Arterial vs Venous Disease

Question 1

Peripheral Arterial Disease (PAD)

Answer 1

Typically appears in 60s to 80s
Largely undiagnosed

Risk factors
Cigarette smoking
Hyperlipidemia
Hypertension
Diabetes mellitus

May affect
Aortoiliac artery
Femoral artery
Popliteal artery
Tibial artery
Fibular artery

Question 2

Pathophysiology PAD

Answer 2

Atherosclerosis – Narrowing of arteries due to plaque build up

Vasospasm

Inflammation

Question 3

History & Physical Assessment

Answer 3

Diabetes mellitus
Smoking
Hypertension
Hyperlipidemia
Obesity
Exercise intolerance
Loss of hair on legs and feet
Decreased or absent peripheral pulses

Question 4

PAD Symptoms

Answer 4

Thin, shiny, taut skin
Loss of hair on lower legs
Diminished or absent pulses
Pedal
Popliteal
Femoral
Paresthesia
Numbness or tingling in toes or feet
Loss of pressure & deep pain sensation
Injuries often go unnoticed

Pallor
Decreased color of foot with elevation
“Dependent rubor”
Reactive hyperemia of foot with dependent position

Question 5

Pain Specific to PAD

Answer 5

Intermittent Claudication
Classic symptom
Ischemic muscle ache or pain
Precipitated by constant level of exercise
Resolves in 10 minutes or less with rest
Reproducible

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

Question 6

Diagnostic Studies

Answer 6

Health & physical examination
Palpation of peripheral pulses
Doppler ultrasound
Segmental blood pressures
Duplex imaging
Angiogram
Magnetic resonance angiography (MRA)

Question 7

Ankle-Brachial Index (ABI)

Answer 7

Hand-held doppler
Divide ankle SBP by arm SBP
Ankle SBP measured with Doppler & B/P cuff
Examples:
130 (ASBP) /125 (SBP) = 1.04
100 (ASBP) /125 (SBP) = .80
65 (ASBP) /125 (SBP) = .48

ABI 0.9 – 1.0 = Normal
Full compression
ABI 0.8 – 0.6 = PAD
Low level compression
ABI 0.5 & below = Severe PAD
Compression contra-indicated

Question 8

Potential Complications of PAD

Answer 8

Atrophy of skin & underlying muscles
Delayed healing
Wound infection
Tissue necrosis
Arterial ulcers
Non-healing arterial ulcers
Gangrene
Amputation

Question 9

Overall Goals / Outcomes

Answer 9

Potential Nursing Diagnoses
Ineffective peripheral tissue perfusion
Impaired skin integrity
Activity intolerance
Ineffective self-health management

Health Promotion
Identify at-risk patients
Diet modification
Proper care of feet
Avoidance of injuries

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

Question 10

Risk Factor Modification

Answer 10

Smoking cessation
All nicotine products
Aggressive treatment of hyperlipidemia
BP maintained <140/90
Glycosylated hemoglobin < 7.0% for people with diabetes
Anti-platelet agents
Aspirin
Ticlopidine (Ticlid)
Clopidogrel (Plavix)
Eptifibatide (Integrilin)
Ticagrelor (Brilinta)

Question 11

Ambulatory / Home care

Answer 11

Importance of meticulous foot care
Importance of gradual physical activity after surgery
Tobacco any form contraindicated
Including environmental smoke
Encourage physical activity
Improves CVD risk factors
Daily foot inspection
Comfortable shoes
Rounded toes
Soft insoles
Lightly laced

Question 12

Diet & Exercise

Answer 12

BMI < 25 kg/m2
Waist circumference
Men < 40 inches
Women < 35 inches
Dietary cholesterol < 200 mg/day
Decreased intake of saturated fat
Soy products substituted for animal protein
Sodium < 2 g/day

Improves oxygen extraction in legs & skeletal metabolism
Walking is most effective exercise for individuals with claudication
30 to 60 minutes/day

Question 13

ACE Inhibitors

Answer 13

Benazepril (Lotensin)
Captopril (Capoten)
Enalapril (Vasotec)
Lisinopril (Prinivil)
Ramipril (Altace)

