Chapter 31
Assessment and Management of Patients with Vascular
Disorders and Problems of Peripheral Circulation
Medical Surgical- Part B
By
Dr. Yousef Aljeesh
Associate Professor
Dr. Motasem Salah
PhD Nursing Administration
1
Objectives:
On completion of this chapter, the learner will be able to:
1. Identify anatomic and physiologic factors that affect peripheral
blood flow and tissue oxygenation.
2. Use the nursing process as a framework of care for patients with
circulatory insufficiency of the extremities.
3. Compare the various diseases of the arteries, their causes,
pathologic and physiologic changes, clinical manifestations,
management, and prevention.
4. Describe the prevention and management of venous thrombosis.
5. Compare the preventive management of venous insufficiency, leg
ulcers, and varicose veins.
6. Describe the relationship between lymphangitis and lymphedema.
7. Define ELEPHANTIASIS
Dr.Yoused Aljeesh
Dr. Motasem Salah
2
Assessment and Management of
patient with vascular disorder
 Vascular system: consist of two interdependent
system
1- Right heart pump: blood to the lung through the
pulmonary circulation.
2- Left heart pumps: blood to all body tissue
through systemic circulation.
 Adequate blood flow → adequate perfusion →
adequate O2 and nutrient to body tissue.
 Characterize: each one depend on another(pulmonary
circulation depend on systemic )
Dr.Yoused Aljeesh
Dr. Motasem Salah
3
 Arteries: distribute oxygenated blood from the
left side of the heart to the tissues
[ blood
distribution]
 Veins: carry deoxygenated blood from the tissues
to the right side of the heart. [blood collection]
 Arterioles: small arteries
 Venules: small veins
 Capillaries: microscopic vessels that carry blood
from small arteries to small veins [ from arterioles
to venules]
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Systemic and Pulmonary Circulation
Dr.Yoused Aljeesh
Dr. Motasem Salah
Blood flow
 Left heart to aorta → arteries→ arterioles →
capillaries → venules → veins → vena cavae →
finally to the right heart.
 This unidirectional flow is caused by pressure
difference between the arterial and venous
systems.
 Arterial pressure a proximal 100 mm Hg is greater
than venous pressure a proximal 4 mm Hg.
 Fluid flows from an area of high pressure to an
area of low pressure.
Dr.Yoused Aljeesh
Dr. Motasem Salah
6
Pathophysiology of the vascular
system
Decrease blood flow to
extremities
Decrease tissue perfusion
↓ o2 and nutrients
Inability to maintain normal
function of tissue
Damage of the tissue
Dr.Yoused Aljeesh
Dr. Motasem Salah
7
Assessment of circulation insufficiency
 The most important point for the diagnosis
of arterial disorders are:
1. Pain
2. Skin color & temperature
3. Pulse (peripheral pulses)
8
1. Pain
 Intermittent claudication: The hallmark clinical
manifestation of peripheral arterial occlusive disease is
intermittent claudication.
 This pain may be described as sever sharp pain induced
by the same degree of exercise or activity as a result of
inadequate blood flow to the tissue and is relieved with
rest.
 During rest, pain is decreased or relieved as result of
↓ metabolic need of the muscles.
 Pain in the extremities, during rest indicate sever degree
of arterial insufficiency.
Dr.Yoused Aljeesh
Dr. Motasem Salah
9
2. Skin appearance and temperature
blood flow → warms the
extremities and give rosy coloring.
Inadequate blood flow results → cool and
pale extremities.
 Cyanosis: bluish coloring of the skin
because the amount of O2 contained in the
blood is reduced
Adequate
Dr.Yoused Aljeesh
Dr. Motasem Salah
10
3. Pulses
 Absence of a pulse may indicate that the site
of stenosis (narrowing or constriction) is
proximal to that location.
 Occlusive arterial disease impairs blood
flow and can reduce palpable pulsations in
the extremities.
