Alteration in Perfusion: Peripheral Vascular and Arterial Disease

Peripheral Artery Disease (PAD)

• Involves thickening of the artery walls and progressive narrowing of arteries of upper and lower extremities

• Atherosclerosis is leading cause in majority of cases

• Symptoms occur when vessels are 60-75% blocked

Peripheral Artery Disease (PAD) risk factors

• Risk factors: Tobacco use, Diabetes, HTN, High cholesterol, Age greater than 60

PAD Clinical Manifestations: intermittent claudication

• Ischemic muscle pain that is caused by a constant level of exercise

• Build up of lactic acid from anaerobic metabolism

• Resolves within 10 minutes or less with rest

PAD Clinical Manifestations: paresthesia

• Numbness or tingling in the toes or feet from nerve tissue ischemia

• Neuropathy causes severe shooting or burning pain

PAD Clinical Manifestations:reduced blood flow to the limbs

• Thin, shiny, and taut skin

• Loss of hair on the lower legs

• Diminished or absent pedal, popliteal, or femoral pulses

• Elevation pallor. Pallor of foot with leg elevation

• Dependent rubor. Reactive hyperemia (excess of blood) of foot with dependent position

PAD Clinical Manifestations

• Pain at rest 

  • Aggravated by limb elevation. Pain relief by gravity

• Critical Limb Ischemia (CLI)

  • Chronic ischemic rest pain lasting more than 2 weeks

  • Nonhealing arterial leg ulcers or gangrene

PAD Complications

• Atrophy of skin and underlying muscles

• Delayed healing

• Wound infection

• Tissue necrosis 

• Arterial ulcers over bony prominences

• Most serious: Nonhealing arterial ulcers and gangrene 

• May result in amputation 

PAD Diagnostics

• Doppler ultrasound 

• Ankle-brachial index (ABI) 

• Magnetic resonance angiography

Ankle-brachial index (ABI)

• Done using a hand-held Doppler

• Calculated by dividing the ankle systolic BP (SBP) by the higher of the brachial SBPs

• Falsely elevated results can be seen in older patients or those with diabetes

• Ex: Ankle systolic is 120 mmHg and the brachial systolic is 140 mmHg, the ABI would be 120/140 = 0.86. 

• Norm: 1-1.3

ABI of

0.9 or less is generally considered abnormal and may indicate PAD

PAD life style changes

• Lifestyle Changes: healthy diet, stop smoking

• Walking is most effective exercise for individuals with claudication

  • 30 to 45 minutes daily, 3 times/wk

• Patients should consult with their HCP before taking any dietary or herbal supplements especially if they are prescribed: NSAIDs, Anticoagulants

PAD nutrition

• Nutrition Therapy: 3% to 5% weight loss yields reduced triglycerides, glucose, A1C, and decreased risk of type 2 diabetes

PAD Collaborative Care

• Proper foot care and check feet every day for wounds

• Avoid heat, cold, and injury to extremities

• Medications

• Percutaneous Transluminal Angioplasty (PTA)/stent

• Surgery

PAD Collaborative Care Medications

• ACE inhibitors: ramipril, captopril, benazepril 

• Antiplatelet agents

• Anticoagulants are not recommended at this point

ACE inhibitors: ramipril, captopril, benazepril

• Increases peripheral blood flow

• Increases ABI 

• Increases walking distance 

antiplatelets

• Aspirin: Low-dose aspirin therapy

• Clopidogrel: for aspirin-intolerant patients (effect decreased with omeprazole).

• Can be used in combination for high-risk patients

• Cilostazol: not with HF patients

• Pentoxifylline

PAD Collaborative Care PTA

PAD Collaborative Care…Occlusion Emergency: causes

• Causes: Thrombus, Embolus, Trauma

PAD Collaborative Care…Occlusion Emergency: symptoms

•  7 “P”s of limb ischemia (different than book)

  • Pain

  • Pulselessness

  • Pallor

  • Poikilothermia (inability to regulate temperature)

  • Paresthesia (numbness, tingling)

  • Paralysis (loss of muscle function)

  • Perfusion (capillary refill greater than 3 sec)

