1. DIAGNOSIS/DEFINITION: Impairment of the flow in the vascular system caused by narrowing, blockage, or spasms, resulting in decreased blood and oxygen flow to the extremities.
2. HEALTH PROMOTION & DISEASE PREVENTION
2.1. Healthy diet- low cholesterol intake, avioiding greasy or fried foods, foods high in sugar
2.2. Quitting smoking
2.3. Maintain a healthy weight, loose weight if in the overweight or obese category
2.4. Stay active- exercise for atleast 30 minutes most days of the week
2.5. Compliance with medications and follow-up appointments for underlying conditions such as:
2.5.1. Diabetes- regular glucose monitoring, insulin as indicated
2.5.2. Hypertension- regular blood pressure monitoring, stress reduction, BP medications
2.5.3. History of stroke or blood clots- strict compliance with prescribed anticoagulants
3. PATHOPHYSIOLOGY: There are various types of peripheral vascular disease, characterized by different ways blood flow is impeded. TYPES of PVD include:
3.1. Artherosclerosis- build up of plaque caused by increased cholesterol levels in the blood, resulting in thickening, hardening, and narrowing of the blood vessel. This impedes adequate blood flow and increases the chance of clot formation. Can produce a heart attack or stroke.
3.2. Carotid artery disease- results from artherosclerosis, where the carotid artery is stenosed/narrowed by fatty plaque build-up. Has same characteristics as stated above.
3.3. Deep vein thrombosis- serious blood clot which forms in a deep vein, usually in the leg. Can form into an embolus.
3.4. Chronic venous insufficiency- characterized by a weakening in the veins, usually of the extrermities, where they are unable to return blood flow to the heart. Causes pooling of blood in the extremeties.
3.5. Raynaud's disease- spasming/constricting of arteries in extremeties causing pain, numbness, and pallor. Usually caused by cold temperatures or stress.
3.6. Buerger's disease- inflammation of blood vessels in the hands and feet restricting blood flow, characterized by pain and dark discoloration of fingers/toes. Usually brought on by smoking or genetics.
3.7. Varicose veins- weakening of superficial veins, causing them to pool blood or swell. Can develop from old age, pregnancy, obesity, or sitting or standing for long periods of time. Varicose veins are mostly harmless.
4. LABORATORY TESTS
4.1. Cholesterol- LDL, HDL, Triglycerides
4.2. Blood glucose levels
4.3. End-organ injury lab tests
4.3.1. BUN, creatinine
4.3.2. CBC
4.3.3. Urine- electrolyte studies
5. EXPECTED FINDINGS (signs/symptoms)
5.1. Skin discoloration
5.1.1. pallor, blue/red/purple color, thin, shiny skin
5.2. Pain, numbness, tingling, weakness, heaviness in extremeties
5.3. hair loss in affected extremeties
5.4. Chronic non-healing wounds
5.5. Coolness
5.6. Weak pulses
5.7. Thickened toe nails
6. SAFETY CONSIDERATIONS
6.1. Wear comfortable, proper fitting shoes, shoes around the house to prevent wounds on feet
6.2. Use caution when cutting/trimming toenails
6.3. Use caution when setting the bath/shower temperature, or using any heating or cooling pads in hands/feet as feeling is gone or diminished.
7. COMPLICATIONS
7.1. Formation of chronic, non-healing wounds that could lead to cellulitis, infections, and sepsis
7.2. Burns if caution is not used as stated in safety considerations
7.3. Blood clots, which can lead to pulmonary embolism, stroke, or heart attack.
7.4. Possible amputation of extremety.
8. DIAGNOSTIC PROCEDURES
8.1. Ankle-brachial index- first-line diagnostic tool for PVD. This test uses a blood pressure cuff and an ultrasound to take the blood pressure in the arm and compare it to the blood pressure in the ankle. A healthy ABI is 1.0 or greater. If the result is less than 0.9, it is an indicator of PVD.
8.1.1. An exercise ABI test is performed the same way after walking on a treadmill. A decrease in the ABI of 20% or more is abnormal.
8.2. 6-minute walking/treadmill test- A provider evaluates the patient's ability to walk for 6 minutes to assess the blood flow and the degree of impaired mobility.
8.3. Doppler ultrasound- evaluates force of blood flow in extremeties
8.4. Angiogram- procedure in which a catheter is inserted into an artery (usually radial or femoral) and guided to the affected area to inject a dye, in which xrays are taken in order to see any blockages in the vessel. Requires some degree of sedation.
8.4.1. Computed Tomography Angiography (CTA)- less invasive procedure where dye is injected into a vein in a CT scanner requiring no sedation.
8.5. Magnetic Resonance Angiography- examines structures of vessels to determine blood flow.
8.6. Leg elevation test- patient lays on their back and raises their legs 45-60 degree angle and holds the position for 1-2 minutes. The lower legs and feet will be examined for pallor, rubor, pain, and tingling. Possible dopplering included.
9. RISK FACTORS
9.1. Smoking
9.2. Age (after 50 y/o)
9.3. Diabetes
9.4. Hypertesion
9.5. Hyperlipidemia
9.6. Genetics- family history of PVD, CAD, stroke
9.7. Obesity (BMI over 30)
9.8. Sedentary lifestyle
10. cilostazol can also be used to relieve pain by reintroducing blood flow to the extremity. It can allow patients to be able to walk longer distances without pain.
11. MEDICATIONS
11.1. Antiplatelets
11.1.1. aspirin clopidogrel apixaban ticagrelor
11.2. Anticoagulants
11.2.1. warfarin enoxaparin heparin
11.3. Cholesterol drugs (statins)
11.3.1. atorvastation pravastatin rosuvastatin lovastatin
11.4. Vasodilators
11.4.1. Ace inhibitors
11.4.1.1. lisinopril, benazepril
11.4.2. ARBS
11.4.2.1. losartan
11.4.3. diltiazem hydralazine verapamil nifedipine amlodipine cilostazol
12. NURSING CONSIDERATIONS
12.1. Nursing care
12.1.1. Provide education, symptom management with listed medications and therapeutic procedures, provide emotional support, wound care if indicated
12.2. Therapeutic Procedures
12.2.1. Anti-embolism stockings, elevate legs in venous insufficiency, lower legs in arterial insufficiency
12.2.1.1. Treatment includes angioplasty, which is a procedure that opens arteries with a balloon or a stent
12.3. Client education
12.3.1. Educate patients on the points listed under signs/symptoms, health promotion, and safety considerations
12.4. Interprofessional Care
12.4.1. Primary care doctor, nutritionist, cardio trainer for exercise that specializes in heart conditions, vascular specialist, diabeties educator if indicated