1. 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. 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

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

6. Assessing Peripheral Pulses

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

8. 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.

9. 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.

10. 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)

11. 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

12. 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

13. 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.

14. 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

15. 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

16. Progression of Atherosclerosis

17. Common Sites of Atherosclerotic Obstruction

18. 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.

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

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

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

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

23. 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.

24. 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

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

26. 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

27. 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.

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

29. 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.

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

31. 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.

32. 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

33. Color Flow Duplex Image

34. 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.

35. 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

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

37. Medical Management
Anti-infective therapy is dependent upon infecting agent
Oral antibiotics are usually prescribed.
Compression therapy
Debridement of wound
Dressings
Other

38. Nursing Process: The Care of the Patient with Leg Ulcers- Diagnoses
Impaired skin integrity
Impaired physical mobility
Imbalanced nutrition

39. Collaborative Problems/Potential Complications
Infection
Gangrene

40. 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.

41. 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

42. 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

43. 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

44. 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.

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

46. 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.

47. 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

48. 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

49. 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

50. 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