Lecture on Peripheral Vascular Disease (PVD)

Hey everyone, it's Sarah with RegisteredNurseRN.com and today we're going to talk about peripheral vascular disease, also known as PVD. And as always, whenever you get done watching this YouTube video, you can access the free quiz that will test you on this condition. So let's get started. PVD is the impediment of blood flow within the peripheral vascular system due to damage to the vessels that make up that system. Now, your peripheral vascular system provides circulation to your arms, your hands, your feet and your legs. So it's a circulation outside of the heart and the brain. And with peripheral vascular disease, it can affect either the arterial system, and if it does this, it's known as peripheral arterial disease, PAD, or it can affect the venous system, which it'll be called peripheral venous disease. But whether it's arterial or venous, most likely your patient is going to show signs and symptoms. their lower extremities because that's what's really going to be affected. However, those signs and symptoms are going to be completely different and that's what I really want you to take away from this lecture for your exams. You want to know the difference between the signs and symptoms of arterial disease versus venous disease. So to help us understand those signs and symptoms, let's quickly review the arterial and venous system. The arterial system carries oxygenated blood from the heart to the extremities. extremities and organs. And here in our illustration, the arterial system is represented in red. So your heart, with the assistance of the lungs, oxygenates the blood. And the heart is going to pump that oxygenated blood out through the body. So it generates so much force where it's able to do that. And you can feel that because when you feel your arteries in your arms and in your feet, that's your heart contracting and shooting that blood to those extremities so they can get oxygen. them because if they don't get that oxygen they can't work and ischemia starts to occur and they will die so with like peripheral arterial disease that is what happens and a big cause of PAD is atherosclerosis and this is where fatty plaques accumulate in these arteries and that's going to limit the amount of blood that can get down and feed those extremities so whenever that happens you get a This will cause the patient pain and the patient can develop arterial ulcers because that tissue is not being fed. It starts to die. If it's severe enough, the patient can start to experience necrosis of that extremity. Some patients, if it's not corrected, may have to have those extremities amputated. Then we have the venous system. It carries deoxygenated blood from the extremities and organs back to the heart so it can be oxygenated and here in our illustration the venous system is represented in blue so the venous system takes the blood this way back to the heart and the arterial system took it this way away from the heart so your arterial and venous system work together and in a sense they're like recycling the blood the arterial system takes the blood to the extremities to give them oxygen they consume it and now we got to do something with it needs to go back to the heart so the venous system achieves that. But it can only do that if you have healthy veins and healthy vein valves. So in some diseases that are known as peripheral venous diseases like varicose veins, those valves are stretched in the veins so the blood really doesn't be able to go back to the heart. It just pulls in those extremities. Or if you have deep vein thrombosis where you have a clot deep in that vein. prevent blood from being able to flow back to the heart. So a lot of patients what's going to happen is they're going to get the collection venous congestion in their extremities of this blood that can't flow back which is going to cause them pain. It'll be a heavy throbbing pain. It can also impair tissue integrity because you have the stagnant blood hanging out which isn't allowing the clearance of that cellular waste so that can break down the skin a lot of patients will have brown pigmentation of their skin and they can develop venous stasis ulcers as well along with a skin infection some patients will develop cellulitis now let's look at the risk factors for peripheral vascular disease and we're going to divide these into the risk factors for PAD versus the risk factors for peripheral venous disease so the risk factors for peripheral Arterial disease include conditions that cause vasoconstriction or actually damage those arteries which is going to affect how blood can be delivered throughout that peripheral vascular system. And some risk factors include smoking, tobacco use because it causes constriction of the arteries, also uncontrolled hypertension because whenever you have such high pressure within those arteries it can damage those arteries. In addition high cholesterol so it's associated with associated with obesity and this is going along with that atherosclerosis where they have such a high fat count in their blood it's starting to adhere to those arterial walls which can affect blood flow. In addition a patient having diabetes also increases the risk of PAD. And some risk factors for peripheral venous disease would be conditions that are going to increase that venous pressure within those veins. damage those or overstretch those valves. So some things that can increase a patient's risk for venous disease would be being female, for instance using birth control pills has been associated with venous disease, pregnancy just because the increased pressure in the venous system, obesity as well, or sitting or standing for a long period of time can damage those veins and valves along with advanced age. We've looked at the risk factors for PVD. Let's dive a little bit deeper and let's talk about those two different types of PVD. So first we're going to talk about PAD, which again is peripheral arterial disease. And this is where we had narrowing of these arteries and we weren't getting that fresh oxygenated blood to those extremities. Now PAD tends to affect the lower extremities, but it can also affect any other area of the peripheral arterial system. So what happens is that ischemia occurs and then tissue integrity is going to be compromised. So a main cause of PAD is atherosclerosis. And I hit on that a little bit earlier. And this is where those fatty plaques collect in those arteries. And this can really be accelerated if the patient is a smoker, which is damaging those vessels. They have uncontrolled