Chapter 30 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

Vascular System Arteries and arterioles Capillaries Veins and venules Lymphatic vessels Function of the vascular system

Systemic and Pulmonary Circulation

Assessment Health history Intermittent claudication, “rest pain,” location of the pain Physical assessment Skin (cool, pale, pallor, rubor, loss of hair, brittle nails, dry or scaling skin, atrophy, and ulcerations) Pulses Diagnostic evaluation

Assessing Peripheral Pulses

Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites

Diagnostic Evaluation Doppler Exercise testing Duplex US CT scanning Angiography Magnetic resonance angiography Contrast phlebography (venography) Lymphoscintigraphy

Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease.

Nursing Process: The Care of the Patient With Peripheral Arterial Insufficiency—Assessment Health history Medications Risk factors Signs and symptoms of arterial insufficiency Claudication and rest pain Color changes Weak or absent pulses Skin changes and skin breakdown

Nursing Process: The Care of the Patient With Peripheral Arterial Insufficiency—Diagnoses Altered peripheral tissue perfusion Chronic pain Risk for impaired skin integrity Knowledge deficient

Nursing Process: The Care of the Patient With Peripheral Arterial Insufficiency—Planning Major goals include increased arterial blood supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program.

Maintaining Tissue Integrity Protection of extremities and avoidance of trauma Regular inspection of extremities with referral for treatment and follow-up for any evidence of infection or inflammation Good nutrition, low-fat diet Weight reduction as necessary

Arterial Disorders Arteriosclerosis and atherosclerosis Peripheral arterial occlusive disease Upper extremity arterial occlusive disease Aortoiliac disease Aneurysms (thoracic, abdominal, other) Dissecting aorta Arterial embolism and arterial thrombosis Raynaud’s phenomenon and other acrosyndromes

Progression of Atherosclerosis

Common Sites of Atherosclerotic Obstruction

Risk Factors for Atherosclerosis and PVD Modifiable Nonmodifiable Nicotine, diet Hypertension Diabetes Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomocysteinemia Age Gender Familial predisposition and genetics

Improving Peripheral Arterial Circulation Exercises and activities: walking, graded isometric exercises. Note: Consult primary health care provider before prescribing an exercise routine. Positioning strategies Temperature; effects of heat and cold Stop smoking Stress reduction

Question The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What should be included in the teaching plan? Elevate the lower extremities. Exercise is discouraged. Keep the lower extremities in a neutral or dependent position. PAD should not cause pain.

Keep the lower extremities in a neutral or dependent position. Answer Keep the lower extremities in a neutral or dependent position. Rationale: For patients with PAD, blood flow to the lower extremities needs to be enhanced; therefore, the nurse encourages keeping the lower extremities in a neutral or dependent position. In contrast, for patients with venous insufficiency, blood return to the heart needs to be enhanced, so the lower extremities are elevated. Exercise can be prescribed to aid in the development of collateral circulation. Some pain is associated with PAD.

Pharmacologic Therapy—PAD Pentoxifylline (Trental) Cilostazol (Pletal) Aspirin Clopidogrel (Plavix) Statins

Characteristics of Arterial Aneurysms

Repair of an Ascending Aortic Aneurysm

Nursing Management: After Endovascular Repair Supine for 6 hours; HOB elevated up to 45 degrees after 2 hours VS and Doppler assessment of peripheral pulses every 15 minutes and then at progressively longer intervals if the patient’s status remains stable Access site (usually the femoral or iliac artery) is assessed when vital signs and pulses are monitored Assess for bleeding, pulsation, swelling, pain, hematoma formation, or skin changes of the lower extremities Temperature every 4 hours; any signs of postimplantation syndrome should be reported

Raynaud's Disease Intermittent arterial vasoocclusion, usually of the fingertips or toes Raynaud's phenomenon is associated with other underlying disease such as scleroderma. Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain Episodes are usually brought on by a trigger such as cold or stress. Occurs most frequently in young women Protect from cold and other triggers. Avoid injury to hands and fingers.

Venous Disorders Venous thromboembolism Chronic venous insufficiency/postthrombotic syndrome Varicose veins Leg ulcers

Venous Thromboembolism Pathophysiology Risk factors Endothelial damage Venous stasis Altered coagulation Manifestations Deep veins Superficial veins

Blood Flow and Function of Valves in Veins Note impaired blood return caused by an incompetent valve.

