Online Audio: Bruit
CHAPTER 30
UNIT 4 NURSING CARE OF CLIENTS WHO HAVE EXPECTED FINDINGS
CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS ●● Burning, cramping, and pain in the legs during exercise
(intermittent claudication)
CHAPTER 30 Peripheral Vascular ●● Numbness or burning pain, primarily in the feet
Diseases
when in bed
●● Pain that is relieved by placing legs at rest in a
dependent position
PHYSICAL FINDINGS
Peripheral vascular diseases include peripheral ●● Bruit over femoral and aortic arteries
●● Decreased capillary refill of toes (greater than
arterial disease (PAD) and peripheral venous 3 seconds)
disorders, both of which interfere with normal ●● Decreased or nonpalpable pulses
●● Loss of hair on lower calf, ankle, and foot
blood flow. PAD affects arteries (blood vessels ●● Dry, scaly, shiny, skin
that carry blood away from the heart), and ●● Thick toenails
●● Cold and cyanotic extremity
peripheral venous disease affects veins (blood ●● Pallor of extremity with elevation
vessels that carry blood toward the heart). ●● Dependent rubor (redness) of the extremity (30.1)
●● Muscle atrophy
●● Ulcers and possible gangrene of toes
Peripheral arterial disease
●● PAD results from atherosclerosis that usually occurs
in the arteries of the lower extremities and is
characterized by inadequate flow of blood.
●● Atherosclerosis is caused by a gradual thickening of the
intima and media of the arteries, ultimately resulting in
the progressive narrowing of the vessel lumen. Plaques
can form on the walls of the arteries, making them
rough and fragile.
30.1 Rubor
●● Progressive stiffening of the arteries and narrowing of
the lumen decreases the blood supply to affected tissues
and increases resistance to blood flow.
●● Atherosclerosis is a type of arteriosclerosis, which
means “hardening of the arteries” and alludes to the
loss of elasticity of arteries over time due to thickening
of their walls.
●● PAD is classified as inflow (distal aorta and iliac
arteries) or outflow (femoral, popliteal, and tibial
arteries) and can range from mild to severe. Tissue
damage occurs below the arterial obstruction.
●● Buerger’s disease, subclavian steal syndrome, thoracic
outlet syndrome, Raynaud’s disease, and popliteal
entrapment are examples of PAD.
DATA COLLECTION
RISK FACTORS
●● Hypertension
●● Hyperlipidemia
●● Diabetes mellitus
●● Cigarette smoking
●● Obesity
●● Sedentary lifestyle
●● Familial predisposition
●● Female clients
●● Older adult clients
PN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 Peripheral Vascular Diseases 201
, DIAGNOSTIC PROCEDURES PATIENT‑CENTERED CARE
Arteriography
NURSING CARE
●● Arteriography of the lower extremities involves arterial ●● Encourage the client to exercise to build
injection of contrast medium to visualize areas of
collateral circulation.
decreased arterial flow on an x‑ray. ◯◯ Initiate exercise gradually and increase slowly.
●● It is usually done only to determine isolated areas of ◯◯ Instruct the client to walk until the point of pain, stop
occlusion that can be treated during the procedure with
and rest, and then walk a little farther.
percutaneous transluminal angioplasty and possible ●● Promote vasodilation and avoid vasoconstriction.
stent placement. ◯◯ Provide a warm environment for the client.
NURSING ACTIONS ◯◯ Have the client wear insulated socks.
●● Observe for bleeding and hemorrhage. ◯◯ Tell the client to never apply direct heat, such as
●● Palpate pedal pulses to identify possible occlusions. a heating pad, to the affected extremity because
sensitivity is decreased, and this can cause a burn.
Exercise tolerance testing ◯◯ Instruct the client to avoid exposure to cold (causes
vasoconstriction and decreased arterial flow).
A stress test is done with or without the use of a treadmill ◯◯ Instruct the client to avoid stress, caffeine, and
with measurement of pulse volumes and blood pressures
nicotine, which also cause vasoconstriction.
prior to and following the onset of manifestations or ■■ Vasoconstriction is avoided when the client abstains
5 min of exercise.
from smoking or chewing tobacco.
●● Medications such as dipyridamole and adenosine may
■■ Vasoconstriction of vessels lasts up to 1 hr after
be given to mimic the effects of exercise in clients who
smoking or chewing tobacco.
cannot tolerate a treadmill.
●● Delays in return to normal pressures and pulse POSITIONING
waveforms indicate arterial disease. ●● Instruct the client to avoid crossing the legs.
●● It is used to evaluate claudication during exercise. ●● Tell the client to refrain from wearing
restrictive garments.
Plethysmography ●● Tell the client to elevate the legs to reduce swelling, but
not to elevate them above the level of the heart because
●● Plethysmography is used to determine the variations
extreme elevation slows arterial blood flow to the feet.
of blood passing through an artery, thus identifying
abnormal arterial flow in the affected limb.
●● Blood pressure cuffs are attached to the client’s upper MEDICATIONS
extremities, a lower extremity, and the plethysmograph
machine. Variations in peripheral pulses between the Antiplatelet medications
upper and lower extremity are recorded.
Aspirin, clopidogrel, pentoxifylline
●● A decrease in pulse pressure of the lower extremity
Antiplatelet medications reduce blood viscosity by
indicates a possible blockage in the leg.
decreasing blood fibrinogen levels, enhancing erythrocyte
flexibility, and increasing blood flow in the extremities.
Segmental systolic blood pressure measurements ●● Medications such as aspirin and clopidogrel may
●● A Doppler probe is used to take various blood be prescribed.
pressure measurements (thigh, calf, ankle, brachial) ●● Pentoxifylline, sometimes referred to as a
for comparison. In the absence of PAD, pressures in hemorheologic medication, was one of the first to be
the lower extremities are higher than those of the used and is still used, but less commonly than other
upper extremities. medications. It may be given to specifically treat
●● With arterial disease, the pressures in the thigh, calf, intermittent claudication in clients who have PAD.
and ankle are lower.
CLIENT EDUCATION
●● The medication’s effects might not be apparent for
Magnetic resonance angiography
several weeks.
A contrast medium, such as gadolinium, is injected to help ●● Monitor for evidence of bleeding (abdominal pain;
visualize blood flow through peripheral arteries. coffee‑ground emesis; black, tarry stools).
Ankle‑brachial index (ABI) Statins
The ankle pressure is compared to the brachial pressure. Simvastatin, atorvastatin: Can relieve manifestations
The expected finding for ABI is 0.9 to 1.3. ABI less than 0.9 associated with PAD (intermittent claudication).
in either leg is diagnostic for PAD.
Doppler‑derived maximal systolic acceleration
A technique that is especially helpful for evaluating PAD in
clients who have diabetes mellitus.
202 CHAPTER 30 Peripheral Vascular Diseases CONTENT MASTERY SERIES
, THERAPEUTIC PROCEDURES ●● Monitor blood pressure. Hypotension can result
in an increased risk of clotting or graft collapse,
Percutaneous transluminal angioplasty while hypertension increases the risk for bleeding
and laser‑assisted angioplasty from sutures.
●● Instruct the client to limit bending of the hip and knee
●● Percutaneous transluminal angioplasty is an invasive
to decrease the risk of clot formation.
intra‑arterial procedure using a balloon and stent to ●● Monitor incisions.
open and help maintain the patency of the vessel. ●● Instruct the client on wound care if revascularization
●● Laser‑assisted angioplasty is an invasive procedure
surgery was done.
in which a laser probe is advanced through a cannula
to the site of stenosis. The laser is used to vaporize CLIENT EDUCATION
atherosclerotic plaque and open the artery. ●● Avoid crossing or raising legs above the level of
the heart.
NURSING ACTIONS ●● Wear loose clothing.
●● The priority action is to observe for bleeding at the ●● Abstain from tobacco use, and avoid exposure to
puncture site.
cold temperatures.
●● Monitor vital signs, peripheral pulses, and ●● Practice adequate foot care (keep feet clean and dry,
capillary refill.
wear good‑fitting shoes, never go barefoot, cut toenails
●● Keep the client on bed rest with the limb straight for
straight across or have the podiatrist cut nails).