hypertension, which again damages the vessels. And they have high cholesterol. level so that fat can just stick to those damaged vessels and it's going to impede blood flow. And what can happen unfortunately is that those fatty plaques can rupture, clot can form, and that can even further impede blood flow. Now a type of peripheral arterial disease that I want to hit on is called Renaud's disease and this is where you have vasospasm of those peripheral arteries. So whenever something vasospasms, it contracts down so whenever where we have that that's going to limit blood flow and it mainly occurs in those peripheral arteries that feed the toes and the fingers and it can also affect the nose and the ears patients can have signs and symptoms there now Renaud's disease is triggered by cold and stress remember that because with education you want to teach your patient to keep those extremities warm so this isn't triggered so what happens is let's say cold is a trigger for this person. They get cold in their extremities and the fingers and the toes start to turn extremely white. They can even turn blue. Then whenever that cold or stress is removed, that vasospasm eases up, the blood flow starts to return, but then they'll start to experience a tingling, prickling sensation in those areas, followed by extreme red extremities. So those are the signs and symptoms associated with that. Then we have birth... Burgers disease, and this actually affects both the arteries and the veins. And this is where you have inflammation of those arteries and veins, and then clots happen. So the inflammation is damaging those vessels. Clots start to form. When we have a clot, that blocks blood flow. And this tends to occur in the feet and the hands. And patients who are at most risk for this are patients who smoke. So a big thing you want to remember from a nursing standpoint is patients who have Burgers disease, You want to educate them about the importance of quit smoking because that's why it's causing this disease So treatment therapy is going to be related to Improving and increasing blood flow which we're going to hit more on in our nursing interventions Then we have peripheral venous disease and venous diseases again are where those veins are Unable to help that blood go back to the heart and this can occur because the veins are damaged or they're vascular of walls are overstretched Or there's a clot somewhere within that vein that is limiting the blood being able to return to the heart. But whatever the case, if it's severe enough, what will happen is that you'll get blood that will start to pull in that extremity. It becomes stagnant. This is going to lead to a lot of swelling, edema, and it's going to alter tissue nutrition, which can lead to the development of ulcers and a bacterial infection like cellulitis. So some things that can lead to this are like varicose veins. And you can notice this in a patient's legs. They will be rope-like veins on the surface of the skin. And this is where those vein walls are overstretched and there are valves. So what can help with this is like compression or they can have procedures to help with those veins. In addition, we have deep vein thrombosis, also called a DVT. And just as the name says, this is the development of clots deep within the veins. And DVTs are dangerous because they can break off and go to the lungs leading to a pulmonary embolism. And some signs and symptoms of a DVT would be that the extremity is extremely warm, has a hardened area, it's very red, patient may have some pain. And an ultrasound can be used to help detect that. So if a patient does have that, you want to report that to the doctor immediately and they can get them on blood thinners. or procedures, a filter to help with that not going to the lungs. And I'm going to be doing a whole lecture on deep vein thrombosis that you may want to check out. Then we have a superficial venous thrombosis. This is a little bit different than a DBT because this is a clot that has developed in the superficial veins, usually to the hands, to the feet. And then we have chronic venous insufficiency. And this is where those veins are just really messed up in that they're over. stretched and it's not allowing blood to return to the heart. Now we're going to talk about the differences between arterial and venous disease in regards to how your patient is going to be presenting and what you're going to be seeing as the nurse. So these are six things you want to assess and ask the patient to help you determine if it's arterial or venous disease and to help us remember those things we're going to remember the word vessel. V is for various positions that help alleviate the pain. So you want to ask your patients about the positions that they put their lower extremities in to help with this. And patients who have arterial disease they're going to tell you that it helps alleviate the pain whenever they dangle their legs down or also known as the dependent position. And the reason for this is because they're having that ischemia and there's issues with that blood going to that extremity. So when they put it down, dangle it, that actually helps increase the blood flow so alleviates the pain. But they will also tell you that when they elevate their extremity it makes the pain worse and why is that well? It's just what we learned to have how that arterial system works elevating the leg that's going to limit blood flow even more So of course those extremities are going to be limited and how much oxygen they're gonna get so they're gonna signal to the person Hey, we're not getting oxygen this hurts So elevating would make the pain worse then on the flip side with venous disease The patient is going to tell you that elevating their legs is actually going to help with the pain and it's going to help decrease the swelling and the reason for this is just how that venous system works remember its goal is to return the blood to the heart so elevating is going to help get that blood going there so that's going to relieve that pain that they're having and decrease that swelling so dangling their legs or setting in a sitting position or standing for long periods of time will actually make their pain worse and increase the edema. So it's the opposite for these two diseases. Then E, you want to ask your patient about their explanation of the pain. Like what's the characteristics of it? So with arterial, your patients are going to report that the pain is sharp and it's going to be worse at night. And this is known as rest pain because what happens is when they're lying