This document provides an overview of the anatomy and physiology of the vascular system and assessment of patients with peripheral vascular disorders. It discusses the components of the circulatory system including the heart, arteries, veins, capillaries, and lymphatic system. It describes how blood flows through the body and the roles of each blood vessel type. The document also outlines how to assess patients for peripheral vascular disorders by examining pulses, skin appearance, edema and performing tests like the ankle-brachial index.

1. Nursing Care of Clients with
Peripheral Vascular Disorders

2. Anatomic and Physiologic Overview

3. Adequate perfusion oxygenates and nourishes body
tissues and depends in part on a properly functioning
cardiovascular system.

4. Adequate blood flow depends on
1. the efficient pumping
action of the heart
2. patent and responsive
blood vessels
3. and adequate circulating
blood volume

5. Factors that influence the rate and adequacy of blood flow
Nervous system activity
blood viscosity
metabolic needs of tissues

6. Anatomic and Physiologic Overview
The vascular system consists of two interdependent systems.
right side of heart pumps blood through lungs to pulmonary
circulation
left side of heart pumps blood to all other body tissues through
systemic circulation.
The blood vessels in both systems channel the blood from the
heart to the tissues and back to the heart
Contraction of the ventricles is the driving force that moves
blood through the vascular systems.

8. Arteries distribute oxygenated blood from the left side of the
heart to the tissues, whereas the veins carry deoxygenated blood
from the tissues to the right side of the heart.
Capillary vessels, located within the tissues, connect the arterial
and venous systems and are the site of exchange of nutrients and
metabolic wastes between the circulatory system and the tissues.
Arterioles and venules immediately adjacent to the capillaries,
together with the capillaries, make up the microcirculation.
The lymphatic system complements the function of the circulatory
system.
Lymphatic vessels transport lymph (a fluid similar to plasma), and
tissue fluids (containing smaller proteins, cells, and cellular debris)
from the interstitial space to systemic veins.

10. ANATOMY OF THE VASCULAR
SYSTEM

11. Arteries and Arterioles
Arteries
thick-walled structures that carry blood from heart to tissues.
Aorta : diameter of approximately 25 mm (1 inch)
divide into smaller arteries that are about 4 mm (0.16 inch) in
diameter by the time they reach the tissues.
Within the tissues, the vessels divide further, diminishing to
approximately 30 µm in diameter; these vessels are called
arterioles.

13. Layers or walls of arteries and
arterioles
1. Intima: an inner endothelial cell layer
2. Media : a middle layer of smooth elastic tissue
3. Adventitia :an outer layer of connective tissue.

15. Layers or walls of arteries and
arterioles
1. Intima
an inner endothelial
cell layer
a very thin layer,
provides a smooth
surface for contact
with the flowing blood

16. Layers or walls of arteries and
arterioles
2. Media
a middle layer of smooth elastic tissue
makes up most of the vessel wall in the aorta and other
large arteries of the body.
composed chiefly of elastic and connective tissue fibers
that give the vessels considerable strength and allow
them to constrict and dilate to accommodate the blood
ejected from the heart (stroke volume) and maintain
an even, steady flow of blood.

18. Layers or walls of arteries and
arterioles
3. Adventitia
an outer layer of connective tissue.
a layer of connective tissue that anchors the vessel to
its surroundings.
much less elastic tissue in the smaller arteries and
arterioles, and the media in these vessels is composed
primarily of smooth muscle.

19. What controls the diameter of the blood
vessels?
Smooth muscle controls the diameter of the
vessels by contracting and relaxing.
What influence the activity of smooth
muscle?
Chemical, hormonal, and nervous system
factors influence the activity of smooth
muscle.

20. Capillaries
Capillary walls
lack smooth muscle and adventitia
composed of a single layer of endothelial cells.
This thin-walled structure permits rapid and efficient
transport of nutrients to the cells and removal of
metabolic wastes.
Distribution varies with the type of tissue.
skeletal tissue, which is metabolically active, has a denser capillary
network than does cartilage, which is less active.

