Peripheral Vascular Disease: Assessments and Interventions

Nursing Assessments for Peripheral Vascular Diseases

• Regularly check peripheral pulses to detect changes in blood flow.
• Monitor skin color changes (pallor, edema, erythema), temperature variations, ulceration, or delayed wound healing as indicators of compromised circulation.
• Assess pain using the COLDSPA mnemonic.
• Evaluate peripheral perfusion by assessing capillary refill time, where delayed refill may suggest circulatory impairment.
• Quantify arterial insufficiency severity by measuring the Ankle-Brachial Index (ABI), with an ABI less than 0.9 usually indicating peripheral artery disease.

Nursing Interventions for Peripheral Vascular Diseases

• Promote circulation by advising patients to avoid leg crossing and encouraging extremity elevation to reduce edema and enhance venous return.
• Facilitate regular, moderate exercise, like walking, to improve blood flow and reduce symptoms.
• Manage pain through prescribed analgesics and antispasmodics, alongside non-pharmacologic methods like warm compresses and relaxation techniques.
• Keep affected areas clean and dry and apply dressings to ulcers/sores while monitoring for infection signs.
• Educate on the significance of smoking cessation to avoid exacerbating vascular conditions.
• Encourage consistent medication adherence (antiplatelet agents, statins) to manage symptoms/prevent progression.
• Encourage lifestyle changes involving dietary adjustments, weight management, and regular physical activity.
• Continuously monitor vital signs, peripheral pulses, and pain levels for any condition changes.
• Implement safety measures to prevent falls, especially for patients with decreased sensation or mobility.

Health Promotion and Maintenance Strategies for Vascular Health

• Adopt a heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats while limiting saturated/trans fats, sodium, and added sugars.
• Aim for 150 minutes weekly of moderately intense exercise.
• Encourage 60 minutes daily of moderate physical activity for children, support sports involvement, and reduce sedentary activities.
• Maintain a healthy weight to reduce strain on the vascular system.
• Adhere to prescribed medications for conditions like hypertension or high cholesterol to reduce vascular issue risk factors.
• Schedule regular medical check-ups to monitor BP, cholesterol, and screenings for atherosclerosis or PAD for early intervention.
• Schedule regular check-ups to monitor growth, BP, and cardiovascular health for early risk factor detection.
• Steer clear of all tobacco products due to their damage to blood vessels and acceleration of vascular aging.
• Alcohol consumption should be moderate, following guidelines.
• Use stress management techniques like mindfulness, yoga, or counseling to mitigate negative impacts on vascular health.

Comparison of Arterial and Venous Disorders

• Arterial disorder (PVD) is caused by atherosclerosis, where plaque buildup narrows/blocks arteries, leading to ischemia in extremities.

• Arterial disorder (PVD) symptoms include intermittent pain/cramping/fatigue in legs during exercise, rest pain, non-healing ulcers, or gangrene in severe cases.

• Risk factors for arterial disorder (PVD) include smoking, diabetes, hypertension, and high cholesterol.

• Monitor for limping, edema, skin discoloration/shininess, and check peripheral pulses, capillary refill, and skin temperature.

• Venous disorder (DVT) is the formation of a blood clot in deep veins, often in legs, because of venous stasis, endothelial injury, or hypercoagulability (Virchow's triad).

• Many patients can experience no symptoms of venous disorder (DVT), but symptoms include unilateral leg swelling, pain, warmth, tenderness, and redness.

• Risk factors for venous disorder (DVT) include orthopedic surgeries, A.Fib, hospitalization, and ischemic stroke.

• Monitor for adequate oxygenation and respiratory changes (SOB, chest pain, cough), edema, redness, and pain in DVT location and its migration.

Pulmonary Embolism

• Pulmonary Embolism (PE) occurs when part of a clot dislodges from a DVT and travels to pulmonary arteries, impairing blood flow to lung tissue.
• Other PE causes include fat embolism from broken bones, tumors, or air bubbles.
• Symptoms include acute SOB, chest pain, cough, excessive sweating, rapid breathing, and shock in severe cases.
• Risk factors include aging, obesity, smoking, heart disease, cancer, birth control, pregnancy, connective tissue disease history, and immobility.
• Monitor for increased BP, indicating pulmonary hypertension.

