CLINICAL TEACHING

ON

VASCULAR DISORDERS

Submitted To:
Asso. Professor.

Presented By:- Mr. Lalchand Lora

M.Sc Nursing Final year.

GENERAL OBJECTIVE
At the end of the class student will be able to understand and have adequate knowledge
regarding vascular disorders and will be able to apply their knowledge in the clinical
setting.
SPECIFIC OBJECTIVE
At the end of the class student will be able to

Anatomy and physiology of blood vessels.

State the meaning of the terms.
Enlist the risk factors.
Classify the vascular disorders.
Enumerate the etiology.
Describe the Pathophysiology
Enlist the clinical manifestations.
Enlist the diagnostic test.
Explain collaborative care.
Explain the medical and surgical management
Explain the nursing management.
Comprehend the complications
Describe the new current trends in vascular disorders

Introduction

Circulatory system is responsible for providing nutrients and energy to all the parts and
organs of our body. Vascular disorders are the defects arising in the Arteries arterioles
capillaries, venules and veins of the body.
ANATOMY AND PHYSIOLOGY OF BLOOD VESSELS
Blood vessels are the vessels that carry blood within the body. Blood vessels are
classified as arteries, arterioles, capillaries, venules and veins. The blood vessels that
supply blood to the blood vessels itself is known as vasa vasorum
ARTERIES
Arteries carry blood away from heart to other organ
Arteries may by elastic arteries or muscular arteries
The wall of artery has three coats or tunics namely tunica interna, tunica media,
tunica externa.
Tunica interna is the innermost coat of blood vessels it contains a lining of simple
squamous epithelium called endothelium, basement membrane and an elastic
tissue called internal elastic lamina.
Tunica media is the thickest layer it consist of elastic fibers and smooth muscle
fibres.
Tunica externa is composed mainly of elastic and collagen fibers
Sympathetic nervous system innervates the vascular smooth muscles, an increase
in the stimulation to sympathetic nervous system helps in the contraction of blood
arteries known as vasoconstriction, in contrast the smooth muscle fibers relax
when sympathetic stimulation decreases or when certain chemicals are released
such as lactic acid, k+, H+, and lactic acid are present. The process is called
vsodilation.
The larger diametered arteries are called elastic arteries because tunica media
contains a high proportion of elastic fibers, they perform an important function
that Is they propel blood even when the ventricles are relaxing eg: aorta, common
carotid artery.
ARTERIOLES
Arterioles are the vessels that supply blood from arteries to the capillaries
They are very small almost microscopic
They perform the function of resistance that is the regulation in their diameter
decides the amount of blood flow to be supplied in the capillaries thus they can
affect the blood pressure

CAPILLARIES
Capillaries are microscopic vessels that connect arteriole to Venules
The flow of blood through the capillaries is called microcirculation
The wall of the capillary is formed only of single layered endothelial cell and
basement membrane.
The prime function of the capillaries is to exchange the nutrition and waste
between cell and blood.
VENULES
Capillaries are united to form small vein like vessels called as venules
Like capillaries venules also have pores and is the site where white blood cells
migrate to the tissues during inflammation from the blood stream.
Venules are united to form the vein
VEINS

The venules unite together to form the vein

They contain all the three layers that is tunica interna, media and externa
But the thickness of the layers is different from that of the arteries.
Tunica interna and media are relatively thinner and tunica externa are relatively
thicker and composed much of collagen and elastic fibers
Most of the veins especially in the limbs have valves which are formed by the
folding of the tunica interna forming cusps facing to the heart
The valve act as a one way system and thus prevents the backflow of the blood
and increases the venous return.

ARTERIOSCLEROSIS
Arteries are blood vessels that carry oxygen and nutrients from heart to the rest of body.
Healthy arteries are flexible and elastic. Over time, however, too much pressure in

