Disorders In Tissue Perfusion

Disorders Of The Peripheral Vascular System

Liz Mathewson

Summary• normal A&P of peripheral vasc. system

• risk factors and causes

• prevention and health teaching

• assessments

• nsg. diagnosis

• medical/surgical/pharmatherapeutic

• nursing measures

Categories of Disorders

• Obstruction: thrombus, embolus, lymphedema

• Inflammation: phlebitis, thrombophlebitis

• Degeneration: arteriosclerosis, atherosclerosis, aneurysm, varicose veins, stasis ulcer

• Unknown causes: Buerger’s disease, Raynauds Disease

Pharmacology

Classifications:

• anticoagulants (and their reversal agents)

• antilipidemics (antihyperlipidemic)

• platelet inhibitors

• thrombolytics

• peripheral vasodilators

Obstructive Disease

• Can affect both venous and arterial circulation as well as lymph system

To the Brain

To the stomachTo the liver

To the Kidneys

Iliac Artery

Femoral Artery

Arterial Obstructive Disease

• (degenerative condition leading to obstructive condition)

• Arteriosclerosis: “hardening of the arteries”– muscle fibers and the endothelial lining of the

walls of small arteries and arterioles become thickened

Obstructive Arterial Disease

Atherosclerosis: affects the intima of the large and medium-sized arteries– caused by an accumulation of lipids, calcium,

blood components, carbohydrates, and fibrous tissue on the intima layer = plaque

Direct effects:

Indirect effects:

Atherosclerosis

• Risk factors:– diet - age– high blood pressure - gender– diabetes - family hx– stress– sedentary lifestyle– smoking

Assessment• Health history and clinical manifestations• Pain (where)• Skin appearance and temperature

– Rubor

– cyanosis

– brittle nails,

– dry scaling skin, atrophy, decrease hair growth, ulceration

Signs and Symptoms

• Occur when vessel is 60% occluded

• Early include pain, changed appearance, or changed sensation

• Pain or “intermittent claudication”

• Pain on exertion or pain at rest?

• Chronic = collateral circulation

Assessment

• Pulses– present or absent, volume, quality, symmetry

“pedal pulses present bilaterally”– Posterior tibial; dorsalis pedis; popliteal;

Assessment

• Mental status

• Edema (Pitting or non-pitting)

• Risk factors:– controllable (modifiable)– not controllable (non-modifiable)

Arterial Assessment Tools• Doppler U/S flow Studies

• Ankle blood pressures

• Exersize tests

• CT

• CT Angiography

• MRI

• Angiography

Progression of Disease

• Decreased oxygen leads to ischemia

• Ischemia leads to infarction

• Infarction leads to necrosis

• Ischemia Infarction Necrosis

Arterial ulcers

Ischemia Infarction Necrosis

Venous Ulcers (characteristics)

Nsg. Diagnosis

• Alteration in peripheral tissue perfusion related to compromised circulation

• Pain related to impaired ability of peripheral vessels to supply tissues with oxygen

• Risk for impaired skin integrity related to compromised circulation

• Knowledge deficit regarding self-care activities

Nursing Diagnosis

• Alteration in peripheral tissue perfusion related to compromised circulation

– Goal: Increase arterial blood supply to extremities

Medical Management

• Medical: modification of risk factors; a controlled exercise program to increase circulation; and medication

Surgical Management

• Surgical: Inflow procedures and outflow procedures– Bypass (artificial graft/insitu graft)– Endarterectomy

Grafts

Endarterectomy

Post-op Care• Maintaining circulation – how?

• Assessment: pulses, colour, temperature, capillary refill, sensory and motor functions

• use doppler (at PRCH, use doppler on Dr.Thompson pts.)

• Complications: decreased urinary output, CVP, mental status, pulse rate and volume = fluid imbalance

Post-op Care

• Bleeding, hematoma

• Edema

• Infection

• Discharge planning

Upper extremity Obstruction

• Arm fatigue and pain with exercise and inability to hold or grasp objects.

