Peripheral vascular disease (PVD), frequently referred to as peripheral artery disease (PAD), is marked by the gradual narrowing of arteries in the limbs, primarily due to structural damage from atherosclerosis. Plaque accumulation obstructs blood flow, most commonly affecting the legs and feet, but potentially impacting any blood vessel outside the heart. Untreated PVD can lead to severe complications including gangrene, amputation, blood clots, kidney failure, heart attack, and stroke.
This article provides a comprehensive guide for healthcare professionals, especially nurses, focusing on nursing diagnoses, assessments, interventions, and care plans for patients with PVD.
Nursing Process in PVD Management
Managing PVD effectively centers on minimizing cardiovascular risks and addressing conditions that impair blood vessels. Nurses are vital in promoting health through patient education, encouraging lifestyle adjustments, medication adherence, and pre- and post-operative care for revascularization procedures such as angioplasty or bypass grafting. Their role ensures patient recovery and prevents complications.
Comprehensive Nursing Assessment for PVD
The initial nursing assessment is crucial, encompassing physical, psychosocial, emotional, and diagnostic data collection. Here, we detail subjective and objective data relevant to PVD.
Detailed Review of Health History
1. Identifying General Symptoms: Common PVD symptoms include:
- General:
- Exacerbated pain during activity
- Cardiovascular:
- Weak or absent peripheral pulses
- Integumentary:
- Skin color changes (pallor, cyanosis, erythema)
- Reduced skin temperature
- Thin, shiny skin on lower extremities
- Gangrenous tissue
- Hair loss on legs
- Non-healing wounds and ulcers
- Thickened toenails
- Reproductive:
- Impotence
- Musculoskeletal:
- Reduced mobility, weakness, muscle heaviness
- Numbness and tingling (paresthesia)
- Intermittent claudication (muscle pain during activity, relieved by rest)
2. Medical History Review: Atherosclerosis is the primary cause of PVD. Note pre-existing conditions that contribute to plaque build-up:
- Diabetes mellitus
- Hypertension
- Hyperlipidemia
- Coronary artery disease
- Cerebrovascular disease
3. Family History: A family history of PVD is significant if a first-degree relative underwent revascularization or stent placement before age 65. Document any family history of heart disease or stroke.
4. Risk Factor Identification: Key PVD risk factors include:
- Smoking
- Sedentary lifestyle
- Male gender
- Advanced age
- Obesity
- African-American ethnicity
5. Dietary Assessment: Diet significantly influences plaque formation. Factors contributing to plaque include:
- High saturated fat intake
- High simple carbohydrate intake
- High sodium intake
Physical Examination for PVD
1. Assess for the 5 P’s: These hallmark symptoms of acute arterial occlusion in PVD are critical:
- Pulselessness
- Paralysis
- Paresthesia
- Pain
- Pallor
Immediate assessment and consultation are necessary if paresthesia or paralysis is present, indicating potential limb-threatening ischemia.
2. Cardiovascular Status Evaluation: Auscultate heart sounds for irregularities or murmurs. Palpate peripheral pulses for bruit and quality in all extremities.
3. Allen Test: This test assesses collateral blood flow to the hands via the radial and ulnar arteries. A negative Allen test signifies insufficient dual blood supply to the hand.
4. Skin Assessment: Skin changes indicative of PVD:
- Alopecia (hair loss)
- Dry, scaly, or erythematous skin
- Persistent pigmentation changes
- Brittle nails
5. Advanced PVD Symptoms: Signs of advanced disease include:
- Pulselessness
- Numbness
- Cyanosis
- Mottling (livedo reticularis)
- Cold extremities
- Paralysis
- Gangrene
- Non-healing wounds and ulcers
6. Pain Assessment: Characterize pain, especially intermittent claudication, which worsens with activity and improves with rest. Resting pain is a more serious indicator of ischemia.
Diagnostic Procedures for PVD
1. Blood Tests: Routine blood tests monitor organ function and assess vascular risk:
- Complete Blood Count (CBC)
- Blood Urea Nitrogen (BUN)
- Creatinine
- Electrolyte levels
- Coagulation tests
- Lipid profiles
2. Inflammatory Markers: Elevated inflammatory markers may correlate with exercise intolerance in PVD:
- D-dimer
- C-reactive protein
- Interleukin-6
- Homocysteine
3. Ankle-Brachial Index (ABI): ABI compares blood pressure in the lower and upper extremities. Lower extremity pressure is typically slightly higher.
4. Doppler Ultrasound: This non-invasive method assesses blood flow. Absent or faint sounds indicate blockage or reduced flow.
5. Transcutaneous Oximetry: Evaluates blood flow impairment, increasingly used in diabetic patients and wound care.
6. Imaging Scans: Provide detailed visualization of blood vessels:
- Magnetic Resonance Imaging (MRI): High detail for plaque visualization.
- Computed Tomography (CT) with contrast: Effective for visualizing arterial insufficiency.
- CT Angiography (CTA): Rapid, noninvasive results.