arteries can make the walls thick and stiff sometimes restricting blood flow to organs
and tissues. This process is called arteriosclerosis, or hardening of the arteries.
Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used
interchangeably. Atherosclerosis refers to the buildup of fats and cholesterol in and on
artery walls (plaques), which can restrict blood flow.
These plaques can also burst, triggering a blood clot. Although atherosclerosis is often
considered a heart problem, it can affect arteries anywhere in body. Atherosclerosis is a
preventable and treatable condition.
Symptoms
Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any
symptoms.
You usually won't have atherosclerosis symptoms until an artery is so narrowed or
clogged that it can't supply adequate blood to your organs and tissues. Sometimes a blood
clot completely blocks blood flow, or even breaks apart and can trigger a heart attack or
stroke.
Symptoms of moderate to severe atherosclerosis depend on which arteries are affected.
For example:
Atherosclerosis in heart arteries, :- symptoms as chest pain or pressure (angina).
Atherosclerosis in the arteries of brain:= sudden numbness or weakness in
arms or legs, difficulty speaking or slurred speech, or drooping muscles of face.
These are signs of a transient ischemic attack (TIA) which, if left untreated
may progress to a stroke.
Atherosclerosis in the arteries of arms and legs, leg pain when walking
(Claudication).
Atherosclerosis in the arteries of kidneys, high blood pressure or kidney failure.
Atherosclerosis in the arteries of genitals, Difficulties in sex, erectile
dysfunction in men. In women, high blood pressure can reduce blood flow to the
vagina, making sex less pleasurable.

Causes
Atherosclerosis is a slow, progressive disease that may begin as early as childhood.
Although the exact cause is unknown, atherosclerosis may start with damage or injury to
the inner layer of an artery. The damage may be caused by:
High blood pressure
High cholesterol, often from getting too much cholesterol or saturated fats in diet
Smoking and other sources of nicotine
Diabetes
Once the inner wall of an artery is damaged, blood cells and other substances often clump
at the injury site and build up in the inner lining of the artery. Over time, fatty deposits
(plaques) made of cholesterol and other cellular waste products also build up at the injury
site and harden, narrowing arteries. The organs and tissues connected to the blocked
arteries then don't receive enough blood to function properly.
Eventually pieces of the fatty deposits may break off and enter bloodstream. In addition,
the smooth lining of a plaque may rupture, spilling cholesterol and other substances into
bloodstream. This may cause a blood clot to form which can completely block the blood
flow to a specific part of body, such as in a heart attack. A blood clot can also travel to
other parts of body and partially or totally block blood flow to another organ.

Development of atherosclerosis

Atherosclerosis is a process in which blood, fats such as cholesterol, and other substances
build up on artery walls. Eventually, deposits called plaques may form. The deposits may
narrow or block arteries. These plaques can also rupture, causing a blood clot.

Risk factors
Hardening of the arteries occurs over time. In addition to simply getting older,
factors that increase the risk of atherosclerosis include:
High blood pressure
High cholesterol
Diabetes
Obesity

 Smoking
A family history of early heart disease.

Pathophysiology

Deposition of lipid in the intima of the heart

Injury to vascular epithelium

Inflammation of the vascular vessels

Ingestion of lipid by vascular epithelium

Attracts platelets and initiate clotting (atheromas)

Narrowing of blood vessels and obstruction of blood flow

Complications:The complications of atherosclerosis depend on the location of the blocked

arteries. For example:

 Coronary artery disease. When atherosclerosis narrows the arteries close to

heart, develops coronary artery disease, which can cause chest pain (angina), or
myocardial infarction.
Carotid artery disease. When atherosclerosis narrows the arteries close to brain,
develops carotid artery disease, which can cause a transient ischemic attack (TIA)
or stroke.
Peripheral artery disease. When atherosclerosis narrows the arteries in arms or
legs, may develop circulation problems in arms and legs called peripheral artery
disease. This can make less sensitive to heat and cold, increasing risk of burns or
frostbite. In rare cases, poor circulation in arms or legs can cause tissue death
(gangrene).
Aneurysms. Atherosclerosis can also cause aneurysms, a serious complication
that can occur anywhere in body. An aneurysm is a bulge in the wall of artery.
Most people with aneurysms have no symptoms. Pain and throbbing in the area of
an aneurysm may occur and is a medical emergency. If an aneurysm bursts, patient
may face life-threatening internal bleeding. Although this is usually a sudden,
catastrophic event, a slow leak is possible. If a blood clot within an aneurysm
dislodges, it may block an artery at some distant point.
Diagnostic evaluation
History and physical examination
A weak or absent pulse below the narrowed area of artery
Decreased blood pressure in an affected limb
Whooshing sounds (bruits) over arteries, heard using a stethoscope
Signs of a pulsating bulge (aneurysm) in abdomen or behind knee
Evidence of poor wound healing in the area where blood flow is restricted
Blood tests. Lab tests can detect increased levels of cholesterol and blood sugar
that may increase the risk of atherosclerosis.

