Peripheral Vascular Disease Nursing Diagnosis: Comprehensive Guide

Peripheral vascular disease (PVD), frequently referred to as peripheral artery disease (PAD), is a common circulatory problem characterized by the gradual narrowing of arteries in the extremities, most commonly the legs and feet. This narrowing is usually caused by atherosclerosis, a condition where plaque builds up inside the artery walls, obstructing blood flow. While PVD predominantly affects the lower extremities, it can impact any blood vessel outside the heart.

If left untreated, PVD can lead to severe complications, including gangrene, potentially necessitating limb amputation. Furthermore, PVD significantly elevates the risk of other serious health issues like blood clots, kidney failure, heart attack, and stroke.

Nurses play a vital role in managing peripheral vascular disease. The primary nursing goal is to mitigate the progression of PVD and reduce the patient’s overall cardiovascular risk. This involves comprehensive patient education, promoting lifestyle modifications, and ensuring adherence to prescribed medications. In cases where conservative management is insufficient, revascularization procedures such as angioplasty or bypass grafting might be necessary. Nurses are crucial in both pre- and post-operative care, aiming to prevent complications and facilitate patient recovery.

This article provides a detailed overview of peripheral vascular disease from a nursing perspective, covering essential aspects from assessment to intervention and care planning.

The Nursing Process in Peripheral Vascular Disease

The nursing process is fundamental to managing patients with PVD. It starts with a thorough nursing assessment to gather comprehensive patient data, followed by the formulation of nursing diagnoses, planning and implementing interventions, and finally, evaluating the effectiveness of care.

Nursing Assessment for Peripheral Vascular Disease

The initial step in nursing care is a comprehensive assessment. This involves collecting subjective and objective data to understand the patient’s condition fully.

Review of Health History

1. Identifying General Symptoms: Recognizing the signs and symptoms of PVD is crucial for early diagnosis. Common symptoms include:

• General Symptoms:
  • Pain that worsens with physical activity and is relieved by rest.
• Cardiovascular Symptoms:
  • Weak or absent peripheral pulses in the affected extremities.
• Integumentary Symptoms:
  • Skin color changes such as pallor (paleness), cyanosis (bluish discoloration), or erythema (redness).
  • Decreased skin temperature in the affected limbs.
  • Skin on the lower extremities that appears thin, taut, and shiny.
  • Presence of gangrenous tissue (tissue death).
  • Hair loss or thinning on the legs.
  • Non-healing wounds and ulcers on the extremities.
  • Thickened and opaque toenails.
• Reproductive Symptoms:
  • Erectile dysfunction (impotence) in men.
• Musculoskeletal Symptoms:
  • Reduced mobility and functional limitations.
  • Muscle weakness in the legs.
  • Feelings of heaviness in the leg muscles.
  • Numbness and tingling sensations (paresthesia).
  • Muscle pain during activity that subsides with rest, known as intermittent claudication.

2. Medical History Review: Atherosclerosis is the primary cause of PVD. It’s important to note any pre-existing conditions that contribute to plaque formation, such as:

• Hypertension (high blood pressure)
• Hyperlipidemia (high cholesterol)
• Diabetes mellitus
• Coronary artery disease
• Cerebrovascular disease

3. Family History: A detailed family history is essential. A family history of PVD is significant if a first-degree relative underwent revascularization or stent placement for PVD before the age of 65. Also, inquire about family history of heart disease or stroke.

4. Risk Factor Identification: Identifying risk factors helps in understanding the patient’s predisposition to PVD. Key risk factors include:

• Smoking – a major modifiable risk factor.
• Sedentary lifestyle and physical inactivity.
• Male sex.
• Older age.
• Obesity.
• African-American ethnicity.

5. Dietary Assessment: Diet significantly impacts plaque buildup in arteries. Assess the patient’s current diet, focusing on:

• High intake of saturated fats (fatty foods).
• High consumption of simple carbohydrates (sugary foods and drinks).
• High sodium intake (processed and salty foods).