• Avoid venopuncture, injury, using tape, taking BP, protect from cold. Assess frequently

• May need bypass

Arterial Embolism

• Usually originate in the chamber of the heart as a result of atrial fibrillation, or CHF, infective endocarditis or MI.

• Carried to left side of heart and into arterial system

• May be caused by catheters, stents, intra-aortic balloon pump.

• Trauma, crush injury, penetrating wound

Signs and Symptoms

• 6 “P”s– pain– pallor– pulselessness– paresthesia– paralysis– poikothermia

X

Treatment

• FAST to prevent tissue infarction

• heparin

• surgery (embolectomy)

• ? Thrombolytic therapy if no contraindications

Venous Obstruction

• Venous Thrombosis

• Deep Vein Thrombosis

• Thrombophlebitis

• Phlebothrombosis

• * not identical disease processes but for clinical purposes used interchangeably

Pathophysiology

Stasis of Blood

Vessel Wall InjuryAltered Blood Coagulation

Virchow’s Triad

Venous Stasis

• Reduced Blood Flow due to :– heart failure or shock– dilated veins due to medications– decreased skeletal muscle contractions due to

paralysis, anesthesia, and bed rest

Vessel Wall Injury

• Damage to the Intima Due to:– direct trauma (fractures, dislocations)– diseases of the veins, (infection/inflammation)– chemical irritation (IV meds and solutions

Increased blood coaguability

• Due to:– abrupt withdrawal of anticoagulants– oral contraceptives– blood dyscrasias (abnormalities)

Clinical ManifestationsOften Non-Specific:

• inflammation or redness along a superficial vein

• limb pain, feeling of heaviness

• functional impairment

• ankle engorgement, edema

• unilateral increase in leg circumference

• increased warmth to touch of leg/foot

• tenderness to touch, rosy colour

Thrombus to Embolus

• Platelets attach to vein wall with a tail-like appendage containing fibrin, RBC, WBC

• grows in direction of blood flow

• elevation in venous pressure (sudden movement, increased muscle movement) cause fragment to break off and travel

Deep Vein Thrombosis

• Sign and symptoms are non specific, sometimes PE is the first sign

• deep veins have thinner walls and less muscle mass in the media than superficial veins

• run parallel to arteries and have the names

• have valves as do the superficial veins

Deep Vein Obstruction

• Creates swelling and edema in extremity because the outflow of venous blood is inhibited

• limb may be warm and superficial veins appear more prominent

• tenderness

• Howman’s sign

Superficial thrombosis

• Pain or tenderness, redness and warmth in involved area

• embolus rare as these thrombi usually dissolve spontaneously

• treated with bed rest at home, elevation of leg, analgesics, and sometimes anti inflammatory

Medical Management for DVT

• Medication

• Surgery: only if anticoagulant or thrombolytic therapy is contraindicated, the danger of PE is extreme, and the venous drainage is so severely compromised that permanent damage to the extremity will result.

Nursing Interventions

• Assessing and monitoring meds

• observing for complications

• providing comfort

• applying elastic stockings

• positioning pt and encouraging exercise

Venous Ulcers (characteristics)

Anticoagulants

• Heparin: two types– fractionated, low-molecular - weight heparin– fractionated heparin is given IV 5 to 7 days and

coumadin (orally) started concurrently– sometimes given prophylactically SC– regulated by monitoring the partial

thromboplastin time, the INR, and the platelet count

Heparin

• LMWH, more $

• SC

• longer 1/2 life

• does are adjusted by wt, does not bind with plasma proteins

• fewer bleeding complications

• can be given to pregnant women

Heparin

Nursing responsibilities:

• monitor blood work

• observe for bleeding

• to reverse heparin = protamine sulfate

• to reverse warfarin = vit K

• drug interactions

Thrombolytic Agents

• i.e. Streptokinase

• lyses thrombi and emboli

• observe for bleeding

• contraindicated: recent bleed, trauma,

Lymphedema

• Primary or secondary

• results from an obstruction of lymph vessels and an accumulation of lymph

• noticed in dependent position

• starts of as soft, pitting and treatable

• progresses to firm, non pitting and does not respond to treatment

Lymphedema

• Obstruction may be in the node or vessel• often seen in the arm following a mastectomy• treatment may include bedrest, elevation,

active and passive exercise, custom fitted stockings

• Pharm: diuretic, antibiotics, • Surgery: excision of tissue and fascia

Venous insufficiency

• Chronic venous insufficiency:• results from venous valve obstruction and a

result of venous hypertension• wall of the vein become distended resulting

in reflux• post thrombotic syndrome• edema altered pigmentation, pain and stasis

dermatitis

Leg ulcers

• 75% of leg ulcers from CVI

• inflamed necrotic tissue sloughs off

• arterial insufficiency ulcers account for approx.. 20% the remaining 5% from SSE, burns and other factors

Arterial Ulcers

• Small circular, deep ulcerations on the tips of toes or in the web spaces between toes

• medial side of hallux or lateral 5th toe

• may result in gangrene of toe

• gangrene usually left alone

Venous Ulcers

• Ulcers are usually in the area of the medial or lateral malleolus and are large, superficial, and highly exudative.

• See pictures on pg 710 of Brunner

Nursing Diagnosis

• Impairment of skin integrity related to vascular insufficiency

• Impaired physical mobility related to activity restrictions of he therapeutic regimen and plan

• Altered nutrition, less than body requirements, related to increased need for nutrients that promote wound healing

Goals

• Demonstrates restored skin integrity

• Increases physical mobility

• Attains adequate nutrition

• How????

Patient Teaching

• venus ulceration from CVI

• antigravity activities

• elevate legs during the day

• sleep with foot of bed elevated

• no prolonged standing

• no cross legs, no trauma

• foot care, stockings

Varicose veins

• Abnormally dilated, tortuous superficial veins caused by incompetent venous valves

• predisposing factors– hereditary– occupation/lifestyle– gender (female)

May be primary or secondary

Varicose Veins

• May result in chronic venous insufficiency: edema, pain, pigmentation and ulceration

• susceptibility to injury and infection is increased

• treatment: surgical, sclerotherapy, stockings

Degeneration of the Vascular System

Aneurysm• A localized sac or dilation involving an

artery formed at a weak point in a vessel wall

• classified by its shape or form

• most common saccular or fusiform

• saccular projects from one side of the vessel only

• fusiform is when entire arterial segment dilates

Aneurysm

• Small aneurysm caused by localized infection is called mycotic aneurysms

• most common is the abdominal aortic (AAA)

• serious because they can rupture leading to hemorrhage and death

Thoracic Aneurysm

• Most common site for a dissecting aneurysm

• common in men between age 40-70

• 1/3 of pts with thoracic aneurysms die from rupture

Signs and symptoms

• Depends on how rapid the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures.

• Usually pain is the prominent symptom

• shortness of breath, dysphasia, loss of voice

• hoarseness, stridor

• dx by chest xray, ct, mri

S & S of AAA• Common in whites, 4:1 men to women

• most occur below the renal arteries

• c/o “heart beating in stomach”

• abd mass

• “blue toe” syndrome as a result of embolus

• 80% can be palpated

• impending rupture include sever pain

• 50 to 75% mortality rate for ruptured AAA

AAA

• surgical repair

• put in a graft

• may be bifurcated

• better if it is below renal arteries

Dissecting Aorta

• A tear develops in the intima or the media degenerates, resulting in dissection

• onset sudden, severe persistent pain, tearing feeling, pain in shoulders, chest, epigastric or abd.

Raynauds Disease

Buerger’s Disease