NSG210 Hinkle Ch. 26: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 26, pp. 818-862 (textbooks/HINKLE_MS_CH26.pdf, also in textbooks/exam03/). Week 08 reading (Alterations in Perfusion / PVD lecture, raw/nsg210_PeripheralVascularDiseases2026.ppt); on Exam 3. Numbering note: the syllabus lists “Ch. 27,” which is hypertension in the 15th edition; the vascular lecture content (PAD, DVT, PE, venous disorders) is in Ch. 26. Detailed PAD lecture notes with slide-vs-textbook differences: nsg210-week-08-peripheral-vascular-diseases-lecture.

Learning Outcomes

1. Identify anatomic and physiologic factors that affect peripheral blood flow and tissue oxygenation.
2. Apply assessment parameters for determining the status of peripheral circulation.
3. Use the nursing process for patients with arterial and venous disorders.
4. Compare pathophysiology, manifestations, management, and prevention of arterial diseases.
5. Describe pathophysiology, manifestations, management, and prevention of VTE, venous insufficiency, leg ulcers, and varicose veins.

I. Anatomy and Physiology Review

• Arteries carry oxygenated blood away from the heart (except pulmonary artery); veins return deoxygenated blood (except pulmonary veins); capillaries exchange nutrients and wastes
• Blood flows from high pressure (arterial about 100 mm Hg) to low pressure (venous); resistance rises as vessels narrow
• Capillary filtration: hydrostatic pressure pushes fluid out at the arterial end, oncotic (albumin) pressure pulls it back at the venous end; extra fluid goes to lymphatics. Edema results from high venous pressure, low plasma proteins, increased capillary permeability, or lymphatic obstruction
• Tissues extract about 50% of arterial oxygen at rest; ischemia occurs when supply cannot meet demand
• Venous return depends on valves, calf muscle pump, and respiratory pressure changes
• Aging stiffens vessels (intimal thickening, calcified media), raising peripheral resistance

II. Vascular Assessment

• Health history: intermittent claudication (reproducible exercise pain relieved by rest; about 50% lumen loss), rest pain (forefoot, nights, relieved by dangling), location of pain (distal to lesion)
• Skin: pallor on elevation, dependent rubor (within 20 seconds to 2 minutes), cyanosis, cool temperature, hair loss, brittle nails, dry skin, ulcers, gangrene
• Pulses: palpate bilaterally and simultaneously; light touch, not the thumb or index finger alone; absent pulse means lesion is proximal
• Doppler: patient supine, HOB 20-30 degrees, gel, probe at 45-60 degrees, light pressure; report loss of a signal that was present

Ankle-brachial index (ABI)

• Supine, rest 5 minutes; correctly sized cuffs (bladder width 40%, length 80% of limb circumference)
• Doppler systolic in both arms and both ankles (posterior tibial and dorsalis pedis)
• ABI = highest ankle pressure for that leg / highest brachial pressure
• Text ranges: over 1.40 noncompressible; 1.00-1.40 normal; 0.91-0.99 borderline; under 0.90 abnormal; 0.50-0.90 claudication; under 0.50 rest pain; under 0.40 severe ischemia/tissue loss
• Slide ranges (lecture): 1.0 normal; 0.95-0.50 claudication; under 0.50 rest pain; under 0.25 severe
• Errors: ABI 1.20 or more or ankle over 250 mm Hg suggests calcified vessels (diabetes, CKD); pressure under 40 mm Hg may be a venous signal
• No nicotine or caffeine 2 hours before; baseline ABI for decreased pulses or age 65 and older (especially with diabetes or nicotine)

Diagnostic tests

• Exercise testing: treadmill 1.5 mph, 12% incline up to 5 minutes; ankle pressure drops in true claudication
• Duplex ultrasound: image plus flow; standard for DVT; NPO 6 hours for abdominal studies
• CT angiography and MRA: contrast; hydrate; urine output at least 0.5 mL/kg/hour; contrast kidney injury may appear 48-96 hours later; MRA - screen for metal and implanted devices
• Angiography (arteriogram): contrast through catheter; warm flush; watch for allergic reaction; slide nursing care - consent, iodine allergy, meds held, NPO after midnight (clears to 2 hours before), bed rest 6 hours, site, pulses, BP, fluids
• Contrast phlebography (venography): rarely used now
• Lymphoscintigraphy: radioactive colloid injected between toes to image lymphatics