Dr.Yoused Aljeesh
Dr. Motasem Salah
11
Assessing Peripheral Pulses
We assess peripheral pulse
through
Dorsalis pedis
Popliteal artery
Posterior tibial art.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Peroneal, Dorsalis Pedis, and
Posterior Tibial Pulse Sites
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Dr. Motasem Salah
Continuous-wave Doppler ultrasound detects blood flow,
this diagnostic technique helps characterize the nature of
peripheral vascular disease.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Risk factors for peripheral
vascular disease
Controllable risk factors
• Tobacco use
• ↑ B.P [hypertension]
• Obesity
• Sedentary lifestyle
• Stress
• D.M.
Noncontrollable risk factors:
• Age
• Gender Dr.Yoused Aljeesh
Dr. Motasem Salah
15
Nursing Process: The Care of the Patient with
Peripheral Arterial Insufficiency: Diagnosis
 Ineffective peripheral tissue perfusion related to
compromised circulation
 Chronic pain related to impaired ability of peripheral
vessels to supply tissues with oxygen
 Risk for impaired skin integrity related to
compromised circulation
 Deficient knowledge regarding self-care activities
Dr.Yoused Aljeesh
Dr. Motasem Salah
Nursing Process: The Care of the Patient with
Peripheral Arterial Insufficiency: Planning
 Major goals include increased arterial blood supply,
promotion of vasodilatation, prevention of vascular
compression, relief of pain, attainment or
maintenance of tissue integrity, and adherence to
self-care program.
Dr.Yoused Aljeesh
Dr. Motasem Salah
1. Improving Peripheral Arterial Circulation
 Exercises and activities: walking, graded isometric
exercises.
 Positioning strategies
 Elevating the head of the bed “sitting position” [in
cause of arterial insufficiency].
 Temperature; effects of heat and cold:
 Smoking cessation
 Stress reduction
Dr.Yoused Aljeesh
Dr. Motasem Salah
Buerger – Allen exercises
 Placing the extremities in 3 position :
 Position 1: the patient lies flat in bed with both legs
elevated above the heart for 2-3 min.
 Position 2: sitting on the edge of the bed with the legs
relaxed and dependent, the patient exercise the feet
and toes [upward + downward , inward + outward] for
about 3 min
 Position 3: the pt lies flat with legs at the same level
as the heart for about 5 minutes.
 [The exercise series is performed 6 times, 4 times day]
Dr.Yoused Aljeesh
Dr. Motasem Salah
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 Note: persons with venous insufficiency
should elevated their leg above the level of
the heart and should avoiding standing &
sitting position because problem worse
 Exercise will be contraindication in case of:
leg ulcer, cellulities, gangrene, acute
thrombotic occlusions.
 All of these cases required the pt to be in
bed rest.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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2- Promoting vasodilation & preventing
vascular compression.
 Warmth promotes arterial flow
 Adequate clothing & warm temperatures
protect the patient from chilling.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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2- Promoting vasodilation & preventing
vascular compression.
 Applying a heating pad to the abdomen can cause
reflex vasodilation in the extremities and is safer than
direct application of heat to affected extremities.
 Instruct the pt stop smoking.
 Instruct the pt to avoid emotional upset & stress.
 Avoid crossing the legs because it leads to further
vascular compression & also avoid constricting
clothing.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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3- Relieving Pain
 Analgesic may be helpful in reducing pain.
 Vasodilator medications are helpful in reducing pain.
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Dr. Motasem Salah
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4- Pt education
 Cleanliness [wash feet daily & use mild soap]
 Warmth [wear extra socks in cold weather]
 Safety [inspect feet daily with mirror]
 Comfort measures [use powder daily between the toes
to promote drying]
 Prevent construction of blood vessels [do not cross
legs & quit smoking]
 Exercise [participate in regular walking exercise]
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Characteristics of Arterial and Venous
Insufficiency
Characteristics
Arterial
Venous
Pain
Intermittent claudication Cramping , aching
to sharp [very painful]
[minimal pain]
Pulse
Diminished or absent
present
Skin
Dry, shiny skin
Reddish, blue in
color
Ulcer
Deep
Superficial
Edema
Minimal
Moderate to sever
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Arteriosclerosis & Atherosclerosis
 Arteriosclerosis is the most common disease of the
arteries; the term means hardening of the arteries. It is a
diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened.

