n325p peripheral venous/arterial circulation

peripheral arterial disease

• thickening/narrowing of artery walls

• reduced blood flow

  • tissues aren’t as oxygenated

• diabetes, HTN, hyperlipidemia, smokers are at higher risk

• legs are most affected bc further away from the heart

• clinical manifestation not present until 60-75% occlusion

athersclerosis

• #1 cause of PAD

• damage to endothelium or arteries

  • due to high BP to push blood thru

  • damage causes inflammation

  • inflammation will have platelets come over and plaque will form

• occlusive thrombus → unstable plaque → could break off → dangerous

PAD modifiable risks

• tobacco use

• diabetes

• HTN

• obesity → build up of lipids and cholesterol

• sedentary lifestyle

• stress

PAD non-modifiable risks

• age

• gender

• family history

• ethnicity

ischemia clinical manifestations

• intermittent claudication

  • leg muscle pain w activity

  • muscle isn’t getting enough blood flow and O2

  • worse w activity, better w rest

  • continuum of pain all the way to cell death

• fontaine scale

  • I = asymptomatic

  • IIa = mild claudication

  • IIb = moderate - severe claudication

  • III = ischemic rest pain

  • IV = ulceration or gangrene

PAD assessment

• perfusion

  • pulses → mark and document grade, use doppler to locate and mark w x

  • temperature → cooler than expected

  • cap refill → greater than 3 secs

  • paresthesia → numbness

  • pain → pain w activity

  • color → pallor

• compare sides

chronic PAD assessment

• no edema

• thin, shiny skin, no hair

  • chronic loss of perfusion to hair cells → no hair growth

• thick, brittle toenails

• numbness, paresthesia, itching

• dependent rubor

  • elevate foot → turns pale

  • lower foot → turns bright red

ankle-brachial index (ABI)

• compare BP in ankle vs arm

  • ideally should be same or slightly higher than in arm

  • if BP in ankle is significantly lower → less blood flow there due to narrowed arteries

  • ABI = 1 is ideal

  • ABI < 1 is when to worry about problems with perfusion

• equipment needed:

  • stethoscope & sphygomomanometer

  • doppler if pulse too faint

• what to do:

  • lay pt supine

  • take BP in both arms and both ankles

  • use highest SBP measure from the arms & legs

• calculate:

  • ABI = SBP ankle/SBP arm

chronic PAD

• most commonly in pelvis and legs

• if have occlusion @ artery → everything under that is at risk

• cramps/pain with exercise

• pain resolves with rest

• intermittent claudication

• with progression, can have pain @ rest

chronic PAD diagnostics

• labs (cholesterol & glucose)

• ABI

• doppler flow studied

• angiography

chronic PAD interventions

• treat atherosclerosis

  • statins for cholesterol

  • antiplatelets → aspirin/clopidogrel

  • anticoagulation → prevent formation/breakdown of thrombus

  • peripheral vasodilators → incr diameter of artery for better flow

  • BP control → make sure hypotension doesn’t happen

  • exercise therapy → BP and BS control

  • stop smoking

• surgery

  • angioplasty → insert catheter to blockage → stent to hold artery open → put pt on blood thinner/antiplatelet bc body will send platelets to new foreign object

  • stent

  • endarterectomy → remove pieces of plaque

  • arterial bypass → graft blood vessel and create new blood pathway to lower extremity

acute arterial occlusion (critical limb ischemia): assessment

• emergency!!

• 6 P’s

  • pain

  • paresthesia

  • paralysis

  • poikilothermia

  • pulselessness

  • pallor

acute arterial occlusion: interventions

• medications

  • thrombolytic → dissolve clots, ex) alteplase (tPA)

  • anticoagulant → prevent formation/growth of clot, ex) heparin

• surgery

  • remove obstruction w angioplasty, stent, bypass

• monitor circulation

  • 6 P’s

• keep warm

  • no direct heat → risk skin breakdown

  • warm blanket is good

  • cold will decr perfusion

• protect skin

  • monitor for pressure ulcer

• promote circulation

  • keep extremity flat/slightly dependent → help blood flow into artery

  • don’t cross legs

  • no restraints to affected extremity

• monitor tx effects

arterial ulcers

• may/may not have pain @ site

• location/appearance

  • bony prominences on toes/feet

  • deep and caved

  • even edges

  • ulcer bed pale

  • little granulation tissue

  • cold feet

  • decreased/absent pulse

  • possible gangrene

• treatment

  • restore circulation→ arterial bypass

  • prevent trauma and infection → good fitting shoes, avoid stepping on things, daily foot checks

  • DON’T ELEVATE → we need blood flow to go there

  • NO COMPRESSION

• patient education: foot care

  • avoid getting nails done at salon not approved

• interventions

  • prevent infection

  • protect site and promote healing w hyperbaric O2 and clean, dry dressings

  • surgery to improve circulation

  • could have to do amputation → but prob won’t heal well

• foot care

  • goal #1: improve blood supply

    • dependent

    • exercise

    • no smoking

    • warmth

  • goal #2: prevent injury

    • inspect feet daily

    • clean feet

    • lamb’s wool → moisture wicking product

    • clip nails straight and even..

