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386 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 6-10. Comparison of Clinical Findings of Arterial and Venous Disorders

Clinical Finding

Arterial Disorders

Venous Disorders

Edema

Mayor may not be

Present

present

Worse at the end of the day

Improve with elevation

Muscle mass

Reduced

Unaffected

Pain

Intermittent claudication

Aching pain

Cramping

Exercise improves pain

Worse with elevation

Bener with elevation

Cramping at night

Paresthesias, pruricus (severe

itching)

Leg heaviness, especially at

end of day

Commonly a positive

Homans' sign

Pulses

Decreased to absent

Usually unaffected but may

Possible systolic bruit

be difficult ro palpate if

edema is present

Skin

Absence of hair

Broad, shallow, painless

Small, painful ulcers on

ulcers of the ankle and

pressure points, espelower leg

cially lateral malleolus

Normal toenails

Tight, shiny skin

Thickened toenails

Color

Pale

Brown discoloration

Dependent cyanosis

Dependent cyanosis

Temperature

Cool

May be warm in presence of

thrombophlebitis

Sensation

Decreased light touch

Pruritus

Occasional itching, tingling, and numbness

Source: Data from JM Black, E Matassarin-Jacobs (eds). Luckmann and Sorensen's

Medical-Surgical Nursing: A Psychophysiologic Approach (4th cd). Philadelphia:

Saunders, 1993; 1261.

VASCULAR SYSTEM ANO HHiATOLOGY 387

• Smoking

• Diabetes mellitus

• H ypenension

• Hyperlipidemia (12- to 14-hour fasting blood sample of cholesterol of more than 260 mgldl or triglyceride of more than 150 mgldl)

• Low levels of high-density lipoproteins

• High levels of low-density lipoproteins

• Gender (Men are at greater risk than women until women reach

menopause; then the risk is equal in both genders.)

•

Inactivity

• Family history

In addition to these risk factors, a high level of an inflammatory

biomarker, C-reactive protein, has been identified as a good predictive

marker for early identification of artherosclerosis,'6

Clinical manifestations of atherosclerosis result from decreased

blood flow through the stenotic areas. Signs and symptoms vary

according to the area, size, and location of the lesion, along with the

age and physiologic status of the patient. As blood flows through a

stenotic area, turbulence will occur beyond the stenosis, resulting in

decreased blood perfusion past the area of atherosclerosis. Generally,

a 50-60% reduction in blood flow is necessary for patients to present

with symptoms (e.g., pain). Turbulence is increased when there is an

increase in blood flow to an area of the body, such as the lower

extremities during exercise. A parient with no complaint of pain at

rest may therefore experience leg pain (intermittent claudication) during walking or exercise as a result of decreased blood flow and the accumularion of merabolic waSte (e.g., lactic acid}.J.6,'4

The following are general signs and symptoms of atherosclerosis17:

• Peripheral pulses that are slightly reduced to absent

• Presence of bruits on auscultation of major arteries (i.e., carotid,

abdominal aorra, iliac, and femoral)

• Coolness and pallor of skin, especially with elevation

• Presence of ulcerations, atrophic nails, and hair loss

388 ACI.JfE CARE HANDBOOK FOR PHYSICAL TI-IERAPISTS

• Increased blood pressure

• Subjective reports of continuous burning pain in toes at rest that

is aggravated with elevation (ischemic pain) and relieved with

walking. Pain at rest is usually indicative of severe, 80-90% arterial occlusion.

•

Subjective reports of calf or lower-extremity pain induced by

walking (intermittent claudication) and relieved by re t

Clinical Tip

Progression of ambulation distance in the patient with

intermittent claudication can be optimized if ambulation is

performed in short, frequent intervals (i.e., before the

onset of claudicating pain).

Symptoms similar to intermittent claudication may have a neurologic origin from lumbar canal stenosis or disk d isease. These symptoms are referred to as pseudoclaudication or neurologic

claudication. Table 6-11 outlines the differences between true claud ication and pseudoclaudication.18 Medications that have been successful in managing intermittent claudication include pentoxifylline and cilostazol,'9

Treatment of atherosclerotic disease is based on clinical presention

and can range from risk-factor modifications (e.g., low-fat diet,

increased exercise, and smoking cessation) to pharmacologic therapy

(e.g., anticoagulation and thrombolytics) to surgical resection and

grafting. Modification of risk factors has been shown to be the most

effective method to lower the risk of morbidity (heart attack or

stroke) from artherosclerosis.15•2o

Aneurysm

An aneurysm is a localized dilatation or Outpouching of the vessel

wall that results from d egeneration and weakening of the supportive network of protein fibers with a concomitant loss of medial smooth muscle cells. Aneurysms most commonly occur in the

abdominal aorta or iliac arteries, followed by the popliteal, femoral, and carotid vessels. 6.15.21,22 The exact mechanism of aneurysm formation is not fully understood but includes a combination of

the following: