Vascular Disorder

Question 1

PAD (Peripheral Arterial Disorder)

Answer 1

What is it?
Reduced arterial blood flow to the extremities

Why?
Atherosclerosis

Where?
Arterial system extending from aorta to tibial artery

Question 2

PAD Symptoms

Answer 2

Symptoms:
Intermittent Claudication:
- begins during exercise
and ends with rest
- Not constant, resolve
within 10 min

• Paresthesia (Numbness or
  tingling)
• Dependent rubour
• Skin change
  - Skin cool to touch,
  pallor, increase cap
  refill, loss of hair, taut
  and thin skin
• Decreased circulation
  - Weak pulse

Question 3

PAD complication

Answer 3

• Continuous pain at rest
• Gangrene
• Limb threatening disease

Question 4

PAD Diagnostic Test

Answer 4

• Anke Brachial Pressure Index
  (ABPI)
  - Ankle SBP/Brachial SBP
  - Normal if 1 - 1.4
• Doppler Ultrasound
• Magnetic Resonance
  angiography

Question 5

Interventions Surgery

Answer 5

Surgery:

• Femoral popliteal bypass
• Percutaneous transluminal angioplasty (PTA) of the femoral
  arteries
• Endarterectomy
• Amputation as last resort

Question 6

Interventions Drug Therapy

Answer 6

Drug Therapy:

• Antiplatelet (e.g. aspirin)
• Statins
• ACE inhibitors
• Meds to treat intermittent claudication
  - Pentoxifylline/Trental
• NSAID

Question 7

Other Interventions

Answer 7

Nutritional Therapy

Exercise therapy

Risk Factor Modification

• Control BP, weight control, smoking cessation, blood glucose control

Question 8

Intervention Surgery

Answer 8

• Femoral popliteal bypass
• Percutaneous transluminal
  angioplasty (PTA) of the
  femoral arteries
• Endarterectomy
• Amputation as last resort

Question 9

Acute Arterial Ischemic Disorder

Answer 9

• Occur suddenly, without
  warning
• Caused by embolism,
  thrombus, or trauma

Clinical manifestations (“6 Ps”):
- Pain, pallor, pulselessness,
paresthesia, paralysis, and
perishingly cold

• Early treatment essential to
  keep limb viable
• Anticoagulant therapy, tPA,
  surgery, amputation

Question 10

Clinical Manifestation of Actue Arterial Ischemic Disorder: 6 Ps

Answer 10

Clinical manifestations (“6 Ps”):
- Pain,

• pallor,

-pulselessness,

 -paresthesia,

• paralysis, and
  • perishingly cold

Question 11

Case Study: Leo Ducharme – a 76 year old man who was admitted to the hospital with rest pain in both legs and a non-healing ulcer on the big toe of his right foot.
PMHX: MI, stroke, hypertension, arthritis and type 1 Diabetes
Underwent left fem-pop bypass 5 years ago
45 year hx of tobacco use
Been using insulin for 30 years
Complains of sudden, intense increase in right foot pain for past 2 hours

Current Meds

Furosemide – 40mg/day PO
Enalapril 5mg/day PO
Insulin R with meals
Lantus insulin 50 units/day subQ
Diltiazem 240mg/day PO
ASA 325 mg/Day PO
Fish oil (self prescribed)

Objective Data

BP 148/92, irregular HR, 90 beats/min, RR – 22/min, temp 36.6 oral
Alert and oriented but anxious, no mental of physical deficits from previous stroke
Decreased right fem pulse, popliteal pulse detected with Doppler only, posterior tibial pulse with Doppler only, absent dorsalis pedis pulse
Left leg pulses weakly palpable
2cm necrotic ulcer on tip of right big toe
Thickened toenails, shiny taught skin on both legs, hair absent on both lower legs
Right foot pale, very cool, mottled in colour and decreased sensation
No peripheral edema
BS glucose 16mmol/L

What are Mr. Ducharme’s risk factors for PAD?

Does Mr. Ducharme have chronic PAD or acute arterial ischemia? What’s the difference?

What could be the cause of the sudden, intense increasing pain in his right foot?

Answer 11

What are Mr. Ducharme’s risk factors for PAD?

Does Mr. Ducharme have chronic PAD or acute arterial ischemia? What’s the difference?

What could be the cause of the sudden, intense increasing pain in his right foot?

