Peripheral vascular disease (PVD), also known as peripheral artery disease (PAD), is a condition characterized by slow and progressive narrowing of the arteries of the extremities.
This condition stems from structural damage in the blood vessels often caused by atherosclerosis when plaque blocks the flow of blood. Though PVD mainly affects the legs and feet, it can affect any blood vessels outside of the heart.
PVD can lead to gangrene and limb amputation in the affected extremity if left untreated. Other complications of PVD include blood clots, kidney failure, heart attack, and stroke.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Chronic Pain
- Ineffective Peripheral Tissue Perfusion
- Risk for Injury
- Risk for Peripheral Neurovascular Dysfunction
Nursing Process
The primary goal in managing peripheral vascular disease is to reduce the risk of developing cardiovascular disorders and chronic conditions that affect the blood vessels. Nurses play a critical role in health promotion efforts through patient education and encouragement to adhere to risk factor modification and drug therapy.
When medications, exercise, and lifestyle changes are not enough to improve the symptoms of PVD, revascularization procedures like angioplasty or bypass grafting may be indicated. Nurses provide pre-op and post-surgical care to prevent complications and ensure recovery.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to PVD.
Review of Health History
1. Determine the patient’s general symptoms.
The following are possible symptoms of PVD:
- General:
- Pain worse with activity
- Cardiovascular:
- Weak/absent pulses in the extremities
- Integumentary:
- Changes in the skin color (pallor, cyanosis, or erythema)
- Decreased skin temperature
- Thin, taut, shiny skin on the lower extremities
- Gangrenous (dead) tissue
- Hair loss/thinning on the legs
- Wounds and ulcers that won’t heal
- Thickened and opaque toenails
- Reproductive:
- Impotence
- Musculoskeletal:
- Reduced mobility
- Weakness
- Heaviness in muscles
- Numbness and tingling (paresthesia)
- Muscle pain with activity that stops during rest (intermittent claudication)
2. Review the medical history of the patient.
Atherosclerosis is the leading cause of PVD. Note the patient’s existing comorbidities that are associated with plaque build-up in the vessels, such as:
- Diabetes mellitus
- Hypertension
- High cholesterol (hyperlipidemia)
- High amino acid (homocysteine) levels
- Coronary artery disease
- Kidney disease
- Blood clotting disorders
3. Obtain a detailed family history.
A family history of PVD is characterized as having at least one first-degree relative who underwent revascularization or stent placement procedure for PVD before age 65. Also, note for a family history of heart disease or stroke.
4. Identify possible risk factors.
Note the following risk factors of PVD:
5. Determine the patient’s current diet.
Diet plays a significant role in the plaque build-up within the arteries, resulting in PVD. The following can contribute to plaque formation:
- Saturated fats (fatty food)
- Simple carbohydrates (high in sugar content)
- Foods high in sodium
Physical Assessment
1. Assess the presence of 5 P’s.
PVD symptoms include the “5 P’s,” which are as follows:
- Pulselessness
- Paralysis
- Paresthesia
- Pain
- Pallor
Note: An immediate assessment and consultation are required since paresthesia and paralysis indicate ischemia with potential limb loss.
2. Assess the cardiovascular status.
Auscultate the heart for any irregularities or murmurs. Palpate for bruit and pulse quality in all peripheral vessels.
3. Perform the Allen test.
The results of the Allen test may reveal the status of the radial and ulnar arteries. The Allen test evaluates collateral blood flow to the hands. A negative Allen test indicates that the patient’s dual blood supply to the hand is insufficient.
4. Assess the skin status.
The skin may demonstrate the following changes associated with PVD:
- Alopecia (hair loss)
- Dry, scaly, or erythematous skin
- Persistent changes in pigmentation
- Brittle nails
5. Assess symptoms of advanced PVD.
Advanced PVD symptoms include the following:
- Pulselessness
- Numbness
- Cyanosis
- Mottling with a “fishnet pattern” (livedo reticularis)
- Cold extremities
- Paralysis
- Gangrene
- Poor healing wounds and ulcers
6. Assess pain.
Intermittent claudication describes the pain felt with PVD. Pain worsens with walking and is relieved by rest. Pain at rest is more concerning for ischemia.
