Ch38 revised peripheral arterialdisease

(Relates to Chapter 38,
“Nursing Management: Vascular Disorders,”
in the textbook)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

 Progressive narrowing and degeneration of
arteries of neck, abdomen, and extremities

 Leading cause
• Atherosclerosis

 Patients between 60s and 80s (typically)
• Much earlier in diabetics


 2X higher in Hispanic ♀ than white ♀
 2-3 X higher in African American than white
 Similar in men and women (when adjusted for age)
 Largely undiagnosed and undertreated
 Risk factors
• Cigarette smoking
• Hyperlipidemia
• Hypertension
• Diabetes mellitus


 Certain segments of more likely
• Coronary carotid
• Common Iliac
• Superficial femoral
• Popliteal
• Tibial arteries

 Clinical symptoms
• When vessel 60-75% occluded


 Peripheral arterial disease (PAD) may affect
• Aortoiliac artery
• Femoral artery
• Popliteal artery
• Tibial artery
• Peroneal artery


 Classic symptom of PAD

• Intermittent claudication
 Ischemic muscle ache or pain that is
precipitated by a constant level of exercise
 Resolves within 10 minutes or less with rest
 Reproducible


 Paresthesia
• Shooting or burning pain in extremity
• Present near ulcerated areas
• Loss of sensations
 Pressure and deep pain
• Injuries often go unnoticed by patient


 Thin, shiny, and taut skin

 Loss of hair on the lower legs

 Diminished or absent pulses

• pedal, popliteal, or femoral
 Pallor

 Reactive hyperemia


 Pain at rest
• Occurs in the forefoot or toes
• Aggravated by limb elevation
• Occurs from insufficient blood flow
• Occurs more often at night


 Atrophy
• Skin
• Underlying muscles
 Delayed healing

 Wound infection

 Tissue necrosis

 Arterial ulcers


 Most serious complications
• Nonhealing arterial ulcers
• Gangrene

 Result = amputation
• If blood flow is not adequately restored
• If severe infection occurs


 Doppler ultrasound

• Segmental blood pressures
 Ankle-brachial index (ABI)

• Done using a handheld Doppler
 Duplex imaging

• Bidirectional, color Doppler
 Angiography

 Magnetic resonance angiography (MRA)


 Smoking cessation

 Aggressive treatment of hyperlipidemia

 Hypertension and diabetes mellitus

 BP maintained <130/80 mm Hg

 Glycosylated hemoglobin <7.0% for diabetics


 Antiplatelet agents

• Aspirin
• Ticlopidine (Ticlid)
• Clopidogrel (Plavix)


 ACE inhibitors
• Ramipril (Altacel)
 ↓ Cardiovascular morbidity
 ↓ Mortality
 ↑ Peripheral blood flow
 ↑ABI
 ↑ Walking distance


 Drugs for tx of intermittent claudication

• Pentoxifylline (Trental)
 ↑ Erythrocyte flexibility
 ↓ Blood viscosity

• Cilostazol (Pletal)
 ↑ Vasodilation
 ↑ Walking distance


 Exercise

 Improves O2 extraction in the legs and

skeletal metabolism
 Walking
• Most effective exercise for claudication
• 30 to 60 minutes daily


 Dietary cholesterol <200 mg/day

↓ intake of saturated fat
 Soy products
• Use in place of animal protein


 Ginkgo biloba
• ↑ walking distance with intermittent claudication

 Folate, vitamin B6, cobalamin (B12)
• Lowers homocysteine levels


 Protect from trauma

 Reduce vasospasm

 Prevent/control infection

 Maximize arterial perfusion

 Other strategies
• Immune modulation therapy
• Angiogenic gene therapy


 Indications
• Intermittent claudication symptoms become
incapacitating
• Pain at rest
• Ulceration or gangrene severe enough to
threaten viability of the limb


 Percutaneous transluminal balloon
angioplasty
• Insertion of a catheter through femoral artery
• Catheter contains a cylindrical balloon
• Balloon is inflated
 Dilates the vessel by cracking the confining
atherosclerotic intimal shell