Question 12

What are Mr. Ducharme’s risk factors for PAD?

Answer 12

Hypertension, Smoking, Diabetes, Age

Question 13

Does Mr. Ducharme have chronic PAD or acute arterial ischemia? What’s the difference?

Answer 13

Acute arterial ischemia

Question 14

What could be the cause of the sudden, intense increasing pain in his right foot?

Answer 14

Caused by an emoblism because of his history of heart conditions

Question 15

Nursing Diagnosis for PAD what are some interventions.

Answer 15

1. Ineffective Tissue Perfusion.
2. Impaired Skin integrity.
3. Acute Pain
4. Activity Intolerance
5. Ineffective Therapeutic Regimen Mgmt.

Question 16

1. Ineffective Tissue Perfusion.

Answer 16

Antiplatelets
walking

Question 17

2. Impaired Skin Integrity

Answer 17

Protect feet, Should not wear tight shoes, keep warm, pt have loss of feeling on feet

Question 18

3. Acute Pain

Answer 18

NSAIDS, anything that increase circulation can help, elevating head of bed

Question 19

4. Activity Intolerance

Answer 19

Encourage gradual increase in activity levels as tolerated.

Plan rest periods to prevent fatigue.

Educate the patient on energy conservation techniques.

Question 20

5. Ineffective Therapeutic Regimen Management

Answer 20

Educate the patient and family about the importance of medication adherence.

Provide information on lifestyle changes, such as smoking cessation and healthy diet.

Ensure the patient understands their treatment plan and follow-up care.

Question 21

Peripheral Venous Disorder: Venous Thrombus

Answer 21

Venous Thrombus:

• Formation of blood clot

Why blood clot forms?
- Virchow’s triad
- Stasis
- Hypercoagulability
- Endothelial damage

As thrombus can be enlarged-> detached -> embolus

Question 22

Peripheral Venous Disorder: Superficial vein thrombosis

Where and Manifestation

Answer 22

• Where?:
  Upper extremities (ie. IV therapy)
  Lower extremities (ie. trauma to varicose vein)
• Manifestation:
  palpable, firm, subcutaneous cordlike vein with the surrounding area tender, reddened and warm

Question 23

Peripheral Venous Disorder: Superficial vein thrombosis

Intervention

Answer 23

• Remove IV
• Elevation of the affected limb
• Warm & moist heat ( warm compress)
• Compression stocking
• Analgesics
• NSAIDs

Question 24

Peripheral Venous Disorder—Deep Vein Thrombosis (DVT)

Answer 24

AKA Venous Thrombo-Embolism (VTE)
Where?

Blood clot form in deep vein

DVT (Deep Vein Thrombosis) is a condition where a blood clot forms in a deep vein, usually in the legs, causing swelling, pain, and warmth. If the clot travels to the lungs, it can cause a potentially life-threatening pulmonary embolism. Prompt treatment is essential.

Question 25

Deep Vein Thrombosis (DVT) Clinical Manifestation

Answer 25

May have no symptoms Unilateral leg edema Extremity pain sense of fullness in thigh or calf warm skin, erythema or cyanotic temp > 38°C Positive Homans sign (classic but very unreliable sign)

Question 26

Peripheral Venous Disorder—Deep Vein Thrombosis (DVT) : Complications

Answer 26

Pulmonary embolism Post thrombotic Syndrome Phlegmasia cerulea dolens Venous leg ulcer

Question 27

Peripheral Venous DisorderDeep Vein Thrombosis (DVT) : Diagnostic Test

Answer 27

PTT, INR, Platelet count D-dimer Venus compression ultrasound Magnetic resonance venography

Question 28

Peripheral Venous DisorderDeep Vein Thrombosis (DVT) : Nursing Diagnosis

Answer 28

Acute pain related to impaired venous return and inflammation Ineffective health maintenance Risk for impaired skin integrity Potential complication: Bleeding Potential complication: Pulmonary embolism

Question 29

Peripheral Venous DisorderDeep Vein Thrombosis (DVT) : Intervention

Answer 29

Early and aggressive mobilization –up 4-6 times/day Bedrest patients – change positions, dorsiflex feet, rotate ankles q2-4h Compression stockings – properly fitted Sequential compression devices

Question 30

Peripheral Venous DisorderDeep Vein Thrombosis (DVT) : Pharmacological treatment

Answer 30

Warfarin 48-72 hours to work INR

Question 31

Thrombin Inhibitor (indirect) Intervention for DVT

Answer 31

Heparin: Monitor PTT, Can have HIT ( heparin induced thrombocythemia) LMWH (Daltaperin/Enoxaparin): less side effect, less likely have HIT

Question 32

Thrombin Inhibitor (direct) Intervention for DVT

Answer 32

Hirudin, Argatroban Directly inhibit thrombin enzyme

Question 33

When monitoring the effects of ________________, an INR is routinely checked.

