Peripheral Arterial Disease Flashcards
What happens to arteries in Peripheral Arterial Disease?
Artery walls thicken, artery becomes more narrow and degenerate. Involves arteries in neck, abdomen and extremities.
- in most cases, atherosclerosis is leading cause.
PAD increases with ____? And is more prevalent in which gender?
Increases with age. Typically appears in 60-80 yrs of age.
- more common in women
Risk factors of PAD
- Cig smoking (most important)
- Hyperlipidemia
- Hypertension
- Diabetes
- elevated C-Reactive protein
What is the classic symptom of PAD?
Intermittent claudication= ischemic muscle pain caused by exercise
- pain resolves in 10 min or less with rest & this pain is reproducible.
- the pain is result of lactic acid building up from anaerobic metabolism (since they dont get enough O2). Once the person stops exercising and the lactic acid clears, the pain goes away.
- PAD in iliac arteries–> pain in butt & thighs
- PAD in femoral or popliteal –> pain in calf
PAD affects which arteries in the lower extremities?
- iliac
- femoral
- popliteal
- peroneal
- femoral popliteal area is most common in non-diabetic patients. Patients who are diabetic tend to develop PAD in arteries below the knee.
Describe the clinical manifestation Paresthesia in PAD?
- Paresthesia (numbness/tingling in the toes or feet)
- usually present near ulcerated areas
- produces loss of pressure sensations and deep pain sensations
injuries can go unnoticed by patient (must teach patient to be cognizant of temperatures in their environment and also foot care).
Describe changes in the appearance of affected extremities in PAD
- Thin, shiny, taut skin
- loss of hair on lower legs
- diminished or absent pedal, popliteal, or femoral pulse
- pallor of foot with leg elevation
- reactive hyperemia (redness/dependent rubor) of foot with dependent position
As PAD progresses, pain develops at rest and occurs…
- occurs in the foot or toes most often.
- pain is aggravated by limb elevation
- pain is result of insufficient blood flow
- ## pain occurs more often at night with cardiac output is less during sleep and limbs are at the same level as the heart when lying down. (patients may dangle feet or prefer sleeping in a chair to ease pain/maximize blood flow)
What are some complications of PAD and of these, which are the most serious?
- Prolonged ischemia leads to atrophy of the skin and underlying muscles
- delayed healing
- wound infections
- tissue necrosis
- arterial ulcers (over bony prominences on toes feet and lower legs)
- *Most serious complications are nonhealing arterial ulcers and gangrene–> may result in amputation if blood flow is not restored or if a severe infection occurs.
Describe the doppler ultrasound used to diagnose PAD
- Doppler ultrasound maps blood flow through the entire region of an artery. If peripheral pulse is non-palpable then a doppler ultrasound can determine the degree of blood flow.
- a palpable pulse and a doppler pulse are not equivalent or interchangeable so segmental BP is obtained using a doppler and sphygmomanometer.
How is segmental blood pressure used to determine PAD?
- using a doppler and BP cuff, BP is taken at the thigh, below the knee, and at the ankle, when patient is supine.
- a drop in segmental BP of more than 30 mmHg suggests PAD.
Describe the ante-brachial index (ABI)
- done using hand-held doppler
- calculated by dividing the ankle systolic BP by the higher of the left and right brachial systolic BP.
- in elderly patients, and diabetic patients, the arteries are often calcified and non compressible resulting in falsely high elevated ABI.
- ABI not recommended after revasculation surgery or on a distal bypass graft because of risk of graft thrombosis.
List values for normal ABI, mild claudication ABI, moderate ABI, severe ABI, and ischemia ABI
Normal: 1.0-1.2 Mild: 0.90-0.70 Moderate: 0.70-0.40 Severe: 0.4-0.3 Ischemia: less than 0.3
what is the first Tx goal in PAD?
The first Tx goal in PAD is to reduce CVD risk factors in all patients regardless of the severity of symptoms
- Done through:
- tobacco cessation
- agressive tx of hyperlipidemia
- BP maintained less than 140/90
- glycosolated hemoglobin (A1C) less than 0.7% for diabetics
How do ACE inhibitors work in PAD?
- ACE inhibitors used to prevent periphery from vasoconstriction because they dialate vessels–> Ramipril (Altace)
- decrease CV morbidity
- decrease mortality
- increase peripheral blood flow
- increase ABI
- increase walking distance
How are anti-platelet drugs used in PAD drug therapy?
- Keep blood from clotting
- critical for reducing risks of CVD events and death in PAD patients.
- Aspirin
- Clopidogrel (Plavix) (for aspirin intolerant patients)
- FYI- never give Plavix with Omeprazole (Prilosec) because it reduces the anti-platelet effect of clopidogrel and increases MI and stroke risk
What are the overall nursing goals for PAD patients
- Good/adequate tissue perfusion
- relief of pain
- increase exercise tolerance
- intact healthy skin on all extremities
What are drugs Rx for Tx of intermittent claudication?
- Cilostazol (Pletal)- inhibits platelet aggregation and increases vasodilation (FYI- Pletal is contraindicated with patients who have had heart failure)
- Pentoxifylline (trental)- Increases erythrocyte flexibility so they move more easy, and decreases blood viscosity
Name some complementary-alternative therapies for PAD?
- Ginkgo biloba- effective in increasing walking distance for patients with intermittent claudication
- folate, vitamin B6, cobalamin (B12) - lower homocysteine levels. (homocysteine is an amino acid that is found in red meat and cont. to increase CVD risk.
