Ch 30: Vascular Disorders and Peripheral Circulation Problems

Surgical Intervention (PAD)

-Percutaneous transluminal angioplasty (like a cardiac cath but in the leg) -Laser-assisted angioplasty -Arterial revascularization surgery (Bypass grafts)

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."

*"Be sure to practice meticulous foot care."* The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patient's symptoms.

Health history of the vascular system

*Intermittent claudication:* arterial problem; leg/calf pain felt upon damage of oxygen in tissue... when not walking, pain goes away. *"rest pain" : *worse. Just sitting there and get pain. Even at rest, your leg for example is not getting what it needs. location of the pain

Risk factors for atherosclerosis and PVD

*Modifiable* Nicotine Diet HTN Diabetes Obesity Stress Sedentary lifestyle C-reactive protein (CRP) Hyperhomocysteinemia *Nonmodifiable* -Age -Gender -Familial predisposition and genetics

Cellulitis

*S&S:* **localized** swelling or redness, fever, chills, sweating *Tx with:* oral or IV antibiotics based on severity ^used bc cellulitis can lead to septicemia Nursing -Elevate -Warm, moist packs to site every 2 to 4 hours -Educate regarding prevention of recurrence -Reinforce education about skin and foot care (wear shoes) *Common with IV drug users*

Physical assessment of the vascular system

*Skin:* pallor, pale, cool, rubor, loss of hair, brittle nails, dry or scaling skin, atrophy, and ulcerations *Pulse:* can't find pedal pulse, get doppler for popliteal?, can't find it still.... call for help and in the meantime feel the leg. Pink: don't really have to call the dotor Cold, no pulse: dependent leg position

Diagnostic evaluation

-**Doppler and ankle-brachial index (ABI)** (arm and ankle pressure, take both at same time then divide) -**Exercise testing** -Duplex US -CT scanning -**Angiography** -Magnetic resonance angiography -Contrast phlebography (venography) -Lymphoscintigraphy

Vascular System is made up of?

-*Arteries* (even a small reduction can cause tissue pain) and arterioles -Capillaries -*Veins* and venules -Lymphatic vessels *Function of the vascular system* To transport blood throughout the body 3 systems (different areas of the vascular system): central, pulmonary, lymphatic

Raynaud's Disease

-*InterMITtent arterial vasoocclusion*, usually of the fingertips or toes (*gets better has you get older*) -Raynaud's phenomenon is associated with other underlying disease such as scleroderma. -Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain -Episodes are usually brought on by a trigger such as cold or stress. -Occurs most frequently in *young women* -Protect from cold (*keep them warm*) and other triggers. -Avoid injury to hands and fingers. can use nitropaste but be careful

Gerontological Considerations

-*Intima thickens* (innermost layer of a vessel) ^already have less blood flow and this makes it worst ^body starts to create own bypasses, so at 60-70 when are heart starts to die down, if we have a heart attack it's really small. -*Elastin fibers of the media become calcified, thin*, and fragmented, and collagen accumulated in the intima and the media -These changes cause the *vessels to stiffen*, which results in increased peripheral resistance, impaired blood flow, and increased LV workload ^body has also creates tributaries so that when the vessel hardens and becomes smaller, they are still fine.

Pharmacologic Therapy—PAD (Peripheral artery disease)

-*Pentoxifylline (Trental)*-increased erythrocyte flexibility, lowers blood fibrinogen, and inhibits neutrophil adhesion. (so can slide through smaller areas) -*Cilostazol (Pletal)*-a vasodilator that inhibits platelet aggregation (no-go for CHF or EF<40%) ^more expensive than aspirin -Aspirin -Clopidogrel (Plavix) -*Statins: 1st line treatment after lifestyle modifications* ^stop formation , decreases inflammation ^don't stop suddenly (encourages inflammatory process) ^body makes about 85-90% of cholesterol

Patho of the vascular system

-*Reduced blood flow* through peripheral blood vessels characterizes all peripheral vascular diseases. -If tissue needs are high, even modestly reduced blood flow may be inadequate to maintain tissue integrity -Tissues then fall prey to ischemia, become malnourished, and ultimately die unless adequate blood flow is restored 1. Pump failure 2. Alteration in blood and lymphatic vessels (edematous tissues cannot receive adequate nutrition from the blood and consequently are more susceptible to breakdown, injury, and infection) 3. Circulatory insufficiency of the extremities

Medical Management of Leg Ulcers

-Anti-infective therapy depends on the infecting agent. Oral antibiotics are usually prescribed. -Compression therapy (*VENOUS ONLY*) -Debridement of wound -Dressings -Other-HBO (hyperbaric oxygen therapy, to dissolve O2 into plasma: used for both venous and arterial to bring more oxygen to the tissues to heal), Wound VAC (*VENOUS ONLY*; draws fluid out) ^look up dressings for wound care^

What are some of the arterial disorders?

