Peripheral Arterial Disease Flashcards
Peripheral Arterial Disease
Build up of fatty substances in the wall of the artery
Peripheral arterial disease (PAD) may affect: Aortoiliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery
- Typically appears at ages 60s to 80s
- Largely undiagnosed- gradual onset
Risk factors: Cigarette smoking Hyperlipidemia Hypertension Diabetes mellitus Obesity Increased level of homocystiene- should start checking as you get older but not routinely ordered. Inflammatory injury (rare) Unusual anatomy
Clinical Manifestations:
- Classic symptom of PAD—intermittent claudication- walking, pain in leg, stop walking, pain goes away, start walking again, pain returns withing 20 minutes
- Ischemic muscle ache or pain that is precipitated by a constant level of exercise
- Resolves within 10 minutes or less with rest
- Reproducible
- Leg will be cool
- Need to be seen
- Paresthesia:
Shooting or burning pain in extremity
Present near ulcerated areas
Produces loss of pressure and deep pain sensations
Injuries often go unnoticed by patient
- Thin, shiny, and taut skin
- Loss of hair on the lower legs
- Diminished or absent pedal, popliteal, or femoral pulses
- Pallor
- Reactive hyperemia
- Pain at rest: Occurs in the forefoot or toes first and is aggravated by limb elevation, Occurs from insufficient blood flow, Occurs more often at night
- Can hang feet off of the bed but if you elevate your feet it makes them worse
- Need to avoid cold weather
- Men will have erectile dysfunction
- Lower leg edema- doesn’t have to be severe
- Need to pay attention to your feet but you can’t feel anymore with the numbness so you won’t know if you injure your feet. Need really good foot care! – lotions (never between the toes)
Complications of PAD
Atrophy of the skin and underlying muscles
Delayed healing
Wound infection
Ischemia of the skin
Tissue necrosis
Arterial ulcers- all the way down to the bone – often on the toes, in between the toes- will have pain even at rest, shooting pain!
Non-healing arterial ulcers and gangrene are most serious complications
May result in amputation if blood flow is not adequately restored or if severe infection occurs
Diagnostics of PAD
Doppler ultrasound: Segmental blood pressures Ankle–brachial index (ABI) - b/p on ankle and arm - Done before and after treadmill - Done using a handheld Doppler Duplex imaging - Bidirectional, color Doppler Angiography - Give a dye Magnetic resonance angiography (MRA) - Same as MRI except of the artery, with or without contrast ***Will have low b/p in the effected limb, will have weak pulses A1C
Collaborative Care for PAD
Goal: To live a normal life!
Risk Factor Modification
- Smoking cessation
- Aggressive treatment of hyperlipidemia, HTN, DM
- BP maintained <130/80
- Glycosylated hemoglobin <7.0% for diabetics
Drug Therapy
- Antiplatelet agents
- Aspirin
- Ticlopidine (Ticlid)
- Clopidogrel (Plavix)
Care of Leg with Critical Limb Ischemia
- Protect from trauma: No bare feet, Well fitted shoes, Keep skin dry and intact, Nails clipped by a pediatrist, Bunyons, Need to treat athlete’s foot immediately
- Reduce vasospasm
- Prevent/control infection
- Maximize arterial perfusion
Other strategies: Immune modulation therapy, Angiogenic gene therapy
Exercise:
- improves oxygenation in the legs and skeletal metabolism
- Walking is the most effective exercise for individuals with claudication because it squeezes the muscles
- Ideal: 30 to 60 minutes daily
- If need be: can go 10 minutes, stop, wait 10 minutes and go again. Doesn’t have to be consecutive
Nutrition (CAD diet)
- Dietary cholesterol <200 mg/day
- Decreased intake of saturated fat
- Soy products can be used in place of animal protein
Alternative Therapy
- Ginkgo biloba: Effective in increasing walking distance for patients with intermittent claudication
- Folate, vitamin B6, cobalamin (B12)
- Lowers homocysteine levels
- Check if lacking in vitamin B
Interventional Radiologic Procedures
Percutaneous transluminal balloon angioplasty
- Involves the insertion of a catheter through the femoral artery
- Catheter contains a cylindrical balloon
- Balloon is inflated, dilating the vessel by cracking the confining atherosclerotic intimal shell
Surgical Therapy
Most common surgical approach is a peripheral arterial bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion
- Synthetic grafts typically used for long bypasses
- Balloon angioplasty with stenting used in combination with bypass surgery
Post-op care:
- First 24 hours: need to do pulse checks. No sitting up in a chair, no crossed legs. Do a doppler q2h.
Other Surgeries:
- Endarterectomy
- Patch graft angioplasty
- Amputation – if leg is turning gang green
- Can open it up and suck out the plaque
Nursing Management for PAD
Acute Intervention
- Frequently monitor after surgery: Skin color and temperature, Capillary refill- is circulation happening in that leg?, Presence of peripheral pulses distal to the operative site, Sensation and movement of extremity
- Monitor for potential complications
- Knee-flexed positions should be avoided except for exercise
- Turn and position frequently
Nursing Diagnoses:
- 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
Ambulatory and Home Care:
- Daily inspection of the feet
- Meticulous foot care
- Comfortable shoes with rounded toes and soft insoles
- Nothing pressing on any portion of the foot
- Shoes lightly laced
- No smoking
- Identify activities that promote circulation – even if it is just rotating the ankles
- Maintain adequate peripheral tissue perfusion
- Experience intact skin, free of infection, on lower extremities
- 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