Physical Assessment

1. Assessing the 5 P’s: The “5 P’s” are classic signs of acute arterial occlusion and are also relevant in PVD assessment:

• Pulselessness: Absence of palpable peripheral pulses.
• Paralysis: Inability to move the affected limb (indicates severe ischemia).
• Paresthesia: Numbness or tingling sensations (indicates nerve ischemia).
• Pain: Leg pain, especially at rest, suggests critical limb ischemia.
• Pallor: Paleness of the skin (indicates reduced blood flow).

Immediate assessment and consultation are vital if paresthesia or paralysis are present, as these suggest severe ischemia and potential limb loss.

2. Cardiovascular Status Assessment:

• Auscultate the heart sounds for any irregularities or murmurs.
• Palpate all peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral, radial, ulnar, carotid) and assess their quality (strength and regularity). Note any bruits (abnormal swishing sounds) over arteries, indicating turbulent blood flow.

3. Allen Test: Perform the Allen test to evaluate the patency of the radial and ulnar arteries, assessing collateral blood flow to the hand. A negative Allen test suggests insufficient dual blood supply to the hand.

4. Skin Assessment: Observe the skin for changes indicative of PVD:

• Alopecia (hair loss on the legs and feet).
• Dry, scaly, or erythematous (red) skin.
• Persistent pigmentation changes, such as pallor or rubor (dusky redness when dependent).
• Brittle or thickened nails.

5. Advanced PVD Symptoms: Recognize signs of advanced PVD, which signal critical limb ischemia:

• Pulselessness in affected limbs.
• Persistent numbness in the feet and toes.
• Cyanosis (bluish discoloration) of the extremities.
• Mottling of the skin with a “fishnet pattern” (livedo reticularis).
• Cold extremities to touch.
• Paralysis (in severe cases).
• Gangrene (tissue necrosis).
• Poorly healing wounds and ulcers, especially on the feet and ankles.

6. Pain Assessment: Characterize the patient’s pain. Intermittent claudication is pain triggered by walking and relieved by rest. Pain at rest, particularly in the foot and toes, is a more serious symptom indicating severe ischemia.

Diagnostic Procedures

1. Blood Tests: Routine blood tests are essential to assess for organ function and risk factors:

• Complete Blood Count (CBC): To evaluate overall health and rule out infection.
• Blood Urea Nitrogen (BUN) and Creatinine: To assess kidney function, as kidney disease is a complication and comorbidity of PVD.
• Electrolyte Levels: To assess overall metabolic status.
• Coagulation Tests (PT/INR, PTT): To assess bleeding risks, especially if anticoagulation therapy is considered.
• Lipid Profile (Cholesterol, Triglycerides, LDL, HDL): To evaluate for hyperlipidemia, a major risk factor for atherosclerosis.

2. Inflammatory Markers: Elevated inflammatory markers may be associated with exercise intolerance in PVD:

• D-dimer: To rule out blood clots.
• C-reactive protein (CRP): A general marker of inflammation.
• Interleukin-6 (IL-6): Another inflammatory cytokine.
• Homocysteine: Elevated levels are linked to increased cardiovascular risk.

3. Ankle-Brachial Index (ABI): ABI is a crucial non-invasive test to assess arterial disease severity. It compares blood pressure in the ankles to the arms. A normal ABI is 1.0 to 1.4. PVD is typically indicated by:

• Borderline PVD: ABI 0.91 to 0.99
• Mild PVD: ABI 0.71 to 0.90
• Moderate PVD: ABI 0.41 to 0.70
• Severe PVD: ABI 0.00 to 0.40

4. Doppler Ultrasound: Doppler ultrasound is a primary non-invasive method to assess blood flow in peripheral arteries. Absence or faintness of Doppler signals indicates blockage or reduced blood flow.

5. Transcutaneous Oximetry (TcPO2): TcPO2 measures tissue oxygenation and is increasingly used in diabetic patients and wound care to assess blood flow impairment and healing potential.

6. Imaging Scans: Imaging provides detailed visualization of blood vessels:

• Magnetic Resonance Imaging (MRI): Offers high-resolution images and detailed plaque visualization.
• Computed Tomography (CT) with Contrast: Effective for visualizing arterial insufficiency and stenosis.
• CT Angiography (CTA): Rapid and non-invasive, provides detailed arterial imaging.
• Magnetic Resonance Angiography (MRA): Highly accurate without radiation but can be costly and less accessible.

