04.06 Nursing Care and Pathophysiology for Arterial Disorders

So in this lesson we're going to talk about arterial disorders.

So what do we mean when we say arterial disorders? Well, remember from Anatomy that oxygenated blood leaves the heart and goes through arteries, then arterioles, then capillaries to drop off the oxygen, then venules, then veins and then back to the heart. So when we talk about arterial disorders we're talking about disorders of the vessels that deliver oxygenated blood to the body. So already you can start thinking about the problems this will cause. When you think about arterial disorders think about a garden hose. The more kinks or clogs you have in your garden hose the less flow you're going to have at the end. In this case the end of the hose is usually the arms, legs, hands, and feet because they're the smallest vessels. We're going to talk about three main examples here so that you can see the different types of arterial disorders.

So first we're going to talk about Peripheral Arterial Disease or PAD. What happens is chronic occlusion of these arteries leads to decreased oxygen supply to the lower extremities. So as you can see in the picture, a really common cause of this is atherosclerosis. The plaque builds up in the artery and the opening where blood can flow becomes narrowed. So this is like having a clog in your garden hose. Blood can’t flow as well past the clog and so the supply of oxygenated blood beyond that is limited. The cardinal sign of PAD is intermittent claudication. Intermittent claudication is pain with a predictable amount of activity that is relieved by rest. So this might mean the patient knows that every time they walk a half a mile they're going to get this severe pain in their lower extremities. As the disease worsens they may even get pain at rest and sometimes it comes on so suddenly that it can wake them up at night. Because of the lack of blood flow you also see hair loss in the lower extremities because the hair follicles aren't being perfused, and the extremities will be cool, pale, and might even be numb because of the lack of perfusion.

So what do we do for PAD? Well you'll see here that the number one thing that needs to happen is the patient needs to stop smoking. Smoking causes vasoconstriction and makes arterial disorders worse. Quitting can have a huge impact on reducing the risk of complications so it's really important to teach the patient to stop smoking. We also want to assess the peripheral pulses. Now sometimes we will have to use a Doppler which is like a little ultrasound machine that gives us a way to hear the pulse even when we can't feel it. We want to teach the patient to limit their activity based on that claudication, meaning they should exercise until the point of pain and then they should rest until it goes away. We also want them to avoid cold whenever possible because cold causes vasoconstriction as well. And they need to avoid crossing their legs because it can cause decreased blood flow because of the occlusion of the vessels in the upper leg.

There are also some surgical options for PAD. One of these options is angioplasty which is done exactly like it is in the heart except with the vessels in the leg. They insert a balloon through the occlusion and inflate it to compress the plaque and may even leave a stent if they need to to hold the vessel open. Also, just like the heart we can do bypass grafting where we place a graft to literally bypass the occlusion in the artery. Now, an endarterectomy is a really cool procedure where they surgically remove plaque from an artery. You can see they cut the artery open, remove the plaque, and then sew it back up. We do this a lot in the carotid artery because those patients are at such high risk for stroke.

The second arterial disorder we’ll talk about is Raynaud's disease. Raynaud's is caused by vasospasm of the tiny, tiny arterioles, usually in the hands. Usually, it happens because of either cold or stress or sometimes even caffeine. The classic sign of Raynaud's is these triphasic color changes. You can see rubor which is a deep red color, or you could see cyanosis which is more of a blue color, or it will just turn white which is called pallor. So remember the red, white, and blue triphasic color changes. But most of the time what you'll see is these classic white fingers. Sometimes it's all five fingers, sometimes just one or two like you see here. They may have some numbness and tingling and a lot of times it's really painful. Sometimes they can even have some swelling in the fingers as they begin to lose blood flow.

Again one of the priorities is smoking cessation. Smoking causes vasoconstriction, so it's only going to make the vasospasms worse. We’ll also teach the patient to identify and avoid any precipitating factors like cold. They should also avoid stress or caffeine - good luck if they’re a nursing student, right?? Then, they definitely need to wear warm clothing or mittens when it’s cold out - that’s super important. As far as medications, we’ll give them analgesics for pain control to make them comfortable. We can also give vasodilators so that we can help open up those blood vessels and relieve the vasospasm. Again, the goal here is to open up the vessels and restore blood flow.

The third disorder we’ll talk about is called Buerger's disease. It's actually an inflammatory disease of the medium to small arteries in the arms, legs, and feet. You can see in this image on the patient's left side where the femoral artery comes all the way down into the leg, but on the right side you can see that there is little to no blood flow coming past about this point on the femoral artery. So what's happening is there's an inflammatory process going on within the vessels that can cause narrowing and even microthrombi - which can lead to more vasospasm. These patients will also experience that intermittent claudication - remember that’s pain with a predictable amount of activity that's relieved by rest. And as the disease progresses they'll even get pain at rest which is usually worse at night. Because of the lack of blood flow, we're going to have diminished pulses in the extremity distal to the occlusion. And a lot of patients with Buerger's disease can even get ulcerations in their extremities because the tissues are beginning to die.

Again, we're going to keep saying this because it's so important, the patient must stop smoking. We’ll give analgesics to help deal with the pain, but we also give calcium channel blockers because they will act on the smooth muscle in the vessels and prevent vasospasms. As far as surgical options these patients are also eligible for bypass grafting or we can do something called a sympathectomy. In a sympathectomy we are dissecting out the nerve endings and that helps to decrease the pain sensation of the affected area.

Check out the care plan attached to this lesson for more details on nursing interventions, but here are the top priority nursing concepts for all of these arterial disorders. Of course at the top of the list is perfusion, so we would assess pulses, skin color and temperature, etc. Then we have comfort because these conditions are usually painful especially because of the intermittent claudication, so we want to make sure we address that. And finally, tissue and skin integrity, because the longer the skin goes without blood flow the more likely it is to break down.

So let's recap - arterial disorders are disorders of the vessels that deliver oxygenated blood to the body. If you can get that you can understand the problems that this is going to cause in the patient. Some possible causes - again it's those kinks and clogs in your garden hose - atherosclerosis, vasospasms, or even inflammation within the vessels. Our treatment priorities will absolutely include smoking cessation and then our aim is going to be to open up those vessels and make sure we manage their pain. As nurses were going to address the concepts of perfusion, comfort, and skin integrity to make sure the patients are getting the blood flow they need, that they're comfortable, and not they don't have any serious skin breakdown.

We hope this helps you guys understand arterial disorders so you can be confident when taking care of patients with these conditions. Make sure you check out all the resources attached to this lesson! Now go out and be your best self today, and, as always, happy nursing!!