N366 Module 1 PowerPoint 2 of 3 (1).pptx

Peripheral Artery
Disease of the
Lower Extremities
Chapter 37 Vascular Disorders
N366 Module 1
Copyright © 2017, Elsevier Inc. All Rights Reserved.

Description
• Involves progressive narrowing and
degeneration of arteries of upper and lower
extremities
• Atherosclerosis is leading cause in majority of
cases
• Patients with PAD are more likely to have
coronary artery disease and/or cerebral artery
disease

Common Sites of Atherosclerotic
Lesions

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

Description
• Peripheral artery disease (PAD) may affect
• Iliac artery
• Femoral artery
• Popliteal artery
• Tibial artery
• Peroneal artery
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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
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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
This Photo by Unknown Author is licensed under CC
BY-ND

Clinical
Manifestations
• 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

• 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
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CC BY-SA

Critical Limb Ischemia (CLI)
• Characterized by:
• Chronic ischemic rest pain lasting more than 2
weeks
• Arterial leg ulcers or gangrene
Copyright © 2017, Elsevier Inc. All Rights Reserved. This Photo by Unknown Author is licensed under CC
BY-SA

Complications
• Atrophy of skin and underlying muscles
• Delayed healing
• Wound infection
• Tissue necrosis
• Arterial ulcers

Complications
• Nonhealing arterial ulcers and gangrene are
most serious complications
• May result in amputation
• If adequate blood flow is not restored
• If severe infection occurs

Diagnostic Studies
• Doppler ultrasound
• Segmental blood pressure
• Ankle-brachial index (ABI)
• Done using a hand-held Doppler
• Angiography and magnetic resonance
angiography
• Duplex imaging
• Bidirectional, color Doppler
This Photo by Unknown Author is
licensed under CC BY

Interprofessional Care
Risk Factor Modification
• Tobacco cessation
• Glycosylated hemoglobin <7.0% for diabetics
• Aggressive treatment of hyperlipidemia
• BP maintained <140/90

Drug Therapy
• ACE inhibitors
• Ramipril (Altace)
• ↓ Cardiovascular morbidity
• ↓ Mortality
• ↑ Peripheral blood flow
• ↑ ABI
• ↑ Walking distance

Drug Therapy
• Antiplatelet agents
• Aspirin
• Clopidogrel (Plavix)
This Photo by Unknown Author is licensed under CC BY-SA-NC

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

Exercise Therapy
• Exercise improves oxygen extraction in legs
and skeletal metabolism
• Walking is most effective exercise for
individuals with claudication
• 30 to 45 minutes daily, 3 times/week

Nutritional Therapy
• BMI <25 kg/m2
• Waist circumference <40 inches for men and
<35 inches for women
• Recommend reduced calories and salt for
obese or overweight persons

Leg With Critical Limb Ischemia
• Revascularization via bypass surgery
• Percutaneous transluminal angioplasty (PTA)
• IV prostanoids (iloprost [Ventavis])
• Spinal cord stimulation
• Angiogenesis

Leg With Critical Limb Ischemia
• Conservative Treatment
• Protect from trauma
• Decrease ischemic pain
• Prevent/control infection
• Improve arterial perfusion

Interventional Radiology Procedures
• Indications
• Intermittent claudication symptoms become
incapacitating
• Pain at rest
• Ulceration or gangrene severe enough to threaten
viability of the limb
This Photo by Unknown
Author is licensed under
CC BY-NC-ND

• 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
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is licensed under CC BY-SA

• Atherectomy
• Removal of obstructing plaque
• Performed using a cutting disc, laser, or rotating
diamond tip

• Cryoplasty
• Combines percutaneous transluminal angioplasty
and cold therapy
• Liquid nitrous oxide

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

Bypass Grafts

Surgical Therapy
• Endarterectomy
• Patch graft angioplasty
• Amputation

Nursing Management
Nursing Assessment
• Past health history
• Diabetes mellitus
• Smoking
• Hypertension
• Hyperlipidemia
• Obesity

Nursing Management
Nursing Assessment
• Exercise intolerance
• Loss of hair on legs and feet
• Decreased or absent peripheral pulses
• Intermittent claudication
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Nursing Management
Nursing Diagnoses
• Ineffective peripheral tissue perfusion
• Activity intolerance
• Chronic pain
• Ineffective health management

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 and treatment plan
This Photo by Unknown Author
is licensed under CC BY-SA

Nursing Management
Nursing Implementation
• Health Promotion
• Identification of at-risk patients
• Diet modification
• Proper care of feet
• Avoidance of injuries
This Photo by Unknown Author is licensed under CC BY-
ND

Nursing Management
• Acute Care
• Frequently monitor after surgery
• Skin color and temperature
• Capillary refill
• Presence of peripheral pulses distal to the operative
site
• Sensation and movement of extremity

