Imbalance Between Myocardial Supply and Demand

Irma B.Ancheta,PhD,RNPeggy McCartt, PhD (c), CCRN, ARNP

Peripheral Vascular Disease (PVD)

• PVD includes disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation. PVD affects the lower extremities much more frequently than the upper extremities. Generally a client with PVD implies arterial disease (rather than just venous disease)

Assessing for Peripheral Vascular Disease (PVD)

Physical Assessment– Assess blood pressure in both arms– Palpate pulses– Listen for a bruit

PVD

• Laboratory Assessment– Lipid Profile

• Cholesterol• Triglycerides

– Homocysteine Amino acid found in the blood homocysteine levels blocks NO dec.elasticity promote plaque build-up

• B6 = Pyridoxine (nuts, soybeans, legumes)• B9 = Folic acid “folium”• B12 = cyanocobalamin (liver,shellfish,salmon)

Interventions• Monitor for Metabolic Syndrome• Diet Therapy• Smoking Cessation• Complementary and Alternative Therapies• Exercise• Drug Therapy

HMG-CoA Mevalonic acid terpenes and steroids (terpenoid lipid) cholesterol

(first enzyme in the metabolic pathway that produces cholesterol and other lipids)

(gene located on the long arm of 5th chromosome) HMG Co-Reductase inhibitors– Niacin– Fibric Acid Derivatives–

Peripheral Arterial Disease (PAD)

• PAD is a manifestation of systemic atherosclerosis and is a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients.

– Inflow Obstructions- distal end of aorta and the common, internal and external iliac arteries

– Outflow obstructions involve infrainguinal arterial segments ( femoral, popliteal, and tibial arteries) and are below the superficial femoral artery.

PAD• Risk Factors and Incidence/Prevalence?

• Physical AssessmentIntermittent claudicationArterial ulcersDiabetic ulcersVenous stasis ulcers

• Radiographic Assessment– Arteriography

• Other Diagnostic Assessments– Segmental systolic blood pressure measurements with a

Doppler– Ankle-brachial index (ABI)– Exercise Tolerance Testing

Int. Claudi.[1] + PainCrampingBurningReproducibleAwakened at nightToes, footArched heels(-) calves-(-) ankles

Arterial U[1]+ PainGreat Toe

Well defborder

DM U[1] (-) PainPlantar foot

Venous U[1]min PainAnkleFoot warm

+Pulse+discoloration

PAD Interventions

• Nonsurgical– Exercise– Positioning– Promoting vasodilation– Drug therapy i.e. anti-platelet medications: aspirin and

Plavix– Percutaneous Transluminal Angioplasty (PTA)- stents/ laser

angioplasty/ atherectomy

• Surgical Management– Arterial revascularization- bypass grafting with PTFE, Gore-

Tex or Dacron

PAD Nursing Diagnoses NICS/NOCS

• Chronic Pain • Ineffective Tissue Perfusion: Peripheral• Risk for Injury

– NICS-• pain management• circulatory care: arterial insufficiency• surveillance: safety

Pre-operative Care for PAD Surgical Patient

• General Preoperative Surgical Care as for any surgery patient

• Postoperative Care- – Assess for Graft occlusion– Assess for Graft Patency

• Care for Graft occlusion (thrombectomy)

– Assess for Infection

Acute Peripheral Occlusion

• Six “Ps” of Ischemia– Pain– Pallor– Pulselessness– Parathesia– Paralysis– Poikilothermia (coolness)

PAD Home and Community Care

• Home Care Management

• Health Teaching

• Health Care Resources

Aneurysms

• Abdominal

• Aortic

• Thoracic

Abdominal Aortic Aneurysm (AAA)

• Diagnosis

• Interventions– Nonsurgical– Surgical

• AAA Resection

• Pre and Postoperative Care

Peripheral Venous Disease Pathophysiology

• Venous Thromboembolism (VTE)

• Venous Insufficiency (Varicose Veins)

• Lack of Skeletal Muscle Contractility

Thrombus DefinitionA thrombus is a blood clot believed to result from

an endothelial injury, venous stasis, or hypercoagulability. The thrombosis may not be specifically attributable to one element, or it may involve all three elements. It is often associated with an inflammatory process. When a thrombus develops, inflammation can occur around the clot, thickening the vein wall and consequently leading to embolization (formation of an embolus).

VTE

• Embolus• Thrombophlebitis• Phlebothrombosis• Deep Venin Thrombophlebitis or Deep Venin

Thrombosis (DVT)• Pulmonary Embolism• Virchos’s triad- stasis of blood flow,

endothelial injury, and hypercoagculability

VTE• Assessment

Look for calf tenderness and pain, and sudden onset of unilateral swelling of the leg. Pain in the calf on dorsiflexion of the foot (positive Homan’s sign) appears in only 10% of clients- many clients(40%) may have no S&S

Localized edema• Tests

Venous DopplerImpedance plethysmographyMRID-dimer