Diagnostic Procedures
1. Obtain blood for testing.
In assessing patients with suspected PVD, routine blood tests will be evaluated to monitor for organ compromise and include:
- Complete blood count (CBC)
- Blood urea nitrogen (BUN)
- Creatinine
- Electrolyte levels
Results of these tests assess the risk of developing vascular disease:
- Coagulation tests
- Lipid profiles
2. Check for inflammatory blood markers.
Exercise intolerance in the lower extremities has been associated with increased levels of inflammatory markers such as:
- D-dimer
- C-reactive protein
- Interleukin-6
- Homocysteine
3. Measure the ABI.
An effective test for comparing pressures in the lower and upper extremities is the ankle-brachial index (ABI). The lower extremities often have a slightly higher blood pressure than the upper.
4. Prepare the patient for Doppler ultrasound.
Doppler ultrasound studies can be the primary non-invasive method to assess blood flow status. Absent sound or faintness signals blocked or decreased blood flow.
5. Consider transcutaneous oximetry.
Transcutaneous oximetry evaluates blood flow impairment and is becoming more prevalent in diabetic patients and wound treatment.
6. Anticipate imaging scans.
Imaging scans are used for better visualization of blood vessels and may include the following:
- Magnetic resonance imaging (MRI) has a high level of visual detail of plaques.
- Computed tomography (CT) with contrast is beneficial for visualizing arterial insufficiency.
- CT angiography (CTA) provides rapid and noninvasive results, while magnetic resonance angiography (MRA) is highly accurate without the use of radiation yet is costly and limited in availability.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with PVD.
1. Prevent disease progression.
The first step in managing PVD is changing one’s lifestyle to stop the disease from progressing. Pharmacological and endovascular procedures may be necessary to manage symptoms and lower cardiovascular risk.
2. Administer medications as prescribed.
Managing underlying conditions is crucial to treat PVD. Medications for PVD may include:
- Statins aid in lowering bad cholesterol (LDL) and increasing good cholesterol (HDL) to prevent the buildup of arterial plaque. These medications reduce the risk of stroke and heart attacks.
- Antihypertensive drugs maintain blood pressure within normal limits.
- Antidiabetic agents help control blood sugar levels.
- Antiplatelets (such as clopidogrel) and anticoagulants (such as warfarin) prevent the formation of blood clots.
- Cilostazol, a vasodilator and an antiplatelet, widens blood vessels and enhances blood flow to the limbs to relieve leg pain in PVD.
3. Manage comorbidities.
Aim to lower blood pressure to less than 120/80 mmHg in non-diabetic patients and 130/80 mmHg in diabetic patients. Achieve a hemoglobin A1c of less than 7% for diabetic patients.
4. Prepare the patient for revascularization.
A patient suffering from incapacitating symptoms that do not respond to treatment and risk reduction may be a candidate for the following procedures:
- Endovascular intervention
- Surgery (such as angioplasty and stent placement or bypass surgery)
- Combined endovascular and surgical intervention
5. Promote exercise.
Exercise therapy programs help significantly reduce the symptoms of claudication. Refer to a physical therapist if necessary.
6. Treat blood clots.
Thrombi or emboli may occur in the setting of PVD and require immediate intervention. Start an infusion of heparin to increase the activated partial thromboplastin time to 1.5 times the normal level.
7. Encourage lifestyle modifications.
Patient education is essential to alleviate symptoms and preserve their cardiovascular status. The following should be emphasized in health teaching:
- Physical activity
- Weight management
- Proper diet
- Quitting smoking
- Adherence to medications
8. Advise the patient to avoid pseudoephedrine.
Advil Cold and Sinus, Sudafed, and other cold and sinus drugs containing pseudoephedrine narrow blood vessels throughout the body and may exacerbate PVD symptoms.
9. Refer to a nutritionist.
Emphasize the need for a heart-healthy diet low in saturated fat, sodium, and processed foods to manage blood pressure and cholesterol levels.
10. Ask the patient to demonstrate proper foot care.
Patients with PVD have a higher risk of poor healing of wounds in the lower extremities (especially when complicated by diabetes). A lack of blood flow can delay healing, placing the patient at risk for infection.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for PVD, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for PVD.
Acute Pain
Acute pain is a usual finding of peripheral vascular disease. The pain usually occurs when walking at the level distal to the blocked artery and is described as a cramp or ache. Since the pain is relieved when the patient rests, it is often left untreated and the condition is undiagnosed.
Nursing Diagnosis: Acute Pain
Related to:
- Vascular system blockage
- Peripheral vascular disease
As evidenced by:
- Expression of pain, cramping, or aching when walking
- Burning pain in the feet (in severe cases)
- Muscle fatigue
- Choosing not to partake in physical activity
Expected outcomes:
- Patient will verbalize reduced pain with walking.
