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Nursing Field Notes / Cardio · Pathophysiology Course
PVD set 1 · Patho & Signs 2 · Causes & Complications → 3 · Treatments →

PVD — Patho & Signs 🦵

Peripheral Vascular Disease I · what it is and how it looks & feels

NG-045 CARDIO ADHD-friendly visual edition

PVD = any disease of the blood vessels OUTSIDE the heart — almost always the legs. It splits into two opposite problems: arteries can't get oxygen IN (PAD), or veins can't get blood back OUT (chronic venous insufficiency). Page 1 teaches the difference. Get that one contrast right and most of the exam falls over.

📄 Simple Nursing original — opens in Drive →

🩸 ARTERIES = blood INCool · pale · hairless · no pulse · ulcer on the TOES · pain when walking.
🫙 VEINS = blood OUTWarm · brown · swollen · pulse present · ulcer at the ANKLE · aches at end of day.
↕️ The trap = positionArterial DANGLE ⬇️ · Venous ELEVATE ⬆️. Opposite answers, same-looking question.
🚨 6 P's = emergencySudden cold, pulseless, painful leg = acute arterial occlusion. Limb is on a clock.
🧭

WHAT IT IS

STEP 1 · TWO PIPES

One leg, two plumbing systems. Arteries deliver, veins drain — and each one fails in its own signature way.

🧭 One leg, two circuits — arteries deliver, veins drain

Every sign in this whole topic comes from asking one question: is the problem getting blood IN, or getting blood OUT?

HEART 🫀 the pump at the top the leg 🩸 ARTERY — blood IN ⬇️ Carries oxygen-rich blood DOWN from the heart into the foot. High pressure, pushed by the heart. FAILS BY: narrowing (plaque) → ISCHEMIA = PAD · peripheral ARTERIAL disease 🫙 VEIN — blood OUT ⬆️ Carries used blood UP against gravity, using one-way VALVES + the calf muscle squeeze. FAILS BY: leaky valves → POOLING = CVI · chronic VENOUS insufficiency (varicose veins are the visible version)
🧠 “A = Away, V = Vacuum.” Arteries carry blood Away from the heart — when they fail you drop the leg down so gravity helps push blood Away and into the foot. Veins Vacuum blood back up — when they fail you lift the leg up and let gravity drain it. This one line answers most position questions on the exam.

🚧 ARTERIAL patho: the pipe narrows, the muscle starves

Answer first: plaque narrows the artery → oxygen supply can't rise when demand rises → pain with activity.

Artery cross-section · the lumen closes NORMAL wide open lumen full O₂ delivery PLAQUE lipids · calcium hard & narrow ISCHEMIA trickle of blood pain · tissue dies

Supply vs demand: at rest the trickle is just enough. Start walking, the calf muscle demands more O₂, supply can't rise → cramping pain that stops when they stop. That's intermittent claudication.

🧠 “Claudication = the limping clock.” Claudicare is Latin for to limp. It shows up at the same distance every time — that reproducible distance is the tell.

🚪 VENOUS patho: the valves quit, blood pools

Answer first: incompetent valves let blood fall backward → pressure builds in the leg veins → fluid and iron leak into the tissue.

Vein valves · the one-way doors ✅ COMPETENT blood only goes UP ❌ INCOMPETENT blood falls back & POOLS POOLING → 💧 edema 🟤 brown staining 🧱 thick skin 🕳️ ankle ulcer …all at the ankle

The brown stain is hemosiderin — iron left behind when pooled red cells break down. It is permanent, and it is the fingerprint of a venous leg.

🧠 “Rusty ankles = venous.” Blood sat still in the ankle so long it rusted the skin brown. Rust doesn't wash off — neither does hemosiderin staining.

