assessment and management of patients with vascular disorders and problems of peripheral circulation
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Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
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
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
Assessment • Characteristics of arterial and venous
insufficiency• Intermittent claudication• Rest pain• Changes in skin and appearance• Pulses• Aging changes
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.
• 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—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
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
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.
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
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
Medical Management
• Prevention• Exercise program• Medications• 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 thromboemboli
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.
Venous Thromboembolism
• Pathophysiology• Risk factors• Endothelial damage– Venous stasis– Altered coagulation
• Manifestations– Deep veins– Superficial veins
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.
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.
• 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
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
Medical Management
• Anti-infective therapy is dependent upon infecting agent– Oral antibiotics are usually prescribed.
• Compression therapy• Debridement of wound• Dressings• Other
Nursing Process: The Care of the Patient with Leg Ulcers- Diagnoses
• Impaired skin integrity• Impaired physical mobility• Imbalanced nutrition
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.
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
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 standing
• Other factors that cause VV are: hereditary, pregnancy
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.
• 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
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
• 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
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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