 Doppler ultrasound. A special ultrasound device (Doppler ultrasound) to measure

blood pressure at various points along arm or leg. These measurements can help to
find out gauge the degree of any blockages, as well as the speed of blood flow in
arteries.
Ankle-brachial index. This test can tell if it is atherosclerosis in the arteries in
legs and feet. It is easy to compare the blood pressure in ankle with the blood
pressure in arm. This is known as the ankle-brachial index. An abnormal
difference may indicate peripheral vascular disease, which is usually caused by
atherosclerosis.
Electrocardiogram (ECG). An electrocardiogram records electrical signals as
they travel through heart. An ECG can often reveal evidence of a previous heart
attack.
Stress test. A stress test, also called an exercise stress test, is used to gather
information about how well heart works during physical activity. Because
exercise makes heart pump harder and faster than it does during most daily
activities, an exercise stress test can reveal problems within heart that might not
be noticeable otherwise. An exercise stress test usually involves walking on a
treadmill or riding a stationary bike while heart rhythm and blood pressure and
breathing are monitored. Stress echocardiogram (ultrasound) or nuclear stress test.
If Patient is unable to exercise, he may receive a medication that mimics the
effect of exercise on heart.
Cardiac catheterization and angiogram. This test can show if coronary arteries
are narrowed or blocked.
Other imaging tests.- computerized tomography (CT) scan or magnetic resonance
angiography (MRA).
Management
Conservative management:Lifestyle changes, such as eating a healthy diet and
exercising, are often the best treatment for atherosclerosis. But sometimes,
medication or surgical procedures may be recommended as well.
Stop smoking.

 Exercise most days of the week.

Eat healthy foods.
Maintain a healthy weight.
Manage stress.
Alternative medicine
Beta-sitosterol (found in oral supplements and some margarines, such as Promise
Activ)
Blond psyllium (found in seed husk and products such as Metamucil)
Calcium, Cocoa, Cod liver oil, Coenzyme Q10, Garlic, Oat bran (found in oatmeal
and whole oats), Omega-3 fatty acids, Sitostanol (found in oral supplements and
some margarines, such as Benecol).
Relaxation techniques, such as yoga or deep breathing, to help you relax and
reduce stress level. These practices can temporarily reduce blood pressure,
reducing risk of developing atherosclerosis.
Medical Management:
Various drugs can slow or sometimes even reverse the effects of
atherosclerosis.
3-Hydroxy-3-methylglutaryl coenzyme A Eg.: atorvastatin
Block cholesterol synthesis, lower LDL and triglyceride levels and increases HDL
levels.
Nicotinic acids
Decrease lipoprotein synthesis, lower LDL and triglyceride levels, and increase
HDL levels.
Fibricacid or fibrates

Eg; Clofibrate (atromid-s)

Decrases synthesis of cholesterol, reduce triglyceride levels, and increase HDL
levels.
Bile acid sequestrants
eg; Cholestyramine
Bind the cholesterol in the intestine, increase its breakdown, and lower LDL levels
with minimal effect on HDLs and no effect on triglyceride levels.
Surgical Management
Sometimes more aggressive treatment is needed. If you have severe symptoms or
a blockage that threatens muscle or skin tissue survival, you may be a candidate
for one of the following surgical procedures:
Angioplasty and stent placement. In this procedure, a long, thin tube (catheter)
is is inserted into the blocked or narrowed part of artery. A second catheter with a
deflated balloon on its tip is then passed through the catheter to the narrowed area.
The balloon is then inflated, compressing the deposits against Artery walls. A
mesh tube (stent) is usually left in the artery to help keep the artery open.
Endarterectomy. In some cases, fatty deposits must be surgically removed from
the walls of a narrowed artery. When the procedure is done on arteries in the neck
(the carotid arteries), it's called a carotid endarterectomy.
Thrombolytic therapy..
Bypass surgery.

THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

This disease was first reported by Buerger in 1908, who described a disease in which the
characteristicpathologic findings acute inflammation and thrombosis (clotting) of arteries

and veins affected the hands and feet. Another name for Buergers Disease is
thromboangiitis obliterans
Thromboangiitis obliterans (Buerger's disease) is a somewhat rare
nonatherosclerotic, segmental, recurrent inflammatory vaso-occlusive disorder of the
small- and medium-sized arteries, veins, and nerves of the upper and lower extremities in
which blood vessels of the hands and feet become blocked.

