NUR 342

UNIT II
Assessment and Management of
Patients With Vascular Disorders
and Problems of Peripheral
Circulation

Vascular System

Arteries and arterioles

Capillaries
Veins and venules
Lymphatic vessels
Function of the vascular system

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Systemic and Pulmonary

Circulation

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Peripheral Blood Flow

Flow rate = P/R

Movement of fluid across the capillary

wall; hydrostatic and osmotic force
Hemodynamic resistance

Blood viscosity
Vessel diameter

Regulation of peripheral vascular

resistance
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Question
Is the following statement True or False?
Intermittent claudication is caused by
the inability of the venous system to
provide adequate blood flow to the
tissues in the face of increased
demands for nutrients and oxygen
during exercise.
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Answer

False

Intermittent claudication is caused by

the inability of the arterial system,
not the venous system, to provide
adequate blood flow to the tissues in
the face of increased demands for
nutrients and oxygen during exercise.
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Pathophysiology of Vascular
System
Pump failure
Alterations in blood and lymphatic
vessels

Gerontological considerations

Circulatory insufficiency of the

extremities
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Assessment

Characteristics of arterial and

venous insufficiency
See Table 30-1, p. 823
Intermittent claudication
Rest pain
Changes in skin and appearance
Pulses
Aging changes
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Assessing Peripheral
Pulses

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Peroneal, Dorsalis Pedis,

and Posterior Tibial Pulse
Sites

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Diagnostic Evaluation
Doppler Ultrasound Flow Studies
Exercise Testing
Duplex Ultrasonography
Computed Tomography and
Angiography
Magnetic Resonance Angiography
Angiography

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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.

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Location of Peroneal Artery,

Lateral Malleolus

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Diagnostic Evaluation
(cont.)
Air Plethysmography
Contrast Phlebography
Lymphangiography and
Lymphoscintigraphy

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Color Flow Duplex Image

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Arterial Disorders

Pathophysiology

Atherosclerosis

Collateral circulation

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Progression of
Atherosclerosis

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Risk Factors for Atherosclerosis

and Peripheral Arterial Disease

Nicotine
Diet
Hypertension
Modifiable
Diabetes
Obesity
Stress
Sedentary lifestyle
C-reactive protein
Hyperhomcysteinem
ia

Age
Gender
Nonmodifiable
Familial
predisposition/g
enetics

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Management of Arterial
Disorders
Medications: bile acid
sequestrants, nicotinic acid,
statins, fibric acids, and lipophilic
substances
Surgical management: inflow
procedures and outflow procedures
Radiologic interventions

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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: pallor, rubor, or cyanosis
Weak or absent pulses
Skin changes and skin breakdown
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Nursing Process: The Care of the

Patient with Peripheral Arterial
Insufficiency:
Diagnosis

Altered peripheral tissue perfusion

Chronic pain
Risk for impaired skin integrity
Knowledge deficiency

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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.

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Improving Peripheral
Arterial Circulation

Exercises and activities: walking, graded

isometric exercises. Consult primary
health care provider before
prescribing an exercise routine.
Positioning strategies
Temperature; effects of heat and cold
Smoking cessation
Stress reduction
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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
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Common Sites of
Atherosclerotic
Obstruction

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Peripheral Arterial Occlusive

Disease

Legs are most frequently affected

Hallmark symptom is intermittent
claudication; positioning of extremity
Pharmacologic therapy is to increase RBC
flexibility & reduce blood viscosity (Trental),
inhibit platelet aggregation, inhibit smooth
muscle cell proliferation, and increase
vasodilation (Pletal, Ticlid, Plavix)
Surgical management includes vascular
grafting (anastamosis) or endarterectomy;
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Aortoiliac Endarterectomy

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Medical Management

Prevention
Exercise program
Medications
Pentoxifylline (Trental) and
cilostazol (Pletal)
Use of antiplatelet agents
Surgical management
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Post-operative Nursing
Management

Maintaining Circulation
Monitoring & Managing Potential
Complications
Promoting Home & Community
Based Care

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Upper Extremity Arterial

Occlusive
Disease
Stenosis
and occlusions
occur due
to atherosclerosis or trauma
Subclavian steal syndrome
characterized by reverse flow in
one vertebral and basilar artery to
provide blood flow to the arm
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Upper Extremity Arterial

Occlusive Disease (contd)

Medical management may be

PTA, carotid-to-subclavian
artery bypass, axillary-toaxillary artery bypass, or
autogenous reimplantation of
the subclavian to the carotid
artery
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Buergers Disease:
Thromboangiitis Obliterans

Recurring inflammatory process of the

small and intermediate vessels of
(usually) the lower extremities; probably
an autoimmune disorder
Most often occurs in men ages 20-35
Risk or aggravating factor: tobacco
Progressive occlusion of vessels results
in pain, ischemic changes, ulcerations,
and gangrene.
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Other Disorders

