NURSING CARE OF CLIENTS WITH
VASCULAR DISORDERS AND PROBLEMS
WITH PERIPHERAL CIRCULATION
Mrs. Ivy Rosales
RAYNAUD’S PHENOMENON
✓ It is a form of intermittent arteriolar
vasoconstriction that results in coldness,
pain, and pallor of the fingertips or toes.
✓ Attacks occur with exposure to cold or
stress.
✓ Episodes may be triggered by emotional
factors or by unusual sensitivity to cold.
2 FORMS:
1. Primary Idiopathic Raynaud’s
(Raynaud’s Disease) – there is no known
cause why the phenomenon occurs;
occurs suddenly
2. Secondary Raynaud’s (Raynaud’s
Syndrome) – there are underlying factors
why the disease occurs
Underlying factors:
a. Connective Tissue Disorders (e.g.
Systemic Lupus Erythematous,
Rheumatoid Arthritis and Obstructive
Arterial Lesions)
PATHOPHYSIOLOGY:
Stress and Cold
Hyperactive Sympathetic Activity
Severe Vascular Constriction of Blood Vessels
Hypoxia
Pallor
Cyanosis
Exaggerated flow due to Vasodilation
CLINICAL MANIFESTATIONS:
✓ The characteristic sequence of color
change of Raynaud’s phenomenon is
described as white, blue, and red.
✓ Numbness, tingling, and burning pain
occur as the color changes. The
involvement tends to be bilateral and
symmetric.
MEDICAL MANAGEMENT:
✓ Avoiding the particular stimuli (eg, cold,
tobacco) that provoke vasoconstriction is
a primary factor in controlling Raynaud’s
disease.
✓ Calcium channel blockers may be
effective in relieving symptoms.
✓ Studies indicate that nifedipine
(Procardia, Adalat) is an effective
calcium channel blocker for treating an
acute episode of vasospasm.
✓ Sympathectomy (interrupting the
sympathetic nerves by removing the
sympathetic ganglia or dividing their
branches) may help some patients.
NURSING MANAGEMENT:
✓ Monitor pulses
✓ Assist the client to identify and avoid
precipitating factors such as cold or
stress
✓ Instruct the client to wear layers of
clothing, hats, mittens, or gloves when
outside during the cold weather.
✓ Advise to avoid injuries to fingers and
hands
✓ Instruct to avoid smoking
✓ Patients should be informed about the
postural hypotension that may result from
medications, such as calcium channel
blockers, used to treat Raynaud’s
disease.
CHRONIC VENOUS INSUFFICIENCY OR
POST THROMBOTIC SYNDROME
✓ Results from obstruction of the venous
valves in the legs or a reflux of blood
through the valves
✓ Resultant venous hypertension can
occur
✓ Venous insufficiency results from
obstruction of the venous valves in the
legs or a reflux of blood back through the
valves.
✓ Superficial and deep leg veins can be
involved. Resultant venous hypertension
can occur whenever there has been a
prolonged increase in venous pressure,
such as occurs with deep venous
thrombosis. Because the walls of veins
are thinner and more elastic than the
walls of arteries, they distend readily
when venous pressure is consistently
elevated.
✓ In this state, leaflets of the venous valves
are stretched and prevented from closing
completely, allowing a backflow or reflux
of blood in the veins.
DUPLEX ULTRASONOGRAPHY
✓ Confirms obstruction and identifies level
of valvular incompetence
✓ 20 – 50% of post DVT patients that
develop deep vein incompetence suffer
post-thrombotic syndrome
CLINICAL MANIFESTATIONS:
✓ Edema
 ✓ Altered pigmentation
✓ Pain
✓ Stasis dermatitis
✓ Stasis Ulcer
✓ Hemosiderin staining – brownish
discoloration of tissues resulting from the
rupture of small skin veins, causing RBC
escape to surrounding tissues and
degenerate.
COMPLICATION:
✓ Venous ulceration is the most serious
complication of chronic venous
insufficiency and can be associated with
other conditions affecting the circulation
of the lower extremities.
✓ Cellulitis or dermatitis may complicate
the care of chronic venous insufficiency
and venous ulcerations.
MEDICAL AND NURSING MANAGEMENT:
✓ Elevating the legs decreases edema,
promotes venous return, and provides
symptomatic relief. The legs should be
elevated frequently throughout the day
(at least 15 to 30 minutes every 2 hours).
✓ Prolonged sitting or standing still is
detrimental; walking should be
encouraged.