 Atherosclerosis. A disease of the arteries in which fatty
plaques develop in their inner walls, with eventual
obstruction of blood flow. It is mainly affect large and
medium arteries.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Progression of Atherosclerosis
Fatty streaks constitute
one of the earliest lesions
of atherosclerosis. Many
fatty
streaks
regress,
whereas others progress to
fibrous
plaques
and
eventually to atheroma,
which may be complicated
by
hemorrhage,
ulceration, calcification,
or thrombosis and may
produce
myocardial
infarction,
stroke,
or
gangrene.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Common Sites of Atherosclerotic Obstruction
These plaques are found
predominantly
in
the
abdominal aorta and the
coronary, popliteal, and
internal carotid arteries.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Risk Factors for Atherosclerosis
Modifiable
Nonmodifiable
 Nicotine
 Diet (↓ fat diet)
 Hypertension
(↓ B.P by diet + medication)
 Diabetes (diet + medication)
 Obesity
 Stress
 Sedentary lifestyle
Dr.Yoused Aljeesh
 Age
 Gender
 Familial
predisposition/genetics
Dr. Motasem Salah
Management
 Prevention (Modification of risk factors)
 Exercise program (Improve circulation and
increase the functioning capacity of the
circulation)
 Medications (Reduce blood lipid levels)
 Use of antiplatelet agents
 Note: We can determined
the obstruction through
angiogram [X-ray examination of blood vessels, a dye is
injected into the artery & X-ray films is taken.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Peripheral arterial occlusive disease
 Arterial insufficiency of the extremities is usually found in
individual over 50 years old. Legs are mostly affected. The
severity are influenced by the number of atherosclerotic risk
factors [ D.M , ↑ B.P, smoking , life style]
Clinical manifestation
 Intermittent claudication: sever sharp pain in the calf & legs
muscles, induced by exercise & relieved by rest
 Coldness or numbness
 Ulcerations & gangrene
 Muscle atrophy
 Peripheral pulses may be diminished or absent
Dr.Yoused Aljeesh
Dr. Motasem Salah
31
Diagnostic evaluation and management:
1- Doppler ultrasonic flow studies :- its an electronic
stethoscope that can reflect the sound of blood flow even
when pulses are not palpable.
2- Angiography : x-ray examination of blood vessels, a dye is injected into
the artery and rapid x- ray films is taken.
Complication of the angiography:
a- local irritation at the injection site
B- allergic reactions [such as dyspnea , nausea + vomiting,
sweating and tachycardia]
Rx : antihistamine and steroids
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Care of the feet & legs for the person with
peripheral vascular problem
1- Cleanliness [wash feet daily, mild soap, dry feet]
2- Warmth [wear clean socks + extra socks in case of
cold weather].
3- Safety [inspect feet daily with mirror for redness wear
soft shoes , & Trim Nails straight after showering]
4- Comfort measures [use cream if feet dry but never
put between the toes], but you can use powder.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Care of the feet & legs for the person with
peripheral vascular problem
5- Prevent constriction of blood vessels [do not
cr0ss legs, quit smoking, avoid compression
around knees]
6- Exercise [participate in regular walking exercise
program to stimulate circulation]
7- Seeking medical attention [contact health care
provider at the onset of skin breakdown ].
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Buerger’s Disease:
Thromboangiitis Obliterans
 Recurring
inflammatory process of the small and
intermediate vessels of (usually) the lower extremities;
probably an autoimmune disorder
 Most often occurs in men ages 20-35
 Risk or aggravating factor: tobacco
 Progressive occlusion of vessels results in pain, ischemic
changes, ulcerations, and gangrene.
Etiology:
 The cause of Buergers disease is unknown but it believed to
be due to autoimmune disease {autoimmune vasculitis}
Dr.Yoused Aljeesh
Dr. Motasem Salah
Clinical manifestation
 The pt will complain of sever sharp cramp pain in the feet or
legs. often exercise [intermittent claudication] which relieved
by rest.
