University of Hail
College of Nursing
Medical-Surgical Nursing
Adult Health Nursing 1 T
NURS 225
Chapter 30
Assessment and Management of
Patients With Vascular Disorders
and Problems of Peripheral
Circulation
Dr. Laila, A. Hamed
LEARNING OBJECTIVES
On completion of this chapter, the learner will be able to:
Identify anatomic and physiologic factors that affect peripheral blood flow and
tissue oxygenation.
Use assessment parameters appropriate for determining the status of peripheral
circulation.
Apply the nursing process as a framework of care for patients with vascular
insufficiency of the extremities.
Compare the various diseases of the arteries and their causes, pathophysiologic
changes, clinical manifestations, management, and prevention.
Describe the prevention and management of venous thromboembolism (VTE).
Compare strategies to prevent and treat venous insufficiency, leg ulcers, and
varicose veins.
Use the nursing process as a framework of care for patients with leg ulcers.
Describe the medical and nursing management of lymphatic disorders.
Vascular System
• Consists of two interdependent systems
– Right side of the heart pumps blood through the
lungs to the pulmonary circulation
– Left side of the heart pumps blood to all other body
tissues through the systemic circulation
• Arteries and arterioles.
• Capillaries.
• Veins and venules.
• Lymphatic vessels (complex network of thin-walled
vessels ). This network collects lymphatic fluid from
tissues and organs and transports the fluid to the venous
circulation)
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Systemic and Pulmonary Circulation
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Function of the Vascular System
• Circulatory needs of tissues from blood.
• Maintain Blood flow
• Maintain Blood pressure
• Capillary filtration and reabsorption
• Maintain Hemodynamic resistance
• Peripheral vascular regulating mechanisms
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Pathophysiology of the Vascular System
• Pump failure (Inadequate peripheral blood flow occurs when the heart’s
pumping action becomes inefficient)
• Alterations in blood and lymphatic vessels
• Circulatory insufficiency of the extremities (produce some of the same
symptoms: pain, skin changes, diminished pulse, and possible edema.)
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Assessment of the Vascular System
• Age: produces changes in the walls of the blood vessels that
affect the transport of oxygen and nutrients to the tissues
• Health history about: pain and its precipitating factors.
A muscular, cramp-type pain, discomfort, or fatigue in the
extremities.
• Physical assessment
– Inspection of the Skin: cool, pale, pallor, rubor, loss of
hair, brittle nails, dry or scaling skin, atrophy, and
ulcerations)
– Palpation of Pulses
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Diagnostic Evaluation
• Exercise testing: used to determine how long a patient can walk and
to measure the ankle systolic blood pressure in response to
walking.
• Duplex ultrasonography: Color flow techniques, which can identify
vessels
• Computed tomography scanning, Magnetic resonance
angiography
• Angiography: used to confirm the diagnosis of occlusive arterial
disease when surgery or other interventions are considered. It
involves injecting a radiopaque contrast agent directly into the arterial
system to visualize the vessels.
• Contrast phlebography (venography)
• Lymphoscintigraphy: injection of a radioactively labeled colloid
subcutaneously in the second interdigital space. The extremity is then
exercised to facilitate the uptake of the colloid by the lymphatic
system, and serial images are obtained at preset intervals.
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Continuous-wave Doppler ultrasound detects blood flow, combined with computation of
ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral
vascular disease
Doppler ultrasound flow studies
Ankle brachial index (ABI): is the ratio of the systolic blood
pressure in the ankle to the systolic blood pressure in the
arm
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Common Arterial Disorders
• Peripheral arterial occlusive disease
• Arteriosclerosis and atherosclerosis
• Upper extremity arterial occlusive disease
• Aortoiliac disease
• Aneurysms (thoracic, abdominal, other)
• Dissecting aorta
• Arterial embolism and arterial thrombosis
• Raynaud phenomenon and other acrosyndromes
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Peripheral Arterial Occlusive Disease
(PAD)
Peripheral arterial disease (PAD) is a common condition where
a build-up of fatty deposits in the arteries restricts blood supply
to leg muscles. This condition known as intermittent claudication
Causes of intermittent claudication:
A bulging artery (aneurysm).
peripheral neuropathy.