in bed, they have their legs straight out in that horizontal position. And this is affecting blood flow. So they'll wake up in the middle of the night. with pain in their leg and then to help the pain they'll throw that leg off the bed and dangle it to alleviate the pain and that again is just going to help get some blood going to that extremity and a hallmark sign and symptom you want to remember for arterial disease is termed intermittent claudication and this is where when the patient does activity such as walking running they will get this severe pain in their legs like the calf muscles the thighs or the buttocks and this is because Because whenever they're doing these actions, activities, this is increasing the demand of oxygen by the extremities, but they have compromised blood flow. So when they're doing those activities, it impedes blood flow even more and it causes the pain. But whenever they rest, the pain will go away. It'll get better. And this pain can be described as a cramping or tingling feeling. However, with venous disease, their explanation of pain characteristics would be, they describe it as heavy, dull, throbbing. achy and the pain is actually worse when they're standing or sitting with their legs dangling for long periods of time and elevating the legs actually eases the pain and swelling so whenever you hear that from your patient that should tip you off oh this is probably Venus then s skin of the lower extremity as a nurse you want to look at the color of that lower extremity and feel the temperature that's going to tell you a lot because with arterial disease remember we have an issue with blood flow going there so the skin is going to feel cool to the touch and the skin is going to look a little unhealthy because it's not getting that nutrients it needs so the skin will be thin dry and scaly there will be no hair growing because there's not enough nutrients to create hair and there's going to be thick toenails and one thing you want to remember is what happens whenever the legs are dangled like what color do they turn versus whenever they're elevated. So to help you remember that, remember Dr. Epp. So when you dangle the patient's legs with arterial disease, the legs will be rubor where they're red and they're warm. That's because of inflammation. However, when you elevate the legs, they will become pale. With venous disease, there's not an issue with blood flow actually getting to that extremity. That's fine. It's an issue with it actually returning. So the extremity is going to feel warm. to the touch and they because they have that pulling that stagnant blood in that extremity the skin is going to be thick and tough and it can have that brownish color to the skin as you can see here in this picture next s is strength of pulse and lower extremity and again for arterial when you go to feel that pulse you're going to have difficulty or even finding it with a doppler it's going to be very poor and in severe cases it can be absent with Venus it's going to be present and typically normal then E for edema present with arterial It's not very common for them to have swelling with Venus It's very common and it tends to be worse at the end of the day then L for lesions and we're talking specifically about ulcers and you want to note the location and the appearance because this is going to tell you a lot and help you differentiate if It's arterial versus venous so for arterial main locations for these ulcers are going to be on the end of the toes, the dorsum of the feet, which is the top of the feet, and the lateral ankle region, that lateral malleolus. So whenever you take your hand, you feel your outside ankle, that's the area we're talking about. And the ulcer is going to have a unique appearance. There's going to be very little drainage. Well, we're not getting a lot of blood flow there, so you can't expect a lot of drainage. And there's going to be little tissue granulation in that womb base. It's going to be pale, very light pink, or it can even be necrotic and black again compromised blood flow and arterial ulcers are going to be deep they are sometimes termed as punched out it literally looks like someone just took their thumb and just punched it out in the skin so because of that that gives it noticeable margins and edges that will give it a round appearance and here you can see an example of an arterial ulcer we have it on the lateral malleolus area It literally looks like a punched out wound there in that area. The skin is very thin and scaly and there's very little drainage and we can see it's nice and round. We can see those edges. Then with venous ulcers the locations are a little bit different. They tend to be found on the medial parts of the lower leg, so below the kneecap, and the medial ankle region, so the medial malleolus. The ulcers tend to be to be swollen with a lot of drainage because remember we have blood pooling there and there's going to be granulation present because we don't have an issue with blood coming there so the wound base can be a deep pink to red color and the edges tend to be irregular they're not going to be round like with arterial and the depth of the wound is going to be shallow and here is an example of a venous ulcer also called a venous stasis ulcer and you can tell it's in the location A venous ulcer usually is. The base of the wound is nice and granulated. It's a deep pink to reddish color. It's very irregular, the edges of the wound, and it's a lot more shallow than that arterial ulcer. Plus notice the swelling. The skin looks very tight and there's that brown pigmentation that we were talking about earlier. Now let's wrap up this lecture and let's talk about the nursing interventions for peripheral arterial disease. disease and peripheral venous disease. So first PAD. Our role as a nurse, we're going to be playing a role with circulation, pain control, and maintaining that skin integrity and educating our patient on how to care for themselves if they have this condition. So circulation, we want to make sure that we are checking those pulses frequently and comparing them bilaterally. Not only are you going to palpate, but you want to use a doppler. This is where you use ultrasound jelly, get this little probe, this little device. You will put that probe over where the pulse site is and you will listen to the sound of the pulse and grade it. Also, you want to look at the color of the extremity. Is it really, really white? Is it starting to turn bluish, necrotic? That is not good. Also, sensation. How does a patient feel you touching their foot, assessing