Arterial Insufficiency

Peripheral arterial disease results from atherosclerotic narrowing that reduces blood flow to extremities, causing intermittent claudication (pain with walking, relieved by rest), pain at rest in severe cases, and pain that worsens with elevation since gravity-assisted flow is already compromised. Skin appears pale, shiny, and hairless with weak or absent pulses, and wounds are typically found on toes or pressure points with a punched-out, well-defined appearance and minimal drainage. The 6 P's (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia) indicate acute arterial occlusion, a vascular emergency requiring immediate intervention to prevent limb loss.

Venous Insufficiency

Venous insufficiency results from damaged or incompetent valves allowing blood to pool in the lower extremities, causing edema, aching or heaviness that improves with elevation, and brown discoloration from hemosiderin deposits. Wounds occur near the medial malleolus, have irregular borders, and produce significant drainage, unlike the dry arterial ulcer. Compression therapy is the cornerstone of venous disease management, along with leg elevation above heart level and regular ambulation to activate the calf muscle pump. The NCLEX trap here is applying compression to a client who also has significant arterial disease, which can worsen ischemia, so ABI must be checked first.

Assessment and Teaching Priorities

The ankle-brachial index (ABI) compares ankle to brachial systolic pressure; a normal ratio is 0.9-1.3, while below 0.9 indicates arterial insufficiency and below 0.5 signals severe disease. For arterial disease, teach clients to keep legs in a dependent position (below heart level) to promote flow, avoid tight clothing and crossing legs, avoid extreme temperatures, and prioritize smoking cessation since nicotine causes vasoconstriction. For venous disease, teach leg elevation, compression stockings, and avoiding prolonged standing or sitting. Mixing up these opposite positioning instructions is one of the most common NCLEX errors, so anchor them to underlying pathophysiology rather than rote memorization.