Aortoiliac disease
Aneurysms

Thoracic aortic aneurysm

Abdominal aortic aneurysm

Aortic dissection

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Characteristics of Arterial
Aneurysm

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Aortic Aneurysm

Localized sac or dilation formed at weak

point in wall of aorta
Thoracic:85% caused by atherosclerosis
Abdominal:most common type of
degenerative aneurysm due to
atherosclerotic changes
Surgical management repairs aneurysm
by resecting the vessel and sewing a
graft in place
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Aortic Aneurysm
Dissecting Aorta is caused
(contd)
by a tear in intima or
media degeneration
Aneurysms may occur in
other peripheral vessels
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Repair of Ascending Aortic

Aneurysm & AVR

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AneuRx Endograft Repair

of Abdominal Aortic
Aneurysm

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Nursing Care: Aneurysms

Pre-operative

Assess for potential rupture/dissection of

aortic aneurysm

Post-operative:Endovascular repair

Positioning
VS/Doppler assessment of peripheral pulses
q15minX4, q30minX4, q1hX4, then as ordered
Assessment of site
Fluids
Mobility
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Arterial Embolism and

Arterial Thrombosis

Acute vascular occlusion may be caused

by trauma or result of invasive
interventions
Arterial emboli most often caused by
atrial fibrillation, MI, or other heart
dysfunction
Medical management is anticoagulation
Surgical management is emergency
embolectomy
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Raynaud's Disease

Intermittent arterial vaso-occlusion, 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/other triggers. Avoid injury to
hands/fingers.
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Venous Thrombus

Pathophysiology
Risk factors
See Chart 30-7: Risk Factors: DVT,PE
Virchows Triad

Endothelial damage
Venous stasis
Altered coagulation

Manifestations

Deep veins
Superficial veins
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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/standing for prolonged periods;
walk 10 minutes every 1-2 hours.
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Management of Venous
Disorders
Medical
Management is
anticoagulation/thrombolytic therapy
Surgical Management is thrombectomy
Compression therapy: Unna Boot
Patient education re: anticoagulants,
Chart 30-10, p.851

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Nursing Management of
Venous Disorders

Assessing & Monitoring

Anticoagulant Therapy
Monitoring & Managing Potential
Complications

Bleeding
Thrombocytopenia
Drug Interactions

Providing Comfort
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Nursing Management
(Cont.)

Applying Elastic Compression

Stockings
Using Intermittent Pneumatic
Compression Devices
Positioning the Body & Encouraging
Exercise
Promoting home and community
care
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Chronic Venous
Insufficiency
Results from obstruction of
venous valves in legs or reflux
of blood back through valves
Venous ulceration is serious
complication
Pharmacological therapy is
antibiotics for infections

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Blood flow and function of valves

in veins. Note impaired blood
return due to incompetent valve.

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Chronic Venous Insufficiency

(contd)
Debridement to promote healing
Topical Therapy may be used with
cleansing and debridement
Compression therapy
Stimulated healing
Hyperbaric oxygen
Negative pressure wound therapy
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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.

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Nursing Process: The Care of

the Patient with Leg Ulcers:
Diagnosis
Impaired skin integrity

Impaired physical mobility

Imbalanced nutrition

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Collaborative Problems/Potential
Complications

Infection
Gangrene

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Nursing Process: The Care of

the Patient with Leg Ulcers:
Major goals include restoration of
Planning
skin integrity, improved physical
mobility, adequate nutrition, and
absence of complications.

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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
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Other Interventions

Skin integrity

Skin care/hygiene and wound care

Positioning of legs to promote circulation
Avoidance of trauma

Nutrition

Measures to ensure adequate nutrition

Adequate protein, vitamins C and A, iron, and
zinc are especially important for wound healing.
Include cultural considerations and patient
teaching in the dietary plan.

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Ulcers Resulting from Arterial

Emboli

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Gangrene of Toes Resulting

from Severe Arterial Ischemia

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Ulcer From Venous Stasis

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Varicose Veins
Abnormally dilated, tortuous
superficial veins caused by
incompetent venous valves
Prevention is to avoid activities
that cause venous stasis
Surgical management is
stripping and sclerotherapy

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Competent and
Incompetent Valves in
Terms of Blood Flow

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Ligation & Stripping of the

Great & Small Saphenous
Veins

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Cellulitis and Lymphatic

Disorders

Cellulitis: most common infectious cause of

limb swelling
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
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Cellulitis
Most common infectious cause of
limb swelling
Medical management is antibiotics
Nursing management is elevation
of extremity; applying warm, moist
packs; and education on
prevention

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Management of
Lymphatic Disorders
Lymphangitis and lymphadenitis

Lymphedema and elephantiasis

Medical Management is active and
passive exercises, compression devices
and stockings, and elevation of
extremity
Diuretics used palliatively
Surgery is performed if uncontrolled by
medical management
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