their extremities? Is there a big decrease in sensation? And the temperature. How does it feel? Is it cold? Is it hot? And we want to teach our patient what they can do to improve circulation because with PAD There's an issue with nice rich oxygenated blood making it to those extremities to provide them with oxygen So we want to teach the patient to avoid wearing tight clothing Socks shoes or putting any constrictive devices on those extremities because that's going to impede blood flow even more And avoiding extreme cold because that causes vaso constriction. So they want to make sure they loosely layer up those lower extremities to keep them warm and avoiding smoking because that causes vasoconstriction and they want to make sure that they have proper positioning. They don't want to do the knee flex position because that's going to impede blood flow or crossing the legs. They want to make sure that they take their medications as ordered and stress the importance of them like medications that lower the cholesterol. It's going to help decrease the amount of fat in the blood so they don't develop more fatty plaques within those arteries. Taking anticoagulants if they are ordered. And I have a whole bunch of videos on warfarin and heparin and your role as the nurse because this ties in with PAD. So if you want to check those out, they're available. And taking antiplatelet medications if ordered. They also want to follow a low-fat diet and participating in a walking program if the physician... thinks that would be beneficial for the patient. These programs can help patients who suffer from the intermittent claudication where they get that leg pain with any type of activity and what a walking program will do is it's going to help with that but it's also going to help increase the oxygen availability to those extremities which is going to help alleviate that pain plus the exercise that they'll be getting will help lower the cholesterol and help them with weight control. control. Other things you want to teach the patient about is inspecting their skin daily because whenever they have altered circulation to those extremities, they can have decreased sensation. So they may not know when they've stepped on something or let's say that they're trying to keep their feet warm. So they're using a heating pad. You want to discourage that because they may not feel when that heating pad is getting too hot to remove it so they could get unnecessary burns. And you want to teach them about testing the bath water before they actually get in it because they're at risk for injury. Also these patients who have severe PAD they are in a lot of pain so we want to make sure we're assessing their pain and managing their pain. And let me talk a little bit about how this can be diagnosed. They can do what's called an ankle brachial index and this is where they will measure the pressure in the legs and compare it to the pressure in the arms. If it's lower in the legs, that ratio of less than 0.9, that could indicate PAD. And many times they will do ABIs also after a patient's had a procedure to make sure the procedure was beneficial and they are actually getting better blood flow. So that ties in with some procedures that a patient can have. This includes percutaneous transluminal angioplasty. That's where they go in to the vessel that is affected. They can widen it. They can even place a stent. and that's going to help open up that vessel so more blood can go to that extremity. They can also do a peripheral artery bypass and just as the name says what they will do is they will let's say the blockage is here they will actually bypass that blockage and reroute the blood flow around that area so they can get blood flow or they can have an arthrectomy where they go in and they remove that fatty plaque. Many times patients to have PAD, they will have these procedures and if it just keeps getting worse and worse, the worst case scenario, they'll have to have an amputation of that affected extremity. And lastly, we have the nurse's role with venous disease. So with a patient who has this, we're going to be playing a huge role in helping increase blood return to the heart so it's not pulling in those lower extremities, providing skin care, preventing infection, identifying quarks. and help treat those clots per the physician's order. So we want to make sure we are monitoring our patients for clots. And again, we are talking about that with the DVTs. So look for any hard and red and warm areas that's causing your patient pain, report that. And a lot of patients will be prescribed anticoagulants. So again, that's like heparin, warfarin, you'll be playing a huge role in monitoring their clotting levels, administering that and teaching the patient those education pieces. And if they can't have an anticoagulant for some reason, they can get a filter place where it will be placed in the inferior vena cava and that will help prevent if a clot breaks off from going to the heart and lungs. So to help increase blood return, some simple things we can do is we can elevate those lower extremities above the heart level. That will help drain that blood back to the heart so it's not hanging out in the lower extremities. Then we can apply compression. compression stockings, whatever the physician orders. This will help facilitate that return of blood flow. So with that, you want to make sure you're putting those on your patients right whenever they get up because remember, as they go through the day, the swelling is going to get worse. You also want to make sure that these compression stockings are always clean and dry because many times these patients have ulcers that can weep and get them wet and we don't want to set them up for like a bacterial infection. And patients Patients who have those venous stasis ulcers that we talked about earlier, you'll be doing wound care. A lot of times wound care will be consulted. They'll come, they'll look at the patient. Either you will be responsible for changing that wound or they will come back and do it. However, your facility is set up with that. But many times patients who have venous stasis ulcers, they will have an Unaboo. And this is a wrap that has zinc oxide on it, which will help keep the wound moist and which will promote healing. And it provides It provides compression because it's wrapped with like an A-spandage. So these boots will help heal that wound, but also provide that compression. And it literally looks like a mid-calf boot on your patient. Okay, so that wraps up this review over peripheral vascular disease.