III. Arterial vs Venous Insufficiency (Table 26-1)

IV. Arterial Disorders

A. Atherosclerosis

• Plaque in the intima of large and medium arteries; generalized disease (if in legs, likely in heart and brain)
• Fatty streak, then fibrous plaque, then complicated lesion (ulceration, calcification, thrombosis)
• Collateral circulation develops around gradual narrowing
• Risk factors: nicotine (most important), diabetes (2-4 times PAD risk, 5-10 times amputation rate), HTN, hyperlipidemia, obesity, inactivity, stress, high CRP, high homocysteine, age, family history
• Prevention: low saturated fat diet; statins first-line for all PAD
• Endovascular: angioplasty (PTA), atherectomy, stents; complications hematoma, embolus, dissection, occlusion, bleeding

B. Nursing care of peripheral vascular problems (Chart 26-4)

• Arterial: legs below heart level (HOB up, recliner, feet on floor); walking program
• Venous: legs above heart; avoid prolonged standing or sitting; walk
• Vasodilation: keep warm; never heating pads or hot-water bottles on legs (heat on abdomen gives reflex vasodilation; direct heat must not exceed body temperature); stop nicotine; stress management; no constrictive clothing; no leg crossing (not over 15 minutes)
• Pain: exercise plus analgesics (watch older adults for delirium, falls)
• Tissue integrity: daily foot inspection, mild soap, pat dry, lotion but not between toes, protective shoes, nails straight across, podiatrist, no barefoot, report blisters or breaks
• Nutrition: protein, vitamins A and C, zinc; low fat; weight loss
• Older adults: gangrene after minor trauma may be the first sign

C. Peripheral artery disease (PAD)

• Usually aorta below renal arteries to popliteal artery; distal disease in diabetes and older adults; more common in men
• Manifestations: claudication, rest pain (worse with elevation, better dependent), coldness, numbness, pallor on elevation, rubor dependent, skin and nail changes, ulcers, gangrene, bruits, weak or absent pulses
• Treatment:
  • Supervised exercise therapy (walk to pain, rest, repeat); home walking is comparable
  • Stop nicotine; weight loss
  • Cilostazol (PDE III inhibitor, vasodilator and antiplatelet) - improves walking in 4-6 weeks; CONTRAINDICATED in heart failure
  • Aspirin or clopidogrel; statins
  • Endovascular: angioplasty, stent, drug-eluting stent (antiplatelets at least 6 months), atherectomy
  • Surgery (rest pain, disabling claudication, limb at risk): endarterectomy; bypass graft (fem-pop, fem-tib, tibial/pedal with autologous vein; outflow vessel at least 50% patent); primary amputation if revascularization not tolerated
• Post-op bypass: pulses (palpation and Doppler), color, temperature, cap refill, sensation, motion every 15 minutes then less often; ABI every 8 hours for 24 hours then daily (not after pedal bypass); LOSS of a pulse = notify surgeon immediately; watch bleeding, hematoma, fluid balance; no leg crossing or prolonged dependency; edema normal but compartment syndrome (severe edema, pain, reduced sensation) must be reported

D. Upper extremity arterial disease

• Usually subclavian stenosis; arm fatigue and pain with use; subclavian steal causes vertigo, ataxia, syncope, visual changes; arm BPs differ by more than 15-20 mm Hg
• Post-procedure: arm at heart level, protected from cold, punctures, tape, constrictive dressings for 24 hours

E. Aortoiliac disease

• Buttock or low back pain with walking, erectile dysfunction, weak femoral pulses
• Iliac stents or aortoiliac/aortobifemoral graft
• Post-op: pulses and extremity checks; urine output at least 0.5 mL/kg/hour; bowel sounds every 8 hours (may not return until day 3); diarrhea before day 3 with rising pain and WBC 20,000-30,000 suggests bowel ischemia