📚 Word check — PVD, PAD, CVI, and the two “-scleroses”

TermWhat it actually meansUse it when…
PVD
peripheral vascular disease		The umbrella — any disease of vessels outside the heart, arterial or venous.The question doesn't specify which side.
PAD
peripheral arterial disease		The arterial half. Narrowed arteries → ischemia.Claudication, absent pulses, toe ulcers.
CVI
chronic venous insufficiency		The venous half. Failed valves → pooling.Ankle edema, brown skin, medial ankle ulcer.
ArteriosclerosisHardening & loss of elasticity of the artery wall — the general aging change.Talking about stiff vessels.
AtherosclerosisAthero = fatty. Plaque (lipids, calcium, clot) inside the lumen. A type of arteriosclerosis.Talking about clogged vessels. This is the PAD driver.
🧠 “AtherO = Oatmeal in the pipe. ArteriO = Old, stiff pipe.” Oatmeal clogs it, age stiffens it. Both narrow flow — only one is a plaque you can rupture.
👀

HOW IT LOOKS & FEELS

STEP 2 · SPOT IT

The single most tested contrast in vascular nursing. Read the leg, then read the ulcer, then check the position that helps.

⭐ THE BIG SIDE-BY-SIDE — arterial leg vs venous leg

🩸 ARTERIAL · PAD blood can't get IN — the tissue is starving ulcers on TOES, heel & outer ankle no hair shiny, taut thin, cool skin thick, brittle nails 🌡️ COOL & PALE pale on ELEVATION, dusky red when hanging 💈 HAIR LOSS · SHINY thick brittle nails 💓 PULSES WEAK or ABSENT may need a Doppler 💧 EDEMA: minimal nothing is pooling 😖 PAIN: CLAUDICATION cramping with WALKING, stops with rest · later, REST PAIN at night in bed 🕳️ ULCER SITE toes, heel, LATERAL ankle — pressure points ⭕ ULCER SHAPE round, deep, “PUNCHED OUT”, even edges, pale dry base · LITTLE drainage · very PAINFUL ⬇️ POSITION: DANGLE Hang the legs DOWN / off the bed. Gravity pushes arterial blood INTO the foot. ❌ never elevate · ❌ no compression stockings 🫙 VENOUS · CVI blood can't get OUT — the leg is flooded ulcer at the MEDIAL (inner) ankle bone varicose veins swollen, warm calf brown stain 🌡️ WARM & RUDDY brown HEMOSIDERIN staining at the ankle 🧱 THICK, LEATHERY weepy stasis dermatitis 💓 PULSES PRESENT arteries are fine — may be buried under edema 💧 EDEMA: HEAVY pitting, worse by evening 😩 PAIN: DULL ACHE heavy, tired legs · worse with STANDING & at the end of the day · itching 🕳️ ULCER SITE MEDIAL malleolus — the inner ankle bone 〰️ ULCER SHAPE shallow, IRREGULAR edges, beefy red moist base · HEAVY drainage · aching, less sharp ⬆️ POSITION: ELEVATE Legs UP above the level of the heart. Gravity drains the pooled venous blood OUT. ✅ compression stockings · ❌ don't dangle or stand
🧠 “ARTERIAL falls DOWN the leg to the TOES. VENOUS pools at the ANKLE.” Arterial damage shows up at the furthest, coldest, bumpiest spots — toe tips, heel, outer ankle. Venous damage shows up where the blood puddles — the inner ankle. And the fix is always the opposite of where the problem is: starving foot → drop it down. Flooded ankle → lift it up.

⭐ The same nine rows, in table form — memorize this grid

Assess🩸 ARTERIAL (PAD)🫙 VENOUS (CVI)
PainIntermittent claudication — cramping with walking, gone with rest. Advanced: rest pain at night, relieved by hanging the leg down.Dull, heavy ache — worse with standing and by evening, relieved by elevating.
PulsesWeak, thready or ABSENT distal to the block.Present (may be hard to palpate through edema).
TemperatureCool / cold foot.Warm leg.
ColorPale when elevated (elevation pallor), dusky red when dependent (dependent rubor).Ruddy / brown — hemosiderin staining that does not fade.
Skin · hair · nailsThin, shiny, taut, HAIRLESS; thick brittle nails; slow cap refill.Thick, leathery, weepy stasis dermatitis; itching; hair usually intact.
EdemaMinimal — nothing is pooling.Marked pitting edema, worse at end of day.
Ulcer locationToes, tips of toes, heel, LATERAL (outer) ankle — bony pressure points.MEDIAL (inner) malleolus — the inner ankle bone.
Ulcer lookRound, deep, “punched-out”, even edges, pale/dry/necrotic base, scant drainage, very painful.Shallow, irregular edges, beefy red moist granulation base, heavy drainage.
What helpsDANGLE / lower the legs ⬇️ · keep warm · NO compressionELEVATE above the heart ⬆️ · compression stockings ✅
🧠 “6 letters, 6 letters.” ARTERY and LATERAL both point outward and downward — arterial ulcers sit on the outer ankle and toes, and you drop the leg down. VEIN and MEDIAL both point inward and upward — venous ulcers sit on the inner ankle, and you lift the leg up.