Narrowed spinal canal.
Risk factors:
 Age: a man over age 55 or a woman over age 60.
 Obesity.
 Lack of exercise regularly
 Family history of claudication , atherosclerosis or peripheral
artery disease
 diabetes, high blood pressure, or high cholesterol
 Smoke
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Intermittent Claudication Symptoms
•
•
•
•
•
•
•
•
•
•
Cramping
Numbness
Pain
Tingling
Weakness
shiny skin on leg or foot
Cold feet
Foot sores
Hair loss on your leg
Impotence in men: Weak arms or legs.
•
•
•
•
Diagnosis
Ankle-brachial index (ABI)..
Ultrasound. magnetic resonance angiography (MRI)
Computed tomography angiography (CTA) scan
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Claudication Treatment
• Lifestyle changes, such as: Stop smoking, reduce weight.
• Eat a healthy diet, A regular walking routine
• control high blood pressure, high cholesterol,
or diabetes.
• Surgery to clear a blood vessel from clot may
use angioplasty (in which they put a thin tube into your
blood vessel to widen it) or a stent (in which they prop
open a narrowed vessel with a tube).
• Bypass surgery to go around the blocked area.
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Nursing intervention for Improving Peripheral Arterial Circulation
Provide health education about:
• Don’t eat foods with saturated fats.
• Don’t smoke or use tobacco.
• Get more physical activity.
• Follow-up cholesterol, blood sugar, and
blood pressure.
• Stay at a healthy weight.
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Arteriosclerosis and Atherosclerosis
• Arteriosclerosis: (hardening of the arteries) i.e: muscle fibers
and the endothelial lining of the walls of small arteries and
arterioles become thickened.
• Atherosclerosis: Accumulation of lipids, calcium, blood
components, carbohydrates, and fibrous tissue on the intimal layer
of the artery and formation of Atheroma or plaques.
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Common Sites of Atherosclerotic Obstruction
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Risk Factors for Atherosclerosis and PVD
Modifiable
Nonmodifiable
• Nicotine, un healthy fatty
diet
• Age
• Hypertension
• Gender
• Familial predisposition
and genetics
• Diabetes
• Obesity
• Stress
• Sedentary lifestyle
• Increased C-reactive
protein
• Hyperhomocysteinemia
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Clinical Manifestations of Atherosclerosis
According to the site:
• Coronary artery disease: cause chest pain (angina), a heart attack or
heart failure.
• Carotid artery disease: narrows the arteries close to brain that cause a
transient ischemic attack (TIA) or stroke, numbness or weakness in
arms or legs, difficulty speaking or slurred speech, temporary loss of
vision in one eye, or drooping muscles in your face
• Peripheral artery disease: narrows the arteries in arms or legs result in
Pain, numbness, .
• Aneurysms. is a bulge in the wall of the artery.
• Symptoms of kidney Failure.
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Medical Management
•
•
•
•
•
•
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Preventive measures:
Quitting smoking
Eating healthy foods
Exercising regularly
Maintaining a healthy weight
Checking and maintaining a healthy blood pressure
Checking and maintaining healthy cholesterol and blood sugar levels
• surgical graft procedures:
inflow procedures, which improve blood
supply from the aorta into the femoral artery, and outflow procedures, which
provide blood supply to vessels below the femoral artery.
• Radiologic Interventions: arteriogram (percutaneous transluminal
angioplasty (PTA) using a balloon-tipped catheter ).
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Question
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
Answer: 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
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PAD
Aneurysms
• Definition: a weakening of an artery wall that creates a bulge, or
distention, of the artery.
Common sites:
• Aortic aneurysm: the main artery carrying blood from the
heart to the body.
