ALEX

1. Arterial
Venous
Lymphatic

2. Arterial Occlusive Disease (PAD-peripheral
arterial disease)
 Narrowing of arterial lumen
 Stenosis or occlusion
 May include intimal lining
damage
 Usually affects lower extremities
and areas with bifurcations
(when a blood vessel splits,
common for plaque to build up.
Common in iliac and femoral
artery
 90% of all PAD secondary to
athrosclorosis
 Can cause CAD, stroke and carotid
artery disease
 Poor public and physician
awareness of disease
epidemiology!!!!!!!!!!!!
 (ACC/AHA, 2011)

3. Incidence
 8 – 12 million Americans
are affected
 Greater incidence in AA
 Compared to Non-hispanic
whites
 Worst outcomes in
diabetic women b/c
 Common/preventable;
 poorly recognized
 Independent risk factor for
CV morbidity/mortality
 PAD tends to be less
intensively managed

4. Pathophysiology: atheroschlerosis,
vasospasm, inflammation

5. Etiology and Risk Factors of Arterial
Disease
 Atherosclerosis
 Embolism
 Thrombosis
 Trauma
 Spasm
 Inflammation
 Obesity
 **Smoking—doubles risk
of amputation; at least ½
of all with PAD smoke!!
 **Diabetes
 Stress
 Hyperlipidemia,Tgl
 HTN
 **> 60 Age
 Sedentary lifestyle
 Chronic kidney disease
 Homocystine- high levels

7. Clinical Manifestations of PAD
 Pain with walking—claudication*; or at rest ischemia (more
severe/advanced disease) can be in the calf, thigh, buttox, or foot
 Cramps/pain at night, relieved when hanging down
 Dependent rubor, blanched on elevation
 Cool extremity
 Weak or absent pulse
 Hypertrophic changes of nails
 Tissue atrophy, ulceration, gangrene
 Paresthesias
 Impotence in males
 Critical limb ischemia-pain at rest, non-
Healing wounds, gangrene

8. What is the Patho?
 Ischemia---anaerobic----lactic acid----pain due to
decreased blood supply
 Vasodilation
 Pain, increases blood flow distally when legs are hung
down
 Collateral circulation- body compensates in other ways
to get blood to where it needs to go by making
alternative blood vessels

9. Arterial vs Venous Assessment
Arterial Venous
Pulses Decreased/0 present
Cap refill > 3 sec < 3 sec
ABI- ankle brachial
index, looks at
pulses and pressure
< 0.75 > .90
Edema 0 +
Hair 0 Present or 0
Ulcer Tips toes, heel, lat
ankle
Medial ankle
Skin color Rubor, elevation
pallor
Brown varicose
veins
Skin texture Thin, shiny Thick, hardened

10. Arterial Ulcer

11. Compare PAD with Venous Ulcer

13. Name that disease! Name
signs/symptoms

14. Assessment Findings—Is IT PAD or Venous
Disease?
 Pulses
 Capillary refill
 Edema
 Hair
 Skin
 Ankle/brachial index
 Doppler- ultrasound
 Duplex scan- involves both
arterial and venous
 Arteriogram- invasive
procedure that injects dye to
look for blockages

15. When would the nurse use the
doppler at the bedside?

16. What is the ABI? What is a normal
measurement? Abnormal?

17. Doppler Ultrasound

18. Name Nursing Diagnoses,Outcomes,
and Interventions for Patients with
PAD

19. Nursing Diagnoses: Impaired Tissue Perfusion
Outcome: Patient will have palpable pulses,
pink/warm dry skin, cap refill < 3 seconds
Interventions:
 Assess & monitor tissue perfusion- specify
 Prevent limb ischemia
 Avoid knee flex positions
 Reverse trendelenberg positioning- head up, feet dwn will increase
perfusion
 Balance activity with rest, bedrest if ulcers present
 Avoid constrictive clothing, crossing legs
 Prevent vasoconstriction
 Avoid tobacco, stress, cold- leads to vasoconstriction
 Provide protective clothing, relaxation exercises, administer
vasodilating drugs, eg. Pletal as ordered and assess response

20. Tissue Perfusion Continued:
Pharmacologic therapy
 Antiplatelet agents
 Aspirin
 Ticlodipine (Ticlid)
 Clopidogrel (Plavix)
 Cilostazol (Pletal) also vasodilates
 Decrease blood viscosity
 Pentoxifylline (Trental)

21. Tissue Perfusion Continued
 Thrombolytic therapy—What is the rationale for these
medications? What are indications? What are
potential complications?
 Streptokinase, urokinase
 Tissue plasminogen activator (TPA)- clot buster drug
 Not used for old calcified blockages
 Side effect could be major bleeding

22. Medication Management-Clinical
Reasoning Questions?
What is the nurse monitoring when the patent is receiving
the following?
Anticoagulant therapy
Heparin
Enoxaparin (Lovenox )
Warfarin (Coumadin)
Low-molecular weight heparin
Why might the patient be on Heparin and Coumadin at
the same time?
What safety precautions and patient teaching must the
nurse perform when caring for patients receiving these
meds??

