Nursing Care

of
Adults
with Vascular Problems
 Problems with arterial perfusion:
Acute arterial occlusion
Causes
• Emboli from the heart
• Sudden thrombus at an atherosclerotic plaque
• Trauma
Atherosclerotic
plaque

Thrombus
Problems with arterial perfusion:
Acute arterial occlusion
Signs and symptoms
1. Poikilothermia (cool)
2. Pulselessness
3. Paresthesia
4. Paralysis
5. Pale
6. Pain
Problems with arterial perfusion:
Chronic arterial occlusion
Primary cause is: Atherosclerosis
Mainly affects legs
Insidious
Symptoms appear with75%
blockage
 Problems with arterial
perfusion: Chronic
arterial occlusion
• Symptoms appear with75%
blockage
• Symptoms are due to:
• O2,
•  nutrients
• lactic acid
 Problems with arterial perfusion:
Chronic arterial occlusion

1. Intermittent claudication in buttocks or legs

2. Advanced to rest pain, especially at night when legs are not

dependent

3. Ulcers and gangrene

4. Numbness or tingling in the toes or feet

5. Pallor or blanching upon elevation of leg

6. Hyperemia (redness) or blue or dusky when limb is dependent

(dependent rubor)

7. Shiny, taut skin with hair loss on lower leg

8. Diminished or absent pedal, popliteal or femoral pulses

What are the risk factors for arterial
occlusive disease ?

Who would you expect to get chronic

arterial occlusive disease at an earlier
age?
Femoral-popliteal area
most comon site
in nondiabetics

Common sites for

diabetics are in
The arteries below
the knees
 Arterial ulcer
characteristics
A. Usually over bony
prominences on toes and
feet
B. Dry & Painful
C. Can lead to gangrene
D. May require amputation
Arterial - ischemic
ulcer over
lateral ankle
Gangrene over
bony prominence
of great toe
 Nursing Interventions

• Assess circulation
• Provide wound care.
• Discuss lifestyle changes
• Teach about medications
• Teach methods to improve
circulation: exercise / no
constricting garments or positions.
 Nursing Interventions
Teach proper foot care

Roomy, comfortable, protective shoes

Keep feet clean with mild soap

Don’t soak feet

Avoid chemicals, heat & cold
Wear wool or cotton socks
 Surgical Therapy
Percutaneous transluminal angioplasty

Atherectomy Arterial bypass

Endarterectomy

Stent

Amputation
Nursing interventions

Acute?

Ambulatory and Home ?

 Thromboangitis obliterans
(Buerger’s disease)
1. Directly related to smoking
2. Most frequent in men aged 25 to 40
3. Inflammation & thrombus obstruct
artery or vein
4. Can lead to amputation
5. Treatment – stop smoking
 Raynaud’s phenomenon
1. Episodic vasospasm of small cutaneous
arteries of fingers & toes
2. More common in women
3. Associated with collagen diseases
4. Symptoms precipitated by cold, stress,
caffeine, tobacco
5. Three color changes: white, blue, red
6. Self limiting
7. Tx: protect from cold and don’t smoke.
Vascular problems

of the

Venous System
 Thrombophlebitis

• Clot formation with

inflammation of a vein
• Can be superficial or deep
• 65% of people with IV’s get
one (superficial)
• 5% of surgical patients get
DVT
Causes of Thrombophlebitis
Virchow’s triad

Venous stasis
Damaged endothelium
Hypercoagulability
Superficial Thrombophlebitis
Signs & Symptoms

Palpable, firm vein

Red, tender, warm skin
surrounding it
 Deep Vein
Thrombophlebitis
Signs & Symptoms
• Unilateral leg edema
• Red, warm skin
• Pain
• Temperature > 38o C
 Care of patient with
DVT ( in patient)
Heparin bolus then continuous
infusion (for up to 7 days)
Infusion titrated according to APPT
Bedrest until pain and swelling
gone)
Elastic compression stockings
Daily circumference measurement
Anticoagulants for 3 – 6 months
Presence of massive DVT

Presence of symptomatic pulmonary embolism

High risk of bleeding with anticoagulant therapy

Presence of comorbid conditions or other factors that

warrant in-hospital care.
 Care of patient with
DVT ( out patient)
The following patients cannot be treated on out patient basis:

•Presence of massive DVT

•Presence of symptomatic pulmonary embolism
•High risk of bleeding with anticoagulant therapy
•Presence of comorbid conditions or other factors that
warrant in-hospital care.

