Upgrade to remove ads
CH. 38 Peripheral Vascular Disease
RNSG1940 MED SURG Chapter 38 Mrs. Bryant
Terms in this set (67)
Ch 38 Peripheral Vascular DiseasePVD
Ch. 38 Peripheral Vascular DiseasePVD
Includes PVD usually implies PAD (peripheral arterial disease rather than venous involvment. Patients may have arterial and venous involvement.
PVD includes disorders
that change the natural flow of blood through the arteries and veins of the peripheral circulation. It affects the legs much more frequently than the arms. Generally, a diagnosis of PVD implies arterial disease (peripheral arterial disease [PAD]) rather than venous involvement. Some patients have both arterial and venous disease.
PAD is a result of systemic atherosclerosis
It is a chronic condition in which partial or total arterial occlusion (blockage) deprives the lower extremities of oxygen and nutrients.
PAD in the legs is sometimes referred to as lower extremity arterial disease (LEAD). Atherosclerosis leads to
blockage of the arteries that supply the lower legs and feet.
The tissues below the blockage (obstruction) cannot live without an adequate oxygen and nutrient supply
May affect any artery in lower extremity.
involves distal end of aorta and iliac arteries (common, internal and external)
involve the femoral, popliteal and tibial arteries. Can cause significant tissue damage.
PAD risk factors
Because atherosclerosis is the most common cause of chronic arterial obstruction: Common risk factors include hypertension, hyperlipidemia,
, cigarette smoking, obesity, and familial predisposition.
Advancing age also increases the risk of disease related to atherosclerosis.
Patients with PAD have an increased risk for developing chronic angina, MI, or stroke and are much more
likely to die within 10 years
Assessment:Intermittent claudication in peripheral arterial occlusive disease
it is the hallmark of PAD.
The pain is described as
aching, cramping, fatigue, or weakness
that is consistently reproduced with the same degree of exercise or activity and relieved with rest.
The pain commonly occurs in muscle groups one joint level below the stenosis or occlusion.
As classic claudication continues:
paresthesia in toes & feet, neuropathy with burning sensation, pain occurs at rest.
Chronic Peripheral Arterial Disease Stages pg chart 38-1
Bruit or aneursym may be present
Decreased or absent Pedal pulses
Muscle pain, cramping with exercise & relieved w/rest
Reproducible symptoms w/exercise
Stage III-Rest Pain
Pain while resting. Night awakening
Numbness, burning pain in distal part of LE
Pain relieved by placing extremity in a DEPENDENT postion
Ulcers, blackened tissue on toes, forefoot & heel
Specific findings for PAD depend
on the severity of the disease.
: loss of hair on the lower calf smooth, shiny skin), ankle, and foot; dry, scaly, dusky, pale, or mottled skin; and thickened toenails. Cool, decreased or absent pulses, intermittent claudication, painful & necrotic ulcers-
: brown pigment around ankles, warm, normal pulses, pain relieved with elevation of LE and compression stockings,
NTK the difference b/t both.
With severe arterial disease, the extremity
is cold and gray-blue (cyanotic) or darkened.
Pallor may occur when the extremity is elevated.
Dependent rubor (redness) may occur when the extremity is lowered.
Lower Extremity Ulcers from arterial PAD
are very painful
Diagnosis & Care PAD Interventions
Exercise/Positioning- collertal circulation ios where other blood supply is established thru other vessals because of the damage.
can elevate but not above their heart
avoid restrictive clothing
inspect feet daily
do not apply heating pads directly to skin
-Drug Therapy: Trental, Aspirin, Plavix
(if doens't work, they may end up with arterial bypass or amputation)
Acute Peripheral Arterial OcclusionAcute Arterial Ischemic Disorder
Embolus / Thrombus
Narrowed artery or trauma
Six "P'S" of Ischemia
(late sign indicative of nerve damage)
Acute Arterial Ischemic Disorder Interventions
Must be immediate to save extremity
Anticoagulation Therapy (Heparin)
Thrombectomy or embolectomy
Will know mediction is working by?
pulse sites better
complication- Compartment Syndrome
N/I- Loosen dressing, raise extremity to level of heart
and notify MD (surgery- faschiotomy)
Tightening of skeletal muscle:
pain on PROM
poor cap refill
localized dilation of an artery, which enlarges the artery to at least two times its normal diameter.
