Chapter 31

Assessment and Management of Patients with

Vascular Disorders and Problems of Peripheral
Circulation
Medical SurgicalPart B
By
Dr. Yousef Aljeesh
Associate Professor
Administration

Dr. Motasem Salah

PhD Nursing
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
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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 )
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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]
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Systemic and Pulmonary

Circulation

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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.
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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
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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)

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.
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2. Skin appearance and

temperature
Adequate 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
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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.
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Assessing Peripheral
Pulses
We assess peripheral pulse
through
Dorsalis pedis
Popliteal artery
Posterior tibial art.

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Peroneal, Dorsalis Pedis, and

Posterior Tibial Pulse Sites

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Continuous-wave Doppler ultrasound detects

blood flow, this diagnostic technique helps
characterize the nature of peripheral vascular
disease.

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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
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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
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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.

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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
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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]
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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.
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Promoting vasodilation & - 2

.preventing vascular compression
Warmth promotes arterial flow
Adequate

clothing
&
warm
temperatures protect the patient from
chilling.

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Promoting vasodilation & - 2

.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.
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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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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]
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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

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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.
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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
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thrombosis and may

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Common Sites of Atherosclerotic

Obstruction
These plaques are found
predominantly in the
abdominal aorta and the
coronary, popliteal, and
internal carotid arteries.

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Risk Factors for Atherosclerosis

Modifiable
Age
Nicotine
Nonmodifiable
Diet ( fat diet)
Hypertension

Gender

Familial

predisposition/genetics

( B.P by diet +
medication)

Diabetes
medication)

(diet +

Obesity
Stress
Sedentary lifestyle
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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.
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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
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Diagnostic evaluation and

Doppler ultrasonic flow studies
:1management

:- 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
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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.

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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 ].

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Buergers 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
vasculitis}

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to

autoimmune
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disease

{autoimmune
Dr. Motasem

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
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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.
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Prognosis
bad prognosis
Gangrene below knee below knee

amputation.
Gangrene above knee above knee

amputation.

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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.

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Characteristics of Arterial
Aneurysms

(A)Normal artery.
(B)False aneurysmactually 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 aneurysmsymmetric, spindle-shaped expansion of
entire circumference of involved vessel.
(E) Saccular aneurysma bulbous protrusion of one side of the
arterial
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wall.
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(F) Dissecting aneurysmthisSalah
usually is a hematoma that splits the

: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.

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:Thoracic Aortic Aneurysm[ 1

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
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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].
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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)
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Repair of an Ascending Aortic

Aneurysm

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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
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Aljeesh
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and
death
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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.

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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.
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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%.
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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
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:Clinical manifestation
Sever pain, gradual loss of sensory & motor

function.
Four P associated with acute arterial

embolism are Pain, Pallor, Pulselessness,

Paresthesia.
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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

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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.
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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
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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

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phlebothrombosis

process
Salah

is

referred

to

as

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DVT [Deep Venous

DVT: is a blood clot that forms in a vein deep in the
Thrombosis]

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.
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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

inflammation.
4- Swelling of the leg
5- Red or discolored skin.
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leg.

Because

of

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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).
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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.

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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.

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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
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Aljeesh
Dr.veous
Motasem
ambulation
is most effective to prevent
stasis.
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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, deep-breathing exercises
Avoid
sitting/standing
for
prolonged
periods; walk 10 minutes every 1-2 hours.
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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.
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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
Dr.Yoused Aljeesh
is unable
to move

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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
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Arterial Ulcer, Gangrene Due to

Arterial Insufficiency, and Ulcer Due
to Venous Stasis

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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].
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Nursing Process: The Care of the

Patient with Leg Ulcers:
Planning
Major goals include restoration of skin

integrity,

improved

physical

adequate

nutrition,

and

mobility,

absence

complications.

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Dr. Motasem

of

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
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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

Salah

Dr. Motasem

Dr.Yoused Aljeesh

Salah

Dr. Motasem

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.
Aljeesh Exercise
Dr. Motasem
7- Dr.Yoused
Swimming
Salah

72

Management
Vein stripping :- an

incision made in the

ankle and metal or
plastic
wire
is
passed and vein
stripping is done.

Dr.Yoused Aljeesh

Salah

Dr. Motasem
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

Salah

Dr. Motasem
74

Cellulitis and Lymphatic

Disorders
Cellulitis: infection and swelling of skin tissues (deep

dermis)
Lymphangitis:

lymphatic

inflammation/infection
channels
duct
(Cause:

of

the

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

congenital or obstruction
Dr.Yoused Aljeesh

Salah

Dr. Motasem

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.
Dr.Yoused Aljeesh

Salah

Dr. Motasem
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, nonpitting and unresponsive to treatment.

Dr.Yoused Aljeesh

Salah

Dr. Motasem
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

78

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

Salah

Dr. Motasem
79