Arterial vs. Venous Lesions

• Arterial lesions are located at the end of toes, top of feet (dorsum), or lateral ankle region (malleolus)

• Arterial ulcers have very little drainage and little tissue granulation

• Arterial wounds can be deep "punched out" with noticeable margins/edges for a round appearance

• Venous lesions are located at the medial parts of the lower legs or medial ankle region

• Venous ulcers are swollen with drainage and granulation present (deep pink to red)

• Venous wounds have irregular and shallow edges

Pulmonary Embolism Development and Management

• PE results from the blockage of pulmonary vascular blood flow due to an embolus.
• PEs can be life-threatening, with half of PE deaths occurring within 2 hours of embolism.
• Unrecognized DVT can lead to PE.
• PE causes occlusion affecting perfusion and ventilation, leading to poor gas exchange or its cessation, resulting in death, pulmonary infarction, lung scarring, or permanent lung damage.
• Management includes anticoagulation, fibrinolytic therapy (lyses embolus), or surgery (embolectomy).

Nursing Care and Management of Peripheral Vascular Disease

• Promote oxygenation and gas exchange, preserve cardiac output, manage pain, and reduce anxiety.
• Place the patient in high Fowler's position with legs dependent.
• Maintain bed rest to reduce tissue oxygen needs and metabolic demand.
• Assess respiratory status frequently (SPO2, rate, depth, effort, lung sounds) and monitor ABGs.
• Instruct patients to report chest pain, assess skin color and temperature, and auscultate heart sounds.
• Monitor cardiac rhythm, administer vasopressors/meds as ordered, and monitor for JVD, edema, and pulmonary artery pressures.
• Maintain IV, arterial access, and central lines for unstable patients.
• To maintain safety, provide stool softeners to prevent constipation.
• Assess for bleeding signs, report abnormal coagulation results, and have protamine sulfate available. Avoid invasive procedures after fibrinolytic therapies and maintain firm pressure on injection sites.
• Soothe anxiety by explaining procedures, giving clear instructions, reducing stimuli, using a calm voice, and allow family presence. Give morphine sulfate for pain and anxiety.

Terms Related to DVT

• Thrombophlebitis: A condition where a blood clot forms and blocks veins.
• Superficial Thrombophlebitis: Blockage near the skin's surface.
• Deep Vein Thrombophlebitis(DVT): Blockage in deep muscle, typically in larger lower leg and thigh veins.
• Thrombus: A clot in a vein or artery.
• Venous Thrombosis: A clot in a vein.

Terms Related to PVD

• Arteriosclerosis: Thickening and reduced elasticity of arterial walls, leading to calcification.
• Atherosclerosis: A subcategory of arteriosclerosis where fat/fibrin obstruct and harden arteries.
• Chronic Venous Insufficiency (CVI): Inadequate venous flow over an extended period.
• Intermittent Claudication: Cramping in calves or thighs with activity.
• Dependent Rubor: Dark reddish color appearing when legs are dependent, indicating poor circulation.
• Venous Stasis: Blood stagnation in the leg, causing CVI from increased venous pressures and impaired arterial circulation.
• Stasis Dermatitis: Circumferential discoloration around the ankle, instep, and lower leg.
• Stasis Pigmentation: Skin discoloration from poor circulation in the lower legs.

Manifestations of Peripheral Vascular Conditions

• Peripheral Atherosclerosis (PAD) causes narrowing of arteries because of plaque buildup, reducing blood flow to the legs and arms.

• Risk factors for PAD include aging, diabetes, and smoking.

• Symptoms of PAD can manifest as numbness, weakness, or heaviness in muscles, burning or aching pain at rest, and paleness when legs are elevated.