Aneurysm: It may be described as :
fusiform (a diffuse dilation affecting the entire circumference of the artery) or
saccular (an outpouching affecting only a distinct portion of the artery).
Aneurysms may also be described as true or false.
In true aneurysms, the arterial wall is weakened by congenital or acquired problems.
False aneurysms occur as a result of vessel injury or trauma to all three layers of the arterial wall
NTK how is it formed? Nursing Q
An aneurysm forms when the middle layer (media) of the artery is weakened, producing a stretching effect in the inner layer (intima) and outer layers of the artery.
As the artery widens, tension in the wall increases and further widening occurs, thus enlarging the aneurysm.
Hypertension (high blood pressure) produces more tension and enlargement within the artery.
As the aneurysm grows, the risk of arterial rupture increases.
When dissecting aneurysms occur, the aneurysm enlarges, blood is lost, and blood flow to organs is diminished
Ascending Aorta & Descending thoracic aorta
- most common
men and women b/t 50-60 yo
Abdominal aortic aneurysms (AAA)
Most common cause: athlerosclerosis.
Also late manifestation of syphilis
Risk: antihypertensive drugs
most often occurs b/t renal arteries and aortic bifircation
Thoracic aortic aneurysms (TAAs)
subclavian and diaphragm
mass is visable above substern noch
do not want to rupture
MONITOR BP- measure ab girth
AAA signs and symptoms
nawing pain in ab or lower back
pt will tell you that they feel their heart beating in upper ab
you may assess by ausculating for a bruit (do NOT palpate)
Dx- angiogram or ab ultrasound
assess perpherial pulses with angiogram.
TAA After surgery:
monitor for bowel sounds
*paralytic illeus (bowel is asleep)
pt's may not lift anything heavy for 3 months anything over 20 lbs.
is the most frequent complication and is life threatening because abrupt and massive hemorrhagic shock results: MEDICAL EMERGENCY
S/S of Rupture
: hypovolemic or cardiogenic shock with sudden severe pain
Monitor: VS every hour, Neuro, Resp, Urinary output, peripheral pulses.
If BP rises by more than 30 mm Hg from previous reading, measure abdominal girth to id possibility of rupture (enlargement)
Thromboangiitis obliterans (Buerger's disease)
Uncommon occlusive inflammation (autoimmune) disorder in medium to small arteries (most common) & veins. Distal portions of upper & lower extremities.
The cause is unknown
Men between 20-35 yrs
Aggravating factor is smoking or chewing tobacco. Tobacco Abstinence a must.
(will relieve symptoms if stops smoking)
Treatment is the same as that for atherosclerotic peripheral arterial disease.
s/s interm claudication
Buerger's is diff than arthoscelerosis
b/c autoimmune disorder
Buerger's Main objectives
prevent progression of the disease
protect extremities from trauma or infection
Raynaud's Phenomenon & disease
Triggered by extreme heat or cold.
Caused by vasospasm of arterioles/arteries of Upper and Lower Exremeties. which cause vasoconstriction
toes and fingers-cyanotic
Disease: occurs bilaterally. Ages 17-40. More common in women and in cold climates and in winter.
: >30 y/o.
Etiology- unknown although many patients also have systemic connective tissue disease
-during an episode the color changes in fingers, toes, ears, and nose, it goes from white to blue than red. They appear pale then cyanotic which goes to rubor after the episode.
pain occurs when goes back to red
Raynaud's brought on by
described as coldness and numbness then followed by throbbing, aching pain, tingling and swelling.
Symptoms precipitated by exposure to cold, emotional upsets, caffeine, and tobacco use.
Usually last only minutes but can go to hours.
