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Peripheral Vascular Disease Arterial and Venous Disorders Marion Technical College NUR 1021 Peripheral vascular disease (PVD) • Disorders that change natural flow of blood through the arteries and veins of the peripheral circulation – Affects legs much more frequently than the arm – Some patients have both arterial and venous disease • Typically appears in patients ages 60 -80 Peripheral vascular disease (PVD) – cont. • Cost of the disease is • very high Is expected to increase as baby boomers age and obesity in the United States continues to be a major health problem. Physiologic Effects • If diminished blood flow to tissues – Tissue integrity is challenged if demands exceed supply of oxygen & nutrients – Ischemia & eventual death of tissue if inadequate blood flow Damaged Arteries • Obstructions from atherosclerotic plaque, thrombus or embolus • Damaged also from – Chemical/mechanical trauma, infections, inflammation, vasospastic disorders & congenital malformations Acute or Gradual Changes • Sudden arterial occlusion – Profound & irreversible tissue ischemia & death • Gradual occlusion – Collateral circulation may develop – Tissue adapts gradually to ↓ blood flow – Less risk of sudden tissue death Veins • Carry deoxygenated blood to heart • Normal venous pressure – Higher than arterial pressure, and lower in the right atrium than in the feet. • This allow veins to channel blood from extremities to heart. Damaged Veins • Damaged by a thrombus, incompetent valves, decreased pumping action of surrounding muscles – Result - increased venous pressure • If the pressure in peripheral veins in greater than the pressure in tissues, where is the fluid going to go? • (Hint: Think about hydrostatic pressures) Venous Diseases • Lead to pooling of blood in extremities, resulting in edema – Edematous tissue- cannot get adequate nutrition – Tissues are susceptible to breakdown, injury & infection • Venous diseases : DVT, varicose veins & venous stasis ulcers Arterial Vessels More Often Affected • Peripheral arterial disease (PAD) may affect – – – – – Aortoiliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery Geriatric Considerations • Arteries become thicker – the intimal layer may become fibrotic & vessels stiffen – Results in increasing peripheral vascular resistance – May lead to ↑ work load of the left ventricle & possible heart failure Risk factors for Peripheral Arterial Disease & Atherosclerosis • • • • • Diabetes Hyperlipidemia Hypertension Nicotine use High homocysteine levels • Familial/genetics • Increasing age • Female gender Which Risk Factors for atheroslcerosis are nonmodifiable? • Familial/genetics • Increasing age • Female gender Assessment of Vascular System • Physical assessment: – Skin – changes occur from inadequate blood flow • Cool, pale extremities- increases with elevation • Rubor- reddish, blue color in dependent position –Severe peripheral arterial damage –Occurs from vessels that cannot constrict & remain dilated Assessment of Vascular System (cont.) • • • • • Dry, shiny, taut skin Loss of hair on extremity Nails thickened & ridged Edema Gangrene after prolonged tissue necrosis Assessment of Vascular System (cont.) • 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 Chronic arterial occlusion • Hallmark symptom: Intermittent claudication • Resting pain when occlusion severe – Elevating leg increases pain – Dependent position relieves pain Assessment of Vascular System (cont.) • Pain in forefoot at rest – REST pain – Severe arterial insufficiency – Relief – put extremity in dependent position → improves perfusion – Often occurs at night • Pulses – Diminished or absent pedal, popliteal, or femoral pulses – Use a Doppler if unable to palpate pulses Assessment of Vascular System (cont.) • Paresthesia – Shooting or burning pain in extremity – Present near ulcerated areas – Produces loss of pressure and deep pain sensations – Injuries often go unnoticed by patient Complications • Atrophy of the skin and underlying • • • • muscles Delayed healing Wound infection Tissue necrosis Arterial ulcers Complications→Serious Outcome • Nonhealing arterial ulcers and gangrene are the most serious complications • May result in amputation if blood flow is not adequately restored or if severe infection occurs • NCLEX Challenge: • The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. What did the nurse most likely assess in this patient? • 1. rubor with extremity elevation • 2. normal hair distribution bilaterally • • over lower extremities 3. peripheral pulses present bilaterally 4. complaints of leg pain upon rest Diagnostic Studies • Continuous wave (CW) doppler study- use of a handheld device to “hear” the pulses – Provides specific information for calculation of ABI Diagnostic Studies • ABI (ankle-brachial index) – ratio of ankle systolic blood pressure to the arm systolic blood pressure – Ankle-brachial index <0.70 in PAD • With increasing arterial narrowing: – There is a progressive