MODULE 4:4

PERIPHERAL VASCULAR DISORDERS

 BASIC CONCEPTS
 Adequate perfusion ensures oxygenation and nourishment of body tissues, and it depends in part on a
properly functioning cardiovascular system.
 Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of
the blood vessels, and the adequacy of circulating blood volume.

PERIPHERAL VASCULAR SYSTEM

 REVIEW OF THE ANATOMY AND PHYSIOLOGY

1. ARTERIES AND ARTERIOLES

A. ARTERIES are thick-walled structures that carry blood from the heart to the tissues.

 The aorta: which has a diameter of approximately 2.5 cm (1 in) in the average-sized adult, gives rise to
numerous branches, which continue to divide into progressively smaller arteries that are 4 mm (0.16 in) in
diameter. The vessels divide further into smallest arteries, called arterioles, are generally embedded within
the tissues.

 LAYERS OF THE WALLS OF THE ARTERIES/ARTERIOLES:

a. INTIMA - an inner endothelial cell layer
b. MEDIA - a middle layer of smooth muscle and elastic tissue
c. ADVENTITIA - an outer layer of connective tissue

B. ARTERIOLES are often referred to as resistance vessels

 Arterioles regulate the volume and pressure in the arterial system and the rate of blood flow to the
capillaries.

2. CAPILLARIES
 The walls are composed of a single layer of endothelial cells
 This thin-walled structure permits rapid and efficient transport of nutrients to the cells and removal of
metabolic wastes.
 The diameter of capillaries ranges from 5 to 10 mcm

3. VEINS AND VENULES

 The walls are thin and less muscular that allows these vessels to distend more than arteries
 The veins are innervated by the sympathetic nervous system

 FUNCTION OF THE VASCULAR SYSTEM

A. Circulatory Needs of Tissues
The percentage of blood flow received by individual organs or tissues is determined by:
1. The rate of tissue metabolism
2. The availability of oxygen,
3. The function of the tissues.
 When metabolic requirements increase, blood vessels dilate to increase the flow of oxygen and nutrients
to the tissues.
 When metabolic needs decrease, vessels constrict and blood flow to the tissues decreases.
 Metabolic demands of tissues increase with physical activity or exercise, local heat application, fever, and
infection.
 Reduced metabolic requirements of tissues accompany rest or decreased physical activity, local cold
application, and cooling of the body.
 If the blood vessels fail to dilate in response to the need for increased blood flow, tissue ischemia results.
 The mechanism by which blood vessels dilate and constrict to adjust for metabolic changes ensures that
normal arterial pressure is maintained

B. Blood Flow
 Blood flow through the cardiovascular system always proceeds in the same direction: left side of the heart
to the aorta, arteries, arterioles, capillaries, venules, veins, vena cava, and right side of the heart.
 This unidirectional flow is caused by a pressure difference that exists between the arterial and venous
systems.
 Arterial pressure (approximately 100 mm Hg) is greater than venous pressure (approximately 40 mm Hg)
and fluid always flows from an area of higher pressure to an area of lower pressure, blood flows from the
arterial system to the venous system.
 Blood flow becomes turbulent when the blood flow rate increases, when blood viscosity increases, when
the diameter of the vessel becomes greater than normal, or when segments of the vessel are narrowed or
constricted.

C. Blood Pressure

D. Capillary Filtration and Reabsorption

 Fluid exchange across the capillary wall is continuous. This fluid, which has the same composition as plasma
without the proteins, forms the interstitial fluid.
 The equilibrium between hydrostatic and osmotic forces of the blood and interstitium, as well as capillary
permeability, determines the amount and direction of fluid movement across the capillary.
 Hydrostatic force is a driving pressure that is generated by the blood pressure.
 Osmotic pressure is the pulling force created by plasma proteins.

 Normally, the hydrostatic pressure at the arterial end of the capillary is relatively high compared with that
at the venous end.
 This high pressure at the arterial end of the capillaries tends to drive fluid out of the capillary and into the
tissue space.
 Osmotic pressure tends to pull fluid back into the capillary from the tissue space, but this osmotic force
cannot overcome the high hydrostatic pressure at the arterial end of the capillary.
The equilibrium between hydrostatic and osmotic forces of the blood and interstitium, as well as capillary
permeability, determines the amount and direction of fluid movement across the capillary.

E. Hemodynamic Resistance
 The most important factor that determines resistance in the vascular system is the vessel radius. Small
changes in vessel radius lead to large changes in resistance.
 Peripheral vascular resistance is the opposition to blood flow provided by the blood vessels.
 This resistance is proportional to the viscosity or thickness of the blood and the length of the vessel and is
influenced by the diameter of the vessels.
 Under normal conditions, blood viscosity and vessel length do not change significantly, and these factors do
not usually play an important role in blood flow.
However, a large increase in hematocrit may increase blood viscosity and reduce capillary blood flow.

I. ASSESSMENT OF THE VASCULAR SYSTEM

A. SUBJECTIVE DATA: HEALTH HISTORY
 Common symptoms:
1. Intermittent claudication ( rest pain)
 A muscular, cramp-type pain, discomfort, or fatigue in the extremities consistently reproduced with the
same degree of exercise or activity and RELIEVED BY REST
 due to inability of the arterial system to provide adequate blood flow to the tissues in the face of increased
demands for nutrients and oxygen during exercise.
 Worse at night and may interfere with sleep.
 This pain frequently requires that the extremity be lowered to a dependent position to improve perfusion
to the distal tissues.
 Intermittent claudication is a symptom of generalized atherosclerosis and may be a marker of occult
coronary artery disease.

B. OBJECTIVE DATA: PHYSICAL ASSESSMENT

B.1. INSPECTION
 Cool and pale extremities
 Rubor - a reddish-blue discoloration of the extremities, may be observed within 20 seconds to 2 minutes
after the extremity is placed in the dependent position.
 With rubor extremity begins to turn pale when elevated
 Cyanosis - is manifested when the amount of oxygenated hemoglobin contained in the blood is reduced.
 Loss of hair, brittle nails, dry or scaling skin, atrophy, and ulcerations
 Edema may be apparent bilaterally or unilaterally
 Gangrenous changes appear after prolonged, severe ischemia

B.2. PALPATION OF PULSES

 Determining the presence or absence, as well as the quality, of peripheral pulses
 Absence of a pulse proximal may indicate that the site of stenosis (narrowing or constriction) is proximal to
that location.

B.3. AUSCULTATION: auscultate for bruit

II. DIAGNOSTIC EVALUATION

A. Doppler Ultrasound Flow Studies - used to detect the blood flow in vessels.
 is used to measure brachial pressures in both arms.
B. Exercise Testing
 Exercise testing is used to determine how long a patient can walk and to measure the ankle systolic blood
pressure in response to walking.
 Typically, the patient walks on a treadmill at 1.5 mph with a 12% incline for a maximum of 5 minutes, or the
test can be modified to walking a set distance in a hallway.
 Normal response to the test is little or no drop in ankle systolic pressure after exercise.
C. Duplex Ultrasonography
 involves B-mode grayscale imaging of the tissue, organs, and blood vessels (arterial and venous) and
permits estimation of velocity changes by use of a pulsed Doppler Duplex ultrasound
 may be used to determine the level and extent of venous disease as well as chronicity of the disease.
 noninvasive and usually requires no patient preparation.
 Patients who undergo abdominal vascular duplex ultrasound, however, should be advised to not eat or
drink (i.e., NPO status) for at least 6 hours prior to the examination to decrease production of bowel gas
that can interfere with the examination.
 standard for diagnosing lower extremity venous thrombosis

D. Computed Tomography Scanning

 provides cross- sectional images of soft tissue and visualizes the area of volume changes to an extremity
and the compartment where changes take place.