F. Aneurysms

• Localized dilation at a weak arterial wall; saccular (one side), fusiform (whole circumference), dissecting, false (pulsating hematoma), mycotic (infection)
• Thoracic aortic aneurysm: mostly atherosclerosis; men 50-70; constant boring pain, dyspnea, brassy cough, hoarseness, dysphagia, distended chest veins; BP control (beta-blockers, ARBs); preop SBP 90-120, MAP 65-75 (esmolol, nitroprusside); endovascular repair with lumbar drain to prevent spinal cord ischemia (CSF pressure 10 mm Hg or less, MAP over 90 for 36-48 hours)
• Abdominal aortic aneurysm (AAA): atherosclerosis; men 2-6 times more; over 65; usually infrarenal; only about 40% have symptoms - feel heartbeat in abdomen, pulsatile mass in middle/upper abdomen, systolic bruit; trash toes from emboli
  • Impending rupture: severe back or abdominal pain; falling BP and hematocrit
  • Retroperitoneal rupture: hematomas in scrotum, perineum, flank, penis; rupture into the peritoneum is rapidly fatal
  • Repair at 5.5 cm or if enlarging; rupture likely over 6 cm with HTN; ultrasound every 6 months for small aneurysms
  • Endovascular repair (EVAR): supine 6 hours (HOB up to 45 degrees after 2 hours); vital signs, Doppler pulses, access site every 15 minutes initially; report coughing, sneezing, vomiting, SBP over 180; watch for embolization (tender, cyanotic skin patches); postimplantation syndrome (fever, leukocytosis, transient low platelets within 24 hours - acetaminophen or ibuprofen)
  • Open repair complications: occlusion, hemorrhage, infection, bowel ischemia, kidney injury, erectile dysfunction
• Peripheral (popliteal) aneurysms: often bilateral; main risk is distal embolization, not rupture
• Aortic dissection: intimal tear; men, 50-70, HTN, blunt trauma, cocaine; sudden severe “tearing” or “ripping” chest or back pain; may mimic MI; BP differs between arms; pallor, sweating, tachycardia; manage like thoracic aneurysm

G. Acute arterial occlusion (embolism and thrombosis)

• Emboli usually from the heart (atrial fibrillation, MI, endocarditis, HF); thrombosis on existing plaque
• Six Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis; distal part colder and paler
• 4-6 hour window before irreversible tissue death
• Immediate IV heparin (60-80 units/kg bolus, then 12-18 units/kg/hour); embolectomy (balloon catheter), mechanical thrombectomy, catheter-directed thrombolytics (t-PA, reteplase, tenecteplase)
• Thrombolytic contraindications: active internal bleeding, cerebral hemorrhage, recent major surgery, uncontrolled HTN, pregnancy
• Nursing before intervention: bed rest, limb level or slightly dependent (15 degrees), room temperature, no heat or cold, no tape or electrodes on limb, heel offloading, bed cradle
• After: pulses, Doppler, ABI, motor and sensory every hour for 24 hours; bleeding precautions (few punctures, no IM, pressure twice as long); watch for reperfusion problems, kidney injury, compartment syndrome

H. Raynaud phenomenon and acrocyanosis

• Intermittent arteriolar vasospasm; WHITE (pallor), BLUE (cyanosis), RED (rubor on reflow); numbness, tingling, burning
• Primary (Raynaud disease, no cause) vs secondary (lupus, RA, scleroderma); women 5 times more, onset before 30
• Triggers: cold, stress, nicotine (including gum and patches), decongestants
• Treatment: avoid triggers; calcium channel blockers (nifedipine, amlodipine) - orthostatic hypotension; sympathectomy for some
• Nursing: layers, hat, gloves outdoors and at the freezer, warm the car first, sweater in air conditioning, careful with sharp objects
• Acrocyanosis: persistent symmetric blue color with clammy, sweaty hands and feet; CCBs not effective

I. Buerger disease (lecture slides only - not in this chapter; full notes in nsg210-week-08-peripheral-vascular-diseases-lecture)

