Unit 2 - Peripheral Arterial Disease

Question 1

There are subtle differences between the terms, PAD and PVD.

Peripheral Arterial Disease (PAD)

Answer 1

afflicts the arteries alone

Question 2

There are subtle differences between the terms, PAD and PVD.

Peripheral Vascular Disease (PVD)

Answer 2

is a broader term which includes any blood vessel including, veins and lymphatic vessels

Question 3

Arteriosclerosis

Answer 3

refers to normal aging that leads to a gradual loss of elasticity and ‘hardening’ of the vessel walls throughout the body

Question 4

Atherosclerosis

Answer 4

refers to the build up of plaque on the inside of arterial blood vessels that may eventually grow to the point of seriously impeding blood flow and eventually block blood flow altogether

Question 5

Atherosclerosis risk factors

FM HHAS fat DIKS

Answer 5

family history
male gender

hypertension
hyperlipidemia
aging
smoking

obesity

diabetes
inactivity
kidney disease
stress

Question 6

Clinical Symptoms of PAD:

may be…

Answer 6

complete or partial blockage of blood flow to a limb

Question 7

Clinical Symptoms of PAD:

symptoms depend on…

Answer 7

where and how the blockage occurs

Question 8

Clinical Symptoms of PAD:

Is it acute or chronic?

Answer 8

may be acute or chronic

Question 9

Acute Arterial Occlusion:

usually…

most often caused by…

Answer 9

sudden

an embolus of blood clot or plaque coming from the proximal circulation and becoming lodged where the artery narrows or divides

Question 10

Acute Arterial Occlusion:

S/S occur where?

Answer 10

distal to the site of occlusion

Question 11

Acute Arterial Occlusion:

The 6 Ps distal to the site of occlusion

Answer 11

Pain
Rest pain that worsens on passive movement of the limb and is most severe in the distal aspects of the ischemic limb.

Pallor
Skin over the ischemic limb initially appears pale and then becomes mottled and purple-blue.

Pulselessness
Absent peripheral pulses distal to the site of occlusion.

Paralysis
Skin over the ischemic limb initially appears pale and then becomes mottled and purple-blue.

Paresthesia
Initial paresthesia (e.g., decreased fine touch sensation) progresses to anesthesia.
An abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause.

Poikilothermia
The ischemic limb is typically cold to touch but may be warm in hot environments (i.e., it takes on the ambient temperature).

Question 12

Acute Arterial Occlusion:

Is this a pressing matter?

Answer 12

this is an emergency situation

Question 13

Acute Arterial Occlusion:

this is an emergency situation!

DO (3)

DO NOT (1)

Answer 13

arrange for immediate transport to hospital
keep limb at or below heart level
protect heel from pressure

DO NOT elevate limb

Question 14

Acute Arterial Occlusion:

Treatment
What is required?
Why?

Answer 14

anticoagulant therapy and surgery

to restore circulation

Question 15

Chronic Arterial Insufficiency:

usually…

Answer 15

signs and symptoms appear gradually

Question 16

Chronic Arterial Insufficiency:

SIGNS

Inspection (3)

Palpation (3)

Answer 16

cool, thin shiny skin
thickened toenails
hair loss

diminished or absent pedal pulses
capillary refill time longer than 3 seconds
dependent rubor with pallor on elevation

Question 17

Chronic Arterial Insufficiency:

SX

1
2
3 a, b, c

Answer 17

numbness or tingling

intermittent claudication

rest pain
> often at night
> gets worse with elevation
> may be masked by neuropathy
OR
> may progress to continuous pain

Question 18

Chronic Arterial Insufficiency:

Wounds
What type?
Describe (5)

Answer 18

non-healing ulcers or gangrene

painful
often on bony prominences
“punched out” appearance

little or no drainage
no signs of healing within 2 weeks

Question 19

Chronic Arterial Insufficiency:

later signs and symptoms may be called?

Answer 19

critical limb ischemia (CLI)

Question 20

Chronic Arterial Insufficiency:

critical limb ischemia

Answer 20

Critical limb ischemia (CLI) is a severe blockage in the arteries of the lower extremities, which markedly reduces blood-flow. It is a serious form of peripheral arterial disease, or PAD, but less common than claudication. … Left untreated, the complications of CLI will result in amputation of the affected limb.

Ischemia can occur in any muscle group, organ, or tissue in the body. For example, in the lower extremities, ischemia can cause claudication in peripheral artery disease (PAD) or may cause critical limb ischemia (CLI) in severe cases.

Question 21

What is used to diagnose peripheral arterial insufficiency? (2)

Answer 21

Doppler ultrasound probe

and

Ankle Brachial Pressure Index (ABPI)

Question 22

Doppler ultrasound probe – how does this work?

Answer 22

Emits and then receives a sound wave that bounces off red blood cells.

This converts blood flow in a vessel into sound that can be heard and displayed in a wave form.

Question 23

Ankle Brachial Pressure Index (ABPI)

How is this measured?

Answer 23

The systolic blood pressure is measured in both arms (brachial pressure) and the highest pressure in either arm will be used to calculate the ABPI in each foot.