PAD Collaborative Care…Occlusion Emergency: emergency treatment

• Anticoagulants, Thrombolytics, and/or Surgery (Revascularization, Amputation)

PAD Collaborative Care…Femoral-Popliteal Bypass Femoral-Tibial Bypass

PAD Collaborative Care… Post Op

• Maintain circulation and check for a re-blockage of the artery

  • Assess pulse, color, temp, capillary refill, bruit

• Monitor pain, BP

• Deep breathing every 1-2 hr

• Monitor for graft occlusion

• Monitor for wound infection

• Monitor for active bleeding, hematoma, thrombosis, embolus, compartment syndrome

• Client education

Other Arterial Disorders

• Aortic Aneurysms

• Thromboangiitis Obliterans (Buerger’s disease)

• Raynaud’s Phenomenon

Aortic Aneurysms (AA)

• Sudden interruption in arterial blood supply 

• Permanent, localized, outpouching, or dilation of wall of aorta

• If untreated, can result in tissue death

AA Clinical Manifestations

• Often asymptomatic

• Pulsatile mass in periumbilical area slightly left of midline. 

• Bruit auscultated over aneurysm

AA Clinical Manifestations assess for

• Assess for shortness of breath, coughing, hoarseness, difficulty swallowing

AA Clinical Manifestations may cause

• May cause back or chest pain, epigastric discomfort, altered bowel elimination, intermittent claudication. 

• Sudden excruciating back or chest pain, symptomatic of thoracic rupture

• Blue Toe syndrome: patchy mottling of feet

AA Complication…Rupture Emergency: Rupture into retroperitoneal space

• Bleeding

• Severe back pain

• May/may not have back/flank ecchymosis (Grey Turner’s sign)

AA Complication…Rupture Emergency: Rupture into thoracic or abdominal cavity

• Massive hemorrhage causes hypovolemic shock, tachycardia, hypotension, pale clammy skin, decreased urine output, altered LOC, abdominal tenderness

• Most do not survive long enough to get to the hospital 

AA Diagnostics

• X-ray of Chest—abnormal widening of thoracic aorta

• Ultrasound: Useful in screening for aneurysms, Monitors aneurysm size

• CT scan or MRI: Diagnose and assess location and severity

AA Collaborative Care

• Vital signs

• Assess pain, Oxygen saturation, circulation

• Cardiac monitoring

• Monitor ABG, electrolytes, CBC, Labs

• Monitor Infection, neurological status

• Monitor Urine output

• Administer O2

• IV access

• Control BP- Antihypertensive

• Surgical repair for AA larger than 5.5 cm

AA Surgery Post Op

• ICU monitoring

• Arterial line for continuous BP assessment  

• Hemodynamic monitoring with Pulmonary Artery catheter (shows heart and lung function)

• Mechanical ventilation

• Peripheral IV lines-maintain hydration with IVF and Blood

• Urinary catheter

• Nasogastric tube-monitor I/O

• Monitor abdominal girth, incision

• Continuous ECG Monitoring, VS with Pulse oximetry; monitor temp   

• Monitor electrolytes (chemistry) and CBC (hematology)

• Pain medication

• Monitor for complication of embolization or graft occlusion, 7 Ps.

Thromboangiitis Obliterans (Buerger’s disease)

• Rare, progressive disease that causes inflammation and blood clots in the small and medium-sized arteries and veins of the hands and feet

  • Nonatherosclerotic

  • Inflammatory thrombus eventually causes ischemia

Thromboangiitis Obliterans (Buerger’s disease) Clinical Manifestations

• Intermittent claudication of feet, hands, or arms

• Rest pain

• Ischemic ulcerations

• Changes in color and temperature

• Paresthesia

• Superficial vein thrombosis

• Cold sensitivity

Thromboangiitis Obliterans (Buerger’s disease) Collaborative Care

• No specific lab or diagnostic tests. Based on history and symptoms and exclusion of other disorders

• No smoking tobacco or marijuana; no nicotine replacements

• Avoid cold exposure

• Walking program

• Antibiotics for ulcers

• Analgesia for pain

• Avoid trauma

• IV iloprost—promotes vasodilation

• Surgery: Bypass surgery, Amputation

• Stem cell therapy (stem cells into a patient's body to promote tissue regeneration and repair)

