1. Chapter 36
Vascular Disorders 1

2. Learning Objectives
Identify specific anatomic and physiologic factors that affect
the vascular system and tissue oxygenation.
Indicate appropriate parameters for assessing a patient
with peripheral vascular disease, aneurysm, and aortic
dissection.
Discuss tests and procedures used to diagnose selected
vascular disorders and the nursing considerations for
each.
Describe the pathophysiology, signs and symptoms,
complications, and medical or surgical treatments for
selected vascular disorders.
Assist in developing a plan of care for patients with selected
vascular disorders.

3. Anatomy and Physiology of the Vascular System3

4. Arteries
Vessels that carry blood away from the heart toward the tissues
Thick-walled structures with three layers: intima, media, and adventitia
Smooth muscles encircle and control the diameter
What is the largest artery in the body?
Contraction of the muscles constricts the vessels, whereas relaxation of the muscles results in vessel dilation. 4

5. Capillaries
Arterioles branch into progressively smaller vessels, then form the capillaries
A single layer of endothelial cells that allow the efficient delivery of nutrients and oxygen into the tissues and the removal of metabolic wastes from the tissues
Tiny vessels that receive blood from the capillaries are venules, the smallest veins
Red blood cells have to conform to the size of the capillaries by changing their shape to fit through the small diameter.
How is the distribution of capillaries determined?
Because capillaries have less smooth muscle than the arteries, the amount of blood in the capillary is controlled by sphincters on the arteriolar side of the capillary. 5

6. Figure 36-1 6

7. Figure 36-2 7

8. Veins The vessels that return blood to the heart
Formed as capillaries organize into larger and larger vessels
Composed of the same layers as the arteries and arterioles, but the layers are less defined
The venous system is less sturdy and more passive than the arterial system.
Because the walls of the veins and venules are thinner and less muscular, they can stretch more than those of the arterial system.
How much of the body’s total blood volume is housed in the venous system? 8

9. Veins Valves Innervation
Allow blood to move in only one direction and prevent backflow of blood in the extremities
Innervation
The sympathetic nervous system acts on the musculature of the veins to stimulate venoconstriction
Blocking of sympathetic nerve stimulation permits venodilation
The venous system is equipped with valves that are composed of endothelial leaflets.
Skeletal muscle contractions compress the veins, forcing blood back toward the heart; this action reduces venous pooling and increases the circulating blood volume.
How are carbon dioxide and other metabolic wastes eliminated? 9

10. Figure 36-3 10

11. Lymph Vessels
Lymph system: small, thin-walled vessels that resemble the capillaries
Accommodate the collection of lymph fluid from the peripheral tissues and the transportation of the fluid to the venous circulatory system
Lymph fluid is composed of plasma-like fluid, large protein molecules, and foreign substances
Movement by the contraction of muscles that encircle the lymphatic walls and surrounding tissues
Because the lymph system interacts with the venous system, it is classified as part of the cardiovascular system.
What are the two main trunks of the lymph system? 11

12. Factors That Affect Blood Flow
Resistance
Controlled by the diameter of the vessels
When vascular diameter increases, peripheral resistance falls and blood flow increases
When vascular diameter decreases, peripheral resistance increases, thereby reducing blood flow
The sympathetic nervous system plays a major role in adjusting vascular resistance.
What factors cause changes in vascular resistance? 12

13. Factors That Affect Blood Flow
Blood viscosity
Thickness of the blood
Can be affected by changes in the proportions of the solid or liquid components
Capillary permeability affects blood viscosity
If capillary permeability altered, the amount and direction of fluid movement changes; results in change in viscosity
What is hemoconcentration?
When the proportion of serum to solid components in the blood is higher than normal, blood is less viscous and the kidneys excrete excess fluid. 13

14. Age-Related Changes Arteriosclerosis Stiffening of the vessel walls
Delivery of oxygen and nutrients to tissues is compromised; buildup of waste products in tissue
Decrease of hemoglobin
Produces a decline in the oxygen-carrying capacity of the blood
Slowing heart rate and decrease in stroke volume
The stiffening of the peripheral vessels associated with aging occurs in both the intima and the media of the vessel wall.
What occurs when there is a loss of elasticity in the peripheral vessels? 14

15. Chief Complaint and History of Present Illness
Focuses on the six classical “Ps” of peripheral vascular disease: pain, pulselessness, poikilothermy, pallor, paresthesia, and paralysis 15

