Peripheral Vascular System

1
Peripheral Vascular System

• Consists of a system of intertwining veins and
  arteries which carry blood to and from the heart
  and lungs
• Also involves the capillaries and lymph system

2
Peripheral Vascular Disease

• Disorders which alter the normal flow of blood
  through the arteries and veins
• Effects the lower extremities more frequently the
  the upper
• A client with a diagnosis of PVD implies arterial
  disease rather than venous
• Some client have both arterial and venous disease

3
Patho

• PVD is the manifestation of systemic
  atherosclerosis
• Chronic condition in which partial or total
  occlusion deprives the lower extremities of
  oxygen and nutrients
• Fatty substances accumulate at the site of vessel
  wall injury and alter or occlude the blood flow
• Risk factors
• Hypertension, smoking, high lipids and
  cholesterol, diabetes, obesity and family
  predisposition

4
Data Collection for PVD

• Subjective symptoms
• Aching calves
• Numbness in legs
• Leg cramps
• Loss of sensation in legs
• Pain in legs during exercise (intermittent
  claudicating)
• History of diabetes, thrombophlebitis,
  hypertension or alcoholism

5
Data Collection for PVD, cont.

• Objective Symptoms
• Cold or blue feet
• Redness (rubor) of leg in dependent position
  (arterial)
• Spares hair distribution
• Dry, scaly, dusky, pale, or mottled skin
• Edema
• Stasis ulcers (venous-occur around ankle and foot
  is warm, arterial- painful,on toes and can become
  gangrene)

• Muscle atrophy
• Varicose veins
• Diminished or absent pulses use grading scale
• Delay in capillary refill
• Bruits heard in major arteries
• Differences in the circumference of legs
• Check for Homans sign

6
Diagnosis

• Arteriography (not widely used), inject dye
  onto arterial system
• Segmental systolic B/P measurements
  noninvasive, inexpensive method which uses
  measurements of B/P at intermittent segments of
  the lower extremities
• Doppler ultrasound sound waves to identify
  changes in the walls of the blood vessels
• Plethsmography used to determine venous
  thrombus and blood flow through the veins

7
Interventions

• Non-surgical
• Elastic stockings/intermittent pneumatic
  compression
• Teach client to avoid tissue trauma wear shoes,
  inspect feet, trim nail straight across
• Exercise
• Positioning
• Promoting vasodilation
• Drug therapy
• PCTA
• Laser assisted angioplasty
• Anthrectomy

8
Interventions, cont.

• Surgical
• Arterial revascularization surgically bypassing
  the occlusion with a saphenous vein or synthetic
  material
• Pre-op care
• NPO, vitals, pulses, IV, Foley, A-line, etc
• Post-op care
• Watch circulation and B/P
• May need anticoagulation
• No crossing legs, no ROM of limb, may be on bed
  rest
• No dependent position for extended period
• May elevate extremity
• Pain RX, may need vasodilators, nitroglycerine,
  NSAIDS

9
Arterial Embolism

• More common in the lower extremity
• Life threatening
• May break loose and travel, causing other
  occlusions
• 6 Ps or S/S
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
• Poikilothermia (coolness)

10
Arterial Embolism, cont.

• Immediate treatment to prevent permanent damage
  or loss of extremity
• 1st intervention is Heparin
• May need embolectomy
• Can be done with arthroscopy
• May need to open and remove embolus
• Post-op care involves watching for color changes
  and signs of occlusion
• May have spasms and swelling
• Also may develop compartment syndrome

11
Raynauds Disease

• Caused by vasospasms of the arterioles and
  arteries of the upper and lower extremities
• Affects hands but can be on toes and tip of nose
• S/S chronic, intermittent, numbness, coldness,
  pain and pallor
• Women 16-40 years of age
• Cause is unknown
• After spasm the skin becomes reddened and
  hyperemic

12
Raynauds Disease, cont.

• Diagnosis is based on symptoms
• Treatment involves relieving the vasospasms and
  prevent pain
• Vasodilators
• Topical nitroglycerine
• Calcium channel blockers
• ACE inhibitors

13
Raynauds Disease, cont.

• Nursing care
• Pain control
• Teach client to avoid stimuli which may trigger
  episode (stress, cold air temp, smoking)
• Keep extremity warm
• Use hair dryer, warm H2O, etc
• Protect area from trauma

14
Buergers Disease(Thromboangiitis Obliterans)

• Uncommon occlusive disease of the medium and
  small arteries and veins
• The distal upper and lower limbs are most
  frequently affected
• In young adult men who smoke
• May result in fibrosis and scarring of the
  perivascular system

