Physical examination often reveals an edematous extremity, noticeable asymmetry, and skin that is pale and oily in appearance. The advanced practice vascular nurse may play a role in the differential diagnosis of lymphedema through history taking and a comprehensive physical examination. However, both generalist and advanced practice vascular nursing interventions are aimed at reducing edema, maintaining the edema-free state, control of infection, and providing education and emotional support.
LEVELS OF VASCULAR NURSING PRACTICE
Generalist practice Registered nurses at the generalist level have completed a nursing program and met state licensure examination requirements. Registered nurses who practice in vascular nursing set-
PAGE 108
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
tings may work as staff nurses, case managers, and nurse managers, and in other roles in the field of vascular nursing. Because of the dynamic nature of today’s health care environment, vascular nurse generalists practice in a variety of settings. These settings vary in purpose, type, location, acuity, and the auspices under which they operate. Practice setting include, but are not limited to, acute and subacute care facilities, home care agencies, ambulatory care clinics, outpatient services, residential facilities, skilled nursing facilities, private practice, physicians’ offices, and wound care clinics. Educational preparation for the vascular nurse generalist ranges from a 2-year associate degree to a 4-year baccalaureate degree.
Advanced practice The advanced practice registered nurse in vascular nursing is a licensed registered nurse who is educationally prepared as a clinical nurse specialist or a nurse practitioner at least at the master’s degree level. Advanced practice vascular nurses have acquired an in-depth knowledge base and clinical skills to prepare them for expansion and advancement in practice. Consistent with a broadened knowledge base, advanced practice vascular nursing is characterized by both increased complexity of clinical decision-making and greater skill in managing organizations and environments. Preparation for any of the advanced practice roles in vascular nursing occurs during graduate education, which includes a common base of knowledge in nursing and an expanded core of knowledge specific to the assessment and management of individuals with vascular disease. Because of the dynamic nature of today’s health care environment, advanced practice vascular nurses also practice in a variety of settings. These settings vary in purpose, type, location, acuity, and the auspices under which they operate. Practice settings include, but are not limited to, acute and subacute care facilities, home care agencies, ambulatory care clinics, outpatient services, residential facilities, skilled nursing facilities, private practice, physicians’ offices, and wound care clinics. Nurses in advanced practice vascular nursing roles may provide comprehensive physical assessment and demonstrate a high level of autonomy and expert skill in the diagnosis and treatment of the complex human responses of individuals, families, or communities to actual or potential health problems. They formulate clinical decisions to manage acute and chronic illness and promote wellness. They provide and deliver health care that is accessible to clients in various settings and throughout the life cycle. Advanced practice vascular nurses integrate education, research, management, leadership, and consultation into clinical roles, and they function in collegial relationships with nursing peers and other professionals and individuals to influence the health care environment. The advanced practice vascular nurse is responsible for identifying the scope of practice permitted by state and federal laws and regulations, the professional code of ethics, and professional practice standards. In addition, the advanced practice nurse’s experience, education, knowledge, and abilities circumscribe the nurse’s competence. Both generalist and advanced practice level vascular nursing practice are characterized by interventions that promote health,
SEPTEMBER 2003
assess for alterations in function, assist patients to regain or improve their function, and prevent further disability. The vascular nurse generalist collaborates with the care team to influence client and family outcomes. They may practice under the direction of the advanced practice vascular nurse. The Standards of Care and Standards of Professional Performance for the generalist and the advanced practice vascular nurse further serve to differentiate generalist and advanced practice.
PROMOTION OF HEALTH The vascular nurse stresses health promotion, reflecting nursing’s long-standing commitment to the well being of the individual, family, group, and community. The vascular nurse performs assessments, targets individuals at risk for vascular disease, and initiates interventions aimed at promoting or maintaining vascular health. These assessments focus on the identification of risk factors for arterial, venous, and lymphatic disease and education of the individual/family regarding these risk factors, which include, but are not limited to, hypertension, smoking, diabetes mellitus, and hyperlipidemia.
ASSESSMENT FOR ALTERATIONS IN FUNCTION The vascular nurse performs assessments and collects data regarding the health status of the individual with vascular disease in a systematic and ongoing manner. Collected data include not only the physical needs of the individual but also the psychosocial and spiritual needs. Out of data collection, nursing diagnoses are formulated, measurable goals are determined, and a plan of care is developed, implemented, and evaluated. Information obtained from the individual or family is communicated to other members of the care team as well.
MEASURES TO MAINTAIN, REGAIN, OR IMPROVE FUNCTION AND PREVENT DISABILITY A major focus of direct nursing care involves teaching the individual/family ways to maintain, regain, or to improve function, as well as to prevent disability. The patient education includes information relative to the individual’s specific vascular problem, as well as instruction on health-promoting behaviors including, but not limited to, diet, exercise, blood glucose control/monitoring, smoking cessation, and hypertension management. Teaching must take into consideration the capabilities and limitations of the individual/family and collaboration with other professional and specialists such as dieticians.
CERTIFICATION Certification is a process that national professional nursing organizations use to recognize advanced practice. Certification requires: graduation from an accredited or approved educational program that provides necessary course work and clinical experience, and a certification examination, recognized nationally by the advanced practice specialty’s professional organization. The American Nurses Credentialing Center offers cardiac/vascular nursing certification examination and recertification. Candidates sitting for the cardiac/vascular examination must meet the fol-
Vol. XXI No. 3
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
lowing guidelines: 1) hold a currently active registered nurse license in the United States or its territories; 2) have practiced the equivalent of 2 years full time as a registered nurse in the United States; 3) hold either an associate’s degree/diploma or a baccalaureate or higher degree in nursing, depending on the examination; 4) have a minimum of 2000 hours of clinical practice in the specialty within the last 3 years; and 5) have had 30 contact hours of continuing education in the specialty within the last 3 years. Faculty may use up to 500 hours of faculty teaching or clinical supervision in the specialty area of practice toward the practice requirement. Students may use up to 500 hours of time spent in an academic program of nursing study toward their clinical practice requirement. Recertification involves completing 1500 clinical practice hours and 150 contact hours of continuing education over the previous 5 years.15
ETHICS The practice of generalist and advanced practice vascular nurse is guided by the Code of Ethics for Nurses established by the American Nurse Association.5 The vascular nurse operating under this code acknowledges the patient’s rights to privacy and confidentiality and the patient’s right to be informed and to be treated with dignity. The vascular nurse recognizes the patient not only as a unique individual but also as part of a broader structure encompassing family or other significant relationship(s). The generalist and advanced practice vascular nurse acknowledge the client’s cultural beliefs, diversity, and individual uniqueness. Vascular nursing care that is provided is nonjudgmental and non-discriminatory. The vascular nurse serves as a client advocate, works to facilitate client decision-making, and promotes an ethical practice environment and professional integrity. In addition, the advanced practice vascular nurse acknowledges the patient’s rights to be informed, of self-determination, and truthful disclosure. The advanced practice vascular nurse considers the client’s cultural beliefs, diversity, and individual uniqueness when diagnosing, prescribing, and planning therapeutic intervention.
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