1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 1 PHAR 741 Peripheral Vascular System

2. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 2 Pregnant Women  Blood pressure decreases.  Peripheral vasodilation occurs.  Blood pools in legs.  Varicosities in legs and vulva may occur.  Hemorrhoids are common. Anatomy and Physiology

3. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 3 Older Adults  Arteries calcify.  Arterial walls lose elasticity and vasomotor tone.  Superficial vessels become more prominent.  Increased peripheral vascular resistance elevates blood pressure. Anatomy and Physiology

4. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 4 Review of Related History

5. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5 History of Present Illness (1)  Leg pain or cramps  Onset and duration  Character  Skin changes  Dizziness  Fatigue  Wakefulness at night Review of Related History

6. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 6 History of Present Illness (2)  Severe headaches  Onset and duration  Location  Character  History of hypertension  Swollen ankles  Onset and duration  Related circumstances  Associated symptoms Review of Related History

7. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 7 History of Present Illness (3)  Treatment attempted  Rest  Massage  Heat  Elevation  Medications  Alternative therapies Review of Related History

8. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 8 Past Medical History  Cardiac surgery or hospitalization  Chronic illness  Cardiovascular  Cerebrovascular  Endocrine (DM) Review of Related History

9. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 9 Family History  Diabetes  Heart disease  Hyperlipidemia  Hypertension (HTN) Review of Related History

10. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 10 Personal and Social History  Employment  Tobacco use  Nutritional status  Use of alcohol or illegal drugs  Use of alternative therapies Review of Related History

11. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 11 Pregnant Women  Blood pressure elevation  Legs  Edema  Varicosities  Pain or discomfort Review of Related History

12. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 12 Older Adults  Leg edema  Claudication  Medications Review of Related History

13. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 13 Peripheral Arteries  Three P’s of occlusion  Pain  Pallor  Pulselessness Examination and Findings

14. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 14 Peripheral Veins  Venous obstruction or insufficiency  Thrombosis  Edema  Varicose veins  Assess for  Constant pain  Swelling or tenderness over muscles  Engorgement of superficial veins  Erythema and/or cyanosis Examination and Findings

15. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 15 Common Abnormalities

16. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 16 Vascular Disease Peripheral obstructive disease Arterial embolic disease Deep vein thrombosis Varicose veins Raynaud’s Disease

17. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 17 Obstructive arterial disease  Caused by plaque buildup, similar to that in the heart.  Patients complain of fatigue, tightness of muscles, pain and weakness in their legs after walking or activity.  These symptoms are often termed intermittent claudication: meaning to limp intermittently.

18. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 18 Obstructive arterial disease

19. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 19 Risk factors  Male  Diabetes  Smoking  Age

20. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 20 Symptoms  Pain occurs after a predictable amount of activity.  Limb may appear normal and healthy.  Pulses may be diminished.  Hair on lower limbs and toes may be sparse or absent.

21. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 21 Arterial embolic disease (AED)  An embolus in the arterial system.  Occludes oxygenated blood flow to tissues below the block.  May lead to necrosis of tissue below blockage.

22. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 22 Risk factors for AED  Atrial Fibrillation  Prosthetic heart valves

23. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 23 Differential diagnosis of AED  Sudden onset of pain.  Distal to emboli the limb may feel: -Cold-Pale-Pulseless -Blue in color  Muscle tenderness

24. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 24 Deep vein thrombosis (DVT)  An clot that forms in veins.  Occurs in 2 milllion Americans each year.

25. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 25 Risk factors for DVT  Women  Age over 40  Cardiovascular disease  Oral contraceptives  Hormone replacement therapy

26. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 26 Risk Factors for DVT  Prolonged immobility  Obesity  Cancer  Stroke  Surgery  Trauma

27. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 27 Signs of DVT  Swelling of affected leg  Possible pain  Skin warm to touch  Reddish-blue discoloration

28. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 28 Example of DVT

29. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 29 Differential diagnosis of DVT  Previous symptoms can be seen in with other disease problems.  Confirmation of DVT must be performed by diagnostic tests. -Duplex or Doppler ultrasonography -Venography-MRI

30. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 30 Undiagnosed DVT  If DVT is undiagnosed it can lead to even more severe pulmonary emboli.

31. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 31 Varicose Veins

32. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 32 Varicose Veins  Veins carry blood back to the heart and act as one way valves.  Blood can leak back, pool and get congested in the veins.  This can enlarge the veins and bring them closer to the surface and change color.

33. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 33 Varicose Veins  Most patients have no symptoms other than physical changes.  Risk Factors -Weak valves -Obesity -Hormone changes (puberty, pregnancy, menopause) -Leg injury -Standing for long periods of time

34. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 34 Raynaud’s disease (1)  Affects blood vessels in the fingers, toes, ears, and nose  Intense vasospasm triggered by cold or emotional stress  Women more likely than men to have the disorder

35. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 35 Raynaud’s Disease (2)  Cold initiates paroxysmal spasm of arterioles in the extremities  Arteries in fingers and toes may collapse

36. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 36 Raynaud’s Disease (3)  Three phases of skin discoloration  White – Pallor caused by spasm of arterioles and artery collapse.  Blue – Cyanosis may appear because of poor perfusion. Fingers and toes may be numb and cold.  Red – As the arterioles relax blood supply returns. May result in throbbing and tingling.

37. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 37 Raynaud’s Disease (4)  The order of color changes is not the same for all patients.  Not all patients will have all three color changes.  An attack can last from less than a minute to several hours.

38. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 38 Raynaud’s Disease  Non-drug Treatments  Take action during an attack.  Keep warm  Stop smoking  Control stress  Exercise regularly

39. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 39 Stasis Dermatitis  With ulceration

40. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 40 Stasis Dermatitis

41. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 41 Edema

42. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 42 Edema

43. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 43 Gangrene

44. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 44 Gangrene

45. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 45 Gangrene

46. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 46 Gangrene

47. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 47 Gangrene

48. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 48 Gangrene