• Thromboangiitis obliterans: recurring inflammation of small and medium arteries and veins with distal thrombosis; bilateral, symmetric; strongly linked to tobacco - must stop completely

V. Venous Disorders

A. Venous thromboembolism (VTE): DVT and PE

• VTE incidence 10-20% in medical patients, up to 80% in critically ill; often silent; most surgical VTE appears after discharge
• COVID-19: hypercoagulable; routine thromboprophylaxis for all hospitalized patients
• Virchow triad (Chart 26-8):
  • Endothelial damage: central lines, dialysis catheters, pacing wires, surgery, trauma, fractures, IV irritants, repetitive motion
  • Venous stasis: age over 65, bed rest or immobility, HF, varicosities, obesity, spinal cord injury, anesthesia
  • Altered coagulation: cancer, oral contraceptives, pregnancy (up to 6 weeks postpartum), factor V Leiden, protein C or S deficiency, antithrombin III deficiency, antiphospholipid syndrome, polycythemia, sepsis, abrupt stop of anticoagulants
• Superficial veins thick-walled; deep veins thin-walled, parallel to arteries; valves keep flow toward the heart; perforating veins move blood from superficial to deep

B. Deep vein thrombosis (DVT)

• Usually calf or thigh; upper extremity 5-10% (higher with central lines; subclavian most common; effort thrombosis/Paget-Schroetter in athletes)
• Thrombus: platelets on vein wall with a fibrin tail that can propagate and break off to the lungs (dislodges with sudden standing or exertion after inactivity)
• Phlebothrombosis: clot without inflammation; thrombophlebitis: with inflammation
• Manifestations are nonspecific (only about half have symptoms): unilateral edema and swelling, warmth, prominent superficial veins, tenderness (later); PE may be the first sign
• Phlegmasia cerulea dolens: massive iliofemoral DVT; whole leg massively swollen, tense, painful, cool; venous gangrene in 20-50%
• Homans sign is NOT reliable
• Assessment: measure leg circumference at several levels (thigh to ankle) and compare sides; heaviness, functional impairment, ankle engorgement, warmth, cordlike vein
• Diagnosis: venous duplex ultrasound (veins noncompressible, dilated); D-dimer; CBC, PT/INR, aPTT baseline; hypercoagulability workup if indicated
• Prevention: early ambulation, leg exercises, graduated compression stockings, intermittent pneumatic compression (IPC), subcut heparin or LMWH for surgical patients; recurrence up to about 14%
• Treatment goals: prevent extension, embolization, recurrence, and postthrombotic syndrome; anticoagulants do NOT dissolve existing clots
• Endovascular (when anticoagulation contraindicated, PE danger extreme, or limb threatened): mechanical thrombectomy, ultrasound-assisted catheter thrombolysis, IVC filter (retrievable up to 6 months), angioplasty/stent for May-Thurner

C. Anticoagulant and thrombolytic agents (Table 26-2)

• Complications: bleeding, thrombocytopenia (HIT: platelets under 100,000 or 25-50% drop), drug interactions
• Slide emphasis: monitor PTT, PT, INR, H&H, platelets, fibrinogen; watch LOC, blood in urine, stool, skin, nose

D. DVT nursing management

• Comfort: elevate affected leg, graduated compression stockings, analgesics, warm moist packs
• Positioning and exercise: on bed rest elevate feet and lower legs above heart periodically; active and passive calf exercises; ambulate once anticoagulated - walk at least 10 minutes every 1-2 hours; avoid sitting more than an hour; leg exercises on long trips; deep breathing helps empty large veins
• Anticoagulant teaching (Chart 26-10): take as prescribed, do not stop on own; warfarin same time daily; medical ID; keep lab appointments; check with provider before OTC drugs, aspirin, NSAIDs, vitamins, herbs; avoid alcohol with warfarin; keep vitamin K intake (green leafy vegetables) CONSISTENT; tell all providers and dentist; electric razor, soft toothbrush, no contact sports; report bleeding, enlarging bruises, red or brown urine, red or black stools; notify provider if pregnancy suspected
• Superficial thrombophlebitis: pain, redness, warmth along the vein; rarely embolizes; warm compresses, elevation, NSAIDs at home

