Peripheral Vascular Disease
Teresa Kelechi, PhD, RN
June 7, 2002
Brief Overview
•	Two interdependent systems
–	central (pump)
–	peripheral

•	Arterial and venous systems
–	arterial (100 mmHg pressure)
–	venous (4 mmHg pressure)

Overview
•	L side of heart        aorta       arteries        arterioles        capillaries       venules        veins         vena cava       R side of heart

•	the site of exchange of nutrients and metabolic wastes and fluids occurs in the capillaries in tissues
•	intravascular/extravascular
Overview
•	Circulation under the influence of physical and hormonal stressors:
–	chemical
–	hormonal
–	nervous system (sympathetic)
•	norepinephrine (constriction)
•	epinephrine
Overview
•	Lymph system
–	serves to collect fluid (extravascular/interstitial) from tissues and organs and transports fluid to into two main structures
•	thoracic duct
•	right lymphatic duct
–	collects large molecules (proteins)
–	regional lymph nodes filter foreign particles
Overview
•	Hydrostatic vs osmotic pressure affect vascular system
–	demands for flow
•	exercise, physical activity, fever, infection, local application of heat, inflammation = increased needs for blood flow
•	rest, decreased physical activity, local cold application, cooling of body, certain nerve blocks = decreased demands for flow
Overview
•	Problems with flow to the tissues
–	ischemia, malnutrition, death (necrosis, gangrene)
•	Related to:
–	heart failture
–	atherosclerotic plaque
–	arteriosclerosis
–	trauma
Overview
•	Venous problems
–	thrombus, valve incompetence, bed rest
•	Obstruction of lymphatic vessels
•	Aging
Overview
•	Peripheral vascular diseases
–	arterial  (PAD, LEAD)
–	venous  (CVI)
–	lymphatics
Arterial
•	Signs and symptoms

Arterial
–	intermittent claudication - pain
–	absent/diminished pulses
–	dry skin
–	shiny appearance of skin
–	decreased/absent hair growth
–	thick nails
–	cold to touch
–	purplish/dependent rubor

Venous
•	Signs and symptoms
Venous
•	Aching/cramping
•	edema
•	telangiectasis
•	hyperpigmentation
•	dermatitis
•	lipodermatosclerosis
Diagnostic/evaluation
•	Doppler ultrasound flow studies
•	segmental pressures
•	exercise testing
•	duplex ultrasound
•	CT/MRI
•	angiography
•	air plethysmography
Diagnostic/evaluation
•	Ankle/brachial index
•	Transcutaneous oximetry
•	laser Doppler imaging/flowmetry
Risk factors
•	Modifiable
–	smoking
–	diet
–	hypercholesterolemia
–	diabetes
–	stress
–	sedentary lifestyle
Risk factors
•	Non-modifiable
–	age
–	gender
Nursing Management
•	Goals
–	increase blood supply to the extremities
•	positioning
•	exercise
•	avoid constrictive clothing
•	do not cross legs
•	drugs
•	smoking cessation
Nursing Management
•	Stress management
•	Injury prevention
•	Keep patient warm
Unreasonable lifestyle accommodations
•	relieve pain
•	maintain tissue integrity
•	promote self care
–	hygiene
–	nutrition
Peripheral arterial disease
•	Surgical management
–	limb-salvaging surgery
•	type of procedure depends on:
–	degree and location of stenosis or occlusion
–	overall health of patient
–	length of procedure that can be tolerated
–	patient’s life expectancy
Endarterectomy
•	Incision into artery to remove atheromatous obstruction
–	check incision/dressing
–	listen for bruits
Bypass graft
•	Reroute blood around stenosis or occlusion
–	anastomosis
•	femoral/popliteal
•	femoral/posterior tibial or anterior tibial or peroneal 
–	autologous (native) or prosthetic material
–	autologous can be in situ or reversed vein graft
Nursing Management
•	Check incision lines
•	pulses
•	color
•	warmth
•	hematoma
•	I&O
•	edema