 The early S & S of Burgers disease is “numbness and coldness”
sensation to cool & burning sensation.
 Pulse may be diminished or absent.
 Ulceration & gangrene and tissue damage eventually occurs.
 Circulatory insufficiency
 Decrease circulation extremities.
 Burning sensation
Dr.Yoused Aljeesh
Dr. Motasem Salah
36
Management & Nursing interventions:
 Improve circulation.
 Protect extremities from trauma and infection.
 Instruct the patient to stop smoking.
 Vasodilators are rarely prescribed because these medication
cause dilation of only healthy vessels.
 Instruct the patient avoid emotional stresses
 Instruct the patient avoid exposure to cold.
 Instruct the pt avoiding high risk.
 Should the pt to avoid trauma.
Dr.Yoused Aljeesh
Dr. Motasem Salah
37
Prognosis
bad prognosis
 Gangrene below knee → below knee amputation.
 Gangrene above knee → above knee amputation.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Aortic aneurysms
Classification 2 types:
1] Thoracic aortic aneurism.
2] Abdominal aortic aneurism
Definition of aneurysms:
 Is a localized sac or swelling in the wall of an artery due to
weak point in the vessel wall.
 An aneurysm is a weak point in a blood vessel wall, most
commonly in an artery.
 We have many forms of aneurysms but the most common
forms of aneurysms are saccular or fusiform aneurysm.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Characteristics of Arterial Aneurysms
(A)Normal artery.
(B)False aneurysm—actually a pulsating hematoma. The clot and connective tissue
are outside the arterial wall.
(C) True aneurysm. One, two, or all three layers of the artery may be involved.
(D)Fusiform aneurysm—symmetric, spindle-shaped expansion of entire
circumference of involved vessel.
(E) Saccular aneurysm—a bulbous protrusion of one side of the arterial wall.
(F) Dissecting aneurysm—this usually is a hematoma that splits the layers of the
arterial wall.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Causes:
1- Atherosclerosis: the most common cause of
aneurysms.
2- Trauma to the wall of the artery.
3- Infection.
 Aneurysms are serious because they can rupture lead
to bleeding & death.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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1] Thoracic Aortic Aneurysm:
 Definition: sac present in the chest cavity.
 Approximately 85% of all cases of thoracic aortic
aneurysm are caused by atherosclerosis. They
occur most frequently in men between the ages 40
and 70 years.
 About one third of patients with thoracic
aneurysms die of rupture of the aneurysm
Dr.Yoused Aljeesh
Dr. Motasem Salah
42
Signs & Symptoms (Thoracic Aortic Aneurysm)
 Some patients are asymptomatic.
 In most cases, pain is the most prominent
symptom. The pain in the chest is usually constant
and boring.
 Dysphagia, dyspnea and horsiness of voice (the
result of pressure of the sac against the trachea,
esophagus, main bronchus, or the lung itself)
 Aphonia [ result from pressure on laryngeal nerve].
Dr.Yoused Aljeesh
Dr. Motasem Salah
43
Diagnosis (Thoracic aortic aneurysm):
 Chest x-rays.
 C.T scan. [computerized tomography] provide an image of
the soft structures of the body particular brain.
Management:
 Surgical repair
 Control blood pressure: by antihypertensive drugs &
controlling risk factors.
 Open heart surgery to remove aneurism
 Physical examination (6 month)
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Repair of an Ascending Aortic Aneurysm
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Dr. Motasem Salah
2) Abdominal Aortic Aneurism
 Definition: aortic aneurism (sac) in the abdominal
cavity
 The most common cause of abdominal aortic aneurysm
is atherosclerosis. (other causes: trauma & infection)
 The condition is more common among Caucasian affects
men four times more than women, most prevalent after
age of 60.
 Most of these aneurysms occur below the renal arteries.
 Untreated, the eventual outcome may be rupture and
death
Dr.Yoused Aljeesh
Dr. Motasem Salah
46
Signs & symptoms:
 Some patients can feel their heart beating in their
abdomen [pulsated mass] when lying down.
