Nursing Care of

Clients with
Peripheral Vascular
Disorders

PERIPHERAL ARTERIAL OCCLUSIVE

DISEASE

Peripheral
Arterial
Occlusive
Disease
Also known as Peripheral
Arterial Disorders (PAD)
-narrowing of the arteries in the
peripherals

Assessment

Intermittent claudication: hallmark of the disease

Is a numbness or burning, often described as feeling like a toothache, that is severe enough
to awaken clients at night
Elevating the extremety or placing it in a horizontal position increases the pain ,whereas
placing the extremety in a dependent position reduces the pain
Coldness or cold sensitivity - associated with blanching or cyanosis due to ischemia

Assessment
Nails: thickened and opaque
Skin : shiny,atropic and dry,with sparse hair growth
Comparison of the right and left extremeties
Edema
Sexual dysfunction
Ulceration and gangrene
Muscle atrophy
Peripheral pulses : pulse grading scale 0-4

Diagnostic
Findings
Ankle-brachial
Indexes(ABIs)

Treadmill testing for

Claudication

Duplex Ultrasonography

Medical Management

Control HPN
Reduce risk factors :control serum lipids,wt. reduction ,low fat and cho diet,daily walking
Cessation of tobacco use
Skin and foot care

Pharmacologic Therapy

1.Hermorheologic agent
.Pentoxifylline (trental)
.Increase flexibility of rbcs
.Decreases blood viscosity

Pharmacologic Therapy

2. Antiplatelet Agents
Aspirin (acetylsalicylic acid,Ancasal)
Clopidogrel (Plavix)
Ticlopidine(Ticlid)
Cilostazol(Pletal)- inhibit platelet aggregation and increase vasodilation
3.Vasodilators
4.Antihyperlipidemics

Surgical
Management
Percutaneous transluminal
angioplasty

Balloon Angioplasty

Laser Angioplasty

Stent Insertion

Atherectomy

Arterial bypass

Endovascular surgery

Endarterectomy
-an incision is made into the
artery
-Atheromatous obstruction is
removed

Femoral-to- popliteal graft

-surgical procedure choice if
atherosclerotic occlusion is
below the inguinal ligament in
the superficial femoral artery

Amputation

Nursing Management

Maintaining Circulation
Maintain skin integrity and prevent infection
Monitoring and managing potential complications
Promoting home and community-based care

Maintaining Circulation

Warm environment temperature

Avoid pressureon affected extremety
Quit smoking
Placelegsin slight dependencyto
promote arterial flow

Monitor the ff. q hr for the 1 st 8hrs

and then 2 hrs for 24hrs:
Pulses
Color and temperature of the
extremity
Capillary refill
Sensory and motor function of the
affected axtremeties
Compare extremeties
Doppler Evaluation
ABI

Exercise

Build up collateral circulation

Initiate gradually and slowly increased
Contraindicated : severe rest pain, venous ulcers ,or gangrene

Positioning

To promote circulation
Elevate feet at rest below heart level ,some have swelling in lower extremeties
Avoid crossing their legs

Monitoring and managing potential complications

UO
Central venous pressure
Mental status
Pulse rateand volume
Permit early recognitionand treatment of fluid imbalances
Bleeding/hematoma
Edema

Promoting home and community-based care

Assess patients ability to manage independently

Encourage to change lifestyle diet,activity ,and promote hygiene
Ensure has knowledge to assess any post op complications
Assist in developing a plan to stop using tobacco

Prevention

1.Primary-provide information
>cigarrete smoking
>HPN
>hyperlipidemia
>obesity
>physical inactivity
>DM

2. Secondary
>encourage the client with early symptoms to
seek medical care
3.Tertiary
>Rehabilitation :Exercise to promote collateral
circulation

Acute
Peripheral
Arterial
occlusion
Arterial embolism
Arterial thrombosis

Most common
cause:embolus or local thrombus
Risk Factors
Atrial fibrillation
Infective Endocarditis
Chronic heart failure

Assessment

six Ps of ischemia
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia (coolness)

Interventions

initiate treatment promptly to avoid

permanent damage or loss of
extremeties
Anticoagulant therapy
Angiography

Surgical treatment

Pre Op Nursing Care

Bed rest w/ extremity slightly elevated (15degrees)

Protect the affected part from trauma
Contraindicated: heating and cooling pads
Use sheepskon and foot cradles to protect legs from injury or trauma

Post Op Nursing Care

Monitor affected extremeties

Mild incisional pain is normal
Fasciotomy - surgical opening into the tissues may be
necessary to prevent further injury and save limb

Buergers Disease
or Thromboangiitis Obliterans

Buergers
Disease

Inflammatory ,non lipid occlusive

condition of small to medium arteries
followed by vein that impairs circulation
to the legs, feet, and occasionally hands
Most often in men 20-35 yrs old

Cause

Unknown
Linked to smoking or
chewing of tobacco

Clinical Manifestations

Intermittent claudication
Foot cramps, especially of the arch after exercising
Often a Burning pain ,and relieved by rest
Intense rubor of the foot
Absence of pedal pulse
Absent/diminished ulnar and radial artery pulse
Definite redness or Cyanosis

Diagnostic Findings

Allens test
To test for abnormal blood circulation
Segmental limb blood pressures
Demontrate distal location of the lesions or occlusions
Duplex Ultrasonography/ Doppler Ultrasonography
Used to document patency of the proximal vessels and to visualize the extent of distal disease