E. Angiography
 An arteriogram produced by angiography may be used to confirm the diagnosis of occlusive arterial disease
when surgery or other interventions are considered.
 It involves injecting a radiopaque contrast agent directly into the arterial system to visualize the vessels

F. Magnetic Resonance Angiography

 Programmed to isolate and visualize the blood vessels; can be rotated and viewed from multiple angles
 MRA is contraindicated in patients with any metal implants or devices such as pacemakers, including old
tattoos

G. Contrast Phlebography (Venography)

 Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the
venous system.
 If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled
vein.
 Injection of the contrast agent may cause brief but painful inflammation of the vein.

COMMON NURSING DIAGNOSIS FOR PERIPHERAL VASCULAR DISORDERS:

1. Altered peripheral tissue perfusion
2. Pain
3. High risk for / impaired skin integrity
4. High risk for infection
5. Knowledge deficit
6. Disturbed body image

DISORDERS OF THE PERIPHERAL ARTERIES

A. PERIPHERAL VASCULAR DISEASE

1. ARTERIAL DISORDERS

1.A. Arteriosclerosis and Atherosclerosis

 ARTERIOSCLEROSIS (hardening of the arteries)

 It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and
arterioles become thickened.

 ATHEROSCLEROSIS involves a different process, affecting the intima of large and medium-sized arteries.
 These changes consist of the accumulation of lipids, calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery referred to as atheromas or plaques.

 PATHOPHYSIOLOGY
 The most common direct results of atherosclerosis in arteries include:
A. Narrowing (stenosis) of the lumen
B. Obstruction by thrombosis
C. Aneurysm, ulceration, and rupture.
 indirect results are malnutrition and the subsequent fibrosis of the organs that the sclerotic arteries supply
with blood
 All actively functioning tissue cells require an abundant supply of nutrients and oxygen and are sensitive to
any reduction in the supply of these nutrients.
 If such reductions are severe and permanent, the cells undergo ischemic necrosis and are replaced by
fibrous tissue, which requires much less blood flow.

 Two types of Atherosclerotic lesions : fatty streaks and fibrous plaque.

1. Fatty streaks are yellow and smooth, protrude slightly into the lumen of the artery, and are composed of
lipids and elongated smooth muscle cells.
2. Fibrous plaques are composed of smooth muscle cells, collagen fibers, plasma components, and lipids.
 They are white to white-yellow and protrude in various degrees into the arterial lumen, sometimes
completely obstructing it.
 These plaques are found predominantly in the abdominal aorta and the coronary, popliteal, and internal
carotid arteries, and believed to be progressive lesions
 Gradual narrowing of the arterial lumen stimulates the development of collateral circulation .
 Collateral circulation arises from pre- existing vessels that enlarge to reroute blood flow around a
hemodynamically significant stenosis or occlusion.
 Collateral flow allows continued perfusion to the tissues, but it is often inadequate to meet increased
metabolic demand, and ischemia results.

 MODIFIABLE RISK FACTORS

1. Nicotine use (i.e., tobacco product such as cigarettes, e-cigarettes, or chewing tobacco)
 one of the most important risk factors in the development of atherosclerotic lesions.
 Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by
stimulating the sympathetic nervous system, causing vasoconstriction.
 It also increases the risk of clot formation by increasing the aggregation of platelets.
 Nicotine from any tobacco product causes vasospasm thereby reducing circulation.
 Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity.
2. Diet - contributing to hyperlipidemia
3. Hypertension - a major risk factor in the development of PAD
4. Diabetes - speeds the atherosclerotic process by thickening the basement membranes of both large and
small vessels
5. Hyperlipidemia
6. Stress
7. Sedentary lifestyle
8. Elevated C-reactive protein
 C-reactive protein (CRP) is a sensitive marker of cardiovascular inflammation, both systemically and locally.
 Slight increases in serum CRP levels are associated with an increased risk of damage in the vasculature,
9. Hyperhomocysteinemia
 Homocysteine is a protein that promotes coagulation by increasing factor V and factor XI activity while
depressing protein C activation and increasing the binding of lipoprotein(a) in fibrin.
 These processes increase thrombin formation and the propensity for thrombosis.