E. Pulmonary embolism (PE)

• Usually a dislodged DVT; also air, fat, amniotic fluid, septic emboli
• Obstruction increases dead space (ventilated but not perfused), causes V/Q mismatch, vasoconstriction, pulmonary hypertension, right ventricular strain and failure, shock
• Symptoms: dyspnea (most frequent symptom), tachypnea (most frequent sign), sudden pleuritic chest pain (may mimic angina), anxiety and sense of doom, tachycardia, cough, hemoptysis, diaphoresis, fever, syncope; massive PE - shock, sudden death
• Diagnosis: CT pulmonary angiography (MDCTA) is the standard; V/Q scan if CT unavailable; pulmonary angiogram; D-dimer; chest x-ray usually normal; ECG shows sinus tachycardia (rate over 100, P before every QRS) and, most often, nonspecific ST-T wave abnormalities (abnormal ST or T that does not name one diagnosis). These ECG findings do not diagnose PE. The classic right-heart strain pattern (S in lead I, Q and inverted T in lead III, sometimes a new right bundle branch block) is not in this chapter or on the slides. ABG hypoxemia with low CO2 (may be normal); slide list also includes CBC, coags, cardiac biomarkers, lower-extremity ultrasound
• Unstable (massive) PE: hypotension, tachycardia, confusion, collapse - stabilize; thrombolytics (t-PA) if severe; contraindications: stroke within 2 months, active intracranial process, active bleeding, surgery within 10 days, recent delivery, trauma, severe HTN; embolectomy if lytics contraindicated
• IVC filter: for recurrent PE despite anticoagulation (not first-line, not with anticoagulation)
• Stable PE: immediate anticoagulation (LMWH, heparin, or DOAC) then long-term (at least 3-6 months, sometimes indefinite) with warfarin or DOAC; select low-risk patients treated as outpatients
• Nursing:
  • Thrombolytics: bed rest, frequent vital signs, avoid invasive procedures, INR/aPTT 3-4 hours after start, manual pressure at least 30 minutes on any puncture, stop infusion for uncontrolled bleeding
  • Pain: semi-Fowler, reposition frequently, opioids for severe pain
  • Oxygen continuously; pulse oximetry; deep breathing and incentive spirometry
  • Watch for right ventricular failure and cardiogenic shock
  • Relieve anxiety: explain, answer questions
  • After embolectomy: pulmonary artery pressure, urine output, catheter site; elevate foot of bed, IPC, isometric exercise; avoid prolonged sitting (hip flexion compresses veins)
  • Teaching (Chart 26-11): stockings as directed, no leg crossing or long sitting, move and exercise legs while traveling, drink fluids, report leg pain/swelling and chest symptoms

F. Chronic venous insufficiency / postthrombotic syndrome

• Incompetent valves cause reflux and venous hypertension; 20-50% of DVT patients develop postthrombotic syndrome
• Edema (worse in the evening), brown hemosiderin pigmentation, pain, stasis dermatitis, dry itchy skin, stasis ulcers at medial malleolus
• Management: protect from trauma; skin clean, dry, soft; elevate legs at least 15-20 minutes 4 times a day; foot of bed up 6 inches at night; walk; avoid prolonged sitting or standing, crossing legs, dangling legs, tight socks

G. Compression therapy

• Graduated compression stockings: 20-30 mm Hg for asymptomatic varicose veins; 30-40 mm Hg for venous ulcers and for 6 months after DVT; TED (anti-embolism) stockings are only 12-20 mm Hg
• Apply after legs elevated (veins emptiest); remove at night for ambulatory patients and reapply before getting out of bed; never roll at the top (tourniquet effect); inspect skin and calves when off
• Contraindicated: severe PAD, epifascial arterial bypass, severe cardiac insufficiency, allergy, severe diabetic neuropathy
• Older adults may need help or an applicator device (OT referral)
• Short-stretch bandages (50% spiral overlap), Unna boot (zinc paste, foot dorsiflexed 90 degrees, up to 1 week), CircAid Velcro wraps
• Intermittent pneumatic compression (IPC): sequential ankle-calf-thigh sleeves at 30-70 mm Hg (slides: 35-55); check fit, pressures, comfort, adherence