PVD is the impediment of blood flow within the peripheral vascular system due to damage to the vessels that make up that system. Now, your peripheral vascular system provides circulation to your arms, your hands, your feet and your legs. So it's a circulation outside of the heart and the brain.

And with peripheral vascular disease, it can affect either the arterial system, and if it does this, it's known as peripheral arterial disease, PAD, or it can affect the venous system, which it'll be called peripheral venous disease. But whether it's arterial or venous, most likely your patient is going to show signs and symptoms. their lower extremities because that's what's really going to be affected.

However, those signs and symptoms are going to be completely different and that's what I really want you to take away from this lecture for your exams. You want to know the difference between the signs and symptoms of arterial disease versus venous disease. So to help us understand those signs and symptoms, let's quickly review the arterial and venous system.

The arterial system carries oxygenated blood from the heart to the extremities. extremities and organs. And here in our illustration, the arterial system is represented in red. So your heart, with the assistance of the lungs, oxygenates the blood.

And the heart is going to pump that oxygenated blood out through the body. So it generates so much force where it's able to do that. And you can feel that because when you feel your arteries in your arms and in your feet, that's your heart contracting and shooting that blood to those extremities so they can get oxygen. them because if they don't get that oxygen they can't work and ischemia starts to occur and they will die so with like peripheral arterial disease that is what happens and a big cause of PAD is atherosclerosis and this is where fatty plaques accumulate in these arteries and that's going to limit the amount of blood that can get down and feed those extremities so whenever that happens you get a This will cause the patient pain and the patient can develop arterial ulcers because that tissue is not being fed. It starts to die.

If it's severe enough, the patient can start to experience necrosis of that extremity. Some patients, if it's not corrected, may have to have those extremities amputated. Then we have the venous system. It carries deoxygenated blood from the extremities and organs back to the heart so it can be oxygenated and here in our illustration the venous system is represented in blue so the venous system takes the blood this way back to the heart and the arterial system took it this way away from the heart so your arterial and venous system work together and in a sense they're like recycling the blood the arterial system takes the blood to the extremities to give them oxygen they consume it and now we got to do something with it needs to go back to the heart so the venous system achieves that. But it can only do that if you have healthy veins and healthy vein valves.

So in some diseases that are known as peripheral venous diseases like varicose veins, those valves are stretched in the veins so the blood really doesn't be able to go back to the heart. It just pulls in those extremities. Or if you have deep vein thrombosis where you have a clot deep in that vein.

prevent blood from being able to flow back to the heart. So a lot of patients what's going to happen is they're going to get the collection venous congestion in their extremities of this blood that can't flow back which is going to cause them pain. It'll be a heavy throbbing pain. It can also impair tissue integrity because you have the stagnant blood hanging out which isn't allowing the clearance of that cellular waste so that can break down the skin a lot of patients will have brown pigmentation of their skin and they can develop venous stasis ulcers as well along with a skin infection some patients will develop cellulitis now let's look at the risk factors for peripheral vascular disease and we're going to divide these into the risk factors for PAD versus the risk factors for peripheral venous disease so the risk factors for peripheral Arterial disease include conditions that cause vasoconstriction or actually damage those arteries which is going to affect how blood can be delivered throughout that peripheral vascular system. And some risk factors include smoking, tobacco use because it causes constriction of the arteries, also uncontrolled hypertension because whenever you have such high pressure within those arteries it can damage those arteries.

In addition high cholesterol so it's associated with associated with obesity and this is going along with that atherosclerosis where they have such a high fat count in their blood it's starting to adhere to those arterial walls which can affect blood flow. In addition a patient having diabetes also increases the risk of PAD. And some risk factors for peripheral venous disease would be conditions that are going to increase that venous pressure within those veins. damage those or overstretch those valves.

So some things that can increase a patient's risk for venous disease would be being female, for instance using birth control pills has been associated with venous disease, pregnancy just because the increased pressure in the venous system, obesity as well, or sitting or standing for a long period of time can damage those veins and valves along with advanced age. We've looked at the risk factors for PVD. Let's dive a little bit deeper and let's talk about those two different types of PVD.

So first we're going to talk about PAD, which again is peripheral arterial disease. And this is where we had narrowing of these arteries and we weren't getting that fresh oxygenated blood to those extremities. Now PAD tends to affect the lower extremities, but it can also affect any other area of the peripheral arterial system.

So what happens is that ischemia occurs and then tissue integrity is going to be compromised. So a main cause of PAD is atherosclerosis. And I hit on that a little bit earlier.

And this is where those fatty plaques collect in those arteries. And this can really be accelerated if the patient is a smoker, which is damaging those vessels. They have uncontrolled hypertension, which again damages the vessels. And they have high cholesterol. level so that fat can just stick to those damaged vessels and it's going to impede blood flow.

