Disorders In Tissue Perfusion
Disorders Of The Peripheral Vascular
System
Liz Mathewson
Summary
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normal A&P of peripheral vasc. system
risk factors and causes
prevention and health teaching
assessments
nsg. diagnosis
medical/surgical/pharmatherapeutic
nursing measures
Categories of Disorders
• Obstruction: thrombus, embolus, lymphedema
• Inflammation: phlebitis, thrombophlebitis
• Degeneration: arteriosclerosis, atherosclerosis,
aneurysm, varicose veins, stasis ulcer
• Unknown causes: Buerger’s disease, Raynauds
Disease
Pharmacology
Classifications:
• anticoagulants (and their reversal agents)
• antilipidemics (antihyperlipidemic)
• platelet inhibitors
• thrombolytics
• peripheral vasodilators
Obstructive Disease
• Can affect both venous and arterial
circulation as well as lymph system
To the Brain
To the liver
To the stomach
To the Kidneys
Iliac Artery
Femoral Artery
Arterial Obstructive Disease
• (degenerative condition leading to
obstructive condition)
• Arteriosclerosis: “hardening of the
arteries”
– muscle fibers and the endothelial lining of the
walls of small arteries and arterioles become
thickened
Obstructive Arterial Disease
Atherosclerosis: affects the intima of the
large and medium-sized arteries
– caused by an accumulation of lipids, calcium,
blood components, carbohydrates, and fibrous
tissue on the intima layer = plaque
Direct effects:
Indirect effects:
Atherosclerosis
• Risk factors:
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diet
high blood pressure
diabetes
stress
sedentary lifestyle
smoking
- age
- gender
- family hx
Assessment
• Health history and clinical manifestations
• Pain (where)
• Skin appearance and temperature
– Rubor
– cyanosis
– brittle nails,
– dry scaling skin, atrophy, decrease hair growth,
ulceration
Signs and Symptoms
• Occur when vessel is 60% occluded
• Early include pain, changed appearance, or
changed sensation
• Pain or “intermittent claudication”
• Pain on exertion or pain at rest?
• Chronic = collateral circulation
Assessment
• Pulses
– present or absent, volume, quality, symmetry
“pedal pulses present bilaterally”
– Posterior tibial; dorsalis pedis; popliteal;
Assessment
• Mental status
• Edema (Pitting or non-pitting)
• Risk factors:
– controllable (modifiable)
– not controllable (non-modifiable)
Arterial Assessment Tools
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Doppler U/S flow Studies
Ankle blood pressures
Exersize tests
CT
CT Angiography
MRI
Angiography
Progression of Disease
• Decreased oxygen leads to ischemia
• Ischemia leads to infarction
• Infarction leads to necrosis
• Ischemia
Infarction
Necrosis
Arterial ulcers
Ischemia
Infarction
Necrosis
Venous Ulcers (characteristics)
Nsg. Diagnosis
• Alteration in peripheral tissue perfusion
related to compromised circulation
• Pain related to impaired ability of peripheral
vessels to supply tissues with oxygen
• Risk for impaired skin integrity related to
compromised circulation
• Knowledge deficit regarding self-care
activities
Nursing Diagnosis
• Alteration in peripheral tissue perfusion
related to compromised circulation
– Goal: Increase arterial blood supply to
extremities
Medical Management
• Medical: modification of risk factors; a
controlled exercise program to increase
circulation; and medication
Surgical Management
• Surgical: Inflow procedures and outflow
procedures
– Bypass (artificial graft/insitu graft)
– Endarterectomy
Grafts
Endarterectomy
Post-op Care
• Maintaining circulation – how?
• Assessment: pulses, colour, temperature,
capillary refill, sensory and motor functions
• use doppler (at PRCH, use doppler on
Dr.Thompson pts.)
• Complications: decreased urinary output,
CVP, mental status, pulse rate and volume =
fluid imbalance
Post-op Care
• Bleeding, hematoma
• Edema
• Infection
• Discharge planning
Upper extremity Obstruction
• Arm fatigue and pain with exercise and
inability to hold or grasp objects.
