Unit 8 Peripheral Circulation

Vasculature

Smooth lining

Lumen patent

Elasticity

Common Altered Peripheral Perfusion Clinical Manifestations 

Pain

Skin changes

Weak or absent pulses

Edema

Ulcers

Weak or Absent Pulses

Specific to peripheral arterial disease, use a dopler to assess

Nursing Assessments

6 P’s and CTEMP

6 P’s

Pain

Pulses

Pallor

Paresthesia

Paralysis

Poikilothermia

Poikilothermia

The inability to maintain a constant core body temperature, causing it to fluctuate with the surrounding environment (coldness)

CTEMPS

Color, Temperature, Edema, Movement, Pulses, Sensation

Hemosiderin

Altered discolored legs

People with Peripheral Arterial Disease in Bed Laying

Are peripherally paler

Lower Extremities in Peripheral Artery Disease

Hairless legs and thickened toe nails

Noninvasive Diagnostic Tests for PAD and PVD

Continuous wave doppler ultrasound (CW)

Exercise testing

Ankle-brachial index

Duplex ultrasound

CT scan/MRI

Air plethysmography

Continuous Wave Dopler

This handheld device emits a continuous signal through the patient’s tissues. The signals are reflected by the moving blood cells and received by the device. The filtered output Doppler signal is then transmitted to a loudspeaker or headphones, where it can be heard for interpretation as arterial or venous signals.

Lower Frequency From Doppler

The deeper the tissue penetration

Lower Extremity Evaluation with Doppler

Patient is placed in the supine position with the head of the bed elevated 20 to 30 degrees; the legs are externally rotated, if possible, to permit adequate access to the medial malleolus.

Acoustic water soluble gel is applied to the patient’s skin to permit uniform transmission of the ultrasound wave.

The tip of the Doppler transducer is positioned at a 45- to 60-degree angle over the expected location of the artery and angled slowly to identify arterial blood flow.

Excessive pressure is avoid because severely diseased arteries can collapse with even minimal pressure.

Ankle Brachial Index

For Peripheral Arterial Disease; Highest Systolic of Ankle/Highest Systolic of Arm

• No smoking or caffeine for at least 2 hours

Gold standard for deep vein thrombosis

Conduction of Ankle Brachial Index (ABI)

Rest in supine for 5 minutes

Appropriate cuff size: 10 cm on an average-sized adult, applied above the malleolus

Duplex Ultrasound

Can reveal underlying atherosclerosis by identifying narrowed or blocked arteries. This is especially useful in the lower extremities to evaluate for peripheral artery disease

Ankle Brachial Index Pressure Ranges

>1.40: Abnormal; indicates noncompressible arteries and requires further testing with a toe-brachial index (TBI).

1.00 to 1.40: Normal

0.91 to 0.99: Borderline

≤0.90: Abnormal

0.50 to 0.90: Usually found in patients with claudication (moderate to mild insufficiency)

<0.50: Found in patients with ischemic rest pain

≤0.40: Found in patients with severe ischemia or tissue loss

Air Plethysmography

Invasive Diagnostic Tests for PAD and PVD

Angiography

CT angiography

MR angiography

Venography

Angiography

Not done rapidly

Confirms diagnosis of occlusive arterial disease

Involves injecting a radiopaque contrast agent directly into the arterial system to visualize the vessels

Delayed allergic reaction to iodine clinical manifestation

Dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities

CT Angiography

Uses a rapid intravenous (IV) infusion of contrast.

Generates detailed 3D images from thin slices.

High risk in

Magnetic Resonance Angiography

Metal precautions and IV contrast precautions.

A panic button is provided to the patient as well to stop the procedure if they feel the need to which is reassuring.

Some patients with claustrophobia may get a sedative before this. Patients should be instructed to close their eyes before entering the tube, and to keep them closed, as this may decrease claustrophobic symptoms.

