Chapter 26
Assessment and
Management of Patients
with Vascular Disorders and
Problems of Peripheral
Circulation
Vascular System
Consists of two interdependent systems
o Right side of the heart pumps blood through the
lungs to the pulmonary circulation
o 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
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Function of the Vascular System
Circulatory needs of tissues
Blood flow
Blood pressure
Capillary filtration and reabsorption
Hemodynamic resistance
Peripheral vascular regulating mechanisms
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Gerontologic Considerations
Aging produces changes in the walls of the blood
vessels that affect the transport of oxygen and
nutrients to the tissues
Changes cause vessels to stiffen and results in:
o Increased peripheral resistance
o Impaired blood flow
o Increased left ventricular workload
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Arterial Disease
Health history
o Intermittent claudication,
o “Rest pain”
o Location of the pain
Physical assessment
o Skin (cool, pale, pallor, rubor, loss of hair, brittle
nails, dry or scaling skin, atrophy, and
ulcerations)
o Pulses
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Assessing Peripheral Pulses
Reprinted with permission from Weber, J. R., & Kelley, J. H. (2018).
Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters
Kluwer.
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Diagnostic Evaluation
Doppler ultrasound flow studies
o Ankle-brachial index (ABI)
Exercise testing
Duplex ultrasonography
Computed tomography scanning
Angiography and magnetic resonance angiography
Contrast phlebography (venography)
Lymphoscintigraphy
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ABI
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Continuous wave (CW) Doppler
Ultrasound
 Handheld ultrasound
device that detects blood
flow, combined with
computation of ankle or
arm pressures
 Signals are reflected by
the moving blood cells
 Diagnostic technique
helps characterize the
nature of peripheral
vascular disease
Photograph courtesy of Kim Cantwell-Gab, MN, ACNP, ANP.
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Improving Peripheral Arterial Circulation
Positioning strategies—body part below the level of
the heart
Exercise program and activities: walking, graded
isometric exercises
o Consult primary provider before engaging in an
exercise routine
Temperature; effects of heat and cold
Discourage use of nicotine
Stress reduction
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Chart 26-2 Range of Ankle-Brachial Index (ABI)
Pressure and Ischemic Manifestations
 ABI >1.40 is abnormal; indicates noncompressible arteries; requires further
testing with a toe-brachial index (TBI)
 ABI of 1.00 to 1.40 is normal
 ABI of 0.91 to 0.99 is borderline
 ABI of ≤0.90 is abnormal
 ABI of 0.50 to 0.90 (i.e., moderate to mild insufficiency) is usually found in
patients with claudication
 ABI of <0.50 is found in patients with ischemic rest pain
 ABI of ≤0.40 is found in patients with severe ischemia or tissue loss
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Arteriosclerosis and Atherosclerosis
 Arteriosclerosis
o Hardening of the arteries
o Diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened
 Atherosclerosis
o Different process, affecting the intima of large and
medium-sized arteries
o Accumulation of lipids, calcium, blood
components, carbohydrates, and fibrous tissue on
the intimal layer of the artery
o Atheromas or plaques
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Progression of Atherosclerosis
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Risk Factors for Atherosclerosis and PAD
Nonmodifiable
Increasing age
Modifiable
 Nicotine use
Familial
predisposition/genetics
 Diabetes
 Hypertension
 Hyperlipidemia
 Diet
 Stress
 Sedentary lifestyle
 C-reactive protein
 Hyperhomocysteinemia
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Peripheral Artery Disease (PAD)
 Hallmark symptom is intermittent claudication described as
aching, cramping, or inducing fatigue or weakness
 Occurs with some degree of exercise or activity
 Relieved with rest
 Pain is associated with critical ischemia of the distal
extremity and is described as persistent, aching, or boring
(rest pain)
 Ischemic rest pain is usually worse at night and often wakes
the patient
 Arterial ulcers are small, circular, deep ulcerations on the
tips of toes or in the web spaces between the toes
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Common Sites of Atherosclerotic
Obstruction
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Pharmacologic Therapy for PAD
Phosphodiesterase III inhibitor
o Cilostazol
Antiplatelet agents
o Aspirin
o Clopidogrel
Statins
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Aneurysms
Localized sac or dilation formed at a weak point in
the wall of the artery
Classified by its shape or form
Most common forms of aneurysms are saccular and
fusiform
o Saccular aneurysm projects from only one side
of the vessel
o When an entire arterial segment becomes
dilated, a fusiform aneurysm develops
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Characteristics of Arterial Aneurysms
Adapted with permission from Sidawy, A. N., & Perler, B. A.