• Avoid venopuncture, injury, using tape,
taking BP, protect from cold. Assess
frequently
• May need bypass
Arterial Embolism
• Usually originate in the chamber of the
heart as a result of atrial fibrillation, or
CHF, infective endocarditis or MI.
• Carried to left side of heart and into arterial
system
• May be caused by catheters, stents, intraaortic balloon pump.
• Trauma, crush injury, penetrating wound
Signs and Symptoms
• 6 “P”s
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pain
pallor
pulselessness
paresthesia
paralysis
poikothermia
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Treatment
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FAST to prevent tissue infarction
heparin
surgery (embolectomy)
? Thrombolytic therapy if no
contraindications
Venous Obstruction
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Venous Thrombosis
Deep Vein Thrombosis
Thrombophlebitis
Phlebothrombosis
• * not identical disease processes but for
clinical purposes used interchangeably
Pathophysiology
Stasis of Blood
Virchow’s Triad
Altered Blood Coagulation
Vessel Wall Injury
Venous Stasis
• Reduced Blood Flow due to :
– heart failure or shock
– dilated veins due to medications
– decreased skeletal muscle contractions due to
paralysis, anesthesia, and bed rest
Vessel Wall Injury
• Damage to the Intima Due to:
– direct trauma (fractures, dislocations)
– diseases of the veins, (infection/inflammation)
– chemical irritation (IV meds and solutions
Increased blood coaguability
• Due to:
– abrupt withdrawal of anticoagulants
– oral contraceptives
– blood dyscrasias (abnormalities)
Clinical Manifestations
Often Non-Specific:
• inflammation or redness along a superficial
vein
• limb pain, feeling of heaviness
• functional impairment
• ankle engorgement, edema
• unilateral increase in leg circumference
• increased warmth to touch of leg/foot
• tenderness to touch, rosy colour
Thrombus to Embolus
• Platelets attach to vein wall with a tail-like
appendage containing fibrin, RBC, WBC
• grows in direction of blood flow
• elevation in venous pressure (sudden
movement, increased muscle movement)
cause fragment to break off and travel
Deep Vein Thrombosis
• Sign and symptoms are non specific,
sometimes PE is the first sign
• deep veins have thinner walls and less
muscle mass in the media than superficial
veins
• run parallel to arteries and have the names
• have valves as do the superficial veins
Deep Vein Obstruction
• Creates swelling and edema in extremity
because the outflow of venous blood is
inhibited
• limb may be warm and superficial veins
appear more prominent
• tenderness
• Howman’s sign
Superficial thrombosis
• Pain or tenderness, redness and warmth in
involved area
• embolus rare as these thrombi usually
dissolve spontaneously
• treated with bed rest at home, elevation of
leg, analgesics, and sometimes anti
inflammatory
Medical Management for DVT
• Medication
• Surgery: only if anticoagulant or
thrombolytic therapy is contraindicated, the
danger of PE is extreme, and the venous
drainage is so severely compromised that
permanent damage to the extremity will
result.
