Metropolitan Community College
NURS 1110
1
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Objective 1: Review the normal structure and
function of the peripheral vascular system.
2
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Vessels that carry blood away from the heart
toward the tissues
Thick-walled structures with three layers:
intima, media, and adventitia
Smooth muscles encircle and control the
diameter



Arterioles branch into progressively smaller
vessels, then form the capillaries
A single layer of endothelial cells that allow
the efficient delivery of nutrients and
oxygen into the tissues and the removal of
metabolic wastes from the tissues
Tiny vessels that receive blood from the
capillaries are venules, the smallest veins
Figure 36-1
Figure 36-2



The vessels that return blood to the heart
Formed as capillaries organize into larger
and larger vessels
Composed of the same layers as the arteries
and arterioles, but the layers are less
defined

Valves
◦ Allow blood to move in only one direction and
prevent backflow of blood in the extremities

Innervation
◦ The sympathetic nervous system acts on the
musculature of the veins to stimulate
venoconstriction
◦ Blocking of sympathetic nerve stimulation permits
venodilation
Figure 36-3

Lymph system: small, thin-walled vessels
that resemble the capillaries
◦ Accommodate the collection of lymph fluid from
the peripheral tissues and the transportation of
the fluid to the venous circulatory system

Lymph fluid is composed of plasma-like
fluid, large protein molecules, and foreign
substances
◦ Movement by the contraction of muscles that
encircle the lymphatic walls and surrounding
tissues

Resistance
◦ Controlled by the diameter of the vessels
 When vascular diameter increases, peripheral
resistance falls and blood flow increases
 When vascular diameter decreases, peripheral
resistance increases, thereby reducing blood flow

Blood viscosity
◦ Thickness of the blood
◦ Can be affected by changes in the proportions of
the solid or liquid components
◦ Capillary permeability affects blood viscosity
◦ If capillary permeability altered, the amount and
direction of fluid movement changes; results in
change in viscosity
14
15

Objective 2. Describe age related changes of
the vascular system.
16


Vascular changes common in elderly and
diabetics
Can cause peripheral vascular disease (PVD)
◦ Arterial or venous
17

Blood flow decreases because
◦ Arteriosclerosis, atherosclerosis which
affect intima & media lining
 Thrombosis or embolism
◦ Venous disease
 Insufficiency from incompetent
valves
18

Objective 3. Perform a nursing assessment of
the peripheral vascular system.
19


Assessment: finds circulation deficit which
creates complications
Arterial disease: leg pain upon elevation,
activity
◦ Intermittent claudication
20

Venous disease: pain when legs dependent
◦ Blood pools at ankles
 Venous claudication
21

Subjective data
◦ Reported risk factors
 Arterio/atherosclerosis
 Smoking
 Diabetes mellitus
 Hypertension
 Hyperlipidemia
 Family history: DM, HTN, CAD,
PVD
22

Objective assessment
◦ Head to toe
◦ Peripheral pulses
check pulses at same time
23
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Pulse amplitude
◦ 0-+4 scale
◦ Capillary refill
◦ Edema
 1+-4+
 Compare extremities
24
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Decreased circulation
◦ Coolness
◦ Pallor
◦ Paresthesia
◦ Paralysis
◦ Rubor
◦ Brown pigment
25

Objective 4. Compare diagnostic tests and
procedures of the peripheral vascular system.
26
◦ Walk 5 minutes, 1.5 MPH
◦ Pulse volume measurements
◦ Assess response to activity
27
◦ Sound waves to assess blood flow
◦ Reduced sound: reduced blood flow
◦ Non-invasive
28
◦ Blood volume/blood flow changes
measured
 Diagnose DVT
 Screens for PVD
 Raise leg 30 degrees
 Pressure cuff inflated, distends veins
 Venous changes are recorded
29
◦ Arterial or venous
◦ Dye injected
◦ Tests for blockage; may be heart, brain,
etc
◦ Invasive
 Prep needed
30

Prep for
artiography
◦
◦
◦
◦
Allergy
Informed consent
NPO 4 hours
Assess post
procedure
31
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Post procedure
assessment
◦
◦
◦
◦
VS
Allergic reactions
Hemorrhage
Obstruction of vessel
32
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Three dimensional image
All parts can be visualized
Non-invasive, prep still needed
◦ Claustrophobia? Anxious?
◦ Machine makes a lot of noise
◦ Any metal implants?
 Open MRI is available
33
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Most accurate test for anterior-posterior
length
Cross-section diameter of aneurysm
Identify any thrombus
34
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Determines pressure in upper and lower
extremities
Pressures should be equal (arms and legs)
35
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Risk assessment
◦ BP in arm
◦ BP for ankle
 Divide ankle systolic by brachial
systolic
 0.75 or less = arterial disease
 Normal: 0.90-1.30
 Mild to moderate PVD = 0.410.89
 Severe = 0.040
36

