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

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

3. Systemic and Pulmonary Circulation

4. 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

5. Assessing Peripheral Pulses

6. Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites

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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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

14. Progression of Atherosclerosis

15. Common Sites of Atherosclerotic Obstruction

16. 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

17. 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

18. 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.

19. 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.

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

21. Characteristics of Arterial Aneurysms

22. Repair of an Ascending Aortic Aneurysm

23. 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

24. 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.

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

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

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

28. 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.

29. 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

30. 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.

31. 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.

32. 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

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

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

35. 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

36. Collaborative Problems and Potential Complications
Infection
Gangrene

37. 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.

38. 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

39. Restoring Skin Integrity
Cleansing wound
Positioning
Avoiding trauma
Avoid heat sources

40. 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

41. 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.

42. 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.

43. 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

44. 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

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

46. 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.