decrease in systolic pressure distal to the involved sites • Continuous-wave Doppler ultrasound – Detects blood flow, combined with computation of ankle or arm pressures – This diagnostic technique helps characterize the nature of peripheral vascular disease Diagnostic Studies • CT: cross sectional images of soft tissue & volume changes – If patient has renal disease, patient should be hydrated (IV or oral) 12 hrs before procedure – Monitor urinary output post procedure – Evaluate for iodine or shellfish allergies • Premedicate -steroids & histamine blockers Diagnostic Studies • Angiography – Injection of radiopaque contrast into arterial system for visualization of vessels – Can identify location of stenosis or aneurysm – Collateral circulation identified – Teach patient that sense of warmth felt with injection of dye – Be alert for severe allergic reaction – Monitor injection site- bleeding or hematoma Diagnostic Studies • Magnetic Resonance Angiography – MRI with special scanner to locate blood vessels – Can rotate image for multiple views – Contraindicated: • Metal implants • Older tattoos (metal materials) – Prepare patient for banging/popping sounds – Panic button- if feeling claustrophobic Diagnostic Studies • Contrast Phlebography (Venography) – Radiopaque contrast injected into veins – Unfilled vein – location of a thrombus – Monitor injection site - bleeding or hematoma • Lymphoscintography – radioactive colloid injected into 2nd digit space – Provides serial images of lymphatic system Are we having fun yet? Something that makes this all happen….Arterial Disorders • • • • • • • • Arteriosclerosis and atherosclerosis Peripheral arterial occlusive disease Upper extremity arterial occlusive disease Aortoiliac disease Aneurysms (thoracic, abdominal, other) Dissecting aorta Arterial embolism and arterial thrombosis Raynaud’s phenomenon Arteriosclerosis • “Hardening of the arteries” • Diffuse disease process – Muscle fibers & endothelial lining of walls of small arteries & arterioles thicken – Results in loss of elasticity, calcification of arterial walls Atherosclerosis • Atheromas or plaques – Result of cholesterol, lipids & cellular debris in inner layers of large and medium-sized arteries – Result→ decreased blood flow from narrowing of lumen→ eventual development of collateral circulation • Creates risk for thrombosis – Vulnerable areasregions where arteries bifurcate C-reactive protein (CRP) • Sensitive marker of cardiovascular inflammation-systemically and locally • Slight increases in serum CRP levels – Associated with an increased risk of damage in the vasculature – Especially if these increases are accompanied by other risk factors such increasing age, HTN or positive family history of cardiovascular disease Signs/Symptoms • Not usually present until artery narrowed by 60% or more • Early red flags include pain or changed appearance or sensation in foot or leg • Intermittent claudication • Resting causes pain to subside Prevention • Heart Healthy Diet – reduce fat intake, use unsaturated fats, decrease cholesterol intake • Medications – Statins to reduce cholesterol • Control hypertension with medications – Often need 2-3 types of HTN medications • Eliminate nicotine Management • Modify risk factors • Correct HTN • Exercise program • Eliminate nicotine • Medication- reduce blood lipids • Low cholesterol diet • Surgical graft procedures • Femoral/popliteal bypass- improves outflow Radiologic Interventions • Angioplasty/percutaneous transluminal • angioplasty (PTA) – Widens area & flattens plaque against wall of artery – Stents - prevent recollapse & reocclusion Complications from procedure – Hematoma, bleeding – Distal embolization, intimal damage artery Stents Small metal mesh tubes I am PRR-fectly ready for whatever comes next Peripheral Arterial Occlusive Disease • A form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities; may be acute or chronic – Femoral popliteal area -most commonly affected in nondiabetic patients – Patient with diabetes mellitus tends to develop PAD in the arteries below the knee Arterial thrombosis & Arterial embolism • Arterial embolism - sudden arterial occlusion caused by emboli • Results in acute ischemia of affected body parts • Most stem from thrombus formation in heart chambers • Arteriosclerotic conditions may predispose patients to emboli formation Embolization of Thrombi… • Noncardiac sources of emboli – Aneurysms – Ulcerated atherosclerotic plaque – Recent endovascular procedures – Venous thrombi – Rarely, arteritis • If thrombi originates in left side of heart – Can obstruct artery of the lower extremity (iliofemoral, popliteal, tibial) • If originate in right side of the heart – Travel to lungs → pulmonary embolus Clinical signs/symptoms • 6” “P’s”of acute arterial ischemia – Pain- as PAD progresses- continuous pain at rest – Pallor (pale)- occurs with leg elevation – Pulselessness – Paresthesia – Paralysis – Poikilothermia (cool) Clinical signs/symptoms(cont) • Toenails thick, skin shiny & dry; sparse hair on leg • 100% blockage= acute arterial occlusion – Immediate intervention or necrosis of tissue in a few hours • Chronic rest pain, ulceration, or gangrene = critical limb ischemia Goal : Keep affected limb viable • Anticoagulant therapy – Continuous IV unfractionated heparin (UH) • Prevent thrombus enlargement & inhibits further embolization • In patients undergoing embolectomy, UH should be followed by long-term anticoagulation with warfarin Interventional Techniques • To restore blood flow - embolus/thrombus is removed ASAP • Options include – percutaneous catheter-directed thrombolytic therapy – percutaneous mechanical thrombectomy with or without thrombolytic therapy – surgical thrombectomy or surgical bypass Extraction of an embolus • Use of balloon-tipped • embolectomy catheter Deflated balloon-tipped catheter - advanced past the embolus, inflated, and then gently withdrawn, carrying the embolic material with it What is catheter-directed intraarterial thrombolytic therapy ? • Use tPA [alteplase] for patients with short-term (less • than 14 days) thromboembolic disease Percutaneous catheter-inserted into femoral artery & threaded to site of clot – Thrombolytic drug is infused – Thrombolytic agents work by directly dissolving the clot over a period of 24 to 48 hours – Catheter may act as a mechanical thrombectomy device- designed to remove or fragment the thrombus Revascularization Approaches • Patient with chronic rest pain, ulceration, or gangrene has critical limb ischemia – Critical limb ischemia often leads to amputation within 6 months if untreated • Percutaneous transluminal balloon angioplasty for non-surgical approach • Atherotomy – use of cutting device or laser to remove plaques Revascularization Approaches • Surgery -indicated in patients with long areas of stenosis or severely calcified arteries – Common surgical approach • Peripheral artery bypass →improves blood flow • beyond a stenotic or occluded artery Use a vein graft or a synthetic graft A, Femoral-popliteal bypass graft around an occluded superficial femoral artery B, Femoral-posterior tibial bypass graft around occluded superficial femoral, popliteal, and proximal tibial arteries Revascularization Approaches • Endarterectomy – Opening the artery and removing the obstructing plaque – Followed by a patch graft angioplasty • Sewing a patch to the opening to widen the lumen NCLEX Challenge: • The nurse recognizes which client is at greatest risk for developing intimal injury leading to atherosclerosis? • a. A client with diabetes who also smokes one pack of • b. • c. • d. cigarettes daily A client with decreased low-density lipoprotein (LDL) and increased high-density lipoprotein (HDL) levels A client with inherited hypolipidemia A client with a sedentary lifestyle Amputation - least desirable end-stage surgical option – May be required if extensive tissue necrosis – If infectious gangrene or osteomyelitis develops – Indicated if all major arteries in the limb are occluded – Every effort made to preserve as much of limb as possible to optimize rehabilitation Postoperative Nursing Care • Main goal -maintain adequate circulation • Check pulses frequently and compare with unaffected extremity – Notify physician immediately if decrease/loss – Monitor color & temp. of extremity – Assess sensation & movement of extremity – Can elevate leg to reduce edema – Avoid knee flex position; no crossing legs – Turn & reposition frequently – Monitor fluid balance Ambulatory and Home Care • Management of risk factors • Importance of meticulous foot care • Importance of gradual physical activity after surgery • Avoid crossing legs • Daily inspection of the feet • Comfortable well-fitting shoes with rounded toes and soft insoles Nursing Management for PAD Nursing Diagnoses • • • • Ineffective tissue perfusion (peripheral) Impaired skin integrity Activity intolerance Ineffective therapeutic regimen management Nursing Management Planning • Overall goals for patient with PAD – Adequate tissue perfusion – Relief of pain – Increased exercise tolerance – Intact, healthy skin on extremities Collaborative Care - PAD Exercise Therapy • Exercise improves oxygen extraction in the legs and skeletal metabolism • Walking is the most effective exercise for individuals with claudication – 30 to 60 minutes daily – use pain as a guide • Bedrest → leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions Collaborative Care Nutritional Therapy • Dietary cholesterol <200 mg/day • Decreased intake of saturated fat • Soy products can be used in place of animal protein Collaborative Care Complementary/Alternative Therapies • Ginkgo biloba – Effective in increasing walking distance for patients with intermittent claudication • Folate, vitamin B6, cobalamin (B12) – Lowers homocysteine levels Collaborative Care Care of Leg with Critical Limb Ischemia • • • • Protect from trauma Reduce vasospasm Prevent/control infection Maximize arterial perfusion Interventions: Promote vasodilation and prevent