Decreases
Cardiovascular morbidity
Mortality
Increases
Peripheral blood flow
ABI
Walking distance

Question 14

Drugs for Intermittent Claudication

Answer 14

Pentoxifylline (Trental)
Decreases
Blood viscosity
Increases
Erythrocyte flexibility

Cilostazol (Pletal)
First line treatment for those who do not respond to exercise therapy
Increases
Vasodilation
Walking distance

Question 15

Critical Limb Ischemia

Answer 15

Characterized by
Chronic ischemic rest pain > 2 weeks
Arterial leg ulcers
Gangrene

Interventions
Protect from trauma
Reduce vasospasm
Prevent/control infection
Maximize arterial perfusion
Revascularization
Other strategies
Hyperbaric oxygen therapy
Angiogenesis

Question 16

Interventional Radiology Procedures

Answer 16

Indications
Incapacitating intermittent claudication
Rest pain
Limb viability threatened with
Ulceration
Gangrene

Percutaneous transluminal balloon angioplasty (PTA)
Stents
Atherectomy
Cutting disc
Laser
Rotating diamond tip

Question 17

Surgical Procedures

Answer 17

Femoral Bypass Grafting
Synthetic grafts for long bypasses
Human umbilical vein
Cryopreserved vein,
Composite sequential graft
Balloon angioplasty /stenting in combination with bypass
Endarterectomy
Patch graft angioplasty
Amputation

Question 18

Post-operative Care

Answer 18

Frequent monitoring: Check extremity every 15- min then every hour
Skin color & temperature
Capillary refill
Pulses distal to operative site
Sensation & movement of extremity
Continued circulatory assessment
Monitor for potential complications
Avoid knee-flexed positions
Except for exercise
Turn / position frequently

Discourage prolonged sitting & leg dependency
May cause pain, edema, increase risk of VTE & stress suture lines
If edema develops:
Position supine
Elevate edematous leg above heart level
Walking is desirable
Potential complications:
Bleeding
Hematoma
Thrombosis
Embolization
Compartment syndrome

Question 19

Evaluation

Answer 19

Activities that promote circulation have been identified & implemented
Adequate peripheral tissue perfusion is maintained
Lower extremity skin remains intact & free infection

Measurable goals:
Plans for walking program
Increased activity tolerance
Able to verbalize key elements of
Therapeutic regimen
Knowledge of disease
Treatment plan
Reduction of risk factors
Proper ulcer/foot care

Question 20

Thromboangitis Obliterans (Buerger’s Disease)

Answer 20

Non-atherosclerotic, segmental, recurrent inflammatory disorder
Small / medium-sized arteries & veins
Upper / lower extremities
Young men (< 40 years)
Tobacco, but no other risk factors
High rate of periodontitis

Question 21

Treatment: Buerger’s Disease

Answer 21

Absolute tobacco cessation
Nicotine replacements contra-indicated
Antibiotics for infection
Analgesics
Avoid trauma to extremities

Surgery
Sympathectomy
Bypass
Selected patients with severe ischemia
Growing new blood vessels
Amputation
3% greater with continued tobacco use

Question 22

Raynaud’s Phenomenon

Answer 22

Episodic vaso-spastic disorder of small, cutaneous arteries
Fingers, toes, ears, nose
Young women
15 – 40 years
Etiology unknown
Exaggerated sympathetic response
Occupational trauma
Heavy metal exposure

Primary
Most common form
Lower physical & mental-health QOL
Secondary
Rheumatoid arthritis (RA)
Systemic lupus erythematosis (SLE)

Question 23

Raynaud’s Phenomenon: Symptoms

Answer 23

Minutes to hours
Decreased perfusion -Pallor (White)
Coldness, numbness
Cyanosis (Blue)
Hyperemic response -Rubor (Red)
Throbbing, aching pain, tingling & swelling
Long Term Changes
Skin thickens
Brittle nails
Punctate lesions
Superficial gangrenous ulcers