Causes, incidence, and risk factors

Thromboangiitis obliterans (Buerger's disease) is caused by vasculitis
(inflammation of the blood vessels).
The blood vessels of the hands and feet are especially affected. They tighten or
become totally blocked. The average age when symptoms begin is around 35
years. Woman and older adults are affected less often.
Thromboangiitis obliterans mostly affects men ages 20 to 40 who have a history of
heavy smoking or chewing tobacco. Only 1 out of 10 patients are women.
The condition may also be related to a history of Raynaud's disease.
This disorder is very uncommon in children, but it may occur in children with
autoimmune diseases

Complications
Amputation
Gangrene (tissue death)

 Loss of circulation beyond the affected hand or foot

If Buerger's disease worsens, blood flow is slowed in your arms and legs. This is
due to blockages that make it hard for blood to reach the tips of your fingers and
toes. Tissues that don't receive blood don't get the oxygen and nutrients needed to
survive. This can cause the skin and tissue on the ends of your fingers and toes to
die (gangrene). Signs and symptoms of gangrene include black or blue skin, a loss
of feeling in the affected finger or toe and a foul smell from the affected area.
Gangrene is a serious condition that usually requires amputation of the affected
finger or toe.

Pathophysiology
Predisposing
factors :

Precipitating
factors:
Cigarette smoking
Chewing tobacco

Age (20-40 years old),

Gender(male),
Caused unknown
(autoimmune)

Narrowing of blood
vessels
Hyperviscosity
state
Blood clots

Foot
paresthesia

Cold feet

Occlusion of
arteries
Progressive decrease in
blood flow
to affected
areas

-claudication

-phlebitis
- swelling of the feet
and hand
- intermittent leg pains

-Foot discoloration
- delayed healing
- increased risk for
wound infection

Arterial
ischemia
Inflammation occurs in small and
medium sized and veins near the
surface of the limb
Restriction of blood
supply
Hypoperfusion of peripheral
body parts

Long term
complications:
- Decay of tissue
- gangrene

Symptoms
Pain- it is the most outstanding symptom - due to intermittent claudication.
Rest pain with persistent ischemia of 1 or more digits - due to occlusion of
decreases blood flow.
Paresthesia due to diminished nerve sensation.
Fingers and toes turn pale when exposed to cold (Raynauds phenomenon) due
to decreased blood flow as affected by cold temperature.
Absent or weak tibial pulse
Cyanosis - (cyanosis bluish discoloration of the skin and mucous membrane due to
lack of oxygen in the blood) a later manifestation.
Ulcerations and gangrene if there is prolonged insufficient blood supply.

Symptoms may worsen with exposure to cold or with emotional stress. Usually, two or
more limbs are affected.
Diagnostic evaluation
The hands or feet may have large, red, tender blood vessels. The pulse in the affected
hands or feet may be low or missing.
The following tests may show blockage of blood vessels in the affected hands or feet:
Arteriography - may indicate a proximal source of emboli. It is the most conclusive
diagnostic procedure for peripheral vascular diseases.
Ultrasound - may indicate presence of distal extremity ischemia (indicated by
claudication, pain at rest, ischemic ulcers or gangrene).
Blood tests for other causes of vasculitis and inflammation may be done. Rarely, in cases
where the diagnosis is unclear, a biopsy of the blood vessel is done.
Buerger allens test is done to confirm the Diagnosis.
2.The Allen's test
Simple test called the Allen's test is performed to check blood flow through the arteries
carrying blood to the limbs. In the Allen's test, patient is told to make a tight fist, which
forces the blood out of his hand. Then the Physician presses on the arteries at each side
of wrist to slow the flow of blood back into hand, making hand lose its normal color.
Next, patient opens his hand and doctor releases the pressure on one artery, then the other.
How quickly the color returns to hand may give a general indication about the health of
arteries. Slow blood flow into hand may indicate a problem, such as Buerger's disease.
DON'T
* Don't perform Allen's test unless your patient can make a tight fist.
* Don't compress one artery before the other-compressions should be simultaneous.
* Don't allow your patient to have a radial artery puncture if Allen's test is negative.
DO

* Explain the procedure and its purpose to your patient.

* Ask her to rest her hands facing upward so you can examine color changes in her
palms.
* Ask her to make a tight fist to begin forcing the blood from her hand.
Medical Management:
Smoking cessation
Although no treatment can cure Buerger's disease, the most effective way to halt the
disease's progress is to quit using all tobacco products. Even a few cigarettes a day can
worsen the disease.
Patient needs to avoid nicotine replacement products because they supply nicotine, which
activates Buerger's disease; there are non-nicotine products that you can use. If the
disease is still active, urine can be checked for the presence of nicotine.
Other treatments
Other treatment approaches exist but are less effective. Options include:

hydralazine, a direct acting vasodilator, is highly selective for arterial resistance

vessels. -Aspirin and vasodilators may also used.