16. Past Medical History
Document a history of hypertension, coronary artery disease, myocardial infarction, or atherosclerosis 16

17. Family History
Relevant diseases: hypertension, coronary artery disease, myocardial infarction, atherosclerosis, aneurysm, and diabetes 17

18. Assessment of the Vascular System
Review of systems
Changes associated with PVD: thick, brittle nails; shiny, taut, scaly, dry skin; skin temperature variations; skin ulcerations; muscle atrophy; localized redness and hardness; and hair loss on the extremities
Assess for chest pain and dyspnea
Assess for symptoms of aneurysms: hoarseness, dysphagia, dyspnea, abdominal or back pain, or swelling of the head and arms
How are a Homans’ sign and an Allen’s test performed? 18

19. Assessment of the Vascular System
Functional assessment
Determines the effect of the disease on the patient’s life 19

20. Assessment of the Vascular System
Physical examination
Inspect the skin for color and lesions
Capillary refill time in the nail beds
Palpate affected areas to evaluate temperature, detect edema, and assess peripheral pulses
Homans’ sign
Allen test 20

21. Figure 36-4 21

22. Diagnostic Tests and Procedures
Ultrasonography
Pressure measurements
Plethysmography
Segmental plethysmography
Exercise (treadmill) test
Angiography
Tomographic angiography
Magnetic resonance angiography
Arteriography
Venography 22

23. Therapeutic Measures Exercise programs Stress management
Pain management
Smoking cessation
Elastic stockings
Intermittent pneumatic compression
Positioning
Thermotherapy
Protection
Patient teaching
Embolectomy is the removal of a blood clot located in a large vessel.
Percutaneous transluminal angioplasty is used to gain access to the arteries in the lower extremities in people who are poor surgical risks.
Endarterectomy: emboli and atherosclerotic plaque are stripped away from the intima of the vessel, and the vessel is surgically closed.
A sympathectomy may be done to improve vascular circulation when the patient has intermittent claudication.
What disorder is treated with vein ligation and stripping?
Sclerotherapy is a method for managing varicose veins, primarily for cosmetic treatment of small, prominent varicosities. 23

24. Figure 36-5 24

25. Figure 36-6 25

26. Therapeutic Measures Surgical procedures Embolectomy
Percutaneous transluminal angioplasty
Endarterectomy
Sympathectomy
Vein ligation and stripping
Sclerotherapy 26

27. Nursing Care Related to Surgery
Preoperative nursing care
Patient with severe cardiovascular disease may have activity restrictions to reduce demands on circulatory system until the surgical procedure is done
Affected extremity should be maintained in a level or slightly dependent position as ordered
Optimize peripheral circulation: keep extremity warm
Protect the limb from further injury
If peripheral pulses disappear, what should be suspected?
During the recovery period, emphasize that the patient should not cross the legs or place the affected extremity in a dependent position for long periods of time.
Elevating the extremity helps prevent edema. 27

28. Nursing Care Related to Surgery
Postoperative nursing care
Primary goal of the postoperative period is to stimulate circulation by encouraging movement and preventing stasis within the extremity
If peripheral pulses disappear, what should be suspected?
During the recovery period, emphasize that the patient should not cross the legs or place the affected extremity in a dependent position for long periods of time.
Elevating the extremity helps prevent edema. 28

29. Nursing Care Related to Surgery
Drugs
Anticoagulants
Thrombolytics
Platelet aggregation inhibitors
Vasodilators
Nonsteroidal anti-inflammatory drugs
Analgesics 29

30. Nursing Care Related to Surgery
Dietary interventions
Low-fat diets reduce serum cholesterol levels
Weight-reduction diet if the patient is obese
Adequate vitamin B, vitamin C, and protein needed to promote healing and improve tissue integrity
Why is obesity a concern for the vascular system? 30

31. Disorders of the Peripheral Vascular System31

32. Arterial Embolism Pathophysiology
Usually forms in the heart, but a roughened atheromatous plaque in any artery also can lead to thrombus formation
If a thrombus breaks loose, it becomes an embolus and travels through the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion
The development of an arterial embolism is a potentially life-threatening event.
What do the affects of arterial occlusion depend on? 32

33. Arterial Embolism Signs and symptoms Severe, acute pain
Gradual loss of sensory and motor function in the affected areas
Pain aggravated by movement or pressure
Absent distal pulses
Pallor and mottling (irregular discoloration)
Sharp line of color and temperature demarcation: tissue beyond the obstruction is pale and cool 33

