Transcript Peripheral Arterial Disease (PAD)

(Relates to Chapter 38,
“Nursing Management: Vascular Disorders,”
in the textbook)
Ulcer Located Near Ankle
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What Kind of Peripheral Vascular Disease Ulcer is This?
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What Type of Ulcers Real Photo
This person also had toe amputations
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Diabetic Foot Ulcer Locations
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Examples of Diabetic Foot Ulcers
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To function properly, veins must be patent (open)
with competent valves
Vein function also requires the assistance of the
surrounding muscle beds to help pump blood
toward the heart
If one or more veins are not operating properly, they
become distended and clinical manifestations occur.
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Three Health Problems Alter Blood Flow in Veins:
1. Thrombus formation (venous thrombosis) can lead to
pulmonary embolism (PE), a life-threatening complication.
Venous Thromboembolism is the current term that includes
both DVT and PE
2. Defective valves lead to venous insufficiency and Varicose
Veins which are not life threatening
3. Skeletal muscles do not contract to help pump blood in the
veins. This problem can occur when weight-bearing is limited
or muscle tone decreases- problems are occur with prolonged
sitting and standing
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Venous Insufficiency
 occurs as a result of prolonged venous hypertension
that stretches the veins and damages the valves.
 valvular damage can cause backup of blood and
further venous hypertension
 results in edema and decreased tissue perfusion.
 Stoppage is called venous stasis & results in venous
stasis ulcers, swelling, and cellulitis.
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The focus of treating venous insufficiency is to decrease edema and
promote venous return from the affected leg.
What type of stockings might be used?
Treatment of chronic venous insufficiency is nonsurgical unless it is
complicated by a venous stasis ulcer that requires surgical débridement.
The desired outcomes of managing venous stasis ulcers are to heal the
ulcer, prevent infection, and prevent stasis with recurrence of ulcer
formation. Collaborate with the wound care nurse or wound, ostomy, and
continence nurse to make recommendations for ulcer care
Nursing: Teach the patient to elevate his or her legs for at least 20
minutes four or five times per day. When the patient is in bed, remind
him or her to elevate the legs above the level of the heart
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Dos and Don'ts For Venous Insufficiency
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Elevate your legs for at least 20 minutes four or five times
a day. When in bed, elevate your legs above the level of
your heart.
Avoid prolonged sitting or standing
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Do not cross your legs. Crossing at the ankles is acceptable
for short periods
Do not wear tight, restrictive pants. Avoid girdles
and garters.
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Varicose Veins: distended, protruding veins that appear darkened and
tortuous
Common in adults older than 30 years whose lives require prolonged
standing.
Varicose veins are frequently seen also in patients with systemic
problems (e.g., heart disease)
Management: compression stockings & elevating the extremities as
much as possible
Patients who have pain or unsightly veins may opt for either
sclerotherapy or surgical removal of the vein
Phlebitis is an inflammation of the superficial veins caused by an irritant
such as peripheral IV therapy
Patient has a reddened, warm area radiating up the arm. Pain, soreness,
and swelling may also occur. Management involves application of
warm, moist soaks, which dilate the vein and promote circulation
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 Peripheral Arterial Disease (PAD)
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FEATURE
ARTERIAL ULCERS VENOUS ULCERS
DIABETIC ULCERS
History
Patient reports
claudication after
walking about 1-2
blocks
Rest pain usually
present
Pain at ulcer site
Two or three risk
factors present
Diabetes
Peripheral
neuropathy
No reports of
claudication
Chronic non-healing
ulcer
No claudication or
rest pain
Moderate ulcer
discomfort
Patient reports of
ankle or leg swelling
Ankle area
End of the toes
Brown
Between the toes
pigmentation
Deep
Ulcer location
Ulcer bed pink
Ulcer bed pale, with
and appearance
Usually superficial,
even edges
with uneven edges
Little granulation
Granulation tissue
tissue
present
Plantar area of foot
Metatarsal heads
Pressure points on
feet
Deep
Pale, with even
edges
Little granulation
tissue
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Other assessment
findings
ARTERIAL
Cool or cold foot
Decreased or
absent pulses
Atrophy of skin
Hair loss
Pallor with
elevation
Dependent rubor
Possible gangrene
When acute,
neurologic deficits
noted
VENOUS
Ankle discoloration
and edema
Full veins when leg
slightly dependent
No neurologic
deficit
Pulses present
May have scarring
from previous
ulcers
DIABETIC
Pulses usually
present
Cool or warm foot
Painless
Treatment
Treat underlying
cause (surgical,
revascularization)
Prevent trauma and
infection
Patient education,
stressing foot care
Long-term wound
care (Unna boot,
damp-to-dry
dressings)
Elevate extremity
Patient education
Prevent infection
Rule out major
arterial disease
Control diabetes
Patient education
regarding foot care
Prevent infection
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 Involves progressive narrowing
and
degeneration of arteries of neck,
abdomen, and extremities
 Atherosclerosis is the leading cause
in majority of cases.
