Review of Anatomy and Review of Anatomy and PhysiologyPhysiology

Vascular Segments•Arteries •Veins•Capillaries/ Capillary beds•Lymphatics – network of

endothelial tubes that drains in your vena cava

Blood Vessel StructureBlood Vessel Structuretunica intima – innermost layer –

Endothelial cellstunica media – middle layer – Elastic

Conn tse and Smooth muscle cellstunica adventitia – outermost layer

Functions of the Vascular System Pressure, Flow and Resistance Capillary Exchange

Diffusion – movt of solute from ↑ to ↓ concentration

Filtration – passive movt of fluids from arterial end to interstitial tissues (↑ to ↓ concentration)

Pinocytosis – cell drinking– Osmosis – movt of particles or fluid from (↑ to

↓ concentration) • Oncotic Pressure (albumin)• Hydrostatic Pressure- vessels to cells

PERIPHERAL VASCULAR DISEASES – characterized by disturbances of blood flow through the peripheral vessels. - disturbances usually damage tissues as a result of ischemia, excessive accumulation of waste, and fluids or both.

HISTORY TAKINGHISTORY TAKING

BIOGRAPHICAL and DEMOGRAPHIC DATAAge Occupation

PAST HEALTH HISTORY– Vascular impairment (vasospastic changes in color

and temp of digits)– Hypertension, DM, stroke, transient ischemic attacks,

changes in vision, leg pain during activity, leg cramps, phlebitis, blood clots, pulmonary emboli, edema, varicose veins, leg ulcers or extremities that are cold, pale or blue

– Medications and Herbal medicine– Allergy to iodine

FAMILY HEALTH HISTORYNote any history of DM, hypertension,CAD, collagen diseases, and PVD

PSYCHOSOCIAL HISTORYOccupational history Smoking or use of any tobacco productsDiet Clinical manifestations

CURRENT HEALTHARTERIAL DISORDERS Intermittent claudication - cramping leg pain in the calf

muscles during ambulation that disappears within 1 to 2 minutes of rest.

It result from inadequate tissue perfusion due to arterial stenosis secondary to atherosclerosis.

Intermittent claudication is predictable and reproducible. Rest pain - Distal forefoot burning, numbness or tingling,

pain at rest, pain that awakens them during the night Elevation of the extremities causes pain; standing and

extremities in dependent position can relieve pain Claudication distance – distance the client can walk

without pain Impotence

Risk factors:A – geR – T smokingT – hrombosis/ embolusE – levated lipidsR – T DMI – ncreased BPA – therosclerosisL – ink to family of PVD

VENOUS DISORDERS – has insidious onset

Pain has slow onset; not associated with rest or activity

Exercise and elevation generally relieve discomfort and swelling

Edema may be the initial complaint Skin changes:

erythemalipodermatosclerosis

drying and flakingstatus dermatitis

ulceration

Venous DisordersRISK FACTORS:

Family history for venous disease Job history involving many hours of standing in one place

Multiple pregnancy Obesity

1. Increased pressure in leg veins

2. Vein walls distention

3. Distended walls prevent valve leaflets from meeting each other when they close

4. Incompetent veins

5. Back flow of blood

6. Increased hydrostatic pressure in the venous end of capillary

7. Fluid from intravascular will shift into the interstitial space

8. Edema

9. Blood flow slows

10. Decreased oxygen supply

11. Hypoxia

CLINICAL MANIFESTATIONS OFLOWER EXTREMITY DISORDER

MANIFESTATION ARTERIAL VENOUSPain Intermittent

claudication. Rest pain may be present, or pain may worsen with elevation

Aching, heavinessExercise and

elevation decrease pain

Nocturnal crampingHeaviness in the legs

at the end of the day

Skin Absence of hair in chronic condition. Thin and shiny. Thick toenails (fungal infxn)

Brown discoloration. Normal toenails

Color Pale with dependent rubor

Brown discoloration. Dependent cyanosis

Temperature Cool No change or may be warmer than unaffected area

Sensation Decreased; tingling, numbness may be present

Pruritus may be present

Pulses Decreased to absent Present, but may be difficult to palpate because of edema

Edema May be present but usually absent

Present, worse at end of day, improved with elevation

Muscle mass Reduced in chronic disease

Unaffected

Ulcers Small, painful ulcers on pressure points, points of trauma, between toes, or distal most point, especially lateral malleolus and toes

Broad, shallow, slightly painful ulcers of the ankle and lower leg. Surrounding skin is brown and fibrotic.