 Most common signs & symptoms the pt will have
abdominal mass.
 Mainly this disease Caucasian people more than others
 Mainly the disease more male than female.
Dr.Yoused Aljeesh
Dr. Motasem Salah
47
Diagnosis:
 Abdominal X-ray confirm the existence of an
aneurysm
 C-T scan is useful for determining the size of
aneurysm.
 Pulsated mass in the middle and upper abdomen.
Management:
 Surgery is the treatment of choice for abdomen
aneurysm larger than 5 cm in diameter.
Dr.Yoused Aljeesh
Dr. Motasem Salah
48
Indication of rupturing abdominal aortic
aneurysm
 Sever constant back pain
 Rigid abdomen
 Decreasing hematocrit
 Hematomas in the scrotum, perineum area, flank
or penis.
 S & S of hypovolemic shock (Hypotension)
 Note : The surgical mortality rate with ruptured
aneurysm is 50 to 75%.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Arterial Embolism & Arterial Thrombosis
 Embolus: material such as blood clot, fat, air, or foreign





body.
Embolism: the condition in which an embolus becomes
lodged in an artery & obstructs its blood flow.
Rx: embolectomy, anticoagulant therapy & streptokinase.
Thrombus: blood clot
Thrombosis: the condition in which the blood changes
from liquid to solid state and produces blood clot.
Thrombosis in an artery obstructs the blood flow to the
tissue it supplies.
Rx: thrombectomy
Dr.Yoused Aljeesh
Dr. Motasem Salah
50
Clinical manifestation:
 Sever pain, gradual loss of sensory & motor function.
 Four P associated with acute arterial embolism are
Pain, Pallor, Pulselessness, Paresthesia.
Dr.Yoused Aljeesh
Dr. Motasem Salah
51
Raynaud's Disease
 Raynauds Disease: is refer to localized, intermittent
arterial vasoocclusion of small arteries of the feet
and hands (fingertips or toes) that cause color and
temperature changes.
Cause : unknown
 Occurs most frequently in young women
 Manifestations: sudden vasoconstriction results in
color changes, numbness, and burning pain
Dr.Yoused Aljeesh
Dr. Motasem Salah
Management of Raynaud's Disease
 Avoiding upsetting situation (cold, stress)
 Avoid smoking.
 Emotional support.
 Avoid injury by sharp object.
 Vasodilator drugs
 Protect from cold/other triggers. Avoid injury to
hands/fingers.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Venous thrombosis
 Factors
play
significant
role
in
venous
thrombosis:
1- Stasis of blood: occur when blood flow is retarded
occur with heart failure, shock, and bed rest.
2- Damage of the blood vessels: creates site for clot
formation.
3- Altered blood coagulation: suddenly stopped the
anticoagulant medication
Dr.Yoused Aljeesh
Dr. Motasem Salah
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THROMBOPHLEBITIS & PHLEBOTHROMBOSIS
 Thrombophlebitis: inflammation of the walls of the vein
and is frequently accompanied by the formation of clot.
 Phlebothrombosis: condition of developing clot in the
veins.
 When a thrombus develops initially in the veins as a result
of stasis or hypercoagulability but without inflammation,
the process is referred to as phlebothrombosis
Dr.Yoused Aljeesh
Dr. Motasem Salah
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DVT [Deep Venous Thrombosis]
DVT: is a blood clot that forms in a vein deep in the
body. Most occur in the leg or hip veins. However, a deep
vein thrombosis also can occur in other parts of the body.
Risk factors:
1- Bed rest, obesity.
2- Spinal cord injury [because of immobilization].
3- Low blood flow in a deep vein due to injury, surgery, or
immobilization.
4- Pregnancy.
5- Malignancy.
Dr.Yoused Aljeesh
Dr. Motasem Salah
56
Clinical manifestation DVT:
1- Deep calf pain when the foot is flexed backwards
[Positive Homans signs].
2- Heaviness on standing because of edema &
swelling of the extremities.