2 to 6 hr before ambulation.
●● Anticoagulant therapy is used during the procedure,
followed by antiplatelet therapy for 1 to 3 months.
COMPLICATIONS
Mechanical rotational abrasive atherectomy
Graft occlusion
Uses a rotational device to scrape plaque from the inside
Graft occlusion is a serious complication of arterial
of the client’s peripheral artery. The device is designed to
revascularization and often occurs within the first 24 hr
cause minimal damage to the surface of the artery.
following surgery.
NURSING ACTIONS
NURSING ACTIONS
●● The priority action is to observe for bleeding at the ●● Promptly notify the surgeon of manifestations of
puncture site.
occlusion (absent or reduced pedal pulses, increased
●● Monitor vital signs, peripheral pulses, and
pain, change in extremity color or temperature).
capillary refill. ●● Be prepared to assist with treatment, which can include
●● Keep the client on bed rest with the limb straight for
an emergency thrombectomy (removal of a clot), local
2 to 6 hr before ambulation.
intra‑arterial thrombolytic therapy with an agent
●● Anticoagulant therapy is used during the procedure,
such as tissue plasminogen activator, infusion of a
followed by antiplatelet therapy for 1 to 3 months.
platelet inhibitor, or a combination of these. With these
treatments, monitor for indications of bleeding.
Arterial revascularization surgery
Used with clients who have severe claudication or limb Wound or graft infection
pain at rest, or with clients who are at risk for losing a
An infection of the surgical wound or graft is a potentially
limb due to poor arterial circulation.
life‑threatening complication.
●● Bypass grafts are used to reroute the circulation around
the arterial occlusion. NURSING ACTIONS
●● Grafts can be harvested from the client (autologous) or ●● Use sterile technique when changing the surgical
made from synthetic materials. dressing or providing wound care.
●● Indications of infection include localized induration,
NURSING ACTIONS
warmth, tenderness, erythema, edema, purulent
●● The priority action is to maintain adequate circulation
drainage, and an elevated WBC. Promptly report
in the repaired artery. The location of the pedal or
findings to the provider.
dorsalis pulse should be marked, and its pulsatile
strength compared with the contralateral leg on a
scheduled basis using a Doppler.
●● Color, temperature, sensation, and capillary refill should
be compared with the contralateral extremity on a
scheduled basis.
●● Monitor for warmth, redness, and edema of the affected
limb as a result of increased blood flow.
●● Monitor for pain, which can be severe due to the
reestablishment of blood flow to the extremity.
PN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 Peripheral Vascular Diseases 203
, Compartment syndrome
Peripheral venous disorders
Compartment syndrome is considered a medical
Peripheral venous disorders are problems with the veins
emergency. Tissue pressure within a confined body space
that interfere with adequate return of blood flow from
can restrict blood flow, and the resulting ischemia can
the extremities.
lead to irreversible tissue damage. (30.2) ●● There are superficial and deep veins in the lower
NURSING ACTIONS extremities that have valves that prevent backflow
●● Manifestations of compartment syndrome include of blood as it returns to the heart. The action
tingling, numbness, worsening pain, edema, pain on of the skeletal muscles of the lower extremities
passive movement, and unequal pulses. Immediately during walking and other activities also promotes
report findings to the provider. venous return.
●● Loosen dressings. ●● Three peripheral venous disorders that nurses should
●● Prepare to assist with fasciotomy (surgical opening into be familiar with are venous thromboembolism (VTE),
the tissues), which can be necessary to prevent further venous insufficiency, and varicose veins.
injury and to save the limb.