- Magnetic Resonance Angiography (MRA): Highly accurate without radiation, though costly and less accessible.
Image: Doppler ultrasound being used to assess blood flow in a patient’s leg, a key diagnostic procedure for Peripheral Vascular Disease.
Essential Nursing Interventions for PVD
Nursing interventions are critical for patient recovery and managing PVD progression.
1. Prevent Disease Progression: Lifestyle modification is the cornerstone of managing PVD. Pharmacological and endovascular interventions may be needed to manage symptoms and reduce cardiovascular risk.
2. Medication Administration: Medications are essential for managing underlying conditions:
- Statins: Lower LDL cholesterol and raise HDL cholesterol, preventing plaque buildup and reducing stroke and heart attack risk.
- Antihypertensive drugs: Maintain normal blood pressure.
- Antidiabetic agents: Control blood sugar levels.
- Antiplatelets/Anticoagulants: Prevent blood clot formation (e.g., clopidogrel, warfarin).
- Cilostazol: Vasodilator and antiplatelet to improve blood flow and relieve leg pain.
3. Comorbidity Management: Aim for blood pressure below 120/80 mmHg (non-diabetic) or 130/80 mmHg (diabetic). Target HbA1c below 7% for diabetics.
4. Prepare for Revascularization: Consider revascularization for patients with severe symptoms unresponsive to conservative treatment:
- Endovascular intervention
- Surgery (angioplasty, stent placement, bypass surgery)
- Combined approaches
5. Promote Exercise Therapy: Exercise programs effectively reduce claudication symptoms. Refer to physical therapy as needed.
6. Treat Blood Clots: Thrombi or emboli require immediate heparin infusion to prolong activated partial thromboplastin time to 1.5 times normal.
7. Lifestyle Modification Education: Emphasize:
- Regular physical activity
- Weight management
- Heart-healthy diet
- Smoking cessation
- Medication adherence
8. Avoid Pseudoephedrine: Advise against decongestants containing pseudoephedrine, as they can worsen PVD symptoms by narrowing blood vessels.
9. Nutritionist Referral: Recommend a heart-healthy, low-sodium, low-saturated fat diet.
10. Foot Care Education: Stress proper foot care due to increased risk of poor wound healing and infection, especially in diabetic patients.
Image: A nurse demonstrating proper foot inspection to a patient, emphasizing the importance of daily foot care in managing Peripheral Vascular Disease.
Nursing Care Plans and Diagnoses for PVD
Nursing care plans prioritize assessments and interventions for short and long-term PVD management goals. Common nursing diagnoses for PVD include:
1. Acute Pain
Acute pain is a frequent symptom of PVD, often occurring during walking and described as cramping or aching distal to the blockage.
Nursing Diagnosis: Acute Pain
Related to:
- Vascular system blockage
- Peripheral vascular disease
As evidenced by:
- Verbalization of pain, cramping, or aching during walking
- Burning pain in feet (severe cases)
- Muscle fatigue
- Avoidance of physical activity
Expected Outcomes:
- Patient will report reduced pain with walking.
- Patient will increase physical activity without pain.
Assessments:
- Pain Characteristics: Detailed pain assessment is crucial for PVD diagnosis, noting location, intensity, and relieving factors. In severe cases, resting pain, especially nocturnal burning foot pain relieved by dangling, is significant.
- Prior Pain Relief Efforts: Understanding previous pain management strategies helps tailor effective interventions and aids in diagnosis.
Interventions:
- Medication Administration: Administer vasodilators like cilostazol for claudication as prescribed, noting it may take up to 12 weeks for full effect.
- Encourage Exercise: Advise walking to pain tolerance, rest, and resume. Aim for 30-45 minute sessions, 3-4 times weekly.
- Lifestyle Modification Education: Emphasize healthy weight, exercise, and chronic condition management to reduce pain.
- Avoid Massaging Affected Extremities: Caution against massage without physician approval due to embolism risk.
2. Chronic Pain
Chronic pain in PVD manifests as intermittent claudication, ischemic pain, and neuropathic pain.
Nursing Diagnosis: Chronic Pain
Related to:
- Limb ischemia
- Atherosclerosis
- Severe claudication
- Sedentary lifestyle
- Obesity
As evidenced by:
- Burning pain
- Paresthesias
- Intermittent claudication
- Altered mobility
Expected Outcomes:
- Patient will report reduced burning, tingling, and numbness.
- Patient will use nonpharmacological pain relief methods.
Assessments:
- Pain Characteristics: Assess burning, tingling, stabbing pain, and sensory changes. Worsening pain indicates disease progression.
- Critical Limb Ischemia Signs: Monitor for resting pain, recumbent pain, ischemic lesions (ulcers, gangrene), and ABI ≤ 0.4, indicating limb threat.
- Phantom Limb Pain Risk: For amputees, assess pre- and post-operative pain, as high pain levels are risk factors for chronic phantom limb pain.
Interventions:
- Prioritize Exercise: Recommend exercise therapy for early PVD and intermittent claudication, collaborating with PT/OT for safe regimens.