• Cerebral aneurysm:
• Popliteal artery aneurysm: the artery behind the knee.
• Mesenteric artery aneurysm: the artery that supplies blood
to the intestine.
• Splenic artery aneurysm: the artery of the spleen.
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Etiologic Classification of Arterial Aneurysms
Congenital:
Primary connective tissue disorders (Marfan syndrome) and other diseases
(focal medial agenesis, tuberous sclerosis, Turner syndrome, Menkes
syndrome)
Mechanical (hemodynamic):
Post-stenotic and arteriovenous fistula and amputation related
Traumatic (pseudo-aneurysms):
Penetrating arterial injuries, blunt arterial injuries, pseudo-aneurysms
Inflammatory (noninfectious):
Associated with arteritis (Takayasu disease, giant cell arteritis, systemic lupus
erythematosus) and periarterial inflammation (i.e., pancreatitis)
Infectious (mycotic):
Bacterial, fungal, spirochetal infections
Pregnancy-related degenerative:
Nonspecific, inflammatory variant.
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Symptoms and diagnosis of Aneurysm
According to the site of the aneurysm, symptoms can include:
• Headache, Dizziness, Vision changes, Confusion
• Pain in abdomen or back
• Pulsating abdominal mass
• Blue coloration (cyanosis) of lower extremities
• Fatigue,
Hoarseness, Swelling in the neck
• Difficulty swallowing
• High-pitched breathing sound
• Chest or upper back pain
• Nausea and vomiting
• Sense of impending doom.
• Shock (low blood pressure, rapid heart rate, clammy skin,
decreased awareness)
• Diagnosis: angiogram, CT scan or ultrasound test to diagnose an
aneurysm.
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Management
Modification risk factors:
• Controlling high blood pressure
• Eating healthy foods
• Getting regular physical activity
• Quitting smoking or using tobacco in any form
surgery to reinforce the artery wall with a stent
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Raynaud Disease
• Definition: is a rare disorder that affects the arteries. Vasospasm of
the arteries which reduces blood flow to the fingers and toes .
Etiology according to Classification of Raynaud’s
1. Etiology of Primary Raynaud’s
• Cold temperature Stress Blood vessels in spasm.
2. Etiology of Secondary Raynaud’s
• Scleroderma Lupus
• Rheumatoid arthritis.
• Carpal tunnel syndrome.
• Repetitive actions Hand and foot injuries.
• Exposure to certain chemicals Medicines Smoking.
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CLINICAL MANIFESTATION
During the Raynaud’s attack, arteries become narrow
and no blood supply to the area, this will cause :
Cold fingers and toes
skin might turn white or blue when it’s cold or when
stressed.
fingers and toes feel tingly or irritable when they start to
warm up.
Diagnosis
•
•
•
•
•
Cold Stimulation Test.
Nail fold Capillaro-scopy.
Antinuclear antibody (ANA).
Erythrocyte sedimentation rate .
C-reactive protein (CRP) tests.
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Management of Raynaud’s phenomena
Medical treatment
• Calcium channel blockers -- Norvasc .
• Alpha blockers --Prazosin
• Vasodilators -- Losartan (Cozaar) .
• Surgical treatment
• Nerve surgery--- sympathectomy.
• Amputation.
• Health Education
• Stop smoking Exercise Control stress.
• Avoid caffeine Avoid caffeine Take care of feet and
hand Dress warmly outdoors
Complication:
- deformities of fingers and toes.
- gangrene, ulcer
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NURSING INTERVENTION
• Assess the patient for the blood circulation, colour and
sensation at the extremities.
• Apply warm compress at the affected area
• Administer the medication as prescribed by doctor such
as vasodilator, calcium channel blockers and alpha
blockers
• Monitor the blood circulation to the extremities every
two hourly (circulation chart)
• Encourage patient to perform extremities exercises while
sitting or during work.