VTEis a blood clot believed to form as a result of venous
stasis, endothelial injury, or hypercoagulability. Thrombus
formation can lead to a pulmonary embolism, which
is a life‑threatening complication. Thrombophlebitis
refers to a thrombus that is associated with
inflammation. (30.3, 30.4)
30.2 Compartment syndrome
30.3 Deep‑vein thrombosis 30.4 Thrombophlebitis
204 CHAPTER 30 Peripheral Vascular Diseases CONTENT MASTERY SERIES
CHAPTER 30
UNIT 4 NURSING CARE OF CLIENTS WHO HAVE EXPECTED FINDINGS
CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS ●● Burning, cramping, and pain in the legs during exercise
(intermittent claudication)
CHAPTER 30 Peripheral Vascular ●● Numbness or burning pain, primarily in the feet
Diseases
when in bed
●● Pain that is relieved by placing legs at rest in a
dependent position
PHYSICAL FINDINGS
Peripheral vascular diseases include peripheral ●● Bruit over femoral and aortic arteries
●● Decreased capillary refill of toes (greater than
arterial disease (PAD) and peripheral venous 3 seconds)
disorders, both of which interfere with normal ●● Decreased or nonpalpable pulses
●● Loss of hair on lower calf, ankle, and foot
blood flow. PAD affects arteries (blood vessels ●● Dry, scaly, shiny, skin
that carry blood away from the heart), and ●● Thick toenails
●● Cold and cyanotic extremity
peripheral venous disease affects veins (blood ●● Pallor of extremity with elevation
vessels that carry blood toward the heart). ●● Dependent rubor (redness) of the extremity (30.1)
●● Muscle atrophy
●● Ulcers and possible gangrene of toes
Peripheral arterial disease
●● PAD results from atherosclerosis that usually occurs
in the arteries of the lower extremities and is
characterized by inadequate flow of blood.
●● Atherosclerosis is caused by a gradual thickening of the
intima and media of the arteries, ultimately resulting in
the progressive narrowing of the vessel lumen. Plaques
can form on the walls of the arteries, making them
rough and fragile.
30.1 Rubor
●● Progressive stiffening of the arteries and narrowing of
the lumen decreases the blood supply to affected tissues
and increases resistance to blood flow.
●● Atherosclerosis is a type of arteriosclerosis, which
means “hardening of the arteries” and alludes to the
loss of elasticity of arteries over time due to thickening
of their walls.
●● PAD is classified as inflow (distal aorta and iliac
arteries) or outflow (femoral, popliteal, and tibial
arteries) and can range from mild to severe. Tissue
damage occurs below the arterial obstruction.
●● Buerger’s disease, subclavian steal syndrome, thoracic
outlet syndrome, Raynaud’s disease, and popliteal
entrapment are examples of PAD.
DATA COLLECTION
RISK FACTORS
●● Hypertension
●● Hyperlipidemia
●● Diabetes mellitus
●● Cigarette smoking
●● Obesity
●● Sedentary lifestyle
●● Familial predisposition
●● Female clients
●● Older adult clients
PN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 Peripheral Vascular Diseases 201
, DIAGNOSTIC PROCEDURES PATIENT‑CENTERED CARE
Arteriography
NURSING CARE
●● Arteriography of the lower extremities involves arterial ●● Encourage the client to exercise to build
injection of contrast medium to visualize areas of
collateral circulation.
decreased arterial flow on an x‑ray. ◯◯ Initiate exercise gradually and increase slowly.
●● It is usually done only to determine isolated areas of ◯◯ Instruct the client to walk until the point of pain, stop
occlusion that can be treated during the procedure with
and rest, and then walk a little farther.
percutaneous transluminal angioplasty and possible ●● Promote vasodilation and avoid vasoconstriction.
stent placement. ◯◯ Provide a warm environment for the client.
NURSING ACTIONS ◯◯ Have the client wear insulated socks.
●● Observe for bleeding and hemorrhage. ◯◯ Tell the client to never apply direct heat, such as
●● Palpate pedal pulses to identify possible occlusions. a heating pad, to the affected extremity because
sensitivity is decreased, and this can cause a burn.
Exercise tolerance testing ◯◯ Instruct the client to avoid exposure to cold (causes
vasoconstriction and decreased arterial flow).
A stress test is done with or without the use of a treadmill ◯◯ Instruct the client to avoid stress, caffeine, and
with measurement of pulse volumes and blood pressures
nicotine, which also cause vasoconstriction.
prior to and following the onset of manifestations or ■■ Vasoconstriction is avoided when the client abstains
5 min of exercise.
from smoking or chewing tobacco.
