When caring for a patient who has intermittent claudication nurse advice the patient to

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. Additional risk factors include:

• Diabetes 
• Hypertension 
• Hyperlipidemia
• Obesity
• Smoking
• Increasing age, over 50 years old

PVD can lead to gangrene and limb amputation in the affected extremity if left untreated. Other complications of PVD include blood clots, kidney failure, and a heightened risk of death from heart attack and stroke. 

Clinical manifestations of PVD will depend on the location and extent of the blockage. Intermittent claudication is the classic sign of lower extremity PVD which is described as an ischemic muscle pain that occurs during exercise and resolves with rest. Other manifestations include the following:

• Paresthesias
• Thin, shiny, and taut skin appearance
• Decreased peripheral pulses 
• Pallor 
• Reactive hyperemia 

Medical history and physical examination are important in diagnosing PVD. Additionally, tests like doppler ultrasound studies, segmental BPs, ankle-brachial index (ABI), duplex imaging, angiography, and magnetic resonance angiography aid in diagnosing PVD.

The Nursing Process

The primary goal in the management of 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, surgical intervention for revascularization like angioplasty and bypass grafting may be indicated.

Nursing Care Plans Related to Peripheral Vascular Disease

Acute Pain Care Plan

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:

• The patient will verbalize reduced pain with walking
• The patient will increase physical activity without experiencing pain

Acute 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.

Acute Pain 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.

Ineffective Peripheral Tissue Perfusion Care Plan

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:

• The patient will demonstrate adequate tissue perfusion with 3+ peripheral pulses
• The patient will verbalize their medication regimen to manage PVD

Ineffective Peripheral Tissue Perfusion 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.

Ineffective Peripheral Tissue Perfusion 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 Care Plan

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 occurred yet and nursing interventions are directed at the prevention of symptoms.

Expected Outcomes:

• The patient will remain free of injury
• The patient will demonstrate two strategies to reduce falls and injury

Risk for 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.

Risk for Injury 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.

References and Sources

1. ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
2. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
3. 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/
4. Peripheral Vascular Disease. Anna Giorgi and Judith Marcin, M.D. Updated September 17, 2018. Healthline. From: https://www.healthline.com/health/peripheral-vascular-disease
5. 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
6. 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