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 Typically appears at ages 60s to 80s
 Largely undiagnosed
 Risk factors
• Cigarette smoking
• Hyperlipidemia
• Hypertension
• Diabetes mellitus
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 Peripheral artery disease
(PAD) may
affect
• Aortoiliac artery
• Femoral artery
• Popliteal artery
• Tibial artery
• Peroneal artery
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 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
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 Paresthesia
• Numbness or tingling in the toes or feet
• Produces loss of pressure and deep pain
sensations
• Injuries often go unnoticed by patient
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 Thin, shiny, and taut skin
 Loss of hair on the lower legs
 Diminished or absent pedal, popliteal,
or femoral pulses
 Pallor of foot with leg elevation
 Reactive hyperemia of foot with
dependent position
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 Pain at rest
• Occurs in the forefoot or toes
• Aggravated by limb elevation-Critical
Thinking-Why?
• Occurs from insufficient blood flow
• Occurs more often at night
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 Atrophy of the skin and underlying
muscles
 Delayed healing
 Wound infection
 Tissue necrosis
 Arterial ulcers
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 Nonhealing arterial ulcers and
gangrene are most serious
complications.
 May result in amputation if blood
flow is not adequately restored, or if
severe infection occurs
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 Doppler ultrasound
• Segmental blood pressures
 Ankle-brachial index (ABI)
• Done using a hand-held Doppler
 Duplex imaging
• Bidirectional, color Doppler
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 Angiography
 Magnetic resonance angiography
(MRA)
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Although chronic peripheral arterial disease (PAD) progresses
slowly, the onset of acute arterial occlusions may be sudden
and dramatic
An embolus (piece of clot that travels and lodges in a new
area) is the most common cause of peripheral occlusions,
although a local thrombus may be the cause
Occlusion may affect the upper extremities, but it is more
common in the lower extremities. Emboli originating from
the heart are the most common cause of acute arterial
occlusions
Most patients with an embolic occlusion have had an acute
myocardial infarction (MI) and/or atrial fibrillation within the
previous weeks.
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 Smoking cessation, including
use of
nicotine products
 Aggressive treatment of
hyperlipidemia
 BP maintained <140/90
 Glycosylated hemoglobin <7.0% for
diabetics
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 Antiplatelet agents
• Aspirin
• Clopidogrel (Plavix)
• What is nursing assessment of patient
taking any anticlotting medications?
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 ACE inhibitors
• Ramipril (Altace)
 ↓ cardiovascular morbidity
 ↓ mortality
 ↑ peripheral blood flow
 ↑ (ankle brachial index) ABI
 ↑ walking distance
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 Drugs prescribed
for treatment of
intermittent claudication
• Pentoxifylline (Trental)
 ↑ erythrocyte flexibility
 ↓ blood viscosity
• Cilostazol (Pletal)
 ↑ vasodilation
 ↑ walking distance
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 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
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 BMI < 25 kg/m2
 Waist circumference
<40 inches for
men and <35 inches for women
 Dietary cholesterol <200 mg/day
 Decreased intake of saturated fat
 Sodium <2 g/day
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 Revascularization
via surgery
 Protect from trauma
 Reduce vasospasm
 Prevent/control infection
 Maximize arterial perfusion
 Other strategies
• Hyperbaric oxygen therapy
• Angiogenesis
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 Indications
• Intermittent claudication symptoms
become incapacitating.