    • no heating pads

    • no bare feet

venous ulcers

• caused by inadequate tissue O2 and nutrient exchange

• veins in legs are not moving blod to heart well

• blood pools in legs instead of flowing back to heart

• poor healing in extremities w/o blood flow

• moderate ulcer discomfort

• location/appearance

  • ankle

  • superficial

  • pink ulcer bed

  • uneven edges

  • granulation tissue present

  • ankle edema (swollen)

  • pulses present

  • brown pigment esp @ ankle

  • scaring from previous ulcers

  • wet wound…serous drainage

• treatment

  • long-term wound care (unna boot, moist dressing)

  • elevate extremity

  • compression hose → we want blood to return back to heart

  • elevation

  • infection prevention

  • moist dressing to promote healing

  • healthy diet

aneurysms

• bulging or ballooning of vessels (usually arteries)

• caused by weakening of artery wall - could be from HTN, smoking, plaque buildup

• most common is in anterior communicating artery and middle cerebral artery

aneurysm risks

• age

• male

• HTN

• CAD

• family hx

• smoking

• hypercholesterolemia

• lower extremity PAD

• carotid artery disease

• obesity

aneurysm locations

• cerebral

• aortic

  • abdominal aorta (AAA - 75% of aortic aneurysms)

  • thoracic aorta (TAA) - above the heart

  • most occur below renal arteries

• popliteal peripheral

aneurysm clinical manifestations

• TAA and AA are often asymptomatic until they are pretty large

• thoracic aortic aneurysm (TAA): deep, diffuse pain that may extend to shoulder

• ascending aortic aneurysm (AAA): angia, chest pain, cough, SOB, hoarseness, decreased venous return, may mimic abdominal/back disorders, pulsatile mass left of midline in periumbilical area may be present

aneurysm complications

• lots of ppl live w them bc repair could be too risky

• rupture

  • if AAA or TAA → massive hemorrhage

  • if cerebral → s/sx of stroke

• dissection

  • false lumen created between layers of artery → blood fills area

  • bleeding but not a rupture → filling pouch of blood

  • if in ascending aortic arch, sx required; otherwise, manage conservatively

aneurysm diagnostics

• often found while imaging for other problems, not a death sentence

• x-ray

• echocardiogram

• CT → primary way found

• MRI

• ultrasound

aneurysm interventions

• prevent rupture & dissection → these will be emergency

• wellness & education (DM, HTN, obesity, lipid management, exercise)

• routine monitoring if < 5.5 cm

• surgical care if > 5.5 cm

  • OAR (open repair)

  • endovascular grafts → cover aneurysm with mesh so it doesn’t rupture

raynaud phenomenon

• episodic, vasospastic disorder of small arteries

  • involves fingers and toes

  • vasoconstriction

• young women (15-40 yrs old)

• auto-immune connection?

• aggravated by cold/stress

• vasospasm - vasoconstriction

  • blanching → turns white

  • cynosis → turns purple or blue

  • hyperemia → rubor when blood returns - turns bright red

• “vasospastic phenomenon where cold/stress causes temporary color changes (white/blue/red) without long-term tissue damage”

raynaud phenomenon interventions

• patient teaching

  • goal is to prevent episodes

  • avoid cold, tobacco, drugs

  • stress reduction

  • when spasms → use warm water to promote vasodilation

• treatment

  • calcium channel blockers → promote vasodilation

  • sympathectomy → cut thru nerves that activate vasoconstriction and vasodilation → have to be severe case to do this

buerger’s disease

• thromboangitis obliteratans

• inflammatory, occlusive, thrombotic arterial disease

• “a rare inflammatory disease caused directly by smoking, leading to thrombosis and gangrene”

• cause is recurrent inflammation

• distal extremities - upper/lower extremities

• occurs in:

  • more men than women

  • ppl under 40 yrs old

  • smokers

  • hx of periodontal disease

• assessment

  • same as PAD

  • color/temp change

  • thrombosis

  • cold sensitivity

• interventions

  • stop smoking

  • can lead to amputation

circulatory system review

• right side of heart → deoxy blood

• left side of heart → oxy blood

• flow of O2 blood: left ventricle → aorta → arteries → arterioles → capillaries

• flow of deoxy blood: capillaries → venules → veins → superior/inferior vena cava → right atrium

