Peripheral Arterial Disease of the Lower Extremities/Test 2 Flashcards
PAD (Peripheral Arterial Disease) is
- Insufficient blood supply to periphery
- Angina of the extremities
- Plaque/atheroma process of extremities
Description of PAD-it may affect
*Femoral artery
*Aortoiliac artery
*Tibial artery
*Popliteal artery
*Peroneal artery
(FATPP)
Risk factors for PAD
- increased cholesterol, lipids
- Smoking
- HTN
- ETOH abuse
- Obesity
- Sedentary lifestyle
- Diabetic
- increased use of vasoconstrictors
- Genetic predisposition
Clinical manifestations of PAD
- Classic symptoms of PAD
- intermittent claudication
Intermittent Claudication
- Pain when walking (ischemic muscle)
- Resolves within 10 minutes or less with rest
- Reproducible
Assessment for clinical manifestations of PAD
- The 5 P’s
- Pulseless, or diminished pulses <2
- Pain
- Pallor
- Polar
- Paresthesia
Clinical Manifestations of PAD
Associated signs
- thin, shiny, and taut skin
- loss of hair on the lower legs
- most important assessment is quality of pulses
PAD is a
progressive disease-rest pain as disease progresses
- occurs in the forefoot or toes and is aggravated by limb elevation
- occurs from insufficient blood flow
- occurs more often at night
Complications r/t decreased arterial blood with PAD
- atrophy of the skin and underlying muscles
- delayed healing
- wound infection
- tissue necrosis
- arterial ulcers
Diagnostic Studies
- Doppler ultrasound
- sound waves reflect off RBC’s as they move through the legs
- Ankle-brachial index (ABI)
- done using a handheld doppler
- sys ankle pressure/sys brachial pressure
- normal ankle pressure same or higher than brachial or 1 or >
- abnormal
- duplex imaging
- both audible and visual waveforms of blood flow
- Angiogram
- Magnetic Resonance Angiography (MRA)
For Diagnosis of PAD, include
- Health and physical examination
- include palpation of peripheral pulses (Most significant)
- the other 5 p’s
- risk factors
- related diseases
Nursing Diagnoses for PAD
- Ineffective tissue perfusion: periphery r/t narrowing of peripheral vessels Aeb:
- Pain: legs r/t ischemia with lactic acid release, hypoxia to the leg muscles aeb:
- Activity Intolerance r/t ischemia of the lower extremities aeb
- Impaired skin/tissue integrity r/t ischemia of the extremities aeb
Collaborative Care/Risk factor modification for PAD
- Smoking cessation
- Aggressive treatment of hyperlipidemia
- Hypertension and diabetes mellitus
- BP maintained <7.0% for diabetes
- Weight, habits controlled
Drug therapy for PAD
- Antiplatelet agents
- aspirin
- ticlopidine (Ticlid)
- clopidogrel (Plavix)
- dipyridamole (Persantine)
- cilostazol (Pletal)
Drugs prescribed for treatment of intermittent claudication
- pentoxifylline (Trental)
- takes 3-6 months to relieve pain
- Heparin, lovenox
- Coumadin
Exercise therapy
- exercise improves oxygen extraction in the legs and skeltal metabolism
- walking is the most effective exercise for individuals with claudication
- 30 to 40 minutes/day
Nutritional Therapy
- Dietary cholesterol less than 200 mg/day
- Decrease intake of saturated fat
- Soy products can be used in place of animal protein
Care of the leg with critical limb ischemia
- Protect from trauma
- keep warm
- think diabetic limb/foot care
- decrease vasospasm
- prevent/control infection
- maximize arterial perfusion
Disease progression
Indications
- intermittent claudication symptoms become incapcitating
- progresses to pain at rest
- ulceration or gangrene severe enough to threaten viability of the limb
Interventional Radiologic Procedures
- percutaneous transluminal balloon angioplasty
- balloon is inflated dilating the vessel by cracking the confining atherosclerotic intimal shell
Surgery for PAD
-Most common surgical approach
A peripheral arterial bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion
Collaborative care/surgical therapy
- Endarterectomy
- Patch graft angioplasty
- amputation
Types of bypass grafting surgery
- Femoral-popliteal
- fem-fem
- popliteal-tibial
- axillo-femoral
- amputation
Nursing post op interventions
- Assessment of graft pulses
- mark pulses
- -compare pulse quality
- Assess skin color temperature cap refill
- Report changes in the 5 P’s
Bypass grafting collaborative care