Venography

AKA Contrast Phlebography

Involves injecting a radiopaque contrast agent into the venous system

Blood Clot= x-ray image reveals an unfilled segment of vein

Post Venography

Will be monitored for 2 hours post venogram for access site oozing or hematoma

Peripheral Arterial Disease

Arteries become narrowed and blood flow decreases due to atherosclerosis

Peripheral Arterial Disease Contributing Factors

Same as Coronary Artery Disease:

Age

Female

Smoking

Obesity

Stress

Family history

↑ C-reactive protein: <1 mg

↑ homocysteine

Hypertension, Hyperlipidemia, Diabetes Mellitus, Atherosclerotic Heart Disease

Lack of exercise

C reactive Protein

Elevated levels can cause vascular inflammation

Homocysteine

Elevated levels contribute to artery damage and blood clot formation in blood vessel

Shown to be brought down by folic acid and b12 but these supplements don’t aid in prevention of cardiovascular events

PAD Clinical Manifestations

Intermittent claudication

Rest pain

Skin changes

Rubor/Pallor

↓ peripheral pulses

↓ sensation

Ulcers

Intermittent Claudification

Brought on by exercise like stable angina. Painful cramping is always below where ever the blockage is.

The 1st sign of PAD

Rest Pain

Worsening = burning

Rubor

When dangling/sitting

Ulcers

Round, punched out, dry small and deep

The 1st sign of PAD in older adults as they are inactive usually

Nursing Diagnoses in PAD

Chronic pain

Risk for infection

Impaired skin/tissue integrity

Ineffective tissue perfusion (peripheral) — #1

Deficient knowledge

Stage 1 PAD

Reduced pulses

Stage 2 PAD

Intermittent Claudication

Stage 3 PAD

Pain even when resting

Stage 4 PAD

Ulcers

Peripheral Arterial Disease Nursing Interventions

Maintain vascular status

Pain management

Promote blood flow

Prevent injury/infection

Lifestyle changes

Administer medications

Provide peri-operative care

No leg crossing

Temperature and Peripheral Artery Disease

Avoid heating or ice packs

Avoid hot tubs and sunburns on legs

Excess heat increases the metabolic rate and the need for O2 beyond what the diseased narrow arteries can supply

Heat pack on abdomen- causes reflex vasodilation in the extremities, which is good

Peripheral Arterial Disease Surgeries

Endovascular management: angioplasty, atherectomy, stent, stent graft

Bypass graft

Amputation (BKA, AKA)- last resort

Angioplasty

Insert balloon-tipped catheter into narrowed artery, pressing plaque against artery wall, widening artery

Atherectomy

Specialized catheter to physically remove plaque buildup from artery wall

Stenting

Small mesh tube inserted into artery after angioplasty to keep artery open

Stent graft placement

Graft tube used in larger arteries or aneurysmal sites to reinforce artery wall, more durability than stent

Drug Eluting Stent

Prevents clots and reduces the risk of restenosis

BKA

Below Knee Amputation

AKA

Above Knee Amputation

Diabetics and amputations

5 to 10 times higher likelihood than those without

Phantom Limb Pain

Tingling, burning, numbness, itching

Phantom Pain Pharmacology

Use gabapentin, ketamine, beta blockers

Mirror Use

To trick the brain for phantom pain

Contracture

Place in prone position to fix

COCA

Color, odor, characteristics, approximate

REDA

Red, Edema, Drainage, Approximate

Toughening the residual limb

Done to prepare for prothesis

Figure 8 Wrap

Minimizes swelling

Post-Op Nursing Interventions (PAD)

Assess vital signs

Assess vascular status

Administer anticoagulants

Provide post amputation care

Provide for rehabilitation

Post Amputation Care

Control edema with soft or rigid compression dressing (cast/ shrinker)/ace wrap)

