Transcript 2016 NUR 1021 Peripheral Vascular Disease

Peripheral Vascular
Disease
Arterial and Venous Disorders
Marion Technical College
NUR 1021
Peripheral vascular
disease (PVD)
• Disorders that change natural flow of
blood through the arteries and veins of the
peripheral circulation
– Affects legs much more frequently than the
arm
– Some patients have both arterial and venous
disease
• Typically appears in patients ages 60 -80
Peripheral vascular
disease (PVD) – cont.
• Cost of the disease is
•
very high
Is expected to
increase as baby
boomers age and
obesity in the United
States continues to
be a major health
problem.
Physiologic Effects
• If diminished blood flow to tissues
– Tissue integrity is challenged if demands
exceed supply of oxygen & nutrients
– Ischemia & eventual death of tissue if
inadequate blood flow
Damaged Arteries
• Obstructions from atherosclerotic plaque,
thrombus or embolus
• Damaged also from
– Chemical/mechanical trauma, infections,
inflammation, vasospastic disorders &
congenital malformations
Acute or Gradual Changes
• Sudden arterial occlusion
– Profound & irreversible tissue ischemia &
death
• Gradual occlusion
– Collateral circulation may develop
– Tissue adapts gradually to ↓ blood flow
– Less risk of sudden tissue death
Veins
• Carry deoxygenated blood to heart
• Normal venous pressure
– Higher than arterial pressure, and lower in the
right atrium than in the feet.
• This allow veins to channel blood from
extremities to heart.
Damaged Veins
• Damaged by a thrombus, incompetent valves,
decreased pumping action of surrounding
muscles
– Result - increased venous pressure
• If the pressure in peripheral veins in greater than
the pressure in tissues, where is the fluid going
to go?
• (Hint: Think about hydrostatic pressures)
Venous Diseases
• Lead to pooling of blood in extremities,
resulting in edema
– Edematous tissue- cannot get adequate
nutrition
– Tissues are susceptible to breakdown, injury
& infection
• Venous diseases : DVT, varicose veins &
venous stasis ulcers
Arterial Vessels More Often
Affected
• Peripheral arterial
disease (PAD) may
affect
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Aortoiliac artery
Femoral artery
Popliteal artery
Tibial artery
Peroneal artery
Geriatric Considerations
• Arteries become thicker – the intimal layer
may become fibrotic & vessels stiffen
– Results in increasing peripheral vascular
resistance
– May lead to ↑ work load of the left ventricle &
possible heart failure
Risk factors for Peripheral Arterial
Disease & Atherosclerosis
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Diabetes
Hyperlipidemia
Hypertension
Nicotine use
High homocysteine
levels
• Familial/genetics
• Increasing age
• Female gender
Which Risk Factors for
atheroslcerosis are nonmodifiable?
• Familial/genetics
• Increasing age
• Female gender
Assessment of Vascular System
• Physical assessment:
– Skin – changes occur from inadequate
blood flow
• Cool, pale extremities- increases with
elevation
• Rubor- reddish, blue color in
dependent position
–Severe peripheral arterial damage
–Occurs from vessels that cannot
constrict & remain dilated
Assessment of Vascular System (cont.)
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Dry, shiny, taut skin
Loss of hair on extremity
Nails thickened & ridged
Edema
Gangrene after prolonged tissue necrosis
Assessment of Vascular System (cont.)
• Classic symptom of PAD—intermittent
claudication
– Ischemic muscle ache or pain that is
precipitated by a constant level of
exercise
– Resolves within 10 minutes or less with
rest
– Reproducible
Chronic arterial occlusion
• Hallmark symptom: Intermittent
claudication
• Resting pain when occlusion severe
– Elevating leg increases pain
– Dependent position relieves pain
Assessment of Vascular System (cont.)
• Pain in forefoot at rest – REST pain
– Severe arterial insufficiency
– Relief – put extremity in dependent position →
improves perfusion
– Often occurs at night
• Pulses
– Diminished or absent pedal, popliteal, or
femoral pulses
– Use a Doppler if unable to palpate pulses
Assessment of Vascular System (cont.)