(2019). Rutherford’s vascular surgery and endovascular
therapy (9th ed.). Philadelphia, PA: Elsevier.
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Venous Disorders
Venous thromboembolism (VTE) condition
o DVT and PE
Chronic venous insufficiency/postthrombotic
syndrome
Leg ulcers
Varicose veins
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Venous Thromboembolism
Risk factors
Endothelial damage
• Venous stasis
• Altered coagulation
Manifestations
• Deep veins
• edema and swelling of the extremity, extremity may
feel warmer, tenderness
• Superficial veins
• pain or tenderness, redness, and warmth in the
involved area
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Preventive Measures
 Early ambulation and leg
exercises
 Graduated compression
stockings
 Intermittent pneumatic
compression devices
 Subcutaneous heparin or LMWH
 Lifestyle changes
o
Weight loss
o
Smoking cessation
o
Regular exercise
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Medical Management
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Patient education
•Take anticoagulation medication as prescribed.
•If prescribed warfarin, take at the same time each day.
•Keep all scheduled appointments for blood tests.
•Avoid alcohol if taking warfarin because it may change the body’s response to the warfarin. There
are no interactions with the oral factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban) and
alcohol.
•Avoid marked changes in eating habits, especially involving foods high in vitamin K, such as green
leafy vegetables, whiccan reduce anticoagulation effectiveness if taking warfarin; dietary habits
have no interactions with the oral factor Xa inhibitors.
•Contact your provider who manages your anticoagulation therapy before having dental work or
surgery.
•Describe potential side effects of coagulation, such as bruising and bleeding, and identify ways to
prevent bleeding.
•If taking warfarin, report the following immediately to your primary provider:
•Any bleeding—for example, cuts that do not stop bleeding
•Bruises that enlarge, nosebleeds, or unusual bleeding from any part of the body
•Reddish or brownish urine
•Red or black bowel movements
•For women: Notify your primary provider and obstetrical provider if you suspect pregnancy.
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Venous insufficiency
Clinical manifestations
Edema
altered pigmentation
pain (worse in the evening)
stasis dermatitis
pigmentation and ulcerations usually occur in the
lower part of the extremity, in the area of the
medial malleolus of the ankle
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Venous insufficiency
Interventions
Elevating the legs decreases edema, promotes
venous return, and provides symptomatic relief.
The legs should be elevated frequently
throughout the day (at least 15 to 20 minutes
four times daily).
At night, the patient should sleep with the foot of
the bed elevated about 15 cm (6 inches).
Prolonged sitting or standing in one position is
detrimental; walking should be encouraged.