Intermittent compression of the arms and legs to increase blood flow to your
extremities.
Spinal cord stimulation
Medications to stimulate growth of new blood vessels (therapeutic angiogenesis),
an approach that is considered experimental by many
Amputation, if infection or gangrene occurs
Surgical management :
- Sympathectomy - a surgical procedure that destroys nerves in the sympathetic
nervous system

-The procedure is performed to increase blood flow and decrease long-term pain in
certain diseases that cause narrowed blood vessels. It can also be used to decrease
excessive sweating.
-bypass graft-Tissue that is taken from one part of a person's body and
transplanted to a different part of the same person consisting of a segment of vein or
artery grafted into place in a bypass.
Surgery to cut the nerves to the affected area (surgical sympathectomy) to control
pain and increase blood flow, although this procedure is controversial
For people who quit smoking but still have arterial occlusion, surgeons may
improve blood flow by cutting certain nearby nerves to prevent spasm. They
seldom perform bypass grafts, because the arteries affected by this disease are too
small.
Nursing management:
-Assist in management of pain
-Prepare pre operatively and postoperative care after amputation
-Teach the client proper care of foot and hands (instruct not to walk barefoot to avoid
injury)
-educate patient on the role of tobacco exposure in the initiation, maintenance, and
progression of the thromboangiitis obliterans
-Assist to develop and implement a plan to stop smoking
-Supportive measures include gentle massage and warmth to increase circulation
-avoid conditions that reduce peripheral circulation, like cold temperatures and sitting or
standing in one position for long periods,
- and avoid wearing tight and restrictive clothing. The disease is progressive in patients
who do not stop smoking.

- Walking 15 to 30 minutes twice a day is recommended, except for people with

gangrene,
sores, or pain at rest; they may need bed rest.
-People should protect their feet with bandages that have heel pads or with foam-rubber
booties.
-The head of the bed can be raised on 6- to 8-inch blocks so gravity helps blood flow
through the arteries.
Nursing diagnosis
1. Altered peripheral tissue perfusion related to compromised circulation
2. Chronic pain related to impaired ability of the peripheral vessels to supply tissues with
oxygen

Buerger-Allen Exercise for Thrombo Angitis Obliterance

The client should repeat the exercises several times during one exercise period and
perform them periodically throughout the day.
1.Support legs in an elevated position at 60-90 degrees for 30-180 seconds, or until
produce blanching of the extremity. The patient is instructed to actively dorsiflex and
plantarflex the ankle throughout the procedure.
2.Allow feet to dangle over the edge of the bed for 2-5 minutes or as long as it takes to
produce hyperemia, then add one minute. The total time should not exceed 5 minutes.
3. Place legs in a horizontal position for 3-5 minutes
Description:

Exercises used to empty engorged vessels, stimulate circulation, and at least partially
relieve swelling (edema) in patients with arterial insufficiency of the lower limbs and
feet Buerger-Allen exercises - A series of exercises administered to patients with
peripheral vascular disease. These exercises are repeated 6-7 times at each sitting and
done several times a day.
PERIPHERAL ARTERIAL DISEASE
DEFINITION
Peripheral arterial disease involves progressive narrowing and degeneration of the
areteries of the neck, abdomen and extremities. Regardless of the anatomic locations,
atherosclerosis is responsible for the majority of the cases of PAD.
Although PAD is a diffuse process certain segments of the arterial tree are
commonly involved like coronary arteries, aortic bifurcation, iliac and common femoral
arteries, profunda femoral arteries, and distal popliteal artery ( mainly the lower
extremities are involved) The involvement is generally segmental with normal segments
interspersed between involved ones.
ETIOLOGY
Atherosclerosis
RISK FACTORS
Smoking, Hyperlipidemia, Hypertension, Diabetes mellitus, Obesity
Hypertriglyceridemia, Hyperurecimia, Family history, Sedantry lifestyle
Stress, High serum level of C reactive protein, fibrinogen, ferritin, homocystiene
and lipoprotein.
PATHOPHYSIOLOGY
Although several risk factors

are present, endothelial

injury is caused by

an

inflammatory response in the intimal layer of the wall and the deposition of lipids
into the wall.
The atages of development of atherosclerosis are a) fatty streak, b) fibrous plaque
resulting from smooth muscle cell proliferation. C) complicated lesion.