Proper positioning to prevent hip or knee joint contracture

Elevate first 24-48 hrs only- to prevent to prevent edema

Exercise to prevent flexion contracture

Amputation Post Op Care

Unwrap dressing and check incision every shift

Manage pain

Enhance body image

Promote independent self-care

Manage complications

Discharge planning

Rehab- prosthetic care

Amputation Complications

Hemorrhage

Infection

Skin breakdown

Phantom pain

Joint contracture

Deep Vein Thrombosis, Pulmonary Embolism

Pneumonia, urinary stasis, constipation

Anorexia

Joint Contracture

Caused by positioning and a protective flexion withdrawal pattern associated with pain and muscle imbalance

Arterial Embolism/Thrombosis Contributing Factors

Peripheral Arterial Disease

Atrial Fibrilation

Myocardial Infarction

Congestive Heart Failure

Iatrogenic injury

Trauma

Fracture

Birth Control

Iatrogenic Injuries

Can occur during insertion of invasive catheters such as those used for arteriography, PTA or stent placement, or an intra-aortic balloon pump, or it may occur as a result of illicit IV drug use

Arterial Embolism/Thrombosis Clinical Manifestations

Acute, severe pain

The 6 P’s:

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia

Arterial Embolism/Thrombosis Management

Surgery

Anticoagulant

Thrombolytic Therapy

Thrombophlebitis Contributing Factors

Virchow’s Triad

• Endothelial damage (damaged blood vessel)

• Venous stasis

• Altered coagulation (hypercoagulability)

Endothelial Damage (Virchow’s Triad)

Creates a site for clot formation. Direct trauma to the veins may occur with fractures or dislocation, diseases of the veins, and chemical irritation of the vein from IV medications or solutions

Venous Stasis (Virchow’s Triad)

When blood flow is reduced, as in heart failure or shock; when veins are dilated, as an effect of some medication therapies; and when skeletal muscle contraction is reduced, as in immobility, paralysis of the extremities, or anesthesia

Like in a plane ride

Altered Coagulation (Hypercoagulability- Virchow’s Triad)

Altered coagulation occurs most commonly in patients for whom anticoagulant medications have been abruptly withdrawn. Oral contraceptive use, elevated CRP levels, and several blood dyscrasias (abnormalities) also can lead to hypercoagulability, with prevalence depending on the ethnicity of the patient

Factor V Leiden and Prothrombin G20210A Mutation

Most prevalent in White persons

Antithrombin III, Protein C, Protein S Deficiency

Most prevalent in Southeast Asian descent

Increase Factor VIII Concentrations

More common among African Americans

Pregnancy and Coagulation

Considered a hypercoagulative state due to increased circulating clotting factors

Superficial Thrombophlebitis Clinical Manifestations

Erythema/redness

Tenderness/pain

Warmth of affected limb

Deep Vein Thrombophlebitis Clinical Manifestations

(These travel to the lung, no issue with pulses)

Edema/swelling

Superficial veins may appear large

Erythema/redness

Tenderness/pain

Warmth of affected limb

Signs/Symptoms of pulmonary embolism may be the first sign indicating DVT

Homans’ Sign

No longer considered valuable in detecting DVT; can be elicited in any painful condition of the leg

To elicit: support the thigh with one hand first, then bend leg slightly at the knee, finally dorsiflex the ankle. This results in deep calf pain which = positive sign

DVT Nursing Assessment

H & P- includes:

Risk factors- Contributing factors

Assess vital signs

Auscultate lungs

Measure circumference of extremities

Assess for Clinical manifestations of PE

Obtain ABG

Perform EKG

Collect specimen for lab

Pulmonary Embolism Clinical Manifestations

Sudden onset of dyspnea

Pleuritic chest pain

Tachypnea- most frequent sign

Other signs: tachycardia, anxiety/apprehension, cough, hemoptysis, fever, diaphoresis, syncope

DVT Diagnostic Test

Duplex Ultrasound

Venography

D-dimer

Multidetector Computed Tomography Angiography MDCTA

A spiral CT scanner and rapid intravenous (IV) infusion of contrast agent are used to image very thin sections of the target area, and the results are configured in three dimensions so that the image can be rotated and viewed from multiple angles. The

MDCTA Precaution

Patients with impaired renal function scheduled for MDCT may require preprocedural treatment to prevent contrast-induced nephropathy. This may include oral or IV hydration 6 to 12 hours pre-procedure or administration of sodium bicarbonate, which alkalinizes urine and protects against free radical damage.