✓ When sitting, the patient should avoid
placing pressure on the popliteal spaces,
as occurs when crossing the legs or
sitting with the legs dangling over the
side of the bed.
✓ Constricting garments such as panty
girdles or tight socks should be avoided.
✓ Elastic compression stockings are
recommended for people with venous
insufficiency (WITH AT LEAST 20-30
mmHg pressure used during 6 months
post-DVT)
✓ Extremities with venous insufficiency
must be carefully protected from trauma;
the skin is kept clean, dry, and soft.
LEG ULCERS
✓ A leg ulcer is an excavation of the skin
surface that occurs when inflamed
necrotic tissue sloughs off.
✓ Inadequate exchange of oxygen and
other nutrients in the tissue is the
metabolic abnormality that underlies the
development of leg ulcers.
✓ When cellular metabolism cannot
maintain energy balance, cell death
(necrosis) results.
CLINICAL MANIFESTATIONS:
Arterial Ulcers
✓ Arterial ulcers are small, circular, deep
ulcerations on the tips of toes or in the
web spaces between toes
✓ Occur on the medial side of the hallux or
lateral fifth toe and may be caused by a
combination of ischemia and pressure
Venous Ulcers
✓ Chronic venous insufficiency is
characterized by pain described as
aching or heaviness.
✓ The foot and ankle may be edematous.
✓ Ulcerations are in the area of the medial
or lateral malleolus (gaiter area) and are
typically large, superficial, and highly
exudative.
ASSESSMENT AND DIAGNOSTIC FINDINGS
✓ The history of the condition is important
in determining venous or arterial
insufficiency.
✓ Assess pulses of lower extremities
✓ Arteriography
✓ Venography
✓ Culture of ulcer bed - may be necessary
to determine whether the infecting agent
is the primary cause of the ulcer.
MEDICAL MANAGEMENT:
1. PHARMACOLOGIC THERAPY
✓ Antiseptics – Povidone Iodine,
Chlorhexidine
✓ Antibiotic therapy is prescribed when the
ulcer is infected; the specific antibiotic is
selected on the basis of culture and
sensitivity test results.
2. COMPRESSION THERAPY
✓ Anti-embolic stockings which is knee
high
3. DEBRIDEMENT
✓ Debridement is the removal of nonviable
tissue from wounds. Removing the dead
tissue is important, particularly in
instances of infection.
Types:
a. Surgical
b. Non-selective
c. Enzymatic
d. Calcium algenate dressings
e. Foam dressings
✓ Sharp surgical debridement - is the
fastest method and can be performed by
a physician, skilled advanced practice
nurse, or certified wound care nurse in
collaboration with the physician.
✓ Nonselective debridement - can be
accomplished by applying isotonic saline
dressings of fine-mesh gauze to the
ulcer.
✓ Enzymatic debridement - It is with the
application of enzyme ointments may be
prescribed to treat the ulcer. The
ointment is applied to the lesion but not
to normal surrounding skin.
✓ Calcium alginate dressings – This can
also be used for debridement when
 absorption of exudate is needed.
Calcium alginate dressings can also be
used for debridement when absorption of
exudate is needed. These dressings are
changed when the exudate seeps
through the cover dressing or at least
every 7 days.
NOTE: For dry gangrene from arterial
insufficiency, it is best left unattended.
4. TOPICAL THERAPY
✓ A variety of topical agents can be used in
conjunction with cleansing and
debridement therapies to promote
healing of leg ulcers.
5. WOUND DRESSING
✓ After the circulatory status has been
assessed and determined to be
adequate for healing (ABI of more than
0.5), surgical dressings can be used to
promote a moist environment.
6. STIMULATED HEALING
✓ Tissue-engineered human skin
equivalent along with therapeutic
compression has been developed by
Apligraf; it is a skin product cultured from
human dermal fibroblasts and
keratinocytes.
✓ When applied, it seems to react to factors
in the wound and may interact with the
patient’s cells to stimulate the production
of growth factors.
7. HYPERBARIC OXYGEN THERAPY
✓ Very useful in diabetic patients for wound
healing
✓ This is beneficial as an adjunct for the
treatment of diabetes mellitus with no
signs of wound healing after 30 days of
standard wound treatment.
✓ A patient is placed in a chamber then
high doses of oxygen is given to the
patient. The treatment varies from 90 to
120 minutes once a day for about 30 to
90 sessions
8. NEGATIVE WOUND PRESSURE
THERAPY
✓ This suggest that negative wound
pressure therapy decreases time of
wound healing especially for wounds that
have not healed over a 3-weeks period.
