Peripheral Vascular Disorders

Adult Health I
NURS 400

1
 Pathophysiology of the
Vascular System
• PVD characterized by reduced blood
flow
• PVD caused by:
• Heart failure
• Arterial insufficiency
• Venous insufficiency

2
 Nursing Assessment
• Pain
• Intermittent claudication – crampy pain
associated with activity
• Pulses
• Skin appearance
• Skin temperature
• Edema

3
 Characteristics of Arterial
Insufficiency
• Intermittent claudication to sharp,
unrelenting pain
• Diminished or absent pulses
• Pallor and coolness
• Loss of hair
• Thickened nails

4
Characteristics of Arterial Ulcers
• Located in areas of pressure, tips of toes
• Very painful
• Deep, may involve joint
• Usually circular in appearance
• Wound base pale to black
• Little, if any, edema

5
 Characteristics of Venous
Insufficiency
• Achy, cramping pain
• Pulses present
• Hyperpigmentation of skin
• Lots of edema

6
Characteristics of Venous Ulcers
• Usually located on medial
malleolus
• Tend to be superficial,
infrequently painful
• Irregular borders
• Wet wounds, wound bed
usually granular or yellow
fibrous
7
 Diagnostics
• Doppler ultrasound
• Ankle Brachial Index (ABI)
• Measure brachial systolic pressure
• Measure dorsalis pedis or posterial tibial systolic
pressure
• Calculate as follows:
• Ankle systolic pressure / brachial systolic pressure
• Ex: 80/100 = 0.8 ABI
• Normal ABI > 0.9

8
 Diagnostics
• Exercise testing
• Duplex sonography
• CT
• CT Angiography
• MR Angiography (MRA)
• Arteriogram
• Plethsmography
• Venography

9
 Atherosclerosis
• Narrowing of the
lumen of the artery
related to plaque
build up
• Can affect all
arteries

10
Risk Factors for Atherosclerosis
Modifiable Non-modifiable
• Tobacco use • Age
• Diet • Gender
• Hypertension • Family history
• DM
• Obesity
• Stress Sedentary
lifestyle
• Elevated CRP and
homocysteine levels
11
Prevention of Atherosclerosis
• Dietary strategies
• Smoking cessation
• Control hyperlipidemia
• Control hypertension
• Reduce weight
• Increase activity

12
 Medical Management of
Atherosclerosis
• Treat risk factors
• Vasodilators
• Surgery
• Angioplasty with ballooning or stenting

13
 Nursing Management
• Patient teaching:
• Smoking cessation
• Exercise
• Stress reduction techniques
• Weight loss
• Avoid exposure to cold
• Avoid crossing legs
• To warm, apply heat to lower abdomen

14
 Peripheral Arterial Disease
(PAD)
• Arterial insufficiency
• Most common in men
• Legs most often affected
• Obstructive lesions
often found in
abdominal aorta, renal
arteries and popliteal
arteries
• Distal disease more
common in elderly and
Diabetics
15
 PAD
Clinical Manifestations
• Intermittent claudication
• May progress to resting leg pain
• Resting leg pain more common at night
• Elevating leg increases pain
• Cold/numb feeling in limb
• Diminished or absent pulses
• Thick nails
• Pallor
• Loss of hair
• Wounds
16
 Medical Management of PAD
Medications
• Pentoxifylline (Trental) – increases flexibility of
rbcs
• Cilostazol (Pletal) – vasodilator with some
antiplatelet activity
• ASA or other antiplatelet (Plavix)
Surgery
• Endarterectomy
• Bypass grafts
• Amputation
17
 Nursing Management of PAD
• Maintain circulation
• Pulse checks q1-2h
• Monitor for potential complications
• Vital signs
• Fluid balance
• Hematoma formation
• Infection
• Pain management

18
 Arterial Embolism &
Arterial Thrombus
• Sudden arterial vascular occlusion
• Results from iatrogenic injury, trauma
• Associated with the 6 P’s
• Pallor
• Pulselessness
• Parasthesia
• Paralysis
• Pain
• Poikilothermia (coolness)

19
 Arterial Embolism &
Arterial Thrombus
Medical Treatment Nursing Measures
• Embolectomy • Bedrest
• Anticoagulation • Keep leg level
• Thrombolytics • Monitor for bleeding
r/t thrombolytic
and/or
anticoagulant use
• Pulse checks
• Monitoring vital
signs

20
 Aneurysm
• Localized dilation of an artery
• Abdominal Aorta accounts for majority
• Risk factors
• Hypertension
• Cigarette smoking
• Physical Exam
• Bruit
• Abdominal or back pain
• SOB

21
 Aneurysm
• Diagnostics
• CT or MRI
• Ultrasound
• Medical
Management
• Monitor growth
• BP control
• Smoking cessation
• Surgery

22
 Aneurysm
• Nursing Management
• Maintain circulation
• Pulse checks q1h
• Elevate HOB no more than 45°
• Monitor for potential complications
• Vital signs
• Fluid balance
• Infection
• Pain management

