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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 )

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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!!!

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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

31. 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

32. 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

33. 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

34. 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