peripheral circulatory system and vascular system

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PERIPHERAL CIRCULATORY SYSTEM AND VASCULAR SYSTEMASSESSMENT Health history Pain and precipitating factors Skin color and temperature Characteristics of peripheral pulse Physical assessment Intermittent claudication Is a muscular, cramp type pain in the extremities consistently reproduced with the same degree of exercise / activity and relieved by rest (experienced by patients with peripheral arterial insufficiency). This pain is caused by the inability of arterial System to provide adequate blood flow to the tissues. Lactic acid isproduced. Pain is experienced when metabolites aggravate the

nerve endings of the surrounding tissue. I.C. will be experienced when 50% of the lumen or 75% of the cross-sectional area is obstructed. Changes in skin appearance and temperature RUBOR - reddish discoloration of the extremities. Suggests severe peripheral arterial damage. Cyanosis - bluish discoloration of the skin. Gangrenous changes appear after prolonged severe ischemia & represent tissue necrosis. Adequate blood flow warms the skin & gives a rosy color. Inadequate blood flow results in cool & pale extremities. Pulse

DIAGNOSTIC EXAMS I. Doppler ultrasound flow studies

- Type of ultrasound that uses sound waves to measure the flow of blood through a blood vessel - The test takes several minutes to assess the flow in each blood vessel being tested, If the test shows a decreased amount of blood flow, other testing may be needed. Interventions: - Supine position, w/ the HOB elevated 20 to 30 degrees - Acoustic gel isapplied - Doppler transducerispositionedat a 45 to 60-degree angle over the expected location of the artery and angle slowly. It is more useful as a clinicaltoolwhencombined w/ ankleblood pressures, which are used to determine the ankle-brachial index(ABI), alsocalled the ankle arm index (AAI). Ankle- brachial index (ABI) ` Ankle- brachial index (ABI) ` Is the ratio of systolic blood pressurein the ankle to the

systolic blood pressure in the arm. ` Objective indicator of arterial disease that allows the examiner to quantify the degree of stenosis. ` Used to measure brachial pressure in both arms. ` To calculate ABI: ` ankle systolic pressure each foot higher of 2 brachial systolic pressure ` Right brachial = 160 mmHg ` Left brachial = 120 mmHg ` Right posterior tibial= 80 mmHg ` Right dorsalispedis= 60 mmHg ` Left posterior tibial = 100 mmHg ` Left dorsalispedis = 120 mmHg ` Right ankle = 80 / 160 mmHg = 0.50 ABI ` Left ankle = 120 / 160 mmHg = 0.75 ABIO II. Exercise testing - is used to determine how long a patient can walk - To measure the ankle systolic blood pressure in response in walking.

- The patient walks on a treadmill at 1.5 mph with a 10% incline for a maximum of 5 minutes. III. Duplex Utrasonography - involves B-mode gray-scale imaging of the tissue, organs, and blood vessels and permits estimation of velocity changes by use of a pulsed Doppler. - It helps determine the level and extent of venous disease. - Non- invasive, requires no patient preparation. IV. Computed tomography (CT) - provides cross-sectional images of soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes take place. *Spiral CT or helical *Multidetector CT (MDCT) four slices or visual Pictures per x-ray tube rotation. V. Computed tomographic angiography (CTA)

- a spiral CT scanner and rapid IV infusion of contrast agent are used to image very thin sections of the target area, and the results are configured in three dimensions so that the image closely remsembles a regular angiogram. - CTA of thoracic or abdominal vasculature may be peformed using 1- 1.5 mm slices. VI. Magnetic resonance angiography - Is used to generate images of the arteries in order to evaluate them for stenosis (abnormal narrowing), occlusion or aneurysms (vessel wall dilatations, at risk of rupture). - Used to isolate the blood vessels - This study is useful in patients with poor renal function or allergy to contrast agent. VII. Angiography - To confirm diagnosis of occlusive arterial disease when considering surgery or other interventions. - It involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessel.