NURSING MANAGEMENT:
1. Restore skin integrity:
✓ Cleansing requires very gentle handling,
a mild soap, and lukewarm water.
✓ Positioning of the legs depends on
whether the ulcer is of arterial or venous
origin. If there is arterial insufficiency, the
patient should be referred to be
evaluated for vascular reconstruction. If
there is venous insufficiency, dependent
edema can be avoided by elevating the
lower extremities.
✓ Avoiding trauma to the lower extremities
is imperative in promoting skin integrity.
✓ When the patient is in bed, a bed cradle
can be used to relieve pressure from bed
linens and to prevent anything from
touching the legs
✓ Heating pads, hot-water bottles, or hot
baths are avoided. Heat increases the
oxygen demands and thus the blood flow
demands of the tissue, which in this case
are already compromised.
2. Improving Physical Mobility
✓ Generally, physical activity is initially
restricted to promote healing.
✓ When infection resolves and healing
begins, ambulation should resume
gradually and progressively.
✓ Until full activity resumes, the patient is
encouraged to move about when in bed,
to turn from side to side frequently, and
to exercise the upper extremities to
maintain muscle tone and strength.
✓ If pain limits the patient’s activity,
analgesics may be prescribed by the
physician.
3. PROMOTING ADEQUATE NUTRITION
✓ A diet that is high in protein, vitamins C
and A, iron, and zinc is encouraged in an
attempt to promote healing.
VARICOSE VEINS
✓ Varicose veins (varicosities) are
abnormally dilated, tortuous, superficial
veins caused by incompetent venous
valves
✓ Most commonly, this condition occurs in
the lower extremities, the saphenous
veins, or the lower trunk; however, it can
occur elsewhere in the body, such as
esophageal varices.
✓ The condition is most common in women
and in people whose occupations require
prolonged standing, such as
salespeople, hair stylists, teachers,
nurses, ancillary medical personnel, and
construction workers.
✓ A hereditary weakness of the vein wall
may contribute to the development of
varicosities, and it is not uncommon to
see this condition occur in several
members of the same family.
✓ Pregnancy may cause varicosities –
because of hormonal changes and
increased pressure of the gravida uterus
TYPES:
1. PRIMARY
✓ Without involvement of deep veins
2. SECONDARY
✓ Resulting from obstruction of deep veins
CLINICAL MANIFESTATIONS:
✓ Asymptomatic (superficial veins), but
may be troubled by their appearance
✓ Dull aches
✓ Muscle cramps
✓ Increased muscle fatigue in the lower
legs
✓ Ankle edema
✓ Feeling of heaviness in the legs
DIAGNOSTIC TESTS:
1. Diagnostic Ultrasound Scan - which
documents the anatomic site of reflux
and provides a quantitative measure of
the severity of valvular reflux.
2. CT Venography - It involves injecting an
x-ray contrast agent into the leg veins so
that the vein anatomy can be visualized
by x-ray studies during various leg
movements.
PREVENTION:
✓ Avoid activities that cause venous stasis,
such as wearing tight socks or a
constricting panty girdle.
✓ Avoid crossing the legs at the thighs
✓ Avoid sitting or standing for long periods
✓ Change position frequently
✓ Elevate legs 3-6 cm higher than the heart
level when tired
✓ Walk for several minutes (30 mins/day)
✓ Swimming
✓ Use knee high compression stockings
✓ Weight reduction plan
MEDICAL MANAGEMENT:
1. LIGATION AND STRIPPING
✓ The saphenous vein is ligated and
divided. The vein is ligated high in the
groin, where the saphenous vein meets
the femoral vein. Additionally, the vein
may be removed (stripped). After the vein
is ligated, an incision is made 2 to 3 in the
knee, and metal or plastic wire is passed
the full length of the vein to the point of
ligation.
2. THERMAL ABLATION
✓ It is a non-surgical approach using
thermal energy. There is a radio
frequency ablation using an electrical
contact inside the vein.
3. SCLEROTHERAPY
✓ In sclerotherapy, a chemical is injected
into the vein, irritating the venous
endothelium and producing localized
phlebitis and fibrosis, thereby obliterating
the lumen of the vein.
✓ Sclerosing is palliative rather than
curative
✓ After the sclerosing agent is injected,
elastic compression bandages are
applied to the leg and are worn for
approximately 5 days.