a) Fatty streak
Fatty streaks the earliest lesion of atherosclerosis are characterized by lipid filled
smooth muscle cells.as streaks of fat develop within the smooth muscle cell. A
yellow tinge appears. Fatty streaks can be observed in coronary arteries by the age
15 and involve an increasing amount of surface area as the patient ages. It is
generally believed that the treatment that lowers LDL chilestrol can reverse this
process.
b) Fibrous plaque resulting from smooth muscle cell proliferation
the fibrous plaque stage is the beginning of progressive changes in the
enodothelium of the arterial wall. These changes can appear in the coronary
arteries by age 30 and increase with age.
Normally the endothelium repairs itself immediately but in the lerson with PAD
the endothelium is not rapidly replaced allowing LDLS and growth factors from
platelets to stimulate smooth muscle proliferation and thickening of arterial wall.
Once endothelial injury has occurred, lipoproteins ( carriers proteins within the
blood stream) transport cholesterol and other lipids into arterial intima. The fatty
streak is eventuallu covered by collagen forming fibrous plaque that appears
grayish or whitish. These plaques can form on one portion of the artery or in a
circular fashion involving the entire lumen. The borders can be smooth or irregular
with rough, jagged edges.the result is a narrowing of the vessel lumen and a
reduction of blood flow to distal tissues.
c) complicated lesion.
The final stage in the development of atherosclerotic lesion is the most dangerous.
As the fibrous plaque grows, continued inflammation can result in plaque
instablility and rupture. Once the integrity of the arteries inner wall has become
compromised, platelets accumulate in a large numbers leading to thrombus.the
throbus may adhere to the wall of the artery , leading to further narrowing or toatal
occlusion of the artery. Activation of exposed platelets causes expression of
glycoprotein IIA/IIIA receptors that bind fibrinogen. this inturn will lead to further

platelet aggretion and adhesion, further enlarging the thrombus. At this stage the
plaque is reffered to as complicated lesion
CLINICAL MANIFESTATION
Intermittent claudication
Ischemic muscle ache at consistent level of exercise due to accumulation of
anerobic cellular metabolic products such as lactic acid.
Erectile dysfunction & sexual dysfunction due to involvement of internal iliac

arteries
paresthesia due to nerve tissue ischemia
true peripheral neuropathies mostly in diabetic patients
skin becomes thin shiny and taut, loss of hair on the lower legs
diminished or absent pedal, poplitial or femoral pulse.
Pallor or blanching of foot is noted in respose to leg elevation (elevation pallor)
Reactive hyperemia(redness of the foot when the leg is hung in a dependent

position
Rest pain occurs when the blood supply is not sufficient to maintain the basic
metabolic requirements of the tissues and nerves of distal extrimities

COMPLICATION
PAD of lower extremities progresses slowly . prolonged ischemia leads to atrophy of the
skin and underlying muscles.because of the deacreased arterial blood flow to the lower
extremities , even minor trauma to the feet even (eg: stubbing ones toe, blister from ill
fitting shoes) may result in delayed healing , wound infection and tissue necrosis,
especially in diabetic patient. arterial( ischemic ulcers most commonly occur in over
boney prominences on the toes feet and lower legs.non healing areterial ulcers and
gangerene are the most serious complication of PAD and may result in lower extremity
amputation if blood flow in not restores adequately or if severe infections occur.if

atherosclerosis has been present for an extended period, collateral circulation may
prevent gangerene of the extremity.
DIAGNOSTIC STUDIES
various test have been outlined to asses the blood flow and to assess the vascular system.
Doppler ultrasound consist of probe transducer containg a crystal that directs high
frequency sound waves towards the artery or vein being examined.the sound wave
bounces off the blood cells at a rate that corresponds with velocity of blood flow.this
emits an sudible signal.when palpation of peripheral pulse is difficult because of severe
PAD, the dopp;er can be useful in determining the blood flow. a palpable pulse and the
Doppler pulse are not equal and these terms should not be used interchangibly.. in
addition segmental blood pressure also are obtained. at the thigh, below the knee and at
ankle while the patien is in supine. afall of segmental BP of more than 30 mmHg
indicates PAD.
the ankle brachial index indicates is determined using a handheld Doppler. the ABI is
determined using a hand held dopller. the ABI is calculated using the ankle systolic
blood pressure (SBP) by the the highest brachial SBP. a normal ABI is 0.91 to 1.30. an
ABI between 0.71 and 0.90 indicates mild PAD, moderate between, 0.41-0.70 and severe
if < 0.40. duplex imaging is another non invasive test uses a bidirectional color Doppler
syatem to syatematically map blood flow throughout the entire region of the artery.. it
provides anatomic and physiologic information about blood vessels. angiography is used
to further delineate the location and extent of the disease process.
COLLABRATIVE CARE
Risk Factor Modification
due to high risk if MI, ischemia , stroke and cardiovascular death in patients with PAD
the first treatment goal is to aggresivley modify cardiovascular risk factors in all patients
regardless of symptoms , smoking cessation is essential for the allowing of the symptoms
of PAD. smoking cessation is