-Arteriosclerosis and atherosclerosis (Coronary artery disease (CAD) is a condition which affects the arteries that supply the heart with blood. It is usually caused by atherosclerosis which is a buildup of plaque inside the artery walls.) *Common sites of obtruction: bifurcation site/saddles* -Arterial embolism and arterial thrombosis -Raynaud's phenomenon and other acrosyndromes

Virchow's Triad

-Endothelial damage -Hypercoagulable state -blood flow stasis

Improving Peripheral Arterial Circulation

-Exercises and activities: walking, graded isometric exercises. **Walk to the point of pain, rest, then walk some more** -Positioning strategies -Temperature; avoid cold, use warmth to vasodilate -Stop smoking (*vasoconstriction, spasms*) -Stress reduction

Maintaining Tissue Integrity in PAD

-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 (*protein, zinc, vitamin C and A*): be careful with high protein diets because it will push all the fluid into your vascular system, low-fat diet -Weight reduction as necessary -Positioning for PAD pts (*dependent legs down, below the heart*) -Promote vasodilation (*keep them warm*) and avoid vasoconstriction -Look in shoes (*pebble, can't feel it*)

ABI (ankle-brachial index)

-Ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the arm -*Objective indicator of arterial disease (SYSTEMICALLY)* -ABI of about 1.0 is normal ^ *<1=arterial disease* ^ -*ankle/arm=ABI* **ABI + DOPPLER (detects blood flow)=helps characterize the nature of peripheral vascular disease**

Interventions for leg ulcers:

-Restoring skin integrity (Skin care/hygiene and wound care, Positioning of legs to promote circulation, Avoidance of trauma/heat sources) -Improving physical 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 before activities/wound cleaning: 30 mins prior) -Promoting adequate 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) *Many patients with peripheral vascular disease are older adults. Particular consideration should be given to their iron intake because many older people are anemic. * -Promoting home- and community-based care (Encourage activities that promote arterial and venous circulation, relieve pain, and promote tissue integrity. Long-term care of the feet and legs to promote healing of wounds and *prevent recurrence of ulcerations is the primary goal*. Participation of family members and home HCP. Regular follow-up with a primary HCP is necessary.

Nursing Process: The Care of the Patient with Leg Ulcers—Assessment

-Venous often form over the medial or lateral malleolus. They are chronic, hard to heal, and often recur. -History of the condition -Treatment depends upon the type of ulcer -Assess for presence of infection-take cultures -Assess nutrition: will need nutrition consult! (one of the only ways we can make an effect on the ulcer: lower sugar, high protein, higher zinc, higher Vitamin a&c) -h/o diabetes, collagen disease, varicose veins -*Assess pain (and tx*), peripheral pulses, edema

*Lymphatic Disorders* (3)

1. *Lymphangitis:* inflammation or *infection* of the lymphatic *channels* 2. *Lymphade(N)itis:* inflammation or *infection* of the lymph *(N)odes* -can feel really well on groin/neck (hot/swell) 3. *LymphEDEMA:* tissue swelling related to *obstruction (block)* of lymphatic flow (extremities will get huge, and generally won't go back to normal) -Primary: congenital -Secondary: acquired obstruction

Varicose Veins

Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves. -pressure on veins, esp lower legs -crossing legs at knees causes a lot of backup pressure *Most commonly occurs in:* LE, the saphenous veins, or the lower trunk but can occur anywhere (esophagel varices) *Signs/Symptoms:* May have dull aches or muscle cramps, edema and feeling of heaviness. Often no symptoms but can cause body image disturbance. *Tx:* ligation and stripping, sclerotherapy, and thermal ablation ^once they have done that, can't use for bipass?^

Medications for VTE

Anticoagulants -Heparin -LMWH (Lovenox) -Warfarin Know nursing actions for these meds! Chart 30-9 Contraindications to anticoagulant therapy Chart 30-10 Patient education, taking anticoagulant medications

A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A) massage both legs firmly with lotion prior to applying the stockings. B) apply the stockings in the morning upon awakening and before getting out of bed. C) roll the stockings down to the knees if they will not stay up on the thighs. D) remove the sticking while out of bed for 1 hr, four times a day to allow the legs to rest.

B. apply the stocking in the morning upon awakening and before getting out of bed. Applying stocking in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time. Massaging the affected area can dislodge a clot and cause embolism. Rolling stocking down can restrict circulation and cause edema. Stocking should be removed at night before going to bed.

The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What should be included in the teaching plan? A) Elevate the lower extremities. B) Exercise is discouraged. C) Keep the lower extremities in a neutral or dependent position. D) PAD should not cause pain.

C) Keep the lower extremities in a neutral or dependent position. Rationale: For patients with PAD, blood flow to the lower extremities needs to be enhanced; therefore, the nurse encourages keeping the lower extremities in a neutral or dependent position. In contrast, for patients with venous insufficiency, blood return to the heart needs to be enhanced, so the lower extremities are elevated. Exercise can be prescribed to aid in the development of collateral circulation. Some pain is associated with PAD.

