Peripheral Artery Disease of the Lower Extremities Chapter

Description § Involves progressive narrowing & degeneration of arteries of upper & lower extremities

Common Sites of Atherosclerotic Lesions Copyright © 2017, Elsevier Inc. All Rights Reserved.

Description § Typically appears at ages in sixth to eighth decades of life §

Description § Peripheral artery disease (PAD) may affect § § § Iliac artery Femoral

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. , a 62 -year-old man, complains of

Clinical Manifestations § Classic symptom of PAD – intermittent claudication Ischemic muscle pain that

Clinical Manifestations § Paresthesia § Numbness or tingling in the toes or feet §

Clinical Manifestations § Thin, shiny & taut skin § Loss of hair on the

Clinical Manifestations § Pain at rest § As PAD progresses § Occurs in feet

Case Study (©Jupiterimages/Photos. com/Thinkstock) § When assessing B. D. , you find that his

Critical Limb Ischemia (CLI) § Increased risk with DM, heart failure, hx CVA §

Complications § Atrophy of skin & underlying muscles § Delayed healing § Wound infection

Complications § Nonhealing arterial ulcers & gangrene are most serious complications § Collateral circulation

Diagnostic Studies § Doppler ultrasound – if poor palpation § Segmental blood pressure §

Case Study (©Jupiterimages/Photos. com/Thinkstock) § An angiography reveals nearly completely obstructed vessels in B.

Interprofessional Care Risk Factor Modification § Tobacco cessation § Glycosylated hemoglobin <7. 0% for

Interprofessional Care Drug Therapy § ACE inhibitors § Ramipril (Altace) § ↓ Cardiovascular morbidity

Interprofessional Care Drug Therapy § Antiplatelet agents § Aspirin § Clopidogrel (Plavix) Copyright ©

Interprofessional Care Drug Therapy § Drugs prescribed for treatment of intermittent claudication § Cilostazol

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. is ordered the following drugs: Aspirin 81

Interprofessional Care Exercise Therapy § Exercise improves oxygen extraction in legs & skeletal metabolism

Interprofessional Care Nutritional Therapy § BMI <25 kg/m 2 § Waist circumference <40 inches

Raynaud’s Phenomenon § An episodic vasospastic disorder of small cutaneous arteries – esp. fingers

Raynaud’s… § Diagnosis based on § Sx for at least 2 years § Characterized

Raynaud’s… § Typical episodes last minutes but may last for hours § Triggers: exposure

Raynaud’s… § Following conservative mgt, meds: § Calcium channel blockers to relax arteriole smooth

Interprofessional Care Leg With Critical Limb Ischemia § Revascularization via bypass surgery § Percutaneous

Thrombophlebitis § Acute inflammation of walls of veins § Venous thrombosis = formation of

Thrombophlebitis… § Etiology of factors: Virchow’s triad § Venous stasis § Inactivity of muscles

Venous thromboembolism § Classic signs of inflammation § May have ulceration § Diagnostic studies:

Interprofessional care… § Prevention & prophylaxis § JCAHO -> policies of prevention § Early

Nursing management § Assessment § Dx: pain, impaired skin integrity, potential complication: bleeding, PE

Pulmonary embolism § When the clot lands in the lungs… § Clinical signs: SOB,

Interprofessional Care Leg With Critical Limb Ischemia § Conservative Treatment § Protect from trauma

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. returns for follow-up in 3 months. §

Interprofessional Care Interventional Radiology Procedures § Done in a cath lab vs. OR §

Interprofessional Care Interventional Radiology Procedures § Percutaneous transluminal angioplasty (PTA) Involves insertion of a

Interprofessional Care Interventional Radiology Procedures § Atherectomy § Removal of obstructing plaque § Performed

Interprofessional Care Interventional Radiology Procedures § Cryoplasty § Combines percutaneous transluminal angioplasty & cold

Interprofessional Care Surgical Therapy § Most common surgical approach § Peripheral artery bypass surgery

Bypass Grafts Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Surgical Therapy § Endarterectomy – open artery & remove the plaque §