Nursing Management
• Acute Care
• Continued circulatory assessment
• Monitor for potential complications
• Knee-flexed positions should be avoided except for
exercise
• Turn and position frequently

Nursing Management
• Ambulatory Care
• Management of risk factors
• Long-term antiplatelet therapy
• Importance of supervised exercise training after
revascularization
• Importance of meticulous foot care

Nursing Management
• Ambulatory Care
• Daily inspection of the feet
• Comfortable shoes with rounded toes and soft
insoles
• Shoes lightly laced

Nursing Management
Evaluation
• Adequate peripheral tissue perfusion
• Increased activity tolerance
• Effective pain management
• Knowledge of disease and treatment plan

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

Acute Arterial
Ischemic Disorders
N366 Module 1

• Etiology and pathophysiology
• Sudden interruption in arterial blood supply to a
tissue, organ, or extremity. If untreated, can result
in tissue death
• Causes: embolism, thrombosis, or trauma
• related to: infective endocarditis, mitral valve
disease, atrial fibrillation, cardiomyopathies, and
prosthetic heart valves
• Noncardiac causes: aneurysms, ulcerated
atherosclerotic plaque, endovascular procedures, and
venous thrombi
Acute Arterial Ischemic Disorders

Clinical
Manifestations
• 6 P’s
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis (late sign)
• Poikilothermia
• Immediate intervention
needed to avoid
ischemia, necrosis, and
gangrene

Interprofessional
Care
• Early diagnosis and treatment
• Anticoagulant—IV heparin
• Restore blood flow—remove
thrombus
• Surgical thrombectomy
• Percutaneous catheter-
directed thrombolytic therapy
• Percutaneous mechanical
thrombectomy with or
without thrombolytic therapy
• Surgical bypass

Thromboangiitis Obliterans
• Buerger’s disease
• Nonatherosclerotic, segmental, recurrent
inflammatory disorder of the small and
medium arteries and veins of the arms and
legs
• Most common in men younger than 45 years
old with history of tobacco and/or
marijuana use without other CVD risk
factors

• Acute phase
• Inflammatory thrombus blocks vessel
• Chronic phase
• Thrombosis and fibrosis causes ischemia
• Symptoms
• Intermittent claudication of feet, hands, or arms;
rest pain, ischemic ulcerations, changes in color and
temperature, paresthesia, superficial vein
thrombosis and cold sensitivity

• No specific lab or diagnostic tests
• Based on history and symptoms and
exclusion of other disorders
• Treatment: no smoking tobacco or
marijuana; no nicotine replacements
• Conservative:
• Avoid cold exposure; walking program, antibiotics
for ulcers, analgesia for pain, avoid trauma

• IV iloprost—promotes vasodilation
• Surgeries
• Lumbar sympathectomy
• Spinal cord stimulator
• Microsurgical flap and omental transfer
• Bypass surgery
• Amputation
• Stem cell therapy

Raynaud’s Phenomenon
• Episodic, vasospastic disorder of small
cutaneous arteries; fingers and toes most
commonly involved
• More common in women, age 15 to 40 years.
• Pathogenesis—abnormalities in vascular,
intravascular, and neuronal mechanisms
that cause vasodilation

• May occur alone or with other diseases
• Contributing factors:
• Use of vibrating machinery
• Work in cold environments
• Exposure to heavy metals
• High homocysteine levels
• Diagnosis: persistent symptoms for at least
2 years

• Characteristic change in color of fingers,
toes, ears, and nose
• White, blue, and red (Fig. 37-3)
• Also: coldness, numbness followed by throbbing,
aching pain, tingling, and swelling
• Several minutes to hours
• Prolonged, frequent attacks causes thick skin,
brittle nails, punctate lesions and gangrenous ulcers
• Triggers: exposure to cold, emotional upset,
tobacco use and caffeine

• Nursing care
• Patient education: prevent episodes
• Avoid temperature extremes; wear
appropriate clothing
• No tobacco products; avoid caffeine
• No vasoconstrictor drugs

• Drug therapy—
• Sustained release calcium channel
blockers to decrease vasospasm
• Vasodilators
• Digital ulceration or critical ischemia
• Prostacyclin infusion, antibiotics,
analgesia
• Surgical debridement
• Botox and statins
• Sympathectomy

Acute and Chronic
Venous Disorders

Phlebitis
• Acute inflammation of the walls of
small cannulated veins of the hand or
arm (related to IV catheter)
• Manifestations: pain, tenderness,
warmth, erythema, swelling, and
palpable cord
• Risk factors: irritation from catheter,
infusion of irritating drugs, and
catheter location (area of flexion)

1,280 × 960

Phlebitis
• Rarely infectious
• Treatment: remove catheter
• Edema
• Elevate extremity
• Pain and inflammation
• NSAIDs
• Warm, moist hear

