Focus on Peripheral Arterial Disease of the Lower Extremities

1. Focus on Peripheral Arterial Disease of the Lower Extremities (Relates to Chapter 38, “Nursing Management: Vascular Disorders,” in the textbook)

2. Peripheral Arterial DiseaseDescription • Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities • Atherosclerosis is the leading cause of majority of cases

3. Fig. 38-1

4. Peripheral Arterial DiseaseDescription • Typically appears at ages 60s to 80s • Largely undiagnosed • Risk factors • Cigarette smoking • Hyperlipidemia • Hypertension • Diabetes mellitus

5. Peripheral Arterial DiseaseClinical Manifestations • 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

6. Peripheral Arterial DiseaseClinical Manifestations • Paresthesia • Pain at rest • Occurs in the forefoot or toes and is aggravated by limb elevation • Occurs from insufficient blood flow • May indicate critical ischemia

7. Peripheral Arterial DiseaseClinical Manifestations • Thin, shiny, and taut skin • Loss of hair on the lower legs • Diminished or absent pedal, popliteal, or femoral pulses • Pallor

8. Peripheral Arterial DiseaseComplications • Atrophy of the skin and underlying muscles • Delayed healing • Wound infection • Tissue necrosis • Arterial ulcers

9. Peripheral Arterial DiseaseComplications • Nonhealing arterial ulcers and gangrene are most serious complications • May result in amputation if blood flow is not adequately restored or if severe infection occurs

10. Peripheral Arterial DiseaseComplications • Arterial Ulcers (see table 38-2) • Small, deep, round “punched out” appearance • Minimal drainage • Typically occur on tips of toes or feet • Ulcer tissue may have black eschar or pale pink granulation

11. Peripheral Arterial DiseaseDiagnostic Studies • Doppler ultrasound • Segmental blood pressures • Ankle–brachial index (ABI) • Done using a handheld Doppler • Angiography • Magnetic resonance angiography (MRA)

12. Collaborative CareRisk Factor Modification • Smoking cessation • Aggressive treatment of hyperlipidemia • Hypertension and diabetes mellitus • BP maintained <130/80 • Glycosylated hemoglobin <7.0% for diabetics

13. Collaborative CareDrug Therapy • Antiplatelet agents • Aspirin • Ticlopidine (Ticlid) • Clopidogrel (Plavix) • ACE inhibitors

14. Collaborative CareDrug Therapy • Drugs prescribed for treatment of intermittent claudication • Pentoxifylline (Trental) • ↓ Blood viscosity • Cilostazol (Pletal) • ↑ Vasodilation

15. Collaborative CareExercise Therapy • Exercise improves oxygen extraction in the legs and skeletal metabolism • Walking is the most effective exercise for individuals with claudication • 30 to 60 minutes daily

16. Collaborative CareNutritional Therapy • Dietary cholesterol <200 mg/day • Decreased intake of saturated fat • Soy products can be used in place of animal protein

17. Collaborative CareCare of Leg with Critical Limb Ischemia • Protect from trauma • Reduce vasospasm • Prevent/control infection • Maximize arterial perfusion • Other strategies • Immune modulation therapy • Angiogenic gene therapy

18. Collaborative CareInterventional Radiologic Procedures • Indications • Intermittent claudication symptoms become incapacitating • Pain at rest • Ulceration or gangrene severe enough to threaten viability of the limb

19. Collaborative CareInterventional Radiologic Procedures • Percutaneous transluminal balloon angioplasty • Involves the insertion of a catheter through the femoral artery • Balloon is inflated dilating the vessel by cracking the confining atherosclerotic intimal shell

20. Collaborative CareSurgical Therapy • Most common surgical approach • A peripheral arterial bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion

21. Fig. 38-7

22. Collaborative CareSurgical Therapy • Endarterectomy • Patch graft angioplasty • Amputation

23. Nursing ManagementNursing Assessment • Past health history • Diabetes mellitus • Smoking • Hypertension • Hyperlipidemia • Obesity

24. Nursing ManagementNursing Assessment • Exercise intolerance • Loss of hair on legs and feet • Decreased or absent peripheral pulses

25. Nursing ManagementNursing Diagnoses • Ineffective tissue perfusion (peripheral) • Impaired skin integrity • Activity intolerance • Ineffective therapeutic regimen management

26. Nursing ManagementPlanning • Overall goals for patient with PAD • Adequate tissue perfusion • Relief of pain • Increased exercise tolerance • Intact, healthy skin on extremities

27. Nursing ManagementNursing Implementation • Health Promotion • Identification of at-risk patients • Community involvement • Diet modification

28. Nursing ManagementNursing Implementation • 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

29. Nursing ManagementNursing Implementation • Acute Intervention • Continued circulatory assessment • Monitor for potential complications • Knee-flexed positions should be avoided except for exercise • Turn and position frequently

30. Nursing ManagementNursing Implementation • Ambulatory and Home Care • Management of risk factors • Importance of meticulous foot care • Importance of gradual physical activity after surgery

31. Nursing ManagementNursing Implementation • Ambulatory and Home Care • Daily inspection of the feet • Comfortable shoes with rounded toes and soft insoles • Shoes lightly laced

32. Nursing ManagementEvaluation • Identify activities that promote circulation • Maintain adequate peripheral tissue perfusion • Experience intact skin, free of infection, on lower extremities

33. Nursing ManagementEvaluation • 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

34. Venous disorders

35. Venous Thrombosis Factors in venous thrombosis (38-7) 1. Venous stasis 2. Endothelial damage 3. Hypercoagulability

36. Superficial Thrombosis • Manifestations • Palpable cord • Red, warm , tender skin • Mild temperature elevation • Possible edema • Care • Elevation • Heat, • Analgesics

37. Deep Vein Thrombosis (DVT) • Manifestations • Unilateral edema • Pain • Warm skin • Fever • Positive Homan’s sign (caveat) • May be minimally symptomatic

38. DVT • Potential Complications • Pulmonary embolism • Chronic venous insufficiency • Diagnosis • Doppler

39. DVT • Prevention oand prophylaxis • Anticoagulation • Prevention AND treatment • Lovenox, heparin, fondaparinux • Coumadin

40. DVT • Nursing Interventions • Management and teaching related anticoagulation • Safety • Monitoring • Diet • Minimization of bleeding risk • Education about signs/symtpoms of PE

41. Chronic Venous Insufficiency • A condition in which the valves of the veins are damaged---> retrograde blood flow, pooling of blood in the legs. • May lead to venous stasis ulcers

42. Chronic Venous Insufficiency • 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

43. Chronic Venous Insufficiency • 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