• Chronic Venous Insufficiency symptoms include aching, cramping, or heavy feeling in legs, tingling, leg swelling/pain worsened by standing but relieved by elevation, edema in the legs, and tan or dusky circumferential discoloration of the legs along with apparent distended veins

• Ulcers in peripheral vascular conditions have dark red color, edema, and irregular margins around ankles/heels/feet/toes and may appear as open red/black/yellow sores.

Nursing Interventions for Peripheral Vascular Disorders

• Regularly check peripheral pulses, skin color/temperature, and capillary refill. Assess intermittent claudication and rest pain which reveals ischemia worsening.

• Administer prescribed meds (statins, antiplatelet agents, antihypertensives, vasodilators) and educate on medication adherence.

• Educate on lifestyle changes to reduce smoking, control blood sugar, and follow a healthy diet/weight management plan.

• Encourage exercise (walking) to improve circulation and reduce claudication. Monitor exercise tolerance and adjust activities as needed.

• Provide foot and leg care by educating on proper foot inspection/care, wearing appropriate shoes to prevent non-healing injuries/ulcers.

• Educate on ischemia warning signs and the need for prompt medical help.

• Regularly inspect lower extremities for edema, skin discoloration, varicosities, and early ulcer formation. Also, monitor for changes in skin integrity and temp in patients with Chronic Venous Insufficiency.

• Use compression stockings/bandages to improve venous return and reduce swelling. Educate on correct use if a known clot is not present.

• Encourage leg elevation to reduce edema and perform gentle exercises (walking/ calf muscle exercises) to improve circulation.

• Encourage hygiene/use of moisturizers to prevent dryness/cracking. Avoid harsh soaps/hot water.

• Encourage weight management, avoid prolonged sitting/standing and constricting garments, elevate legs regularly, and ambulate often to promote blood flow and reduce venous stasis. Discuss avoiding smoking where applicable.

Ulcer Care in Peripheral Vascular Disorders

• Assess ulcer size/depth/location/exudate and infection signs. Document changes to assess the healing progress.
• Cleanse wounds with proper solutions and keep moist. Use debridement protocol for necrotic tissue, if present, and aseptic technique must be maintained.
• Monitor for infection signs such as redness, pain, warmth, and purulent discharge. Report changes and make sure proper hand hygiene/precautions are taken during procedures.
• Promote a balanced diet with plenty of protein, minerals, and vitamins.
• Teach proper wound care practices and stress hand hygiene.

Ankle-Brachial Index: Purpose and Interpretation

• The Ankle-Brachial Index (ABI) compares systolic blood pressure in upper arm by dividing the systolic blood pressure of the ankle.
• The ABI can diagnose and assess PAD or PVD severity.
• Normal ABI values range from 0.9-1.40.
• Mild PAD: 0.71-0.89.
• Moderate PAD: 0.41-0.70.
• Severe PAD: <0.40.
• Highest systolic ankle pressure/highest brachial systolic pressure = ABI.
  • ABI > 1.4 indicates vessel hardening.

Deep Vein Thrombosis and Virchow's Triad

• Deep Vein Thrombosis happens when blood clots form.
• Virchow's Triad are the main pathological factors:
  • Venous stasis is from poor venous return because of sedentary behavior, immobility, or valve dysfunction, causing blood pooling and clot formation.
  • Vessel (endothelial) injury is when vascular damage from surgery or trauma leads to endothelial injury, inflammation, platelet aggregation, and clot formation.
  • With hypercoagulability, conditions that increase blood coagulation (cancers, high estrogen states) raise DVT risk.

Deep Vein Thrombosis: Clinical Manifestations

• Clinical manifestations of DVT include heaviness, fullness in the legs, and fatigue.

DVT Prophylaxis

• Low molecular weight heparin (Enoxaparin/Lovenox) prevents new clots and existing clots from enlarging.
• TED hose increases blood flow velocity and prevents venous distension after surgery.
• Sequential Compression Devices (SCDs) improve blood flow by imitating walking, preventing clots.
• Early mobilization and leg exercises reduce immobility effects, pain, edema, and improve life quality.