 NONMODIFIABLE RISK FACTORS

1. Increasing age
2. Female gender
3. Familial predisposition/genetics

 PREVENTION
1. Measure serum cholesterol - include diet modification
2. Control blood pressure
3. Elimination of all controllable risk factors particularly the use of nicotine products

 CLINICAL MANIFESTATIONS
 The clinical signs and symptoms resulting from atherosclerosis depend on the organ or tissue affected.

 MEDICAL MANAGEMENT
 The management of atherosclerosis involves:
 Modification of risk factors
 Controlled exercise program to improve circulation and functioning capacity
 Medication therapy - Antihyperlipidemic agents e.g. Statins
 Interventional or surgical graft procedures.

A. SURGICAL MANAGEMENT
 Vascular surgical procedures are divided into two groups:
1. Inflow procedures ( Angioplasty, Stent placement, CABG) which improve blood supply from the aorta into
the femoral artery
2. Outflow procedures - which provide blood supply to vessels below the femoral artery.

B. RADIOLOGIC INTERVENTIONS
1. Percutaneous transluminal angioplasty (PTA)(angioplasty) / Atherectomy - isolated lesion or lesions
 Complications from PTA and atherectomy include:
 Hematoma formation
 Embolus
 Dissection (separation of the intima) of the vessel
 Acute arterial occlusion
 Bleeding

 NURSING MANAGEMENT
A. Improving Peripheral Arterial Circulation
Arterial blood supply to a body part can be enhanced by
1. Lower the extremities below the level of the heart (if arterial in nature)
 Elevate extremities above the heart if venous in origin
2. Encourage moderate amount of walking or graded extremity if no contraindication exist.
3. Discouraged standing still or sitting for prolonged period of time
4. Graded isometric exercises that may be prescribed to promote blood flow and encourage the
development of collateral circulation.

B. Promoting Vasodilation and Preventing Vascular Compression

1. Maintain warm temperature and avoid chilling to promote arterial flow
2. Discourage the use of tobacco products - inform of the effects of nicotine on circulation
3. Counsel in ways to avoid emotional upsets - emotional stress causes peripheral vasoconstriction by
stimulating SNS
4. Encourage avoidance of constrictive clothing and accessories - it impedes circulation and promotes venous
stasis.
5. Encourage avoidance of leg crossing - causes compression of the vessels with impediment of circulation
leading to venous stasis.
6. Administer vasodilators and adrenergic blocking agents as prescribed - vasodilators relaxes smooth
muscles and adrenergic blocking agent blocks the response of SNS

C. Relieving Pain
1. Promote increased circulation through exercise - enhance peripheral circulation, increase oxygenation
2. Administer analgesic - reduce pain and allow client to participate in activities

1.B. RAYNAUD PHENOMENON

 is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the
fingertips or toes.
 is five times more common in women with the typical onset before age 30

 TWO FORMS
1. Primary or idiopathic Raynaud’s (Raynaud disease) occurs in the absence of an underlying disease.
2. Secondary Raynaud’s (Raynaud syndrome) occurs in association with an underlying disease, usually a
connective tissue disorder, such as systemic lupus erythematosus, rheumatoid arthritis, or scleroderma;
trauma; or obstructive arterial lesions.
 Episodes may be triggered by emotional factors or by unusual sensitivity to cold.
 It is characterized by vasospasm and fixed blood vessel obstructions that may lead to ischemia, ulceration,
and gangrene.

 Cause of Primary Raynauds:Unknown

 CLINICAL MANIFESTATIONS:
 CLASSIC CLINICAL PICTURE - characteristic sequence of color change is described as white, blue, and red.
 pallor
 bluish
 red color(Rubor)
 Numbness, tingling, and burning pain occur as the color changes
 Bilateral and symmetric and may involve toes and fingers
 Acrocyanosis marked clamminess and hyperhidrosis of their hands and feet
 Finger color normalizes when the hands are transferred from the dependent to horizontal position
 COLLABORATIVE CARE:
 DIAGNOSTIC STUDY:– ANGIOGRAM - confirm the diagnosis
 Conservative treatment
a. Avoid particular stimuli that provoke vasoconstriction
b. clients must keep hands warm by wearing gloves
c. smoking cessation
d. better methods of stress relief
e. lifestyle changes