22. Veins and Venules
walls of veins are thinner and considerably less muscular.
wall of the average vein amounts to only 10% of the vein
diameter, in contrast to 25% in the artery.
Walls are composed of three layers, although these layers are
not as well defined.

23. Veins have thin and less musculature. Is
this an advantage or not?
Why or why not?
The thin, less muscular structure of the vein
wall allows these vessels to distend more
than arteries.
Greater distensibility and compliance
permit large volumes of blood to be
stored in the veins under low pressure.
Approximately 75% of total blood volume is
contained in the veins.
That is why veins are also called
Capacitance vessels

24. What stimulates the veins to constrict?
Sympathetic Nervous System
innervates the vein musculature
can stimulate venoconstriction
thereby reducing venous volume and increasing
the volume of blood in the general circulation

25. Contraction of skeletal muscles in extremities
creates the primary pumping action to facilitate venous
blood flow back to the heart.
What facilitate venous blood flow back
to the heart?

26. Bicuspid valves.
Do veins have them?
Some veins are equipped with valves.
In general, veins that transport blood against the force of
gravity, as in the lower extremities, have one-way bicuspid
valves that interrupt the column of blood to prevent blood
from seeping backward as it is propelled toward the heart.
Valves are composed of endothelial leaflets, the competency
of which depends on the integrity of the vein wall.

29. Lymphatic Vessels
are a complex network of thin-walled vessels similar to the
blood capillaries.
collects lymphatic fluid from tissues and organs and
transports the fluid to the venous circulation.

30. Lymphatic Vessels
converge into two main structures:
(1) thoracic duct and (2) right lymphatic duct
These ducts empty into the junction of the subclavian and the
internal jugular veins.
The right lymphatic duct conveys lymph primarily from the
right side of the head, neck, thorax, and upper arms. The
thoracic duct conveys lymph from the remainder of the body.
Peripheral lymphatic vessels join larger lymph vessels and pass
through regional lymph nodes before entering the venous
circulation. The lymph nodes play an important role in filtering
foreign particles.

33. Assessment

34. Arms Assessment
• Observe arm size and venous pattern; also look for edema
• Observe for coloration of the hands and arms
• Palpate the client’s fingers, hands, arms, and note the temperature
• Palpate to assess for capillary refill time
• Palpate for radial pulse
• Palpate the ulnar pulse
• palpate the brachial pulses if suspect arterial insufficiency
• Palpate the epitrochlear lymph nodes
• Perform the Allen Test
34 Maria Carmela Domocmat, RN, MSN 9/9/2012

35. Legs Assessment
• Observe skin color while inspecting both legs from the
toes to the groin
• Inspect distribution of hair
• Inspect for lesions or ulcers
• Inspect for edema
• Palpate edema
• Palpate bilaterally from temperature of feet and legs
35 Maria Carmela Domocmat, RN, MSN 9/9/2012

36. Legs Assessment
• Palpate the superficial inguinal lymph nodes
• Palpate the femoral pulses
• Auscultate the femoral pulses
• Palpate the popliteal pulses
• Palpate the dorsalis pedis pulses
• Palpate the posterior tibial pulses
• Inspect for varicosities and thrombophlebitis
• Check for Homan’s sign
36 Maria Carmela Domocmat, RN, MSN 9/9/2012

37. Special Tests for Arterial or Venous
Insufficiency
• Position change test for arterial insufficiency
• Ankle-Brachial pressure index (ABPI)
• Manual compression test
• Trendelenburg test
37 Maria Carmela Domocmat, RN, MSN 9/9/2012

38. Assessment
Health History and Clinical Manifestations
Intermittent Claudication
Changes in Skin Appearance and Temperature
Pulses
Diagnostic Evaluation

39. Intermittent claudication
A muscular, cramp-type pain in the extremities consistently
reproduced with the same degree of exercise or activity and
relieved by rest
experienced by patients with peripheral arterial insufficiency.