😖 Claudication vs rest pain — the arterial timeline

🚶 Stage 1 · No symptoms — plaque is there, flow is still enough
▼
🦵 Stage 2 · Intermittent claudication — cramping calf pain at a reproducible distance, gone in minutes of rest
▼
🌙 Stage 3 · REST PAIN — burning pain in the forefoot/toes at night; client hangs the leg off the bed to relieve it
▼
🖤 Stage 4 · Tissue loss — ulcer, necrosis, gangrene = critical limb ischemia

Why the night? Lying flat removes the gravity assist and cardiac output falls in sleep — the foot loses its last bit of perfusion. Hanging the leg over the side of the bed is a diagnostic clue, not a bad habit.

🧠 “Walks in pain → sleeps in pain → loses tissue.” Pain moving earlier in the day and closer to the toes means the disease is advancing. Rest pain is the alarm before the ulcer.

🔬 The position test at the bedside: pallor ⬆️ / rubor ⬇️

Arterial leg · watch the color change RAISE it 60° for 1 min → PALE 😶 gravity beats the weak arterial push = pallor Then HANG it down → DUSKY RED 🟥 = DEPENDENT RUBOR blood finally reaches the foot & sits there A healthy leg does NEITHER — color stays the same.

Normal color returns in about 10 s and normal veins refill in about 15 s after lowering. Marked delay points to arterial disease.

🧠 “Up = white, down = red, both = arterial.” A venous leg goes the other way — elevating it makes it feel better and look less swollen.

⚠️ Look-alikes that get confused with a venous leg

  • DVT — sudden, one-sided calf pain, swelling, warmth and redness in a leg that was fine yesterday. CVI is chronic and gradual; DVT is acute. SEE NG-223
  • Cellulitis — hot, sharply demarcated red skin with fever and rising WBC. Venous stasis skin is brown and chronic, not febrile.
  • Heart-failure edema — bilateral, symmetric, comes with weight gain, crackles and JVD. Venous insufficiency edema is often one leg worse and has skin staining.
  • Lymphedema — non-pitting, firm, involves the toes and foot dorsum, no brown staining.
🧠 “Both legs = the heart. One leg = the vein.” Then ask how fast: yesterday-fast = DVT, months-slow = chronic venous insufficiency.
🚨

RED FLAGS & ASSESSMENT

STEP 3 · WHEN TO ESCALATE

Chronic PVD is managed. A limb that goes cold, white and pulseless is an emergency measured in hours.

🚨 ACUTE ARTERIAL OCCLUSION — the 6 P's · time is tissue

Sudden block → six findings, in this order CLOT everything downstream is cut off 1 · PAIN sudden, severe, not relieved by rest or by opioids 2 · PALLOR white, waxy, then mottled blue-gray marbling 3 · PULSELESSNESS no pulse below the block — confirm with a Doppler 4 · PARESTHESIA numbness, tingling, loss of light touch — LATE, nerve dying 5 · PARALYSIS 🚨 can't wiggle the toes = the LATEST & WORST sign 6 · POIKILOTHERMIA the limb goes COLD — it takes on room temperature
1
🛑 Stop and stay with the client — assess both legs, compare, mark where you found (or lost) the pulse with a pen.
2
📞 Notify the provider / rapid response IMMEDIATELY — this is a limb-threat, not a next-round finding.
3
⬇️ Keep the limb DEPENDENT (below heart level) and at rest — never elevate an acutely ischemic leg.
4
🧣 Keep it comfortably warm with a light blanket — never apply a heating pad, hot water bottle, or ice.
5
🍽️ Keep NPO and get IV access — anticipate anticoagulation, thrombolytics, embolectomy or angiography.
🧠 The 6 P's in order of doom: Pain → Pallor → Pulselessness → Paresthesia → Paralysis → Poikilothermia. The first three say “something's wrong.” The last three say the nerve and muscle are dying — those are the ones you shout about.