23
 Deep Vein Thrombosis (DVT)
Development of a blood clot
in the venous circulation

Three Factors Play Role

24
 Risk Factors for DVT
Venous stasis Vessel wall injury
• bedrest • Trauma
• Obesity • Surgery
• Varicosities • Pacing wires
• Spinal cord injury • Central venous
• Age >65y catheters
• Dialysis access
catheters
• Local vein damage
• Repetitive motion
injury
25
 Risk Factors for DVT
Altered coagulation • Prothrombin 20210A
• Cancer defect
• Pregnancy • Hyperhomocysteinemia
• Oral contraceptives • Elevated factors II, VIII,
• Protein c deficiency IX, XI
• Protein s deficiency
• Antithrombin III
deficiency
• Antiphospholipid Ab
• Polycythemia
• Factor V Leiden defect
• Septicemia

26
 S/S of DVT
• Often nonspecific
• May have:
• Edema
• Tenderness
• (+) Homan’s sign
• Redness
• Increased warmth
• (+) D-dimer

27
 Medical Management of DVT
• Un-fractionated Heparin
• IV infusion given over 5-7d or until INR
therapeutic (2-3_
• Warfarin (Coumadin) started at the same
time
• Usual dose: 80units/kg bolus followed by
18units/kg/hr
• Requires monitoring of PTT levels

28
 Medical Management of DVT
• Low Molecular Weight Heparin
(LMWH)
• Enoxaparin (Lovenox)
• Dosed based on weight
• Dose different for treatment of DVT vs
prevention of DVT
• Less bleeding issues
• More cost effective

29
 Medical Management of DVT
• Warfarin
• Used for long-term therapy
• Antidote = vitamin K
• Dose individualized
• Monitor PT/INR levels closely
• Started on day 1 with LMWH or Un-
fractionated heparin
• Multiple drug and food interactions!

30
 Medical Management of DVT
• Thrombolytics
• Used less frequently
• Big concern is hemorrhage
• Dosing individualized
• Patient must be monitored in critical care
setting

31
 Medical Management of DVT
Contraindications to Anticoagulants
• Active bleeding
• Hemorrhagic blood dyscrasias
• Aneurysms
• Recent or impending surgery
• Recent stroke
• Recent delivery of a baby
• Hazardous Occupations
• Alcoholism

32
 Medical Management of DVT
• Surgical
Management
• Thrombectomy
• Insertion of
Inferior Vena
Cava filter

33
 Nursing Management of DVT
• Monitor for bleeding
• Monitor PT/INR with Warfarin
• Monitor PTT levels with unfractionated
Heparin
• Pain management
• Elevate affected extremity
• AROM/PROM while on bedrest
• Patient education
34
 Nursing Management of DVT
• Prevention of DVT is
best!
• Recognize who is at
risk
• Patient education
• Early ambulation
• Compression therapy
• LMWH as
appropriate
35
 Chronic Venous Insufficiency
• Occurs as result of venous obstruction
or incompetent valves
• Leads to venous stasis and blood
pooling
• Clinical manifestations
• Edema
• Altered pigmentation
• Pain
• Stasis dermatitis
36
 Chronic Venous Insufficiency
• Complications
• Chronic pain
• Ulcers
• Infection
• Management
• Leg elevation
• Compression hose
• Avoid prolonged sitting or standing
• Avoid pressure on popliteal spaces
37
 Leg Ulcers
• Causes multifactorial
• Good assessment can often distinguish
between arterial and venous ulcers
• Arterial Ulcers
• Be careful with debridement techniques
with poor circulation

38
 Medical and Nursing
Management of
Leg Ulcers
• Antibiotics if infected
• Pain management
• Compression therapy (venous)
• Debridement
• Surgical
• Enzymatic
• Autolytic
• Mechanical

39
 Medical and Nursing
Management of
Leg Ulcers
• Dressings
• Calcium alginates
• Hydrogels
• Hydrocolloids
• Wet to moist saline dressing
• Hyperbaric Oxygen
• Apligraf

40
 Other Circulatory Problems
• Varicose Veins
• Dilated superficial veins caused by
incompetent valves
• Raynaud’s Disease
• Intermittent arteriolar vasoconstriction

41
 Nursing Diagnoses
• Altered tissue perfusion
• Chronic pain
• Risk for impaired skin integrity
• Deficient knowledge
• Risk for infection

42
 Case Study
JM is a 75y male who lives alone. He has a hx of CHF,
Type II DM and CAD. He presents to your hospital
with a non-healing ulcer of his left leg. His left DP
and PT pulse is non-palpable and he has 3+ edema
of both legs.

1. What factors contribute to his leg ulcer?

43
 Practice Question
When obtaining a health history from a
72y male with PAD of the lower
extremities, the nurse asks about a
history of related conditions such as:
a. venous thrombosis
b. venous stasis ulcers
c. pulmonary embolism
d. carotid artery disease

44
 Practice Question
During the care of the patient following femoral
bypass graft surgery, the nurse immediately
notifies the health care provider if the patient
experiences:
a. fever and redness at the incision site
b. 2+ edema of the extremity and pain at the
incision site
c. a loss of palpable pulses and numbness and
tingling of the feet
d. decreased ABI indices and serous drainage
from the incision
45
 Practice Question
The nurse teaches the patient that with
any venous disorder the best way to
prevent venous stasis and increase
venous return is to:
a. walk
b. sit with legs elevated
c. frequently rotate ankles
d. continuously wear compression
stockings
46