Nursing Interventions for Peripheral Vascular Disease

Nursing interventions are critical for managing PVD, focusing on slowing disease progression, managing symptoms, and preventing complications.

1. Prevent Disease Progression: Lifestyle modification is the cornerstone of PVD management. Pharmacological and endovascular interventions are adjuncts to manage symptoms and reduce cardiovascular risk.

2. Medication Administration: Prescribed medications are essential to manage underlying conditions and directly treat PVD:

• Statins: Lower LDL (“bad”) cholesterol and raise HDL (“good”) cholesterol, reducing plaque buildup and the risk of stroke and heart attack.
• Antihypertensive Drugs: Maintain blood pressure within target ranges to reduce arterial stress.
• Antidiabetic Agents: Control blood sugar levels in diabetic patients, crucial for preventing vascular damage.
• Antiplatelets (e.g., Clopidogrel, Aspirin) and Anticoagulants (e.g., Warfarin, Heparin): Prevent blood clot formation, reducing the risk of acute arterial occlusion.
• Cilostazol: A vasodilator and antiplatelet agent that improves blood flow to the limbs and alleviates leg pain in claudication.

3. Comorbidity Management: Aggressively manage comorbidities:

• Blood pressure target: <120/80 mmHg for non-diabetic patients and <130/80 mmHg for diabetic patients.
• Hemoglobin A1c target: <7% for diabetic patients to optimize blood glucose control.

4. Revascularization Preparation: For patients with severe, unresponsive symptoms, prepare them for potential revascularization procedures:

• Endovascular interventions (angioplasty, stenting).
• Surgical bypass grafting.
• Hybrid procedures combining endovascular and surgical approaches.

5. Exercise Promotion: Supervised exercise therapy programs are highly effective in reducing claudication symptoms. Refer patients to physical therapy for structured programs.

6. Blood Clot Management: If acute thrombi or emboli develop, immediate intervention is needed. Initiate heparin infusion to achieve a therapeutic activated partial thromboplastin time (aPTT) of 1.5 to 2.5 times the normal control value.

7. Lifestyle Modification Education: Patient education is paramount:

• Emphasize regular physical activity and structured exercise.
• Promote weight management and weight loss if overweight or obese.
• Encourage a heart-healthy diet low in saturated fat, sodium, and processed foods.
• Strongly advise smoking cessation and provide resources for quitting.
• Stress medication adherence and understanding of prescribed regimens.

8. Avoid Pseudoephedrine Counseling: Advise patients to avoid cold and sinus medications containing pseudoephedrine (e.g., Sudafed, Advil Cold and Sinus) as they can constrict blood vessels and worsen PVD symptoms.

9. Nutritional Counseling Referral: Refer patients to a registered dietitian or nutritionist for personalized dietary guidance on heart-healthy eating.

10. Foot Care Education: Comprehensive foot care education is vital, especially for patients with diabetes:

• Daily foot inspection for cuts, blisters, redness, or swelling.
• Proper foot hygiene and gentle washing.
• Moisturizing dry skin, but avoiding moisture between toes.
• Wearing well-fitting shoes and avoiding walking barefoot.
• Prompt reporting of any foot problems to healthcare providers.

Peripheral Vascular Disease Nursing Care Plans

Nursing care plans guide nursing care by prioritizing diagnoses, assessments, and interventions, setting both short-term and long-term goals. Common nursing diagnoses for PVD include:

Acute Pain

Acute pain related to reduced blood flow is a frequent symptom of PVD, particularly during activity.

Nursing Diagnosis: Acute Pain related to vascular system blockage secondary to peripheral vascular disease.

As evidenced by:

• Patient verbalizes pain, cramping, or aching in the legs during walking.
• Patient reports burning pain in the feet (in severe cases).
• Muscle fatigue and weakness in the legs.
• Patient avoids physical activity due to pain.

Expected Outcomes:

• Patient will report reduced pain levels with walking.
• Patient will gradually increase physical activity tolerance without significant pain.

Nursing Assessments:

1. Pain Characteristics Assessment: Detailed pain assessment is crucial to understand the nature, location, intensity, aggravating and relieving factors of pain. Note if pain occurs at rest, which indicates severe ischemia.
2. Prior Pain Relief Efforts: Assess what methods the patient has used for pain relief and their effectiveness to guide tailored interventions.