 DRUG THERAPY:
 Calcium channel blockers (Nifedipine [Procardia], Amlodipine [Norvasc])

 For severe symptom not relieved by drugs – lumbar SYMPATHETECTOMY

 NURSING MANAGEMENT: teach client:

 Instructs the patient to avoid situations that may be stressful or unsafe.
 Minimize exposure to cold must be minimized
 Avoid all forms of nicotine

1.C. THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE)

 is an occlusive vascular disease in which small and midsized peripheral arteries become inflamed and
spastic, causing clots to form.
 Its exact aetiology is unknown.
 Cigarette smoking is the single most significant cause of the disease.

 PATHOPHYSIOLOGY
 Inflammatory cells infiltrate the wall of small and midsized arteries in the feet and possibly the hands.
the inflammatory process is accompanied by thrombus formation and vasospasms impairing
blood flow as the disease progresses the affected vessels become scarred and fibrotic
 Adjacent veins and nerves also may be affected.

 ASSESSMENT FINDINGS:
1. Pain – primary manifestation
2. Intermittent Claudication - cramping pain in the calves and feet or the forearms and hands, and rest pain in
the fingers and toes may occur
 pain on exertion induced by exercise
3. Diminished sensation of the affected part
4. Skin becomes thin and shiny and the nails are thickened and malformed
5. Digits and/or extremities are pale, cyanotic or ruddy, and cool or cold to touch.
6. Distal pulses are either difficult to locate or absent even with a Doppler device.
7. Painful ulcers and gangrene may develop as a result of severely impaired blood flow.

 LABORATORY AND DIAGNOSTIC TESTS

 History and physical examination.
1. Doppler studies
2. Angiography and Magnetic Resonance Imaging

 CONSERVATIVE TREATMENT
1. Insist client to stop smoking
2. Keep extremities warm - avoid cold or prolonged cold temperature
3. Manage stress
4. Keep extremities in dependent position
5. Buerger-Allen exercise
 specific exercises intended to improve circulation to the feet and legs. The lower extremities are elevated
to a 45 to 90 degree angle and supported in this position until the skin blanches
(appears dead white).
 The feet and legs are then lowered below the level of the rest of the body until redness appears (care shoul
d be taken that there is no pressure against the back of the knees)
 finally, the legs are placed flat on the bed for a few minutes.
 The length of time for each position varies with the patient's tolerance and the speed with which color cha
nge occurs.
 Usually the exercises are prescribed so that the legs are elevated for 2 to 3 minutes, down 5 to 10 minutes,
and then flat on the bed for 10 minutes.

 MEDICATIONS
 There are no specific drugs for thromboangiitis obliterans.
1. Calcium channel blockers / or oxpentifylline which decrease blood viscosity and increase red blood cell
flexibility to improve peripheral blood flow

 SURGERY
 Surgical approaches for thromboangiitis obliterans include:
1. Sympathectomy - interrupts sympathetic nervous system input to affected vessels, reducing
vasoconstriction and spasm.
2. Arterial bypass grafts - may be useful when larger vessels are affected by the disease.
3. Amputation may be necessary if gangrene develops

 NURSING CARE
 focuses on promoting arterial circulation and preventing prolonged tissue hypoxia.
 care focuses on smoking cessation and relieving acute manifestations.

2.DISORDERS OF THE AORTA AND ITS BRANCHES

 ANEURYSM
 is a localized sac or dilation formed at a weak point in the wall of the artery
 Aneurysms are potentially serious; if located in large vessels that rupture, can lead to hemorrhage and
death.

 PATHOPHYSIOLOGY
 Defect in the middle layer of the arterial wall (tunica media) damaged, stretching and segmental dilation
occur Thinned wall may contain calcium deposits and atherosclerotic plaque making the wall brittle
possible rupture
 If HPN is present blood flow slows resulting to ischemia.

