(Relates to Chapter 38,“Nursing Management: Vascular Disorders,”                         in the textbook)Copyright © 2010,...
 Progressive narrowing and degeneration of arteries of neck, abdomen, and extremities Leading cause • Atherosclerosis P...
   2X higher in Hispanic ♀ than white ♀   2-3 X higher in African American than white   Similar in men and women (when ...
 Certain segments of more likely • Coronary carotid • Common Iliac • Superficial femoral • Popliteal • Tibial arteries C...
Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
 Peripheral arterial disease (PAD) may affect • Aortoiliac artery • Femoral artery • Popliteal artery • Tibial artery • P...
 Classic symptom of PAD • Intermittent claudication   Ischemic muscle ache or pain that is    precipitated by a constant...
 Paresthesia • Shooting or burning pain in extremity • Present near ulcerated areas • Loss of sensations   Pressure and ...
 Thin, shiny, and taut skin Loss of hair on the lower legs Diminished or absent pulses • pedal, popliteal, or femoral ...
 Pain at rest • Occurs in the forefoot or toes • Aggravated by limb elevation • Occurs from insufficient blood flow • Occ...
 Atrophy • Skin • Underlying muscles Delayed healing Wound infection Tissue necrosis Arterial ulcers                 ...
 Most serious complications • Nonhealing arterial ulcers • Gangrene Result = amputation • If blood flow is not adequatel...
 Doppler ultrasound • Segmental blood pressures Ankle-brachial index (ABI) • Done using a handheld Doppler Duplex imagi...
 Smoking cessation Aggressive treatment of hyperlipidemia Hypertension and diabetes mellitus BP maintained <130/80 mm ...
 Antiplatelet agents • Aspirin • Ticlopidine (Ticlid) • Clopidogrel (Plavix)                      Copyright © 2010, 2007,...
 ACE inhibitors • Ramipril (Altacel)   ↓ Cardiovascular morbidity   ↓ Mortality   ↑ Peripheral blood flow   ↑ABI   ↑...
 Drugs for tx of intermittent claudication • Pentoxifylline (Trental)   ↑ Erythrocyte flexibility   ↓ Blood viscosity •...
 Exercise Improves O2 extraction in the legs and skeletal metabolism Walking • Most effective exercise for claudication...
 Dietary cholesterol <200 mg/day↓   intake of saturated fat Soy products • Use in place of animal protein              ...
 Ginkgo biloba • ↑ walking distance with intermittent claudication Folate, vitamin B6, cobalamin (B12) • Lowers homocyst...
 Protect from trauma Reduce vasospasm Prevent/control infection Maximize arterial perfusion Other strategies • Immune...
 Indications • Intermittent claudication symptoms become   incapacitating • Pain at rest • Ulceration or gangrene severe ...
 Percutaneous transluminal balloon angioplasty • Insertion of a catheter through femoral artery • Catheter contains a cyl...
 Most common surgical approach • A peripheral arterial bypass operation   Autogenous vein or synthetic graft material  ...
 Peripheral arterial bypass operation(cont’d) • Balloon angioplasty with stenting used in   combination with bypass surge...
 Past health history • Diabetes mellitus • Smoking • Hypertension • Hyperlipidemia • Obesity                       Copyri...
 Exercise intolerance Loss of hair on legs and feet Decreased or absent peripheral pulses                   Copyright ©...
 Ineffective tissue perfusion (peripheral) Impaired skin integrity Activity intolerance Ineffective therapeutic regime...
 Overall goals for patient with PAD • Adequate tissue perfusion • Relief of pain • Increased exercise tolerance • Intact,...
 Health Promotion • Identification of at-risk patients • Community involvement • Diet modification                       ...
 Acute Intervention • Frequently monitor after surgery   Skin color and temperature   Capillary refill   Presence of p...
 Acute Intervention • Continued circulatory assessment • Monitor for potential complications • Knee-flexed positions shou...
 Ambulatory and Home Care • Management of risk factors • Importance of meticulous foot care • Importance of gradual physi...
 Ambulatory and Home Care • Daily inspection of the feet • Comfortable shoes w/ rounded toes, soft insoles • Shoes lightl...
 Identify activities that promote circulation Maintain adequate peripheral tissue perfusion Experience intact skin,    ...
 Plans for walking program Increased activity tolerance Verbalize key elements of therapeutic regimen, knowledge of dis...
 62-year-old male complains of pain when walking his dog that is relieved with rest He has a history of hypertension and...
 He has edema in his feet Angiography reveals nearly obstructed vessels in lower extremities He is diagnosed with perip...
1.   What risk factors for peripheral arterial     disease does he display?2.   What can he do to prevent further     comp...