•	Elevate?
•	TED hose?
Nursing Management
•	Signs and symptoms of failure

•	Pain
•	severe edema
•	decreased sensation
•	coolness below
•	cyanosis
Upper extremity occlusions
•	Result from atherosclerosis or trauma
–	unilateral coolness, pallor, arm fatigue, BP difference of 20 mmHg

–	No needle sticks to arm, keep warm (don’t apply heat), no tape or constrictive dressings
Buerger’s disease
•	Also known as: Thromboangitis Obliterans
–	autoimmune disease
–	pain
–	paresthesias
–	cold sensitivity
–	bilateral and symmetric
Other diseases
•	Aorititis - inflammation
•	Aortoiliac disease
•	Aortic aneurysm
–	sac vs fusiform vs mycocytic
•	causes: trauma, congenital, inflammatory, pregnancy, ***atherosclerosis
–	dissecting
•	common is thoracic aneurysm
Abdominal aortic aneurysm
•	Surgical repair if > 5 cm (2 inches)
–	symptoms: complaints that pants too tight, see a throbbing “mass”, blue toe syndrome
–	Surgical complications:
•	bleeding, hematoma, infection, distal ischemia, embolism, dissection or perforation, rupture, renal failure
•	low back pain, decreased BP, Hct
Embolism/thromosis
•	Thrombus - slowly developing clot that usually occurs where the arterial wall has been damaged as a result of atherosclerosis
–	form occlusion related to trauma, surgical event
•	Signs and symptoms
–	5 P’s: pain, pallor, paralysis, paresthesia, pulsesness
Treatment
•	Depends on its cause
–	surgical vs. medical management

–	Usually patients are heparinized
•	5,000 to 10,000 unit bolus
•	IV - 1000 u/hr
•	may use intra-arterial thrombolytic agentns
–	streptokinase, urokinase
Nursing Management
•	Pre-op: same as for arterial occlusion
Raynaud’s disease/phenomena
•	Form of intermittent arteriolar vasoconstriction which results in:
–	coldness, pain, pallor, cyanosis, rubor
•	Disease often accompanies immunologic disorders such as lupus, scleroderma, rheumatoid arthritis
•	Episodes triggered by emotional factors, cold
Management
•	Teach patient to:
–	avoid cold exposure, smoking cessation
–	may be taking calcium channel blockers (Procardia)
–	may have surgery (sympathectomy)
–	stress management/reassure 
–	layer clothing/injury prevention
–	avoid alcohol intake
Venous disorders
•	Deep vein thrombosis (blood clot)
–	causative factors:
•	thrombophlebitis (inflammation of vein walls)
•	pregnancy
•	bedrest
•	trauma
•	oral contraceptives
•	obesity
S&S
•	Edema/swelling
•	redness
•	limb pain
•	heaviness
•	+ homan’s sign not indicative of DVT
Management
•	Compression stockings
•	intermittent pneumatic compression device
•	anticoagulation therapy
–	heparin (IV) vs. low mollecular weight heparin
–	coumadin
•	monitor INR, PTT
–	thrombolytic therapy
–	thrombectomy (vena cava filter to trap emboli)
Care of patients on anticoagulation therapy
•	Goal:  detect and/or prevent bleeding
–	IV pump
–	IV push
–	oral: INR (2.0 to 3.0) or PTT (1.5 to 2X normal)
–	check urine for blood, nosebleeds, bleeding gums