Raynaud’s Phenomenon

• Vasospasm/vasoconstriction of arterioles & arteries

• Effects fingers & toes

• No loss of pulses

• Precipitated by cold, emotional upsets, caffeine, tobacco

• Extremity color changes: pallor, cyanosis

• Feels like numbness & tingling

• Associated with autoimmune disorders (RA, Lupus)

• Also, associated with trauma (frostbite)

Raynaud’s Collaborative Care

• Avoid temperature extremes; wear appropriate clothing

• No tobacco products

• Avoid caffeine

• No vasoconstrictor drugs

• Stress management

• Immerse hands in warm water to help decrease vasospasm

• Sustained release calcium channel blockers to decrease vasospasm

• Vasodilators: Topical nitroglycerin 2% ointment, Prostacyclin infusion

• Antibiotics

• Analgesia

Venous Disorders

• Phlebitis

• Venous Thrombosis 

  • Superficial Vein Thrombosis

  • Venous Thromboembolism (VTE)

    • Deep vein thrombosis (DVT)

    • Pulmonary embolism (PE)

Phlebitis

• Acute inflammation of the walls of small cannulated veins of the hand or arm (related to IV catheter)

Phlebitis clinical manifestations

• Clinical Manifestations: pain, tenderness, warmth, erythema, swelling, and palpable cord

Phlebitis treatments

• Remove catheter

• Edema…Elevate extremity to promote fluid reabsorption

• Pain and inflammation…NSAIDs 

• Warm, moist heat

Venous Thrombosis

• Formation of a thrombus (clot) with vein inflammation

• Most common disorder of the veins

• Superficial vein thrombosis…saphenous vein

• Deep vein thrombosis (DVT)…iliac and/or femoral veins

• Venous thromboembolism (VTE) – preferred term

  • Represents spectrum from DVT to pulmonary embolism (PE)

Venous Thrombosis

• Virchow’s triad - 3 key factors that cause venous thrombosis  

  • Venous stasis (slow blood)

  • Damage to endothelium (inner lining of vessel)

  • Hypercoagulability of blood (sticky cells)

• Patients at risk for developing VTE usually have predisposing conditions to these 3 factors

VTE SV DVT PE Prevention and Collaborative Care

• Early and progressive mobilization. Walk 4 to 6 times/day. 

• Pneumatic compression devices, TEDs (Not recommended if VTE already exists)

• Flex and extend feet, knees and hips every 2 to 4 hours while awake

• Passive and active ROM, as indicated

• OOB to chair

VTE SV DVT PE Prevention and Collaborative Care: Anticoagulants

• Warfarin. Antidote: vitamin K. Lab: INR (Norm 0.8-1.2). Norm while on warfarin is 2 to 3 higher (ie. If normal is 1, the pt on warfarin will have an INR of 2 to 3)

• Heparin. Antidote: protamine sulfate Lab: PTT. (Partial Thromboplastin Time norm 30-40): Norm while on heparin is 60-100 secs (1.5 to 2.5 times norm/control).

• Enoxaparin. Antidote: protamine sulfate

Superficial Vein Thrombosis: risk factors

• Risk factors: pregnancy, obesity, cancer, recent fracture(s), estrogen therapy, recent sclerotherapy, recent surgery or long-distance travel

Superficial Vein Thrombosis clinical manifestations

• Palpable, firm, cordlike vein. Varicose Vein.

• Itchy, painful, red, and warm

• Mild fever, leukocytosis

• Often involves varicose veins

Superficial Vein Thrombosis diagnosis

• ultrasound

Superficial Vein Thrombosis treatment

• Treatment of clot smaller than 5 cm and not near saphenous femoral junction

  • Oral (or topical) NSAIDs

  • Compression stockings 

  • Warm compresses

  • Elevate limb above heart

  • Mild exercise

Venous Thromboembolism (VTE)…Deep Vein Thrombosis (DVT): Clinical Manifestation

• Unilateral edema

• Pain, tenderness with palpation

• Paresthesia (burning, prickling, tingling, or numb)