Frequent and prolonged episodes of raynaud's
Frequent and prolonged episodes can affect skin and
cause ulcers and sometimes gangrene.
No diagnostic tests
If avoiding the above does not work than
the calcium channel blocker Procardia is effective or a sympathectomy may help some patients.
Venous thromboembolism Phlebitis
is an inflammation of the vein.
Formation of a thrombus with inflammation of the vein is a thrombophlebitis.
Classified as: superficial thrombophlebitis or deep vein thrombosis(DVT).
Thrombophlebitis- occurs in 65% of patients receiving I.V. therapy.
not flushing N/S properly
occurs in at least 5% of all surgery patients. It is more serious because the clot can move and turn into an embolus.
consists of venous thrombosis & PE
Thrombosis of superficial veins produces pain or tenderness, redness, and warmth in the involved area.
Risk of the superficial venous thrombi becoming dislodged or fragmented is very low because most of them dissolve spontaneously.
elevation of extremity to increase venous return and decrease edema.
Apply heat for pain and edema.
In lower extremities elastic compression stockings should be applied
if put on before it can cause clot to dislodge
Deep Vein thrombosis (DVT) Clinical manifestations-
Calf/Groin tenderness and pain
Sudden onset of swelling of leg - unilateral
Observe for assemmetry of legs from groin to feet
Measure diameters of calves
Pain on dorsiflexion of foot (positive Homan's sign)-
not always present.
If DVT confirmed, DO NOT elicit Homan's sign as it increases risk for embolization.
systemic fever 100.4 F
DVT Prevention is the key.
Venous Duplex Ultrasonography
Venogram- chks blood flow (not doing as much bc of sensitivity to the dye)
Fibrinogen scanning: D-Dimer test
oral contraceptions increas risk for DVT's
chronic venous insufficiency(regurg causing edema,increased pigmentation, secondary varicosities, ulceration, cyanosis in dependent position),
Phlegmasis cerulea dolens
-swollen blue and painful legs rarely occurs but can cause gangrene in severe cases.
DVT Drug therapy-
Low molecular wt heparin (LMWH)
eventually to Coumadin
IV bolus: 80-100 units/kg OR 5000 units followed by continuous fusion
MD order: med, concentrations (in 5% dextrose in water);
number of units or mL/hour needed to maintain PTT
(usually 30,000 units per 24 hours)
PTT measured daily. (facility determines target range
Call MD if >70. Normal: 30 to 45 seconds
Heparin Antidote: Protamine Sulfate
Low molecular weight heparin (LMWH)
Preferred treatment. Managed at home. aPTT's not needed
If receiving continuous heparin, may be added after 5th day.
IV heparin continued for 3-4 days WITH coumadin until desired effect achieved.
If LMWH: give after 1st dose of LMWH.
ANTIDOTE: Vitamin K
: t-PA, Reteplase
Most serious SE is intracerebral bleeding (monitor for decreased LOC)
Surgical management- venous thromboectomy rarely done,
also Greenfield filter to prevent pulmonary embolism. Goes into vessel to prevent clot from goin into inf. vena cava
not given with hep and is noncompatible
NOT IN SAME IV line
If we are going fro hep IV to lovenox-
the hep IV must be dc'd for 30 minutes before first dose of Lovenox (never massage)
do not aspirate
DVT Nursing Care pt 1
Close observation for bleeding and observation of labs
Teaching patient the foods which interfere with Coumadin therapy as well as the herbal preparations which might interfere.
Bedrest for 5-7 days, elevation ABOVE LEVEL OF HEART of affected limb, analgesics for pain, warm moist packs to affected leg. When the patient begins walking use elastic compression hose (put on prior to getting out of bed and take off at bedtime).
DO NOT MASSAGE AFFECTED EXTREMITY
avoid contact supports
pg 819 chart
DVT Nursing Care pt 2
Monitor for SOB, Chest pain, Neuro changes
A person who refuses to discontinue alcohol use should not receive anticoagulant therapy because chronic alcohol use decreases the effectiveness. In patients with liver problems the potential for bleeding may become exacerbated by anticoagulant therapy.
