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

1. Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

2. Vascular System • Arteries and arterioles • Capillaries • Veins and venules • Lymphatic vessels • Function of the vascular system

3. Systemic and Pulmonary Circulation

4. 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

5. Assessment • Characteristics of arterial and venous insufficiency • Intermittent claudication • Rest pain • Changes in skin and appearance • Pulses • Aging changes

6. Assessing Peripheral Pulses

7. Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites

8. Hematologic, Peripheral Vascular, and Lymphatic Systems

9. 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.

10. 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)

11. 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

12. 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

13. 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.

14. 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

15. 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

16. Progression of Atherosclerosis

17. Common Sites of Atherosclerotic Obstruction

18. Common Peripheral Vascular

19. Common Peripheral Vascular

20. Common Peripheral Vascular

21. Common Peripheral Vascular

22. Common Peripheral Vascular

23. Common Peripheral Vascular

24. Nicotine Diet Hypertension Diabetes Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomcysteinemia Age Gender Familial predisposition/genetics Risk Factors for Atherosclerosis and PVD Modifiable Nonmodifiable

25. Medical Management • Prevention • Exercise program • Medications • Pentoxifylline (Trental) and cilostazol (Pletal) • Use of antiplatelet agents • Surgical management

26. 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

27. 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.

28. Venous Thromboembolism • Pathophysiology • Risk factors • Endothelial damage • Venous stasis • Altered coagulation • Manifestations • Deep veins • Superficial veins

29. 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.

30. Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

31. Clinical Manifestation • Deep veins: • Edema and swelling of extremities • Warm (affected extremity) • Superficial vein appears more prominent • Tenderness • +vehoman’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.

32. 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

33. Color Flow Duplex Image

34. 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.

35. 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

36. Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis

37. Medical Management • Anti-infective therapy is dependent upon infecting agent • Oral antibiotics are usually prescribed. • Compression therapy • Debridement of wound • Dressings • Other

38. Nursing Process: The Care of the Patient with Leg Ulcers- Diagnoses • Impaired skin integrity • Impaired physical mobility • Imbalanced nutrition

39. Collaborative Problems/Potential Complications • Infection • Gangrene

40. 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.

41. 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

42. 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

43. 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

44. 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.

45. Dx test is duplex scan ( document the anatomic site of reflux and provide a measure for the severity of valvular reflux

46. 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.

47. 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

48. 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

49. 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

50. 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