•	Counseling regarding diet: Vitamin K or foods containing Vit. K
–	drugs (check page 709 of text)
•	NSAIDs, ASA, antibiotics, cold medicines
•	Patient may be:
–	on bedrest, stockings, elevation, analgesics, warm moist packs, dorsiflexion exercises
Stockings
•	Antiembolism (12 to 18 mmHg)
•	Avoid rolling at knee
•	check circulation by checking toes
Other measures
•	Intermittent pneumatic compression devices
•	Exercise/positioning
–	deep breathing, calf muscle pumping actions, elevate and lower legs
•	Avoid alcohol
•	Weekly blood tests
Chronic venous insufficiency
•	Goals for nursing:
–	good skin care
–	compression: graduated, knee high, moderate to high compression
–	elevation
–	walk!!!!
–	pain management
Varicose veins
•	Dilated tortuous superficial veins due to incompetent valves that occur mostly in the legs (deep veins are intact)
–	ache, muscle cramps, muscle fatigue, heaviness
•	Surgical ligation
–	stripping
–	sclerotherapy
Management
•	Post-surgical
–	compression for 1 week, elevate, walk, check bleeding and dressings through stockings, analgesics
–	may experience burning after sclerotherapy
Disorders of the Lymphatics
•	Lymphangitis - acute inflammation of lymphatic channel due to infection (strept) - enlarged nodes, red, tender
–	treat with antibiotics
•	Lymphedema - swelling of tissues in extremities due to obstruction of lymph vessels or nodes
Lymphatics
•	Elephantiasis - extremity edema with abnormal skin changes thought to be related to parasitic infection

•	major problem with lymph disorders is edema
Management
•	Goal: reduce/control edema/prevent infection
–	compression garments
–	controversy  about “pumping” the leg of an obstruction
–	manual therapy
–	elevation
–	surgical interventions
Hypertension
•	Primary – unidentified cause – also called essential (most common type)
•	Secondary – identified cause such as from renal disease
The hypertensive patient
•	Your role is to: 
–	Monitor BP
–	Support and teach the patient to adhere to the treatment regiment
•	Lifestyle changes
•	Take meds as prescribed
•	Attend regular follow-up appointments
Nursing role
•	Instruction  (p. 721)
–	Lose weight
–	Limit alcohol intake
–	Increase exercise
–	Reduce sodium intake
–	Maintain adequate potassium
–	Stop smoking
What to report
•	Headache, nosebleeds
•	Symptoms of low blood pressure: 
–	 dizziness
–	 edema
–	 anginal pain
–	 shortness of breath
–	  alterations in speech, vision or balance,

•	Nocturia

•	Potential complications:
–	LVH
–	MI
–	Heart failure
–	TIAs/ stroke

•	Renal insufficiency
•	Retinal hemorrhage
Goal is to promote self care
•	Understand expected side effects of medications
•	How to measure BP at home
•	Recognize orthostatic hypotension
•	How to simplify regimen
•	Involve family members
•	Recognize progression of disease

–	Blurred vision
–	Diminshed visual acuity
–	Spots in front of eyes

•	Prevent end-organ damage

Recognize hypertensive emergency (crisis)
•	BP requires immediate lowering which are acute and life-threatening
–	Conditions associated with HE:
•	Acute MI
•	Dissecting aortic aneurysm
•	Intracranial hemorrhage
–	Hypertensive urgency – BP requires lowering within a few hours
Case study
•	You are assigned to care for LJ, 70, a truck driver, admitted for R leg DVT. A thrombus in the external iliac vein extending distally to the lower leg, was diagnosed via Doppler.  Labs were PT 12.4 sec, INR 1.11, PTT 25 sec, cholesterol 206 mg/dl.   He has a 48 pack-year smoking history, has at fib, and arthritis.  He was SOB and had leg swelling.

•	Identify at least five problems from his history that represent his personal risk factors for DVT.

•	What are the most important assessment you should make during your physical examination and assessment upon admission?

•	What is the most serious complication of DVT?

•	What instructions will you give him about his activity?

•	You identify pain as a key issue in the care of the patient.  List four interventions you would choose to address pain.

•	The patient is started on heparin therapy.

–	What pertinent laboratory values/tests would you expect the physician to order and you to monitor?

•	He has responded to heparin therapy and was started on Coumadin.  He is excited about discharge because he is flying to his grandson’s wedding in Arizona.  What would you say to him?