The systolic pressure for each ankle is measured at the post tibial and dorsalis pedis pulses and the highest of the two readings is used.

Question 24

Ankle Brachial Pressure Index (ABPI)

How is this calculated?

Answer 24

In the following formula:

Highest systolic ankle pressure
DIVIDED BY
Highest systolic brachial pressure

= Ankle Brachial Pressure Index

Question 25

Interpretation of ABPI normal

Answer 25

> 0.90 - 1.2

Question 26

Interpretation of ABPI claudication

Answer 26

0.50-0.90

Question 27

Interpretation of ABPI ischemia

Answer 27

< 0.50

Question 28

Measuring to calculate ABPI In what situation might ABPI be falsely elevated? When is this commonly seen?

Answer 28

If the ankle vessels cannot be compressed due to calcification of the leg arteries common in diabetics

Question 29

Measuring to calculate ABPI If ABPI is falsely elevated because the ankle vessels cannot be compressed d/t calcification of the leg arteries, what is measured instead?

Answer 29

toe pressures

Question 30

Measuring to calculate ABPI Systolic toe pressure potential for healing

Answer 30

> 45 mmHg

Question 31

Measuring to calculate ABPI Systolic toe pressure possible but slowed healing indicated

Answer 31

30 to 45 mmHg

Question 32

Measuring to calculate ABPI Systolic toe pressure unlikely to heal, palliative measures

Answer 32

< 30 mmHg

Question 33

Goals and Treatments for PAD: P2 M3

Answer 33

prevent complications of ulceration, infx or amputation pain mgmt PRN maintain mobility and quality of life medical treatment of chronic arterial insufficiency medical management of hypertension, diabetes, hyperlipidemia, kidney disease

Question 34

Goals and Treatments for PAD: WALS MM

Answer 34

walking exercise antiplatelet therapy lifestyle changes to manage weight and stress smoking cessation Medical management of hypertension, diabetes, hyperlipidemia, kidney disease

Question 35

Goals and Treatments for PAD: if worsening of condition?

Answer 35

family physician refers to vascular surgeon

Question 36

Goals and Treatments for PAD: if worsening of condition family physician refers to vascular surgeon who may? (2)

Answer 36

order an angiogram evaluate for possible revascularization

Question 37

Goals and Treatments for PAD: if worsening of condition family physician refers to vascular surgeon who may order an angiogram and/or evaluate for possible revascularization. How is the latter accomplished?

Answer 37

by–pass surgery angioplasty

Question 38

Goals and Treatments for PAD: Re. lesions secondary to? (3)

Answer 38

advice on potential to heal of any lesions wound care needs to be based on good assessment of potential to heal with an appropriate choice between dry or moist wound healing pain management as needed

Question 39

Goals and Treatments for PAD: Risk factor modifications (7) Lifestyle Labs (3) VS Rx

Answer 39

- Smoking cessation - LDL cholesterol < 100 mg/dL - LDL < 70mg/dL if high risk - HbA1c < 7.0% - BP < 140/90 mmHg - BP< 130/80 mmHg if diabetic or renal disease -Anti-platelet therapy

Question 40

If risk factors modified and limitations that affect quality of life still present, then what?

Answer 40

Suspected proximal lesion

Question 41

Limitations that affects quality of life are Ax'ed how?

