Transcript Peripheral Arerial Diseases

Peripheral Arerial Diseases
PAD
Key points
• PAD results from atherosclerosis in the arteries of the
lower extremities and is characterized by inadequate
flow of blood (mild, moderate, severe)
• PAD is classified as:
▫ inflow (distal aorta, iliac arteries)
▫ outflow (femoral, popliteal, and tibial artery)
• Tissue damage occurs below the arterial obstruction.
• Acute arterial occlusion ; is a sudden occlusion of
an artery by an embolus/ thrombus (more common in
lower extremities).
• Acute occlusion may cause severe ischemia (S&M
loss).
Key points
• Examples of peripheral arterial diseases:
▫ Buerger’s disease
▫ Raynaud’s disease and
▫ Raynaud’s phenomenon.
• The most common cause of PAD is
atherosclerosis.
Risk Factors
• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Cigarette smoking
• Obesity
• Familial predisposition
• Age
• Male gender
In acute arterial occlusion, the origin of the embolus is
most often from the heart (recent MI, atrial
fibrillation).
The history includes: sudden onset of severe pain,
coldness, numbness, and pallor in an extremity with
absent pulses distal to the obstruction.
Diagnostic Procedures and Nursing Interventions
• Arteriography of lower extremities (injection of
contrast medium to visualize areas of decreased
arterial flow on an x-ray).
• Exercise Tolerance Testing: Stress test or
treadmill (pulse volumes & BP prior to and
following the onset of symptoms or 5 min of
exercise.
• Delays in return to normal pressures and pulse
waveforms indicate arterial disease. Used to
evaluate claudication without rest pain.
Diagnostic Procedures and Nursing Interventions
• Plethysmography: Used to determine the variations of
blood passing through an artery, thus identifying
abnormal arterial flow in the affected limb.
• Segmental Systolic Blood Pressure (BP)
Measurements: The use of a Doppler probe to take
various BP measurements (thigh, calf, ankle,
brachial) for comparison.
• With arterial disease, the pressures in the thigh, calf,
and ankle are lower than brachial pressures (normally
higher).
Therapeutic Procedures and Nursing Interventions
• Percutaneous Transluminal Angioplasty (PTA): intra-arterial
procedure using a balloon and stent to open and help
maintain the patency of the vessel.
• Laser-Assisted Angioplasty: a laser probe is advanced through
a cannula to the site of stenosis. The laser is used to vaporize
atherosclerotic plaque and open the artery. Observe for
bleeding at the puncture site postop, since anticoagulant
therapy is used during the operative procedure, followed by
antiplatelet therapy for 1 to 3 months following the procedure
• Atherectomy: a high-speed rotary metal burr to scrape plaque
out of affected arteries and improve blood flow to ischemic
limbs.
• Arterial revascularization surgery is used when the severity
threatens the loss of a limb or for clients with severe pain at
rest or claudication interfering with their ability to work.
• Bypass Grafts:
Assess/Monitor
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Peripheral pulses
Fluid status
Coagulation status
Pain
Exercise tolerance
NANDA Nursing Diagnoses
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Chronic pain
Ineffective tissue perfusion (peripheral)
Risk for injury
Risk for peripheral neurovascular dysfunction
Nonsurgical Nursing Interventions
• Encourage exercise to build up collateral circulation – initiat
gradually, increase slowly.
• Positioning:
▫ Avoid crossing legs.
▫ Refrain from wearing restrictive garments.
▫ Elevate to reduce swelling but not above the level of the heart
• Promote vasodilation and avoid vasoconstriction.
▫ Provide warm environment.
▫ Wear insulated socks.
▫ Never apply direct heat to the affected extremity as sensitivity is
decreased and the client may inadvertently be burned.
▫ Avoid exposure to cold (causes vasoconstriction and decreased
arterial flow).
▫ Stop smoking, and avoid stress, caffeine, and nicotine, which also
cause vasoconstriction.
Nonsurgical Nursing Interventions
• Administer medications as prescribed.
▫ Hemorheologic drugs, such as pentoxifylline
(Trental), to increase the RBCs flexibility & to
decrease blood viscosity, thus increasing blood
flow in the extremities.
▫ Antiplatelet agents, such as aspirin (acetylsalicylic
acid) and clopidogrel (Plavix).
▫ Antihypertensives to improve tissue perfusion by
maintaining pressures that are adequate to
perfuse the periphery but not constrict the vessels.
Postoperative Nursing Interventions
• Immediately postoperative, mark the site where the distal
pulse is best palpated or heard by Doppler.
• Assess the extremity and compare to the contralateral
extremity (every 15 min for the first hour, then hourly) for
changes in color, temperature, pulse intensity, circulatory
refill, and pain
• Warmth, redness, and edema of the affected limb are expected
outcomes of
surgery as a result of increased blood flow.
• Monitor for pain.