Preventive Measures Elastic hose Pneumatic compression devices Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy Positioning: periodic elevation of lower extremities Exercises: active and passive limb exercises; deep breathing exercises Early ambulation Avoid sitting or standing for prolonged periods; walk 10 minutes every 1 to 2 hours.

Which patient is at highest risk for venous thromboembolism? Question Which patient is at highest risk for venous thromboembolism? A 50-year-old postoperative patient A 25-year-old patient with a central venous catheter in place to treat septicemia A 71-year-old otherwise healthy older adult A pregnant 30-year-old woman due in 2 weeks

Answer A 25-year-old patient with a central venous catheter in place to treat septicemia Rationale: Some risk factors for venous thromboembolism include but are not limited to age older than 65 years, patients undergoing surgery, central venous catheter placement, septicemia, and pregnancy. The client in this question with two risk factors is the 25-year-old with a central venous catheter in place to treat septicemia. All other patients only have one risk factor.

Varicose Veins Prevention Avoid activities that cause venous stasis (wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods). Elevate the legs 3 to 6 inches higher than heart level. Walk for several minutes of every hour to promote circulation and 1 or 2 miles each day if there are no contraindications. Wear graduated compression stockings. Overweight patients should be encouraged to begin weight reduction plans.

Nursing Process: The Care of the Patient With Leg Ulcers—Assessment History of the condition History of diabetes, collagen disease, varicose veins Assess pain, peripheral pulses, edema Treatment depends on the type of ulcer Assess for presence of infection Assess nutrition

Arterial Ulcer, Gangrene Caused by Arterial Insufficiency, and Caused by to Venous Stasis

Medical Management Anti-infective therapy depends on the infecting agent. Oral antibiotics are usually prescribed. Compression therapy Debridement of wound Dressings Other

Nursing Process: The Care of the Patient With Leg Ulcers—Diagnoses Impaired skin integrity related to vascular insufficiency Impaired physical mobility related to activity restrictions of the therapeutic regimen and pain Imbalanced nutrition: less than body requirements related to increased need for nutrients that promote wound healing

Collaborative Problems and Potential Complications Infection Gangrene

Nursing Process: The Care of the Patient With Leg Ulcers—Planning Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications.

Nursing Process: The Care of the Patient With Leg Ulcers—Interventions Restoring skin integrity Improving physical mobility Promoting adequate nutrition Promoting home- and community-based care

Restoring Skin Integrity Cleansing wound Positioning Avoiding trauma Avoid heat sources

Improving Physical Mobility With leg ulcers, activity is usually initially restricted to promote healing. Gradual progression of activity Activity to promote blood flow; encourage patient to move about in bed and exercise upper extremities Diversional activities Pain medication before activities

Promoting Adequate Nutrition Protein Vitamins C and A Iron Zinc Many patients with peripheral vascular disease are older adults. Particular consideration should be given to their iron intake because many older people are anemic.

Home- and Community-Based Care Encourage activities that promote arterial and venous circulation, relieve pain, and promote tissue integrity. Long-term care of the feet and legs to promote healing of wounds and prevent recurrence of ulcerations is the primary goal. Participation of family members and home health care providers Regular follow-up with a primary health care provider is necessary.

Lymphatic Disorders Lymphangitis: inflammation or infection of the lymphatic channels Lymphadenitis: inflammation or infection of the lymph nodes Lymphedema: tissue swelling related to obstruction of lymphatic flow Primary: congenital Secondary: acquired obstruction

Cellulitis S&S: localized swelling or redness, fever, chills, sweating Treat with oral or IV antibiotics based on severity Nursing Elevate Warm, moist packs to site every 2 to 4 hours Educate regarding prevention of recurrence Reinforce education about skin and foot care

Question Is the following statement true or false? Cellulitis cannot be differentiated from lymphangitis.

Answer False Rationale: Cellulitis needs to be differentiated from lymphangitis. With cellulitis, the swelling and redness are localized and anatomically nonspecific. With lymphangitis, characteristic red streaks appear denoting the outline of the lymphatic vessels that are affected.