Question 24

Interventions for Raynaud’s Phenomenon

Answer 24

Primary focus is patient teaching
Symptoms precipitated by:
Exposure to cold
Warm, loose clothing
Gloves to use refrigerator / freezer & handle cold objects
Avoid temperature extremes at all times
Immerse hands in warm water to decrease vasospasm
Emotional upset
Biofeedback
Relaxation training
Stress management

Tobacco cessation
Avoid caffeine
Avoid medications with vasoconstrictive effect
Amphetamines
Cocaine
Pseudoephedrine
Calcium channel blockers
Thoracic Sympathectomy

Monitor for connective tissue or auto-immune disorders
Rheumatoid arthritis (RA)
Systemic lupus erythematosus (SLE)
Scleroderma

Question 25

Assessment: Venous Ulcers

Answer 25

inflammation
swelling
aching
itchy, hardened skin
scabbing or flaking
brown or black stained skin
discharge

Question 26

Risk Factors for Venous Disease

Answer 26

Family history
Weaknesses of venous structure
Female gender
Use of oral contraceptives or hormone therapy
Tobacco use
Increasing age
Obesity
Pregnancy
History of venous thromboembolism
Occupations that require prolonged standing/sitting

Question 27

Treatment: Venous Ulcers

Answer 27

Compression
Assess for PAD
ABI > 0.9
Moist dressings
Nutrition
Antibiotics for infection after wound culture
Split thickness skin graft or bio-engineered skin (Dermagraft)

Question 28

Deep Vein Thrombosis: Risk Factors

Answer 28

Virchow’s Triad (1846)
Venous stasis / Vessel damage / Altered clotting mechanisms
Orthopedic trauma or surgery
Venous stasis caused by incorrectly applied casts or traction
Local pressure on a vein
Immobility
Lower extremity procedures
Hip & knee procedures
> 45 years old
Elderly patients w/ hip fractures
35% - 60 % incidence

Question 29

Deep Vein Thrombosis: Signs & Symptoms

Answer 29

Inflammation & Obstruction
Pain, tenderness at or below site
Aching, cramping, sharp, dull
Severe or mild
Constant or intermittent
Often increases with movement / weight bearing

Swelling at or below site
Mild to severe pitting edema
Redness

Question 30

Deep Vein Thrombosis

Answer 30

Identify high risk groups
Prophylaxis
SQ Low molecular weight heparin (Lovenox-enoxaparin)
Lovenox: administer SQ-Usually for 3 – 7 days. Up to 3 weeks for hip replacement
Low intensity oral anticoagulation
Adjusted dose heparin
Physical measures
Early ambulation, ankle exercises
Graded compression stocking
Intermittent external compression

Question 31

Deep Vein Thrombosis: Treatment

Answer 31

Heparin therapy
Initial bolus then continuous infusion
Therapeutic goal: PTT (partial thromboplastin time)1.5 - 2.5x control
Normal range (60 – 70 seconds)
Antidote for heparin: protamine sulfate
Lovenox (Enoxaparin)
Low molecular weight heparin (LMWH)
Has a longer half-life than heparin
Does not need extensive monitoring
Effects are more predictable than heparin
Coumadin (Warfarin)
Started 2 – 3 days into Heparin Therapy
INR target range 2.0 - 3.0
Continued for 3 - 6 months
PT (prothrombin time)
Antidote for Coumadin: Vitamin K

Question 32

Novel Oral Anticoagulants(NOAC’s)

Answer 32

rivaroxaban (Xarelto)
dabigatran (Pradaxa)
apixaban (Eliquis)
edoxaban (Savaysa)
fondaparinux (Arixtra)
**AndexXa is the only FDA approved antidote for Xarelto, Eliquis and Savaysa (approved 2018)
**Praxbind is the only FDS approved antidote for Pradaxa (approved 2015)

Question 33

Antiplatelets vs Anticoagulants

Answer 33

Antiplatelets interfere with the binding of platelets, or the process that actually starts the formation of blood clots.
Anticoagulants interfere with the proteins in your blood that are involved with the coagulation process. These proteins are called factors. Different anticoagulants interfere with different factors to prevent clotting.