• Monitor blood pressure (Hypotension may indicate
hypovolemia,
which can increase the risk of clotting or graft collapse/ HTN
causes bleeding from sutures).
• Limit ROM of the affected limb (bending of hip and knee is
contraindicated) to decrease the risk of clot formation.
Complications and Nursing Implications
• Graft occlusion
• Compartment syndrome
• Acute arterial occlusion
• Ulcer formation
Peripheral Venous Disease
PVD
Key points
• PVD is a disease of the veins that interferes with adequate flow of
blood from the extremities. This includes both venous
thromboembolism
(VTE) and venous insufficiency.
• Three reasons alter blood flow in veins:
▫ thrombus formation,
▫ Defective valves, and
▫ lack of skeletal muscle contractility.
• VTE is the blocking of a blood vessel by a thrombus that moved
from a different place (including : DVT and PE).
• A thrombus (thrombosis) is a blood clot believed to result from an
endothelial injury, venous stasis, or hypercoagulability (Virchow’s
triad).
Key points
• Thrombus formation can lead to PE, a lifethreatening complication
• Thrombophlebitis refers to a thrombus that is
associated with inflammation. This can occur in
any vein, but most frequently occurs in deep
veins in lower extremities.
• DVT and thrombophlebitis present a greater risk
of PE.
• PE is when a dislodged blood clot travels to the
pulmonary artery. It is a life-threatening
situation.
Key points
• Venous insufficiency occurs as a result of prolonged
venous HTN, which stretches the veins and damages
the valves.
• Defective valves lead to venous insufficiency and
varicose veins, which are problematic but not lifethreatening.
• Treatment for venous stasis focuses on decreasing
edema and
promoting venous return
• Varicose veins are enlarged, twisted superficial veins
that may occur in any part of the body, but are most
commonly observed in the lower extremities and in
the esophagus.
Risk Factors
• Risk Factors of Venous Thromboembolism
▫ Hip surgery, total knee replacement, open
prostate surgery
▫ Heart failure
▫ Immobility
▫ Pregnancy
• Risk Factors of Venous Insufficiency
▫ Sitting or standing in one position for a long
period of time
▫ Obesity
▫ Pregnancy
▫ Thrombophlebitis
Risk Factors
• Risk Factors: Varicose Veins
▫ Older than 30 with an occupation requiring
prolonged standing
▫ Pregnancy
▫ Obesity
▫ Systemic diseases (for example, heart disease)
▫ Family history
Diagnostic Procedures and Nursing
Interventions: DVT and Thrombophlebitis
• Venous duplex ultrasonography & Doppler flow
studies, are noninvasive procedures that can
confirm a DVT
• If the above tests are negative but a DVT is still
suspected, a venogram may be needed for
accurate diagnosis.
• MRI scan is noninvasive and useful for finding
DVTs in inferior vena cava or pelvic veins.
• A D-dimer test; a negative D-dimer test
can exclude a DVT without an ultrasound.
Diagnostic Procedures and Nursing
Interventions: Varicose Veins
• The Trendelenburg test assists with a diagnosis of
varicose veins.
▫ Place the client in a supine position with legs elevated.
▫ When the client sits up, the veins will fill from the proximal
end if varicosities are present (veins normally fill from the
distal end).
Therapeutic Procedures and Nursing Interventions:
Varicose Veins
• Sclerotherapy; a solution is injected into the
vein, followed by the application of a pressure
dressing.
• An incision and drainage of the trapped blood in
the sclerosed vein are preformed 14 to 21 days
after the injection, followed by the application of
a pressure dressing for 12 to 18 hr.
Therapeutic Procedures and Nursing
Interventions: Varicose Veins
• Vein Stripping; Varicose veins are removed if they are larger than 4 mm
in diameter or if they are in clusters.
• Preoperatively
▫ Evaluate pulses as baseline for comparison postoperatively.
• Postoperatively
▫ Maintain elastic bandages on the client’s legs.
▫ Monitor the groin and leg for bleeding through the elastic bandages.
▫ Monitor the extremity for edema, warmth, color, and pulses.
▫ Elevate the legs above the level of the heart.
▫ Encourage ROM exercises of the legs.
▫ Instruct the client to elevate the legs when sitting and avoid leg
dangling or chair sitting.
▫ Emphasize the importance of wearing elastic stockings after bandage
removal.
Therapeutic Procedures and Nursing
Interventions: Varicose Veins
• Application of Radiofrequency (RF) Energy: The
vein is heated from the inside by
• the RF and shrinks. Collateral veins take over.
• Laser Treatment: Endovenous laser treatment
uses a laser fiber to heat and close
• the main vessel that is contributing to the
varicosity.
Assessment
• Deep Vein Thrombosis and Thrombophlebitis
• The client may be asymptomatic.
• Classic signs are calf or groin pain or tenderness and
sudden onset of swelling of the leg.