Objective 5. List common therapeutic measures
for the client with peripheral vascular disease
(PVD).
37

If arterial or venous problem detected:
nursing diagnosis is Ineffective Tissue
perfusion (peripheral) RT…
38
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
Prevent a thrombus
If thrombus: prevent embolus
39
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Interventions aimed at
◦
◦
◦
◦
Identify clients at risk
Assess lower extremities
Evaluate lifestyle factors
Teach and prevent further problems
40

1. Exercise
◦ Walking stimulates movement of blood
◦ Bed rest if ulcers, gangrene, acute
thrombosis
◦ Buerger-Allen Exercises
41
42
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Stress Management
◦ Stress causes vasoconstriction
◦ Reduce stress with lifestyle changes, massage,
relaxation, other stress-reducing activities
43
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Pain Management
Immobility makes problems worse
◦
◦
◦
◦
Promote circulation
Analgesics
Rest if intermittent claudication
Avoid restrictive clothing
44
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Smoking Cessation
Smoking = vasoconstriction
“Quit Kits”
Medication: bupropion, Nicotine patches
45
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Elastic Stockings
◦
◦
◦
◦
Sustained, evenly distributed pressure
Compress superficial veins, improved blood flow
Must apply correctly
Stockings off 10-20 min. a day; in bed or legs nondependent position
46
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Intermittent Pneumatic Compression
◦ Use for clients confined to bed
◦ Post major surgery
◦ Prevent DVT as stockings sequentially inflate from
ankles, calves, thighs, then deflate
47
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Positioning
If in bed: position changes vital
Lower extremities = increased arterial flow
Raising extremities = increased venous flow
If able to be up, legs non-dependent position
48
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Thermotherapy
Warm: increases blood flow (vasodilation)
Cold: decreases blood flow (vasoconstriction)
◦ Caution with warm: can burn the client
49
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Protection
Must protect from injury: no scratching,
vigorous rubbing
Proper shoes, clean socks
Nails trimmed
No walking barefoot
50
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
Client Education
Must understand the disease, the treatment
plan
Include
◦ Cleanliness, warmth, safety, comfort measures, no
constriction of blood flow, exercise, S/S to report,
drug therapy, importance of not smoking
51

Surgical procedures
◦ Embolectomy: removal of blood clot
◦ PTA: balloon used to dilate artery
◦ Endarterectomy: strip emboli & atherosclerotic
plaque
◦ Sympathectomy: excision of sympathetic ganglia
◦ Vein ligation/stripping: will discuss
◦ Sclerotherapy: will discuss
52

Objective 6. Define venous thrombosis,
thrombophlebitis, phlebitis and
phlebothrombosis.
53
54

Thrombosis: formation, development, or
existence of a blood clot in the vascular
system
◦ Thrombus does not move
◦ Can save life, or can threaten life
◦ Can become an embolus
55

Formation of a clot due to inflammation in
wall of vessel
56
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Inflammation in wall of vein
No clot formation
57
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Formation of clot because blood pools,
trauma to vessel
Can occur because of coagulation problem
Little to no inflammation present
◦ Virchow’s triad
58
59
Metropolitan Community College
NURS 1110
Part 2
60

Objective 7. Describe the risk factors,
assessments, treatments and nursing care
of the client with a blood clot.
61
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Virchow’s triad
Bed rest: prolonged
Leg trauma
Oral contraceptives
Obesity
62
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Varicose veins
Hip fractures
Total hip or knee replacement
63
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If blood clot:
◦ Superficial
◦ Deep vein
64
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Red streak over vein
Superficial site is
◦ Red
◦ Warm
◦ Tender
◦ Swollen
◦ Hard to the touch
65
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Thrombosis may have no symptoms
If symptoms present
◦ Do NOT do Homan’s sign
66
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Medical therapy for superficial
◦ Warm sock or wrap
◦ Acetaminophen or NSAID for pain
◦ Elevation
◦ TEDs
67
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If DVT
◦ Bed rest
◦ Warm moist packs
68

Can include
◦ Anticoagulants
◦ Thrombolytic drugs
 Will discuss later
69
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
Thrombectomy or embolectomy: done if
ischemia or gangrene
Vena cava interruption or venalcaval plication:
◦ Filter or umbrella filter place in inferior
vena cava, or tie off the vein
70