H. Leg ulcers

• 80-90% venous; PAD second; 26% mixed
• Arterial ulcers: small, circular, deep, toe tips and web spaces, very painful
• Venous ulcers: large, superficial, highly exudative, gaiter area; take 6-12 months to heal; nearly 100% recur within 36 months without compression
• Neuropathic (diabetic) ulcers: painless, over metatarsal heads
• Compression for venous ulcers only after confirming ankle pressure over 60 mm Hg and ABI over 0.80
• Infection signs (erythema, induration, exudate, malodor): culture and SYSTEMIC (oral) antibiotics; topical antibiotics not recommended
• Cleansing: neutral cleanser; avoid hydrogen peroxide, Dakin’s, chlorhexidine, high-concentration acetic acid
• Debridement: surgical (fastest), sharp, chemical, ultrasonic, hydrosurgical, larval, enzymatic, autolytic (alginate or hydrofiber dressings for exudative wounds); wet-to-dry not recommended
• Dry gangrene of a toe in an older adult with poor circulation: keep clean and dry, do NOT debride - let it autoamputate (an open wound will not heal and may lead to higher amputation)
• Moist semiocclusive dressings; skin substitutes (Apligraf); hyperbaric oxygen (diabetic wounds not healing after 30 days; ear barotrauma, confinement anxiety); negative pressure wound therapy (groin wounds)
• Nursing: gentle cleansing; position by type (arterial - refer for revascularization; venous - elevate and compress); protect from trauma (heel boots, bed cradle, clear paths); no heating pads; gradual activity; analgesics before activity; diet high in protein, vitamins A and C, iron, zinc

I. Varicose veins

• Dilated, tortuous superficial veins from incompetent valves; 23% of adults; occupations with prolonged standing; heredity; pregnancy
• Symptoms: dull ache, cramps (especially at night), fatigue, ankle edema, heaviness; secondary varicosities can lead to venous insufficiency and ulcers
• Diagnosis: duplex ultrasound (standing or reverse Trendelenburg)
• Prevention: avoid tight socks, leg crossing, long sitting or standing; walk several minutes every hour and 30 minutes a day; elevate legs 3-6 inches above heart when tired; stairs; swimming; compression stockings; weight loss
• Treatment: thermal ablation (radiofrequency or laser) with tumescent anesthesia; cyanoacrylate glue; microphlebectomy; foam sclerotherapy; ligation and stripping (requires patent deep veins)
• Nursing after ablation: compression 24 hours then stockings for at least 1 week; no strenuous exercise for 2 weeks; bruising and cramps expected; NSAIDs, cool compresses
• After stripping: ambulate 5-10 minutes every hour while awake first 24 hours; stockings about 1 week; elevate foot of bed; avoid standing and sitting; check groin dressing for bleeding; report “pins and needles” or hypersensitivity (saphenous nerve injury); shower after 24 hours, pat dry, no lotion until healed, sunscreen on incisions
• After sclerotherapy: burning for 1-2 days; walking and mild analgesic

VI. Lymphatic Disorders and Cellulitis

• Lymphangitis: acute inflammation of lymph channels (usually strep) with RED STREAKS up the limb; lymphadenitis - enlarged, tender nodes; antibiotics; compression stocking for months after
• Lymphedema: primary (congenital, lymphedema praecox in women before 35) or secondary (axillary node dissection, chronic lymphangitis, filariasis/elephantiasis); soft pitting becomes firm nonpitting
  • Treatment: exercise, compression pumps, custom stockings or sleeves (over 40 mm Hg), manual lymphatic drainage (light touch), multilayer bandages, meticulous skin care (cellulitis risk), furosemide initially, antibiotics for infection; surgery (excision, lymph node transfer, lymphaticovenous bypass) if severe
  • Post-op: constant elevation, inspect dressing, report drainage or inflammation; no heating pads or sun on area
• Cellulitis: most common infectious cause of limb swelling; strep or S. aureus enters broken skin; localized redness, warmth, swelling, pain, fever, chills; “orange peel” skin; oral antibiotics (mild) or IV (severe); find entry point (cracks between toes)
  • Nursing: elevate 3-6 inches above heart; COOL packs every 2-4 hours until inflammation resolves, then WARM packs (lukewarm with sensory deficits); skin and foot care education
  • Cellulitis vs lymphangitis: cellulitis is localized and nonspecific; lymphangitis has red streaks along lymph vessels