• Pain in the calf on dorsiflexion of the foot (positive
Homans’ sign) is NOT ADVISED for diagnosis because it
only occurs in 10% of cases. May represent false positive.
• Examine the area, compare the site to the contralateral
limb, gently palpate the site, and observe for induration
along the blood vessel and for warmth and edema.
• Measure, record, and compare Rt and Lt calf and thigh
circumferences for changes over time; observe for
localized edema.
• Monitor for SOB and chest pain (????)
Assessment
• Venous Insufficiency
▫ Stasis dermatitis or brown discoloration along the
ankles and extending up to the calf
▫ Edema
▫ Ulcer formation
• Varicose Veins
▫ Distended, protruding veins that appear darkened
and tortuous
▫ Pain in legs with dull aching after standing
▫ A feeling of fullness in the legs
▫ Ankle edema
NANDA Nursing Diagnoses
• Risk for ineffective tissue perfusion (peripheral)
• Acute pain
• Risk for injury
Nursing Interventions
• Deep Vein Thrombosis and Thrombophlebitis
▫ Encourage REST.
 Facilitate bed rest and elevation of the extremity
above the level of the heart as ordered .
 Administer intermittent or continuous warm moist
compresses as ordered (to prevent thrombus from
dislodging and becoming an embolus, do NOT
massage the affected limb).
 Provide thigh-high compression or antiembolism
stockings as prescribed to reduce venous stasis.
Nursing Interventions
• Administer medications as prescribed.
▫ Anticoagulants
 Unfractionated heparin (UFH) IV based on body
weight is given to prevent formation of other clots
and to prevent enlargement of the existing clot,
followed by oral anticoagulation with warfarin
(Coumadin).
 Monitor activated partial thromboplastin time
(aPTT) to allow for adjustments of heparin dosage.
 Monitor platelet counts for heparin-induced
thrombocytopenia
Nursing Interventions
• Monitor for hazards and side effects associated with anticoagulant
therapy.
• Low-molecular weight heparin (LMWH) is given subcutaneously.
• Enoxaparin (Lovenox), is approved for the prevention and
treatment of DVT.
• The client must be willing to learn self injection or have
family/friend/home care nurse administer the subcutaneous
injections.
• Monitor the client for evidence of bleeding (blood in stools
• Warfarin works in the liver to inhibit synthesis of the four vitamin
K-dependent clotting factors and takes 3 to 4 days before it can
exert therapeutic anticoagulation.
• Heparin is continued until the warfarin therapeutic anticoagulation
effect is achieved, then IV heparin may be discontinued.
• Monitor for bleeding. Ensure that vitamin K (the antidote for
warfarin) is available in case of excessive bleeding.
Nursing Interventions
• Thrombolytic Therapy
▫ It must be initiated within 5 days after the onset of
symptoms to be most effective.
▫ The advantage is the prevention of valvular damage
and consequential venous insufficiency, or
“postphlebitis syndrome.”
▫ It is contraindicated during pregnancy and following
surgery, childbirth, trauma, a cerebrovascular
accident, or spinal injury.
▫ The primary complication of thrombolytic therapy is
seriousmbleeding (for example, intracerebral
bleeding). Closely monitor the
client for bleeding.
Analgesics: Administer as ordered to reduce
pain.
Nursing Interventions
• Venous Insufficiency
▫ Consult with a dietician and wound care specialist as
needed.
▫ Instruct the client:
 To elevate legs for at least 20 min four to five times a day.
 To elevate legs above the level of the heart.
 To avoid prolonged sitting or standing, constrictive
clothing, or crossing legs when seated.
 To wear elastic or compression stockings during the day
and evening as prescribed.
 Put elastic stockings on before getting out of bed after
sleep.
 Clean the elastic stockings each day, keep the seams to
the outside, and do not wear bunched up or rolled down.
 Replace worn out compression stockings as needed.
Nursing Interventions
Varicose Veins
• Emphasize the importance of anti-embolism stockings as
prescribed.
• Instruct the client to elevate legs as much as possible.
• Instruct the client to avoid constrictive clothing and
pressure on the legs.
Complications and Nursing Implications
• Ulcer Formation: Typically over malleolus, more often
medially than laterally.
• Ulcers are chronic, hard to heal, and recurrence is
common. They may lead to amputation and/or death.
(Apply occlusive dressings, administer systemic
antibiotics as prescribed).
Complications and Nursing Implications
• Pulmonary Embolism: Occurs when a
thrombus is dislodged, becomes emboli, and lodges
in the pulmonary vessels.
• Symptoms include sudden onset dyspnea, pleuritic
chest pain, restlessness and apprehension, feelings
of impending doom, cough and hemoptysis.
Signs include, tachypnea, crackles, pleural friction
rub, tachycardia, S3 or S4 heart sound, diaphoresis,
low-grade fever, petechiae over chest and axillae,
and decreased arterial oxygen saturation.