• Red, warm, Fever greater than 100.4° F (38° C)

Venous Thromboembolism (VTE)…Deep Vein Thrombosis (DVT): complications

PE

VTE DVT Diagnostics

• Lab: ACT (Activated Clotting Time), aPTT, INR, bleeding time, Hgb, Hct, platelet count, D-dimer, fibrin monomer complex

• Noninvasive venous: venous compression ultrasound, duplex ultrasound

VTE DVT Diagnostics Invasive

• Invasive venous: CT venography, MR venography, contrast venography

VTE DVT Collaborative Care medications

• Anticoagulation

  • Heparin

    • PTT: Norm while on heparin is *60-100 secs (1.5 to 2.5 times norm/control).

    • Complication: HIT-Life threatening

VTE DVT Collaborative Care

• Bed rest initially…do not move clot

• No Compression Stockings/boots to affected limb…do not move clot

• No massaging, lotion to lower limbs…do not move clot

• Daily Measurements of limb

• Guaiac Stools…check for additional bleeding

• Surgery: Thrombectomy, Inferior Vena Cava (IVC) filter: Greenfield Filter

VTE DVT complication: Heparin Induced Thrombocytopenia (HIT)

• Immune response to receiving heparin. Bleeding and simultaneous clotting

• Sudden reduction in platelet count (norm = 150,000-450,000)

  • If platelet count decreases by 50% or goes severely below normal level

• Paradoxical increase in venous and arterial thrombosis. Infarcts damage organs

when can Heparin Induced Thrombocytopenia (HIT) occur

• Occurs 5-14 days after heparin therapy

Heparin Induced Thrombocytopenia (HIT) treatment

• STOP all Heparin

• Non-heparin agent if anticoagulation still needed (thrombin inhibitors-argatroban)

VTE Pulmonary Embolism (PE)

• Blockage of 1 or more pulmonary arteries by thrombus, fat or air embolus, or tumor tissue

• Clot in venous system into pulmonary circulation then lodges in small blood vessel and obstructs alveolar perfusion 

• Most PEs arise from deep vein thrombosis (DVT)

VTE Pulmonary Embolism (PE) clinical manifestations

• Dyspnea most common; mild-moderate hypoxemia

• Tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound

massive PE clinical manifestations

• Massive PE: change in mental status, hypotension, feeling of impending doom, cardiorespiratory arrest/death

VTE PE Collaborative Care

• Oxygen: via mask or cannula by hypoxemia; FIO2 is titrated based on ABG analysis; mechanical ventilation may be needed

• Elevate the HOB slightly for improved breathing

• Pulmonary hygiene: prevent atelectasis

VTE PE Collaborative Care medications

• Shock: IV fluids, vasopressors

• HF: diuretics

• Pain: opioids

• Anticoagulation – immediate

• Fibrinolytic agents—dissolve clot

  • Tissue plasminogen activator (tPA)

  • Alteplase (Activase)

VTE PE Collaborative Care surgery

• Surgery: Embolectomy, IVC filter

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement?

A. “I should not use heating pads to warm my feet.”

B. “I should cut back on my walks if it causes pain in my legs.”

C. “I will examine my feet every day for any sores or red areas.” 

D. “I can quit smoking if I use nicotine gum and a support group.”

A patient in the outpatient clinic has a new diagnosis of chronic peripheral artery disease (PAD). Which of the following medications will the nurse be prepared to include when providing patient teaching about PAD management? Select all that apply.

• Captopril

• Clopidogrel

• Omeprazole

• Heparin

• Aspirin

The client admitted with deep vein thrombosis is ordered heparin. Two months after discharge, the Healthcare provider orders lab work. Which lab result would be a concern to the nurse?

A. PTT 75 seconds

B. INR is less than 1

C. Platelets 80,000

D. Hgb 15 g/dL

Following an aortic aneurysm repair, the patient suddenly develops severe pain with some numbness and tingling in the right lower extremity. The right pedal pulse is decreased, the capillary refill takes 6 seconds, and the right foot is cool and pale. Which complication should the nurse suspect?

A. Hypothermia

B. A wound infection

C. Bleeding from the graft site

D. An embolization or graft occlusion