Arteriography
radiography of an artery, carried out after injection of a dye to see an obstruction or occlusion of
arteries
Plethysmography
to measure how much air you can hold in your lungs.
Venography
uses an injection of contrast material to show how blood flows through your veins

Management

Main objective : improve circulation to extremities, prevent progression of disease, and

protect extremities from trauma and infection
Exercise : promoting adequate circulation
Monitor pulses
Stop smoking
Avoid injury to the extremities

Antibiotics ,analgesics
Debridement of necrotic tissue :minimize infection
Regional symphatetic block or ganglionectomy : promote vasodilation and incease
blood flow
Amputation

Surgical Management of complications

Amputation
- if gangrene of a toe develops as a result of arterial occlusion

Nursing Management

incision is monitored for sign of hematoma

grief, fear,or anxiety r/t loss of limb

Aneurysms

Aneurysm

an excessive localized enlargement of an

artery caused by a weakening of the artery
wall.

Aortic Aneurysm

Aortic
Aneurysm

Abnormal dilatation of the arterial wall

caused by localized weakness and
stretching in the medial layer or wall of an
artery
An aneurysm is a localized sac or
dilation formed at a weak point in wall of
aorta
Can be located anywhere along the
aorta

CLASSIFICATION

Saccular aneurysm
-projects from one side of the vessel only

by shape or
form

Fusiform aneurysm
-if an entire arterial segment becomes dilated
Mycotic aneurysm
-very small aneurysms due to localized
infection

True aneurysm
-all three tunica layers are involved
False aneurysm

also known as pseudoaneurysm

-one in which the entire wall is injured blood
escapes between tunica layers and they
separate, a clot may form resulting in a
dissecting aneurysm

By location
Abdominal
Thoracic

Etiologic classification of
arterial aneurysms
Atherosclerotic changes in the aorta
Congenital:primary connective tissue
disorder (marfans syndrome)
Mechanical (hemodynamic): post stenotic
and arteriovenous fistula and amputationrelated
Traumatic(pseudoaneurysms)penetra
ting arterial injuries, blunt arterial
injuries
Inflammatory (non infectious):
associated with arteritis and periarterial
inflammation ex.Pancreatitis
Infectious (mycotic) bacterial, fungal,
sprirochetal infections

Risk factors
Genetic predisposition
Smoking
Hypertention
Obesity
Stress
Hypercholesterolemia

Thoracic Aortic
Aneurysm

atherosclerosis : most common cause

Occur most frequently in men, 40-70
yrs old
Thoracic area-most common site for a
dissecting aneurysm
About one third of patients with thoracic
aneurysms die of rupture of the aneurysm

Clinical
manifestations

Chest pain- most prominent

symptom, may occur only when
person is supine
Unequal pulses and arterial
pressure in upper
extremities,tracheal deviation
,cyanosis,weakness
Dyspnea
Cough

Hoarseness, stridor,or weakness or

complete aphonia
Dysphagia
Dilated superficial veins of the chest,
neck, or arms

Diagnostic findings

Chest xray
- to locate and describe the shape of the
aneurysm
Transesophageal echocardiography
- give the result of the heart structure
and function
Ct scan
- to see the image of the organ to be
diagnosed

Abdominal aortic
aneurysm

Atherosclerosis: most common cause

affects men four times more often than
women: most prevalent in elderly patients
Most occur below the renal arteries
If untreated , the eventual outome may
be rupture and death

Clinical
manifestations

Feel abdominal mass or abdominal

throbbing
Pulsatile mass in middle and upper
abdomen-most important diagnostic
indication
Systolic bruit over mass
embolism
Blue toes

Diagnostic findings

Duplex ultrasonography or ct scan

-Used to determine the size ,length, and
location of the aneurysm
Ultrasonography
Conventional angiography
-is used to diagnose the renal area

Management:
Aneurysm

Goals:
Limit progression
-size <5cm and asymptomatic, follow up with
serial ultrasound every 3-12 months
Growth rate normally 2-8mm
/yr , if 4mm/yr consider
electivesurgery

Symptomatic: mandates repair

Control bp: systolic bp is maintained at
about 100 to 120 mm Hg with anti
hypertensive medication
Prevent rupture
Pulse rate is reduced because of
antihypertensive drugs like propranolol

Surgical management

Endoaneurysmorrhaphy
-opening the sac and suturing a
prosthetic graft to the normal aorta within
the aneurysm(gortex)
Endovascular repair
Elective aneurysm repair
-standard treatment
Open surgical repair of the aneurysm by
resecting the vessel and sewing a bypass
graft in place

Post surgical complications

Post op renal failure
Ischemic colitis
Acute leg ischemia
Spinal cord ischemialigation of the artery of
adamkiewicz which supplies
the spinal cord
Aortic graft infection
sexual dysfunction

post op nursing interventions

monitor for signs of hemorrhage
monitor chest tubes for an increase in
chest drainage
assess sensation and motion of all
extremities ad notify physician for deficits
monitor serum creatinine, BUN, and
hourly outputs

monitor for dysrhythmias

monitor respiratory status
encourage coughing and deep
breathing
no lifting of heavy objects for 6-12 wks
avoid straining activities

surgical management

endovascular grafting
-placement of endovascular stents
:Note for potential complications:
Bleeding
Hematoma, or wound infection at the
femoral insertion site
graft thrombosis

Nursing management

Pre Op
anticipate rupture
assess fumctional capacity of all organ
systems
medical thrapies to stabilize physiologic
function should be implemented
Post Op
intense monitoring of pulmonary
,cardiovascular,renal,and neurogic status