Peripheral Vascular

Alterations
Chapter 30
Interventions for
Clients with Vascular
Problems

Arteriosclerosis and
Atherosclerosis
Arteriosclerosis: thickening or hardening of the
arterial wall
Atherosclerosis: type of arteriosclerosis involving
the formation of plaque within the arterial wall
Etiology ( exact cause unknown) genetic
predisposition
Factors related to atherosclerosis include
obesity, lack of exercise, smoking, and stress.
Usually occurs between ages 60-80, more

common in diabetics and African Americans

Most common locations: coronary arteries,
carotid arteries, aortic bifurcation, iliac and
common femoral arteries, profunda femoris
artery, supreficial femoral artery, and distal
popliteal artery

Modifiable Risk Factors :

*Cigarette smoking: 3-4 years after

person stops smoking the risk is the

same as a person who has never smoked.
Physical inactivity: 30 minutes a day of
exercise 3x/week or more
Obesity: BMI >30
Psychological factors:
Stress/Type A personality!
Chronic disease: *DM, *yperlipidemia
(diet), *hypertension, are at greater risk.
*Most significant risk factors

Nonmodifiable Risk Factors

Increasing age
Gender
Family genetics

Diagnostics
Lipid level, including cholesterol and

triglycerides, is elevated in atherosclerosis

clients.
High serum levels of homocysteine can allow
cell walls to become vulnerable to plaque
buildup.
The Goal for Patients is LDL, Less than
100mg/dL
For patients with comorbities, Less than 70mg/dL

Secondary Goals:
Total cholesterol Less than 200mg/dL and
Triglycerides less than 150 mg/dL
HDL > 40mg/dL

Clinical Manifestations
Depends on organ or tissue affected:
Angina
MI
CVA
TIA
Anuerysm
Renal Stenosis
Extremities with atherosclerotic lesions

Medical Management
Surgery
Femoral-popliteal bypass

(fempop)
Radiological Interventions
Percutaneous Transluminal
angioplasty (PTA)

Nursing Dx
Altered Tissue perfusion
Impaired Skin Integrity
Knowledge Deficit
Alteration in Comfort
Activity Intolerance
Potential for injury/infection

Peripheral Arterial
Disease

Disorders that alter the natural flow of

blood through the arteries and veins

of the peripheral circulation
Manifestation of systemic
atherosclerosis: a chronic condition in
which partial or total arterial occlusion
deprives the lower extremities of
oxygen and nutrients

Physical Assessment
Intermittent claudication ( to limp)

Usually can walk only a certain

distance before a cramping , burning
pain begins.
Pain that occurs even while at rest;
numbness and burning
Inflow disease: experience discomfort
affecting the lower back, buttocks, or
thighs( iliac artery or aorta )
Outflow disease:describe cramping in
calves, ankles, and feet( obstruction
at or below the popliteal artery)
(Continued)

Physical Assessment
(Continued)
Thin, shiny, taunt skin
Hair loss and thickened toenails ( no hair

on lower legs or toes)

Diminished or absent pulses
Pallor of feet on elevation, dependent
rubor (redness when in dependent
position)
Complications: Ulcers: arterial ulcers,
usually over bony prominences on the
toes, feet, and lower legs, can have
gangrene. Amputation may be required

Diagnostic Test
Segmental systolic blood pressure

measurements( using a doppler) at

the thigh, calf and ankle.
Exercise tolerance testing( by stress
test or treadmill)
Plethysmography( measures arterial
flow in the lower extremities)

Pharmacological agents
and Treatments
Exercise. 30 min 3x/week minimum
Positioning( dont cross legs)
Promoting vasodilation ( warm

enviornment, keep legs warm)

Drug therapy(exp: Trental: increases
flexibility of RBC, Pletal)
Percutaneous transluminal
angioplasty( PTA arteries dialated with
ballon cath stents placed)
Laser-assisted angioplasty( similar to PTA)
Atherectomy ( scrapes plaque away )

Surgical Management
Preoperative care( same as others

consent, education, IV, VS, etc)

Operative procedures

(Continued)

Surgical Management
(Continued)
Postoperative care
Assessment for graft occlusion (check

pulses, temperature and capillary refill)

Promotion of graft patency
Treatment of graft occlusion
Monitoring for compartment
syndrome( occurs when a confined
space becomes elevated & restricts
blood flow, this can lead to tissue
damage and tissue death)
Assessment for infection (site infection)

Acute Peripheral Arterial

Occlusion
Embolus: the most common cause of occlusions,
PAD:
although local thrombus may be the cause
Assessment: the 6 Ps: pain, pallor,

pulselessness, paresthesia, paralysis,

poikilothermia( coolness)
Hallmark symptoms is Intermittent Claudication
(pain with activity/cramp, relieved with rest)
Drug therapy( anticoagulant therapy)
Surgical therapy( to remove the occlusion)
Nursing care( monitor for improvement in
color,temp, pulse)

Buergers Disease
(Thromboangiitis obliterans):

relatively uncommon occlusive disease

limited to the medium and small
arteries and veins
Often identified with tobacco smoking
and men.
Cause is unknown, associated with
tobacco smoking and familial tendency

Assessment
First clinical manifestation is usually

pain in muscles from inadequate blood

supply
Sensitivity to cold
Numbness
Ulcerations and gangrene seen in the
digits
Interventions prevent progression ,
relieve pain, promote vasodilation
***STOP SMOKING

Raynauds Phenomenon
and Raynauds Disease
Caused by vasospasm of the arterioles

and arteries of the upper and lower

extremities usually unilaterally/
Raynauds disease occurs bilaterally
terms are sometimes used
interchangeably.
Phenomenon occurs in people over 30
effects both sexes and Raynauds
disease occurs between the ages of 17
and 50 years and effects women more

Raynauds cont
Clinical signs/symptoms:
Color changes in fingers, toes, ears, nose (white,

blue, or red)
Usually last only a few minutes
Symptoms precipitated by cold, caffeine, tobacco,
or emotional upset
Dx: based on symptoms
TX: avoid temperature extremes (wear coverings),

avoid all tobacco products

Drugs: Calcium channel blockers, first line defense

Venous Thromboembolism
Thrombus: a blood clot
Thrombophlebitis( refers to a thrombus

that is associated with inflammation)

Deep vein thrombosis(DVT) develops
more often in the legand is more serious
because it poses a greater risk for PE)
Pulmonary embolism( PE, is a disloged
clot that travels to the pulmonary artery.
A very High rate of death with PE

Assessment
classic S/S Calf or groin tenderness or

pain and
Sudden onset of unilateral swelling of
the leg
Positive Homans sign( in only about
10% of cases and false positives are
common)
Localized edema( measure and compare
each leg)
Venous flow studies may be done to
confirm

Nonsurgical Management
Rest (Dorsal flex foot and rotate

ankles q2), elevate extremity, and

anticoagulation
Drug therapy includes:
Unfractionated heparin therapy
Lowmolecular weight

heparin( Lovenox)
Warfarin therapy( coumadin)
Thrombolytic therapy( TPA)

Surgical Management
Thrombectomy( removes clot)
Inferior vena caval interruption
Ligation or external clips

Nursing Dx: DVT

Acute pain R/T venous congestion or

impaired return/inflammation
Ineffective health maintenance r/t lack of
knowledge about disorder/tx
Risk for impaired skin integrity r/t altered
tissue perfusion
Potential complication: bleeding r/t
anticoagulant therapy
Potential complication: PE r/t embolization
of thrombus, dehydration and immobility

Goals of tx
Relief of pain
Decreased edema
No skin ulceration
No complications from anticoagulant therapy
No evidence of pulmonary emboli
Discharge teaching:
SS of PE
Side effect of anticoagulant therapy/follow up labs
Proper hydration
Exercise program

Venous Insufficiency
Result of prolonged venous

hypertension, stretching veins and

damaging valvesleading to a backup of
blood and further venous hypertension
Leads to stasis( stoppage) dermatitis,
stasis ulcers
Management of edema
Management of venous stasis ulcers
Drug therapy
Surgical management

Venous insufficiency cond

The skin of the lower exts is leathery, which

causes the skin to become brown

Skin hardens as it is replaced by fibrous tissue
Edema and stasis dermatitis are often
present, pruritus is a common complaint
Management: Compression stockings/wraps
Moist environment dressings
Monitor nutritional status
Monitor for venous ulcers (if developed, usually

debrided)
Teach proper foot care/monitoring

Varicose Veins
Distended, protruding veins that

appear darkened and tortuous can

occur in anyone more common in
clients over 30 years old
Collaborative management includes:
Elastic stockings
Elevation of extremities
Sclerotherapy
Surgical removal of veins
Radio frequency energy to heat the

veins

Phlebitis
Inflammation of the superficial veins

caused by an irritant such as IV

therapy
Management: warm, moist soaks and
elastic stocking
Complications: tissue necrosis,
infection, or pulmonary embolus

Aneurysms
A permanent localized dilation of an artery,

which enlarges the artery in diameter

May be described as a fusiform ( affecting the
entire circumference) or sacular ( an
outpouching of a portion of the artery)
Tend to occur at specific anatomical site
May or may not have any signs and
symptoms of aneurysm
Of all AAA aneurysms 50% may rupture
within 1 year smaller than 6mm 15-20%
rupture

Continue Anyeurysms
Thoracic account for 25% they are frequently

misdiagnosed
Aneurysms can cause symptoms by exerting
pressure on surrounding organs or by
rupturing
Rupture is life threatening and is the most
frequent complication
Atherosclerosis is the most common cause of
all aneurysms.
The goal of management is to prevent
aneurysm from rupturing

Surgical repair
Surgical repair of AAA involves:
Incising the diseased segment of the aorta
Removing intraluminal thrombus or plaque
Inserting a synthetic graft
Suturing the native aortic around the graft
Preoperative is monitoring the patient for rupture
Overall goals : Normal tissue perfusion, intact

motor and sensory function, and no complications

from surgical repair (ex: thrombus or infection

Cond AAA
Postoperative surgery:
Patient will be monitored in CC unit, be mechanically

ventilated with arterial line and central line. CVP will

be monitored. Pt will have urinary catheter, NGT, and
on cont EKG and pulse ox monitoring
Nursing care:
Monitor graft patency
Adequate renal perfusion
Maintain BP
Antibiotics to prevent infection
Monitor peripheral pulses,skin temp/color, capillary
refill, sensation and movement of extremities
Hourly urine output and record

Expected outcomes
Patent arterial graft with adequate distal

perfusion
Adequate urine output
Normal body temperature
No S/S of infection