15
Buergers Disease(Thromboangiitis Obliterans)

• Pain in the arch of the foot is the first
  clinical indicator
• Pain may be ischemic in nature
• Clients have increased sensation to cold
• Pulses may be diminished in the distal
  extremities and are cool and red or cyanotic
• Ulcerations and gangrene may occur
• Treatment is same as with Raynauds

16
Aneurysms

• Permanent localized dilation of an artery
• Area stretches and weakens, and balloons out
• As it enlarges the risk of rupture increases
• Can be acquired or congenital
• Acquired are caused by trauma, arteriosclerosis,
  or infection
• Abdominal aorta is most prevalent site (AAA are
  about 75)

17
Aneurysms, cont.

• S/S
• Most are asymptomatic
• May be discovered on routine exam
• Pain may be caused by the pressure on organs
  surrounding the aneurysm
• May notice a pulsation in the upper abdomine or
  by hearing a bruit

18
Aneurysms, cont.

• Clients with a rupturing AAA are critically ill
• Will go into hemorrhagic shock (hypovolemic)
• Hypotension
• Diaphoresis, mental confusion, oliguria,
  dysrhythemias
• Retroperitioneal hemorrhage produces flank
  bruising
• Abdominal distention may occur
• Shortness of breath, hoarseness, and difficulty
  swallowing may be signs of a thoracic aneurysm

19
Aneurysms, cont.

• Diagnosis
• Abdominal or lateral of the spine
• CT scan
• Ultrasound

20
Aneurysms, cont.

• Interventions
• Nonsurgical
• Monitor growth
• Maintain B/P
• Frequent CT scans

21
Aneurysms, cont

• Surgical
• Elective mortality 2-5
• Emergency 50
• AAA resection with graph
• Preop as described for vascular surgery
• Postop client in ICU
• Monitor vitals, A-line, EKG, etc.
• Watch for
• MI, graph occlusion, hypovolemia, renal failure,
  respiratory distress, paralytic ilius

22
Aortic Dissection, cont.

• Symptom
• Pain which is a tearing, ripping, stabbing that
  tends to move from the point of origin
• Pain may be in the anterior chest, back, neck,
  throat, jaw or teeth
• Emergency care
• Elimination of pain
• Control B/P 100 to 120 systolic or lower
• If uncomplicated may be conservative treatment
• If dissection is in the proximal aorta, require
  CPB

23
Aortic Dissection

• Not a rupturing aneurysm
• Dissecting hematoma or aortic dissection
• Caused by a sudden tear in the aortic intima
• Hypertension is a contributing factor
• Relatively common - 2000/year in the US
• Ascending aorta and the descending thoracic aorta
  are the most common sites

24
Varicose Veins

• Dilated, tortuous leg veins with back flow of
  blood caused by incompetent valve closure, which
  results in venous congestion and vein enlargement
• Usually affects the saphenous vein and its
  branches
• Causes
• Unknown but may be R/T congenital weakness of
  valve
• Thrombophlebitis
• Venous stasis pregnancy, prolonged standing
• Familial tendency

25
Varicose Veins, cont.

• Data Collection
• Subjective
• Aching
• Cramping and pain
• Feeling of heaviness
• Objective
• Palpable nodules
• Ankle edema
• Dilated veins
• Pigmentation of calves and ankles

26
Varicose Veins, cont.

• Diagnosis
• History and physical
• Venogram
• Trendelburgs test demonstrates the backward
  flow of the blood in the venous system

27
Varicose Veins, cont.

• Treatment
• Conservative
• Avoid standing or sitting for long periods of
  time
• Weight reduction
• Support hose
• No restrictive clothing

28
Varicose Veins, cont.

• Surgical treatment
• Vein stripping, ligation or sclerosing
• Postop care
• Pain RX
• Elevate leg
• Watch for bleeding
• May need to rewrap leg q shift from toes to thigh
• Watch for CMS

29
Venous Thrombosis(plebitis, thrombophlebitis,
deep vein thrombosis)

• Phlebitis is inflammation
• Thrombophlebitis is a clot in the vein
• DVT is presence of a clot in a deep vein rather
  than a superficial vein

30
Venous Thrombosis, cont.

• Risk factors
• Bedrest
• Surgery
• Leg trauma with cast
• Venous insufficiency
• Obesity
• Oral contraceptives
• Malginancy

31
Venous Thrombosis, cont.

• Treatment
• Anticoagulant, bedrest, elevate extremity, warm
  soaks, TED hose
• Nursing care
• Control pain
• Watch skin
• Help anxiety
• Assess tissue perfusion
• Watch respiratory status for embolus

32
Venous Thrombosis, cont.

• S/S
• May not have any signs
• With obstruction
• Edema
• Warmth
• Pain, tenderness
• Positive Homans sogn
• Diagnosis
• Venogram
• Doppler