Lecture vs Textbook Differences

From the Week 08 PVD deck (nsg210-week-08-peripheral-vascular-diseases-lecture); full Exam 3 list in nsg210-exam-3-lecture-vs-textbook.

High-Yield Numbers

• Claudication at about 50% lumen (75% area) narrowing (slides: 50-70%)
• ABI: normal 1.00-1.40; PAD under 0.90; rest pain under 0.50; severe under 0.40 (slides: under 0.25)
• Rubor appears 20 seconds to 2 minutes after dependency
• Cilostazol benefit 4-6 weeks; contraindicated in HF
• Drug-eluting stent: antiplatelets at least 6 months
• Bypass outflow vessel at least 50% patent; ABI every 8 hours for 24 hours after bypass
• AAA repair at 5.5 cm; rupture risk over 6 cm; small AAA ultrasound every 6 months
• EVAR: supine 6 hours, HOB 45 after 2 hours; report SBP over 180
• Acute arterial occlusion: 4-6 hour window; heparin 60-80 units/kg bolus, 12-18 units/kg/hour
• Raynaud: women 5 times, onset before 30; white, blue, red
• VTE: 10-20% medical, up to 80% ICU patients
• Warfarin INR 2.0-3.0; heparin aPTT 1.5-2 times control (slides: 1.5 times)
• HIT: platelets under 100,000 or 25%+ drop
• Thrombolytic puncture pressure at least 30 minutes
• Walk 10 minutes every 1-2 hours after DVT; no sitting over 1 hour
• Postthrombotic syndrome after 20-50% of DVTs
• Compression: TED 12-20; varicose 20-30; ulcers and post-DVT 30-40 mm Hg
• Venous ulcer compression only if ankle pressure over 60 and ABI over 0.80
• Leg ulcers 80-90% venous

Priority Nursing Actions and Red Flags

• Arterial = legs DOWN; venous = legs UP
• No heating pads on ischemic limbs
• New loss of a pulse after bypass or arterial procedure: notify surgeon now
• Six Ps after an embolic source (A-fib): emergency, heparin, prepare for embolectomy
• Severe back or abdominal pain with a known AAA, falling BP: rupture - emergency
• Sudden tearing chest or back pain with unequal arm BPs: aortic dissection
• Unilateral leg swelling, warmth, increased calf circumference: suspect DVT - do not massage, notify provider
• Sudden dyspnea, tachypnea, pleuritic chest pain, anxiety: suspect PE - oxygen, HOB up, notify
• On anticoagulants: watch LOC changes, blood in urine or stool, bleeding gums, nosebleeds; know reversal agents
• Heparin with falling platelets: think HIT
• Compression stockings must not roll at the top
• Dry toe gangrene in a poorly perfused older adult: keep dry, do not debride
• Cellulitis: cool packs first, then warm

Related

• nsg210-week-08-peripheral-vascular-diseases-lecture - PAD lecture notes (slides plus text, slide-vs-text differences)
• nsg210-hinkle-ch37-musculoskeletal-trauma - amputation (same lecture)
• nsg210-hinkle-ch21-cardiovascular-assessment - pulses, Doppler
• nsg210-hinkle-ch19-chest-lower-respiratory-disorders - pulmonary hypertension, PE overview
• nsg210-dvt-simulation-prep - DVT simulation prep
• INDEX - NSG210 chapter index
• nsg210-textbook-chapter-crosswalk