CLINICAL MANIFESTATIONS OF LOWER EXTREMITY DISORDER

MANIFESTATION ARTERIAL VENOUS

ARTERIAL LEG DISORDER

PHYSICAL EXAMINATION

Inspection, palpation, auscultation

Nursing Responsibilities:

Prepare the environmentProvide natural lighting Warm the environmentProvide a quiet environment

INSPECTION SKIN HAIR DISTRIBUTION CAPILLARY REFILL

– Blanch Test MUSCLE ATROPHY EDEMA

– grade 0= no edema; 1= barely detectable; 2= <5mm; 3= 5 to 10 mm; 4= >1cm

VENOUS PATTERN ULCERS ELEVATION PALLOR – arterial insufficiency; perform

only when needed; note the degree of pallor at rest TRENDELENBURG’S TEST – help detect abnormal

venous filling time; reveals valvular incompetence of the deep veins

TRENDELENBURG TEST

PALPATION TEMPERATURE PULSES • ALLEN’S TEST HOMAN’S

SIGN

AUSCULTATION Limb BP Bruit

DIAGNOSTIC PROCEDURESNON-INVASIVEI. DOPPLER ULTRASONOGRAPHY – permit assessment of

arterial diseases through: 1) Evaluation of audible arterial signals; 2) Limb BP measurement

II. ANKLE – BRACHIAL INDEX – commonly used parameter for overall evaluation of extremity status

ABI = higher systolic ankle pressure higher systolic brachial pressure

- 1 or more – normal; 0.5 to 0.8 – claudication, <0.4 – rest pain

III. ULTRASONIC DUPLEX SCANNING – are used to 1) localize vascular obstruction; 2) evaluate the degree of stenosis; 3) determine the presence or absence of vascular refluxMost sensitive and specific non-invasive modality for detecting DVT

IV. AIR PLETHYSMOGRAPHY - measure volume changes in the legs; venous volume, ejection fraction and residual volume fractions are also measured

V. IMPEDANCE PLETHYSMOGRAPHY – used to measure venous blood volume changes in the extremities

VI. EXERCISE TESTING – provides an objective measurement of the severity of intermittent claudication.

NI: PRE-PROCEDURE• Inform client about the purpose and risks of exercise testing.

Informed consent.• Instruct client not to eat or smoke 2 to 3 hours before the

test and dress appropriately for exercise.• No strenuous activities should be made at least 12 hours

before the test• Obtain a resting ECG• Prepare skin for electrode placement

PROCEDURE:• Obtain baseline VS and ECG strip

• Observe ECG monitor constantly for changes• Monitor the client for chest pain, dysrhythmias, ST segment

changes, unexpected changes in BP and other cardiac manifestations.

VII. COMPUTED TOMOGRAPHY – provides a cross-section of vessel walls and other structures.

VIII. MAGNETIC RESONANCE IMAGING – tissue changes, tumors, aneurysm, and DVT

VIII. MAGNETIC RESONANCE ANGIOGRAPHY – uses magnetic imaging techniques to access blood vessels (3-dimensional-angiogram.-images are not obscured by bone, bowel, gas, fat or vascular calcification

Magnetic Resonance AngiographyMagnetic Resonance Angiography

INVASIVEANGIOGRAPHY – most invasive of the diagnostic procedures for arterial

disorders and poses the greatest risk for the client- Injecting contrast agent to arterial system and performing

radiographic studies.Preprocedure:Explain procedureNPO 2-6 hours before procedure

Postprocedure:V/S, NVS, Distal pulse checksAssess puncture site for hematomaBed rest 6-8 hrs. with extremity kept in straight alignment if transfemoral

approach Continous IV hydratio 6-8 hrs. to assist contrast excretionBUN and Crea levels monitored the next day

Watch out for Pseudoaneurysm (significant complication) - blood leaking outside the vessel wall but within a contained area adjacent

to artery.- Provide site for infection, source of emboli, cause intravascular thrombosis

II. VENOGRAPHY – performed in a manner similar to angiography, used to examine the venous system; ca detect DVT and other abnormalities (incompetent valves)

PROCEDURE: 1. Ascending – to record valvular patency2. Descending – to determine valve reflux and competence

PREPROCEDURE: 1. Document the presence and quality of peripheral pulses2. Clear liquids for 3 to 4 hours before the procedure to maintain hydrationPOSTPROCEDURE: 1. Place a pressure dressing on the injection site 2. Bed rest for 2 hours if the femoral vein was punctured3. Monitor pulses for the next 4 to 6 hours4. Continue IV fluids for 8 to 24 hours5. Assess fluid balance

III. VASCULAR ENDOSCOPY (ANGIOSCOPY) –permits imaging of intra-arterial disease with the use of fiberoptic technology. Images are in color and in three dimensions.

Flexible fiberoptic angioscope, light source, irrigation system, camera, video recorder and monitor

Allows internal visualization of vessel lumen; can identify thrombus & plaque,

Post procedure care same as angiography

IV.INTRAVASCULAR UTZ – provides information about the atherosclerotic intima beneath the luminal surface. It can determine the thickness of the arterial wall and can distinguish thrombus and calcium from vascular tissues

END of PRESENTATION!