❌ NEVER — the four that fail students

  • Never apply heat (heating pad, hot soak) to an ischemic or neuropathic limb — the skin can't feel it and can't dissipate it. Burn on a foot that can't heal.
  • Never elevate a leg with arterial disease for comfort — elevation is the venous answer. Arterial legs go down.
  • Never apply compression stockings or wraps to an arterial leg — squeezing a starving limb finishes the job. Compression is the venous answer, and only after arterial supply is confirmed adequate.
  • Never let the client cut their own corns, calluses or toenails — trimming is done by a podiatrist / provider.
🧠 “Hot, high, and tight — all three are wrong for arteries.” No hot packs, don't hold it high, don't wrap it tight.

✅ What the nurse actually assesses, every shift

Where you put your fingers 🖐️ FEMORAL groin crease POPLITEAL behind the knee POSTERIOR TIBIAL behind the inner ankle bone DORSALIS PEDIS top of the foot Compare LEFT vs RIGHT Grade 0 absent → 3+ bounding
  • 💓 Bilateral pulses — palpate, compare sides, mark the spot; if you can't feel it, get a Doppler before you chart “absent.”
  • 🎨 Color, temperature, cap refill (<3 s normal), hair distribution, nail thickness.
  • 👣 Inspect the feet daily — including between the toes and the heels.
  • 📏 Measure calf circumference at the same marked point each time.
  • 🚶 Ask the distance: “how far can you walk before the cramp starts?” A shrinking distance = disease progressing.
🧠 “The 6 T's of a foot check” — Temperature, Tone (pulse), Tint (color), Toes (between them), Time (cap refill), Trimming (who does the nails). Same six every shift.

➡️ Where this goes next

🩸 Arterial thread

Risk factors that build plaque and the complications when it ruptures → page 2. ABI, antiplatelets, statins, revascularization → page 3.

⬇️ DANGLE stays true on every page

🫙 Venous thread

Why valves fail and where venous ulcers come from → page 2. Compression, positioning and vein procedures → page 3. Acute clot → NG-223 DVT.

⬆️ ELEVATE stays true on every page
PVD set 1 · Patho & Signs 2 · Causes & Complications → 3 · Treatments → ＋ DVT →
⚡

QUICK RECALL

SAY IT OUT LOUD
🩸 ArterialCool, pale, hairless, pulseless · toe/heel/lateral ulcer, round & punched out · pain when walking · DANGLE ⬇️
🫙 VenousWarm, brown, swollen, pulse present · medial ankle ulcer, irregular & weepy · pain when standing · ELEVATE ⬆️
🕳️ Ulcer shortcutArterial = Away & down (toes, outer). Venous = in the middle (medial malleolus).
🚨 6 P'sPain · Pallor · Pulselessness · Paresthesia · Paralysis · Poikilothermia = call NOW, keep the leg down & warm.
🎯 Cover & check — 6 rapid-fire questions
Q1: A client's leg ulcer sits over the medial malleolus, is shallow with irregular edges and drains heavily. Arterial or venous — and how do you position the leg?
VENOUS. Elevate the leg above the level of the heart, and compression stockings are appropriate once arterial supply is confirmed adequate.
Q2: A round, deep, “punched-out” ulcer on the tip of the great toe with a pale dry base and scant drainage. Which one, and what position?
ARTERIAL. Keep the leg dependent — dangle it. Do NOT elevate, do NOT apply compression, do NOT apply heat.
Q3: What is intermittent claudication and what makes it stop?
Cramping muscle pain brought on by walking at a reproducible distance, caused by O₂ demand outrunning a narrowed arterial supply. It stops within minutes of RESTING.
Q4: The client hangs their foot off the side of the bed at night to relieve burning foot pain. What does that tell you?
ARTERIAL rest pain — advanced PAD. Gravity is the only thing getting blood into the forefoot. It signals disease has progressed past claudication and needs to be reported.
Q5: Name the 6 P's and say which one is the most ominous.
Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia. PARALYSIS (inability to move the toes) is the latest and worst — the muscle and nerve are dying.
Q6: Which leg findings are pulses PRESENT in — arterial or venous disease?
VENOUS. The arteries are healthy; the pulse may just be buried under edema. Absent or weak pulses point to ARTERIAL disease.