✓ Elastic compression stockings are then
worn for an additional 5 weeks.
LYMPHANGITIS AND LYMPHADENITIS
ANATOMY:
✓ The lymphatic system is consisted of set
of vessels that spread throughout the
body.
✓ Lymph – is the fluid drained from the
interstitial space by the system
LYMPHANGITIS
- It is an acute inflammation of the lymphatic
channels. It arises most commonly from a
focus of infection in an extremity. Usually,
the infectious organism is a hemolytic
Streptococcus.
- The characteristic red streaks that extend up
the arm or the leg from an infected wound
outline the course of the lymphatic vessels
as they drain
LYMPHADENITIS
- The lymph nodes located along the course
of the lymphatic channels also become
enlarged, red, and tender.
- They can also become necrotic and form an
abscess (suppurative lymphadenitis).
- The nodes involved most often are those in
the groin, axilla, or cervical region
MANAGEMENT:
1. Antibiotics
2. After acute attacks, advise the client to
wear graduated compression stocking for
several months
LYMPHEDEMA AND ELEPHANTIASIS
LYMPHEDEMA
- Lymphedemas are classified as primary
(congenital malformations) or secondary
(acquired obstructions).
- Tissue swelling occurs in the extremities
because of an increased quantity of lymph
that results from obstruction of lymphatic
vessels.
Types:
1. CONGENITAL EDEMA (LYMPHEDEMA
PRAECOX)
✓ The most common type is congenital
lymphedema (lymphedema praecox),
which is caused by hypoplasia of the
lymphatic system of the lower
extremity.
✓ This disorder is usually seen in
women and first appears between
ages 15 and 25.
ELEPHANTIASIS ✓ Also called essential hypertension,
- Lymphatic obstruction caused by a parasite defined as high BP from an unidentified
(filaria), frequently seen in tropics cause (95%)
- Chronic swelling of extremity 2. SECONDARY HYPERTENSION
- Carrier is a mosquito which causes cross- ✓ The term used to signify high blood
infection pressure from an identified cause.
MEDICAL MANAGEMENT: ✓ Occurs when cause of high BP can be
✓ The goal of therapy: To reduce and identified (kidney diseases, renal artery
control edema and prevent infection stenosis, sleep apnea, pregnancy,
1. Active and passive exercises pheochromocytoma, etc.) (5%)
2. Use of external compression device
3. If ambulatory, use compression CLASSIFICATION OF BLOOD PRESSURE
stockings FOR ADULTS 18 AND OLDER
4. When leg is affected, bed rest with leg CLASSIFICATION SBP DBP
elevated 1. NORMAL <120 <80
5. Manual Lymphatic Drainage – this is 2. PRE- 120-139 80-89
performed by professionally trained HYPERTENSION
therapist which is designed to direct or 3. STAGE 1 140-159 90-99
shift the congested limb through HYPERTENSION
functioning lymphatics that have 4. STAGE 2 > 160 >100
preserved damage. HYPERTENSION
6. Pharmacologic Therapy (diuretics and
antibiotics) ✓ Major risk factor for coronary, cerebral,
7. Surgery – excision of affection renal and peripheral vascular disease
subcutaneous tissue or fascia with skin ✓ Hypertension is sometimes called “the
grafting silent killer” because people who have it
a. Lymph node transfer – involves the are often symptom free.
surgical relocation of a superficial ✓ Hypertension can result from increase in
lymphatic vessel into the deep cardiac output, increase in peripheral
lymphatic system resistance or both.