• Pain at rest
• Ulceration or gangrene severe enough to
threaten viability of the limb
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 Percutaneous
transluminal balloon
angioplasty
• Involves the insertion of a catheter
through the femoral artery
• Catheter contains a cylindrical balloon.
• Balloon is inflated dilating the vessel by
cracking the confining atherosclerotic
intimal shell.
• Stent is placed.
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 Atherectomy
• Removal of the obstructing plaque
• Performed using a cutting disc,
laser, or rotating diamond tip
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 Most common surgical approach
• A peripheral artery bypass operation
with autogenous vein or synthetic graft
material to bypass blood around the
lesion
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Fig. 38-7. 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.
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 Most common surgical approach
(cont’d)
• Synthetic grafts typically used for long
bypasses
• Balloon angioplasty with stenting used
in combination with bypass surgery
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 Endarterectomy
 Patch graft angioplasty
 Amputation
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 Past health history
• Diabetes mellitus
• Smoking
• Hypertension
• Hyperlipidemia
• Obesity
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 Exercise
intolerance? Claudication?
 Loss of hair on legs and feet?
 Skin integrity? Ulcers?
 Decreased or absent peripheral pulses?
 Cool skin temperature/cyanosis?
 Rubor when legs dependent position?
 Paor llwhen legs elevated?
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 Ineffective
tissue perfusion
(peripheral)
 Impaired skin integrity
 Activity intolerance
 Ineffective self-health management
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 Overall
goals for patient with PAD
• Adequate tissue perfusion
• Relief of pain
• Increased exercise tolerance
• Intact, healthy skin on extremities
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 Health promotion
• Identification of at-risk patients
• Diet modification
• Proper care of feet
• Avoidance of injuries
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 Acute intervention
• Frequently monitor after surgery.
 Skin color and temperature
 Capillary refill
 Presence of peripheral pulses distal to
the operative site- critical thinking-why?
 Sensation and movement of extremity
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 Acute intervention
• Continued circulatory assessment
• Monitor for potential complications.
• Knee-flexed positions should be avoided
except for exercise.
• Turn and position frequently.
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 Ambulatory and home care
• Management of risk factors
• Importance of meticulous foot care
• Importance of gradual physical activity
after surgery
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 Ambulatory and home care
• Daily inspection of the feet
• Comfortable shoes with rounded toes
and soft insoles
• Shoes lightly laced
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 Identify
activities that promote
circulation.
 Maintain adequate peripheral tissue
perfusion.
 Experience intact skin, free of
infection, on lower extremities.
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 Plans for walking program
 Increased activity tolerance
 Verbalize
key elements of
• Therapeutic regimen
• Knowledge of disease
• Treatment plan
• Reduction of risk factors
• Proper ulcer/foot care
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Audience Response Question
A patient with peripheral vascular disease has marked
peripheral neuropathy. An appropriate nursing diagnosis for
the patient is:
1. Risk for injury related to decreased sensation.
2. Impaired skin integrity related to decreased peripheral
circulation.
3. Ineffective peripheral tissue perfusion related to
decreased arterial blood flow.
4. Activity intolerance related to imbalance between oxygen
supply and demand.
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Audience Response Question
When teaching a patient with peripheral arterial disease, the
nurse determines that further teaching is needed when the
patient says,
1. “I should not use heating pads to warm my feet.”
2. “I will examine my feet every day for any sores or red
areas.”
3. “I should cut back on my walks if they cause pain in my
legs.”
4. “I think I can quit smoking with the use of short-term
nicotine replacement and support groups.”
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 62-year-old man complains of pain
when walking his dog that is relieved
with rest.
 He has a history of hypertension and
hyperlipidemia, and smokes one pack
of cigarettes per day.
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 He feet have increased
pain when
elevated
 Angiography reveals nearly
obstructed
vessels in lower extremities.
 He is diagnosed
with peripheral artery
disease.
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1.
What risk factors for peripheral artery
disease does he display?
2.
What can he do to prevent additional
complications?
3.
What patient teaching is essential for
him to help manage his disease?
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