 Venous disorders • Venous Thrombosis • Chronic Venous Insufficiency                    Copyright © 2010, 2007, 2004, 200...
Factors in venous thrombosis 1. Venous stasis 2. Endothelial damage 3. Hypercoagulability                 Copyright © 2010...
 Manifestations • Palpable cord • Red, warm , tender skin • Mild temperature elevation • Possible edema Care • Elevation...
 Manifestations • Unilateral edema • Pain • Warm skin • Fever • Positive Homan’s sign (caveat) • May be minimally symptom...
 Potential Complications • Pulmonary embolism • Chronic venous insufficiency Diagnosis • Doppler                    Copy...
 Prevention and prophylaxis Anticoagulation • Prevention AND treatment • Lovenox • Heparin • Fondaparinux • Coumadin    ...
 Nursing Interventions • Management and teaching r/t anticoagulation   Safety   Monitoring   Diet   Minimization of b...
 Valves of the veins are damaged---> • Retrograde blood flow • Pooling of blood in the legs May lead to venous stasis ul...
 Manifestations • Brawny skin, possible eczema • Edema , possible severe • Venous ulcers   Tend to occur above medial ma...
 Care of ulcers • Compression of venous insufficiency    *avoid if concurrent PAD • Moist dressings • Balanced diet with ...
Ch38 revised peripheral arterialdisease
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Ch38 revised peripheral arterialdisease

  1. 1. (Relates to Chapter 38,“Nursing Management: Vascular Disorders,” in the textbook)Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  2. 2.  Progressive narrowing and degeneration of arteries of neck, abdomen, and extremities Leading cause • Atherosclerosis Patients between 60s and 80s (typically) • Much earlier in diabetics Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  3. 3.  2X higher in Hispanic ♀ than white ♀ 2-3 X higher in African American than white Similar in men and women (when adjusted for age) Largely undiagnosed and undertreated Risk factors • Cigarette smoking • Hyperlipidemia • Hypertension • Diabetes mellitus Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  4. 4.  Certain segments of more likely • Coronary carotid • Common Iliac • Superficial femoral • Popliteal • Tibial arteries Clinical symptoms • When vessel 60-75% occluded Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  5. 5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  6. 6.  Peripheral arterial disease (PAD) may affect • Aortoiliac artery • Femoral artery • Popliteal artery • Tibial artery • Peroneal artery Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  7. 7.  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 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  8. 8.  Paresthesia • Shooting or burning pain in extremity • Present near ulcerated areas • Loss of sensations  Pressure and deep pain • Injuries often go unnoticed by patient Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  9. 9.  Thin, shiny, and taut skin Loss of hair on the lower legs Diminished or absent pulses • pedal, popliteal, or femoral Pallor Reactive hyperemia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  10. 10.  Pain at rest • Occurs in the forefoot or toes • Aggravated by limb elevation • Occurs from insufficient blood flow • Occurs more often at night Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  11. 11.  Atrophy • Skin • Underlying muscles Delayed healing Wound infection Tissue necrosis Arterial ulcers Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  12. 12.  Most serious complications • Nonhealing arterial ulcers • Gangrene Result = amputation • If blood flow is not adequately restored • If severe infection occurs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  13. 13.  Doppler ultrasound • Segmental blood pressures Ankle-brachial index (ABI) • Done using a handheld Doppler Duplex imaging • Bidirectional, color Doppler Angiography Magnetic resonance angiography (MRA) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  14. 14.  Smoking cessation Aggressive treatment of hyperlipidemia Hypertension and diabetes mellitus BP maintained <130/80 mm Hg Glycosylated hemoglobin <7.0% for diabetics Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  15. 15.  Antiplatelet agents • Aspirin • Ticlopidine (Ticlid) • Clopidogrel (Plavix) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  16. 16.  ACE inhibitors • Ramipril (Altacel)  ↓ Cardiovascular morbidity  ↓ Mortality  ↑ Peripheral blood flow  ↑ABI  ↑ Walking distance Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  17. 17.  Drugs for tx of intermittent claudication • Pentoxifylline (Trental)  ↑ Erythrocyte flexibility  ↓ Blood viscosity • Cilostazol (Pletal)  ↑ Vasodilation  ↑ Walking distance Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  18. 18.  Exercise Improves O2 extraction in the legs and skeletal metabolism Walking • Most effective exercise for claudication • 30 to 60 minutes daily Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  19. 19.  Dietary cholesterol <200 mg/day↓ intake of saturated fat Soy products • Use in place of animal protein Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  20. 20.  Ginkgo biloba • ↑ walking distance with intermittent claudication Folate, vitamin B6, cobalamin (B12) • Lowers homocysteine levels Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  21. 21.  Protect from trauma Reduce vasospasm Prevent/control infection Maximize arterial perfusion Other strategies • Immune modulation therapy • Angiogenic gene therapy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  22. 22.  Indications • Intermittent claudication symptoms become incapacitating • Pain at rest • Ulceration or gangrene severe enough to threaten viability of the limb Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  23. 