Nursing Management Nursing Assessment § Past health history § Diabetes mellitus § Smoking §

Nursing Management Nursing Assessment § Exercise intolerance § Loss of hair on legs &

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. undergoes bilateral PTA with stenting. § What

Nursing Management Nursing Diagnoses § Ineffective peripheral tissue perfusion § Activity intolerance § Chronic

Nursing Management Planning § Overall goals for patient with PAD § Adequate tissue perfusion

Nursing Management Nursing Implementation § Health Promotion § Identification of at-risk patients § Diet

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. comes to the recovery area after PTA

Nursing Management Nursing Implementation § Acute Care § Frequently monitor after surgery § Skin

Nursing Management Nursing Implementation § Acute Care § Continued circulatory assessment § Monitor for

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. is being discharged home. § What will

Nursing Management Nursing Implementation § Ambulatory Care § Management of risk factors § Long-term

Nursing Management Nursing Implementation § Ambulatory Care § Daily inspection of the feet §

Nursing Management Evaluation § Adequate peripheral tissue perfusion § Increased activity tolerance § Effective

Nursing Management Evaluation § Plans for walking program § Increased activity tolerance § Verbalize

Audience Response Question A patient with peripheral artery disease has marked peripheral neuropathy. An

Audience Response Question The nurse teaches a patient with peripheral arterial disease. The nurse

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Description § Involves progressive narrowing & degeneration of arteries of upper & lower extremities § Atherosclerosis is leading cause in majority of cases § Patients with PAD are more likely to have coronary artery disease &/or cerebral artery disease Copyright © 2017, Elsevier Inc. All Rights Reserved.

Description § Typically appears at ages in sixth to eighth decades of life § Largely underdiagnosed § Risk factors § § § Tobacco use Chronic kidney disease Diabetes mellitus Hypertension Hypercholesterolemia Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. , a 62 -year-old man, complains of pain in his lower legs when walking his dog. § Pain is relieved with rest. § He has a history of hypertension & hyperlipidemia. § He smokes one pack of cigarettes per day. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § Classic symptom of PAD – intermittent claudication Ischemic muscle pain that is caused by a constant level of exercise § Resolves within 10 minutes or less with rest § Reproducible § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § Paresthesia § Numbness or tingling in the toes or feet § Produces loss of pressure & deep pain sensations § Injuries often go unnoticed by patient § True peripheral neuropathy in DM Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § Thin, shiny & 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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § Pain at rest § As PAD progresses § Occurs in feet or toes § Aggravated by limb elevation § Occurs from insufficient blood flow § Occurs more often at night Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § When assessing B. D. , you find that his feet are pale & cool to touch. § He has diminished pedal and posterior tibial pulses & decreased sensation. § He has a small open area on the lateral side of his left ankle. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Limb Ischemia (CLI) § Increased risk with DM, heart failure, hx CVA § Characterized by: Chronic ischemic rest pain lasting more than 2 weeks § Arterial leg ulcers or gangrene § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Complications § Atrophy of skin & underlying muscles § Delayed healing § Wound infection § Tissue necrosis § Arterial ulcers – most often over bony prominences on toes, feet, lower legs Copyright © 2017, Elsevier Inc. All Rights Reserved.

Complications § Nonhealing arterial ulcers & gangrene are most serious complications § Collateral circulation may prevent gangrene § May result in amputation § If adequate blood flow is not restored § If severe infection occurs Copyright © 2017, Elsevier Inc. All Rights Reserved.