- Patient will increase physical activity without experiencing pain.
Assessment:
1. Assess pain characteristics.
Meticulous pain assessment can help establish the diagnosis of peripheral vascular disease. In severe cases of PVD, pain also occurs with rest. It is described as a burning pain in the feet that is worse at night and can be relieved by dangling the feet over the side of the bed.
2. Assess the patient’s prior pain relief efforts.
Assessing what the patient has tried to relieve their pain and the outcome will help the nurse tailor interventions as well as aid in diagnosis.
Interventions:
1. Administer medications as indicated.
Cilostazol is a vasodilator that can help treat claudication. It may take up to 12 weeks to take effect.
2. Encourage exercise.
Despite walking causing PVD pain, it is the best treatment for reducing disease severity. Patients should be instructed to walk until reaching their pain tolerance, pausing, and restarting once the pain is relieved. Walking sessions should last 30-45 minutes, 3-4 times per week.
3. Educate on lifestyle modifications.
Treating PVD and corresponding pain requires lifestyle modifications of maintaining a healthy weight, exercising, and managing chronic conditions.
4. Instruct the patient to avoid massaging affected extremities.
Massaging the affected extremities may feel good, but can dislodge an embolus. Speak with your doctor first before attempting.
Chronic Pain
PVD/PAD is a condition that causes chronic pain in the form of intermittent claudication, ischemic pain, and neuropathic pain.
Nursing Diagnosis: Chronic Pain
Related to:
- Limb ischemia
- Plaque buildup in the blood vessels of the extremities (atherosclerosis)
- Severe claudication in the extremities
- Sedentary lifestyle
- Obesity
As evidenced by:
- Burning pain
- Paresthesias
- Intermittent claudication
- Altered mobility
Expected outcomes:
- Patient will report decreased burning, tingling, and numbness in the extremities.
- Patient will utilize nonpharmacological methods to reduce pain.
Assessment:
1. Assess the pain characteristics.
Burning, tingling, stabbing pain, and decreased sensations are common complaints with PVD. Pain usually worsens with activity and alleviates with rest. Worsening pain is associated with disease progression.
2. Note for signs of chronic critical limb ischemia.
The following are symptoms of limb ischemia and indicate a threat to the limb:
- Pain that continues at rest
- Recumbent pain
- Ischemic skin lesions (such as ulcers or open gangrene)
- An ankle-brachial index of 0.4 or less
3. Assess for phantom limb pain.
Amputation may be a last resort for pain control if all other interventions fail. High pain levels before and immediately following surgery are risk factors for chronic pain. Phantom limb pain is pain felt in a limb that is no longer there and is extremely common in amputees.
Interventions:
1. Exercise first.
In early PVD, exercise therapy is recommended for intermittent claudication. Collaborate with PT and OT to develop exercise regimens and safety modifications to reduce pain.
2. Consider psychological techniques.
Biofeedback, mirror therapy, imagery, and meditation may be beneficial in conjunction with medications and other treatments for chronic pain.
3. Discuss spinal cord stimulation.
Patients with severe ischemic pain from PVD who have not responded to other analgesics may find relief in a spinal cord stimulator, which is an implanted device that sends pulses of electricity to the nerves to mask pain.
4. Support the patient in coping with the chronic pain.
Living with chronic pain can be difficult as it affects sleep quality, appetite, social interactions, and mood. Note that both mental and physical health are closely connected. Inquire about the patient’s emotional status and refer to mental health support services as necessary.
5. Prepare for surgical interventions.
Revascularization treatments are utilized to restore blood flow to a blocked artery or vein and can aid in relieving pain in PVD.
Ineffective Peripheral Tissue Perfusion
Patients with peripheral vascular disease have decreased peripheral tissue perfusion due to atherosclerotic plaque build-up in the arterial walls causing blocked arteries and poor circulation.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Atherosclerotic plaque buildup
- Reduced blood flow
As evidenced by:
- Absent/weak peripheral pulses
- Muscle weakness and fatigue
- Cool and cyanotic skin
- The skin on legs is shiny and hairless
- Decreased blood pressure in extremities
- Delayed peripheral wound healing
- Edema
- Extremity pain
- Femoral bruit
- Intermittent claudication
- Paresthesia
- Skin color pales with limb elevation
Expected outcomes:
- Patient will demonstrate adequate tissue perfusion with 3+ peripheral pulses.
- Patient will verbalize their medication regimen to manage PVD.
Assessment:
1. Assess peripheral pulses.
Reduced or absent peripheral pulses indicate arterial insufficiency that can result in ischemia and necrosis.