• Encourage the patient to Soak hands in warm water at
the first sign of an attack
• Keeping your hands and feet warm in cold weather
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• Avoiding triggers,Copyright
such
certain
medicines
and stress
Venous Disorders
Reduction in venous blood flow caused in pathologic
changes including coagulation defects, edema formation and tissue
breakdown, and an increased susceptibility to infections.
Forms of venous disorders:
• Venous thromboembolism (DVT) and pulmonary
embolism (PE)
• Varicose veins
• Chronic venous insufficiency/post-thrombotic
syndrome
• Leg ulcers
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Venous Thromboembolism (DVT) (PE)
Definition: a blood clot forms in a deep vein. These clots usually develop in the
lower leg, thigh, or pelvis.
Risk factors
1- Endothelial damage as: (Trauma, Surgery, Pacing wires, Central venous
catheters, Dialysis access catheters, Local vein damage, Repetitive motion injury)
II- Venous stasis: (Bed rest or immobilization, Obesity, History of varicosities,
Spinal cord injury, Age (>65 years)
III- Altered coagulation: (Cancer, Pregnancy, Oral contraceptive us )
Manifestations
–Extremity becomes: massively swollen, tense, painful, and cool to the
touch. tenderness, redness, and warmth.
Complications of Venous Thrombosis
• Pulmonary emboli from dislodged thrombi.
• Increased venous pressure.
- Venous gangrene
• Varicosities, Venous ulcers, Venous obstruction:
• Increased distal pressure, Fluid stasis, Edema.
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Preventive Measures
•
•
•
•
•
Application of graduated compression stockings
Pneumatic compression devices
Early ambulation
Subcutaneous heparin or LMWH
Lifestyle changes
– Weight loss
– Smoking cessation
– Regular exercise
Q: 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.
Answer:
B.
A 25-year-old patient with a central venous catheter in place to treat septicemia
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
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Varicose Veins
Definition: abnormally dilated, tortuous, superficial veins caused
by incompetent venous valves.
Causes: Weak or damaged valves can lead to varicose veins
Risk factors:
Aging: causes wear and tear on the valves.
Sex: Women are more likely to develop the condition. Due to
Hormonal changes.
Standing or sitting for long periods of time.
Pregnancy.
Family history. .
Obesity.
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Symptoms of Varicose Veins
 Veins that are dark purple or blue in color
 Veins that appear twisted and bulging
 dull aches, muscle cramps.
 increased muscle fatigue in the lower legs.
 ankle edema, and a feeling of heaviness of the legs.
 Nocturnal cramps.
Assessment and Diagnostic Findings
• duplex ultrasound scan, typically performed in a reverse
Trendelenburg position or with the patient standing.
• Venography it involves injecting a radiopaque contrast agent into
the leg veins so that the vein anatomy can be visualized by x-ray
studies.
• CT venography can be helpful
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Management of Varicose vein
 Elevation of the legs above the level of the heart 3 or 4 times a day for
about 15 minutes at a time.
 Compression stockings: These elastic stockings squeeze the veins and
prevent blood from pooling.
 Anti-infective therapy depends on the infecting agent.
– Oral antibiotics are usually prescribed
 Sclerotherapy: A salt (saline) or chemical solution is injected into the
varicose veins.
 Thermal ablation: A tiny fiber is inserted into a varicose vein through
a catheter and the laser or radiofrequency energy is used to deliver heat
that destroys the wall of the varicose vein.
 Vein stripping.: surgery to remove varicose veins.
 Microphlebectomy.: Special tools inserted through small cuts
(incisions) are used to remove varicose veins.
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Nursing care
 Assessment of predisposing factors.
 Instruct the patient about preventive measures as:
 Avoid wearing socks that are too tight .
 Avoid crossing the legs at the thighs.
 Avoid sitting or standing for long periods)
 Instruct the patient to Elevate the legs 3 to 6 inches higher than heart
level
 Encourage to walk 30 minutes each day if there are no
contraindications
 Wear graduated compression stockings
 Overweight reduction plans.
 Instructions about Complications as:
 Bleeding.
