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CHAPTER 38 KEY POINTS FOR BLOCK 2 CONCEPTS PERIPHERAL ARTERIAL DISEASE & PERIPHERAL VENOUS DISEASE Peripheral vascular disease occurs in disorders that alter the natural flow of blood through the peripheral arteries and veins, especially the lower extremities. Most patients are not diagnosed with PAD until they develop leg pain. Most patients initially seek medical attention for a characteristic leg pain known as intermittent claudication, able to walk only a certain distance before a cramping, burning muscle discomfort or pain forces them to stop. Recognize that clinical manifestations of peripheral vascular disease (PVD) depend on whether it affects the arteries or veins. Rest pain, which may begin while the disease is still early, is a numbness or burning sensation, described like a toothache that is severe enough to awaken patients. Arterial function of foot is assessed by the quality of the posterior tibial & the pedal pulses Note early signs of the complication of skin ulcer formation. Doppler used if pulses not palpable Magnetic resonance imaging may also be used to assess blood flow in the peripheral arteries. The interventions of exercise to increase collateral circulation, position changes, promotion of vasodilation, drug therapy, and invasive nonsurgical procedures are used to increase arterial flow to the affected limb. Vasodilating drugs or surgery are used for arterial vascular diseases. For chronic disease, prescribed drugs include antiplatelet agents. A nonsurgical but invasive method of improving arterial flow is percutaneous transluminal angioplasty, which opens the vessel lumen and improves arterial blood flow creating a smooth inner-vessel surface, sometimes with stent placement. Laser-assisted angioplasty vaporizes the arteriosclerotic plaque in smaller arteries. The technique of mechanical rotational abrasive atherectomy is used to improve blood flow to ischemic limbs in people with PAD. o The rotablator device is designed to scrape “hard” surfaces (e.g., plaque) while minimizing damage to the vessel surface. Arterial revascularization is the surgical procedure most commonly used. If graft occlusion occurs, notify the surgeon immediately! o Perfusion through the graft must be resolved promptly to avoid ischemic injury to the limb. ACUTE PERIPHERAL ARTERIAL OCCLUSION Acute arterial occlusions may be sudden and dramatic, usually caused by an embolus from recent acute myocardial infarction and/or atrial fibrillation. Those with acute arterial insufficiency often present with the “six P’s” of ischemia: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia. Anticoagulant therapy with unfractionated heparin is usually the first intervention. A surgical thrombectomy or embolectomy with local anesthesia may also be performed. PERIPHERAL VENOUS DISEASE Venous disease causes blood to back up into the distal areas and can lead to edema and thromboses that can become emboli, a life-threatening complication. Venous thromboembolism refers to deep vein thrombosis and pulmonary embolism, with symptoms of tenderness and pain or asymptomatic. Deep vein thrombosis is the most common type of peripheral vascular problem. When symptoms are present (but may not always be present) they include swelling, redness, localized pain, and warmth. The preferred diagnostic test is venous duplex ultrasonography, a noninvasive test. It is most often treated medically using a combination of rest, drug therapy such as anticoagulants, and preventive measures. Closely observe the patient receiving anticoagulants or thrombolytics for signs of bleeding and monitor appropriate laboratory values for desired outcome values. Inferior vena caval interruption may be indicated for recurrent thrombosis or emboli not responding to treatment and for patients who cannot tolerate anticoagulation. Venous insufficiency occurs as a result of prolonged venous hypertension which results in edema, venous stasis ulcers, swelling, and cellulitis. Treatment of chronic venous insufficiency is primarily nonsurgical, unless it is complicated by a venous stasis ulcer that requires surgical débridement. Varicose veins are distended, protruding veins that appear darkened and tortuous. Postoperatively, after varicose vein surgery- assess the groin and leg for bleeding through the elastic bandage, keep legs elevated, and perform range-of-motion exercises of the legs at least hourly. Teach patients ways to prevent deep vein thrombosis and subsequent embolism. In the hospital setting, provide measures, such as wearing graduated compression stockings, to prevent or manage DVT. Teach patients about self-care when they have venous insufficiency Closely observe the patient receiving anticoagulants or thrombolytics for signs of bleeding, and monitor appropriate laboratory values for desired outcome values.