40. Pathophy
Caused by inability of arterial system to provide adequate
blood flow to tissues in the face of increased demands for
nutrients during exercise.
As the tissues are forced to complete the energy cycle
without the nutrients, muscle metabolites and lactic acid are
produced.
Pain is experienced as the metabolites aggravate the nerve
endings of the surrounding tissue.

41. Usually, about 50% of the arterial lumen or 75% of the
cross-sectional area must be obstructed before intermittent
claudication is experienced.
When the patient rests and thereby decreases the metabolic
needs of the muscles, the pain subsides.
The progression of the arterial disease can be monitored by
documenting the amount of exercise or the distance a patient
can walk before pain is produced.

42. Rest pain
Persistent pain in the forefoot when the patient is resting
indicates a severe degree of arterial insufficiency and a
critical state of ischemia.
is often worse at night and may interfere with sleep.
frequently requires that the extremity be lowered to a
dependent position to improve perfusion pressure to the
distal tissues.

43. The site of arterial disease can be deduced from the location
of claudication, because pain occurs in muscle groups below
the disease.
As a general rule, the pain of intermittent claudication occurs
one joint level below the disease process.
Calf pain may accompany reduced blood flow through the
superficial femoral or popliteal artery, whereas pain in the
hip or buttock may result from reduced blood flow in the
abdominal aorta or the common iliac or hypogastric arteries.

45. Changes in Skin Appearance and
Temperature
Adequate blood flow warms the extremities and gives them a rosy
coloring.
Pallor
Due to inadequate blood flow
whiter or more blanched appearance (esp when the extremity is elevated)
Rubor
reddish blue discoloration of the extremities, may be observed within 20
seconds to 2 minutes after the extremity is dependent.
suggests severe peripheral arterial damage in which vessels that cannot
constrict remain dilated.
Even with rubor, the extremity begins to turn pale with elevation.
Cyanosis
a bluish tint on the skin
is manifested when the amount of oxygenated hemoglobin contained in the
blood is reduced.

47. Other changes
Additional changes resulting from a chronically reduced
nutrient supply include
loss of hair
brittle nails
dry or scaling skin
Atrophy
Ulcerations

48. Edema Gangrene
may be apparent bilaterally appear after prolonged,
or unilaterally severe ischemia and
is related to the affected represent tissue necrosis.
extremity’s chronically In elderly patients who are
dependent position inactive, gangrene may be
because of severe rest pain. the first sign of disease.

49. 49 Maria Carmela Domocmat, RN, MSN 9/9/2012

51. Pulses
Determine presence or absence & quality of peripheral
pulses is important in assessing the status of peripheral
arterial circulation
Absence of a pulse
indicate that site of stenosis is proximal to that location.
Ex: Occlusive arterial disease

52. How do you assess pulse?
Pulses should
be palpated bilaterally and simultaneously
comparing both sides for symmetry in rate, rhythm, and
quality.

53. How can you prevent committing the
mistake of taking your own pulse for
that of the patient?
Use light touch
avoid using only the index finger for palpation,
because this finger has the strongest arterial
pulsation of all the fingers.
The thumb should not be used for the same
reason.

56. Diagnostic Evaluation

57. Diagnostic Evaluation
Doppler ultrasound flow studies
Duplex ultrasonography
Exercise testing
Computed tomography (CT)
Computed tomographic angiography (CTA)
Magnetic resonance angiography (MRA)
Angiography
Air plethysmography
Contrast phlebography
Lymphangiography
Lymphoscintigraphy

58. Doppler ultrasound flow studies
When pulses cannot be reliably palpated, use of a
microphone-like, hand-held Doppler ultrasound device,
called a transducer or probe, may be helpful in detecting and
assessing peripheral flow.
Continuous-wave (CW) Doppler ultrasound device