Nursing Interventions
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Assessing and monitoring meds
observing for complications
providing comfort
applying elastic stockings
positioning pt and encouraging exercise
Venous Ulcers (characteristics)
Anticoagulants
• Heparin: two types
– fractionated, low-molecular - weight heparin
– fractionated heparin is given IV 5 to 7 days and
coumadin (orally) started concurrently
– sometimes given prophylactically SC
– regulated by monitoring the partial
thromboplastin time, the INR, and the platelet
count
Heparin
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LMWH, more $
SC
longer 1/2 life
does are adjusted by wt, does not bind with
plasma proteins
• fewer bleeding complications
• can be given to pregnant women
Heparin
Nursing responsibilities:
• monitor blood work
• observe for bleeding
• to reverse heparin = protamine sulfate
• to reverse warfarin = vit K
• drug interactions
Thrombolytic Agents
• i.e. Streptokinase
• lyses thrombi and emboli
• observe for bleeding
• contraindicated: recent bleed, trauma,
Lymphedema
• Primary or secondary
• results from an obstruction of lymph vessels
and an accumulation of lymph
• noticed in dependent position
• starts of as soft, pitting and treatable
• progresses to firm, non pitting and does not
respond to treatment
Lymphedema
• Obstruction may be in the node or vessel
• often seen in the arm following a
mastectomy
• treatment may include bedrest, elevation,
active and passive exercise, custom fitted
stockings
• Pharm: diuretic, antibiotics,
• Surgery: excision of tissue and fascia
Venous insufficiency
• Chronic venous insufficiency:
• results from venous valve obstruction and a
result of venous hypertension
• wall of the vein become distended resulting
in reflux
• post thrombotic syndrome
• edema altered pigmentation, pain and stasis
dermatitis
Leg ulcers
• 75% of leg ulcers from CVI
• inflamed necrotic tissue sloughs off
• arterial insufficiency ulcers account for
approx.. 20% the remaining 5% from SSE,
burns and other factors
Arterial Ulcers
• Small circular, deep ulcerations on the tips
of toes or in the web spaces between toes
• medial side of hallux or lateral 5th toe
• may result in gangrene of toe
• gangrene usually left alone
Venous Ulcers
• Ulcers are usually in the area of the medial
or lateral malleolus and are large,
superficial, and highly exudative.
• See pictures on pg 710 of Brunner
Nursing Diagnosis
• Impairment of skin integrity related to
vascular insufficiency
• Impaired physical mobility related to
activity restrictions of he therapeutic
regimen and plan
• Altered nutrition, less than body
requirements, related to increased need for
nutrients that promote wound healing
Goals
• Demonstrates restored skin integrity
• Increases physical mobility
• Attains adequate nutrition
• How????
Patient Teaching
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venus ulceration from CVI
antigravity activities
elevate legs during the day
sleep with foot of bed elevated
no prolonged standing
no cross legs, no trauma
foot care, stockings
Varicose veins
• Abnormally dilated, tortuous superficial
veins caused by incompetent venous valves
• predisposing factors
– hereditary
– occupation/lifestyle
– gender (female)
May be primary or secondary
Varicose Veins
• May result in chronic venous insufficiency:
edema, pain, pigmentation and ulceration
• susceptibility to injury and infection is
increased
• treatment: surgical, sclerotherapy, stockings
Degeneration of the Vascular
System
Aneurysm
• A localized sac or dilation involving an
artery formed at a weak point in a vessel
wall
• classified by its shape or form
• most common saccular or fusiform
• saccular projects from one side of the vessel
only
• fusiform is when entire arterial segment
dilates
Aneurysm
• Small aneurysm caused by localized
infection is called mycotic aneurysms
• most common is the abdominal aortic
(AAA)
• serious because they can rupture leading to
hemorrhage and death
Thoracic Aneurysm
• Most common site for a dissecting
aneurysm
• common in men between age 40-70
• 1/3 of pts with thoracic aneurysms die from
rupture
Signs and symptoms
• Depends on how rapid the aneurysm dilates
and how the pulsating mass affects
surrounding intrathoracic structures.
• Usually pain is the prominent symptom
• shortness of breath, dysphasia, loss of voice
• hoarseness, stridor
• dx by chest xray, ct, mri
S & S of AAA
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Common in whites, 4:1 men to women
most occur below the renal arteries
c/o “heart beating in stomach”
abd mass
“blue toe” syndrome as a result of embolus
80% can be palpated
impending rupture include sever pain
50 to 75% mortality rate for ruptured AAA
AAA
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surgical repair
put in a graft
may be bifurcated
better if it is below renal arteries
Dissecting Aorta
• A tear develops in the intima or the media
degenerates, resulting in dissection
• onset sudden, severe persistent pain, tearing
feeling, pain in shoulders, chest, epigastric
or abd.
Raynauds Disease
Buerger’s Disease