compression • Arterial dilation -may not be possible if artery is severely sclerosed or damaged • Teaching: – Warmth promotes arterial flow and cold causes vasoconstriction – Nicotine causes vasospasm – Emotional upsets cause vasoconstriction – Avoid constricting clothing – Place extremity below level of heart Foot care guidelines - Same as diabetic foot care • Prevent foot injury and blisters • Treat any injury or blister immediately • Use neutral soaps & body lotionsprevent skin drying • Pat skin dry – avoid vigorous rubbing • Stockings or socks clean and dry • Soak fingernails and toenails before trimming • Trim nails straight across – may need podiatrist • Don’t cut corns and calluses NCLEX Challenge • A client who has returned to the unit after arterial • • • • revascularization states that pain similar to that before the procedure is felt in the affected limb. Which is the nurse’s best action? a. Notifying the surgeon b. Elevating the extremity c. Administering pain medication d. Placing a warm blanket on the operative limb Collaborative Care Drug Therapy • Antiplatelet agents – Aspirin – Ticlopidine (Ticlid) – Clopidogrel (Plavix) Collaborative Care Drug Therapy (Cont’d) • ACE inhibitors – Ramipril (Altacel) • ↓ Cardiovascular morbidity • ↓ Mortality • ↑ Peripheral blood flow • ↑ABI • ↑ Walking distance Collaborative Care Drug Therapy (Cont’d) • Drugs prescribed for treatment of intermittent claudication – Pentoxifylline (Trental) • ↑ Erythrocyte flexibility • ↓ Blood viscosity – Cilostazol (Pletal) • ↑ Vasodilation • ↑ Walking distance NCLEX Challenge: • In reviewing the menu selections of a client who is ordered a low-cholesterol diet, the nurse questions which selection? • • • • a. b. c. d. Oatmeal Eggs Banana Wheat toast Buerger’s Disease (Thromboangiitis obliterans) • Inflammatory changes in both arteries and veins • Results in destruction of small and medium vessels • Usually affects lower extremities but can also be seen in upper extremity vessels Etiology • Affects male cigarette smokers between ages 20 and 40, small incidence in females • Long history of tobacco use – Do not have other CVD risk factors (hypertension, hyperlipidemia, DM) Pathophysiology • Inflammatory process damages the blood vessel wall • Lymphocytes and giant cells infiltrate the vessel wall with fibroblast proliferation • Ultimately, thrombosis and fibrosis occur in the vessel, causing tissue ischemia. Signs and Symptoms • Symptoms- may be confused with PAD or autoimmune disorders as scleroderma • High rate of periodontitis & presence of Phorphyromonas gingivalis (periodontal pathogen) in occluded blood vessels – Suggests possible bacterial cause • Pulses decreased/absent • Pain – cramps in feet (esp. arches) or legs after exercise (intermittent claudication) - relieved by rest – Rest pain, burning/sensitivity to cold may be early symptoms • May progress to painful ulceration – Amputation rate if patient continues tobacco use is almost 3 times greater than for those who do not Management • Same as that for nursing care of patient with arterial peripheral disease • Complete cessation of tobacco use in any form – Use of nicotine replacement products is contraindicated – Patients have a choice between tobacco and their affected limbs, but not both Treatment • Antibiotics -treat any infected ulcers & analgesics to manage ischemic pain • Sympathectomy & implantation of a spinal cord stimulator – Improves distal blood flow & reducing pain – Neither alters the inflammatory process. • Amputation- if ulceration & gangrene Raynaud’s Phenomenon • Characterized by vasospasm of the arterioles and arteries of the upper and lower extremities, usually unilaterally • Raynaud's disease occurs bilaterally Difference in Disorders • Primary or idiopathic Raynaud’s (Raynaud’s disease) occurs in absence of underlying disease. • Secondary Raynaud’s (Raynaud’s syndrome) – – Associated with an underlying disease • Usually a connective tissue disorder- systemic lupus erythematosus, rheumatoid arthritis, or scleroderma Clinical Manifestations • Classic clinical picture -- Raynaud’s – Pallor brought on by sudden vasoconstriction. – Skin then becomes bluish (cyanotic) -of pooling of deoxygenated blood during vasospasm – As a result of exaggerated reflow (hyperemia) due to vasodilation, a red color (rubor) is produced when oxygenated blood returns to the digits after the vasospasm stops Color Changes –Raynaud’s • Characteristic sequence of color change of Raynaud’s phenomenon • White, blue, and red • Numbness, tingling, and burning pain occur as the color changes • Manifestations tend to be bilateral and symmetric and may involve toes and fingers Management • Avoiding stimuli (e.g., cold, tobacco) that provoke vasoconstriction – Is a primary factor in controlling Raynaud’s phenomenon – Calcium channel blockers (nifedipine [Procardia], amlodipine [Norvasc]) • May be effective in relieving symptoms • Wear gloves when outside; avoid touching cold items as steering wheel If I got this ---you can too!!