●● Medications such as dipyridamole and adenosine may
■■ Vasoconstriction of vessels lasts up to 1 hr after
be given to mimic the effects of exercise in clients who
smoking or chewing tobacco.
cannot tolerate a treadmill.
●● Delays in return to normal pressures and pulse POSITIONING
waveforms indicate arterial disease. ●● Instruct the client to avoid crossing the legs.
●● It is used to evaluate claudication during exercise. ●● Tell the client to refrain from wearing
restrictive garments.
Plethysmography ●● Tell the client to elevate the legs to reduce swelling, but
not to elevate them above the level of the heart because
●● Plethysmography is used to determine the variations
extreme elevation slows arterial blood flow to the feet.
of blood passing through an artery, thus identifying
abnormal arterial flow in the affected limb.
●● Blood pressure cuffs are attached to the client’s upper MEDICATIONS
extremities, a lower extremity, and the plethysmograph
machine. Variations in peripheral pulses between the Antiplatelet medications
upper and lower extremity are recorded.
Aspirin, clopidogrel, pentoxifylline
●● A decrease in pulse pressure of the lower extremity
Antiplatelet medications reduce blood viscosity by
indicates a possible blockage in the leg.
decreasing blood fibrinogen levels, enhancing erythrocyte
flexibility, and increasing blood flow in the extremities.
Segmental systolic blood pressure measurements ●● Medications such as aspirin and clopidogrel may
●● A Doppler probe is used to take various blood be prescribed.
pressure measurements (thigh, calf, ankle, brachial) ●● Pentoxifylline, sometimes referred to as a
for comparison. In the absence of PAD, pressures in hemorheologic medication, was one of the first to be
the lower extremities are higher than those of the used and is still used, but less commonly than other
upper extremities. medications. It may be given to specifically treat
●● With arterial disease, the pressures in the thigh, calf, intermittent claudication in clients who have PAD.
and ankle are lower.
CLIENT EDUCATION
●● The medication’s effects might not be apparent for
Magnetic resonance angiography
several weeks.
A contrast medium, such as gadolinium, is injected to help ●● Monitor for evidence of bleeding (abdominal pain;
visualize blood flow through peripheral arteries. coffee‑ground emesis; black, tarry stools).
Ankle‑brachial index (ABI) Statins
The ankle pressure is compared to the brachial pressure. Simvastatin, atorvastatin: Can relieve manifestations
The expected finding for ABI is 0.9 to 1.3. ABI less than 0.9 associated with PAD (intermittent claudication).
in either leg is diagnostic for PAD.
Doppler‑derived maximal systolic acceleration
A technique that is especially helpful for evaluating PAD in
clients who have diabetes mellitus.
202 CHAPTER 30 Peripheral Vascular Diseases CONTENT MASTERY SERIES
, THERAPEUTIC PROCEDURES ●● Monitor blood pressure. Hypotension can result
in an increased risk of clotting or graft collapse,
Percutaneous transluminal angioplasty while hypertension increases the risk for bleeding
and laser‑assisted angioplasty from sutures.
●● Instruct the client to limit bending of the hip and knee
●● Percutaneous transluminal angioplasty is an invasive
to decrease the risk of clot formation.
intra‑arterial procedure using a balloon and stent to ●● Monitor incisions.
open and help maintain the patency of the vessel. ●● Instruct the client on wound care if revascularization
●● Laser‑assisted angioplasty is an invasive procedure
surgery was done.
in which a laser probe is advanced through a cannula
to the site of stenosis. The laser is used to vaporize CLIENT EDUCATION
atherosclerotic plaque and open the artery. ●● Avoid crossing or raising legs above the level of
the heart.
NURSING ACTIONS ●● Wear loose clothing.
●● The priority action is to observe for bleeding at the ●● Abstain from tobacco use, and avoid exposure to
puncture site.
cold temperatures.
●● Monitor vital signs, peripheral pulses, and ●● Practice adequate foot care (keep feet clean and dry,
capillary refill.
wear good‑fitting shoes, never go barefoot, cut toenails
●● Keep the client on bed rest with the limb straight for
straight across or have the podiatrist cut nails).
