Related to compromised blood flow secondary to:
Related to immobilization
Related to presence of invasive lines
Related to pressure sites/constriction (elastic compression bandages, stockings, restraints)
Related to blood vessel trauma or compression
Situational (Personal, Environmental)
Related to pressure of enlarging uterus on pelvic vessels
Related to pressure of enlarged abdomen on pelvic vessels
Related to vasoconstricting effects of tobacco
Related to decreased circulating volume secondary to dehydration
Related to dependent venous pooling
Related to hypothermia
Related to pressure of muscle mass secondary to weight lifting
Focus Assessment Criteria
TABLE II.26 Arterial Insufficiency vs Venous Insufficiency: A Comparison of Subjective Data
||Feet, muscles of legs, toes
||Ankles, lower legs
||Burning, shocking, prickling, throbbing, cramping, sharp
||Increase in severity with increased muscle activity or elevation
||Varies with fluid intake, use of support hose, and decreased muscle activity
||Brought on predictably by exercise
Use of affected muscle groups
|Greater in evening than in morning
Increases during course of day with prolonged standing or sitting
||Cessation of exercise
Compression stockings or Ace wraps
||Numbness, tingling, burning, decreased touch sensation
||No change unless arterial system or nerves are affected
TABLE II.27 Arterial Insufficiency vs Venous Insufficiency: A Comparison of Objective Data
||Pale on elevation, dependent rubor (reactive hyperemia)
Typical brown discoloration around ankles
||Absent or weak
||Present unless there is concomitant arterial disease, or edema may obscure them
||Decreased motor ability with nerve and muscle ischemia
||Motor ability unchanged unless edema is severe enough to restrict joint mobility
||Occurs on foot at site of trauma or at tips of toes (most distal to be perfused)
Ulcers are deep with well-defined margins
Surrounding tissue is shiny and taut with thin skin
|Occurs around ankle (area of greatest pressure from chronic venous stasis due to valvular incompetence)
Ulcers shallow with irregular edges
Surrounding tissue edematous with engorged veins
Assess for Defining Characteristics
Pain (associated with, time of day)
Pallor, cyanosis, paresthesias
Change in motor function
Assess for Related Factors
Smoking (never, quit, years)
History of phlebitis
Family history of heart disease, vascular disease, stroke, kidney disease, or diabetes mellitus
Assess for Defining Characteristics
Temperature (cool, warm)
Color (pale, dependent rubor, flushed, cyanotic, brown discolorations)
Ulcerations (size, location, description of surrounding tissue)
Bilateral pulses (radial, femoral popliteal, posterior tibial, dorsalis pedis)
Normal, easily palpable
Paresthesia (numbness, tingling, burning)
Edema (location, pitting)
Capillary refill (normal less than 3 seconds)
Motor ability (normal, compromised)
Assess Causative and Contributing Factors
Inhibited venous blood flow
Hypothermia or vasoconstriction
Inhibited arterial blood flow
Fluid volume excess or deficit
Activities related to symptom/sign onset
Promote Factors that Improve Arterial Blood Flow
Keep extremity in a dependent position.
Keep extremity warm (do not use heating pad or hot water bottle, because the person with a peripheral vascular disease may have a disturbance in sensation and will not be able to determine if the temperature is hot enough to damage tissue; the use of external heat also may increase the metabolic demands of the tissue beyond its capacity).
Reduce risk for trauma.
Change positions at least every hour.
Avoid leg crossing.
Reduce external pressure points (inspect shoes daily for rough lining).
Avoid sheepskin heel protectors (they increase heel pressure and pressure across dorsum of foot).
Encourage range-of-motion exercises.
Promote Factors that Improve Venous Blood Flow
Elevate extremity above the level of the heart (may be contraindicated if severe cardiac or respiratory disease is present).
Avoid standing or sitting with legs dependent for long periods.
Consider the use of elastic compression bandages or below-knee elastic stockings to prevent venous pooling.
Reduce or remove external venous compression that impedes venous flow.
Avoid pillows behind the knees or Gatch bed, which is elevated at the knees.
Avoid leg crossing.
Change positions, move extremities, or wiggle fingers and toes every hour.
Avoid garters and tight elastic stockings above the knees.
Measure baseline circumference of calves and thighs if person is at risk for deep venous thrombosis, or if it is suspected.
Discuss the Implications of Condition and Choices
Encourage client to share feelings, concerns, and understanding of risk factors, disease process, and effect on life.
Assist client to select lifestyle behaviors that he or she chooses to change (Burch et al., 1991).
Avoid multiple changes.
Consider personal abilities, resources, and overall health.
Be realistic and optimistic.
Plan a Daily Walking Program
Provide reasons for program.
Teach client to avoid fatigue.
Instruct client to avoid increase in exercise until assessed by physician for cardiac problems.
Reassure client that walking does not harm the blood vessels or the muscles; “walking into the pain,” resting, and resuming walking improves the oxidative metabolic capacity of the muscle.
Emphasize that it is not the speed or distance but the action of walking that is important.
Assist client to set goals and the steps to achieve them.
Suggest a method to self-monitor progress (eg, graph, checklist).
Initiate Health Teaching, as Indicated
Teach Client to
Avoid long car or plane rides (get up and walk around at least every hour).
Keep dry skin lubricated (cracked skin eliminates the physical barrier to infection).
Wear warm clothing during cold weather.
Wear cotton or wool socks.
Use gloves or mittens if hands are exposed to cold (including home freezers).
Avoid dehydration in warm weather.
Give special attention to feet and toes.
Wash feet and dry well daily.
Do not soak feet.
Avoid harsh soaps or chemicals (including iodine) on feet.
Keep nails trimmed and filed smooth.
Inspect feet and legs daily for injuries and pressure points.
Wear clean socks.
Wear shoes that offer support and fit comfortably.
Inspect the inside of shoes daily for rough lining.
Briefly Explain the Relation of Certain Risk Factors to the Development of Atherosclerosis
Constant trauma of pressure causes damage to the vessel lining, which promotes plaque formation and narrowing.
Decreases muscle tone and strength
Excess weight (>10% of ideal)
Fatty tissue increases peripheral resistance and claudication.
Fatty tissue is less vascular.
Teach Methods to Relieve Pain
Assume dependent position for ischemic pain.
Elevate extremities for relief of venous aching.
Relieve phantom pain after an amputation by massaging or tapping stump or opposite limb.
Use other nursing measures such as relaxation or distraction to assist in pain relief.
If these methods do not relieve pain, refer to a physician or pain specialist.
Teach symptoms/signs of underlying disease and when to call the physician or health care professional.