59. Procedure
supine position with head of bed elevated 20 to 30 degrees
legs are externally rotated, if possible, to permit adequate access
to the medial malleolus.
Acoustic gel is applied to the patient’s skin to permit uniform
transmission of the ultrasound wave (electrocardiogram gel is not
used because it contains sodium, which may dissolve the epoxy
that covers the transducer’s tip).
tip of Doppler transducer is positioned at a 45- to 60-degree angle
over the expected location of the artery and angled slowly to
identify arterial blood flow.
Excessive pressure is avoided because severely diseased arteries
can collapse with even minimal pressure.

60. CW Doppler
is more useful as a clinical tool when combined with ankle
blood pressures, which are used to determine the ankle-
brachial index (ABI), aka: ankle-arm index (AAI).
ABI is the ratio of ankle systolic BP to the arm systolic BP.
an objective indicator of arterial disease that allows the
examiner to quantify the degree of stenosis.
With increasing degrees of arterial narrowing, there is a
progressive decrease in systolic pressure distal to the involved
sites.

61. Measuring the ankle systolic pressure with a continuous-wave Doppler
probe, pneumatic cuff and gauge.
This reading would be compared with that at the brachial artery.
Since pressure drops with increasing arterial stenosis, an ankle-brachial
index of less than 0.95 would be considered abnormal.

62. ABI
supine position (not seated) for at least 5 minutes.
appropriate- sized BP cuff is applied to ankle above
malleolus.
Identify arterial pulse at posterior tibial and dorsalis pedis
obtain systolic ankle pressures in both feet.
If pressure in these arteries cannot be measured, pressure can
be measured in the peroneal artery, which can also be
assessed at the ankle .
Diastolic pressures cannot be measured with a Doppler.

63. To calculate ABI, the ankle systolic pressure for each foot is
divided by the higher of the two brachial systolic pressures;

64. Let’s practice!
Compute the ABI for patient M who has the ff systolic
pressures:
Right brachial: 160 mm Hg
Left brachial: 120 mm Hg
Right posterior tibial: 80 mm Hg
Right dorsalis pedis: 60 mm Hg
Left posterior tibial: 100 mm Hg
Left dorsalis pedis: 120 mm Hg
ABI =highest systolic pressure for each ankle / highest brachial
pressure

65. Let’s practice!
Compute the ABI for patient M who has the ff systolic pressures:
Right brachial: 160 mm Hg
Left brachial: 120 mm Hg
Right posterior tibial: 80 mm Hg
Right dorsalis pedis: 60 mm Hg
Left posterior tibial: 100 mm Hg
Left dorsalis pedis: 120 mm Hg
The highest systolic pressure for each ankle (80 mm Hg for
right, 120 mm Hg for left) would be divided by the highest
brachial pressure (160 mm Hg).
Right: 80/160 mm Hg = 0.50 ABI
Left: 120/160 mm Hg = 0.75 ABI

66. Normal findings
In general, systolic pressure in ankle of a healthy person is same
or slightly higher than brachial systolic pressure,
resulting in an ABI of about 1.0 (no arterial insufficiency).
ABI of 0.95 to 0.50 : mild to moderate insufficiency
patients with ischemic rest pain have an ABI of less than 0.50,
and patients with severe ischemia or tissue loss have an ABI of
0.25 or less.

67. Doppler ultrasonography
used to measure brachial pressures in both arms.
Both arms are evaluated because the patient may have an
asymptomatic stenosis in the subclavian artery, causing
brachial pressure on the affected side to be 20 mm Hg or
more lower than systemic pressure.
The abnormally low pressure should not be used for
assessment.

68. Exercise testing
used to determine how long a patient can walk and to
measure the ankle systolic blood pressure in response to
walking.
walks on a treadmill at 1.5 mph with a 10% incline for a
maximum of 5 minutes.
normal response : little or no drop in ankle systolic pressure
after exercise.
(+) claudication : ankle pressure drops
Combining this hemodynamic information with the walking
time helps the physician determine whether intervention is
necessary.