3- Tenderness & affected leg may feel warmer than
the unaffected leg. Because of inflammation.
4- Swelling of the leg
5- Red or discolored skin.
Dr.Yoused Aljeesh
Dr. Motasem Salah
57
Management DVT:
 When treating DVT, the goals are to stop the clot from getting
bigger, keep the clot from traveling to the lungs, and reduce the
chance of having another blood clot. Common treatments for this
condition include medications, and graduated compression
stockings.
1- Bed rest.
2- Foot of bed elevated to 15 cm to decrease edema
3- Thrombolytic and anticoagulant therapy
4- One leg is compared with the other at the same level to determined
size differences.
5- Applying elastic compression stockings (For ambulatory patients,
elastic compression stockings are removed at night and reapplied before
the legs are lowered from the bed to the floor in the morning).
Dr.Yoused Aljeesh
Dr. Motasem Salah
58
Superficial vein thrombosis
 Superficial vein thrombosis is a thrombus formation in
a superficial vein.
 The skin over the vein becomes red, swollen, and
painful.
 Superficial vein thrombosis most often affects the
superficial veins in the legs but may also affect
superficial in the arms.
 S & S: Pain, Redness , local swelling, warmth in the
involved area.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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 Note: superficial veins thrombosis [have negative
Homans sign]
Management:
 Most of superficial veins thrombosis dissolve
spontaneously, and this condition can be treated at
home. with bed rest elevation of the leg.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Preventive Measure
[Venous Thrombosis, DVT, Thrombophlebitis]
1- Elastic stocking: exert pressure over the entire surface of the
calves, which reduce the caliber of the superficial vein in the leg
lead to ↑ flow in the deeper vein . [Night→ Removal → Re applied
→Morning]
2- Body position & exercise
 Lower legs should be elevated that allow the vein to empty rapidly.
 Passive & active leg exercises should be performed pre & post-
operatively to ↑ venous flow.
 Early ambulation is most effective to prevent veous stasis.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Preventive Measures
 Anticoagulant therapy: Subcutaneous heparin,
warfarin (Coumadin) for extended therapy
 Positioning: periodic elevation of lower extremities
 Exercises: active and passive limb exercises, deepbreathing exercises
 Avoid sitting/standing for prolonged periods; walk
10 minutes every 1-2 hours.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Anticoagulant therapy: Patient teaching
 Carry identification, indicating anti-coagulant therapy being taken
 Contact or informed the physician a- dental extraction
 If any of the following sign appear report immediately.
- Sever abdominal pain.
- Red or brown color of urine.
- Bleeding such as cut that do not stop.
- Nasal bleeding
- Red or black bowel movements.
 Avoid injury.
 The pregnant woman should notify their physician.
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Blood flow and function of valves in veins. Note
impaired blood return due to incompetent valve.
Competent valves
showing blood flow
patterns when the
valve is open (A) and
closed (B), allowing
blood to flow against
gravity.
(C) With faulty or
incompetent valves,
the blood is unable to
move toward the
heart.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Leg Ulcers
 Leg ulcer is an excavation of the skin surface that occurs
when inflamed necrotic tissue sloughs off.
Pathophysiology:
 Arterial/venous insufficiency → ↓ blood supply → ↓ O2 &
nutrients in the tissue → damage of the tissue → ulcer.
Clinical manifestation:
 According to cause.
1- Chronic arterial disease: pain caused by activity are relieved
p- few minutes of rest. Pain [characterized by intermittent
claudication].
2- Chronic venous insufficiency : pain described as cramping or
heaviness. Edema of the legs esp. foot and ankle.
Dr.Yoused Aljeesh
Dr. Motasem Salah
65
Arterial Ulcer, Gangrene Due to Arterial
Insufficiency, and Ulcer Due to Venous Stasis
Dr.Yoused Aljeesh
Dr. Motasem Salah
Diagnostic evaluation Leg Ulcer:
 The pulses of the lower extremities
 Doppler ultrasonic flow studies
 Angiography
 The history of the condition.
