peripheral vascular lecture one chronic (exam 2)

Peripheral Vascular Disease

Disorders that alter the natural blood flow through arteries and veins. It affects the upper and lower extremities, with the lower extremities affected more often.

Types of Peripheral Vascular Disease

Peripheral Arterial Disease (PAD), Lower Extremity Arterial Disease (LEAD), and Peripheral Venous Disease.

Vasodilation

Opening of a blood vessel.

Blood Flow

Movement of blood around the body, closely controlled by alterations in resistance and pressure.

Vasoconstriction

Closing or tightening of a blood vessel.

Resistance

The resistance that must be overcome by pressure to maintain blood flow throughout the body.

Pressure

The force that overcomes resistance to maintain blood flow throughout the body.

Arterial Embolism

An acute arterial occlusive disorder caused when a thrombus detaches, travels through the systemic arterial system, and obstructs an artery.

Causes of Arterial Embolism

Thrombi can develop in the chambers of the heart due to atrial fibrillation, MI, infective endocarditis, atherosclerotic aneurysm, CHF, valvular problems, cardiomyopathy, and trauma.

Arterial Embolism Pathway

A thrombus detaches and is pumped out of the LEFT ventricle into the systemic arterial system, where it obstructs an artery. It does NOT come from the right side of the heart.

Possible Locations of an Arterial Embolus

An embolus may travel to cerebral, renal, coronary, or extremity arteries, especially arteries of the lower extremities.

Extremity Arterial Occlusion Signs

Severe pain, loss of sensory and motor function, loss of pulses, and a pale and numb extremity.

6 Ps of Acute Arterial Occlusion

Pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

Poikilothermia

Coolness of an extremity; one of the 6 Ps of acute arterial occlusion.

Why Is Arterial Embolism an Emergency?

Lack of blood flow can progress from ischemia to necrosis to gangrene and eventually loss of the limb.

Thrombolytics for Arterial Embolism

Streptokinase and t-PA (tissue-type plasminogen activator). These medications may be injected directly into the clot. (dissolves the clot)

Heparin in Arterial Embolism

Used to keep additional clots from forming.

Abciximab (ReoPro)

An IV GP IIa/IIIb inhibitor listed as a treatment for arterial embolism.

Embolectomy

Surgery performed to remove an arterial clot.

Nursing Care for Arterial Embolism

Administer anticoagulants, encourage leg movement after the clot is dissolved to prevent stasis and increase circulation, provide wound care, and perform pulse checks.

Peripheral Arterial Disease (PAD)

Also called atherosclerosis obliterans. Plaque forms in arteries, causing thickening of the intima and progressive narrowing of the artery.

Atherosclerosis Obliterans

Another name for Peripheral Arterial Disease (PAD).

PAD Pathophysiology

Cholesterol-containing plaque causes progressive narrowing of the artery. The exact mechanism is not understood, but inflammation and injury play a role.

Typical PAD Patient

PAD usually affects men over 50 years of age.

Common Location of PAD Lesions

Usually in the lower extremities, from below the renal arteries to the popliteal arteries.

PAD Disease Progression

PAD is a slow, progressive disease similar to coronary artery disease.

When Do PAD Symptoms Usually Occur?

Symptoms occur when approximately 60% of the vessel is occluded.

Lower Extremity Arteries Affected by PAD

Iliac, femoral, popliteal, tibial, and peroneal arteries. Any combination can be affected.

Modifiable Risk Factors for PAD

Smoking, diabetes, hypercholesterolemia, sedentary lifestyle, diet, obesity, and stress.

Nonmodifiable Risk Factors for PAD

Age, sex, and family history.

Classic Symptom of PAD

Intermittent claudication.

Intermittent Claudication

Ischemic muscle pain caused by a constant level of exercise that resolves with rest.

Cause of Intermittent Claudication

Build-up of lactic acid from anaerobic metabolism caused by inadequate blood flow during exercise.

Intermittent Claudication and Rest

Pain usually resolves within 10 minutes or less with rest.

Is Intermittent Claudication Reproducible?

Yes. It occurs at a reproducible level of exercise.

Paresthesia in PAD

Numbness or tingling in the toes or feet caused by ischemia of nerve tissue.

Neuropathy in PAD

Can cause severe shooting or burning pain.

Loss of Sensation in PAD

Reduced blood flow can cause loss of pressure and deep pain sensations, allowing injuries to go unnoticed.

Skin Changes in PAD

Thin, shiny, taut skin and loss of hair on the lower legs.

Pulses in PAD

Pedal, popliteal, or femoral pulses may be diminished or absent.

Elevation Pallor

Pallor of the foot that occurs when the leg is elevated; associated with PAD.

Dependent Rubor

Reactive hyperemia/redness of the foot when it is placed in a dependent position.

PAD Rest Pain

Occurs with progressive disease, most often in the feet or toes, due to insufficient blood flow to distal tissues.

What Makes PAD Rest Pain Worse?

Elevation of the affected limb.

When Is PAD Rest Pain Common?

It occurs more often at night.

What Relieves PAD Rest Pain?

Gravity or placing the extremity in a dependent position.

Critical Limb Ischemia (CLI)

Severe arterial insufficiency characterized by chronic ischemic rest pain lasting more than 2 weeks, nonhealing arterial leg ulcers, or gangrene.

Risk Factors for Critical Limb Ischemia

Diabetes, heart failure, and history of stroke.

Complications of PAD

Atrophy of skin and underlying muscles, delayed healing, wound infection, tissue necrosis, and arterial ulcers.

Most Serious Complications of PAD

Nonhealing arterial ulcers and gangrene.

When Can PAD Lead to Amputation?

