PVD Flashcards
Generally pathologic conditions of the circulatory system result in problems with _____
supplying nutrients and/or removing waste products.
Three layers of the arterial system
Tunica intima, tunica media, tunica adventitia
Where are the pressures in the arteries greater? More elastic components? More muscular components?
In the major arteries nearer to the heart.
Near the heart.
The periphery.
What are the two major LE veins?
great and small saphenous veins
What is the lymphatic system?
Capillaries and peripheral plexuses, collecting vessels, and the lymph nodes
What 2 purposes do lymph nodes serve?
filtering and phagocytosis & lymphocyte production.
Where does most of the lymph proceed through?
The thoracic duct into the systemic circulation
Risk factors for PVD
Smoking, diabetes, high-fat diet, hypertension
50% of all non-traumatic amputations are caused by
Diabetes Mellitus
What is diabetes?
Inappropriate elevation in the blood glucose level, disturbed lipid and protein metabolism. Causes an accelerated version of atherosclerotic process.
Arteriosclerosis obliterans
Peripheral manifestation of generalized atherosclerosis, most common form of chronic occlusive arterial disease affecting LE.
What is the earliest presenting symptom in arteriosclerosis obliterans
Intermittent claudication. About 50% occlusion of vessel until there is pain with activity. 80-90% occlusion till rest pain.
What are some other signs of Arteriosclerosis obliterans
diminished or absent pedal pulses, positive rubor of dependency, trophic changes, ulcerations (as a result of ischemia)
What are trophic changes?
thickening of nails, loss of hair, shiny changes of skin tone/texture
Who is primarily affected by Thromboangiitis obliterans (Buerger’s Disease)
young, male smokers. Cessation of smoking arrests the disease.
What is Thromboangiitis obliterans (Buerger’s Disease)
Similar to Arteriosclerosis obliterans. Inflammatory process starts distally, proceed proximally.
What is acute arterial occlusive disease?
an EMERGENCY situation.
What are the most common forms of acute arterial occlusive disease?
arterial embolism, arterial thrombosus, vasospastic diseases (raynauds)
What are the 5 P’s
Classic signs and symptoms of Acute arterial occlusive disease
Pain, Pallor, Loss of pulses, paresthesia, paralysis
What is gangrene?
The peripheral body parts lose blood supply as the blood goes to vital organs. The cold can be a reason.
Can be of the wet or dry variety.
What are 3 vasospastic diseases?
Raynaud’s syndrome, Acrocyanosis, Erythromelalgia
What is Raynaud’s syndrome
Etiology: idiopathic or related to scleroderma, RA, SLE
spasm of arterioles affecting the digits.
Cyanosis of digits with cold or emotional upset. Intense redness/warmth after vasodilation phase.
What is acrocyanosis
Cyanosis of the distal extremities, usually affecting hands/fingers or feet and toes.
Caused by arterial spasm in the small arterioles.
NO rebound erythema.
Erythromelalgia
Bilateral vasodilations affecting the extremities
Redness, burning, throbbing sensations and increased skin temp.
What can venous insufficiency be the result of?
venous occlusion, valvular defect, problems in calf muscle pump
What’s a major risk factor for venous dysfunction?
Family history, or people on their feet a lot, overweight/pregnant
What is venous thrombosis
Obstruction of the blood flow secondary to collection of coagulated blood
What is “charlie horse” related to?
Periphlebitis: inflammation to the tissues around the vein in venous thrombosis.
What is superficial venous thrombosis?
True phlebitis, conspicuous cordlike palpable nodules. Not as concerning as DVT because there is no direct path to lungs/heart.
What are Homan’s signs of DVT
Edema/limb girth, painful palpation, painful passive stretch of vein, warmer to touch
Who tends to get varicose veins?
If it’s in the family, occupation with prolonged standing, obesity, pregnancy
What is chronic venous insufficiency
increased venous hypertension, unilateral LE, venous reflux
What are macrocirculatory components of the venous system?
Calf muscle pump, venous plexus of the foot (activated with each step)
What is hemosiderin staining?
Hallmark of cutaneous changes. Stasis pigmentation. Iron gets into the tissue and stains it
What is stasis dermatitis?
Inflammatory condition of the skin caused by pooling blood. High ambulatory pressure, capillary dilation, subsequent dermal ulceration or varicose veins
What do venous wounds look like?
Swelling, staining, color changes, non-uniform, not symmetric, moist, exudative.
What is the 5 PT method?
pain, position, presentation, periwound, pulses, temperature
Diff Dx of arterial wounds
severe pain caused by tissue ischemia (worse with activity), difficulty sleeping, trauma is leading precipitating factor, usually in LE/toes, periwound decreased perfusion, epidermis thinner/shiny/dry/loss of hair growth/pale, dusky, cynaotic, muscle atrophy, dorsal pedal and post tib pulses compromised, cool/cold to the touch.
What do arterial wounds look like?
Dry, uniform, round, minimal to no drainage. Granulation tissue is pale/gray, necrotic can be black or yellow. Not much swelling.
Diff Dx of Venous Ulcers
5PT as well.