Lab Monitoring for DVT

• International Normalized Ratio (INR) indicates proper anticoagulation, with a range between 2 and 3 commonly required.
• Prothrombin Time (PT) detects bleeding or clotting disorders.
• Activated Partial Thromboplastin Time (aPTT) measures the time it takes for plasma to clot. The reference range is 30-40 seconds.
• Detects how long blood takes to form clot
• Anti-Xa measures heparin levels and monitors anticoagulation therapy.

Additional Diagnostic Test for DVT

• Doppler ultrasound shows changes in blood flow, and the absence of blood flow confirms DVT.

Pulmonary Embolism

• PE is a sudden blockage in the pulmonary arteries from a blood clot.
• The clot typically breaks off the deep veins in the legs & travels to the lungs.
• Diagnostic tests to confirm PE:
  • Chest CT with contrast
  • CXR
  • PT pulmonary angiography
  • Lung scans (perfusion and ventilation scans)
  • Plasma D-dimer
  • Electrocardiography
  • ABG
  • ETCO2 (End Tidal Carbon Dioxide)
  • Coagulation studies

Pulmonary Embolism: Patient Education

• Provide an overview that PE is a blockage in pulmonary arteries and treatment with medications & changes can help prevent recurrence.
• Anticoagulants ensure regular INR blood tests, and managing the risk of bleeding by reporting bruising, wearing protective gear, or changes to their diet.

Warning Signs of Pulmonary Embolism

• Immediately, the patient needs to call the HCP or their is...
  • Sudden difficulty breathing
  • New Pain / discomfort in the leg is present
  • Signs of severe bleeding
  • Keeping a symptom diary.

Lifestyle And Activity Modifications to Avoid Pulmonary Embolism

• Avoid sedentary lifestyle, hydration and a good diet

Anticoagulant Agents: Mechanism and Therapeutic Use

• Platelet Inhibtors (Clopidogrel): Inhibits platelet aggregation to prevent clots.
• Anticoagulants: Slow down clotting process & reduce the growth of existing clots.
• Thrombolytics: Activate fibrinolytics to eliminated clots that already exist

Heparin

• Activates antithrombin & inhibits new clots from forming
• Key SE: Bleeding, hypersensitivity
• Monitor aPTT
• Antidote = Protamine Sulfate

Warfarin

• Vitamin K antagonist, prevents formation of clotting factors:
• Key SE: bleeding, GI upset, Hepatitis Monitor PT/ INR levels

Nursing with Anticoagulant Admninistration

• Prevent risky activities
• Report bleeding
• Get health history

Key aspects when placing a Thrombolytic Altelepase?

• Monitor Neuro Stats Typically in ICU
• Monitor for Cardiac Dysrhythmias

Antidotes

• Protamine sulfate is the antidote for heparin.
• Vitamin K (phytonadione) is the antidote for coumadin/Warfarin.
• Protamine sulfate 1mg for every mg of Enoxaparin is the drug that you will want to use.

Heparin

• Potentiates the inhibitory effect of antithrombin on factor Xa & thrombin.
• Prevents the formation of thrombus

Labs in patients with Enoxaparin include these

• Monitor Factor Xa, CBC (platelet count)

Key considerations on blood thinners education

• Clodipogrel is easily absorbed in the GI Tract (cause GI Pain & Bleeds)
• Aspirin can eat at your stomach because it is acidic

Teaching Aspects

• Clodipogrel, you can avoid if the pathology is bleeding.
• Aspirin, avoid pregnancy and if signs is present call specialist.

Key aspects when you have lab testing

• PT/INR - is used for wafranin
• APTT - is used for heparin

Acidic/Basidic levels

• Blood pH (determine acidity or alkalinity of blood)
• Normal is 7.35 - 7.45
• Less than 7.35 is Acidic Greater than 7.45 is Alkalotic PaCO2 (CO2 concentration in arterial blood)
• Normal is 35 - 45 mmHg
• Less than 35 mmHg is Alkalotic
• Greater than 45 mmHg is acidic HCO3/Bi-carb level (tells us if we have compensation)
• Normal is 22 - 26 mEq/L
• Less than 22 mEq/L is Acidotic Greater than 26 mEq/L is Alkalotic