Diagnostic Studies § Doppler ultrasound – if poor palpation § Segmental blood pressure § Ankle-brachial index (ABI) calculations § Done using a hand-held Doppler § Angiography & magnetic resonance angiography § Duplex imaging § Bidirectional, color Doppler Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § An angiography reveals nearly completely obstructed vessels in B. D. ’s lower extremities. § He is diagnosed with peripheral artery disease. § What treatment plan will you anticipate? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Risk Factor Modification § Tobacco cessation § Glycosylated hemoglobin <7. 0% for diabetics, aim for 6% § Aggressive treatment of hyperlipidemia § BP maintained <140/90, if DM: <130/80 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § ACE inhibitors § Ramipril (Altace) § ↓ Cardiovascular morbidity § ↓ Mortality § ↑ Peripheral blood flow § ↑ ABI § ↑ Walking distance Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Drugs prescribed for treatment of intermittent claudication § Cilostazol (Pletal) § Inhibits platelet aggregation § ↑ Vasodilation § Pentoxifylline (Trental) § Improves deformability of RBCs and WBCs § Decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. is ordered the following drugs: Aspirin 81 mg daily § Simvastatin (Zocor) 10 mg hs § Ramipril (Altace) 2. 5 mg daily § Pentoxifylline (Trental) 400 mg tid § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Exercise Therapy § Exercise improves oxygen extraction in legs & skeletal metabolism – increases survival rates § Walking is most effective exercise for individuals with claudication § 30 to 45 minutes daily, 3 times/week – minimum of 3 months Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Nutritional Therapy § BMI <25 kg/m 2 § Waist circumference <40 inches for men and <35 inches for women § Recommend reduced calories & salt for obese or overweight persons Copyright © 2017, Elsevier Inc. All Rights Reserved.

Raynaud’s Phenomenon § An episodic vasospastic disorder of small cutaneous arteries – esp. fingers & toes § More common in women § Caused by imbalance between vasodilation & vasoconstriction § May be in isolation or assoc. with… scleroderma, lupus, RA Copyright © 2017, Elsevier Inc. All Rights Reserved.

Raynaud’s… § Diagnosis based on § Sx for at least 2 years § Characterized by § Vasospasm induced color changes of fingers, toes, nose § Decreased perfusion – white § Cyanosis – blue § Hyperemic response – red with: Throbbing, pain, tingling & edema Copyright © 2017, Elsevier Inc. All Rights Reserved.

Raynaud’s… § Typical episodes last minutes but may last for hours § Triggers: exposure to cold, emotional upsets, tobacco, caffeine… § Primary focus – teaching prevention Loose, warm clothing § Place hands in warm water § Stress management § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Raynaud’s… § Following conservative mgt, meds: § Calcium channel blockers to relax arteriole smooth muscles § Vasodilators § Prompt intervention for digital ulceration &/or critical ischemia Meds, surgical debridment § Statins § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Leg With Critical Limb Ischemia § Revascularization via bypass surgery § Percutaneous transluminal angioplasty (PTA) § Non-surgical candidates: IV prostanoids (iloprost [Ventavis]) to decrease pain & improve ulcer healing § Spinal cord stimulation § Angiogenesis – growth factors, gene & stem cell therapy to stimulate blood vessel growth Copyright © 2017, Elsevier Inc. All Rights Reserved.

Thrombophlebitis § Acute inflammation of walls of veins § Venous thrombosis = formation of clot § Superficial thrombosis – often benign but… 25% also have… § Deep vein thrombosis that may lead to DVT or PE in first 3 months Copyright © 2017, Elsevier Inc. All Rights Reserved.

Thrombophlebitis… § Etiology of factors: Virchow’s triad § Venous stasis § Inactivity of muscles § Dysfunctional valves § Endothelial damage § Injury to vessels cause platelet activation § Hypercoagulability of blood § Many disorders § Estrogen based oral contraceptives Copyright © 2017, Elsevier Inc. All Rights Reserved.

Venous thromboembolism § Classic signs of inflammation § May have ulceration § Diagnostic studies: § Blood studies – bleeding time, INR, HCT, platelet count… § D-dimer – formed with clot lysis § Ultrasound studies § MRI venography Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional care… § Prevention & prophylaxis § JCAHO -> policies of prevention § Early mobilization § Compression stockings § Intermittent compression devices § Drug therapy – anticoagulants § Surgical therapy – thrombectomy, insertion of inferior vena cava filters Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing management § Assessment § Dx: pain, impaired skin integrity, potential complication: bleeding, PE § Acute care: Monitor for & decrease bleeding risk § Anticoagulant therapy § § Avoid IM injections § Teach avoidance of ASA, fish oils, NSAIDS… § Well-balanced diet Copyright © 2017, Elsevier Inc. All Rights Reserved.