• blood moves back to heart with original force of LV, muscular contraction, and valves to keep blood flowing in one direction

arteries

• moves blood AWAY from heart

• moves oxygenated blood

• thicker and more elastic vessels

• higher pressure

• no valves

• ex) aorta, carotid artery

capillaries

• connects arteries and vein

• site of O2 exchange

• no valves

• one cell thick

• very low pressure

• ex) lung and tissue capillaries

veins

• moves blood TOWARD the heart

• deoxygenated blood

• low pressure

• has valves for one way flow

• thin wall, less muscular

• ex) vena cava, jugular vein

peripheral venous disease

• venous thrombosis: deep and superficial (DVT and SVT)

  • superficial thrombosis is closer to skin and outside of body

  • deep thrombosis is deeper inside the body and are more troublesome, involving the iliac and femoral deep veins

• virchow’s triad: vessel wall injury, venous stasis, hypercoagulable state

  • all these will contribute to formation of thrombus

risk for DVT

• venous stasis

  • see in younger men w muscles that compress veins

  • age

  • CHF

  • obesity

  • orthopedic surgery

  • pregnancy → fetus grows and compresses inferior vena cava

  • prolonged immobility

  • varicose veins → damaged valves in veins cause swollen/twisted/enlarged veins

• vessel wall injury

  • surgery

  • IV therapy

  • IV meds or drug use

  • metabolic syndrome

  • DM

  • HTN

  • smoking

  • trauma

• hypercoaguable state

  • prolonged immobility

  • meds

  • clotting disorders

  • high altitudes

  • hormone replacement therapy

  • prengnacy

  • maligancies

  • tobacco

  • polycythemia vera → exessive RBCs

why is smoking bad for PVD?

• nicotine-induced vasoconstriction

• increased hyper-coagulability

• endothelial damage

• reduced O2-carrying capacity

  • body responds by incr RBCs → cause further endothelial damage

• impairs venous valve function

• increases inflammation

• reduced physical activity

• alteration of fibrinolytic system

• synergistic effect with other risk factors

DVT clinical manifestations

• edema

• UNILATERAL SWELLING

• redness

• pain

• tenderness

• temp > 100.4

• sense of fullness in extremity

DVT diagnostic tests

• clinical assessment

• d-dimer > 0.5 mg/L

  • elevated d-dimer means body is breaking down clot

  • doesn’t necessarily mean DVT is present, just that the body is breaking a clot down

• ultrasound - most common

• MRI

• venography

  • inject dye into veins and look

DVT interventions

• do not mobilize an existing clot

  • avoid valsalvas

  • no massage

• prevent new thrombus from forming

  • administer anticoagulants

• elevate limb

• use SCDs to stimulate muscular contraction, but not over clot site

• administer analgesics for comfort

• monitor for complications - pulmonary embolism is big prob!

DVT intervention - direct oral anti-coagulants

• factor Xa inhibitors

  • apixaban

  • rivaroxaban

• thrombin inhibitors

  • dabigatran

• vitamin K anagonist

  • warfarin

DVT anticoagulant therapy

• give meds like apixaban, rivaroxaban, dabigatran, warfarin

• watch for bleeding

• bleeding precautions

• report signs of bleeding → black stools, nose bleeds, excessive bruising, AMS

• avoid aspirin, NSAIDs, certain supplements

• wear an alert bracelet

• carry pharmacy card

DVT intervention - low molecular weight heparin

• lovenox

• inactivates factor Xa

• baseline coagulation studies before administering

• SQ (can give bolus IV dose to start)

• antidote is protamine sulfate

• once daily vs BID for heparin

• requires less monitoring than heparin

• comes in prefilled syringe for easier self administration

• 40 mg dose is DVT pph

DVT: general-post op prevention

• active

  • active ROM

  • TCDB

  • early ambulation

  • body alignment

  • feet supported if sitting

• passive

  • passive ROM

  • intermittent pneumatic compression

  • compression stockings

  • adequate hydration

  • leg elevation, raise foot of bed

DVT/VTE surgical management

• goal: prevent PE

• thromboectomy

• greenfield filter

• ligation or external clips

varicose veins - etiology

• hereditary

• prolonged standing

• pregnancy

• tumors

• chronic disease: heart disease, cirrhosis

• obesity

varicose veins - assessment

• raised vessels: dark, tortous

• feelings of heaviness, aching

• LE edema

varicose veins - diagnosis

• doppler flow studies

• venography

• plethysmography

varicose veins - prevention

• walking/exercise

• weight reduction

• compression socks or tights

• no clothing that binds (garters, leggings that bind/roll, spanx)

• no crossing legs, prolonged standing or sitting

varicose veins - treatment

• sclerotherapy: irritating chemical injection into the vein

• laser ablation

• surgery: vein ligation and stripping