Nursing Interventions:

1. Medication Administration: Administer prescribed analgesics and vasodilators like cilostazol to manage pain. Educate the patient on medication action and potential side effects.
2. Exercise Encouragement: Encourage structured walking exercise within pain tolerance. Explain the benefits of exercise in improving circulation and reducing claudication.
3. Lifestyle Modification Education: Reinforce the importance of lifestyle changes (weight management, smoking cessation, diet modification) in pain management and disease control.
4. Avoid Massage of Affected Extremities Education: Instruct the patient to avoid massaging affected extremities without consulting a doctor, as it could potentially dislodge an embolus.

Chronic Pain

Chronic pain in PVD encompasses intermittent claudication, ischemic pain at rest, and neuropathic pain due to nerve damage.

Nursing Diagnosis: Chronic Pain related to limb ischemia secondary to plaque buildup (atherosclerosis) in peripheral blood vessels.

As evidenced by:

• Patient reports burning, stabbing, or tingling pain in the extremities.
• Paresthesias (numbness and tingling).
• Intermittent claudication limiting mobility.
• Altered mobility and reduced activity levels.

Expected Outcomes:

• Patient will report a decrease in burning, tingling, and numbness in the extremities.
• Patient will utilize non-pharmacological pain management techniques effectively.

Nursing Assessments:

1. Pain Characteristics Assessment: Thoroughly assess the characteristics of chronic pain, including type, location, intensity, duration, and aggravating/relieving factors. Differentiate between claudication and ischemic rest pain.
2. Signs of Critical Limb Ischemia: Assess for signs of critical limb ischemia, which poses a threat to limb viability: persistent rest pain, non-healing ischemic ulcers or gangrene, and significantly reduced ABI (<0.4).
3. Phantom Limb Pain Assessment: If amputation is considered or performed, assess for risk factors and signs of phantom limb pain.

Nursing Interventions:

1. Prioritize Exercise Therapy: Emphasize exercise therapy as the first-line treatment for intermittent claudication. Collaborate with physical and occupational therapists to develop tailored exercise regimens and safety precautions.
2. Psychological Pain Management Techniques: Introduce and encourage psychological techniques such as biofeedback, mirror therapy, guided imagery, and meditation as adjuncts to medication for chronic pain management.
3. Spinal Cord Stimulation Discussion: For patients with severe ischemic pain unresponsive to analgesics, discuss spinal cord stimulation as a potential pain relief option.
4. Psychosocial Support: Provide emotional support to help patients cope with chronic pain’s impact on sleep, mood, appetite, and social interactions. Refer to mental health services as needed.
5. Surgical Intervention Preparation: Prepare patients for potential surgical revascularization interventions to improve blood flow and relieve pain.

Ineffective Peripheral Tissue Perfusion

Reduced blood flow due to arterial narrowing directly leads to ineffective peripheral tissue perfusion in PVD.

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to disease process (atherosclerosis) and reduced arterial blood flow.

As evidenced by:

• Absent or weak peripheral pulses.
• Muscle weakness and fatigue in the legs.
• Cool and cyanotic skin of the extremities.
• Shiny and hairless skin on the legs.
• Decreased blood pressure in the affected extremities.
• Delayed peripheral wound healing.
• Edema in the legs and feet.
• Extremity pain, especially at rest.
• Femoral bruit (abnormal sound in the femoral artery).
• Intermittent claudication.
• Paresthesia.
• Pallor of the skin with limb elevation.

Expected Outcomes:

• Patient will demonstrate adequate peripheral tissue perfusion, indicated by palpable 3+ peripheral pulses.
• Patient will verbalize understanding of their medication regimen and lifestyle modifications to manage PVD and improve tissue perfusion.

Nursing Assessments:

1. Peripheral Pulse Assessment: Regularly assess and document peripheral pulse strength (pedal, popliteal, femoral) to monitor arterial blood flow. Reduced or absent pulses indicate worsening arterial insufficiency.
2. Ankle-Brachial Index (ABI) Measurement: Obtain and monitor ABI values to quantify the degree of peripheral arterial disease and tissue perfusion.

