A nurse is providing instructions about foot care for a client who has peripheral arterial disease

Peripheral vascular disease (PVD) nursing review that covers peripheral arterial disease (PAD) and peripheral venous disease.

As a nursing student or nurse, you must be familiar with peripheral vascular disease. This review will give you an easy to remember mnemonic to help you remember the differences between arterial and venous disease, nursing interventions, and treatment.

Peripheral Vascular Disease Lecture

• It can occur due to peripheral artery or venous vessel damage. In other words, the peripheral arterial or venous system can be affected (sometimes both).
• Peripheral vascular disease mainly affects the blood flow to the lower extremities.
• The peripheral vascular system is the circulation to the feet, hands, arms, and legs. Therefore, we’re talking about the impediment of the blood flow of the vessels that are not within the heart and brain.

An important concept to remember is that although PVD can affect the arterial or venous system, the signs and symptoms the patient will experience will vary depending on if it’s an arterial or venous problem (know the differences between arterial and venous for exams…example: signs and symptoms).

Review of the Peripheral Arterial and Venous System

• Arterial circulation carries oxygenated blood that flows to the extremities. This blood comes from the heart. When you feel the pulses in the upper or lower extremities you can feel the impact of how the heart is contracting to pump this arterial blood (NOTE: patients with arterial disease can have diminished or absent pulses compared to patients with venous disease). If arterial circulation is compromised to the extremities it leads to ischemia. The extremities won’t receive arterial blood so they start to feel cool, pale, painful, and can eventually die.
• Venous circulation carries deoxygenated blood from the extremities back to the heart so it can get replenished with oxygen. In order for the blood to go back to the heart it must be squeezed back to the heart with the assistance of the valves in the veins. If the vein or the valves within the veins are unhealthy, blood will not be able to drain back to the heart successfully. Therefore, venous congestion occurs in the lower extremities. This will alter tissue nutrition because there isn’t the clearance of cellular waste, development of clots from where the blood is pooling, and skin infections/venous stasis ulcer formation.

Risk Factors for Peripheral Vascular Disease

Peripheral Artery disease (PAD):

PAD occurs with conditions that cause vasoconstriction or damage to the peripheral arteries.

• Smoking
• High cholesterol (obesity)
• Diabetes
• Uncontrolled hypertension

Peripheral Venous Disease:

Peripheral venous disease occurs in conditions that cause peripheral venous congestion. This will increase venous pressure that will damage the veins or valves.

• Being female (history of using birth control pills)
• Pregnancy
• Obesity
• Sitting or standing for long periods
• Advanced age

So let’s look at the two types of peripheral vascular disease:

Peripheral arterial disease (PAD): is the narrowing or occlusion of peripheral arteries that mainly affects the lower extremities (the lower legs) but it can affect any area of the arterial peripheral system.

Result: Leads to a decrease in rich oxygenated blood being delivered to extremity. This leads to ischemia and damages the skin tissue (remember tissue needs oxygen to survive and the shortage of oxygen won’t meet the tissue’s demands so it starts to die and ulcers develop).

Main cause: atherosclerosis: plaques of fat adhere to the arterial vessel wall. This damages and narrows the vessel and impedes arterial blood flow. The risk factors for atherosclerosis are uncontrolled high blood pressure, smoking, or high lipid levels in the blood.

• These plaques can rupture and cause clot formation (which will lead to more compromised blood flow) or the clot can break off and become an emboli.

Other causes/types of PAD:

• Raynaud’s Disease: vasospasm of peripheral arteries mainly to the fingers and toes.
  • This vasospasm occurs when there is exposure to cold or during stressful events.
  • The fingers or toes (it can also affect the ears or nose) start to feel numb or tingle and turn white or bluish. Then when the cold or stress is removed they turn a red color with a prickling sensation.
• Buerger’s Disease: can occur in the arteries and veins
  • It occurs with heavy tobacco usage, like smoking.
  • This results from inflammation of the vessels and clots formation (mainly in the hands and feet).