Dull aching leg pain or heaviness caused by venous hypertension and peripheral edema. Pain increases with dependency and relieved by elevation or compression. Pain may be severe with infection or concommitent arterial insufficiency. Located on the medial aspect of lower leg/medial malleolus & in areas exposed to trauma (anterior shin) not on plantar aspect and rarely above the knee. Cellulitis, dermatitis, dry scaling skin causing itching. LE edema almost always present. May become firm. Skin changes: erythema, long term skin and stained hemosiderin. Pedal pulse generally present but may be difficult to palpate. Cellulitis or edema can cause increase in skin temp.
Primary Lymphadema
born with it. ducts, collecting vessels, etc didn’t form or overdeveloped (congential agensis or aplasia)
Secondary Lymphadema
Acquired afterwards (pelvic mass, space-occupying lesion, mastectomy with removed nodes from axilla, groin injury, testicular cancer)
Lymphadema (general)
Failure of transport system causes increase in protein-rich fluid; damaging arterial and venous system; lymphostatic hemangiopathy, inflammatory response
Important subjective information
How body responds to cold, heat, position, minor or severe trauma?
Past Hx: varicosities, PE, limb circulation issues, DM, HTN, atrial fib, CHF, MI, tobacco, previous surgeries.
What will the skin look like with absent or decreased arterial flow?
Chalky white.
What will the skin look like with partial or inadequate arterial flow?
Red or cyanotic, depending on temperature and oxygenation. Cyanosis more common.
Where do you takes pulses in teh LE?
Common iliac, femoral, popliteal, dorsalis pedis, posterior tibial
Pulse grades
2+ normal, 1+ diminished, 0 absent
What is an arteriovenous fistula?
Where blood is shunted between the artery and the vein.. You can listen for them over large scars with a stethoscope.
Normal sensation monofilamet size? Protective sensation?
Semmes Weinstein
Normal: 4.17
Protective: 5.07
Percussion Test
Venous insufficiency.
Tests greater saphenous vein. Pt stand 2 minutes, you percuss the vein at the medial leg.
Homan’s Test
DVT. Squeeze gastroc while forcibly DF the foot. Looking for PAIN. Can use blood pressure cuff to 40 mmHg.
Rubor of Dependency
Arterial Test. Legs up to 45 feet drain, drop legs down watch them refill, 10 + seconds for refill is bad, watch for rebound erythema is bad.
Venous Filling TIme
Arterial Test. Looking for the veins to refill. greater than 10-15 sec indicate insufficiency.
Claudication time
pt walk 1 mph on treadmill, looking for calf pain, NOT exertional fatigue
Stemmer’s Test
presence of lymphadema. inability to pick up a fold of skin at the base of the second toe.
How do you treat chronic arterial insufficiency?
Gradually stress c-v system and hope for collateral circulation [with regular, graded ex.]
Patient education in the proper care and protection of the skin, esp. feet and proper shoe selection
Treat any open wounds appropriately
How do you treat chronic venous insufficiency?
intermittent compression pump
custom-fitted stockings
General exercise programs, with elevation of legs afterward until heart rate returns to normal
Education about disease, foot care.
Walking is the best thing, stimulates venous plexus.
What is LEAP?
Lower Extremity Amputation Prevention
What are the 5 Steps of LEAP?
Annual foot screening, patient education, daily self inspection of the foot (if you cant see it at least feel it), appropriate footwear selection, management of simple foot problems.
Appropriate foot care
feet washed each night with mild soap/warm water
apply liberal amnt of vasoline and pat off remaining water (apply clean socks)
Wear clean socks daily
WHITE socks are preferable.
Shoes loose fitting
cut toenails straight across or have them done by someone
Do not cut corns/callouses
No tight/constrictive clothing
alternate shoes for air drying
hand in shoe to feel for foreign objects
No medications/ointments unless prescribed
no tobacco products
Management of lymphadema
Prevention is the best strategy Intermittent mechanical compression elevation above level of heart 30-45 degrees manual massage distal to proximal support garmets
What to avoid with lymphadema
static, dependent positions, application of local heat/hot environments, harsh chemicals/detergents, skin abraisons, insect bites
Moisturizers with proper pH
How should shoes fit for proper footcare?
loose fitting, preferably custom, high and wide toe box, resilient inner sole, rocker bottom unloads foot.
What is ABI?
Ankle Brachial Index. Divide BP @ ankle by BP @ brachial artery. Predicts severity of PAD. Can use doppler US for it too.
What is doppler US used for? Normal values?
Non-palpable pulses. Normal value= 1.19 - 0.95
Abnormal Doppler US values relating to ABI
- 94-0.75 shows mild arterial involvement, minimal symptoms/intermittent claudication.
- 74-0.50 moderate arterial involvement, usually have symptoms; rest pain
ABI values
> 1.2 falsely elevated, arterial disease, diabetes
1.19-0.95 normal
.94-.75 Mild arterial disease (+) intermittent claudication
.74-.50 Moderate disease, (+) rest pain
Air Plethysmography (APG)
Venous test. Pressure in LE with arterial filling. Then see how much it drains on its own then with muscle pumping.