• Paresthesia
– Shooting or burning pain in extremity
– Present near ulcerated areas
– Produces loss of pressure and deep pain
sensations
– Injuries often go unnoticed by patient
Complications
• Atrophy of the skin and underlying
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•
•
•
muscles
Delayed healing
Wound infection
Tissue necrosis
Arterial ulcers
Complications→Serious Outcome
• Nonhealing arterial ulcers and gangrene
are the most serious complications
• May result in amputation if blood flow is
not adequately restored or if severe
infection occurs
• NCLEX Challenge:
• The nurse suspects that a patient is
experiencing the effects of peripheral
atherosclerosis. What did the nurse
most likely assess in this patient?
• 1. rubor with extremity elevation
• 2. normal hair distribution bilaterally
•
•
over lower extremities
3. peripheral pulses present bilaterally
4. complaints of leg pain upon rest
Diagnostic Studies
• Continuous wave (CW) doppler study- use
of a handheld device to “hear” the pulses
– Provides specific information for calculation of
ABI
Diagnostic Studies
• ABI (ankle-brachial index) – ratio of ankle
systolic blood pressure to the arm systolic
blood pressure
– Ankle-brachial index
<0.70 in PAD
• With increasing arterial narrowing:
– There is a progressive decrease in systolic
pressure distal to the involved sites
• Continuous-wave Doppler ultrasound
– Detects blood flow, combined with computation of
ankle or arm pressures
– This diagnostic technique helps characterize the
nature of peripheral vascular disease
Diagnostic Studies
• CT: cross sectional images of soft tissue &
volume changes
– If patient has renal disease, patient should be
hydrated (IV or oral) 12 hrs before procedure
– Monitor urinary output post procedure
– Evaluate for iodine or shellfish allergies
• Premedicate -steroids & histamine blockers
Diagnostic Studies
• Angiography
– Injection of radiopaque contrast into arterial
system for visualization of vessels
– Can identify location of stenosis or aneurysm
– Collateral circulation identified
– Teach patient that sense of warmth felt with
injection of dye
– Be alert for severe allergic reaction
– Monitor injection site- bleeding or hematoma
Diagnostic Studies
• Magnetic Resonance Angiography
– MRI with special scanner to locate blood
vessels
– Can rotate image for multiple views
– Contraindicated:
• Metal implants
• Older tattoos (metal materials)
– Prepare patient for banging/popping sounds
– Panic button- if feeling claustrophobic
Diagnostic Studies
• Contrast Phlebography (Venography)
– Radiopaque contrast injected into veins
– Unfilled vein – location of a thrombus
– Monitor injection site - bleeding or hematoma
• Lymphoscintography
– radioactive colloid injected into 2nd digit space
– Provides serial images of lymphatic system
Are we having fun yet?
Something that makes this all
happen….Arterial Disorders
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Arteriosclerosis and atherosclerosis
Peripheral arterial occlusive disease
Upper extremity arterial occlusive disease
Aortoiliac disease
Aneurysms (thoracic, abdominal, other)
Dissecting aorta
Arterial embolism and arterial thrombosis
Raynaud’s phenomenon
Arteriosclerosis
• “Hardening of the arteries”
• Diffuse disease process
– Muscle fibers & endothelial lining of walls of
small arteries & arterioles thicken
– Results in loss of elasticity, calcification of
arterial walls
Atherosclerosis
• Atheromas or plaques
– Result of cholesterol,
lipids & cellular debris
in inner layers of large
and medium-sized
arteries
– Result→ decreased
blood flow from
narrowing of lumen→
eventual development
of collateral circulation
• Creates risk for
thrombosis
– Vulnerable areasregions where arteries
bifurcate
C-reactive protein (CRP)
• Sensitive marker of cardiovascular
inflammation-systemically and locally
• Slight increases in serum CRP levels
– Associated with an increased risk of damage
in the vasculature
– Especially if these increases are
accompanied by other risk factors such
increasing age, HTN or positive family history
of cardiovascular disease
Signs/Symptoms
• Not usually present until artery narrowed
by 60% or more
• Early red flags include pain or changed
appearance or sensation in foot or leg
• Intermittent claudication
• Resting causes pain to subside
Prevention
• Heart Healthy Diet
– reduce fat intake, use unsaturated fats,
decrease cholesterol intake
• Medications – Statins to reduce
cholesterol
