Review of Anatomy and

Physiology
Vascular Segments
•Arteries
•Veins
•Capillaries/
Capillary beds
•Lymphatics – network of
endothelial tubes
that drains in your
vena cava
 Blood Vessel Structure
 Blood Vessel Structure
 tunica intima – innermost layer –
Endothelial cells
 tunica media – middle layer – Elastic
Conn tse and Smooth muscle cells
 tunica 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 TAKING
 BIOGRAPHICAL and DEMOGRAPHIC DATA
Age
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 HISTORY
Note any history of DM, hypertension,
CAD, collagen diseases, and PVD

 PSYCHOSOCIAL HISTORY
Occupational history
Smoking or use of any tobacco products
Diet
Clinical manifestations
 CURRENT HEALTH
ARTERIAL 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
Risk factors:
A – ge
R – T smoking
T – hrombosis/ embolus
E – levated lipids
R – T DM
I – ncreased BP
A – therosclerosis
L – 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:
erythema
lipodermatosclerosis
drying and flaking
status dermatitis
ulceration
Venous Disorders
RISK 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 OF
LOWER EXTREMITY DISORDER

MANIFESTATION ARTERIAL VENOUS

Pain Intermittent claudication. Aching, heaviness
Rest pain may be Exercise and elevation
present, or pain may decrease pain
worsen with elevation Nocturnal cramping
Heaviness in the legs at
the end of the day
Skin Absence of hair in chronic Brown discoloration.
condition. Thin and Normal toenails
shiny. Thick toenails
(fungal infxn)
Color Pale with dependent rubor Brown discoloration.
Dependent cyanosis
Temperature Cool No change or may be
warmer than
unaffected area
Sensation Decreased; tingling, Pruritus may be present
numbness may be
present
 CLINICAL MANIFESTATIONS OF LOWER EXTREMITY DISORDER

MANIFESTATION ARTERIAL VENOUS

Pulses Decreased to absent Present, but may be

difficult to palpate
because of edema
Edema May be present but usually Present, worse at end
absent of day, improved with
elevation
Muscle mass Reduced in chronic disease Unaffected
Ulcers Small, painful ulcers on Broad, shallow, slightly
pressure points, points of painful ulcers of the
trauma, between toes, or ankle and lower leg.
distal most point, Surrounding skin is
especially lateral brown and fibrotic.
malleolus and toes
ARTERIAL LEG
DISORDER
PHYSICAL EXAMINATION

Inspection, palpation,
auscultation

Nursing Responsibilities:

Prepare the environment

Provide natural lighting
Warm the environment
Provide 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 PROCEDURES
NON-INVASIVE
I. 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 reflux
Most 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

IV. 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 Angiography
 INVASIVE
ANGIOGRAPHY – 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 procedure
NPO 2-6 hours before procedure

Postprocedure:
V/S, NVS, Distal pulse checks
Assess puncture site for hematoma
Bed rest 6-8 hrs. with extremity kept in straight alignment if transfemoral
approach
Continous IV hydratio 6-8 hrs. to assist contrast excretion
BUN 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:
 Ascending – to record valvular patency
 Descending – to determine valve reflux and competence

PREPROCEDURE:
1. Document the presence and quality of
peripheral pulses
2. Clear liquids for 3 to 4 hours before the
procedure to maintain hydration
POSTPROCEDURE:
1. Place a pressure dressing on the injection site
2. Bed rest for 2 hours if the femoral vein was punctured
3. Monitor pulses for the next 4 to 6 hours
4. Continue IV fluids for 8 to 24 hours
5. 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!