And what can happen unfortunately is that those fatty plaques can rupture, clot can form, and that can even further impede blood flow. Now a type of peripheral arterial disease that I want to hit on is called Renaud's disease and this is where you have vasospasm of those peripheral arteries. So whenever something vasospasms, it contracts down so whenever where we have that that's going to limit blood flow and it mainly occurs in those peripheral arteries that feed the toes and the fingers and it can also affect the nose and the ears patients can have signs and symptoms there now Renaud's disease is triggered by cold and stress remember that because with education you want to teach your patient to keep those extremities warm so this isn't triggered so what happens is let's say cold is a trigger for this person. They get cold in their extremities and the fingers and the toes start to turn extremely white.

They can even turn blue. Then whenever that cold or stress is removed, that vasospasm eases up, the blood flow starts to return, but then they'll start to experience a tingling, prickling sensation in those areas, followed by extreme red extremities. So those are the signs and symptoms associated with that. Then we have birth...

Burgers disease, and this actually affects both the arteries and the veins. And this is where you have inflammation of those arteries and veins, and then clots happen. So the inflammation is damaging those vessels. Clots start to form.

When we have a clot, that blocks blood flow. And this tends to occur in the feet and the hands. And patients who are at most risk for this are patients who smoke.

So a big thing you want to remember from a nursing standpoint is patients who have Burgers disease, You want to educate them about the importance of quit smoking because that's why it's causing this disease So treatment therapy is going to be related to Improving and increasing blood flow which we're going to hit more on in our nursing interventions Then we have peripheral venous disease and venous diseases again are where those veins are Unable to help that blood go back to the heart and this can occur because the veins are damaged or they're vascular of walls are overstretched Or there's a clot somewhere within that vein that is limiting the blood being able to return to the heart. But whatever the case, if it's severe enough, what will happen is that you'll get blood that will start to pull in that extremity. It becomes stagnant.

This is going to lead to a lot of swelling, edema, and it's going to alter tissue nutrition, which can lead to the development of ulcers and a bacterial infection like cellulitis. So some things that can lead to this are like varicose veins. And you can notice this in a patient's legs.

They will be rope-like veins on the surface of the skin. And this is where those vein walls are overstretched and there are valves. So what can help with this is like compression or they can have procedures to help with those veins. In addition, we have deep vein thrombosis, also called a DVT.

And just as the name says, this is the development of clots deep within the veins. And DVTs are dangerous because they can break off and go to the lungs leading to a pulmonary embolism. And some signs and symptoms of a DVT would be that the extremity is extremely warm, has a hardened area, it's very red, patient may have some pain.

And an ultrasound can be used to help detect that. So if a patient does have that, you want to report that to the doctor immediately and they can get them on blood thinners. or procedures, a filter to help with that not going to the lungs.

And I'm going to be doing a whole lecture on deep vein thrombosis that you may want to check out. Then we have a superficial venous thrombosis. This is a little bit different than a DBT because this is a clot that has developed in the superficial veins, usually to the hands, to the feet. And then we have chronic venous insufficiency. And this is where those veins are just really messed up in that they're over.

stretched and it's not allowing blood to return to the heart. Now we're going to talk about the differences between arterial and venous disease in regards to how your patient is going to be presenting and what you're going to be seeing as the nurse. So these are six things you want to assess and ask the patient to help you determine if it's arterial or venous disease and to help us remember those things we're going to remember the word vessel. V is for various positions that help alleviate the pain. So you want to ask your patients about the positions that they put their lower extremities in to help with this.

And patients who have arterial disease they're going to tell you that it helps alleviate the pain whenever they dangle their legs down or also known as the dependent position. And the reason for this is because they're having that ischemia and there's issues with that blood going to that extremity. So when they put it down, dangle it, that actually helps increase the blood flow so alleviates the pain.

But they will also tell you that when they elevate their extremity it makes the pain worse and why is that well? It's just what we learned to have how that arterial system works elevating the leg that's going to limit blood flow even more So of course those extremities are going to be limited and how much oxygen they're gonna get so they're gonna signal to the person Hey, we're not getting oxygen this hurts So elevating would make the pain worse then on the flip side with venous disease The patient is going to tell you that elevating their legs is actually going to help with the pain and it's going to help decrease the swelling and the reason for this is just how that venous system works remember its goal is to return the blood to the heart so elevating is going to help get that blood going there so that's going to relieve that pain that they're having and decrease that swelling so dangling their legs or setting in a sitting position or standing for long periods of time will actually make their pain worse and increase the edema. So it's the opposite for these two diseases. Then E, you want to ask your patient about their explanation of the pain.

Like what's the characteristics of it? So with arterial, your patients are going to report that the pain is sharp and it's going to be worse at night. And this is known as rest pain because what happens is when they're lying in bed, they have their legs straight out in that horizontal position.

