Lesson H: Disorders of the Peripheral Blood Vessels Manuel Barbosa RN, MSN-Ed. CCCRN, PCCN Modified by Persephone Gee, RN, PHN, MSN

Objectives By the end of this lesson, the vocational nursing student will be able to: Describe venous insufficiency including definition, etiology, symptomatology, and impact on overall health. Describe arterial insufficiency including definition, etiology, symptomatology, and impact on overall health. Compare and contrast thrombophlebitis and Buerger’s disease including etiology, symptomatology, diagnostic tests, treatment modalities and nursing care utilizing the nursing process. Summarize the occlusive disorders including description, etiology, symptomatology, diagnostic test, treatment modalities and nursing care utilizing the nursing process. Differentiate between varicose veins and aneurysms including definition, etiology, symptomatology, diagnostic tests, treatment modalities and nursing care utilizing the nursing process.

Lesson Outline Venous Insufficiency Arterial Insufficiency Infectious and Inflammatory Disorders Thrombophlebitis Buerger’s Disease Occlusive Disorders Arteriosclerosis Atherosclerosis Raynaud’s Disease Thrombosis Embolism Disorders of the Vessel Walls Varicose Veins Aneurysm

Venous Insufficiency Effects of the disorder: Flow of venous blood impaired, lower extremities Pathophysiology and etiology Consequences: venous congestion Increased hydrostatic fluid pressure Localized edema; fluid-filled space Cells subjected to accumulating amounts of CO2; unoxygenated cells> cell death> inflammatory process ensues Hemoglobin from blood cells escape into extravascular space Serous fluid oozes from skin Venous stasis ulcer

Venous Insufficiency Assessment findings: Signs and symptoms Swollen foot or feet; testing for pitting Superficial veins; skin color; serous fluid Infection; pedal and tibial pulses Congestion of venous fluid Assessment findings: Diagnostic findings Doppler ultrasound Photoplethysmography: Venous pathology Air plethysmography: Measures venous pressure; cuff with air

Venous Insufficiency Medical and surgical management Promote venous circulation; elastic compression stockings; unna boot Pneumatic compression pump therapy Mild analgesics; vascular surgery Stasis ulcer Chronic, non-healing skin lesions Nursing management Assesses: Extremities and circulation Ulcers; rate of pain; application of stockings; wound care; client teaching

Arterial Insufficiency lack of enough blood flow through the arteries Causes: occlusive atherosclerotic plaques or emboli; damaged, diseased, or intrinsically weak vessels; arteriovenous fistulas; aneurysms; hypercoagulability states; or heavy use of tobacco. Signs: reduced or absent peripheral pulses; in advanced disease, arterial ulcers and atrophy of muscles in the involved extremity. Diagnosis: checking and comparing peripheral pulses in contralateral extremities, angiography, ultrasound using a Doppler device, and skin temperature tests. Treatment: a diet low in saturated fats, moderate exercise, sleeping on a firm mattress, use of a vasodilator, and, if indicated, surgical repair of an aneurysm or arteriovenous fistula. Use of tobacco products, prolonged standing, and sitting with the knees bent are discouraged.

Thrombophlebitis Pathophysiology and Etiology Inflammation of vein; clot formation Pulmonary embolus; postphlebitic syndrome; Virchow’s triad Assessment Findings Discomfort in affected extremity; Homans’ sign; heat; redness; swelling; fever; malaise; anorexia; slow capillary refill Venography; Doppler ultrasound; impedance plethysmography Medical and Surgical Management Complete rest of arm or leg; continuous warm, wet packs Anticoagulant therapy; oral anticoagulants; drugs Thrombectomy; surgical procedures on vena cava: Ligation; vena caval filter insertion; vena caval plication

Nursing Process: The Client With Thrombophlebitis Assessment Client history: Blood clots; other risk factors Homan’s sign; color; temperature Capillary refill of extremities Leg or arm circumference measurement Low-grade fever; chest pain; dyspnea Monitor: Laboratory test results—drug therapy Diagnosis, Planning, and Interventions Promote activity and exercise; Ankle-pumping exercises; elastic stockings Risks: Pain; ineffective tissue perfusion; pulmonary embolus; bleeding Evaluation of Expected Outcomes Pain; venous circulation; blood flow to heart Extremities: Size, temperature, and color; negative Homans’ sign; PE; bleeding

Thromboangiitis Obliterans (Buerger’s Disease) Pathophysiology and Etiology Spasms that constrict arterial lumen Inflammatory lesions; hypoxia; anoxia; ulcerations; gangrene Assessment Findings Cold, numb, burning, and tingling feet Cyanosis; redness of feet and legs Mottled skin; leg ulcers Black, gangrenous toes and heels Thick nails; peripheral pulses disappear Prolonged capillary refill Intermittent claudication Doppler ultrasound; IPG; angiography