PCTA: percutaneous transluminal
angioplasty
◦ Relieves arterial stenosis
◦ Balloon catheter passed into vessel
 Balloon inflated pressing outward
against vessel walls
 This dilates the vessel thus
improving blood flow
 Must apply pressure to catheter
insertion site post procedure
71
72

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Diet: adequate hydration
Activity: bed rest in acute phase
◦ Elevate leg
◦ Do not massage
73

Health promotion
◦ Early ambulation
◦ Sequential hose
◦ Anticoagulants
◦ Elevate legs
◦ Leg exercises
◦ Deep breathing
74

Client education
◦ 2-3 quarts fluid
◦ Do not sit with legs crossed, knee
gatch up on bed
◦ Elevate legs when sitting
◦ Avoid sitting/standing for long
periods
◦ Support hose
75

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Shift weight frequently
Call MD ASAP if leg pain, tenderness,
swelling, difficulty breathing, chest pain.
76

Objective 8. Describe drugs used to treat
peripheral vascular disease.
77
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Anticoagulants
Thromboembolytics
Vasodilators
Antiplatelet drugs
78

Anticoagulants
◦ Lovenox
◦ Heparin
◦ Warfarin
 Oral
79

Lovenox and heparin parenteral drugs
◦ Act somewhat differently
◦ Doses regulated by
 PTT (partial thromboplastin time)
 APTT (activated partial
thromboplastin time)
 Antidote for Heparin: protamine
sulfate
80

Warfarin sodium (Coumadin)
◦ Oral
◦ Regulated by
 Prothrombin time (PT)
 International normalized ratio
(INR)
 Slow onset, prevention, not
treatment
 Antidote: Vitamin K
81

Thromboembolytics
◦ Urokinase (Abbokinase)
◦ Streptokinase (Streptase)
◦ Tissue plasminogen activator (t-PA, Alteplase)
82
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
Breaks up clots already formed
Main complication: bleeding
83
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Vasodilators
◦ Calcium channel blockers
 Dilates peripheral and coronary
arteries
 Can cause dizziness, headache,
nausea
 May see orthostatic hypotension
84

Nursing interventions
◦ Monitor BP
◦ Assess for edema
◦ Limit caffeine, avoid alcohol, teach how
to manage postural hypotension
85

Alpha-adrenergic blockers
◦ Decreases vascular resistance, lowers BP
◦ Can cause: dizziness, headache,
drowsiness, nausea
◦ May see postural hypotension, edema,
palpitations
86

Nursing interventions
◦ Teach: management orthostatic
hypotension, safety precautions if dizzy
◦ Monitor weight daily
◦ First dose, or increased dose at bedtime
87


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Antiplatelet drugs
Cilostazol (Pletal) inhibits platelet
aggregation, used to treat intermittent
claudication
Can cause
◦ Cardiac dysrhythmias, CHF, MI, cerebral
infarct
88

Nursing interventions
◦ Monitor for bleeding, other adverse
events
◦ Can be 12 weeks before the drug works
89


Aspirin (ASA) inhibits platelet aggregation,
decreases inflammation, fever, pain
Can cause
◦ GI irritation, tinnitus, pruritus, headache,
bleeding
90

Nursing interventions
◦ Assess for bruising, bleeding, give with
milk or food if GI irritation
91

Antianginal
◦ Nitroglycerin as a patch, ointment,
capsule
◦ Dilates coronary arteries, reduces
peripheral resistance
92

Can cause headache, flushing, dizziness,
orthostatic hypotension
93

Hemorrheologic agent
◦ Pentoxifylline (Trental)
 Decreases blood viscosity,
fibrinogen, and platelet
aggregation
 Increases flexibility of RBCs to
allow passage through small
vessels
 Used to treat intermittent
claudication
94

Side effects
◦ Dyspepsia, epistaxis, dizziness
◦ N/V, angina, tachycardia, cardiac
dysrhythmias
◦ Leukopenia, headache, tremors, rash
95

Nursing interventions
◦ Assess VS
◦ Give with meals
◦ Safety
◦ Client to report rapid or irregular
pulse
◦ Teach management of epistaxis
◦ Monitor WBC
96

Objective 9. Compare arterial embolism and
peripheral arterial occlusive disease in cause,
assessments, treatments, and nursing care.
97

Cause
◦ Life threatening
◦ Usually forms in heart
◦ Embolism gets lodged in a vessel, cuts off
circulation
98

