Peripheral Vascular Disease (PVD)

• Peripheral Vascular Disease (PVD) involves disorders of the veins, arteries, and lymphatic system.

Peripheral Vascular System

• The right side of the heart pumps blood to the lungs.
• The left side of the heart pumps blood to all other body tissues.
• Arteries distribute oxygenated blood from the left side of the heart to the body tissues.
• Arterioles have little elasticity, possess more smooth muscle, and respond to O2 and CO2 levels by dilating and contracting.
• Veins carry deoxygenated blood from tissues to the right side of the heart.
• Lymphatic vessels are thin-walled and form a complex network that collects lymph fluid from tissues and organs, transporting it to the venous system.

Metabolic Requirements

• When metabolic requirements increase, blood vessels dilate.
• Metabolic demands increase with physical activity heat application, fever and infection.
• When metabolic requirements decrease, blood vessels constrict.
• Metabolic demands decrease with rest and cold application.

Blood Flow

• The equilibrium between hydrostatic and osmotic forces of the blood and interstitium determines the amount and direction of fluid movement.
• Hemodynamic resistance affects blood flow
• The peripheral vascular system regulates blood flow.
• The sympathetic nervous system, through norepinephrine stimulation, causes vasoconstriction.
• Epinephrine causes vasodilation in muscles and the brain.
• Angiotensin causes vasoconstriction.
• Arterial pressure is greater than venous pressure.
• Smaller radius = more resistance.
• Thicker blood(increased viscosity) reduces blood flow.

Pathophysiology of PVD

• Reduced blood flow in the peripheral vascular system leads to PVD.
• If tissue needs are high and blood supply is diminished, tissue integrity will get damaged.
• Causes include pump failure or alterations in blood or lymphatic vessels.

Signs and Symptoms of Circulatory Insufficiency

• Pain
• Skin changes
• Decreased pulse
• Edema

Assessment of PVD

• Health History: Includes assessing pain, fatigue of extremities, and any rest pain.
• Physical Assessment: Involves inspecting skin for warmth and rosy color and palpating pulses for presence and quality.
• Arterial issues lead to pale skin that pools, especially in the lower leg
• Venous issues lead to brown, leathery looking skin.
• Arterial stenosis may cause an absence of pulse.
• Veins may have a pulse but tough to feel due to edema.

Pain Characteristics

• Venous pain is often described as cramping. Elevating the legs can relieve it.
• Arterial pain is sharp and constant. Lowering the legs can at times relieve it.
• Intermittent claudication, discomfort, or fatigue in a muscle occurs with the same degree of exercise or activity and is relieved by rest.
• Pain at rest = critical ischemia.

Diagnostic Tests

• Doppler Ultrasound: Used to hear blood flow through vessels.
• Ankle-Brachial Index (ABI): Highest ankle blood pressure divided by the highest brachial blood pressure.
• Exercise Testing: Ankle systolic pressure is measured in response to walking.
• Duplex Ultrasound: Imaging of tissues, organs, and blood vessels.
• CT Scan: Cross-sectional images for volume evaluation.
• Angiography: Contrast is injected into the arterial system to visualize vessels.
• MRA: Provides a more detailed picture; can isolate blood vessels.
• Venography: Contrast is injected in veins to visualize them.

Arteriosclerosis and Atherosclerosis

• Arteriosclerosis: Most common disease where the endothelial lining of small arteries and arterioles thickens.
• Atherosclerosis: Affects the intima of large and medium-sized arteries, involving accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue.
• Results in thrombosis, aneurysm, ulceration, or rupture.
• Often found in extremeties but affects other sites.

Risk Factors for Atherosclerosis & PAD

• Modifiable: Smoking, hypertension, increased fat diet, obesity, sedentary lifestyle, stress, type 2 diabetes.
• Non-modifiable: Increased age, female gender, genetics, type 1 diabetes.

Arterial Disease Manifestations

• Intermittent claudication: pain with walking, relieved by rest; cool to touch.
• Hairless, shiny, dry skin.
• Paresthesia: numbness and tingling.
• Reactive hyperemia and muscle atrophy.
• Severe pain at rest, worse at night.
• Gangrene.