Thromboangiitis Obliterans (Buerger’s Disease) Assessment Findings Doppler ultrasound IPG (impedance plethysmography ) Angiography Medical Management Tobacco restriction Buerger-Allen exercises; walking Active foot exercises; analgesics Leg ulcers: Moist dressings; topical antiseptics; antibiotic ointments Surgical Management Sympathectomy; wound debridement Skin grafting; amputation

Thromboangiitis Obliterans (Buerger’s Disease) Nursing Management History; smoking history; symptoms; pain Physical examination: Affected areas for redness, swelling, and color changes; nail, skin; skin temperature; peripheral pulses; Capillary refill time Foot ulcers: Meticulous wound care Restrictions: Caffeine, tobacco, and OTC drugs causing vasoconstriction Client teaching, supervision Buerger-Allen leg exercises; leg position; self-care; smoking cessation Adherence: Exercise schedule; trauma prevention; protective clothing against cold; footwear Daily inspection and cleaning: Fingernails, toenails, skin on arms and legs

Arteriosclerosis Pathophysiology and Etiology Loss of elasticity, artery hardening which accompanies aging Calcium deposition in the cytoplasm Reduced volume of oxygenated blood delivered to organs

Atherosclerosis Pathophysiology and etiology Contributing factors Condition where artery lumens fill with plaque Mechanisms by which lipids are formed and metabolized Causes contributing to higher risk factors for vascular diseases Hyperlipidemia High levels of blood fat Contributing factors – Gender, heredity, diet, and diseases Obese people with metabolic syndrome Homocysteine: Scarring of arterial walls

Atherosclerosis Pathophysiology and Etiology (Cont’d) Inflammation Infection Chlamydia pneumoniae Blood test: HS-CRP and WBC Inflammation Body fat: Production of inflammatory and thrombotic proteins Proinflammatory proteins Client with elevated lipid levels Endothelial: Derived relaxing factors Coronary thrombosis

Peripheral Atherosclerosis Gradual, progressive disease Common in diabetics Thin, shiny skin Loss of hair on extremities Ulcers, gangrene may develop Intermittent Claudication Deficient blood supply in exercising muscle Pain, aching, cramps, weakness Occurs in calf, thigh, hip, buttocks on walking Relieved by rest (2 - 5 minutes )

Peripheral Atherosclerosis Acute Arterial Occlusion Sudden blockage by embolism, plaque, thrombus Can result from vessel trauma The 5 Ps of acute occlusion Pain, worsening over several hours Pallor, cool to touch Pulselessness Paresthesias, loss of sensation Paralysis

Occlusive Disorders of Peripheral Blood Vessels: Raynaud’s Disease Assessment findings: Signs and symptoms Exposure to cold Symptoms of occurrence in hand Hallmark symptoms: Ischemia, pain, and paresthesias Relief measures; early stages Mild and long-term symptoms Assessment findings: Diagnostic findings History of the symptoms and examination Laboratory blood tests

Raynaud’s Disease Medical and surgical management Treatment: Avoid factors that precipitate attacks Drug therapy with peripheral vasodilators IV infusion of prostaglandin E Sympathectomy; gangrenous areas Nursing management Physiology of blood flow; smoking McIntyre maneuver; ischemic episodes Client and family education; nail care Relief of hay fever; sympathectomy

Thrombosis, Phlebothrombosis, & Embolism Pathophysiology and etiology Location; occurrence Orthopedic surgical procedures Precipitation: Arterial thrombosis and subsequent embolization Occluded blood flow Assessment findings: Signs and symptoms Arterial clot; total occlusion; cramping Loss of sensation and ability; shock Clients with phlebothrombosis; DVT Assessment findings: Diagnostic findings Arteriography or venography Doppler ultrasonography Plethysmography

Thrombosis, Phlebothrombosis, & Embolism Medical and surgical treatment Treatment depends on vessel and degree of occlusion Arterial occlusive disease Vasodilating drugs; heparin; sympathetic nerve block; narcotics; thrombolytic agents; pulmonary embolism; surgery Venous occlusive disease Treatment: Bed rest, elevation, heat, analgesics, and heparin therapy DVT: Surgical removal of the clot Nursing management History: Characteristics of pain Homan’s sign: Palpate peripheral pulses Examine extremities, skin color, and calf Heparin; anticoagulation therapy Client teaching

Deep Vein Thrombophlebitis Inflammation of lower extremities, pelvic veins with clot formation Usually begins with calf veins Precipitating factors Injury to venous endothelium Hypercoagulability Reduced blood flow (venous stasis)

Deep Vein Thrombophlebitis Signs/Symptoms May be asymptomatic Pain, tenderness Fever, chills, malaise Edema, warmth, bluish-red color Pain on ankle dorsiflexion during straight leg lifting (Homan’s sign) Palpable “cord” in calf clotted veins May progress to pulmonary embolism!!!

