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
The hypertensive patient