Nursing Interventions:

1. Chronic Condition Management: Ensure optimal management of underlying conditions like diabetes, hypertension, and hyperlipidemia to slow atherosclerosis progression and improve tissue perfusion.
2. Avoid Prolonged Sitting: Encourage frequent ambulation and discourage prolonged sitting or standing to promote venous return and arterial blood flow.
3. Statin Therapy Consideration: Advocate for statin therapy, if appropriate, to manage hyperlipidemia and improve atherosclerotic disease, enhancing tissue perfusion.
4. Surgical Intervention Preparation: Prepare and educate patients who require surgical revascularization to restore blood flow and improve tissue perfusion in severe cases.

Risk for Injury

Patients with PVD are at increased risk of injury due to impaired sensation, reduced mobility, and potential for falls.

Nursing Diagnosis: Risk for Injury related to disease process, tissue hypoxia, altered peripheral sensation, and decreased lower extremity strength.

As evidenced by: (Risk diagnosis – no “as evidenced by”)

Expected Outcomes:

• Patient will remain free from injury.
• Patient will demonstrate two or more strategies to reduce the risk of falls and injury.

Nursing Assessments:

1. Environmental and Self-Care Abilities Assessment: Assess the patient’s home environment for safety hazards (stairs, rugs, clutter) and evaluate their self-care abilities, mobility, and need for assistive devices or support services.
2. Mobility Issue Assessment: Thoroughly assess mobility limitations, balance issues, and muscle weakness to identify fall risks and plan preventive measures.

Nursing Interventions:

1. Fall Prevention Strategies: Implement fall prevention measures, especially during exercise programs. Recommend assistive devices like canes or walkers if needed.
2. Foot Care Education: Reinforce meticulous foot care practices to prevent skin breakdown, infection, and injury, especially in patients with diabetes.
3. Smoking Cessation Support: Strongly encourage smoking cessation and provide resources, as smoking is a major risk factor for limb ischemia and amputation.
4. Physical and Occupational Therapy Referral: Refer to PT/OT for comprehensive assessment of mobility and home safety, and for tailored exercise programs and recommendations for environmental modifications.

Risk for Peripheral Neurovascular Dysfunction

PVD compromises blood flow to extremities, placing patients at risk for neurovascular dysfunction.

Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction related to plaque buildup in blood vessels (atherosclerosis), reduced blood flow to extremities, and sedentary lifestyle.

As evidenced by: (Risk diagnosis – no “as evidenced by”)

Expected Outcomes:

• Patient will maintain adequate peripheral neurovascular function, evidenced by palpable peripheral pulses and normal skin color.
• Patient will not report new or worsening numbness and tingling (paresthesia).

Nursing Assessments:

1. Neurovascular Status Assessment: Regularly assess and document neurovascular status, including peripheral pulse strength, skin color, skin temperature, capillary refill, sensation, and motor strength, comparing both extremities.
2. Balance and Gait Monitoring: Observe balance and gait during ambulation to identify any abnormalities indicative of neurovascular compromise.
3. “5 P’s” Assessment: Continuously monitor for the “5 P’s” (pain, paralysis, paresthesia, pulselessness, pallor) as indicators of acute neurovascular compromise.

Nursing Interventions:

1. Positioning Education: Instruct patients to avoid leg crossing and extreme leg elevation, recommending leg elevation slightly above heart level to improve venous return without compromising arterial flow.
2. Medication Administration and Education: Ensure timely administration of prescribed medications (antihypertensives, statins, antiplatelets, anticoagulants) and educate patients on their purpose and importance for neurovascular health.
3. Supervised Exercise Program Enrollment: Encourage participation in a supervised exercise program to improve circulation and prevent neurovascular dysfunction.
4. Neurovascular Dysfunction Sign Education: Educate patients and families about the signs and symptoms of worsening neurovascular dysfunction that require immediate medical attention (e.g., rest pain, numbness, color changes, diminished pulses).
5. Clinical Image Documentation: With patient consent, consider documenting relevant clinical findings (skin changes, ulcers, nail abnormalities) with images to track disease progression and neurovascular status changes over time.

References

(References would be listed here, following standard citation format, as per original article if applicable, or with updated relevant sources for the English version.)