Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of peripheral vascular disease
- Identify the common laboratory and diagnostic tests for peripheral vascular disorders
- Describe the clinical manifestations and nursing care for venous insufficiency
- Describe the clinical manifestation and nursing care for arterial insufficiency
- Evaluate the efficacy of nursing care for the patient with peripheral vascular disease
- Discuss the medical therapies that apply to the care of peripheral vascular disease
Peripheral vasculature is the vasculature extending beyond the heart. It includes the arteries, arterioles, capillaries, venules, and veins (Figure 12.29). Understanding this anatomy and physiology is important to the understanding of peripheral vascular disease.
Arterioles direct blood flow to organs. They respond to systemic vascular resistance through dilation and constriction in response to the autonomic nervous system. Capillaries are very thin, fragile, single endothelial layered vessels that are the conduit between arterioles and venules. One example of capillary sites is fingers and toes. Venules connect from the capillaries to the veins, which assist in the return of deoxygenated blood to the heart (Tucker et al., 2023).
Pathophysiology
A chronic, progressive disorder, peripheral vascular disease (PVD) causes blood vessels outside of the heart and brain to narrow, block, or spasm; it affects both venous and arterial circulation. Chronic venous insufficiency, or peripheral venous disease, is compromised blood flow of the venous system, and peripheral arterial disease is compromised blood flow of the arterial system (Figure 12.30). Peripheral venous disease is more common in females and those who are older and have obesity (Rabe et al., 2020). While veins are supposed to return blood flow to the heart for re-oxygenation, noncompliant veins confront a flow issue and valvular incompetence causes backward reflux into the vasculature of the legs (Weiss, 2020).
Reduced blood flow from atherosclerotic blockages is known as peripheral arterial disease. When arterial blood is obstructed by narrowed, constricted vessels (Figure 12.31, the legs encounter a perfusion defect, and the patient may experience pain during ambulation, which is known as intermittent claudication. Peripheral arterial disease afflicts over 230 million people, who are older, smoke, and have other comorbidities of heart disease and diabetes (Aday & Matsushita, 2021). Both males and females over age 60 are affected equally by peripheral arterial disease (CDC, 2022). In patients with diagnosed coronary artery disease, aortic disease, or carotid artery disease, there is a high likelihood of peripheral arterial disease.
Diagnostics and Laboratory Values
A patient with suspected peripheral vascular disease will first undergo noninvasive imaging with an ultrasound to visualize flow in the vessels. Another noninvasive method utilized is the ankle-brachial index (Figure 12.32), in which blood pressures are evaluated in the legs and arms at rest and after the patient walks on a treadmill on a slight incline. Discrepancies in the blood pressure will suggest a blood flow abnormality that is reproduced with activity. There are also invasive diagnostic tests, such as a peripheral angiogram, that may be performed. Risk stratification in identifying disease prevalence will be supported by elevated lipids (hyperlipidemia) and elevated hemoglobin A1C (diabetes).
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety: Ankle Brachial Index
Disclaimer: Always follow the agency’s policy for medication administration.
Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as workarounds and dangerous abbreviations).
Skill: Use appropriate strategies to reduce reliance on memory (such as forcing functions and checklists). The nurse will:
- Take a baseline blood pressure of the patient’s bilateral arms and legs.
- Have the patient walk for several minutes on a treadmill with a slight incline.
- Take another series of blood pressure measurements.
- Have the patient repeat the treadmill walk at a slightly faster pace and higher incline.
- Document any symptoms of intermittent claudication. In a positive result, the pressures will reduce with incremental increases in the incline and speed of the treadmill, while also noting if the patient reports pain in the legs with activity.
Attitude: Value the contributions of standardization/reliability to safety.
(QSEN Institute, n.d.)
Venous Insufficiency: Clinical Manifestations and Nursing Care
Veins in the lower extremities that struggle to return blood back to the heart for reoxygenation and recirculation likely have incompetent valves causing venous blood to pool. When this occurs, the patient may report cramping and aching in the legs, or pain that worsens with standing and relieved with rest. Edema may be observed, and varicose veins may be evident on assessment (Figure 12.33). The nurse must assess the warmth of the extremity, noting the character of the pulses and the color of the extremity. Note the patient’s hair distribution, the presence of varicose veins, and nail integrity; nail beds may be raised, thick, and discolored. In patients with darker skin tone, assessing for capillary refill in the great toe may assist with identifying a vascular compromise. At times, a venous stasis ulcer may surface along the medial and lateral distal part of the leg (Figure 12.34). These wounds may have a shallow depth and irregular shape with a periwound of brown or yellow and may be painless.
The patient is encouraged to change positions often to avoid prolonged standing. Wearing compression stockings will assist with venous return; if not, the patient may have to rest and elevate their legs on a pillow. Hydration is critical to avoid pooled venous blood from aggregating. The patient may need an interprofessional referral to a wound care or vascular specialist for venous stripping of painful varicose veins. For edema of 3 to 4+, a diuretic may be recommended to assist with removal of excess fluid.
Arterial Insufficiency: Clinical Manifestations and Nursing Care
Decreased perfusion to the limbs due to atherosclerotic changes will create intermittent claudication. On assessment, the affected limb may feel cold to touch, pulses may be weak, and the skin will exhibit color changes such as pallor or decreased capillary refill due to insufficient blood getting to the limbs from arterial insufficiency. Shiny skin and a lack of hair will occur due to poor perfusion to the extremities. Similar to venous insufficiency, arterial ulcers may appear; however, they are centralized to the toes, heels, and ankles and other bony prominences. Arterial ulcers are rounder and more circular than venous ulcers and have minimal to no drainage (Figure 12.35).
Interventions will be focused on educating the patient to limit excess ambulation to avoid intermittent claudication. Patients are encouraged to avoid high-cholesterol foods and stop smoking to prevent further vasoconstriction. Wound care may be ordered to assist with dressings and wound debridement. Chronic pharmacological management will consist of statin therapy to avoid further plaque formation.
Evaluation of Nursing Care of the Patient with Peripheral Vascular Disease
The following goals are examples the nurse may consider when evaluating care:
- The patient will report reduced pain or increased activity to physical limits with ambulation.
- The patient’s wounds will reduce in size and be free of signs and symptoms of infection.
- The patient will participate in an exercise regimen.
- The patient will display reduced edema and report increased comfort.
- The patient will return a demonstration of elevating legs for pain management.
- The patient will demonstrate compliance with a healthy lifestyle and adherence to the medication regimen.
Depending on disease severity, goals may require adjustment to reflect the status of peripheral vascular disease. Ultimately, independence, physical capabilities and comfort will guide goal creation for the patient.
Medical Therapies and Related Care
Medical therapies include pharmaceuticals, including statins and antiplatelet/anticoagulation agents, hypertension management if present, diabetes management if present, exercise, and smoking cessation as necessary. More severe cases of arterial insufficiency may require surgical intervention such as angiography, endovascular repair, or arterial bypass (Figure 12.36).