2 to 6 hr before ambulation.
●● Anticoagulant therapy is used during the procedure,
followed by antiplatelet therapy for 1 to 3 months.
COMPLICATIONS
Mechanical rotational abrasive atherectomy
Graft occlusion
Uses a rotational device to scrape plaque from the inside
Graft occlusion is a serious complication of arterial
of the client’s peripheral artery. The device is designed to
revascularization and often occurs within the first 24 hr
cause minimal damage to the surface of the artery.
following surgery.
NURSING ACTIONS
NURSING ACTIONS
●● The priority action is to observe for bleeding at the ●● Promptly notify the surgeon of manifestations of
puncture site.
occlusion (absent or reduced pedal pulses, increased
●● Monitor vital signs, peripheral pulses, and
pain, change in extremity color or temperature).
capillary refill. ●● Be prepared to assist with treatment, which can include
●● Keep the client on bed rest with the limb straight for
an emergency thrombectomy (removal of a clot), local
2 to 6 hr before ambulation.
intra‑arterial thrombolytic therapy with an agent
●● Anticoagulant therapy is used during the procedure,
such as tissue plasminogen activator, infusion of a
followed by antiplatelet therapy for 1 to 3 months.
platelet inhibitor, or a combination of these. With these
treatments, monitor for indications of bleeding.
Arterial revascularization surgery
Used with clients who have severe claudication or limb Wound or graft infection
pain at rest, or with clients who are at risk for losing a
An infection of the surgical wound or graft is a potentially
limb due to poor arterial circulation.
life‑threatening complication.
●● Bypass grafts are used to reroute the circulation around
the arterial occlusion. NURSING ACTIONS
●● Grafts can be harvested from the client (autologous) or ●● Use sterile technique when changing the surgical
made from synthetic materials. dressing or providing wound care.
●● Indications of infection include localized induration,
NURSING ACTIONS
warmth, tenderness, erythema, edema, purulent
●● The priority action is to maintain adequate circulation
drainage, and an elevated WBC. Promptly report
in the repaired artery. The location of the pedal or
findings to the provider.
dorsalis pulse should be marked, and its pulsatile
strength compared with the contralateral leg on a
scheduled basis using a Doppler.
●● Color, temperature, sensation, and capillary refill should
be compared with the contralateral extremity on a
scheduled basis.
●● Monitor for warmth, redness, and edema of the affected
limb as a result of increased blood flow.
●● Monitor for pain, which can be severe due to the
reestablishment of blood flow to the extremity.
PN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 Peripheral Vascular Diseases 203
, Compartment syndrome
Peripheral venous disorders
Compartment syndrome is considered a medical
Peripheral venous disorders are problems with the veins
emergency. Tissue pressure within a confined body space
that interfere with adequate return of blood flow from
can restrict blood flow, and the resulting ischemia can
the extremities.
lead to irreversible tissue damage. (30.2) ●● There are superficial and deep veins in the lower
NURSING ACTIONS extremities that have valves that prevent backflow
●● Manifestations of compartment syndrome include of blood as it returns to the heart. The action
tingling, numbness, worsening pain, edema, pain on of the skeletal muscles of the lower extremities
passive movement, and unequal pulses. Immediately during walking and other activities also promotes
report findings to the provider. venous return.
●● Loosen dressings. ●● Three peripheral venous disorders that nurses should
●● Prepare to assist with fasciotomy (surgical opening into be familiar with are venous thromboembolism (VTE),
the tissues), which can be necessary to prevent further venous insufficiency, and varicose veins.
injury and to save the limb.
VTEis a blood clot believed to form as a result of venous
stasis, endothelial injury, or hypercoagulability. Thrombus
formation can lead to a pulmonary embolism, which
is a life‑threatening complication. Thrombophlebitis
refers to a thrombus that is associated with
inflammation. (30.3, 30.4)
30.2 Compartment syndrome
30.3 Deep‑vein thrombosis 30.4 Thrombophlebitis
204 CHAPTER 30 Peripheral Vascular Diseases CONTENT MASTERY SERIES