 Most common surgical approach

• A peripheral arterial bypass operation
 Autogenous vein or synthetic graft material
 Bypass blood around the lesion
• Synthetic grafts typically used for long
bypasses


 Peripheral arterial bypass operation(cont’d)

• Balloon angioplasty with stenting used in
combination with bypass surgery
 Endarterectomy

 Patch graft angioplasty

 Amputation


 Past health history

• Diabetes mellitus
• Smoking
• Hypertension
• Hyperlipidemia
• Obesity


 Exercise intolerance

 Loss of hair on legs and feet

 Decreased or absent peripheral pulses


 Ineffective tissue perfusion (peripheral)

 Impaired skin integrity

 Activity intolerance

 Ineffective therapeutic regimen
management


 Overall goals for patient with PAD

• Adequate tissue perfusion
• Relief of pain
• Increased exercise tolerance
• Intact, healthy skin on extremities


 Health Promotion

• Identification of at-risk patients
• Community involvement
• Diet modification


 Acute Intervention
• Frequently monitor after surgery
 Skin color and temperature
 Capillary refill
 Presence of peripheral pulses distal to the operative
site
 Sensation and movement of extremity


 Acute Intervention
• Continued circulatory assessment
• Monitor for potential complications
• Knee-flexed positions should be avoided
except for exercise
• Turn and position frequently


 Ambulatory and Home Care

• Management of risk factors
• Importance of meticulous foot care
• Importance of gradual physical activity after
surgery


 Ambulatory and Home Care

• Daily inspection of the feet
• Comfortable shoes w/ rounded toes, soft insoles
• Shoes lightly laced


 Identify activities that promote circulation

 Maintain adequate peripheral tissue perfusion

 Experience intact skin, free of infection, on lower
extremities


 Plans for walking program
 Increased activity tolerance
 Verbalize key elements of therapeutic
regimen, knowledge of disease,
treatment plan, reduction of risk
factors, and proper ulcer/foot care


 62-year-old male complains of pain
when walking his dog that is relieved
with rest

 He has a history of hypertension and
hyperlipidemia, and he smokes one
pack of cigarettes per day


 He has edema in his feet

 Angiography reveals nearly obstructed
vessels in lower extremities

 He is diagnosed with peripheral arterial
disease


1. What risk factors for peripheral arterial
disease does he display?

2. What can he do to prevent further
complications?

3. What patient teaching is essential for
him to help manage his disease?

 Venous disorders

• Venous Thrombosis
• Chronic Venous Insufficiency


Factors in venous thrombosis
1. Venous stasis

2. Endothelial damage

3. Hypercoagulability


 Manifestations
• Palpable cord
• Red, warm , tender skin
• Mild temperature elevation
• Possible edema
 Care
• Elevation
• Heat,
• Analgesics

 Manifestations
• Unilateral edema
• Pain
• Warm skin
• Fever
• Positive Homan’s sign (caveat)
• May be minimally symptomatic


 Potential Complications
• Pulmonary embolism
• Chronic venous insufficiency

 Diagnosis
• Doppler


 Prevention and prophylaxis

 Anticoagulation
• Prevention AND treatment
• Lovenox
• Heparin
• Fondaparinux
• Coumadin


 Nursing Interventions
• Management and teaching r/t anticoagulation
 Safety
 Monitoring
 Diet
 Minimization of bleeding risk

• Education about signs/symtpoms of PE


 Valves of the veins are damaged--->

• Retrograde blood flow
• Pooling of blood in the legs

 May lead to venous stasis ulcers


 Manifestations
• Brawny skin, possible eczema
• Edema , possible severe
• Venous ulcers
 Tend to occur above medial malleolus
 Weepy, - extensive drainage
 shallow, irregular shaped
 Larger than arterial ulcers


 Care of ulcers
• Compression of venous insufficiency
*avoid if concurrent PAD
• Moist dressings
• Balanced diet with adequate protein,
vitamins A/C
• Antibiotics if infection is present


Ch38 revised peripheral arterialdisease

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