Chart 38-6: Patient Teaching: Anticoagulant Therapy
Chart 38-7: Drugs that interfere with Coumadin
Chronic venous insufficiency (AKA-Great Sapheous Reflux)
Results from prolonged hypertension (stretches and damages valves) of the venous valves in the legs.
Can lead to reflux of blood back through the valves > increased hypertension > edema.
Both superficial and deep leg veins can be involved.
Chronic venous insufficiency most common in
in the elderly. Because the walls of veins are thinner and more elastic than arteries, they distend readily when venous pressure is elevated.
Leads to venous stasis (stoppage) > ulcers, swelling, and cellulitis.
Calculating Hep and knowing that the medications are working.
1.5-2.5 x the normal control value
Normal PTT- 35-40 sec
Normal PT 11-45 sec
Normal INR 1-2 sec
CVI- The brownish pigmentation
and ulcerations usually occur in the lower part of the extremity, in the area of the ankle. The skin becomes dry, cracks, and itches, subcutaneous tissue fibrose and atrophy, the risk of injury and infection of the extremities is increased.
Complications- ulcerations, cellulitis or dermatitis may complicate the care.
Persons who stand/sit in 1 postion for long periods (Teachers, office workers)
Can lead to amputation and death
Management of CVI
management is directed at reducing venous stasis and preventing ulcerations.
Any measure that increases the venous flow is utilized such as:
elevation of leg,
compression of superficial veins with elastic compression stockings or
Foods that interfere with coumadin
HIGH IN VITA K
Avoid while on coumadin these meds
if you choos to come off coumadin and take the NSAIDS they will increas risk of strokes.
CVI Nutrition balance
protein, calories, vit A, C and Zinc.
For diabetics the goal will be to have normal glucose levels.
Avoid trauma, appropriate activity and exercise, and proper limb positioning.
Care for venous ulcers:Occlusive Dressings
Aseptic technique. Standard & Contact Precautions
leave in place 3-5 days. Debridement/ absorption/ protect
Oxygen permeable polyethylene film: debridement/ protection
Oxygen- impermeable: DuoDerm (brand name)
used for light to moderate exudating wounds
To promote healing the CVI wound
is kept clean of drainage and necrotic tissue. Debridement is the removal of nonviable tissue from wounds. It can be accomplished by different methods:
Surgical: with scalpel or scissors. May require graft
Cotton Gauze Dressing-
Wet to dry; continuous Dry, Continuous Wet
Biologic- artificial skin or graft
Enzymatic -chemical to help increase sloughing
Calcium alginate: used to pack deep & infected wounds
Dilated, tortuous subcutaneous veins mostly found in the saphenous system
Primary-superficial veins are dilated and valves may or may not be incompetent. Familial tendency
Secondary-veins in the esophagus, anorectal area, and AV fistulas and malformation.
Varicose veins- assessment
Appearance, Edema, Pain after prolonged standing (relieved by walking or elevation), night cramps & edema
Complication-superficial thrombophlebitis most common, rare is rupture of veins and ulceration of skin.
pt in supine position w/legs elevated
Have pt sit up and observe filling f veins: veins will feel from
proximal end (normal would be distal end- VEINS).
The superficial veins of the foot and leg interconnect to form a complex network below the skin.
Varicose veins cont'd
Care- rest, elevate limb, compression stockings, exercise and walking.
Sclerotherapy-Injects solution into vein or uses laser followed by pressure dressing for 24-72 hours
This set is often in folders with...
Med Surg 38 - Vascular Problems - Venous Disease
Digestive System, Digestive system
You might also like...
CH. 38 Peripheral Vascular DiseasePVD
Med Surge Chapter 38
Med Surg Exam 2: PAD & PVD
Other sets by this creator
Heart and Neck Vessels- AU Nursing
Peripheral Vascular System and Lymphatic System- A…
Respiratory System-AU Nursing
Abcaudill N100 Exam II