And this is affecting blood flow. So they'll wake up in the middle of the night. with pain in their leg and then to help the pain they'll throw that leg off the bed and dangle it to alleviate the pain and that again is just going to help get some blood going to that extremity and a hallmark sign and symptom you want to remember for arterial disease is termed intermittent claudication and this is where when the patient does activity such as walking running they will get this severe pain in their legs like the calf muscles the thighs or the buttocks and this is because Because whenever they're doing these actions, activities, this is increasing the demand of oxygen by the extremities, but they have compromised blood flow. So when they're doing those activities, it impedes blood flow even more and it causes the pain.

But whenever they rest, the pain will go away. It'll get better. And this pain can be described as a cramping or tingling feeling.

However, with venous disease, their explanation of pain characteristics would be, they describe it as heavy, dull, throbbing. achy and the pain is actually worse when they're standing or sitting with their legs dangling for long periods of time and elevating the legs actually eases the pain and swelling so whenever you hear that from your patient that should tip you off oh this is probably Venus then s skin of the lower extremity as a nurse you want to look at the color of that lower extremity and feel the temperature that's going to tell you a lot because with arterial disease remember we have an issue with blood flow going there so the skin is going to feel cool to the touch and the skin is going to look a little unhealthy because it's not getting that nutrients it needs so the skin will be thin dry and scaly there will be no hair growing because there's not enough nutrients to create hair and there's going to be thick toenails and one thing you want to remember is what happens whenever the legs are dangled like what color do they turn versus whenever they're elevated. So to help you remember that, remember Dr. Epp.

So when you dangle the patient's legs with arterial disease, the legs will be rubor where they're red and they're warm. That's because of inflammation. However, when you elevate the legs, they will become pale. With venous disease, there's not an issue with blood flow actually getting to that extremity.

That's fine. It's an issue with it actually returning. So the extremity is going to feel warm.

to the touch and they because they have that pulling that stagnant blood in that extremity the skin is going to be thick and tough and it can have that brownish color to the skin as you can see here in this picture next s is strength of pulse and lower extremity and again for arterial when you go to feel that pulse you're going to have difficulty or even finding it with a doppler it's going to be very poor and in severe cases it can be absent with Venus it's going to be present and typically normal then E for edema present with arterial It's not very common for them to have swelling with Venus It's very common and it tends to be worse at the end of the day then L for lesions and we're talking specifically about ulcers and you want to note the location and the appearance because this is going to tell you a lot and help you differentiate if It's arterial versus venous so for arterial main locations for these ulcers are going to be on the end of the toes, the dorsum of the feet, which is the top of the feet, and the lateral ankle region, that lateral malleolus. So whenever you take your hand, you feel your outside ankle, that's the area we're talking about. And the ulcer is going to have a unique appearance.

There's going to be very little drainage. Well, we're not getting a lot of blood flow there, so you can't expect a lot of drainage. And there's going to be little tissue granulation in that womb base.

It's going to be pale, very light pink, or it can even be necrotic and black again compromised blood flow and arterial ulcers are going to be deep they are sometimes termed as punched out it literally looks like someone just took their thumb and just punched it out in the skin so because of that that gives it noticeable margins and edges that will give it a round appearance and here you can see an example of an arterial ulcer we have it on the lateral malleolus area It literally looks like a punched out wound there in that area. The skin is very thin and scaly and there's very little drainage and we can see it's nice and round. We can see those edges.

Then with venous ulcers the locations are a little bit different. They tend to be found on the medial parts of the lower leg, so below the kneecap, and the medial ankle region, so the medial malleolus. The ulcers tend to be to be swollen with a lot of drainage because remember we have blood pooling there and there's going to be granulation present because we don't have an issue with blood coming there so the wound base can be a deep pink to red color and the edges tend to be irregular they're not going to be round like with arterial and the depth of the wound is going to be shallow and here is an example of a venous ulcer also called a venous stasis ulcer and you can tell it's in the location A venous ulcer usually is. The base of the wound is nice and granulated. It's a deep pink to reddish color.

It's very irregular, the edges of the wound, and it's a lot more shallow than that arterial ulcer. Plus notice the swelling. The skin looks very tight and there's that brown pigmentation that we were talking about earlier.

Now let's wrap up this lecture and let's talk about the nursing interventions for peripheral arterial disease. disease and peripheral venous disease. So first PAD.

Our role as a nurse, we're going to be playing a role with circulation, pain control, and maintaining that skin integrity and educating our patient on how to care for themselves if they have this condition. So circulation, we want to make sure that we are checking those pulses frequently and comparing them bilaterally. Not only are you going to palpate, but you want to use a doppler. This is where you use ultrasound jelly, get this little probe, this little device.

You will put that probe over where the pulse site is and you will listen to the sound of the pulse and grade it. Also, you want to look at the color of the extremity. Is it really, really white?

Is it starting to turn bluish, necrotic? That is not good. Also, sensation.

How does a patient feel you touching their foot, assessing their extremities? Is there a big decrease in sensation? And the temperature.

How does it feel? Is it cold? Is it hot?