Pulmonary embolism § When the clot lands in the lungs… § Clinical signs: SOB, crackles, hypoxemia, syncope, cough, chest pain… § Dx: d-dimer, scans, ventilation/perfusion scan (V/Q) § Prevention of DVTs Turn, cough, deep breathe, Inc. Spirometry § Anticoagulants, ambulation § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Leg With Critical Limb Ischemia § Conservative Treatment § Protect from trauma § Decrease ischemic pain § Prevent/control infection – inspect, cleanse, lubricate feet § Cover ulcers with DSD to maintain cleanliness § Deep wounds – wound care products § § Improve arterial perfusion Select soft, roomy & protective footwear, avoid extremes of heat & cold Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. returns for follow-up in 3 months. § His BP & lipid levels are stabilizing, but he complains of increasing leg pain at rest. § His physician determines that it is time to consider an intervention to improve his circulation. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Interventional Radiology Procedures § Done in a cath lab vs. OR § Indications § Intermittent claudication symptoms become incapacitating § Pain at rest § Ulceration or gangrene severe enough to threaten viability of the limb Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Interventional Radiology Procedures § Percutaneous transluminal angioplasty (PTA) Involves insertion of a catheter through femoral artery § Catheter contains a cylindrical balloon § Balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining § Stent is placed, may elute drug to prevent restenosis § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Interventional Radiology Procedures § Atherectomy § Removal of obstructing plaque § Performed using a cutting disc, laser, or rotating diamond tip Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Interventional Radiology Procedures § Cryoplasty § Combines percutaneous transluminal angioplasty & cold therapy § Liquid nitrous oxide Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Surgical Therapy § Most common surgical approach § Peripheral artery bypass surgery with autogenous vein or synthetic graft to bypass blood around the lesion § PTA with stenting may also be used in combination with bypass surgery Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Surgical Therapy § Endarterectomy – open artery & remove the plaque § Patch graft angioplasty – open artery, remove plaque & sew patch to widen lumen § Amputation – with extensive necrosis, gangrene, osteomyelitis, loss of blood supply Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Assessment § Exercise intolerance § Loss of hair on legs & feet § Decreased or absent peripheral pulses § Intermittent claudication Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. undergoes bilateral PTA with stenting. § What nursing diagnoses are appropriate for him? § What goals would you develop for him postoperatively? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Diagnoses § Ineffective peripheral tissue perfusion § Activity intolerance § Chronic pain § Ineffective health management Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Planning § Overall goals for patient with PAD § Adequate tissue perfusion § Relief of pain § Increased exercise tolerance § Intact, healthy skin on extremities § Increased knowledge of disease & treatment plan Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Identification of at-risk patients § Diet modification § Proper care of feet § Avoidance of injuries Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. comes to the recovery area after PTA with stenting. § He has bilateral dressings on his groins. § He is positioned supine. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § Frequently monitor after surgery § Skin color & temperature § Capillary refill § Presence of peripheral pulses distal to the operative site § Sensation & movement of extremity Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § Continued circulatory assessment § Monitor for potential complications § Knee-flexed positions should be avoided except for exercise § Turn & position frequently Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (©Jupiterimages/Photos. com/Thinkstock) § B. D. is being discharged home. § What will you teach him regarding immediate care & precautions at home? § What patient teaching is essential for him to help manage his disease? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Management of risk factors § Long-term antiplatelet therapy § Importance of supervised exercise training after revascularization § Importance of meticulous foot care Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Daily inspection of the feet § Comfortable shoes with rounded toes and soft insoles § Shoes lightly laced Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Evaluation § Adequate peripheral tissue perfusion § Increased activity tolerance § Effective pain management § Knowledge of disease & treatment plan Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Evaluation § 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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is a. Risk for injury related to decreased sensation. b. Impaired skin integrity related to decreased peripheral circulation. c. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d. Activity intolerance related to imbalance between oxygen supply and demand. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question 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. ” Copyright © 2017, Elsevier Inc. All Rights Reserved.