Complications of Arterial Disease

• Arterial Ischemic Ulcers: Deep and often located on the tips of toes or between the toes. The borders are more regular. Most serious result= infection.
• Wound Infection
• Tissue Necrosis in Diabetic patients
• Pulse decrease or absent
• Loss of hair on legs
• Punched out- round smooth margins
• Pain at rest
• Dependency Rubor
• Thin shiny skin
• Cool temp
• No edema
• Red skin- ruddy when lowered

Nursing Diagnoses for Peripheral Arterial Insufficiency

• Altered peripheral tissue perfusion r/t compromised circulation(priority).
• Chronic pain r/t peripheral vascular insufficiency.
• Risk for impaired skin integrity r/t peripheral vascular insufficiency.

Goals of Care for Peripheral Arterial Insufficiency

• Increase arterial blood supply.
• Promote vasodilation.
• Prevent vascular compression.
• Relief of pain.
• Maintain tissue integrity.

Management of Peripheral Arterial Occlusive Disease

• Promote exercise and smoking cessation.
• Diet management
• Foot Care to avoid trauma.
• Surgical Management is sometimes needed.
• Maintain adequate circulation post op.

Bypass Graft Post-Op Care

• 1st day post-Op: Check extremity every 15 minutes for skin color, temp, pulses, sensation, and movement, then every hour.
• Check ABI every 8 hours (not with pedal artery bypass), use Doppler to check pulses distal to graft.
• Loss of palpable pulses necessitates immediate notification of MD.
• Check for bleeding and compartment syndrome.
• No sitting with knees flexed.
• Anti-embolism stocking may be used with care.

Medications for PVD

• Antiplatelets (ASA) inhibit platelet aggregation to prevent thromboemboli.
• Clopidogrel- Reduces risk of MI, CVA.
• Pentoxifylline- Increases erythrocyte flexibility, decreases viscosity, increasing O2 to tissue.
• Cilostazol Increases vasodilation which inhibits platelet aggregation
• Statin lowers bad cholesterol which improves endothelial function.

Angioplasty

• A balloon tipped catheter is maneuvered across area of stenosis helping to flatten the plague against the vessel wall, then stent is placed.
• Elevate HOB.
• Bedrest
• Femoral: 6 hours
• Brachial: 2-3 hours
• Ice pack or sand bag to prevent bleeding.
• Promote smoking cessation.

Arterial Embolism & Thrombosis

• An acute vascular occlusion may be caused by an embolus or acute thrombosis.
• Causes include invasive catheters, stent placement, IV drug use, trauma, crush injury, fracture, penetrating wound, A-fib, and MI.
• S & S depend on the size and organ affected, causes cessation of distal blood flow and ischemia.
• 6 Ps: Pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis.

Management of Arterial Embolism and Thrombosis

• Surgery - Embelectomy, thrombectomy
• Bedrest, no hot or cold compresses, monitor for bleeding, avoid IM injections, longer pressure on puncture sites, MD order for activity, check pulses (Doppler), motor/sensory function.

Heparin Therapy

• Inhibits platelet function and prevents further clots.
• Monitor aPTT (norm 25-35 seconds) and maintain therapeutic range (1.5-2.5 times the normal, 50-70 seconds when on anticoagulants).
• Antidote is protamine sulfate, administered based on patient weight.
• Enoxaparin (Lovenox) is a Low molecular weight heparin, used to tx
• Coumadin takes a few days to start working.

Medication Patient Education

• Same time each day
• Wear ID
• Keep appointments
• OTC med interactions
• No crash diets
• No Coudamin without direction
• Notify if pregnant

Buerger's Disease

• Recurring inflammation of small and intermediate vessels.
• Affects the Upper and lower extremities
• Risk : Tobacco
• Familial Tendency
• Middle East, North American, European
• Causes: pain, ischemic changes, ulcerations, gangrene
• Tx= STOP SMOKING, burger exercises, or amputation

Raynaud's Phenomenon

• Intermittent arteriolar vasoconstriction leads to coldness, pain, pallor of fingertips and toes. 2 types:
  • primary - alone
  • secondary - another (ex: lupus, RA) -Causes: emotions and cold Tx- avoid triggers, wear warm clothing, no caffeine

Venous Disorders

• DVT and PE
• Risk Factors: history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, major surgery or injury
• Venous thromboembolism: aggregation of platelets that attach to the vein wall
• Cause: Unknown, but endothelial damage, venous stasis, altered coagulation play a role
• Superficial thrombosis S/S: pain, redness warmth
• DVT: redness, swelling, tender, increase temp
• Prevention: compression socks, leg exercises, stop smoking and losing weight