And we want to teach our patient what they can do to improve circulation because with PAD There's an issue with nice rich oxygenated blood making it to those extremities to provide them with oxygen So we want to teach the patient to avoid wearing tight clothing Socks shoes or putting any constrictive devices on those extremities because that's going to impede blood flow even more And avoiding extreme cold because that causes vaso constriction. So they want to make sure they loosely layer up those lower extremities to keep them warm and avoiding smoking because that causes vasoconstriction and they want to make sure that they have proper positioning. They don't want to do the knee flex position because that's going to impede blood flow or crossing the legs.

They want to make sure that they take their medications as ordered and stress the importance of them like medications that lower the cholesterol. It's going to help decrease the amount of fat in the blood so they don't develop more fatty plaques within those arteries. Taking anticoagulants if they are ordered.

And I have a whole bunch of videos on warfarin and heparin and your role as the nurse because this ties in with PAD. So if you want to check those out, they're available. And taking antiplatelet medications if ordered.

They also want to follow a low-fat diet and participating in a walking program if the physician... thinks that would be beneficial for the patient. These programs can help patients who suffer from the intermittent claudication where they get that leg pain with any type of activity and what a walking program will do is it's going to help with that but it's also going to help increase the oxygen availability to those extremities which is going to help alleviate that pain plus the exercise that they'll be getting will help lower the cholesterol and help them with weight control. control.

Other things you want to teach the patient about is inspecting their skin daily because whenever they have altered circulation to those extremities, they can have decreased sensation. So they may not know when they've stepped on something or let's say that they're trying to keep their feet warm. So they're using a heating pad.

You want to discourage that because they may not feel when that heating pad is getting too hot to remove it so they could get unnecessary burns. And you want to teach them about testing the bath water before they actually get in it because they're at risk for injury. Also these patients who have severe PAD they are in a lot of pain so we want to make sure we're assessing their pain and managing their pain. And let me talk a little bit about how this can be diagnosed.

They can do what's called an ankle brachial index and this is where they will measure the pressure in the legs and compare it to the pressure in the arms. If it's lower in the legs, that ratio of less than 0.9, that could indicate PAD. And many times they will do ABIs also after a patient's had a procedure to make sure the procedure was beneficial and they are actually getting better blood flow.

So that ties in with some procedures that a patient can have. This includes percutaneous transluminal angioplasty. That's where they go in to the vessel that is affected. They can widen it. They can even place a stent.

and that's going to help open up that vessel so more blood can go to that extremity. They can also do a peripheral artery bypass and just as the name says what they will do is they will let's say the blockage is here they will actually bypass that blockage and reroute the blood flow around that area so they can get blood flow or they can have an arthrectomy where they go in and they remove that fatty plaque. Many times patients to have PAD, they will have these procedures and if it just keeps getting worse and worse, the worst case scenario, they'll have to have an amputation of that affected extremity.

And lastly, we have the nurse's role with venous disease. So with a patient who has this, we're going to be playing a huge role in helping increase blood return to the heart so it's not pulling in those lower extremities, providing skin care, preventing infection, identifying quarks. and help treat those clots per the physician's order.

So we want to make sure we are monitoring our patients for clots. And again, we are talking about that with the DVTs. So look for any hard and red and warm areas that's causing your patient pain, report that.

And a lot of patients will be prescribed anticoagulants. So again, that's like heparin, warfarin, you'll be playing a huge role in monitoring their clotting levels, administering that and teaching the patient those education pieces. And if they can't have an anticoagulant for some reason, they can get a filter place where it will be placed in the inferior vena cava and that will help prevent if a clot breaks off from going to the heart and lungs. So to help increase blood return, some simple things we can do is we can elevate those lower extremities above the heart level. That will help drain that blood back to the heart so it's not hanging out in the lower extremities.

Then we can apply compression. compression stockings, whatever the physician orders. This will help facilitate that return of blood flow.

So with that, you want to make sure you're putting those on your patients right whenever they get up because remember, as they go through the day, the swelling is going to get worse. You also want to make sure that these compression stockings are always clean and dry because many times these patients have ulcers that can weep and get them wet and we don't want to set them up for like a bacterial infection. And patients Patients who have those venous stasis ulcers that we talked about earlier, you'll be doing wound care. A lot of times wound care will be consulted.

They'll come, they'll look at the patient. Either you will be responsible for changing that wound or they will come back and do it. However, your facility is set up with that. But many times patients who have venous stasis ulcers, they will have an Unaboo.

And this is a wrap that has zinc oxide on it, which will help keep the wound moist and which will promote healing. And it provides It provides compression because it's wrapped with like an A-spandage. So these boots will help heal that wound, but also provide that compression.

And it literally looks like a mid-calf boot on your patient. Okay, so that wraps up this review over peripheral vascular disease.

Transcript for:Lecture on Peripheral Vascular Disease (PVD)

Transcript for:
Lecture on Peripheral Vascular Disease (PVD)