34. Arterial Embolism Medical and surgical treatment
Intravenous anticoagulants and thrombolytic agents
Embolectomy
When should anticoagulants and thrombolytic agents not be used? 34

35. Interventions Ineffective Tissue Perfusion Fear
Impaired Physical Mobility
Impaired Skin Integrity
Ineffective Therapeutic Regimen Management 35

36. Peripheral Arterial Occlusive Disease
Atherosclerosis obliterans, arterial insufficiency, and peripheral vascular disease
Pathologic changes in the arteries, typically plaque formations that arise where the arteries branch, veer, arch, or narrow
Common sites for arterial occlusion are the distal superficial femoral and the popliteal arteries
Occlusions prevent delivery of oxygen and nutrients to the tissues
Hypoxia affects all tissues distal to the occlusion
Peripheral nerves and muscles are more susceptible to harm from hypoxia than the skin and subcutaneous tissues.
What are the effects of severe oxygen deprivation? 36

37. Figure 36-7 37

38. Peripheral Arterial Occlusive Disease
Signs and symptoms
Intermittent claudication
Absence of peripheral pulses below occlusive area
Rest pain
Tingling or numbness or both in the toes
Extremity is cold, numb, and pale
Shiny, scaly skin; subcutaneous tissue loss; hairlessness on the affected extremity; and ulcers with a pale gray or yellowish hue, especially at ankles
What may cause the toenails to thicken?
If one extremity is affected more than the other, size differences between the extremities may be apparent. 38

39. Peripheral Arterial Occlusive Disease
Medical diagnosis
Duplex imaging
Angiography 39

40. Peripheral Arterial Occlusive Disease
Medical and surgical treatment
Lifestyle changes
Smoking cessation, exercise, weight management
Treatment for hypertension, hyperlipidemia, or diabetes
Drugs for claudication: cilostazol and pentoxifylline
Surgical interventions
Percutaneous transluminal angioplasty, atherectomy, and endarterectomy
What frequency of exercise programs have been found to be most successful with peripheral arterial disease?
An endarterectomy with a graft is the surgical replacement of a diseased segment of an artery with a graft of some type—either synthetic or from another blood vessel.
Percutaneous transluminal angioplasty (PTA) is used to enlarge the interior diameter of the blood vessel. 40

41. Peripheral Arterial Occlusive Disease
Assessment
Assess the pulses distal to the surgical site and compare with the same pulses in the unaffected extremity
Assess vital signs, color, and temperature of affected extremity, fluid intake and output, central venous pressure, and mental status
Cessation of a pulse suggests possible arterial occlusion, and the surgeon must be notified immediately. 41

42. Peripheral Arterial Occlusive Disease
Interventions
Activity Intolerance
Chronic Pain
Impaired Skin Integrity
Pain
Disturbed Body Image
Ineffective Tissue Perfusion
Risk for Infection
Decreased Cardiac Output
Ineffective Therapeutic Regimen Management
Impaired Physical Mobility 42

43. Thromboangiitis Obliterans
Also called Buerger’s disease
Inflammatory thrombotic disorder of arteries and veins in lower and upper extremities
Cause is unknown, but it occurs only in smokers
Signs and symptoms: intermittent claudication, rest pain, skin color/temperature changes in affected areas, cold sensitivity, abnormal sensation, ulceration, gangrene
Diagnosis based on physical findings and arteriography
Most important treatment is smoking cessation
Palliative treatments include sympathectomy and drugs, such as calcium channel blockers, antibiotics, and anticoagulants 43

44. Raynaud’s Disease Pathophysiology Signs and symptoms Medical diagnosis
Intermittent constriction of arterioles; affects hands primarily, but it can affect the toes and tip of the nose
Signs and symptoms
Chronically cold hands, numbness, tingling, and pallor
During an arterial spasm, the skin color changes from pallor to cyanosis to redness
Medical diagnosis
Based on the signs and symptoms and on the absence of evidence of occlusive vascular disease
The cause of this condition is unknown, but it may be related to hypersensitivity to cold or release of serotonin.
Who is primarily affected by Raynaud’s disease?
Finger involvement is not symmetric, and the thumb is not usually affected. 44