2. Assess ankle-brachial index (ABI).
ABI measures the systolic blood pressure at the ankle compared to the arm using a manual BP cuff. An ABI less than 0.9 is found in patients with PVD.
Interventions:
1. Manage chronic conditions.
Patients with PVD often have atherosclerosis, diabetes, hypertension, or other chronic conditions that affect blood vessels. Ensure patients are receiving and adhering to their treatment plan in order to prevent worsening complications.
2. Avoid long periods of sitting.
Ambulation is crucial in the treatment of PVD and patients should avoid sitting for long periods to increase venous return.
3. Consider the use of statins.
Statin medications used for hyperlipidemia improve atherosclerotic disease. This coupled with lifestyle changes can improve PVD.
4. Prepare the patient for surgical intervention if indicated.
Surgical intervention is usually reserved for severe cases. Prepare the patient preoperatively for revascularization procedures such as balloon angioplasty, stent placement, or bypass grafting.
Risk for Injury
Patients with peripheral vascular disease are at risk for injury as it can significantly impair physical functioning. The patient is at risk for falls, trauma, and skin breakdown.
Nursing Diagnosis: Risk for Injury
Related to:
- Disease process
- Tissue hypoxia
- Altered peripheral sensation
- Decreased lower extremity strength
- Impaired balance
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free of injury.
- Patient will demonstrate two strategies to reduce falls and injury.
Assessment:
1. Assess the environment and self-care abilities.
Patients with PVD are often of older age. Assess where the patient lives and if there are additional risks to safety such as stairs. Assess their ability to manage their health and if support services are needed.
2. Assess for mobility issues in addition to symptoms of PVD.
It is critical to determine the patient’s functional ability and appropriately plan ways to prevent falls and other injuries.
Interventions:
1. Prevent falls when walking.
Initial treatment for patients with PVD and intermittent claudication is an exercise program. If patients are reluctant due to poor balance or strength, provide assistive devices such as a cane or walker.
2. Instruct the patient on foot care.
PVD coupled with diabetes increases the risk of injury to the feet from decreased blood flow and poor wound healing. Instruct the patient to wear proper footwear when walking and to inspect the feet and lower legs daily.
3. Stop smoking.
Smoking is the key risk factor for limb ischemia and increases the risk of amputation. Nurses can work with patients on finding a smoking cessation program that works for them.
4. Refer to PT/OT.
Institute the help of a physical or occupational therapist to ensure the patient’s living environment is safe for activity. They can also instruct the patient on appropriate exercise programs.
Risk for Peripheral Neurovascular Dysfunction
Peripheral vascular disease (PVD/PAD) causes the narrowing of blood vessels outside of the heart, compromising the blood flow to the extremities (especially the legs).
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction
Related to:
- Plaque buildup in the blood vessels (atherosclerosis)
- Reduced blood flow to the extremities
- Sedentary lifestyle
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will not display a decrease in peripheral pulses or pallor.
- Patient will not report feelings of numbness and tingling (paresthesia).
Assessment:
1. Assess the neurovascular status.
Check the peripheral pulse strength, skin color and temperature, capillary refill, sensation, and muscle strength. It is essential to compare the left with the right side to assess the blood flow of both extremities.
2. Monitor the balance and gait.
Have the patient stand and walk to assess for balance and gait abnormalities. Patients with PVD have an irregular gait pattern with shorter steps.
3. Assess the “5 Ps”.
These signs signify reduced or blocked blood flow to the extremities:
- Pain
- Paralysis
- Paresthesia (numbness and tingling)
- Pulselessness
- Pallor
Interventions:
1. Instruct on positioning.
The patient with neurovascular compromise from PVD should not cross their legs to prevent further blood flow interference. Elevation of the legs is recommended, but not above the level of the heart, as extreme elevation slows arterial blood flow.
2. Administer medications as ordered.
Medications are utilized to manage chronic conditions and ensure good blood flow to the extremities. These medications include:
- Antihypertensive medications
- Statins (cholesterol-lowering drugs)
- Antiplatelet or anticoagulant medications
3. Enroll the patient in a supervised exercise program.
A carefully monitored exercise program will enable blood circulation and prevent neurovascular dysfunction. A structured program typically involves supervised treadmill walking at least three times per week.