Venous Thrombosis
• Formation of a thrombus (clot) with vein
inflammation
• Most common venous disorder
• Superficial vein thrombosis
• Deep vein thrombosis (DVT)
• Venous thromboembolism (VTE)
• DVT to pulmonary embolism (PE)

Venous Thrombosis Embolism
(VTE) Causes
• Venous stasis
• Endothelial damage
• Direct damage
• Surgery, burns, IV catheter, trauma, prior
VTE
• Indirect damage
• Chemotherapy, diabetes, sepsis
• Hypercoagulability of blood

VTE: Manifestations
• Deep veins of arms or legs, pelvis, vena cava,
and pulmonary system
• Manifestations
• Lower extremity
• Unilateral edema
• Pain, tenderness with palpation
• Dilated superficial veins
• Full sensation in thigh or calf
• Paresthesias
• Red, warm
Fever greater than 100.4° F (38° C)

VTE: Diagnosis
• Diagnosis:
• Assessment, D-dimer and/or ultrasound
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BY-SA

VTE: Complications
• Most serious:
• PE
• Chronic thromboembolic pulmonary
hypertension
• Postthrombotic syndrome (PTS)
• Phlegmasia cerulea dolens
This Photo by Unknown Author is
licensed under CC BY-NC-ND

VTE: Diagnostic Studies
• Blood: ACT, aPTT, INR, bleeding time,
Hgb, Hct, platelet count, D-dimer,
fibrin monomer complex
• Noninvasive venous: venous
compression ultrasound, duplex
ultrasound
• Invasive venous: CT venography, MR
venography, contrast venography

VTE: Interprofessional Care
• Early and aggressive mobilization
• Graduated compression stockings
• Thromboembolic deterrent (TED)
• Intermittent pneumatic compression
devices (IPCs) - increased venous return
• Drug therapy: anticoagulants
• VTE prophylaxis: prevent clot formation
• Existing VTE: prevent: new clot formation, spread of
the clot, and embolization

VTE: Drug Therapy
• Vitamin K antagonists: Warfarin
• Inhibits Vitamin K-dependent coagulation factors II,
VII, IX, and X and anticoagulant proteins C and S
• For long-term or extended anticoagulation
• Takes 48 to 72 to be effective; often
overlap with parenteral anticoagulant for 5
days
• Monitor INR
• Antidote: Vitamin K
This Photo by Unknown Author is licensed under CC BY-NC-ND

VTE: Drug Therapy
• Thrombin inhibitors
• Heparin (continued)
• Serious side effect:
heparin-induced
thrombocytopenia (HIT)
• Long-term side effect:
osteoporosis
• LMWH—enoxaparin
• More predictable, longer
half-life, fewer bleeding
complications
• Antidote: protamine

VTE: Drug Therapy
• Direct thrombin inhibitors
• Hirudin derivative—bivalirudin (Angiomax)
• Synthetic (Argatroban)
• Factor Xa Inhibitors
• Fondaparinux (Arixtra)—Subcutaneous
• Rivaroxaba (Xarelto), apixaban (Eliquis),
edoxaban (Savaysa)—oral
• Andexant Alfa—reverses rivaroxaban and
apixaban

VTE: Interprofessional care
• Anticoagulant therapy for VTE treatment
• INR—maintain 2.0 to 3.0 (VKA therapy)
• Thrombolytic therapy for VTE treatment
• Thrombolytic drug (tPA or urokinase)
administered via catheter to dissolve clots,
reduce acute symptoms, improve deep
venous flow, reduce valvular reflux, and 
PTS

VTE: Interprofessional
care
• Surgical and interventional
radiology therapies
• Open venous
thrombectomy—
incision into vein to
remove clot
• Inferior vena cava
interruption devices—
filters placed via
right femoral or
internal jugular veins
to trap clots without
impeding blood flow

VTE: Interprofessional care
• Percutaneous endovascular interventional radiology
procedures
• Options: Mechanical thrombectomy,
pharmacomechanical devices, post-
thrombus extraction, angioplasty, and/or
stenting
• Can be used with catheter-directed
thrombolytic therapy
• Nursing care: Maintain catheter systems,
monitor for bleeding, embolization, and
impaired perfusion; and teach VTE
prevention

Nursing Management: VTE
• Nursing assessment
• Subjective data
• Important health information
• Past history
• Medications
• Surgery or other treatments
• Functional health patterns
• Health-perception–Health management
• Activity–exercise
• Cognitive–perceptual

• Nursing assessment
• Objective data
• General
• Integumentary
• Cardiovascular
• Possible diagnostic findings
Copyright © 2017, Elsevier Inc. All Rights Reserved. This Photo by Unknown Author is licensed
under CC BY