a difficult process with high incidence of smoking

relapse.agressive treatment oh hyperlipidemia is other goal of therapy.treatment of PAD

has shown to reduce cholesterol and reduces cardiovascular morbidity and mortality.

statin is also associated with improved walking diatance in patients with PAD.
hypertension and diabetes meliitus are important risk factors for PAD progression. so BP
and blood glucose should be tightly controlled.
Drug Therapy
antiplatelet agents such as aspirin, ticlopedin and clopidogrel are considered typically
important for reducing the risk of MI,ischemic stroke and cardiovascular related related
death in patients with PAD. aspirin is however not tolerated by some patients because of
gastrointestinal distress. triclopidine, and clopidogrel which inhibit platelet aggrrigation,
also are effective in reducing the risk of MI and stroke. triclopedine is prescribed less
frequently for patients with PAD since a number of serious side effets have been observed
, including thrombocytopenia, neutropenia and thrombotic thrombocytopenic perpura.
based on the best available evidence , first line oral anti platelet therapy for patients with
PAD should be aspirin( 160 to 325 mg/ day)or clopidogrel when combination antiplatelet
therapy is recommended if a patient has vascular events with single drug therapy.
antiplatelet agents have not been shown to the effective in treating claudication.
Exercise Therapy
the primary non pharmacologic treatment for claudication is formal a formal exercise
traing programme. a tharough exercise training programme. although exercise training
has not been shown to increase collatrel blood flow to the legs, it improves oxygen
extraction in the legs , skeletal muscle metabolism and vascular endothelium function
unfortunately, recent nursing research indicates that only about 50% of PAD patients
participate in regular exercise
Nutritional Therapy
Patients with PAD should taught to evaluate their dietry intake overall caloric intake
should be adjusted so that the body mass index is < 25kg/m 2 and waist circumference is
less than 14 inches for men and less than 35 inches for women. Within the diet , dietry
cholesterol should be less than 200 mg / day. And the saturated fat intake should be
should be substantially reduced soy protein products (eg tofu , miso) can be used in place
of animal proteien to help lower total cholesterol , LDL cholesterol and triglyserides as

well as increase high densities lipoprotein ( HDL) cholesterol dietry sodium should be
not more than 2gm/ day.
Complimantary and alternative therapy
Ginkgo biloba is effective in increasing walking distance for patients with intermittent
claudication. Side effects of ginko biloba includesheadache, nausea, giastric symptoms,
diarhhoea and allergic skin reactions
Care of the limb with critical limb ischemia
Critical limb ischemia is a a chronic condition characterized by ischemic rest pain,
arterial ulcers, and or gangerene of the leg due to advanced PAD. Concervative
management goals of the patients with critical limb ischemia includes protecting the
extremity from trauma, decreasing vasospasm, preventing and controlling infection, and
maximizing areterial perfusion.careful inspection, cleansing and lubrication of both feet
are advised to prevent cracking of the skin and infection.if the ulceration is present the
affected limb should be kept clean and dry.cover the ulcer with clean sterile dressing.
Footware should be soft roomy and protective. Chemicals, heat and cold should be
avoided. The patients heal should be kept free of pressure.prostaglandin E1(PGE1) had
better pain relief and healing of arterial leg ulcers compared to those treated with placebo.
Interventional radiologic procedures
Interventional radiologic procedures are indicated when
Intermittent claudication symptoms become incpaciating
The patient experiences rest pain
Severe ulceration or limb threatening gangarene exists
Percutaneous transluminal angioplasty involves the insertion of catheter through the
femoral artery. However the catheter is special and contains a cylindrical balloon.the end
of the catheter is advanced to the narrowed area of the artery , the balloon is inflated and
the balloon dialates the vessel cracking the confining atherosclerotic intimal shell while
also streachinhg the underlying media. Placement of intravascular stents