Effects depend upon
◦ Size of embolus
◦ Organs involved
◦ Extent to which collateral circulation can
maintain blood supply
99

Assessments/client complaints
◦ Severe, acute pain
◦ Gradual loss of sensory and motor function in
affected areas
◦ Pain aggravated by movement or pressure
◦ Absent distal pulses
10
0
◦ Pallor and mottling
◦ Sharp line of color and temperature
demarcation:
 Tissue beyond the obstruction is pale
and cool
10
1

Treatments
◦ Medical: intravenous anticoagulant and
Thrombolytic agents
◦ Can’t use with active internal bleeding CVA, recent
major surgery, uncontrolled hypertension and
pregnancy
10
2
◦ Surgical
 Embolectomy
10
3

Nursing care
◦ Assess the vascular system
◦ Interventions aimed at
 Ineffective tissue perfusion
 Impaired physical mobility
 Impaired skin integrity
 Ineffective therapeutic regimen
management
10
4

Cause
◦ Plaque formation in arteries
◦ Occlusions prevent delivery of
oxygen/nutrients
◦ Compensatory mechanisms attempt to
maintain circulation: collateral blood
vessels, vasodilation, anaerobic
metabolism
10
5

Risk factors
◦ Atherosclerosis, embolism, thrombosis,
trauma, vasospasm, inflammation,
autoimmune responses
◦ Hyperlipidemia, diabetes, hypertension,
cigarette smoking, stress
10
6
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
Assessment
Same as other vascular assessments
10
7
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Signs and symptoms: develop gradually
Intermittent claudication
Absence of peripheral pulses
Rest pain
Cold, numb
Muscle atrophy
Skin pale
10
8
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Dependent position: skin red
Nails thicken
Skin is shiny, scaly
Subcutaneous tissue loss
Hairlessness
Ulcers
One extremity affected more: size differences
10
9
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Treatment
Vasodilators
Hemorrheologic agent
Surgery: sympathectomy, endarterectomy,
PCTA
11
0


Nursing care
Interventions aimed at nursing diagnoses
of
◦ Activity intolerance
◦ Chronic pain
◦ Impaired skin integrity
◦ Ineffective tissue perfusion
◦ Ineffective therapeutic regimen
management
11
1

Objective 10. Define Raynaud’s disease, its
nursing assessment and treatments.
11
2

Raynaud’s is characterized by
◦ Intermittent spasm of digital arteries and
arterioles
◦ Results in decreased circulation fingers
and toes
◦ Spasms last about 15 minutes
11
3

Signs and symptoms
◦ Fingers pale, then cyanotic
◦ As circulation returns: fingertips red,
have throbbing pain
11
4
11
5

May find nail fold problems in clients with
Raynaud’s phenomenon that is secondary to
other problems
11
6
11
7

Diagnosis
◦ 2 history of S/S, no evidence of other
underlying disease
◦ CBC
◦ Digital blood pressure measurement
◦ Digital plethysmography waveforms
11
8
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Cold-challenge test
Sedimentation rate
Antinuclear antibody
Rheumatoid factor
X-rays of hands
11
9

Assessments
◦ History of vasospastic episodes
◦ Difficulty handling frozen foods
◦ Jobs requiring repetitive movements
◦ Observe digits for: pallor, blanching,
cyanosis, rubor, coldness, texture,
appearance
12
0

Medical treatment
◦ Medications
◦ Avoid exposure to cold, repetitive
hand motion, caffeine
◦ Stop smoking
◦ Alternative therapy: stress
management
◦ Mittens vs gloves in cold weather
12
1

Surgical treatment
◦ Sympathectomy
 Excision of nerve, plexus, or
ganglion of sympathetic portion of
autonomic nervous system
12
2

Objective 11. Describe what is meant by
varicose vein disease and how it is treated.
12
3

Varicosities (varicose veins)
◦ Irregular, tortuous veins
◦ Poorly functioning (incompetent) valves
12
4
12
5

Assessment
◦ Severe, aching leg pain
◦ Leg fatigue or heaviness
◦ Itching of affected leg
◦ Heat in affected leg after long standing
◦ Visibly distended veins in legs
12
6

Medical diagnosis
◦ Plethysmography
◦ Lower limb venography
◦ Doppler ultrasonography
12
7

Medical treatment
◦ Avoid restrictive garments, prolonged
standing or sitting, crossing the legs or
knees, injury to compromised areas
◦ Weight loss if obese
◦ Support stockings
12
8