Disorder of the Vessel Wall: Varicose Veins Dilated, elongated, tortuous superficial veins usually in lower extremities Dilated veins; both sexes suffer equally Saphenous leg veins commonly affected Pathophysiology and etiology Varicosities: Dilated, torturous veins Cause: Interfere with venous return Thrombophlebitis; infection; slow healing Assessment findings: Signs and symptoms Heaviness in the legs; variations in skin Swelling on leg; distended leg veins Abnormal capillary refill

Varicose Veins Varicose Veins Assessment findings: Diagnostic findings Brodie-Trendelenburg test Congenital weakness/absence of venous valves Congenital weakness of venous walls Diseases of venous system (Deep thrombophlebitis) Prolonged venostasis (pregnancy, standing) Signs/Symptoms May be asymptomatic Feeling of fatigue, heaviness Cramps at night Orthostatic edema Ulcer formation Rupture may cause severe bleeding Control with elevation and direct pressure

Varicose Vein Nursing management Postoperative measures Assess skin, distal circulation, peripheral edema, and ability to perform isometric leg exercises Postoperative measures Consult physician; ambulate Application of elastic antiembolism stockings Adequate fluid to decrease potential thrombosis; client and family teaching Treatment by the physician Elastic support stockings

Disorders of Blood Vessel Walls: Aneurysm Stretching and bulging of arterial wall Most common: Aneurysms of the aorta Pathophysiology and etiology Elasticity of the tunica media affected Blockage of the vessel; leakage of blood into surrounding cavities; tissue necrosis Assessment findings: Signs and symptoms Identification of disease; massive hemorrhage; pressure; hypertensive Pulsating mass; sudden illness; shock BP on both arms and legs

Aneurysm Assessment findings: Diagnostic findings Radiographs: Demonstrate aneurysm Aortography: Size and location Medical and surgical management Drug therapy: Antihypertensives Surgically treated Repair: Bypass or replacement grafting Nursing management Measures to control hypertension; monitor vital signs, urine output, and pain Client preparation: Diagnostic testing

Aortic Aneurysm Localized abnormal dilation of blood vessel, usually an artery Thoracic Dissecting Abdominal

Thoracic Aortic Aneurysm Usually results from atherosclerosis Weakened aortic wall bows out - lumen distends Most common in males age 50 – 70 Sign/Symptoms Dyspnea, Cough Hoarseness/Loss of voice Substernal/back pain or ache Lower extremity weakness/ paresthesias Variation in pulses, BP between extremities

Dissecting Aortic Aneurysm Intima tears Column of blood forms false passage, splits tunica media lengthwise Most common in thoracic aorta Most common in blacks, chronic hypertension, Marfan’s syndrome Signs/Symptoms Sudden “ripping” or “tearing” pain anterior chest or between shoulders May extend to shoulders, neck, lower back, and abdomen Rarely radiates to jaw or arms Pallor, diaphoresis, tachycardia, dyspnea

Dissecting Aortic Aneurysm Signs/Symptoms Normal or elevated upper extremity BP in “shocky” patient CHF if aortic valve is involved Acute MI if coronary ostia involved Rupture into pericardial space or chest cavity with circulatory collapse CNS symptoms from involvement of head/neck vessel origins Chest pain + neurological deficit = aortic aneurysm

Abdominal Aortic Aneurysm Signs/Symptoms Usually asymptomatic until large enough to be palpable as pulsing mass Usually tender to palpation Excruciating lower back pain from pressure on lumbar vertebrae May mimic lumbar disk disease or kidney stone Leaking/rupture may produce vascular collapse and shock Often presents with syncopal episode May result in unequal lower extremity pulses or unilateral paresthesia Urge to defecate caused by retroperitoneal leaking of blood Erosion into duodenum with massive GI bleed

Aortic Aneurysm Management ABCs High concentration O2 NRB Assist ventilations if needed Package patient for transport in MAST, inflate if patient becomes hypotensive IVs x 2 with LR enroute Draw labs 12 Lead ECG enroute if time permits If patient hypertensive consider reducing BP Nitropaste Beta blocker Consider analgesia Tolerated best if hypertensive Consider transport to facility with vascular surgery capability