Ch38 revised peripheral arterialdisease

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

(Relates to Chapter 38, “Nursing Management: Vascular

Disorders,” in the textbook)


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 healingWound infectionTissue 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


ExerciseImproves 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 infectionMaximize 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 programIncreased activity toleranceVerbalize 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 thrombosis1. 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

Date post:	02-Nov-2014
Category:	Documents
Upload:	kellydudley
View:	252 times
Download:	1 times

Ch38 revised peripheral arterialdisease

Documents