45. Raynaud’s Disease Medical and surgical treatment Drugs Sympathectomy
Calcium channel blockers, transdermal nitroglycerin, an endothelin receptor antagonist, phosphodiesterase inhibitors, and intravenous prostaglandins
Sympathectomy
What are the goals of medical treatment for Raynaud’s disease? 45

46. Interventions
Pain and Ineffective Tissue Perfusion
Fear 46

47. Aneurysms Pathophysiology
A dilated segment of an artery caused by weakness and stretching of the arterial wall; can be congenital or acquired
What conditions are associated with congenital aneurysms?
Acquired aneurysms can be caused by arteriosclerosis, trauma, or infection.
The most common cause of aneurysms is atherosclerosis. 47

48. Aneurysms Signs and symptoms
Thoracic aneurysms usually have no symptoms, though some report deep, diffuse chest pain
If aneurysm puts pressure on the recurrent laryngeal nerve, patient may complain of hoarseness
Pressure on the esophagus may cause dysphagia
If superior vena cava compressed, edema of the head and arms
Signs of airway obstruction may be present if the aneurysm presses against pulmonary structures
Abdominal aneurysms may be palpated as a pulsating mass in the area slightly left of the umbilicus 48

49. Aneurysms Complications Medical diagnosis
Rupture, thrombus formation that obstructs blood flow, emboli, pressure on surrounding structures
Medical diagnosis
Physical findings, echocardiography, ultrasonography, computed tomography, aortography
Medical and surgical treatment
Repair of aneurysms done by replacing the dilated segment of the artery with synthetic graft or, in some cases, by suturing or patching the defective area
Repair is usually done as soon as possible but may be delayed until the patient is evaluated for other problems that increase surgical risk.
What factors affect the decision to repair an aneurysm? 49

50. Aneurysms Preoperative nursing care
It is important to document chronic conditions, such as emphysema or heart disease, that increase the risk of postoperative complications 50

51. Postoperative Nursing Care
Assessment
Monitor vital signs, hemodynamic status, renal function, and fluid balance. Inspect and palpate the extremities for color, warmth, and peripheral pulses 51

52. Postoperative Nursing Care
Interventions
Impaired Urinary Elimination
Risk for Injury
Ineffective Breathing Patterns
Decreased Cardiac Output
Ineffective Tissue Perfusion 52

53. Aortic Dissection
A small tear in the intima permits blood to escape into the space between the intima and the media
Blood accumulates between the layers, causing the media to split lengthwise
The split may extend up and down the aorta, where it can occlude major arteries 53

54. Aortic Dissection
If no complications, patient managed with antihypertensives and drugs to decrease the strength of cardiac contractions
Otherwise, affected area is replaced with a synthetic graft
A key aspect of postoperative care: keep blood pressure at lowest possible level
In other respects, the care is similar to that of a patient who has had an aneurysm repair 54

55. Varicose Vein Disease Pathophysiology
Varicosities are dilated, tortuous, superficial veins, often the saphenous veins in the lower extremities
Dilation of the vessels results from incompetent valves in the veins
Classified as primary (only superficial veins affected) and secondary (characterized by deep vein obstruction)
What are the risk factors of varicose vein disease?
In addition to peripheral veins, varicosities can occur in other areas such as the esophageal and hemorrhoidal veins. Incompetent valves cannot be repaired. 55

56. Varicose Vein Disease Signs and symptoms
Oversized, discolored (purplish), and tortuous veins
Dull aching sensations when standing or walking; a feeling of heaviness in the affected legs; muscle cramps, especially at night; increased muscular fatigue in the affected area; and ankle edema
The onset of varicose vein disease is gradual, but the condition is progressive.
What are symptoms that postphlebitic syndrome has developed? 56

57. Figure 36-8 57

58. Varicose Vein Disease Varicose vein disease Medical diagnosis
Based on their appearance and duplex ultrasonography
Medical and surgical treatment
Avoid restrictive garments, prolonged standing or sitting, crossing the legs or knees, and injury to compromised areas
Weight reduction
Support stockings
Sclerotherapy or laser therapy
Ligation and stripping
Conservative treatments of varicosities are used whenever possible.
When would surgery be recommended for varicose vein disease? 58

59. Varicose Vein Disease Assessment
Health history determines pain, edema, cramps, and muscle fatigue
Note family history of varicose veins
Patient’s occupation and usual activities
Physical examination: inspect the legs for color, edema, turgor, and capillary refill
Palpate the legs for tenderness 59