• Control hypertension with medications
– Often need 2-3 types of HTN medications
• Eliminate nicotine
Management
• Modify risk factors
• Correct HTN
• Exercise program
• Eliminate nicotine
• Medication- reduce blood lipids
• Low cholesterol diet
• Surgical graft procedures
• Femoral/popliteal bypass- improves outflow
Radiologic Interventions
• Angioplasty/percutaneous transluminal
•
angioplasty (PTA)
– Widens area & flattens plaque against wall of
artery
– Stents - prevent recollapse & reocclusion
Complications from procedure
– Hematoma, bleeding
– Distal embolization, intimal damage artery
Stents
Small metal mesh tubes
I am PRR-fectly ready for
whatever comes next
Peripheral Arterial Occlusive Disease
• A form of arteriosclerosis involving
occlusion of arteries, most commonly in
the lower extremities; may be acute or
chronic
– Femoral popliteal area -most commonly
affected in nondiabetic patients
– Patient with diabetes mellitus tends to
develop PAD in the arteries below the knee
Arterial thrombosis &
Arterial embolism
• Arterial embolism - sudden arterial occlusion
caused by emboli
• Results in acute ischemia of affected body parts
• Most stem from thrombus formation in heart
chambers
• Arteriosclerotic conditions may predispose
patients to emboli formation
Embolization of Thrombi…
• Noncardiac sources
of emboli
– Aneurysms
– Ulcerated
atherosclerotic plaque
– Recent endovascular
procedures
– Venous thrombi
– Rarely, arteritis
• If thrombi originates in
left side of heart
– Can obstruct artery of
the lower extremity
(iliofemoral, popliteal,
tibial)
• If originate in right side
of the heart
– Travel to lungs →
pulmonary embolus
Clinical signs/symptoms
• 6” “P’s”of acute arterial ischemia
– Pain- as PAD progresses- continuous pain at
rest
– Pallor (pale)- occurs with leg elevation
– Pulselessness
– Paresthesia
– Paralysis
– Poikilothermia (cool)
Clinical signs/symptoms(cont)
• Toenails thick, skin shiny & dry; sparse
hair on leg
• 100% blockage= acute arterial occlusion
– Immediate intervention or necrosis of tissue in
a few hours
• Chronic rest pain, ulceration, or gangrene
= critical limb ischemia
Goal : Keep affected limb viable
• Anticoagulant therapy
– Continuous IV unfractionated heparin (UH)
• Prevent thrombus enlargement & inhibits further
embolization
• In patients undergoing embolectomy, UH should
be followed by long-term anticoagulation with
warfarin
Interventional Techniques
• To restore blood flow - embolus/thrombus
is removed ASAP
• Options include
– percutaneous catheter-directed thrombolytic
therapy
– percutaneous mechanical thrombectomy with
or without thrombolytic therapy
– surgical thrombectomy or surgical bypass
Extraction of an embolus
• Use of balloon-tipped
•
embolectomy catheter
Deflated balloon-tipped
catheter - advanced
past the embolus,
inflated, and then gently
withdrawn, carrying the
embolic material with it
What is catheter-directed
intraarterial thrombolytic therapy ?
• Use tPA [alteplase] for patients with short-term (less
•
than 14 days) thromboembolic disease
Percutaneous catheter-inserted into femoral artery &
threaded to site of clot
– Thrombolytic drug is infused
– Thrombolytic agents work by directly dissolving the
clot over a period of 24 to 48 hours
– Catheter may act as a mechanical thrombectomy
device- designed to remove or fragment the thrombus
Revascularization
Approaches
• Patient with chronic rest pain, ulceration,
or gangrene has critical limb ischemia
– Critical limb ischemia often leads to
amputation within 6 months if untreated
• Percutaneous transluminal balloon
angioplasty for non-surgical approach
• Atherotomy – use of cutting device or laser
to remove plaques
Revascularization Approaches
• Surgery -indicated in patients with long
areas of stenosis or severely calcified
arteries
– Common surgical approach
• Peripheral artery bypass →improves blood flow
•
beyond a stenotic or occluded artery
Use a vein graft or a synthetic graft
A, Femoral-popliteal bypass graft around an occluded
superficial femoral artery
B, Femoral-posterior tibial bypass graft around
occluded superficial femoral, popliteal, and proximal
tibial arteries
Revascularization
Approaches
• Endarterectomy
– Opening the artery and removing the
obstructing plaque
– Followed by a patch graft angioplasty
• Sewing a patch to the opening to widen the lumen
NCLEX Challenge:
• The nurse recognizes which client is at greatest risk for
developing intimal injury leading to atherosclerosis?