- Chronic venous insufficiency
 Thrombophlebitis: Blood clots in the vein of the leg.
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Leg Ulcers
Definition of Leg Ulcers
• a break in the skin of the leg or an excavation of the skin surface that
occurs when inflamed necrotic tissue sloughs off.
Causes:
• Venous Disease .
• Arterial Disease .
• Clotting and circulation disorders
• Other causes : diabetes and rheumatoid arthritis.
S&S: a swollen leg , feel burning or itching, rash, redness, brown
discoloration or dry, scaly skin.
Nursing Assessment:
• History of the condition
• Assess pain, peripheral pulses, edema, Wound
Treatment depends on the type of ulcer
• Antibiotics, if an infection is present
• Anti-platelet or anti-clotting medications to prevent a blood clot
• Topical wound care therapies
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Wound Care at Home
• Keeping the wound clean and dry
• Changing the dressing as directed
• Taking prescribed medications as directed
• Drinking plenty of fluid
• Following a healthy diet, as recommended, including
plenty of fruits and vegetables
• Exercising regularly, as directed by a physician
• Wearing appropriate shoes
• Wearing compression wraps
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Lymphatic Disorders
Forms of lymphatic disorders:
Lymphangitis: inflammation or infection of the lymphatic channels
Lymphadenitis: inflammation or infection of the lymph nodes
Lymphedema: tissue swelling related to obstruction of lymphatic
flow.
Causes:
• Elevated central venous pressure.
• Lymphatic outflow obstruction, narrowing or blockage of the
largest lymphatic channel in the chest .
• Traumatic injury of lymphatic channels following esophageal
surgery.
• Congenital lymphatic disorder.
• Congenital localized lymphatic malformations,
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Symptoms of lymphatic disorders
 Chylothorax: (chyle within the chest)
 Chylous ascites: (chyle within the abdomen)
 Chylopericardium: (chyle around the heart)
 Protein-Losing Enteropathy: (loss through the intestinal tract)
 Plastic Bronchitis :leak into the airways)
 Chylous emesis: (loss from the upper GI tract)
 Chyluria: (leak into the urinary tract)
 Lymphatic leak at surgical sites.
Diagnosis:
Conventional Intranodal Lymphangiography: contrast dye is directly injected
into the lymph nodes and imaged in the lymphatic system by fluoroscopy (X-ray)
Magnetic Resonance Lymphangiography: contrast dye is directly injected into
the lymph nodes and imaged in the lymphatic system by MRI
Lymphoscintigraphy. injecting radio-labeled dye into the body and observing its
flow through the lymphatic system
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Medical Management
- Active and passive exercises assist in moving lymphatic fluid into
the bloodstream.
- External compression devices make the fluid proximally from the
foot to the hip or from the hand to the axilla.
- skin care, pressure gradient sleeves, and pneumatic pumps,
depending on the severity and stage of the lymphedema.
- Diuretic furosemide (Lasix) .
- Antibiotic If lymphangitis or cellulitis is present.
•Surgical Management
•Excision of the affected subcutaneous tissue and fascia, with skin
grafting to cover the defect.
•Lymphatico-venous bypasses performed with anastomosing the
end of the lymphatic vessels to the side of veins to reduce lymphatic
flow in the limbs
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Cellulitis
Definition: bacterial skin infection that causes redness, swelling, and pain
in the infected area of the skin
Causes:
• Skin Injuries.
• Infections after surgery
• Long-term skin conditions such as eczema
• Foreign objects in the skin
• Bone infections
S&S: localized swelling or redness, fever, chills, sweating
Treat with oral or IV antibiotics based on severity
• Nursing Care:
– Elevate affected area
– Warm, moist packs to site every 2 to 4 hours
– Educate regarding prevention of recurrence
– Reinforce education about skin and foot care
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References
Hinkle J., Cheever K.,(2018), Brunner & Suddarth's
Textbook of Medical-Surgical Nursing, 14th ed,
Philadelphia, Wolters Kluwer
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