- Allergic reaction to iodine; manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. - It may include the administration of epinephrine, antihistamines, or corticosteroids. VIII. Air plethysmograph - isused to quantifyvenous reflux and calf muscle pumpejection. - provides information about venousfilling time, functionalvenous volume, ejected volume, and residual volume - Useful in evaluating patients with suspected valvular incompetence or chronic venous insufficiency but not used for deep vein thrombosis IX. Contrast Phlebography - Also known as venography - involves injecting a radiopaque contrast agent into the venous system. X. Lyphangiography - Way of detecting lymph node involvement resulting from

metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery. XI. Lymphoscintigraphy - is a reliable alternative to lymphangiography. - a radioactively labeled colloid is injected subcutaneously in the second interdigital space. LABORATORY EXAMS Complete blood count (CBC) Bone marrow aspiration - is used to document infection or tumor within the marrow Hemoglobin electrophoresis Coombs test - also referred to as the direct antiglobulin test (DAT)

ARTERIAL PROBLEMS I. Arteriosclerosis - the common disease of the arteries; the term means hardening of the arteries - It is a diffuse process whereby the muscle fibers and the endothelial

lining of the walls of small arterioles become thickened. Atherosclerosis - affects the intima of the large and medium-sized arteries. - Intermittent claudication (pain, weakness, numbness, or cramping in muscles due to decreased blood flow) Atherosclerotic lesions: 1. Fatty streaks 2. Fibrous plaques Surgical Management Vascular Surgical procedures: Inflow Procedures which improve blood supply from the aorta into the femoral artery Outflow Procedures which provide blood supply to vessels below the femoral artery. Radiologic Interventions Angioplasty also called percutaneous transluminal angioplasty (PTA). - A balloon-tipped catheter is maneuvered across the area of stenosis. - It widens the arterial lumen by cracking and flattening

the plaque against the vessel wall. Dissection separation of the vessel, and bleeding - Stents may be inserted to support the walls of blood vessels and prevent collapse immediately after the balloon inflation. II. Peripheral Arterial Occlusive disease - Peripheral vascular disease (PVD), commonly referred to as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD), refers to the obstruction of large arteries not within the coronary, aortic arch vasculature, or brain.

- Arterial insufficiency of the extremities occurs most often in men and is a common cause of disability. - Obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below

the renal arteries to the popliteal artery. Signs and symptoms: Intermittent claudication coldness or numbness of extremities decreased ability to walk ischemic rest pain. Nursing Management: Maintaning circulation Avoid leg cross and prolong extremity dependency Medical Management: Pentoxifylline (Trental) Cilostazol (pletal) Vascular grafting or endarterectomy - is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an artery constricted by the buildup of soft/hardening deposits. Bypass graft to reroute the blood flow around the stenosis or occlusion. Distal anastomosis Thromboangitisobliterans (Buerger s disease) is a recurring progressive inflammation and thrombosis

(clotting) of small and medium arteries and veins of the hands and feet. It is strongly associated with use of tobacco products, primarily from smoking, but also from smokeless tobacco. III.UPPER EXTREMITY ARTERIAL OCCLUSIVE DISEASE - arterial occlusions occur less frequently in the upper extremities than in the legs and cause less severe symptoms because the collateral circulation is significantly better than in the arms. - stenosis and occlusions in the upper extremity result from atherosclerosis or trauma. Signs and symptoms: coolness and pallor of the affected extremity Decreased capillary refill Difference in arm blood pressures of more than 20mmHg Nursing Management: Arm kept at heart level or elevated, with the fingers at the highest level.

BP assessment every hour for 8 hours. Doppler assessment of the arterial flow every hour for 8 hours. Medical Management: PTA if a focal lesion is identified IV. Buerger s Disease (THROMBOANGIITIS OBLITERANS) - is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and upper extremities. - The cause is unknown, but it is believed to be an autoimmune vasculitis - occurs in men between 20 and 35 years of age. - Superficial thrombophlebitis may be present. Pathophysiology: Cause is UNKNOWN Probably an Autoimmune disease Inflammation of the arteries thrombus formation occlusion of the vessels Signs and symptoms:

Rubor (reddish-blue discoloration) Absence of pedal pulse Paresthesias Nursing Management: Advise to stop using tobacco Medical Management: Same treatment of Buerger s disease Regional sympathetic block or ganglionectomy to produce vasodilation and increase blood flow. Amputation V. Raynaud s Disease is a vasospastic disorder causing discoloration of the fingers, toes, and occasionally other areas. Also known as "Primary Raynaud's phenomenon" Causes of Reynaud s Disease Scleroderma Carpal Tunnel S