69. Duplex ultrasonography
is a combination of the Doppler technology with pulse-echo
imaging.
After sending off ultrasound pulses into the tissue, the
instrument converts the echoes received from various
locations into dots of varying strength, forming an image of
the blood vessel.
The gold standard for diagnosing venous
thrombosis
http://www.surgery.hku.hk/vdc_diagnostics.php

70. Duplex ultrasonography
helps determine level and extent of disease
Is universally employed to evaluate the venous system.
image and assess blood flow
evaluate the runoff status of the distal vessels
locate the disease (stenosis versus occlusion),
determine anatomic morphology and the hemodynamic
significance of plaque causing stenosis.

71. Duplex ultrasonography
noninvasive
requires no patient preparation.
equipment is portable, making it useful anywhere for initial
diagnosis or follow-up evaluations.

72. Duplex ultrasonography

73. Transverse view of an abdominal
aortic aneurysm.
Longitudinal scan of an atherosclerotic
plaque in the internal carotid artery.

74. Duplex ultrasonography
Carotid and Vertebral Scan Detection for Deep Vein
Indications: Stroke Thrombosis
Transient ischaemic attack Indication: lower limb oedema /
High risk screening pain
Abdominal Scan Evaluation of Venous Valve
Indications: Severe hypertension Competence
Abdominal aortic aneurysm Indications: Varicose vein
Graft Surveillance Venous ulcer
Stent Surveillance
http://www.surgery.hku.hk/vdc_diagnostics.php

75. Computed tomography (CT)
provides cross-sectional images of soft tissue and can identify
area of volume changes to an extremity and compartment
where changes take place.
CT of a lymphedematous arm or leg, for example,
demonstrates a characteristic honeycomb pattern in the
subcutaneous tissue.

76. In spiral (also called volumetric) CT scan
the scan head moves circumferentially around the patient as the
patient passes through the scanner, creating a series of
overlapping images that are connected to one another in a
continuous spiral
Scan times are short; however, the patient is exposed to x-
rays, and contrast agent usually must be injected to
adequately visualize the blood vessels.
Using computer software, the slicelike images are
reconstructed into three-dimensional images that can be
rotated and viewed from multiple angles.

77. Computed tomographic angiography
(CTA)
a spiral CT scanner and rapid intravenous infusion of contrast
agent are used to image very thin (1-mm) sections of the
target area;
the results are configured in three dimensions so that the
image closely resembles a regular angiogram
CTA shows the aorta and main visceral arteries better than it
shows smaller branch vessels.
Scan times are usually between 20 and 30 seconds.
Requires large volume of contrast agent
limits the usefulness of this study in patients with allergy to the
contrast agent or with significantly impaired renal function.

79. Magnetic resonance angiography
(MRA)
performed with a standard MRI scanner but with image-
processing software specifically programmed to isolate the blood
vessels.
The images are reconstructed to resemble a standard angiogram,
but because the images are reassembled in three dimensions, they
can be rotated and viewed from multiple angles.
no contrast agent is necessary
useful in patients with poor renal function or allergy to contrast
agent.
Scan time is long, and motion artifacts are common, restricting
the use of the test to relatively short segments of the vascular
system

82. Angiography
An arteriogram produced by angiography may be used to
confirm the diagnosis of occlusive arterial disease
when considering surgery or other interventions.
involves injecting a radiopaque contrast agent directly into
the vascular system to visualize the vessels.
The location of a vascular obstruction or an aneurysm
(abnormal dilation of a blood vessel) and the collateral
circulation can be demonstrated.
Usually, patients experience a temporary sensation of
warmth as the contrast agent is injected, and local irritation
may occur at the injection site.