Management:
 [All ulcer have the potential to become infected]
 Antibiotic therapy [C& S]
 Debridement: removal of dead tissue + to promote healing.
 Wound dressing [which provide barrier for protection
because they adhere to the wound].
Dr.Yoused Aljeesh
Dr. Motasem Salah
67
Nursing Process: The Care of the
Patient with Leg Ulcers: Planning
 Major goals include restoration of skin integrity,
improved physical mobility, adequate nutrition,
and absence of complications.
Dr.Yoused Aljeesh
Dr. Motasem Salah
Varicose Veins
 Abnormally dilated superficial vein. This




condition occur in lower extremities.
Most common in women & persons who
require prolong standing.
Increased pressure in the superficial
venous system
normally blood flows from superficial
system to deep
If the valves protecting the superficial
veins become incompetent there is higher
pressure in the superficial veins and they
become varicose
Dr.Yoused Aljeesh
Dr. Motasem Salah
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Causes
 Varicose veins may be considered primary (without
involvement of deep veins) or secondary (resulting from
obstruction of deep veins)
Primary
 Congenital abnormality, most common cause
Secondary
 Anything that raises intra-abdominal pressure or raises
pressure in superficial/deep venous system
 Pregnancy
 Abdominal/pelvic mass
 Ascites
 Obesity
 Constipation
Dr.Yoused Aljeesh
Dr. Motasem Salah
Dr.Yoused Aljeesh
Dr. Motasem Salah
Prevention & health promotion:
1- Avoid activities that cause venous stasis such as
sitting or standing for along period of time.
2- The patient should encourage to walk.
3- Elevating legs when they are tired.
4- ↓ weight.
5- Elastic stockings.
6- Walking up the stairs rather than using the
elevator.
7- Swimming Exercise
Dr.Yoused Aljeesh
Dr. Motasem Salah
72
Management
 Vein stripping :- an
incision made in the
ankle and metal or
plastic wire is passed
and vein stripping is
done.
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Dr. Motasem Salah
73
Postoperative management:
1- Bed rest for 24 hrs.
2- Elastic compression of the leg is maintained for
one week.
3- Elevation of the foot.
4- Analgesic to ↓ pain.
Dr.Yoused Aljeesh
Dr. Motasem Salah
74
Cellulitis and Lymphatic Disorders
 Cellulitis: infection and swelling of skin tissues (deep dermis)
 Lymphangitis: inflammation/infection of the lymphatic
channels “duct” (Cause: hemolytic streptococcus)
 Lymphadenitis: inflammation/infection of the lymph
nodes
 The lymph nodes become enlarged, red and tender. [the node
involved in the groin, axilla or cervical reg.
 Lymphedema: accumulation of lymph in the tissues,
causing swelling, it could be due to
obstruction
Dr.Yoused Aljeesh
congenital or
Dr. Motasem Salah
Elephantiasis
 Elephantiasis: Enlargement of the arms, legs, or
genitals to elephantoid size.
Pathophysiology:
 Lymphatic system → obstruction of lymphatic vessels
→ chronic swelling → frequent infection &
inflammation→ thickening of the subcutaneous
tissues, and hypertrophy (enlargement) of the skin
 Signs + symptoms:
1- Swelling in the extremities are most common.
2- Swelling in scrotum, breast may involved.
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Dr. Motasem Salah
76
 edema due to obstruction of lymphatic vessels.
Edema will be soft, pitting and relieved by
treatment, as the condition progresses the edema
becomes firm, non-pitting and unresponsive to
treatment.
Dr.Yoused Aljeesh
Dr. Motasem Salah
77
Cause
 It is caused by thread-like
parasitic worms
 Obstruction
of
the
lymphatic vessels leads to
swelling in the lower
extremities and genital
area
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Management:
 The goal of therapy is to reduce edema by legs elevated.
 Active & passive exercise help in moving lymphatic fluid
into the bloodstream .
 Lasix to prevent fluid overload.
 Antibiotic therapy in case of lymphangitis.
 Dithylcarbamazine
Dr.Yoused Aljeesh
Dr. Motasem Salah
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