- Psychological Techniques: Consider biofeedback, mirror therapy, imagery, and meditation alongside medical treatments.
- Spinal Cord Stimulation: For severe ischemic pain unresponsive to analgesics, spinal cord stimulation may offer relief.
- Support Coping: Address the impact of chronic pain on sleep, appetite, mood, and social life; offer mental health support referrals.
- Prepare for Surgery: Revascularization procedures can relieve pain by restoring blood flow.
3. Ineffective Peripheral Tissue Perfusion
Reduced blood flow due to atherosclerotic plaque is a hallmark of PVD, leading to ineffective tissue perfusion.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related to:
- Disease process (PVD)
- Atherosclerotic plaque buildup
- Reduced blood flow
As evidenced by:
- Absent/weak peripheral pulses
- Muscle weakness and fatigue
- Cool, cyanotic skin
- Shiny, hairless legs
- Decreased extremity blood pressure
- Delayed wound healing
- Edema
- Extremity pain
- Femoral bruit
- Intermittent claudication
- Paresthesia
- Pallor with limb elevation
Expected Outcomes:
- Patient will demonstrate adequate tissue perfusion with palpable (3+) peripheral pulses.
- Patient will articulate their medication regimen for PVD management.
Assessments:
- Peripheral Pulses: Assess pulse strength; reduced or absent pulses indicate arterial insufficiency and ischemia risk.
- Ankle-Brachial Index (ABI): Measure ABI; values < 0.9 suggest PVD.
Interventions:
- Manage Chronic Conditions: Ensure management of comorbidities like atherosclerosis, diabetes, and hypertension to prevent complications.
- Avoid Prolonged Sitting: Encourage ambulation and avoid prolonged sitting to enhance venous return.
- Consider Statins: Statins, alongside lifestyle changes, can improve atherosclerotic disease and PVD.
- Surgical Preparation: Prepare patients for revascularization procedures (angioplasty, stenting, bypass) in severe cases.
4. Risk for Injury
PVD increases the risk of falls, trauma, and skin breakdown due to impaired physical function.
Nursing Diagnosis: Risk for Injury
Related to:
- Disease process (PVD)
- Tissue hypoxia
- Altered peripheral sensation
- Decreased lower extremity strength
- Impaired balance
As evidenced by:
Risk diagnosis – no evidence by symptoms, interventions are preventative.
Expected Outcomes:
- Patient will remain free from injury.
- Patient will demonstrate two strategies to reduce falls and injury.
Assessments:
- Environmental and Self-Care Assessment: Evaluate home environment for safety hazards (stairs) and assess self-care abilities, considering older age often associated with PVD.
- Mobility Issues: Assess functional ability and plan for fall prevention strategies.
Interventions:
- Fall Prevention During Walking: Provide assistive devices (cane, walker) if balance or strength is compromised during exercise programs.
- Foot Care Instruction: Emphasize proper footwear and daily foot inspection to prevent injury, especially with co-existing diabetes.
- Smoking Cessation: Strongly encourage smoking cessation to reduce ischemia and amputation risk.
- PT/OT Referral: Refer to physical and occupational therapy to ensure a safe home environment and appropriate exercise programs.
5. Risk for Peripheral Neurovascular Dysfunction
PVD-related narrowing of blood vessels compromises blood flow to extremities, increasing risk of neurovascular dysfunction.
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction
Related to:
- Atherosclerosis
- Reduced blood flow to extremities
- Sedentary lifestyle
As evidenced by:
Risk diagnosis – no evidence by symptoms, interventions are preventative.
Expected Outcomes:
- Patient will maintain peripheral pulses and skin color.
- Patient will not report paresthesia.
Assessments:
- Neurovascular Status: Assess peripheral pulses, skin color and temperature, capillary refill, sensation, and muscle strength bilaterally.
- Balance and Gait: Observe gait and balance; PVD patients may exhibit irregular gait with short steps.
- Assess the 5 P’s: Monitor for pain, paralysis, paresthesia, pulselessness, and pallor, which indicate compromised blood flow.
Interventions:
- Positioning Education: Advise against leg crossing to avoid blood flow restriction. Leg elevation is recommended, but not above heart level to maintain arterial flow.
- Medication Administration: Administer prescribed antihypertensives, statins, and antiplatelet/anticoagulant medications to manage conditions and improve blood flow.
- Supervised Exercise Program: Enroll patients in structured exercise programs, like supervised treadmill walking, to enhance circulation.
- Neurovascular Dysfunction Education: Teach patients to recognize and report signs requiring immediate medical attention: burning foot pain, paresthesia, diminished pulses, pale/cyanotic extremities, cool skin, prolonged capillary refill, decreased sensation, and motor function changes.
- Image Documentation: With consent, document PVD progression using clinical images to track skin changes, hair loss, and nail abnormalities.
Image: A healthcare professional palpating the dorsalis pedis pulse of a patient, a routine assessment for Peripheral Vascular Disease.