Answer 41

``` - History of significant exercise limitation or - Reduced treadmill performance or - Reduced function by questionnaire ```

Question 42

If proximal lesion suspected, how is the lesion localized?

Answer 42

Localize the lesion: - Conventional angio - MRI or CTA - Ultrasound - Hemodynamic localization Computed tomography angiography (CTA) uses an injection of contrast material into your blood vessels and CT scanning to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages.

Question 43

Treatment for localized lesion

Answer 43

Revascularization > Endovascular > Surgical

Question 44

Approximate magnitude of the effect of risk factors on the development of critical limb schema in patients with peripheral arterial disease:

Answer 44

Increased lipids x2 Age > 65 x2 ABPI < 0.7 x2 ABPI < 0.5 x2.5 Smoker x3 Diabetes x4

Question 45

Natural Outcomes of Patients > 50 years of age with PAD

Answer 45

97 to 99% present with claudication or no symptoms 1 to 3% will present with critical limb ischemia of this 1 to 3%, after 1 year, 30% will have had an amputation and 25% will have died

Question 46

Natural Outcomes of Patients > 50 years of age with PAD | AFTER FIVE YEARS

Answer 46

70 to 80% have stable claudication 10 to 20% have worsening of claudication 10% have critical limb ischemia

Question 47

Effects of PAD on the Lower Limb: (3)

Answer 47

thin skin is more fragile and easily injured thickened nails exert more pressure on nail beds and sulci leading to greater potential for tissue damage minor injury can become major limb threatening disease!

Question 48

Effects of PAD on the Lower Limb: thin skin is more fragile and easily injured -- HOW? (2)

Answer 48

from minor trauma | poorly fitted shoes

Question 49

Effects of PAD on the Lower Limb: minor injury can become major limb threatening disease -- HOW? (cascade 4)

Answer 49

poor blood flow limits normal immune response infection can spread more easily infection can spread to bone antibiotics cannot easily reach infected tissue

Question 50

Effects of PAD on General Health and Mobility: | cascade 4

Answer 50

pain from claudication or injury will decrease walking decreased walking leads to muscle atrophy and stiffness decreased activity tolerance may seriously impair ability to manage ADL independently prolonged impaired mobility eventually negatively effects all body systems

Question 51

Effects of PAD on Common Foot Pathologies of Nails and Skin: | 3

Answer 51

fragile skin is more prone to injury over bony prominences increases the production of hyperkeratotic tissue in skin and nails thicker corns, calluses and nails put even more pressure on underlying tissue

Question 52

Nursing Foot Care for Clients with PAD: Assessment (5) A Q IOU

Answer 52

1st AX — is PAD in present (S/S) question client about and leg/foot pain; onset, duration, what makes it better or worse? identify any history of PAD or testing done (e.g., ABPI) other health care providers involved e.g. family doctor, vascular surgeon, wound specialist understanding of condition and any current treatments

Question 53

Nursing Foot Care for Clients with PAD: Planning (3)

Answer 53

plan realistic goals for treatment in consultation with client and based on their preferences for treatment plan interventions including education and referrals with client plan frequency of treatment based on rate of nail growth and client preference

Question 54

Nursing Foot Care for Clients with PAD: Intervention Nursing teaching (3)

Answer 54

strongly advise smoking cessation for all smokers advise clients of their increased risk for foot complications and how to prevent and manage minor injury teach client to monitor all accidental or minor breaches of skin very carefully and seek medical attention for any pain, redness, swelling or discharge.

Question 55

Nursing Foot Care for Clients with PAD: Intervention In terms of actual foot care (4)

Answer 55

question the client about any changes monitor and record pedal pulses at each visit identify any areas of pressure from footwear and work with client to prevent skin breakdown exercise particular caution to protect fragile skin during foot and nail care

Question 56

Nursing Foot Care for Clients with PAD: Evaluation (3)

Answer 56

evaluate effectiveness of interventions including teaching and referrals if maintenance is the goal, share achievement of same periodically with client and document document changes to care plan along with any new goals or interventions

Question 57

Information re. wound care repeats (word-for-word) @ end of this unit. Questions about same appear in Deck 1 Questions 93-100

Answer 57

Yah so!

Question 58

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD SRAFC Sarah Runs A Fight Club!

Answer 58

``` Supportive Referrals Advocating Follow-up Communication ```

Question 59

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD Supportive: (4)

Answer 59

demonstrate support for whatever treatment and caregivers are currently in place encourage clients to ask questions and be active participants in their own care encourage all clients to manage risk factors for PAD and refer for help if needed.

Question 60

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD Referrals: (3)

Answer 60

refer client back to doctor if claudication gets worse or progresses to rest/night pain refer client back to doctor if develops a non healing lesion that is present for more that 2 weeks refer clients back to the home care or wound care nurse for questions about therapy

Question 61

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD Advocating: (3)

Answer 61

advocate for clients to have access to a family physician can suggest calling Health Links or Manitoba Medical Association for a list of physicians taking new clients advocate for home care assessment through family physician if needed.

Question 62

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD Follow-up: (1)

Answer 62

document referrals and ask the client about outcomes at subsequent visits

Question 63

Role of the Foot Care Nurse as a Member of the Health Care Team Managing PAD Communication (2)

Answer 63

if concerns are urgent or more detail is required consider a phone call, letter or FAX to clarify communication keep a record of communications

Question 64

angiogram

Answer 64

an X-ray test that uses a special dye and camera (fluoroscopy) to take pictures of the blood flow in an artery (such as the aorta) or a vein (such as the vena cava). An angiogram can be used to look at the arteries or veins in the head, arms, legs, chest, back, or belly

Question 65

angioplasty

Answer 65

If you have coronary artery disease, the arteries in your heart are narrowed or blocked by a sticky material called plaque. Angioplasty is a procedure to restore blood flow through the artery. You have angioplasty in a hospital. The doctor threads a thin tube through a blood vessel in the arm or groin up to the involved site in the artery. The tube has a tiny balloon on the end. When the tube is in place, the doctor inflates the balloon to push the plaque outward against the wall of the artery. This widens the artery and restores blood flow.

Question 66

by-pass surgery

Answer 66

Peripheral artery bypass is surgery to reroute the blood supply around a blocked artery in one of your legs. Fatty deposits can build up inside the arteries and block them. A graft is used to replace or bypass the blocked part of the artery. The graft may be a plastic tube, or it may be a blood vessel (vein) taken from your body (most often the opposite leg) during the same surgery.

Question 67

intermittent claudication

Answer 67

Intermittent claudication is a symptom of peripheral arterial disease. Intermittent claudication is a tight, aching, or squeezing pain in the calf, foot, thigh, or buttock that occurs during exercise, such as walking up a steep hill or a flight of stairs. This pain usually occurs after the same amount of exercise and is relieved by rest.