- IV fluid-low molecular weight dextrose
- plasmanate
- ntg possible
- heparin IV-check PTT
- rationale- keep patent
- serious danger of reocclusion
Post op care
- Pain mangement
- Positioning- never crimp or occlude a graft
- bed cradle
- oxygen
- nutrition
- telemetry
Evaluation after surgery
- Check the 5 p’s
- Improve perfusion
- Improve activity
- Less pain
Discharge teaching
- Control risks
- Begin progressive ambulation
- Avoid crossing extremeties
- Get rid of cigarettes
- Control BP
Sudden acute occlusion/embolism
- Sudden ischemic pain-maybe an embolism
- May occur with injury to already compromised vessel
- May occur after vascular procedure
- or from an injury to a limb
- or from plaque progression to total occlusion
Symptoms of excruciating pain
- MI of the leg
- Cold
- Mottled to dusky
- Pulseless
- Compare both sides
- Compare to prior assessment
Embolism in toe/Acute intervention
- Reperfuse
- thrombolytics-tPA
- Prevent extension of clot
- heparin
- PTCA
- Surgery-Embolectomy
- Possible bypass grafting
Collaborative Care/Embolism in toe
*Treat as post op graft patient
Untreated or untratable PAD List outcomes
- Raynaud’s Syndrome
- Arterial Ulcers
- Venous disorders
- DVT
- Thromophlebitis
Raynaud’s Syndrome
- small arteries/arterioles constrict
- more common in women
- more common in upper extremities
- associated with autoimmune disorders
Raynaud’s is aggravated by
*stress, cold, exacerbations of chronic diease
Treatment for Raynaud’s
- Control underlying conditions
- Stay warm, protect extremities
- Stop smoking, caffeine and associated risks
- Calcium channel blockers-reduce spasm
- Antiplatelet meds
Arterial Ulcers
- Cause: ischemia-decreased blood flow
- Location: between toes, tip of toes, heels, ankles
- Depth- deep, well defined edges
- Appearance-pale grey base, decreased blood necrotic
- Painful
Nursing diagnoses for Arterial Ulcers
- Ineffective tissue perfussion
- Pain
- infection
- PC: sepsis
Outcomes and interventions for arterial ulcers
- Maximize perfussion
- free from gangrene, sepsis, loss of limb
- pain reduced to 4
- healing of site without infection
Treatment/Wound care for arterial ulcer
- Dressing changes
- Gauze-to debride
- Saline, elase or chemical wound debridement
- Pain management
- Oxygen
- antibiotics
- eventually bypass grafting
Evaluation of arterial ulcer
- Free from necrosis
* Consider bypass graft and skin graft
Venous disorders
- Varicose veins
- Venous insufficiency
- risks of gentics, multiple pregnancies, standing or sitting professions
- valves weaken-backflow
- symptoms of swelling, tired, heavy legs
- relieved by elevation
- antiembolic hose comforting
- Thrombophlebitis-DVT
Thrombophlebitis/DVT
- inflammation of the wall of the vein, clot formation
- *Risks-surgery, injury, increased clotting factors from inflammatory diseases ie CA, inactivity, obesity, venous insufficiency
Nursing diagnoses/Outcomes for DVT
- Ineffective perfusion: impaired venous return
- Pain: inflammation
- PC: PE
Symptoms PAD vs. DVT
- Homan’s sign
- Pain in calf of affected side
- Redness
- Swelling
- Warmth
Diagnostics for DVT
- Venous duplex scanning
- Doppler ultrasound
- D-Dimer
- VQ scan
Collaborative Care for DVT:
- Bedrest
- Moist heat
- Anticoagulation
- conservative lovenox SQ at home
- advantage-slow continuous release
- Acute care
- Heparin therapy PTT 1 1/2- 2 1/2 xs control
- Possible coumadin- INR- 2.0-3.0
Prevention of DVT
- Ambulation best
- Exercise
- Dorsi/plantar flexion
- Rotation of ankles
Prevention of DVT’s
- promote venous return
- position
- antiembolic stockings/SCDs
- reduce risks
- early recongmition of s/s
Evaluation for DVT
- Decrease pain, redness, swelling
- Negative scans
- Knowledgeable about prevention
Venous ulcers:
- Cause venous congestion
- Sites-ankles, medial common
- Depth-more superficial
- Appearance- uneven edges, pink or dark red base d/t venous congestion
- discomfort but NOT pain of arterial
- Compare to arterial
Collaborative care for Venous Ulcers
- Antibiotics
- Wet-dry dressing changes
- Gauze
- Vicodin
- elevate limb
- no debridement usually needed, no grafting, should heal
Evaluation of Venous ulcer
- healing of ulcer
- understanding of prevention
- control risks