23. Nursing Diagnosis: Impaired Tissue Integrity
Outcome: Patient’s skin will remain intact or the wound
that is present will not increase in size, redness, drainage
and will demonstrate s/s of granulation tissue growth
Interventions:
 Regular skin care (specify) and assess
 Prevent pressure-float heels
 Monitor tops of toes, medial malleolus
 Foot cradle
 Foot care
 Provide roomy protective footwear
 Prevent injury
Wound care if skin breakdown present

24. What Do We Teach Our Patients
About Foot Care?

25. Nursing Diagnosis: Imbalanced Nutrition
Outcome: Patient will maintain weight of ____;
albumin levels will remain at least 3mg/dl
Interventions:
 Dietary consult for weight control and nutrition plan
 Lipid control – no more than 30% daily calories from
fat and no more than 7% from saturated and trans-fats.
 Limit sodium (Na) to no more than 2,400 mg (2.4 g)
per day

26. Diagnosis: Alteration in Comfort: Pain
Outcome: Pain will be < 4/10
Interventions:
 Appropriate positioning
 Avoid standing for more than a few minutes
 Avoid leg crossing
 Assess for edema
 Antiplatelet and vasodilating drugs as ordered
 Chronic pain management- gabapentin- seizure
medication used for chronic pain along with lyrica and
sometimes antidepressants

27. Nursing Diagnosis:Activity Intolerance
Outcome: Patient will be able to walk at least 10 feet without pain;
rest pain will be < 4/10 (different for every patient depending on
disease severity)
Interventions:
 Careful history to identify activities that are poorly
tolerated
 PT, structured walking program
 Clients who should not exercise include those
with:
 Ulcers
 Deep vein thrombosis
 Pain at rest
 Cellulitis
 Gangrene

28. Medical Management of PAD
 Slow progression of disease
 Promote arterial blood flow to relieve symptoms,
savage limbs, and improve functional status
 Prevent a CV event: MI, stroke, vascular death
(ACC/AHA, 2011)

29. To Summarize:Interventions for
Arterial disease
Weight loss—BMI 18.5-24.9
 Structured gradual exercise-EB
 Smoking cessation
 Proper positioning
 Glucose control in diabetes
 Low fat, low cholesterol diet-LDL <100, or 70
 B/P control-BB--ACEI--<140/90 or 130/80 if
DM/renal insuff.
 Foot care
 Pharmacologic therapy to promote blood flow-EB
 Revascularization procedures (ACC/AHA, 2011)

30. Surgical Interventions
 Angioplasty with or without stent placement
 Peripheral artery bypass graft
 Patch graft angioplasty
 Endarterectomy or arthrectomy
 Amputation

31. Indications for Revascularization:
 Predicted or observed lack of adequate response to exercise therapy and
claudication pharmacotherapies
 Presence of a severe disability, with the patient being unable to perform
normal work or having very serious impairments of other activities important
to the patient
 Absence of other disease that would limit exercise even if the claudication was
improved (e.g., angina or chronic respiratory disease)
 Anticipated natural history and prognosis of the patient
 Morphology of the lesion, which must be such that the appropriate
intervention would have low risk and a high probability of initial and long-term
success
 Adapted from Dormandy JA, Rutherford RB: Management of peripheral arterial disease (PAD). TASC
Working Group. TransAtlantic Inter-Society Concensus (TASC). J Vasc Surg 2000;31(Suppl):S1-S296.
© 2000, with permission from Elsevier.

33. Patch Graft Angioplasty

34. Peripheral Arteriogram-What is included in the
patient-teaching pre-procedure? Describe the
nursing care after the procedure?

35. Nursing Implications Post Angioplasty Care
 Monitor tissue perfusion, compare to pre-procedure
perfusion.
 Monitor for bleeding: puncture site, swelling,
ecchymosis, hematoma, decrease in hemoglobin or
hematocrit
 Check renal function; IVF; implications of dye
 Re-occlusion requires re-do sometimes

36. Clinical Reasoning
 What are your primary concerns when caring for a
patient post-arteriogram?
 What are the rationales for these concerns?
 What nursing diagnosis statements will guide your
plan of care?
 What medical or nursing interventions will you
initiate based on these concerns?
 What are some of the worst possible consequences to
anticipate?