 CLASSIFICATIONS
1. According to the arterial wall involved
 True aneurysm - one, two, or three layers of the artery are involved
 Fusiform - spindle shaped expansion of the entire circumference of involved vessel
 Saccular - protrusion to one side of the arterial wall
 Dissecting - hematoma that splits the layer of the arterial wall
 False aneurysm - a pulsating hematoma, clot and connective tissue that are outside of the arterial wall

2. According to location
 Aortic – occur in the aorta between renal arteries and iliac branches
 Thoracoabdominal – involve thoracic and abdominal aorta
 Abdominal – occur often 4x more often than thoracic aneurysm
 Cerebral – occur in the anterior cerebral artery in the circle of willis

3. According to etiology
 Congenital
 Acquired
 Atherosclerotic
 Mycotic

 ABDOMINAL AORTIC ANEURYSM(AAA)

 Dilation, stretching or ballooning of the aorta
 It occurs most often below the renal arteries,
 When untreated ENLARGE RUPTURE DEATH

 CAUSE: Atherosclerosis - the most common

 Congenital weakening of connective component of the artery wall or trauma
 Trauma
 Disease

 RISK FACTOR:
1. Genetic predisposition
2. Smoking
3. HPN

 CLINICAL MANIFESTATIONS:
1. Signs of impending rupture: intense Abdominal pain and back pain - intermittent or persistent
2. Pulsating abdominal mass in the middle and upper abdomen
3. Rupture AAA: constant intense back pain, decrease BP, decrease Hct
4. A retroperitoneal rupture may result in hematomas in the scrotum, perineum, flank, or penis.

 LABORATORY AND DIAGNOSTIC TESTS

1. Abdominal ultrasound
2. CT scan or MRI
3. Duplex ultrasonography or CTA
4. Renal function studies
5. Chest Xray
 MEDICAL MANAGEMENT:

1. DRUG THERAPY
 Antihypertensive agents

2. ENDOVASCULAR AND SURGICAL MANAGEMENT

 OPEN SURGICAL REPAIR - standard treatment of the aneurysm

 ENDOVASCULAR MANAGEMENT - mainstay of therapy for treating an infrarenal abdominal aortic

aneurysm

 NURSING MANAGEMENT
1. Monitor client for s/s of possible rupture
2. Monitor VS and refer
3. Post endovascular repair
A. Place in supine for 6 Hours;elevate the head of the bed up to 45 degrees after 2 hours.
B. Promote bed rest; use bedpan
C. Monitor vs q 15 minutes especially temperature / doppler assessment until stable
 Assesses for: Bleeding, pulsation, swelling, pain, and hematoma formation.
 Assess for signs of embolization and report immediately, includes:
 extremely tender, irregularly shaped, cyanotic areas, as well as any changes in vital signs, pulse quality,
bleeding, swelling, pain, or hematoma, report immediately
D. Monitor for signs of post implantation syndrome should be reported.
 typically begins within 24 hours of stent graft placement and consists of a: spontaneously occurring fever,
leukocytosis, and occasionally, transient thrombocytopenia, increased risk of hemorrhage
 Notify the primary provider of persistent coughing, sneezing, vomiting, or systolic blood pressure greater
than 180 mm hg. - signs of hemorrhage
E. Encourage fluid intake and maintain and regulate IVF to assist in excretion of IV contrast agent

 POSSIBLE COMPLICATIONS OF SURGERY:

1. Arterial occlusion
2. Hemorrhage
3. Infection
4. Ischemic bowel
5. Kidney injury
6. Impotence

COMMON NURSING DIAGNOSIS FOR PERIPHERAL VASCULAR DISORDERS:

7. Altered peripheral tissue perfusion
8. Pain
9. High risk for / impaired skin integrity
10. High risk for infection
11. Knowledge deficit
12. Disturbed body image

Prepared by: Mrs. Robeanna M. Diesto, MN

REFERENCE:
Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia:
Wolters Kluwer.