Goal of treatment is to improve blood flow.

Peripheral venous disease: the veins are insufficient to push blood back to the heart because they are either too damaged (the veins are overstretched), vein valves are damaged (varicose veins), or there is a clot (DVT or superficial venous thrombophlebitis) impeding blood from flowing back to the heart.

Result: This causes pooling of blood in the veins (it becomes static and congested in the extremity) because it’s not draining back to the heart. This leads to edema/swelling, which will lead to the alteration in tissue nutrition (development of stasis ulcers) and breakdown of the skin (leading to cellulitis: bacterial infection of the skin that can spread to the bloodstream if not treated). In addition, because the blood is pooling in the extremities, clots can form.

Goal is to help blood move forward to the heart (not be static in the extremities).

Types/Causes of Venous Disorders:

• Varicose veins: vein walls and valves are weak and dilated
  • This will appear like rope-like veins in the legs. Treatment is compression and procedures to help the affected veins.
• Deep vein thrombosis: clot form in the DEEP veins.
  • This is dangerous because the clot can break off and go to the lungs.
  • Signs and symptoms: the site will be red, painful, swollen, warm, patient may report cramping or pain in the extremity.
  • An ultrasound is used to detect the clot.
• Chronic venous insufficiency: veins are overstretched and valves are damaged.

Arterial Disease vs. Venous Disease (Signs and Symptoms)

6 Things to Assess and Ask the Patient to determine if it’s Arterial or Venous?

Remember: “Vessel”

• Various positions that help alleviate discomfort/pain
• Explanation of the pain (when it happens, characteristics of the pain)
• Skin (color, temperature, nails)
• Strength of Pulse
• Edema
• Lesions (ulcers and their location and appearance)

Various positions help alleviate the pain…

Arterial:

• Dangling the legs down (dependent position) helps with the pain

Venous:

• Elevation of the legs decreases swelling and helps with blood flow
  • Dangling legs or standing/sitting for long periods makes the pain and edema worst

Explanation of the pain?

Arterial:

• Sharp (worst at night)
• “Rest Pain”: the patient wakes up from sleep with pain (when the legs are in the horizontal position it impedes blood flow), and the patient will dangle the extremity off the bed to alleviate the pain.
• Intermittent Claudication: activity (running, walking etc.) causes severe pain in the calf muscles, thighs, buttocks etc. However, when activity is stopped the pain eases up.
  • Why? The muscle is being deprived of blood flow during activity due to the peripheral arterial disease so it causes pain.

Venous:

• Heavy, dull, throbbing, achy
• Pain is worst when standing or sitting for long periods.
• Elevating legs eases the pain and swelling.

Skin of lower extremity (color, temperature)?

Arterial:

• Cool to the touch
• Thin, dry/scaly skin
• Hairless
• Thick toenails

“Dr. EP”

• Dangle legs =  turns Rubor
• Elevate legs = turns Pale

Venous:

• Warm to the touch
• Thick, tough skin
• Brownish colored

Strength of Pulse in Lower Extremity?

Arterial: Very poor or even absent! Remember this occurs due to a decrease of blood flow going TO the extremities…so pulses will definitely be poor.

Venous: Present, typically normal. Remember there isn’t an issue will blood getting to the extremity BUT leaving it.

Edema Present?

Arterial: NOT common

Venous: Yes, it tends to be worst at the end of the day.

Lesions (location and appearance?)

Arterial:

Location: end of toes, top of feet (dorsum), lateral ankle region (lateral malleolus)

Ulcer’s Appearance?

• Very little drainage
• Little tissue granulation (pale/very light pink) OR necrotic/black
• Deep “punched out” w/ noticeable margins/edges that gives it a round appearance

Click Here to see -> Arterial Ulcer…note the punched out appearance, how it is located on the lateral malleolus, it has little drainage, and the wound base is very pale (in addition, the surrounding skin is very scaly/dry).

