Assessment and Management of Patients with Vascular Disorders

Vascular System Anatomy and Function

• Constituents: Arteries, arterioles, capillaries, venules, veins, and lymphatic vessels.

• Hemodynamic Factors: Blood flow and pressure are influenced by tissue needs, vessel radius, vessel length, and blood viscosity.

• Pathophysiology: Characterized by reduced blood flow through peripheral vessels due to pump failure, vessel alterations, or circulatory insufficiency.

Assessment and Diagnostic Evaluation

• Physical Assessment: Inspect skin color and palpate pulses including Popliteal, Posterior tibial, and Dorsalis pedis.

• Ankle-Brachial Index (ABI): The ratio of systolic blood pressure in the ankle to the arm.

  • Normal: $1.00$ to $1.40$

  • Borderline: $0.91$ to $0.99$

  • Abnormal/Arterial Disease: $\le 0.90$

  • Moderate Insufficiency/Claudication: $0.50$ to $0.90$

  • Ischemic Rest Pain: < 0.50

  • Severe Ischemia/Tissue Loss: $\le 0.40$

  • Calcification/Hardened Vessels: Greater than $1.40$

• Diagnostics: Doppler Ultrasound/Duplex Ultrasonography, Exercise Testing (walking response), CT Scanning (cross-sectional images), and Angiography (to confirm occlusive disease).

Comparison of Arterial and Venous Insufficiency

• Arterial Insufficiency:

  • Pain: Intermittent claudication or sharp, constant pain.

  • Pulses: Diminished or absent.

  • Skin Features: Dependent rubor, pallor on elevation, shiny/dry skin, hair loss, and cool temperature.

  • Ulcers: Deep, circular, located on toe tips/web spaces/heels; very painful.

• Venous Insufficiency:

  • Pain: Aching, throbbing, or cramping.

  • Pulses: Present but often difficult to palpate through edema.

  • Skin Features: Pigmentation in gaiter area (malleolus), thickened/tough skin, and reddish-blue color.

  • Ulcers: Superficial with irregular borders, located on the medial or lateral malleolus; moderate to severe edema.

Arterial Disorders and Nursing Management

• Atherosclerosis: Accumulation of lipids/fibrous tissue (atheromas or plaques) in the intimal layer of large/medium arteries.

• Modifiable Risk Factors: Nicotine use, diabetes, hypertension, hyperlipidemia, diet, and stress.

• Acute Arterial Embolism (6 Ps): Pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis.

• Medical Management:

  • Surgical: Inflow (aorta to femoral) and Outflow (below femoral) procedures.

  • Endovascular: Percutaneous transluminal angioplasty (PTA) or atherectomy; complications include embolus and dissection.

• Nursing Interventions:

  • Lower extremities below the heart for arterial supply; elevate for venous congestion.

  • Encourage supervised exercise; avoid crossing legs or constrictive clothing.

  • Provide meticulous hygiene and protective shoes.

Venous Thromboembolism (VTE) and Pulmonary Embolism (PE)

• Virchow Triad: Three factors contributing to VTE: endothelial damage (trauma/surgery), venous stasis (bed rest/obesity/age > 65), and altered coagulation (cancer/pregnancy/oral contraceptives).

• Deep Vein Thrombosis (DVT): Characterized by edema, warmth, and tenderness in the extremity; incidence is $10\%$ to $20\%$ in general medical patients.

• DVT Prevention: Early ambulation, compression stockings, intermittent pneumatic compression devices, and Heparin or low-molecular-weight heparin (LMWH).

• Pulmonary Embolism (PE): Obstruction of the pulmonary artery by a dislodged thrombus.

  • Signs/Symptoms: Dyspnea (most frequent symptom), tachypnea (most frequent sign), sudden pleuritic chest pain, and anxiety.

  • Diagnosis: Chest x-ray, ECG (ST-T abnormalities), D-dimer assay, and MDCTA.

  • Management: Stabilization, long-term anticoagulation, or thrombolytic therapy ($t-PA$) if hemodynamically unstable.

  • Thrombolytic Contraindications: Stroke within $2$ months, active bleeding, surgery within $10$ days, or severe hypertension.