• a. A client with diabetes who also smokes one pack of
• b.
• c.
• d.
cigarettes daily
A client with decreased low-density lipoprotein (LDL)
and increased high-density lipoprotein (HDL) levels
A client with inherited hypolipidemia
A client with a sedentary lifestyle
Amputation - least desirable end-stage
surgical option
– May be required if extensive tissue necrosis
– If infectious gangrene or osteomyelitis
develops
– Indicated if all major arteries in the limb are
occluded
– Every effort made to preserve as much of limb
as possible to optimize rehabilitation
Postoperative Nursing Care
• Main goal -maintain adequate circulation
• Check pulses frequently and compare with unaffected
extremity
– Notify physician immediately if decrease/loss
– Monitor color & temp. of extremity
– Assess sensation & movement of extremity
– Can elevate leg to reduce edema
– Avoid knee flex position; no crossing legs
– Turn & reposition frequently
– Monitor fluid balance
Ambulatory and Home Care
• Management of risk factors
• Importance of meticulous foot care
• Importance of gradual physical activity
after surgery
• Avoid crossing legs
• Daily inspection of the feet
• Comfortable well-fitting shoes with
rounded toes and soft insoles
Nursing Management for PAD
Nursing Diagnoses
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Ineffective tissue perfusion (peripheral)
Impaired skin integrity
Activity intolerance
Ineffective therapeutic regimen
management
Nursing Management
Planning
• Overall goals for patient with PAD
– Adequate tissue perfusion
– Relief of pain
– Increased exercise tolerance
– Intact, healthy skin on extremities
Collaborative Care - PAD
Exercise Therapy
• Exercise improves oxygen extraction in
the legs and skeletal metabolism
• Walking is the most effective exercise for
individuals with claudication
– 30 to 60 minutes daily
– use pain as a guide
• Bedrest → leg ulcers, cellulitis, gangrene,
or acute thrombotic occlusions
Collaborative Care
Nutritional Therapy
• Dietary cholesterol <200 mg/day
• Decreased intake of saturated fat
• Soy products can be used in place of
animal protein
Collaborative Care
Complementary/Alternative
Therapies
• Ginkgo biloba
– Effective in increasing walking distance for
patients with intermittent claudication
• Folate, vitamin B6, cobalamin (B12)
– Lowers homocysteine levels
Collaborative Care
Care of Leg with Critical
Limb Ischemia
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Protect from trauma
Reduce vasospasm
Prevent/control infection
Maximize arterial perfusion
Interventions:
Promote vasodilation and prevent
compression
• Arterial dilation -may not be possible if
artery is severely sclerosed or damaged
• Teaching:
– Warmth promotes arterial flow and cold
causes vasoconstriction
– Nicotine causes vasospasm
– Emotional upsets cause vasoconstriction
– Avoid constricting clothing
– Place extremity below level of heart
Foot care guidelines - Same
as diabetic foot care
• Prevent foot injury
and blisters
• Treat any injury or
blister immediately
• Use neutral soaps
& body lotionsprevent skin drying
• Pat skin dry – avoid
vigorous rubbing
• Stockings or socks clean and dry
• Soak fingernails and
toenails before
trimming
• Trim nails straight
across – may need
podiatrist
• Don’t cut corns and
calluses
NCLEX Challenge
• A client who has returned to the unit after arterial
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revascularization states that pain similar to that
before the procedure is felt in the affected limb.