Venous:

Location: medial parts of lower legs & medial (malleolus) ankle region

Ulcer’s Appearance?

• Swollen w/ drainage
• Granulation present (deep pink to red)
• Edges are irregular and depth is shallow

Click Here to see -> Venous Stasis Ulcer…note it is located on the medial part of the lower leg and medial malleolus, wound base is a deep red color, edges are irregular, and the skin surrounding the wound is tight and has edema and brown pigmented.

Nursing Interventions for Peripheral Artery Disease (PAD)

Circulation, pain, and skin integrity focus

Circulation: assess color of extremities, patient’s pain, pulses, sensation

• Palpate and Doppler pulses bilaterally per protocol and document.

To help promote circulation teach patient:

• Avoid constrictive clothing, foot wear etc.
• Avoid extreme cold (causes vasoconstriction) and always keep extremities LOOSELY layered to keep warm…this encourages vasodilation and promotes circulation
• Quit smoking (causes vasoconstriction)
• Avoid knee-flex position or crossing the legs (impedes blood flow)
• Take antiplatelet or anticoagulants as prescribed
• Medications lower cholesterol and low fat diet
• Exercise program (walking program): helps with intermittent claudication, increases availability of oxygen to help with maintain tissue integrity…also helps with lower cholesterol and weight loss
• Skin care:
  • Avoid excessive pressure on pressure points of extremities (educate the patient to remember there may be decreased sensation in the lower extremities and to avoid ill-fitting footwear and to watch out for potential burns…hot water, heating pads etc.)

Pain management per MD order

ABIs: ankle-brachial index (less than 0.9 can indicate PAD)

• An ABI compares the pressure in the ankle to the pressure in the arms…a lower pressure in the ankles indicated PAD (it helps to diagnose PAD and may be used after surgery to assess the outcome of revascularization).

Surgery for PAD:

• percutaneous transluminal angioplasty with or without a stent (makes the vessel wider so blood can flow), or a stent is placed to keep vessel opened.
• remove the blockage: atherectomy
• peripheral artery bypass: “bypasses” the blockage and re-routes the blood flow around it.
• amputation (worst case scenario): some patients will have the above procedures but they fail to provide long-term benefit and may have to have the extremity removed.

Nursing Interventions for Peripheral Venous Disease

Preventing stasis of blood (compression), wound care, preventing infection, monitoring for clots, and helping treat clots 

Monitor for clot development (along with signs and symptoms it broke off):

• Clot signs and symptoms: red, swollen, painful, warm area
• Signs and symptoms clot broke off and travelled to the lungs: dyspnea, chest pain, increased respirations, decrease oxygen saturation etc.
• Treatment blood thinners (heparin, warfarin)
  • A filter may be placed in the inferior vena cava to block the clots from going to the heart and lungs (especially in patients who can’t take blood thinners).

Helping blood return:

• Elevate lower extremities above heart level throughout the day (promotes blood return to the heart) and avoid standing for long periods of time.
• Wear elastic compression stockings on affected extremity routinely (make sure they are clean and changed daily to prevent infection).

Assess wound for infection and provide wound care per physician’s order. Goal is to heal the ulcer and then prevent further ones from developing. Healthy nutrition to promote wound healing.

Popular dressing type for venous stasis ulcers:

• Unna Boot: a wrap that provides compression and contains zinc oxide that helps keep the wound moist and promotes wound healing. They can be wrapped with an ACE bandage to provide compression…it looks like a mid-calf boot on the patient.

Now take the peripheral vascular disease quiz.

References:

Peripheral Artery Disease (Also Known as P.A.D.) Retrieved 4 October 2019, from https://www.nhlbi.nih.gov/health-topics/peripheral-artery-disease

Treatment Strategies for Patients with Lower Extremity Chronic Venous Disease (LECVD). Retrieved 4 October 2019, from https://www.cms.gov/medicare-coverage-database/details/technology-assessments-details.aspx?TAId=104&bc=AAAQAAAAAAAAAA%3d%3d&