Pulmonary Embolism Diagnostic Test

VQ Scan- use radioactive components

Check BUN and Creatinine

DVT Nursing Diagnoses

Ineffective tissue perfusion (peripheral/cardio-pulmonary)

Pain

Risk for peripheral neurovascular dysfunction

Risk for infection

Anxiety

Deficient knowledge

Deep Vein Thrombosis Nursing Interventions

Administer: anticoagulant/thrombolytic medications

Maintain IV therapy

Elevate extremity

Maintain bed rest until anticoagulant therapy is initiated (and therapeutic levels are achieved)

Provide compression stockings - Sequential Compression Device (NOT on affected legs)

Active and passive ROM

Encourage deep breathing

Administer O2 therapy

Provide warm, moist heat

Provide emotional support

Provide patient teaching

Sequential Compression Device

Aka intermittent pneumatic compression devices can be used in conjunction with elastic bandages or graduated compression stockings to support venous circulation and prevent DVT.

Compression devices consist of an electric controller that is attached by air hoses to either knee-high or thigh-high sleeves.

For:  patients who are not physically able to apply compression bandages or wraps, or don a pair of stockings

Nursing measures in caring for patients who use these devices include ensuring that sleeves are properly encircling the extremity and the prescribed pressures are set and not exceeded, assessing for patient comfort, and ensuring adherence to therapy.

DVT Pharmacologic Interventions

Administer Thrombolytic Therapy

Administer Anticoagulants

Administer Antibiotics

Administer Anti-inflammatory agents

Anticoagulation Therapy

Heparin SQ- prevent development of DVT (5000u SQ q12h or q8hrs)

Heparin intermittent or continuous IV infusion for 5-7 days to prevent the extension of thrombus and development of new thrombi

Monitor aPTT- partial thromboplastin time

Antidote- Protamine Sulfate

Heparin IV Nursing Interventions

Always use IV pump

Do not interrupt infusion

Do not alter rate without order

Do not piggyback into infusion

Follow hospital protocols for monitoring PTT and titrating IV infusion (therapeutic range- 2 - 2.5x baseline values.)

Coumadin- warfarin

Monitor PT/INR- international normalized ratio and platelet count

Antidote- Vitamin K

Started while still on Heparin IV- takes 3-5 days for full coagulation. Therapeutic effect-PT: 1.5 to 2x control

INR- 2.0 - 3.0

Given in the afternoon or pm when lab results can be evaluated

Teaching- diet, bleeding, and lab monitoring (be careful with dark leafy greens- don’t increase)

Low-Molecular Weight Heparin

Enoxaparin (Lovenox)

Dalteparin (Fragmin)

Action: prevents extension of thrombus and formation of new ones

Doses based on weight

Longer half-life than heparin

Less likely to have side effect of bleeding or Heparin-Induced Thrombocytopenia

No need for daily coagulation studies

Safe for pregnant women

Heparin-Induced Thrombocytopenia

Rare but serious condition that occurs when the body's immune system develops antibodies against heparin, a blood-thinning medication. These antibodies can cause a decrease in platelet count (thrombocytopenia) and an increased risk of blood clots (thrombosis)

Nursing Interventions Anticoagulant Therapy

Assess for bleeding

Avoid trauma

Assess for HIT (heparin induced thrombocytopenia)

Provide patient teaching

DVT Surgical Interventions

Thrombectomy

Balloon angioplasty/stent

Ultrasound-assisted thrombolysis

Vena cava filter

Thromboectomy

Mechanical method of clot removal that may involve using intraluminal catheters with a balloon or other devices. Some devices spin to break the clot, while others use oscillation to facilitate removal