If adequate blood flow cannot be restored or severe infection occurs.

Ankle-Brachial Index (ABI)

A diagnostic test for PAD calculated by dividing the ankle systolic blood pressure by the highest brachial systolic blood pressure.

ABI Formula

Ankle systolic blood pressure ÷ highest brachial systolic blood pressure.

Normal ABI

1.0.

ABI for Minimal Disease

0.8 to 0.9.

ABI for Moderate Disease

0.4 to 0.8.

ABI for Severe Disease

0 to 0.4.

Goals of PAD Management

Slow progression of disease, protect the extremity, decrease vasospasm, and improve collateral circulation.

Walking for PAD

Gradually increase walking time and distance to improve collateral circulation.

What Should a PAD Patient Do When Pain Occurs While Walking?

Stop, rest, and then continue walking. Over time, the patient should be able to tolerate longer distances.

Cold Exposure and PAD

Avoid exposure to cold because warmth promotes vasodilation.

PAD Foot Care

Foot care is extremely important and should be performed similarly to diabetic foot care.

Leg Crossing and PAD

Do not cross the legs.

Tobacco and PAD

Tobacco cessation is an important part of risk-factor modification.

Hemoglobin A1C Goal for Diabetic Patients With PAD

Less than 7%.

Blood Pressure Goal Listed for PAD

Less than 140/90.

Hyperlipidemia and PAD

Aggressive treatment of hyperlipidemia is recommended.

Ramipril (Altace)

An ACE inhibitor used in PAD that decreases cardiovascular morbidity and mortality and increases peripheral blood flow, ABI, and walking distance.

Cilostazol (Pletal)

Inhibits platelet aggregation (sticking together) and increases vasodilation.

Pentoxifylline (Trental)

Increases erythrocyte flexibility and decreases blood viscosity (thickness) by decreasing platelet aggregation and fibrinogen.

Platelet Inhibitors Listed for PAD

ASA (aspirin) and Plavix and Ticlid reduce platelet clumping and arterial clots

Coumadin in PAD (warfarin)

Interferes with clotting factors instead of directly stopping the platelets from getting together, and it is an anticoagulant

Critical Limb Ischemia Interprofessional Care

Revascularization through bypass surgery, percutaneous transluminal angioplasty (PTA), IV prostanoids such as iloprost, spinal cord stimulation, and angiogenesis.

Conservative Treatment for Critical Limb Ischemia

Protect from trauma, decrease ischemic pain, prevent or control infection, and improve arterial perfusion.

Arterial Ischemic Ulcer Treatment

Topical and/or systemic antibiotics, individualized wound care, possible debridement, and measures to improve blood flow.

Positioning for an Arterial Ischemic Ulcer

Elevate the head of the bed on blocks to increase blood flow to the extremity.

Diet for Arterial Ischemic Ulcer Healing

High protein, zinc, vitamin C, and iron.

Hematocrit for Arterial Ulcer Healing

The slide states that the patient must have a hematocrit of 24 to heal.

Indications for Interventional Radiology in PAD

Incapacitating intermittent claudication, rest pain, or ulceration/gangrene severe enough to threaten viability of the limb.

Percutaneous Transluminal Angioplasty (PTA)

An interventional radiology procedure used to improve arterial blood flow in PAD. (make a new route for the vein) this is what you do for critical limn ischemia

Atherectomy

An interventional radiology procedure used in PAD.

Cryoplasty

An interventional radiology procedure used in PAD.

Most Common Surgical Approach for PAD

Peripheral artery bypass surgery using an autogenous vein or synthetic graft to bypass blood around the lesion.

PAD Bypass Grafting

Uses an autogenous vein or synthetic graft to route blood around an arterial obstruction.

PTA With Stenting

May be used in combination with bypass surgery for PAD.

Other PAD Surgical Therapies

Endarterectomy, patch graft angioplasty, and amputation.

PAD Nursing Assessment Health History

Assess for diabetes mellitus, smoking, hypertension, hyperlipidemia, and obesity.

PAD Nursing Assessment Findings

Exercise intolerance, loss of hair on legs and feet, decreased or absent peripheral pulses, and intermittent claudication.

Nursing Diagnoses for PAD

Ineffective peripheral tissue perfusion, activity intolerance, chronic pain, and ineffective health management.

Overall Goals for a Patient With PAD

Adequate tissue perfusion, pain relief, increased exercise tolerance, intact healthy skin on extremities, and increased knowledge of the disease and treatment plan.

PAD Health Promotion

Identify at-risk patients, modify diet, provide proper foot care, and avoid injuries.

Assessment After PAD Surgery or Revascularization

Frequently assess skin color and temperature, capillary refill, peripheral pulses distal to the operative site, and sensation and movement of the extremity.

PAD Ambulatory Care

Manage risk factors, use long-term antiplatelet therapy, participate in supervised exercise training after revascularization, and perform meticulous foot care.

Daily Foot Care for PAD

Inspect the feet every day.

Shoes for a Patient With PAD

Wear comfortable shoes with rounded toes and soft insoles, and lace shoes lightly.

Evaluation of PAD Care

Adequate peripheral tissue perfusion, increased activity tolerance, effective pain management, and knowledge of the disease and treatment plan.

Buerger's Disease

Also called thromboangiitis obliterans; an inflammatory disease affecting small- and medium-sized blood vessels, primarily in the hands and feet.

Thromboangiitis Obliterans

Another name for Buerger's disease.

Buerger's Disease Pathophysiology

Inflammation and thrombosis cause decreased blood flow and tissue ischemia.

Major Association With Buerger's Disease

Strongly associated with tobacco use.