60. Varicose Vein Disease Interventions
Improve activity tolerance and manage pain
Surgical patient
Patient teaching 60

61. Venous Thrombosis Pathophysiology Phlebitis Thrombophlebitis
Inflammation of the vein wall
Thrombophlebitis
Clot has formed at the site of inflammation within a vein
Phlebothrombosis
Presence of a thrombus in a vein as a result of stasis, deviation of the intima, or hypercoagulability
Deep vein thrombosis
Clot in a deep vein rather than in superficial vessels 61

62. Venous Thrombosis Risk factors Prescribed bed rest
Surgery for people older than 40 years of age
Leg trauma resulting in immobilization from casts or traction
Previous venous insufficiency
Obesity
Use of oral contraceptives
What is Virchow’s triad? 62

63. Venous Thrombosis Signs and symptoms Deep vein Superficial vessels
Edema, warmth, and tenderness at the area of compromise; positive Homans’ sign
Superficial vessels
Pain, redness, warmth, or tenderness in the affected area 63

64. Venous Thrombosis Medical diagnosis
Venography, Doppler ultrasonography, and duplex ultrasonography
Lung scan, pulmonary angiogram, or spiral CT scan if pulmonary embolism is suspected 64

65. Venous Thrombosis Medical and surgical treatment
Anticoagulant or thrombolytic therapy, or both
Patient teaching about the disease; ongoing assessment for pulmonary emboli; bed rest; elevation of the extremity; warm, moist soaks to the affected area; and antiembolism hose
Surgery considered when patient cannot receive anticoagulants or thrombolytic therapy or when high possibility of pulmonary emboli
What are the goals of treatment for venous thrombosis? 65

66. Venous Thrombosis Interventions Impaired Skin Integrity Pain Anxiety
Activity Intolerance
Ineffective Tissue Perfusion
Impaired Gas Exchange
Ineffective Therapeutic Regimen Management 66

67. Chronic Venous Insufficiency
Pathophysiology
Culmination of long-standing pressure that stretches the veins and damages the valves
Signs and symptoms
Edema around the lower legs, pain, brownish skin discoloration (stasis dermatitis), and stasis ulcerations
Heaviness or dull ache in the calf or thigh
Skin temperature is cool, and nails are normal
Feet and ankles often cyanotic when in a dependent position
Ulcers may form because of the pressure exerted by edema or as a result of trauma.
Where do ulcers most often develop? 67

68. Chronic Venous Insufficiency
Medical diagnosis
Physical examination 68

69. Chronic Venous Insufficiency
Medical and surgical treatment
Compression
Elastic or compression stockings and pneumatic compression device
If patient has an ulcer, special dressings, systemic antibiotics, topical débriding agents such as Elase, and Unna boots
Hyperbaric oxygen therapy
Unna boots are medicated dressings used to allow the patient to be ambulatory while protecting the ulcer in a sterile environment.
What is the overall goal for medical management of ulcerations? 69

70. Chronic Venous Insufficiency
Assessment
Inspect the lower extremities for rubor and stasis dermatitis, palpate skin temperature, and determine the presence of pain in the affected extremity 70

71. Chronic Venous Insufficiency
Interventions
Ineffective Tissue Perfusion
Disturbed Body Image
Risk for Infection
Impaired Skin Integrity 71

72. Lymphangitis Pathophysiology
Acute inflammation of the lymphatic channels
The inflammation is the result of an infectious process, usually caused by streptococcus 72

73. Lymphangitis Signs and symptoms
Enlargement of the lymph nodes along the lymphatic channel
Tenderness as these nodes are assessed
Red streak from the infected wound extends up the extremity along the path of the lymphatics
Elevated temperature and chills
Where are the lymphatic nodes located?
The infectious material can localize into an abscess with necrotic, suppurative discharge from the area. 73

74. Lymphangitis Medical diagnosis
Classic signs and symptoms, supported by wound culture results
Lymphangiography 74

75. Lymphangitis Medical and surgical treatment Antimicrobials
Abscess is incised to drain the suppurative material
Rest and elevation of the limb; warm, wet dressings; and elastic support hose 75

76. Lymphangitis Assessment Interventions
Inspect skin for open wounds, inflammation, and red streaks along the paths of lymphatic channels
Palpate lymph nodes in groin and underarm areas for enlargement
Interventions
Analgesics, antimicrobials, and elevation of the extremity to reduce lymphedema
Application of warm, moist soaks to the infected areas
Elastic support hose 76