What is the most effective exercise for claudication?
Walking. Recommend 30-60 min per day at least 3 times per week.
Describe nutritional therapy for PAD?
- BMI less than 25 kg/m2
- waist circumference less than 40 inches for men and less than 35 for women
- diet high in fruits, veg, whole grains, low cholesterol, low sat fat, low salt
- dietary cholesterol less than 200 mg/day
- decrease intake of sat fat
- use soy products in place of animal protein
What is critical limb ischemia?
condition characterized by chronic ischemia rest pain lasting more than 2 weeks, arterial leg ulcers, or gangrene of the leg as a result of PAD.
- optimal therapy is revascularization via bypass surgery.
How does the nurse care for patients with critical limb ischemia?
- protect limb from any trauma
- decrease ischemic pain
- prevent infections/ control infections
- carefully inspect, cleanse and lube feet to prevent cracking of skin and infection. Dont soak.
- improve arterial profusion (drugs)
- other therapies are spinal cord stim. to manage pain and Angiogenesis cell therapy to stim new vessel growth
Before doing a bypass graft surgery for limb ischemia, what are the indications for implementation of radiology procedures?
- Intermittent claudication symptoms become incapacitating
- pain at rest
- ulceration or gangrene severe enough to threaten viability of the limb
Describe Percutaneous Tansluminal balloon angioplasty (PTA)
- PTA is a radiology procedure
- involves insertion of catheter through femoral artery
- catheter contains cylindrical balloon
- balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining
- stent is placed to keep vessel open
Describe Atherectomy
- radiology procedure
- removal of obstructing plaque preformed by cutting disc, laser, or rotating diamond tip
Describe a Cryoplasty
- radiology procedure
- combines percutaneous transluminal angioplasty cold therapy or liquid nitrous oxide
Describe a bypass graft
- peripheral artery bypass surgery with autogenous vein or synthetic graft to bypass blood around lesion
- sometimes a PTA is used in combo with bypass surgery
Nursing first priority in patients with bypass grafts
- control BP (because a high BP could blow the graft)
- check pulses distal to incision site (may need to use doppler)
- monitor incision sites for bleeding
Important data needed in assessment of PAD patient
Subjective Data: - diabetes - smoking hx - hypertension - hyperlipidemia - obesity - exercise intolerance - buttock, thigh, or calf pain that begins w/ exercise and subsides w/ rest (Int. Claud.) or progresses to pain at rest. Objective Data: - loss of hair on legs and feet - pallor w/ elevation - dependent rubor - gangrene - decreased or absent peripheral pulses - cap refill more than 3 sec.
Common nursing diagnoses for patients with PAD
- ineffective peripheral tissue perfusion related to deficient knowledge of contributing factors
- activity intolerance related to imbalance between oxygen supply and demand
- ineffective self-health mngmt related to lack of knowledge of disease and self care measures
In the implementation stage of nursing process, what should nurses frequently monitor after surgery in PAD patients?
- after surgical or radiological interventions, check opertaive extremity every 15 min initially and then hourly for:
- skin color and temp.
- capillary refil
- presence of peripheral pulses distal to operative site
- sensation and movement of extremities
- continued circulatory assessment (BP)
- monitor for potential complications
- knee-flexed positions should be avoided except for exercise
- turn patients frequently, turn-cough-deep breathe every 2 hrs (or incentive sipirometer use)
What might be signs of a blocked graft or stent
- dramatic increase in pain
- loss of previously palpable pulses
- extremity pallor or cyanosis
- decreasing ABIs
- numbness or tingling
- cold extremity
- report to physician immediately
Ambulatory an home care for PAD patients
- asses for CVD risk factor and work on management of risk factors
- emphasize importance of foot care
- emphasize importance of gradual physical activity after surgery
- daily inspection of feet
- comfy shoes with round toes and soft insoles
- lightly laced shoes
What are the expected outcomes for patients with PAD?
- maintain adequate tissue perfusion
- increased activity tolerance
- knowledge of disease and tx plan
- plans for walking program
What is Thromboangitits Obliterans (Buergers Disease)?
- nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium sized arteries and veins of the upper and lower extremities.
- usually occurs in men less than 40 yrs, sometimes in women
- related to tobacco and/or marijuana use and chronic periodontal infection, but without other CVD risks (HTN, hyperlipidemia, etc. )
- intermittent claud of feet, hands or arms
- progression leads to rest pain, ischemic ulcerations
- color, temp changes, paresthesias, thrombophlembitis and cold sensitivity
How is Buergers Disease Diagnosed and Tx?
- Diagnosis made based on age of onset, Hx, Sx
- Tx- tobacco cessation
- avoid trauma to extremities
- some meds used with varying degress of success (Calcium channel blockers, antiplatelets, andrenergic blockers, anticoagulants)
Describe Raynauds Phenomenon
- episodic, vasospastic disorder involving fingers and toes- due to abnormalities in vascular, intravascular, and neuronal mechanisms between vasodilation and vasoconstriction.
- usually in women ages 15-40 yrs
- induces color changes (pallor to bluish purple, then to red), coldness, numbness, pain
- Sx associated with exposure to cold, emotional upsets, caffeine and tabacco use
How is Raynauds managed?
- avoid extreme temps
- avoid tabacco and caff
- avoid all drugs with vasoconstriction effect
- first line of drug tx is calcium channel blocker to relax smooth muscles.
- primary focus is on teaching patient to wear gloves, etc.