during

angioplasty helps relieve the problems of restenosis and arterial dissection. Newer drug
such as paclitaxel are being studied to replace stent as they prevent growth of new tissue

in the area. Anti platelet agents are necessary after the stenting procedures to redice the
risk of platelet aggeretion
Surgical therapy
Many surgical procedures to improve the blood flow beyond the occluded lesion is now
available. Peripheral arterial bypass operation is one of the surgery in which autogenous
(native) or synthetic graft material to bypass or carry blood around the lesion .
Endarterectomy is a surgical procedure in which the artery is opened and the obstructing
plaque is removed.
Patch graft angioplasty is a procedure in which artery is opened, plaque is removed and a
patch is sewed to the opening to widen the lumen.
Amputation is the least desirable end stage surgical option but may be required if
gangerene is extensive, infection is present inn the bone( osteomylitis) or all the major
arteries in the limb are occluded.

NURSING MANAGEMENT
Health promotion
The patient should be assessed for the risk factors and taught how to control them. The
nurses role in the inpatient setting includes identifying at risk patients. The nurse also
should be include in the community level, sucha s screening clinics for the PAD,
hyperlidemia, hypertension, obesity and diabetes. Young people and adults should be
educated about the hazards of tobacco use and the importance of regular physical
activity . the nurse should assist in teching diet modification to reduce the intake of
cholesterol, saturated fat and refined sugars. Proper care of the feet and avoidance of
injury to the extremities. Patients with positive family history of cardiac, diabetic or
vascular diseases, should be encouraged to receive regular vascular care.
Acute intervention
After surgical or radiologic intervention the patient is kept in the recovery area for close
observation.the operative extremity should be checked every 15 minutes initially and then
hourly for skin color, temperature, capillary rephill, presence of peripheral pulses, and
sensation and movement of the extremity. Doppler sound over the pulse necessitates

immediate attention of the physiscian and radiologist for prompt intervention.ankle

brachial index(ABI) may be ordered and the indices should increase from patients
preoperative baseline.they should remain constant if the bypass or stent remains patent.
All of these findings should be compared with patients preoperative baseline and with the
findings in the opposite limb.many patients with PAD have a chronic ischemic rest pain
preoperatively and may be opiod tolerant.they may require aggressive pain managent
postoperatively.
After the patient leaves the recovery area the patient care should continually focus
on.continued circulatory assessment and monitoringfor potential complications.these
include bleeding, hematoma, thrombosis, embolization,and compartment syndrome.a
dramatic increase in the level of pain, loss of palapable pulse,or pulse distal to operative
site , extremity pallor or cyanosis, decreasing ABIs, cyanosis, numbness or tingling or
cold extremity temperature may indicate occlusion of the bypass graft and should report
to the physician immediately.
Knee flexed position should be avoided except for the exercise, the patient sjould be
turned and positioned frequently with pillows to cushion the incision. Typically by the
first postoperative day the patient should be out of bad several times a day.short periods
of different leg or body position have not been found to impair post operative skin
oxygen levels. Sitting for long periods of time should be discouraged because leg
dependency may cause significant edema resulting in discomfort and stress to suture line.
And may increase the risk of deep vein thrombosis. If a significant sweeling develops
then a reclining position is preferred with edematous leg elevated above the
heart.occationally elastic bandages or elastic support stokings are used to control leg
edema. Walking even short distances Is desirable. The use of walker may be useful in
patients especially in older ones.
Women with PAD have reported decreased physical functioning more bodily pain and
greater mood disturbances than men with PAD.the women may nedd require higher
dosages of pain medication, greater assistances of activities with daily living.and more
social support than men in post operative period.

Ambulatory and home care

Atherosclerosis is a systemic disease process and not just localized to lower extremities.
Therefore the overall approach to the control of atherosclerotic occlusive diease
involvesrisk factor managemt.tobacco in any form is totally contraindicated because of
vasoconstrictive effect of nicotine, also it affects on the utilization of oxygen in the
body.increases blood viscosity and blood homocystiene.
Meticulous foot care should be advised to patient after the surgery. The importance of
gradual physical activity should be emphsised as the physical activity has shown to
reduce the cardiac risk factors.

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Joyce.M.Black et al, Medical Surgical Nursing, Saunders publication, Page No
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Brunner and Siddharth, Medical Surgical Nursing, Lippincott Williams and
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F.P.Anita and Philip Abraham, Clinical Dietetics and Nutrition,4 th edition,Oxford
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K Sembulingam and Prema Sembulingam,Essentials of medical Physiology,
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