Surgical treatment
◦ Sclerotherapy
◦ Ligation and stripping
 May see both done in the same client
12
9

Nursing interventions
◦ Focus on teaching self-care
 Want to improve activity tolerance
 Manage pain
 Any measures to improve venous
return
13
0

Surgical client
◦ Client education as often same-day
surgery
◦ Pressure bandages on
◦ Types of stockings
◦ Activity restrictions
◦ Positioning of legs
13
1

Objective 12. Discuss chronic venous
insufficiency regarding cause, assessments,
treatment and nursing care.
13
2

Long-standing problem of venous
hypertension
◦ Stretches the veins and damages
valves
◦ Elevated pressures = edema
◦ Red blood cells seep into tissues,
combine with metabolic wastes
◦ Ulcers can form
 Resistant to healing
13
3

Signs and symptoms
◦ Edema around lower legs
◦ Pain
◦ Brownish skin discoloration
◦ Stasis ulcerations
◦ Client C/O heaviness, dull ache in calf or
thigh
13
4
◦ Skin temperature cool
◦ Nails normal
◦ Peripheral pulses present/difficult to feel
◦ Feet and ankles often cyanotic when
dependent
13
5

Medical diagnosis
◦ Doppler ultrasonography
◦ Plethysmography
◦ Culture if stasis ulcer is draining
13
6

Medical and surgical treatment
◦ Elastic stockings/compression stockings
◦ Ulcer: various treatments used to heal
the wound
◦ Infected ulcer: antibiotics
◦ Seldom see surgery, not very effective
13
7

Nursing assessment
◦
◦
◦
◦
◦
Complete general assessment
Inspect lower extremities: rubor, stasis dermatitis
Palpate skin temperature
Assess Homan’s sign
Assess pain
13
8

Nursing diagnoses include
◦ Ineffective tissue perfusion
◦ Risk for infection
◦ Impaired skin integrity
◦ Disturbed body image
13
9

Nursing interventions
◦ Dependent upon the diagnosis
◦ Focus on improving circulation
◦ Avoidance of ulcers
◦ Avoid infection if ulcers present
◦ Client education on self care
14
0

Objective 13. Develop a care plan for the
client with stasis ulcers.
14
1
14
2
14
3


Care of stasis ulcer
Nursing diagnoses include
◦ Altered tissue perfusion
◦ Risk for infection
◦ Chronic pain
◦ Impaired skin integrity
◦ Ineffective management of therapeutic
regimen
14
4

Goals relate to the problem
◦ Want to reduce it, maintain it, or prevent
it
14
5

Altered tissue perfusion
◦ Exercise
◦ Elevate legs above level of heart when
resting
◦ Avoid smoking
◦ Support stockings
14
6
◦ Avoid prolonged walking, standing
◦ Teach wound care as needed
◦ Assess ulcer, pulses, skin color, skin
temperature, pain, edema
14
7

Risk for infection
◦ Hand hygiene, wound care
◦ Diet with protein, vitamins
◦ Teach S/S of infection
◦ Teach about antimicrobial therapy
14
8

Chronic pain
◦ Encourage client to increase
movement and maintain warmth
◦ Teach pain relief measures and
include relaxation, deep breathing,
behavior modification
◦ Explain analgesics
◦ Assess effectiveness of measures
14
9

Impaired skin integrity
◦ Assess and document condition of ulcer
◦ Use gentle soaps for bathing, avoid
trauma
◦ Good nutrition, adequate fluid
◦ Wound care: MD or Wound Care Nurse
15
0

Ineffective management of therapeutic
regimen
◦ Assess understanding of condition &
self-care
◦ Advise avoiding restrictive clothing,
smoking
◦ No weight gain
◦ Explore sources of stress and coping
strategies
15
1

Objective 14. Identify common nursing
diagnoses and appropriate nursing
interventions for the client with PVD.
15
2

Objective 15. Discuss nutritional concepts as
they relate to the care of the client with
peripheral vascular disorders.
15
3

Diet
◦ Low fat diets to reduce serum cholesterol
◦ Weight reduction if obese
◦ Adequate vitamin B, vitamin C, protein
for healing, tissue integrity
15
4

Objective 16. Be able to utilize medical
terminology and medical abbreviations.
15
5

Objective 17. Demonstrate mastery of
mathematical calculations.
15
6
angiography
embolism
resistance
phlebitis
blood viscosity
intermittent
phlebothrombosis
sclerotherapy
claudication
ischemia
plethysmography
sympathectomy
embolectomy
paresthesia
poikilothermia
thermotherapy
thrombophlebitis
15
7