Which is the nurse’s best action?
a. Notifying the surgeon
b. Elevating the extremity
c. Administering pain medication
d. Placing a warm blanket on the operative limb
Collaborative Care
Drug Therapy
• Antiplatelet agents
– Aspirin
– Ticlopidine (Ticlid)
– Clopidogrel (Plavix)
Collaborative Care
Drug Therapy (Cont’d)
• ACE inhibitors
– Ramipril (Altacel)
• ↓ Cardiovascular morbidity
• ↓ Mortality
• ↑ Peripheral blood flow
• ↑ABI
• ↑ Walking distance
Collaborative Care
Drug Therapy (Cont’d)
• Drugs prescribed for treatment of
intermittent claudication
– Pentoxifylline (Trental)
• ↑ Erythrocyte flexibility
• ↓ Blood viscosity
– Cilostazol (Pletal)
• ↑ Vasodilation
• ↑ Walking distance
NCLEX Challenge:
• In reviewing the menu selections of a client who
is ordered a low-cholesterol diet, the nurse
questions which selection?
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•
•
•
a.
b.
c.
d.
Oatmeal
Eggs
Banana
Wheat toast
Buerger’s Disease (Thromboangiitis
obliterans)
• Inflammatory changes in both arteries and
veins
• Results in destruction of small and
medium vessels
• Usually affects lower extremities but can
also be seen in upper extremity vessels
Etiology
• Affects male cigarette smokers between
ages 20 and 40, small incidence in
females
• Long history of tobacco use
– Do not have other CVD risk factors
(hypertension, hyperlipidemia, DM)
Pathophysiology
• Inflammatory process damages the blood
vessel wall
• Lymphocytes and giant cells infiltrate the
vessel wall with fibroblast proliferation
• Ultimately, thrombosis and fibrosis occur
in the vessel, causing tissue ischemia.
Signs and Symptoms
• Symptoms- may be confused with PAD or
autoimmune disorders as scleroderma
• High rate of periodontitis & presence of
Phorphyromonas gingivalis (periodontal
pathogen) in occluded blood vessels
– Suggests possible bacterial cause
• Pulses decreased/absent
• Pain – cramps in feet (esp. arches) or
legs after exercise (intermittent
claudication) - relieved by rest
– Rest pain, burning/sensitivity to cold may
be early symptoms
• May progress to painful ulceration
– Amputation rate if patient continues
tobacco use is almost 3 times greater
than for those who do not
Management
• Same as that for nursing care of patient
with arterial peripheral disease
• Complete cessation of tobacco use in any
form
– Use of nicotine replacement products is
contraindicated
– Patients have a choice between tobacco and
their affected limbs, but not both
Treatment
• Antibiotics -treat any infected ulcers &
analgesics to manage ischemic pain
• Sympathectomy & implantation of a spinal
cord stimulator
– Improves distal blood flow & reducing pain
– Neither alters the inflammatory process.
• Amputation- if ulceration & gangrene
Raynaud’s Phenomenon
• Characterized by vasospasm of the
arterioles and arteries of the upper and
lower extremities, usually unilaterally
• Raynaud's disease occurs bilaterally
Difference in Disorders
• Primary or idiopathic Raynaud’s
(Raynaud’s disease) occurs in absence of
underlying disease.
• Secondary Raynaud’s (Raynaud’s
syndrome) –
– Associated with an underlying disease
• Usually a connective tissue disorder- systemic
lupus erythematosus, rheumatoid arthritis, or
scleroderma
Clinical Manifestations
• Classic clinical picture -- Raynaud’s
– Pallor brought on by sudden vasoconstriction.
– Skin then becomes bluish (cyanotic) -of
pooling of deoxygenated blood during
vasospasm
– As a result of exaggerated reflow
(hyperemia) due to vasodilation, a red color
(rubor) is produced when oxygenated blood
returns to the digits after the vasospasm stops
Color Changes –Raynaud’s
• Characteristic sequence of color change of
Raynaud’s phenomenon
• White, blue, and red
• Numbness, tingling, and burning pain
occur as the color changes
• Manifestations tend to be bilateral and
symmetric and may involve toes and
fingers
Management
• Avoiding stimuli (e.g., cold, tobacco) that
provoke vasoconstriction
– Is a primary factor in controlling Raynaud’s
phenomenon
– Calcium channel blockers (nifedipine
[Procardia], amlodipine [Norvasc])
• May be effective in relieving symptoms
• Wear gloves when outside; avoid touching
cold items as steering wheel
If I got this ---you can too!!