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

Peripheral Blood Flow Flow rate = ΔP/R Movement of fluid across the capillary wall; hydrostatic and osmotic force Hemodynamic resistance Blood viscosity Vessel diameter Regulation of peripheral vascular resistance

Assessment Characteristics of arterial and venous insufficiency Intermittent claudication Rest pain Changes in skin and appearance Pulses Aging changes

Assessing Peripheral Pulses

Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites

Hematologic, Peripheral Vascular, and Lymphatic Systems Figure 33–13 (continued) Evaluation of edema. A, Palpating for edema over the tibia. B, Four-point scale for grading edema.

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.

ABI interpretation: ABI=1 normal (no arterial insufficiency) ABI= 0.95 mild arterial insufficiency ABI=0.5 moderate ABI< 0.5 ischemic rest pain ABI<0.25 sever ischemia (tissue loss)

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.

Improving Peripheral Arterial Circulation Exercises and activities: walking, 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

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

Progression of Atherosclerosis

Common Sites of Atherosclerotic Obstruction

Common Peripheral Vascular Figure 35–10 Common locations of venous thrombosis. A, The most common sites of DVT. B, DVT extending from the calf to the iliac veins. C, Superficial venous thrombosis.

Common Peripheral Vascular Figure 35–4 A magnetic resonance angiogram (MRA) showing a circumferential aneurysm of the lower abdominal aorta.

Common Peripheral Vascular Figure 35–5 An angiogram showing a saccular (berry) aneurysm in the carotid artery of a 50-year-old man.

Common Peripheral Vascular Figure 35–6 An angiogram showing a large aneurysm of the ascending aorta and aortic arch.

Common Peripheral Vascular Figure 35–7 An angiogram showing several popliteal aneurysms.

Common Peripheral Vascular Figure 35–9 Hands of a client with Raynaud’s phenomenon. Note cyanosis of fingers on the right hand and the left thumb and the extreme pallor of the other digits of the left hand.

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

Medical Management Prevention Exercise program Medications Pentoxifylline (Trental) and cilostazol (Pletal) Use of antiplatelet agents Surgical management

Medical management Trental (pentoxifylline): increase erythrocyte flexibility, reduce blood viscosity, and has antiplatlet effect. Pletal (cilostazol): decrease platelets aggregations, inhibit smooth muscles cell proliferations increase vasodilatations. Anti-platelets aggregating agents (aspirin, clopidogrel (Plavix)): prevent the formation of thromboemboli

Surgical managements Amputations (if occlusion is sever) Vascular grafting (anastemosis) depends on the degree and location of stenosis or occlusion. Endarterectomy: thrombus that obstruct the artery removed through incision to the artery affected.

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

Pathophysiology The exact cause is not known, but three reasons are known called Virchow’s triad: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. Thrombophelibitis: Phlebothrombosis: stasis or hypercoagulability but without inflammation.

Blood flow and function of valves in veins Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

Clinical Manifestation Deep veins: Edema and swelling of extremities Warm (affected extremity) Superficial vein appears more prominent Tenderness +ve homan’s sign (not specific) Superficial veins: Pain or tenderness, redness, and warmth. Can be treated with bed rest, leg elevations, analgesics, and anti-inflammatory drug.

Diagnosis: 1. Venography: The radiologist injects contrast material into a vein on the top of the foot. The blood clot appears as a defect in contrast material on the X-ray picture of the veins. 2. Duplex ultrasound: noninvasive procedure reflects gray-scale imaging for vein or artery. Help in determination the level and extent of venous disease and locate the disease stenosis or occlusion

Color Flow Duplex Image

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

Nursing Process: The Care of the Patient with Leg Ulcers—Assessment History of the condition Treatment depends upon the type of ulcer Assess for presence of infection Assess nutrition

Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis

Medical Management Anti-infective therapy is dependent upon 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 Impaired physical mobility Imbalanced nutrition

Collaborative Problems/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.

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 prior to activities

Other Interventions Skin integrity Nutrition Skin care/hygiene and wound care Positioning of legs to promote circulation Avoidance of trauma Nutrition Measures to ensure adequate nutrition Adequate protein, vitamin C and A, iron, and zinc are especially important for wound healing Include cultural considerations and patient teaching in the dietary plan

Varicose Veins (Varicosities) Are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves Occurs in lower extremities, in the saphenous system or the lower trunk Correlated with ↑ age, most in women, and people with occupation required prolonged standing Other factors that cause VV are: hereditary, pregnancy

Pathophysiology: Primary: without involvement of deep veins) Secondary: resulting from obstruction of deep veins Reflux of venous blood result in venous stasis Clinical Manifestations: Dull aches muscle cramps ↑ muscle fatigue in lower legs Ankle edema Feeling of heaviness of the legs If deep veins obstructed pt will have S&S of chronic venous insufficiency (edema, pain, pigmentation, ulceration) Increased susceptibility to infection and injury.

Dx test is duplex scan ( document the anatomic site of reflux and provide a measure for the severity of valvular reflux

Prevention: Avoid activity that cause venous stasis as ( wearing constrictive clothing, crossing the legs, sitting or standing for long periods) Change position frequently Elevating the legs Walking 1-2 miles each day Elastic stoking Control wt.

Medical Management Ligation and stripping: is done for primary VV, deep veins should be patent. Saphenous vein ligated in the groin where the saphenous vein meets the femoral vein, then 2-3 incision is made below the knee, stripper( wire) is inserted to the point of ligation, the wire is then withdrawn and vein as it is removed. Thermal ablation sclerotherapy

Nursing Management After surgery: Bed rest is discouraged and early ambulation is encouraged Instruct pt to walk Q one hour for 5-10min while awake for the 1st 24hr, then ↑ activity as tolerated Wear elastic stocking continuously for 1wk Elevate foot of bed Standing and sitting are discouraged

Promote comfort and understanding: give analgesic, inspect dressing for bleeding, alert for reported sensations of “pins and needles.” Hypersensitivity to touch in the involved extremity may indicate a temporary or permanent nerve injury resulting from surgery The patient is instructed to dry the incisions well with a clean towel using a patting technique, rather than rubbing The patient is instructed to apply sunscreen or zinc oxide to the incisional area prior to sun exposure If the patient underwent sclerotherapy, a burning sensation in the injected leg may be experienced for 1 or 2 days

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