23.  Percutaneous transluminal balloon angioplasty • Insertion of a catheter through femoral artery • Catheter contains a cylindrical balloon • Balloon is inflated  Dilates the vessel by cracking the confining atherosclerotic intimal shell Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  24. 24.  Most common surgical approach • A peripheral arterial bypass operation  Autogenous vein or synthetic graft material  Bypass blood around the lesion • Synthetic grafts typically used for long bypasses Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  25. 25.  Peripheral arterial bypass operation(cont’d) • Balloon angioplasty with stenting used in combination with bypass surgery Endarterectomy Patch graft angioplasty Amputation Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  26. 26.  Past health history • Diabetes mellitus • Smoking • Hypertension • Hyperlipidemia • Obesity Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  27. 27.  Exercise intolerance Loss of hair on legs and feet Decreased or absent peripheral pulses Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  28. 28.  Ineffective tissue perfusion (peripheral) Impaired skin integrity Activity intolerance Ineffective therapeutic regimen management Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  29. 29.  Overall goals for patient with PAD • Adequate tissue perfusion • Relief of pain • Increased exercise tolerance • Intact, healthy skin on extremities Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  30. 30.  Health Promotion • Identification of at-risk patients • Community involvement • Diet modification Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  31. 31.  Acute Intervention • Frequently monitor after surgery  Skin color and temperature  Capillary refill  Presence of peripheral pulses distal to the operative site  Sensation and movement of extremity Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  32. 32.  Acute Intervention • Continued circulatory assessment • Monitor for potential complications • Knee-flexed positions should be avoided except for exercise • Turn and position frequently Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  33. 33.  Ambulatory and Home Care • Management of risk factors • Importance of meticulous foot care • Importance of gradual physical activity after surgery Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  34. 34.  Ambulatory and Home Care • Daily inspection of the feet • Comfortable shoes w/ rounded toes, soft insoles • Shoes lightly laced Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  35. 35.  Identify activities that promote circulation Maintain adequate peripheral tissue perfusion Experience intact skin, free of infection, on lower extremities Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  36. 36.  Plans for walking program Increased activity tolerance Verbalize key elements of therapeutic regimen, knowledge of disease, treatment plan, reduction of risk factors, and proper ulcer/foot care Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  37. 37.  62-year-old male complains of pain when walking his dog that is relieved with rest He has a history of hypertension and hyperlipidemia, and he smokes one pack of cigarettes per day Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  38. 38.  He has edema in his feet Angiography reveals nearly obstructed vessels in lower extremities He is diagnosed with peripheral arterial disease Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  39. 39. 1. What risk factors for peripheral arterial disease does he display?2. What can he do to prevent further complications?3. What patient teaching is essential for him to help manage his disease? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  40. 40.  Venous disorders • Venous Thrombosis • Chronic Venous Insufficiency Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  41. 41. Factors in venous thrombosis 1. Venous stasis 2. Endothelial damage 3. Hypercoagulability Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  42. 42.  Manifestations • Palpable cord • Red, warm , tender skin • Mild temperature elevation • Possible edema Care • Elevation • Heat, • Analgesics Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  43. 43.  Manifestations • Unilateral edema • Pain • Warm skin • Fever • Positive Homan’s sign (caveat) • May be minimally symptomatic Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  44. 44.  Potential Complications • Pulmonary embolism • Chronic venous insufficiency Diagnosis • Doppler Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  45. 45.  Prevention and prophylaxis Anticoagulation • Prevention AND treatment • Lovenox • Heparin • Fondaparinux • Coumadin Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  46. 46.  Nursing Interventions • Management and teaching r/t anticoagulation  Safety  Monitoring  Diet  Minimization of bleeding risk • Education about signs/symtpoms of PE Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  47. 47.  Valves of the veins are damaged---> • Retrograde blood flow • Pooling of blood in the legs May lead to venous stasis ulcers Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  48. 48.  Manifestations • Brawny skin, possible eczema • Edema , possible severe • Venous ulcers  Tend to occur above medial malleolus  Weepy, - extensive drainage  shallow, irregular shaped  Larger than arterial ulcers Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  49. 49.  Care of ulcers • Compression of venous insufficiency *avoid if concurrent PAD • Moist dressings • Balanced diet with adequate protein, vitamins A/C • Antibiotics if infection is present Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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