• Nursing diagnoses
• Acute pain
• Impaired tissue
integrity
• Impaired mobility
• Risk for bleeding
• Planning/goals:
• The patient will have:
• Pain relief
• Decreased edema
• Increased
knowledge of
disease and
treatment plan
• No skin
ulceration
• No bleeding
complications
• No evidence of
PE

• Nursing implementation: Acute care
• Focus on prevention of thrombi and reduction of
inflammation
• Monitor anticoagulation and significant lab studies;
titrate drug doses and administer reversal agents as
needed
• Monitor and reduce the risk of bleeding
• Acute VTE—initial bed rest
• Early ambulation
• Teach importance of physical activity

Nursing
Management: VTE
• Ambulatory care
• Discharge teaching
• VTE risk factors
• Drug doses, actions, side
effects and routine blood
tests; wear medic-alert ID
• Dietary and Exercise
Instructions
• Guidelines for follow-up
• Evaluation
• Expected outcomes:
• Minimal to no pain
• Intact skin
• Increased knowledge of
disorder and treatment
plan
• No signs of hemorrhage or
occult bleeding

Varicose Veins
(Varicosities)

Varicose Veins (Varicosities)
• Etiology and pathophysiology
• Superficial veins in legs become dilated and
tortuous from retrograde blood flow and  venous
pressure
• Risk factors:
• Family history of venous problems, female,
tobacco use, aging, obesity, multiparity,
history of VTE, venous obstruction,
phlebitis, leg injury, prolonged sitting or
standing

Varicose Veins (Varicosities
• Clinical manifestations
• Most common symptoms: heavy, achy feeling or
pain after prolonged standing or sitting;
relieved by walking or limb elevation
• Other: pressure, itchy, burning, tingling, throbbing,
or cramp-like sensation
• Complications
• Most common: superficial venous thrombosis
• Other: rupture of varicosities results in bleeding and
skin ulcerations

• Diagnosis
• Examination
• Duplex ultrasound
• Interprofessional care
• Conservative treatment:
• Rest with limb elevation
• Leg-strengthening exercises
• Weight loss
This Photo by Unknown Author is licensed under CC BY-NC

• Drug therapy
• Venoactive drugs
• Interventional and Surgical Therapies
• Sclerotherapy—ablates vein by direct injection of
sclerosis agent
• Transcutaneous laser therapy or high-intensity
pulsed light therapy
• Endovenous ablation—radiofrequency or laser
therapy

Varicose Veins
• Interventional and surgical therapies
• Traditional: ligation of vein and branches
• Ambulatory phlebectomy
• Transilluminated powdered phlebectomy
• Complications: bleeding, bruising, and
infection

Nursing Management: Varicose
Veins
• Prevention
• Avoid prolonged sitting or standing
• Maintain ideal weight
• Avoid injury
• Avoid restrictive clothing
• Walk every day
• Postoperative
• Deep breathing
• Neurovascular assessment
• Elevate legs
• Graduated compression stockings—remove every 8
hours for short time then reapply

Nursing Management: Varicose
Veins
• Long-term management
• Improve circulation and appearance
• Relieve discomfort
• Avoid complications and ulcerations
• Patient teaching
• Elevate legs
• Weight management
• Position changes
• Dietary and herbal supplements

Chronic Venous
Insufficiency and
Venous Leg Ulcers

Chronic Venous Insufficiency
(CVI)
• CVI—abnormalities of venous system
include edema, skin changes, and venous
leg ulcers
• Etiology and Pathophysiology
• Primary varicose veins and PTS
• Ambulatory venous hypertension
• Serous fluid and RBC leak results in edema
and chronic inflammatory changes
• Hemosiderin—brown skin discoloration
• Skin is hard, thick, and contracted

Chronic Venous
Insufficiency (CVI)
• Clinical Manifestations and
Complications
• Lower leg—brown, leathery
and edematous
• Eczema with itching and
scratching (Table 37-1)
• Venous ulcers (Fig. 37-13)
• Pain especially with
dependent position
• Risk of infection

and Venous Leg Ulcers
• Interprofessional and nursing care
• Compression for healing and prevention of
recurrence
• Stockings, bandages, IPCs, wraps
• Teach proper fit and application
• Assess for PAD prior to compression
• Activity guidelines and limb positioning
• Avoid prolonged sitting or standing
• Elevate legs above heart
• Daily walking
• Avoid trauma
• Daily foot and leg care

and Venous Leg Ulcers
• Interprofessional and nursing care
• Wound care and dressings—moist
environment
• Nutrition—adequate protein, vitamins A and
C, zinc
• Diabetics—normal blood glucose levels
• Monitor for infection
• Debridement, excision, antibiotics
• Drug therapy—pentoxifylline or micronized
flavonoid fraction
• Other: skin replacement (e.g., grafts)
• Daily moisturizing

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