Peripheral Vascular Diseases

1. Arterial Manifestations: Diminished or absent pulses Smooth, shiny, dry skin, no hair No edema Round, regularly shaped painful ulcers on distal foot, toes or webs of toes Dependent rubor Pallor and pain when legs elevated Intermittent claudication Brittle, thick nails Venous Manifestations: Normal pulses Brown patches of discoloration on lower legs Dependent edema Irregularly shaped, usually painless ulcers on lower legs and ankles Dependent cyanosis and pain Pain relief when legs elevated No intermittent claudication Normal nails Peripheral Vascular Diseases

2. Peripheral Arterial Occlusive Disease (830) • Pathophysiology: Narrowing and sclerosis of large arteries (femoral, iliac, popliteal) especially at bifurcations due to plaque formation • Risk factors: smoking, obesity, sedentary lifestyle, HTN, DM, hyperlipidemia, Fa hx • S/S: see previous slide. May also have bruit over femoral or popliteal : doppler area • Dx Tests: US, exercise testing (822), pulse volumes, angiography (823), Trendelenberg test (see Assessment text)

3. Treatment of PAOD • Meds-antiplatelets, antilipidemics, vasodilators, Trental (misc.) • Good skin and foot care-podiatrist for probs • Avoid standing for long periods, crossing legs, tobacco • Low fat diet, lose weight • Exercise to point of pain; Buerger-Allen exercises • Surgery-fem-pop bypass, endardarectomy, amputation

4. Nursing Management of PAOD • Administer and monitor meds • Patient education: • Meds • Good skin and foot care • Avoiding pressure, tobacco • Diet and exercise • S/S of acute occlusion • Pre and postop care if indicated

5. Nursing Management of Pt. with Fem-Pop Bypass (832-3) • Preop Goal: Prevent trauma and maintain circulation • Keep leg level or slightly dependent • Protect leg from trauma • Administer anticoagulants • Assess and monitor VS and NV status • Assess and monitor anxiety • Education on above and on what to expect after surgery

6. Nursing Management of Fem-pop Bypass cont’d • Postop Goal: Maintain adequate circulation through graft (saphenous, umbilical, Gore-Tex) • ICU at first • Assess VS, pulse ox, I&O, PT, PTT, lytes, BUN, creat • Monitor NV status (6 Ps) q1h x 8, then q2h x 24 using doppler. Compare to other extremity. • Assess ankle-brachial index (ABI) q8h x 24 • Administer anticoags, analgesics • TEDs for some surgeons, no leg crossing, or prolonged extremity dependency • Pt education on meds, activity, how to recognize vascular complications

7. Nursing Management cont’d • Notify surgeon immediately for: • Absence of pulse • Abnormal ABI • Abnormal VS • Hemorrhage • Severe edema with pain and <sensation (may indicate compartment syndrome)

8. Acute Arterial Occlusive Disease (arterial embolism-840) • Pathophysiology: blood clots from arteries, left ventricle, or trauma suddenly break loose and become free flowing, lodge in bifurcations, causing obstruction distally with acute and sudden symptoms • Assessment: +6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia), ABI<1, +US, MRI, or angiography

9. Management of Arterial Embolism • Medical: • Anticoagulants-heparin bolus then 1000U/hr • Thrombolytics • Surgical (depends on occlusion time): • Embolectomy (840) • Bypass • Angioplasty with stent placement • Nursing: • Administer and monitor anticoag or thrombolytic tx • If surgery, then monitor for postop angioplasty and stent placement, bypass, or embolectomy (similar to bypass except no ICU and hospital time is less).

10. Buerger’s Disease (thromboangiitis obliterans-834) • Pathophysiology: obstructive and inflammatory disease of small and medium sized arteries and veins. Believed to be autoimmune. Has exacerbations and remissions. Smoking is very high risk factor. • Assessment: pain and instep claudication, intense rubor, absence of distal pulses (pedal, radial, ulnar), paresthesias; segmental limb blood pressures, US, angiography

11. Management of Buerger’s Disease • Medical/Surgical: • Pain meds • Stop smoking • Treatment of infection and gangrene • Sympathectomy (removal of sympathetic ganglia or branches-causes permanent vasodilation • Amputation • Nursing: • Support stopping smoking • Administer pain meds • Education regarding protection extremities from cold and trauma.

12. Raynaud’s Disease (841) • Pathophysiology: arterial spasms of small cutaneous vessels of fingers and toes. May have too many alpha 2 receptors leading to vasoconstriction and not enough beta receptors. Aggravated by cold and stress. • Assessment: classic tri-color symptoms-pallor, cyanosis, rubor, pain, and paresthesia. Bilateral and symmetric.

13. Management of Raynaud’s Disease • Medical/Surgical: • Avoiding cold, stress, nicotine • Ca++ channel blockers (particularly nifedipine) especially for acute vasospasm • sympathectomy • Nursing: • Avoid stress, take stress mgmt classes • Avoid cold and trauma • Teach about nifedipine (can cause orthostatic hypotension)

14. Hypertension (855) • Definitions and Etiology: • SBP > 140 and DBP > 90 at least 3 times. • Affects 20-25% of population. 90-95% have primary or essential HTN (unknown etiology). Other 5-10% have secondary, meaning there is a disease process causing it (i.e., thyrotoxicosis, renal artery stenosis, pheochromocytoma). Hypertensive crisis-DBP > 120. Malignant HTN-rises rapidly. White coat HTN-increased BP when patient goes to MD. • Risk factors are similar to CAD • Classifications p. 855, Table 32-1

15. S/S: Usually absent unless severe or advanced If symptoms they include HA, blurred vision, dizziness, nosebleeds BP > 140/90 S4 gallop rhythm Dx Tests: BP readings CBC, UA, lytes, lipids, glucose, renal and liver functions ECG CXR Echo Assessment of HTN

16. Management of HTN • Monitoring of BP: recommendations for F/U on p. 856, Table 32-2. • Algorithim p. 859. Lifestyle changes and meds. • Lifestyle changes include wt reduction, heart healthy diet, no nicotine, regular exercise. • Meds: 50%-1; 90%-2. Stepped approach with: • Diuretics • Beta and alpha blockers • Vasodilators • ACEIs and Angiotensin receptor blockers • Ca++ channel blockers

17. Management of HTN cont’d • Treat complications: • Angina, MI • CHF-from LV hypertrophy • CRF • CVA • Retinal hemorrhages

18. Nursing Management of HTN • History: assess for all risk factors • Physical assessment: heart sounds, pulses, VS, lungs, carotid bruit, retina, thyroid, abd, neuro • Pt education: lifestyle modifications, monitor BP and daily wts and keep a record, keep appts, safety r/t hot showers and environments, orthostatic BPs, first dose syncope, meds, don’t stop meds suddenly, OTC meds, keep list of meds, interacting meds-BCPs, steroids, NSAIDs, some antidepressants, antihistamines, nasal decongestants