83. Risks/ complications
immediate or delayed allergic reaction to the iodine
contained in the contrast agent.
Manifestations include dyspnea, nausea and vomiting, sweating,
tachycardia, and numbness of the extremities.
Any such reaction must be reported to the physician at once;
treatment may include the administration of one or more of
epinephrine (adrenaline), antihistamines, or corticosteroids.
Additional risks include vessel injury, bleeding, and CVA
(brain attack, stroke).

84. Air plethysmography (APG)
Is a pneumatic plethysmograph designed for non-
invasively measuring venous function and absolute
volume changes in the lower extremities.
Changes in volume are measured with the patient’s legs
elevated, with the patient supine and standing, and after the
patient performs toe-ups (patient extends ankle while
standing; stands on tip-toes).
provides information about venous filling time, functional
venous volume, ejected volume, and residual volume.
useful in evaluating patients with suspected valvular
incompetence or chronic venous insufficiency.

86. Influence of high-heeled shoes on venous
function in young women
http://www.sciencedirect.com/science/article/pii/S0741521412001176

87. Air-
Air-Plethysmography (APG)
Detection for Chronic Venous Obstruction
Measurement of Venous Reflux
Indications: Varicose veins
Venous ulcer
Quantifies volume change in a limb caused by alterations in
BP.
This information would indicate the presence of obstruction
by venous thrombosis and the degree of venous reflux in the
lower limb as a result of chronic venous insufficiency.
http://www.surgery.hku.hk/vdc_diagnostics.php

88. Contrast phlebography
Also known as venography
involves injecting radiographic contrast media into the
venous system through a dorsal foot vein.
If a thrombus exists, the x-ray image discloses an unfilled
segment of vein in an otherwise completely filled vein.
Injection of the contrast agent may cause a brief but painful
inflammation of the vein.
generally performed if patient is to undergo thrombolytic
therapy

89. Lower limb phlebography
(two projections): Contrast material fills the deep veins of the leg and passes
through the perforate branches (arrow) into the superficial veins (double
arrow). The veins are dilated in the region of the varicosity.

90. Lymphangiography

91. Lymphangiogram
used to evaluate the possible spread of cancers and the
effectiveness of cancer therapy.
X-rays may also help determine the cause of swelling in an arm or
leg and check for parasitic diseases.
performed by injecting blue dye into an area to be tested.
blue dye helps to locate the lymphatic vessels where the catheter
will be placed.
Once the lymph vessels are found, contrast medium is injected
through the catheter and X-rays are taken to monitor its progress
as it spreads through the lymph system up the legs, into the groin,
and along the back of the abdominal cavity.
The next day, another set of X-rays is taken.

92. Lymphangiography
Procedure
a lymphatic vessel in each foot (or hand) is injected with
contrast agent.
A series of x-rays are taken at the conclusion of the injection, 24
hours later, and periodically thereafter, as indicated.
The failure to identify subcutaneous lymphatic collection of
contrast agent and the persistence of contrast agent in the tissue
for days afterward help to confirm a diagnosis of lymphedema.

93. Lymphoscintigraphy
is a technique that is used to determine the sentinel lymph
node
Aka: lymphoscintigram, lymphangiogram
a reliable alternative to lymphangiography.
used to diagnose lymphedema and lipedema.
http://breastcancer.about.com/od/breastcancerglossary/g/lymphoscintig.htm

94. Lymphoscintigraphy
Procedure
A radioactively labeled colloid is injected subcutaneously in the
second interdigital space.
The extremity is then exercised to facilitate the uptake of the
colloid by the lymphatic system, and serial images are obtained
at preset intervals.
a computer records the path of the radioactive material towards
the draining lymph nodes.
The blue dye will assist the surgeon in finding the sentinel
lymph nodes, which will be removed and tested for metastasis.
No adverse reactionshave been reported.
http://breastcancer.about.com/od/breastcancerglossary/g/lymphoscintig.htm

95. Abnormal
Normal lymphoscintigram lymphoscintigram