Answer 33

When monitoring the effects of Warfarin, an INR is routinely checked.

Question 34

The therapeutic effects of Heparin are measured in routine intervals with this lab test.

Answer 34

The therapeutic effects of Heparin are measured in routine intervals with this lab test. aPTT (activated partial thromboplastin time). Answer: aPTT

Question 35

These medications must be injected deep into subQ tissue so the ABD site is recommended.

Answer 35

Heparin and Dalteparin.

Question 36

T/F Dalteparin is derived from heparin.

Answer 36

True

Question 37

Vitamin K is the antidote for this medication

Answer 37

Warfarin

Question 38

Long term use of this medication can cause osteoporosis.

Answer 38

Heparin

Question 39

This medication is often given instead of heparin, as it has more bioavailability, more predictable effects, and less complications.

Answer 39

Dalteparin

Question 40

Differentiate Peripheral Artery Disease (PAD):

Answer 40

Intermittent claudication: Pain in the legs during exercise due to insufficient blood flow. 6 P’s (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia): Key indicators of severe blood flow obstruction. Dependent rubor: Patients often keep their legs down to relieve pain, causing a reddish color. Marker of advanced atherosclerosis: Indicates severe narrowing of arteries by plaque buildup.

Question 41

Differentiate Peripheral Vascular Disease (PVD):

Answer 41

Use of compression stockings: Recommended to improve blood flow and reduce swelling. Hemosiderin release: Brown, leathery skin in the extremities due to iron deposits. At risk for PE (Pulmonary Embolism): Blood clots from PVD can travel to the lungs. Virchow’s triad (stasis, hypercoagulability, endothelial injury): Contributing factors for clot formation. Swelling: Common symptom due to blood pooling and poor circulation.

Question 42

What is the difference between PVD and PAD

Answer 42

PAD primarily affects the arteries and results in poor blood flow to the extremities, causing pain and severe symptoms like the 6 P’s. PVD encompasses issues in both arteries and veins but is more commonly associated with venous problems like swelling, brown skin discoloration, and the risk of blood clots leading to pulmonary embolism.

Question 43

A 55-year-old male client is being admitted to the nursing unit after left femoral popliteal bypass graft. The nurse is completing the initial assessment. What assessment data should alert the nurse to a possible complication? Client is lethargic with respiratory rate of 14 breaths per minute. Client complains of pain along the incision line of 10 on a scale of 10. The dressing has a small area of dark red-brown drainage. The dorsalis pedis and posterior tibia pulses are weak.

Answer 43

The dorsalis pedis and posterior tibia pulses are weak.

Question 44

A client has come to the clinic for complaint of leg pain upon ambulation. During the interview, the client states that the pain occurs after the start of ambulation and progressively gets worse. The pain is relieved by sitting. The client also states that the pain is bilateral. After listening to the client describe the pain and the conditions under which the client experiences the pain, the nurse suspects what condition? Arterial leg ulcers Restless legs syndrome (RLS) Deep vein thrombosis Intermittent claudication

Answer 44

Intermittent claudication Intermittent claudication is a classic symptom of peripheral arterial disease (PAD). It is characterized by pain in the legs that occurs with exertion (such as walking) and is relieved by rest. The pain results from inadequate blood flow to the muscles due to arterial narrowing or blockages. This condition is typically bilateral, progressive with activity, and relieved by stopping or sitting.

Question 45

A female client is being discharged to home with a large venous stasis ulcer on her right ankle. The nurse is providing the client with discharge instructions. Which intervention should the nurse incorporate into the education? Place legs in a dependent position at least four times a day for 10 to 15 minutes. Wear long heavy cotton or wool socks to protect the legs when outdoors. Rest in bed with your right foot flat on the bed for several hours a day. Take walks several times a day, incorporating rest periods with your legs elevated.

Answer 45

Take walks several times a day, incorporating rest periods with your legs elevated.