4. Teach the patient the signs of neurovascular dysfunction.
Neurovascular function should be monitored closely. Note the following signs that would require immediate medical attention, such as:
- Burning pain in the feet
- Numbness and tingling (paresthesia)
- Diminished pulses
- Pale or cyanotic extremities
- Cool skin temperature
- Prolonged capillary refill
- Decreased sensations
- Decreased motor function
5. Document with images.
After obtaining patient consent, consider documenting the patient’s PVD using clinical images to monitor for the progression of skin color changes, hair loss, toenail abnormalities, and more.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Cleveland Clinic. (2022, November 24). Peripheral vascular disease: Causes, symptoms & treatment. Retrieved July 2023, from https://my.clevelandclinic.org/health/diseases/17357-peripheral-artery-disease-pad
- Gul, F., & Janzer, S. F. (2022, May 1). Peripheral vascular disease – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved July 2023, from https://www.ncbi.nlm.nih.gov/books/NBK557482/
- Hardman, R., Jazaeri, O., Yi, J., Smith, M., & Gupta, R. (2014). Overview of classification systems in peripheral artery disease. Seminars in Interventional Radiology, 31(04), 378-388. https://doi.org/10.1055/s-0034-1393976
- Johns Hopkins Medicine. (2021, August 8). Peripheral vascular disease. Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved July 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/peripheral-vascular-disease
- Khaleghi, M., Isseh, I. N., Bailey, K. R., & Kullo, I. J. (2015, September 15). Family history as a risk factor for peripheral arterial disease. PubMed Central (PMC). Retrieved July 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206951/
- Lippincott. (2023, April). Neurovascular Assessment. Lippincott NursingCenter | Professional Development for Nurses. Retrieved August 2023, from https://www.nursingcenter.com/getattachment/Clinical-Resources/nursing-pocket-cards/Neurovascular-Assessment/Pocket-Card_Neurovascular-Assessment_April2023.pdf.aspx
- Mayo Clinic. (2022, June 21). Peripheral artery disease (PAD) – Diagnosis and treatment – Mayo Clinic. Retrieved July 2023, from https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/diagnosis-treatment/drc-20350563
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Pande, R. L., & Creager, M. A. (2015, July 1). Socioeconomic inequality and peripheral artery disease prevalence in US adults. PubMed Central (PMC). Retrieved July 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219271/
- Peripheral Arterial Disease. Zemaitis MR, Boll JM, Dreyer MA. [Updated 2022 Jul 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430745/
- Peripheral artery disease (PAD): Symptoms & treatment. (2022, November 24). Cleveland Clinic. Retrieved August 2023, from https://my.clevelandclinic.org/health/diseases/17357-peripheral-artery-disease-pad#management-and-treatment
- Peripheral Vascular Disease. Anna Giorgi and Judith Marcin, M.D. Updated September 17, 2018. Healthline. From: https://www.healthline.com/health/peripheral-vascular-disease
- Peripheral Vascular Disease. Everett Stephens, MD; Chief Editor: Erik D Schraga, MD. Updated: May 24, 2022. The Hear.org Medscape. From: https://emedicine.medscape.com/article/761556-overview
- Peripheral Vascular Disease. John Hopkins Medicine. Copyright © 2022 The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. From: https://www.hopkinsmedicine.org/health/conditions-and-diseases/peripheral-vascular-disease
- Seretny, M., & Colvin, L. (2016). Pain management in patients with vascular disease. British Journal of Anaesthesia, 117, ii95-ii106. https://doi.org/10.1093/bja/aew212
- Stephens, E. (2023, June 30). Peripheral vascular disease treatment & management: Approach considerations, prehospital and emergency department care, surgical care. Diseases & Conditions – Medscape Reference. Retrieved July 2023, from https://emedicine.medscape.com/article/761556-treatment#showall
- Szymczak, M., Krupa, P., Oszkinis, G., & Majchrzycki, M. (2018). Gait pattern in patients with peripheral artery disease. BMC Geriatrics, 18(1). https://doi.org/10.1186/s12877-018-0727-1
- USA Vascular Centers. (2023, June 20). Avoid these foods to lower your risk of PAD | USA vascular. Peripheral Artery Disease Treatment | USA Vascular Centers. Retrieved July 2023, from https://www.usavascularcenters.com/blog/avoid-foods-lower-risk-pad/
- Yale Medicine. (2020, October 22). Peripheral vascular disease (PVD). Retrieved July 2023, from https://www.yalemedicine.org/conditions/peripheral-vascular-disease
- Zisquit, J., Velasquez, J., & Nedeff., N. (2022, April 30). Allen test – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved July 2023, from https://www.ncbi.nlm.nih.gov/books/NBK507816/
