Chapter 31 Assessment and Management of Patients With Vascular

Assessment and
Management of Patients
With Vascular Disorders and
Problems of Peripheral
Vascular System
Arteries and arterioles
Veins and venules
Lymphatic vessels
Function of the vascular system
Systemic and Pulmonary Circulation
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
• Characteristics of arterial and venous
• Intermittent claudication
• Rest pain
• Changes in skin and appearance
• Pulses
• Aging changes
Assessing Peripheral Pulses
Peroneal, Dorsalis Pedis, and Posterior
Tibial Pulse Sites
Hematologic, Peripheral
Vascular, and Lymphatic Systems
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
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)
Nursing Process: The Care of the Patient
with Peripheral Arterial Insufficiency—
Health history
Risk factors
Signs and symptoms of arterial insufficiency
Claudication and rest pain
Color changes
Weak or absent pulses
Skin changes and skin breakdown
Nursing Process: The Care of the Patient
with Peripheral Arterial Insufficiency—
Altered peripheral tissue perfusion
Chronic pain
Risk for impaired skin integrity
Knowledge deficient
Nursing Process: The Care of the Patient
with Peripheral Arterial Insufficiency—
• 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.
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
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
Progression of Atherosclerosis
Common Sites of Atherosclerotic
Common Peripheral Vascular
Common Peripheral Vascular
Common Peripheral Vascular
Common Peripheral Vascular
Common Peripheral Vascular
Common Peripheral Vascular
Risk Factors for Atherosclerosis and PVD
Sedentary lifestyle
C-reactive protein
• Age
• Gender
• Familial
Medical Management
Exercise program
Pentoxifylline (Trental) and cilostazol (Pletal)
Use of antiplatelet agents
Surgical management
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
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
Venous Thromboembolism
• Pathophysiology
• Risk factors
• Endothelial damage
– Venous stasis
– Altered coagulation
• Manifestations
– Deep veins
– Superficial veins
• 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.
Blood flow and function of valves in
veins. Note impaired blood return due
to incompetent valve.
Clinical Manifestation
Deep veins:
Edema and swelling of extremities
Warm (affected extremity)
Superficial vein appears more prominent
+ve homan’s sign (not specific)
• Superficial veins:
- Pain or tenderness, redness, and warmth.
- Can be treated with bed rest, leg elevations, analgesics, and antiinflammatory drug.
• 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
Color Flow Duplex Image
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.
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
Arterial Ulcer, Gangrene Due to Arterial
Insufficiency, and Ulcer Due to Venous
Medical Management
• Anti-infective therapy is dependent upon infecting
– Oral antibiotics are usually prescribed.
Compression therapy
Debridement of wound
Nursing Process: The Care of the Patient
with Leg Ulcers- Diagnoses
• Impaired skin integrity
• Impaired physical mobility
• Imbalanced nutrition
Collaborative Problems/Potential
• Infection
• Gangrene
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.
• 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
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, vitamin C and A, iron, and zinc are
especially important for wound healing
– Include cultural considerations and patient teaching
in the dietary plan
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
• Other factors that cause VV are: hereditary,
• 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,
- Increased susceptibility to infection and injury.
• Dx test is duplex scan ( document the anatomic
site of reflux and provide a measure for the
severity of valvular reflux
• 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.
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
Nursing Management
After surgery:
• Bed rest is discouraged and early ambulation is
• Instruct pt to walk Q one hour for 5-10min while
awake for the 1st 24hr, then ↑ activity as
• Wear elastic stocking continuously for 1wk
• Elevate foot of bed
• Standing and sitting are discouraged
• 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
- If the patient underwent sclerotherapy, a burning
sensation in the injected leg may be experienced
for 1 or 2 days
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

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