A nurse is caring for a client who has a deep vein thrombosis and has been taking unfractionated heparin for 1 week. The client's condition is improving. Two days ago, the primary care provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following responses is appropriate for the nurse to give to the client? A) "Your provider must have forgotten the you were already taking heparin. I will remind her." B) "Your blood was so thick that two anticoagulants were needed." C) Warfarin takes 3-4 days to achieve therapeutic anticoagulant effects. Heparin will be discontinued soon." D) "Only one of these medications is being given to treat your DVT."

C. "Warfarin takes 3-4 days to achieve therapeutic anticoagulant effects. Heparin will be discontinued soon." Warfarin takes 3-4 days to achieve therapeutic anticoagulant effects because it depresses synthesis of clotting factors, but does not have any effect on clotting factors that are already present. Effects are delayed until the clotting factors that are present decay.

T or F: Cellulitis cannot be differentiated from lymphangitis.

Cellulitis needs to be differentiated from lymphangitis. With cellulitis, the swelling and redness are localized and anatomically nonspecific. With lymphangitis, characteristic red streaks appear denoting the outline of the lymphatic vessels that are affected.

Preventive measures for VTE

Elastic hose Pneumatic compression devices Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy Positioning: periodic elevation of lower extremities Exercises: active and passive limb exercises; deep breathing exercises Early ambulation Avoid sitting or standing for prolonged periods; walk 10 minutes every 1 to 2 hours. Fluids

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 Diagnosis: Altered peripheral tissue perfusion Chronic pain Risk for impaired skin integrity Knowledge deficient

Potential complications of Leg Ulcers

Infection Gangrene

Venous Disorders

Problems with the veins that interfere with adequate return of blood flow from the extremities. Superficial and deep veins in the LE (lower extremities) that have valves that prevent backflow. Skeletal muscles of the LE promote venous return during walking and other activities. -Venous thromboembolism -Chronic venous insufficiency/postthrombotic syndrome -Varicose veins -Leg ulcers

Prevention is key.. how to prevent varicose veins?

Prevention is key (prevent venous stasis) -Avoid activities that cause venous stasis (wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods). -Elevate the legs 3 to 6 inches higher than heart level. -Walk for several minutes of every hour to promote circulation and 1 or 2 miles each day if there are no contraindications. -Wear graduated compression stockings. -Overweight patients should be encouraged to begin weight reduction plans.

What does the lymph system do?

The lymphatic system is a network of tissues and organs that help rid the body of toxins, waste and other unwanted materials. The primary function of the lymphatic system is to transport lymph, a fluid containing infection-fighting white blood cells, throughout the body. *Helps w/ healing/infection/inflammatory process*

Venous Thromboembolism: risk factors, dx, manisfestations, complications

Venous blood clot formed as a result of venous stasis, endothelial injury, or hypercoagulability. *(Virchow's Triad)* *Risk factors:* surgery, HF, immobility, pregnancy, Oral Contraceptives, septicemia, cancer (Chart 30-7) *Dx:* D-dimer: biproducts of clotting (they are the products left behind when a clot breaks down in the body) -negative d-dimer= 100% no VTE -positive d-dimer= do V/Q scan venous duplex ultrasonography, venogram *Manifestations:* Can be asymptomatic, calf or groin pain, tenderness, swelling of leg. Palpate for warmth, edema, and induration and hardness over area. Measure and record. *Complications:* travels and can cause PE and stroke ^if it doesn't travel then will have swelling for a little bit

Which patient is at highest risk for venous thromboembolism? A) A 50-year-old postoperative patient B) A 25-year-old patient with a central venous catheter in place to treat septicemia C) A 71-year-old otherwise healthy older adult D) A pregnant 30-year-old woman due in 2 weeks

b) A 25-year-old patient with a central venous catheter in place to treat septicemia ^the only one with 2 RF^ Rationale: Some risk factors for venous thromboembolism include but are not limited to age older than 65 years, patients undergoing surgery, central venous catheter placement, septicemia, and pregnancy. The client in this question with two risk factors is the 25-year-old with a central venous catheter in place to treat septicemia. All other patients only have one risk factor.

2 types of ulcers

excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off *VENOUS (more common)* -75% -Aching or heavy pain, ulcer itself is painless -Edematous -Rusty color -Skin starts to split -Large, *superficial*, and highly exudative -Discolored (*Never goes away, RBCs trapped and died*) -Side of foot over metatarsal heads *ARTERIAL* 20% -Inadequate exchange of oxygen and nutrients causes cell death -Intermittent claudication -*Small, thin, deep ulcerations* on tips of toes or in web spaces -Dry gangrene (wait for it to fall off) -*Pinpoint blackdots *