Out patients may need to learn how to inject the LMWH and
Will need info on bleeding complications ( table 38-13)

What other nursing interventions are needed?

 Surgery to prevent PE

Intracaval filter
 Heparin (IV)
• Inhibits conversion of fibrinogen
to fibrin
• Tested with APTT
• Antidote: protamine sulphate
• Does not dissolve clots, but
prevents clots from expanding &
prevents new clots
• Nothing is compatible with it in
the IV
Warfarin (Coumadin)
• Given p.o.
• Takes time to work.
• Inhibits synthesis of Vit K
dependent clotting factors,
including prothrombin
• Monitored with INR
• Influenced by dietary Vit K
• Many medications interfere with
Vit K
• Antidote: Vit K, but takes days to
work
 Varicose veins

• Dilated, tortuous, SQ veins

• Due to incompetent valves
(congenital, or from
previous DVT, obesity,
pregnancy, prolonged
standing)
 Usual venous blood flow
Superficial veins to perforators

Perforators drain to deep veins

Skeletal muscle contraction moves

blood (Valves prevent backflow)

Inspiration  thoracic pres & abd pres

 When venous valves don’t work
Incompetent valves let blood fall back

Excess blood in deep veins flows

through perforators to superficial veins

Superficial Excessive hydrostatic

veins bulge. pressure leads to edema.

Edema can block

arterial flow.
 Varicose veins
Treatment

• Elevate limb
• Compression stockings
• Avoid sitting or standing for long time
• Maintain ideal weight
• Don’t constrict blood flow
• Sclerosis
• Ligation and removal (vein stripping)
 Venous leg ulcers

• Lower leg leathery and brown

• Edema
• Ulcer usually around lower leg or
ankle
• Often wet or draining
• May have new tissue
• Pedal pulses present, sometimes
weak
• Pain relieved by elevating feet
 Venous leg ulcer Treatment
• Elevate leg
• Apply dressing that absorbs drainage
• Later hydrocolloid dressing & external
compression
• Antibiotics if infected
• Good nutrition
• Prevention – avoid trauma, good skin
care, compression stockings, frequent
rest and leg elevation
When obtaining a health history from a 72
year old man with peripheral artery disease
Of the lower extremities the nurse asks the
patient about a history of other atherosclerotic
manifestations such as

1. Venous thrombosis

2. Venous leg ulcers

3. Pulmonary embolism

4. Carotid artery disease

 Complications

• Pulmonary embolism
• Amputation
Arterial or venous disease?

1. Paresthesia

2. Heavy ulcer drainage

3. Edema around the ankles

4. Gangrene over bony prominences on

toes and feet

5. Decreased peripheral pulses

6. Brown pigmentation of the legs

7. Thickened brittle nails

8. Ulceration around the medial malleolus

9. Pallor on elevation of the legs

10. Dull ache in calf

 Pulmonary Embolism
Signs & Symptoms
• Sudden unexplained
dyspnea, tachypnea, or
tachycardia
• Cough
• Chest pain
• Hemoptysis
• Crackles
• Fever
• Mental status change
Pulmonary Embolism
Diagnostics
• ABG’s
• D-dimer
• Venous studies
• Chest X
• Lung scan
• EKG
 Pulmonary Embolism
Treatment
• Anticoagulants – prevent
thrombus formation & growth

• Bed rest – prevent emboli

• HOB, oxygen, ET tube &

mechanical ventilation prn, treat
shock prn

• Surgery – embolectomy,
intracaval filter
 Amputation
• What is phantom
limb pain?
• How are hip flexion
contractures
prevented?
• What does the
compression bandage
do?