37. Bypass Graft
 Grafts – synthetic arteries or veins (eg saphenous
vein) taken from other areas and are surgically
connected to bypass the occluded area.
 Can reocclude
 Monitor for perfusion, wound healing, infection
 Anticoagulants and antiplatelet drugs to prevent
re-occlusion
 Ace wraps only if swelling occurs
 Sometimes many trips back to OR due to re-occlusion
or infection

40. Case Study
 42 year old female with type 1 diabetes presents with paresthesias
and pain in LE at rest.
 PMH: DM X 35 years, history of angina, S/P CABG 1997,
retinopathy, nephropathy, pericarditis. Family history of CAD.
Client smoked X 25 yrs.—quit 1997. Has had intermittent
claudication X 5 years.
 V.S.: P: 80; b/p: 148/90; RR: 18
 Assessment: Pale, thin, cool, pulseless legs that become
purple/red when dependent. States 5/10 burning, stabbing
bilateral leg pain at rest and can only transfer self to/from
wheelchair; unable to walk.
 Duplex of LE reveals severe bilateral stenosis of popliteal artery.
Femoral/popliteal bypass is performed.

41. Case Study Analysis: Clinical Reasoning/Critical
Thinking: Identifying Relationships
CC: “Parasthesias and rest pain”
Past History Home Meds
 Diabetes
 Angina
 CABG
 Nephropathy, retinopathy,
 Neuropathy
 Claudication
 What meds would you expect
to see this patient taking?

42. House of Cards: Patho
Past Medical History What came first? What happened
next? How does it all relate?

43. What is the relationship b/t the medical
history and the Chief Complaint?
 Medical History
 Chief Complaint:
 How is your assessment related to the chief complaint
and the medical history?

44. Amputation
 For gangrene or osteomyelitis or chronic wounds
that do not resolve.
 Level of amputation
 Types of amputations: open, closed
 Post-op care focuses on:
 Stump care
 Pain management including phantom limb pain
 Prevention of injury/falls
 Promotion of mobility
 Body image changes
 Prosthesis management

45. Levels of Amputation—What
Determines the Level of
Amputation?
Medscape, 2012

46. Amputation
 Flap  Guillotine

47. Unfolding Case
 An 81-year-old patient presented to the hospital with
rest pain, non-healing ulcers and gangrene. The
patient was hypertensive, diabetic, a previous smoker, had
a prior cerebral vascular accident and a local infection of
the treatment limb. Duplex scan revealed 100% occlusion
of superficial femoral artery and > 70% stenosis of the
popliteal artery. The patient underwent angioplasty of the
femoral and popliteal arteries on the affected leg.
Restenosis of the popliteal artery occurred 1 month later,
the foot now developed gangrene. Amputation of the foot
was scheduled.

48. Case Study Analysis

49. Acute Arterial Occlusion- Ischemia
 Embolis or thrombosis; maybe acute trauma
 Clinical manifestations = 6 P’s:
 Pulselessness
 Pain
 Pallor
 Paresthesias
 Paralysis
 Poikilothermia (cold)

50. Buerger’s Disease
 Vasculitis of small and
medium-sized veins and
arteries
 Cause unknown-ETOH,
more often in men?
 Manifestations
 Pain arches feet especially
 Digital ulcers
 Temperature and color
changes hands & feet
 Treatment
 Vasodilators
 Pain management
 Smoking cessation

51. Raynaud’s Syndrome  Arterial spasm
 Intermittent spasm
affecting digital arteries
caused by nicotine, cold,
caffeine, stress
 Clinical manifestations
 Pallor of hands followed by
cyanosis and then rubor
 Treatment
 Calcium channel blockers,
alpha blockers, keep hands
warm, smoking cessation

52. Raynaud’s Syndrome

53. Varicose Veins—a chronic Venous
problem

54. Venous Disorders
 Acute
 Superficial
thrombophlebitis
 Deep vein
thrombophlebitis
 Chronic
 Chronic venous
insufficiency

55. Venous System

56. What Do They Look Like?
What Do We Assess?
What Do We Teach Our Patients?

57. Chronic Venous Insufficiency
 Identify causes: what are
they?
 Can lead to chronic edema
 Can lead to cellulitis
 Can lead to difficult to heal
ulcers
 Can lead to chronic venous
stasis changes—stasis
dermatitis
 What is the Management of
venous stasis ulcers?
 Promotion of venous return
 Prevention of skin
breakdown

