Peripheral Vascular Disease III · what you actually do about it
NG-161CARDIO · PHARMADHD-friendly visual edition
Every treatment on this page is chosen by answering one question first: arterial or venous? Arterial legs get antiplatelets, statins, walking programs and DANGLING. Venous legs get compression, less standing and ELEVATION. Give the venous treatment to an arterial leg and you can cost the client the limb.
>1.40 is NOT “extra healthy.” It means the vessel is calcified and won't compress — common in long-standing diabetes and renal disease. The result is unreliable; the provider orders a toe-brachial index or imaging instead.
🧠 “One is fine, under nine is a sign, over one-four is a lie.” ABI 1.0 = healthy · <0.90 = PAD · >1.40 = falsely high from stiff, calcified vessels.
🔊 Doppler & duplex ultrasound — listen to the flow
Handheld Doppler — when you cannot palpate a pulse, you listen for it. Chart “Doppler-only,” never “absent,” until you've tried the Doppler.
Duplex ultrasound — ultrasound + color flow. Shows where the narrowing is, how fast blood moves through it, and on the venous side shows valve reflux and clot.
Venous duplex is the go-to test for suspected DVT.SEE NG-223
🧠 “Duplex = double duty.” One probe answers both questions: is the artery narrowed, and is the vein clotted or leaking backward?
🩻 The rest of the workup
Segmental limb pressures — cuffs up the leg localize the level of the block (thigh, calf, ankle).
Exercise / treadmill ABI — a resting ABI can look normal; walking unmasks the drop.
CT angiography / MR angiography — maps the vessels before a procedure.
Contrast angiography — the invasive gold-standard map. Nursing: assess allergy (iodine/shellfish history) and kidney function (BUN/creatinine) before, hydrate after, monitor the puncture site, and check distal pulses frequently afterward.
🧠 Any test with the word “angio” = dye. Dye means kidneys and allergies before, and pulses + puncture site after. That pairing is worth easy points.
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PHARMACOLOGY & PROCEDURES
STEP 2 · OPEN THE PIPE
Two drug jobs on the arterial side: stop platelets from clumping, and stop plaque from building. Then the mechanical fixes.
💊 “AC” = Anti-Clogging of Arteries — A for ASA, C for Clopidogrel
Keeps platelets from clumping together on rough plaque. This is not a blood thinner in the anticoagulant sense — it stops the first step of clot formation.
⚠️ BLEEDING. Teach: soft toothbrush, electric razor, no NSAID stacking, report black tarry stools, bleeding gums, unusual bruising, blood in urine. Take aspirin with food for GI upset; report ringing in the ears (tinnitus). Held before some procedures — on provider order only.
Blocks the liver enzyme that makes cholesterol → LDL falls, plaque stabilizes. “Stay clean.”
⚠️ LIVER TOXIC — monitor LFTs, report dark urine, jaundice, RUQ pain, appetite loss. ⚠️ NO GRAPEFRUIT juice — it raises drug levels and toxicity risk. ⚠️ MUSCLE: report unexplained muscle pain, tenderness or weakness with dark cola-colored urine → possible rhabdomyolysis; the provider checks CK. ❌ Contraindicated in pregnancy.
🧠 “A·C keeps arteries clear — but the STATIN has 3 G's: Grapefruit ❌, Guts (liver) 🧫, and Groaning muscles 💪.” If a statin client says “my legs ache and my urine looks like cola,” that is not claudication — that's rhabdomyolysis. Report it.
💊 The other lipid drugs you'll see beside a statin
Ezetimibe — blocks cholesterol absorption in the small intestine. Often added when a statin alone isn't enough.
Fibrates (gemfibrozil, fenofibrate) — mainly lower triglycerides. Combined with a statin they raise muscle-injury risk.
Niacin — raises HDL; causes flushing. Flushing is uncomfortable, not dangerous.
Bile acid sequestrants (cholestyramine, colesevelam) — bind bile in the gut. Cause constipation, and can block absorption of other drugs, so they are separated in time from other medications.