Graduated compression stockings
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Chapter 27
Assessment and
Management of Patients
with Hypertension
Hypertension
High blood pressure
Most common chronic disease among U.S. adults
Defined by the American College of Cardiology
(ACC)/American Heart Association (AHA) as a
systolic blood pressure (SBP) of 130 mm Hg or
higher or a diastolic blood pressure (DBP) of 80 mm
Hg or higher
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Classification of Blood Pressure for Adults
Age 18 Years and Older
Normal Blood Pressure
o Systolic <120 mm Hg and Diastolic <80 mm Hg
Elevated Blood Pressure
o Systolic 120–129 mm Hg and Diastolic <80 mm
Hg
Stage 1 hypertension
o Systolic 130–139 mm Hg or Diastolic 80–89 mm
Hg
Stage 2 hypertension
o Systolic >140 mm Hg or Diastolic >90 mm Hg
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Incidence of Hypertension—“The Silent
Killer”
Primary hypertension: essential
o 90–95% of patients; unidentifiable cause
Secondary hypertension
o 5–10% of patients; renal disease, sleep apnea,
pregnancy related
About 33% of the adult population of the United
States has hypertension
About 46% do not have it under control
Highest prevalence in African Americans
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Manifestations of Hypertension
Usually no symptoms other than
elevated blood pressure
Symptoms related to organ damage are
seen late and are serious
Retinal and other eye changes
Renal damage
Myocardial infarction
Cardiac hypertrophy
Stroke
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Pathophysiologic Processes
Can result from increases in cardiac output,
peripheral resistance, or both
Must also be a problem with the body’s control
system
Dysfunction of the autonomic nervous system
Increased renin–angiotensin–aldosterone system
Resistance to insulin action
Activation of the immune system
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Measuring Blood Pressure
Correct arm cuff size
Sit quietly with arm at the level of the heart
Confirmation of diagnosis by average of two blood
pressure readings
Can also evaluate lifestyle modifications and success
of prescription medications
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Alternative Manifestations
Masked
hypertension
• Blood pressure
that is suggestive
of hypertension
that is
paradoxically
normal in health
care settings
White coat
hypertension
• Hypertensive blood
pressure readings
in the health care
setting that is
paradoxically
normal ranges in
other settings
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Abnormal Physical Examination Findings
Absent or weak pulses
Additional cardiac sounds
Retinal hemorrhages
Distended jugular veins
Renal artery bruit
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Major Risk Factors
Hypertension
Smoking
Obesity
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or GFR <60 mL/min
Older age
Family history
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Medical Management
Maintain blood pressure
o <130/80 mm Hg
Lifestyle modifications
o Weight reduction
o DASH diet, decreased sodium intake
o Regular physical activity
o Reduced alcohol consumption
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Medical Management
Pharmacologic therapy
o Decrease peripheral resistance, blood volume
o Decrease strength and rate of myocardial
contraction
Diuretics, beta-blockers, alpha1-blockers, combined
alpha- and beta-blockers, vasodilators, ACE
inhibitors, ARBs, calcium channel blockers,
dihydropyridines, and direct renin inhibitors
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Medication Treatment
Stage I hypertension:
o African American and patients >60 years:
calcium channel blocker or thiazide diuretic
o Non African American and patients <60 years:
ACE-I or ARB
Low doses are initiated, and the medication dosage
is increased gradually if blood pressure does not
reach target goal
Multiple medications may be needed to control blood
pressure
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Complications
Left ventricular hypertrophy
Myocardial infarction
Heart failure
Transient ischemic attack (TIA)
Cerebrovascular disease (CVA, stroke, or brain
attack)
Renal insufficiency and chronic kidney disease
Retinal hemorrhage
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Interventions
Support and educate the patient about the
treatment regimen
Reinforce and support lifestyle changes
Taking medications as prescribed
Follow-up care
Monitoring for potential complications
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Gerontologic Considerations
Medication regimen can be difficult to remember
Expense can be a challenge
Monotherapy, if appropriate, may simplify the
medication regimen and make it less expensive
Ensure that older adult patients understand the
regimen and can see and read instructions, open
medication containers, and get prescriptions refilled
Include family and caregivers in educational
program
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Hypertensive Crises
Hypertensive emergency
o Blood pressure >180/120 mm Hg and must be
lowered immediately to prevent further damage
to target organs
Hypertensive urgency
o Blood pressure >180/120 mm Hg but no
evidence of immediate or progressive target
organ damage
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Hypertensive Emergency
 Reduce blood pressure by no more than 25% in first hour
 Reduce to 160/100 mm Hg within 2 to 6 hours
 Then gradual reduction to normal 24 to 48 hours of
treatment
 Exceptions are ischemic stroke and aortic dissection
 Medications
o IV vasodilators: sodium nitroprusside, nicardipine,
fenoldopam mesylate, enalaprilat, nitroglycerin
 Need very frequent monitoring of BP and cardiovascular
status
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Hypertensive Urgency
Oral agents can be administered with the goal of
normalizing blood pressure within 24 to 48 hours
Fast-acting oral agents:
o Beta-adrenergic blocker—labetalol
o Angiotensin-converting enzyme inhibitor—
captopril
o Alpha2-agonist—clonidine
Patient requires close monitoring of blood pressure
and cardiovascular status
Assess for potential evidence of target organ
damage
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