58. Venous Ulcer-How do you know?
How is it different than an arterial
ulcer/wound?

59. What are the characteristics of a
Venous Wound?

60. How Do We Treat Venous Ulcers
 Treat cause of edema
 Diuretics
 Antibiotics if cellulitis and s/s of infection
 Ace wraps
 Dressing Changes
 Unna Boot
 If chronic wounds, constantly infected, frequent
septicemia, multiple hospitalizations, interfering with
quality of life---- patient may need an amputation

61. Compression---Unna Boot

62. VTE—Venous Thromboembolism
(DVT is one example)
 Etiology and risk factors:
 Venous stasis
 Hypercoagulability
 Injury to vein wall

63. Pathophysiology of DVT
 Begins with platelet adherence to endothelium
 Platelet plug develops
 Inflammation develops
 Clot can dislodge and become an embolus
 Pulmonary embolus may be lethal.

65. VTE Prophylaxis:
 Active and passive ROM
 Ambulation, leg exercises
 Ted hose, sequential compression devices (SCD’s)
 Elevate legs to promote venous return
 Deep breathing & coughing promotes venous
return
 Avoid hip and knee flexion
 Pharmacologic agents: ASA, low-dose heparin
(5,000 units subc, q12h), lovenox

66. Clinical Manifestations
 Superficial phlebitis
 Local redness, pain, warmth,
palpable vein, purulent
drainage (late sign of
suppurative phlebitis).
 DVT (VTE)
 Erythema, pain, edema,
warmth, low-grade fever,
dilated veins, positive
homan’s sign (not reliable-not
used in practice)
 50% of clients are
ASYMPTOMATIC

67. Diagnosis of DVT-what is the
patient teaching involved with
each of these diagnostic tests?
 Doppler
 Duplex
 D-dimer

68. Medical Management
 Anticoagulation
 Heparin
 Lovenox
 Warfarin (Coumadin)
 Thrombolytic agents
 Vena Cava filter/Greenfield/ “Umbrella”

69. Nursing Diagnoses
 Impaired tissue perfusion
 Pain
 Risk for injury: bleeding related to anticoagulant therapy
 Knowledge deficit
Patient Outcomes:
 Patient will not exhibit s/s of PE:
 Patient will be pain free
 Patient will not exhibit s/s of bleeding
 Patient will be able to re-state what the plan of care will be
related to anti-coagulation

70. Nursing Management of DVT
 Bedrest until anticoagulated
 Elevate extremity
 Avoid constriction of affected extremity
 Ted hose or elastic wraps (ace wraps) on other
extremity
 Monitor anticoagulant therapy, s/s bleeding
 Monitor for pulmonary embolism
 Maybe heparin continuous IV or maybe low molecular
weight heparin subq may be used

71. Monitoring Anticoagulant Therapy: Heparin
IV continuous
 Most heparin dosing is weight-based.
 Initial IVP bolus followed by IV infusion on pump
 Monitor activated Partial Thromboplastin Time
(aPTT or PTT). The goal is 1.5-2 X control. (60-90
seconds on Heparin—high so no clots)
 Monitor PTT q6H until stable
 Antidote for heparin – protamine sulfate
 Note: Heparin given subq usually does not alter the
PTT greatly.

72. Monitoring Coumadin dosing:
 Takes several days to achieve therapeutic blood level.
 Therefore, heparin begun first.
 Protime (PT) and International Normalized Ratio
(INR) are monitored for therapeutic blood levels of
coumadin. (INR between 2-3)
 Coumadin administered orally.
 Antidote for Coumadin – Vitamin K
 What are implictations for diet teaching?
 What other things should be included
in the patient centered teaching plan?

73. Patient Safety!!! Monitor for S/S
bleeding:
 GI blood loss
 Stools for occult blood, bloody emesis
 Conjunctival hemorrhage
 Bleeding gums after brushing teeth
 Bleeding from any skin lesions, catheter insertion sites
 Hemoptysis
 Hematuria,
 Flank pain—what might this be a sign of?
 Subcutaneous bruising
 What PTT levels would be too high if the patient was receiving
Heparin?
 What INR levels would be too high if the patient was receiving
Coumadin?

74. Institute bleeding precautions:
 What should be taught about shaving?
 Is it OK to take rectal temperatures or give rectal
suppositories to patients on anticoagulants? Why?
Why not?
 Institute fall precautions

75. Evaluation
 Adequacy of tissue perfusion-limb salvage
 Skin integrity/wound healing
 Pain management
 Prevention of injury/complications
 Appropriate management of anticoagulation therapy
 Improvement of functional status
 Patient demonstrates knowledge of therapeutic
regimen