🧠 “Statin stops making it · Ezetimibe stops absorbing it · Sequestrant sticks to it · Fibrate fights fat (triglycerides) · Niacin flushes.” Five drugs, five verbs.
💊 Drugs aimed at the symptom, not the plaque
Cilostazol — improves walking distance in intermittent claudication (vasodilation + antiplatelet effect). ❌ Contraindicated in heart failure. Takes weeks to show benefit — teach the client not to quit early.
Pentoxifylline — makes red cells more flexible so blood flows through narrow vessels more easily.
Antihypertensives / glucose control — treat the risk factors that keep the plaque growing.
Venous side: there is no “statin for veins.” If a clot forms, the drugs are anticoagulants — heparin, warfarin, DOACs. SEE NG-223
🧠 “Cilostazol = Can't-in-CHF.” Both start with C. If the stem says heart failure, that drug is the wrong answer.
🛠️ INTERVENTIONS — mechanical ways to reopen or reroute
🩸 ARTERIAL procedures
🫙 VENOUS procedures
Angioplasty ± stent — balloon opens, mesh holds. Atherectomy — shaves the plaque out. Bypass graft (e.g. femoral-popliteal) — reroutes blood around the block. Endarterectomy — surgeon strips plaque out of the vessel, classically the carotid. Amputation — last resort for gangrene.
Sclerotherapy — injected agent scars a varicose vein closed. Endovenous ablation — laser/radiofrequency seals the vein. Vein ligation & stripping — the vein is tied off and removed. Debridement + moist wound care for stasis ulcers. Compression therapy — the backbone of every venous plan.
Post-op priority:pulse, color, temperature, movement & sensation distal to the graft. Avoid knee flexion, crossing legs, prolonged sitting, and pressure on the graft.
Post-op priority:elevate the legs, apply compression as ordered, and get them AMBULATING early — walking is the venous pump.
🧠 “Arterial post-op = FEEL the foot. Venous post-op = LIFT the leg and WALK.” Same surgery day, opposite nursing focus.
🎓
POSITIONING & TEACHING
STEP 3 · THE PART THEY TEST
If you only memorize one thing from all three pages, memorize the direction of the legs.
⭐ VEINS = ELEVATE (Vacuum) · ARTERIES = HANG (Away)
Straight from the source:“PVD with varicose veins — wear compression socks & limit standing to aid with blood return to the heart.” Compression + elevation + movement are the entire venous plan.
🧠 “Veins Vacuum UP ⬆️ · Arteries carry blood AWAY, so let them HANG ⬇️.”V for Vacuum and the V shape points up. A for Away and the leg goes down. Say it before you answer any position question.
🅲 AVOID the C's — everything that CONSTRICTS or CHILLS the vessel
💅T — Toenailstrimmed ONLY by the provider / podiatrist
Every C does the same thing: it makes an already-narrow vessel narrower. The T is different — it prevents a wound that a poorly perfused foot cannot heal.
🚭 Smoking cessation is the single most important teaching point in arterial disease. Nothing else on the list comes close.
🧦 Keep the feet warm with socks and blankets — warmth by clothing, never by heating pad, hot water bottle, or hot soaks. Neuropathy means they can't feel a burn.
👟 Well-fitting closed shoes, never barefoot, and inspect inside the shoe before putting it on.
🧠 “5 C's and a T.”Cross · Constrict · Cigarettes · Caffeine · Cold — then Toenails by the doctor. Chant it as a rhythm: “cross, constrict, cigarettes, caffeine, cold — toenails told.”
🚶 The walking program — pain is the dose, not the danger
A supervised walking program is first-line therapy for stable claudication. Walking repeatedly to the point of moderate pain stimulates collateral vessels — the body's own bypass. Done regularly over weeks, pain-free walking distance increases.
Stop and report instead of pushing through if pain becomes rest pain, or the foot turns cold, numb or pale — that's ischemia, not exercise.
🧠 “Walk to the pain, not through the pain.” Claudication pain during a program is expected and therapeutic. Rest pain is never therapeutic — it gets reported.