b. Lymphatic venous bypass – ✓ It is a multifactorial condition
performed with anastomosing the end
of the lymphatic vessel to the side of BLOOD PRESSURE:
the veins to reduce lymphatic flow on ✓ Product of cardiac output x peripheral
the nerve. resistance
CARDIAC OUTPUT:
NURSING MANAGEMENT: ✓ Heart rate x stroke volume
After surgery
1. Constant elevation of affected extremity RISK FACTORS:
2. Observe for complications ✓ Advancing adult age
3. Instruct patient/caregiver to inspect the ✓ African-American race
dressing daily ✓ Drinking too much alcohol
4. Inform patient regarding loss of sensation ✓ Family history of hypertension
in affected area ✓ Gender related (men have greater risk)
5. Avoid application of heating pads ✓ Overweight and obesity
✓ Poor diet habits
NURSING CARE OF CLIENTS WITH ✓ Sedentary lifestyle
HYPERTENSION ✓ Use of tobacco products such as
cigarettes
HYPERTENSION ✓ Stress
- Hypertension is a systolic blood pressure ✓ Sleep apnea
greater than 140 mm Hg and a diastolic
pressure greater than 90 mm Hg over a CLINICAL MANIFESTATIONS:
sustained period, based on the average of ✓ May be asymptomatic
two or more blood pressure measurements ✓ Headache
taken in two or more contacts with the health ✓ Visual disturbances
care provider after an initial screening. (ASH ✓ Dizziness
& ISH) ✓ Chest pain
TYPES: ✓ Tinnitus
1. PRIMARY HYPERTENSION ✓ Flushed face
✓ The reason for the elevation in blood ✓ Epixtasis
pressure cannot be identified. ✓ Retinal changes
ASSESSMENT AND DIAGNOSTIC FINDINGS
1. The retinas are examined, and laboratory
studies are performed to assess possible
target organ damage.
2. Routine laboratory tests include
urinalysis, blood chemistry (ie, analysis
of sodium, potassium, creatinine, fasting
glucose, and total and high-density
lipoprotein [HDL] cholesterol levels), and
a 12-lead electrocardiogram.
3. Echocardiography
4. Creatinine clearance, renin level, 24-hour
urine protein – to assess kidney function
5. Risk assessment
MEDICAL MANAGEMENT:
✓ Individualized for each client,
medication selection is based on age,
culture, pre-existing conditions,
severity of hypertension and client’s
preferences.
a. Diuretics
b. Vasodilators
c. ACE Inhibitors
d. Angiotensin-2 Blockers
e. Calcium-Channel Blockers
NURSING INTERVENTIONS:
1. Emphasize the concept of controlling
hypertension rather than curing it
2. Advise on restricted sodium and fat,
increase fruit and vegetable diet
3. Implement physical mobility
4. Advise to limit alcohol intake
5. Avoid tobacco use
6. Promote adherence to therapeutic
regimen
HYPERTENSIVE CRISIS
✓ There are two hypertensive crises
that require nursing intervention:
hypertensive emergency and
hypertensive urgency.
1. HYPERTENSIVE EMERGENCY
- Hypertensive emergency is a
situation in which blood pressure
must be lowered immediately (not
necessarily to less than 140/90
mm Hg) to halt or prevent damage
to the target organs.
- Conditions associated with
hypertensive emergency include
acute myocardial infarction,
dissecting aortic aneurysm, and
intracranial hemorrhage.
- The medications of choice in
hypertensive emergencies are
those that have an immediate
effect. Intravenous vasodilators,
including sodium nitroprusside
(Nipride, Nitropress), nicardipine
hydrochloride (Cardene),
fenoldopam mesylate (Corlopam),
enalaprilat (Vasotec I.V.), and
nitroglycerin (Nitro-Bid IV, Tridil),
have an immediate action that is
short lived (minutes to 4 hours),
and they are therefore used as the
initial treatment.
2. HYPERTENSIVE URGENCY
- Hypertensive urgency is a
situation in which blood pressure
must be lowered within a few
hours.
- Severe perioperative
hypertension is considered a
hypertensive urgency
- Hypertensive urgencies are
managed with oral doses of fast-
acting agents such as loop
diuretics (bumetanide [Bumex],
furosemide [Lasix]), beta-blockers
propranolol (Inderal), metoprolol
(Lopressor), nadolol (Corgard),
angiotensin-converting enzyme
inhibitors (benazepril [Lotensin],
captopril [Capoten], enalapril
[Vasotec]), calcium antagonists
(diltiazem [Cardizem], verapamil
[Isoptin SR, Calan SR, Covera
HS]), or alpha2-agonists, such as
clonidine (Catapres) and
guanfacine (Tenex).
INTERVENTION:
1. Maintain patent airway
2. Administer hypertensive medications a s
prescribed.
3. Monitor vital signs every 5 minutes is
appropriate if the blood pressure is
changing rapidly or may check vital signs
at 15- or 30-minutes intervals if the
situation is more stable.
4. Maintain bed rest with head elevated at
45-degree angle
5. Assess for hypotension, place in supine
hypotension if it occurs
6. Have emergency medications and have
equipment readily available
7. Monitor IV therapy, assess for fluid
overload
8. Insert foley catheter as prescribed
9. Monitor I&O, if oliguria or anuria occurs,
notify the doctor.