🧦 Compression stockings — right leg, right way, right time
Confirm arterial supply first — compression on an arterial leg can cause tissue death. ABI is what tells you it's safe.
Correctly sized and measured — a stocking that rolls down becomes a tourniquet.
Inspect skin and pulses each time they come off.
🧠 “Stockings before standing.” Put them on before the legs fill up — once the leg is swollen, the stocking is both harder to apply and less effective.
👣 Foot care teaching — the checklist that saves the limb
🔍 Inspect both feet daily, including between the toes and the soles (a mirror helps). Report any new redness, blister, crack or sore the same day.
🧼 Wash with mild soap and lukewarm water — test the water with a thermometer or the elbow, never with the foot. Pat dry, especially between the toes.
🧴 Lotion on the tops and bottoms — not between the toes (moisture there breeds fungus and breakdown).
💅 Toenails trimmed straight across by the provider or podiatrist.Never let the client cut their own corns or calluses, and never use over-the-counter corn removers.
👟 Well-fitting, closed-toe shoes with clean seamless socks.Never barefoot, never brand-new shoes for a long day.
🚭 Stop smoking — repeat it every visit. It is the intervention with the biggest effect.
🧠 “Look, wash, dry, grease, but not between; nails by the pro; shoes always on.” Six habits. A client who does all six rarely reaches the amputation ladder on page 2.
Page 3 — Treatments (here): ABI proves which side · antiplatelet + statin + walking + revascularization for arterial · compression + elevation + less standing for venous.
🧠 Three pages, one sentence:find out which pipe is broken, then push blood the direction that pipe can't.
⚡
QUICK RECALL
SAY IT OUT LOUD
📏 ABIAnkle ÷ arm systolic. 1.00–1.40 normal · ≤0.90 = PAD · ≤0.40 severe · >1.40 calcified & unreliable.
💊 A · C · statinASA + Clopidogrel = anti-clumping (bleeding risk) · statin = liver toxic, NO grapefruit, muscle pain + dark urine → report.
🅲 5 C's + TCross · Constrict · Cigarettes · Caffeine · Cold · Toenails by the provider only.
Q1: The ankle systolic is 90 and the highest arm systolic is 120. What is the ABI and what does it mean?
90 ÷ 120 = 0.75 → PAD in the mild-to-moderate range (0.41–0.90). Expect intermittent claudication.
Q2: A client with long-standing diabetes has an ABI of 1.6. Is their circulation excellent?
No. Above 1.40 means the vessels are calcified and won't compress, so the reading is falsely high and unreliable. Expect the provider to order a toe-brachial index or imaging.
Q3: A client on lovastatin reports aching thighs and dark, cola-colored urine. What do you do?
Hold the next dose and report immediately — this suggests rhabdomyolysis/myopathy. Anticipate a CK level. Also reinforce: no grapefruit juice, and report jaundice or RUQ pain (hepatotoxicity).
Q4: A client with an ABI of 0.5 asks to wear their spouse's compression stockings for the swelling. Response?
No. Compression is contraindicated in arterial insufficiency — squeezing an already-starved limb worsens ischemia. Compression is a VENOUS therapy, and only after adequate arterial supply is confirmed.
Q5: Which client dangles the legs and which elevates them?
ARTERIAL/PAD dangles — hang the legs down so gravity pushes blood into the foot. VENOUS/CVI elevates above heart level so gravity drains the pooled blood back to the heart.
Q6: Name the C's to avoid and the T.
Cross legs, Constrictive clothing, Cigarettes, Caffeine, Cold temperatures — and Toenails trimmed only by the provider/podiatrist.
Q7: The client says walking makes their calf cramp, so they've stopped walking. Correct?
No. A walking program is first-line therapy: walk to the point of moderate claudication pain, rest until it eases, then walk again. Repeated over weeks it builds collateral circulation and increases pain-free distance. Rest pain, or a foot that turns cold/pale/numb, is different — that gets reported.