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Peripheral Artery Disease of the Lower Extremi6es • Progressive narrowing and degenera6on of arteries of upper and lower extremi6es • Atherosclerosis is leading cause in majority of cases • PVD vs PAD *What does this disease sound like and can you an2cipate the interprofessional management (medical, nursing) 1 Fall 2019 Spring 2020

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Page 1: Peripheral)Artery)Disease)of)the) Lower)Extremi6es))lahc323325.weebly.com/uploads/1/1/0/6/110686185/chapter...Peripheral)Artery)Disease)of)the) Lower)Extremi6es)) • Progressive)narrowing)and)degeneraon)of)

Peripheral  Artery  Disease  of  the  Lower  Extremi6es    

•  Progressive  narrowing  and  degenera6on  of  arteries  of  upper  and  lower  extremi6es  

•  Atherosclerosis  is  leading  cause  in  majority  of  cases  

•  PVD  vs  PAD  *What  does  this  disease  sound  like  and  can  you  an2cipate  the  interprofessional  management  (medical,  nursing)    

1  Fall  2019  -­‐  Spring  2020  

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Common  Sites  of  Atherosclero6c  Lesions  

•  Risk  Factor:  –  Tobacco  use  –  Chronic  kidney  disease  –  Diabetes  mellitus  –  Hypertension  –  Hypercholesterolemia  –  Obesity  –  Sedentary  Lifestyle  

2  Fall  2019  -­‐  Spring  2020  

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OXYGENATION  NEEDS  

 •  Ven6la6on    •  Perfusion  •  Diffusion    *What  concept  is  involved?  *Your  pa6ent  is  a  scheduled  admit  who  has  had  leg  pain  with  ac6vity  and  while  at  rest  for  2  weeks,  what  is  the  plan  of  care?  *What  nursing  physical  assessments  are  involved?  

Fall  2019  -­‐  Spring  2020   3  

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A  pa6ent  with  peripheral  artery  disease  has  marked  peripheral  neuropathy.  An  appropriate  nursing  diagnosis  for  the  pa6ent  is  a.  Risk  for  injury  related  to  decreased  sensa6on.  b.  Impaired  skin  integrity  related  to  decreased  peripheral  

circula6on.  c.  Ineffec6ve  peripheral  6ssue  perfusion  related  to  decreased  

arterial  blood  flow.  d.  Ac6vity  intolerance  related  to  imbalance  between  oxygen  

supply  and  demand.    

4  

Audience  Response  Question  

Fall  2019  -­‐  Spring  2020  

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Clinical  Manifesta6ons  •  “Intermi[ent  

claudica6on”  –  Ischemic  muscle  pain  that  is  caused  by  a  constant  level  of  exercise  

–  Resolves  within  10  minutes  or  less  with  rest  

–  Reproducible  •  “Paresthesia”  

–  Nerve  6ssue  ischemia  –  Produces  loss  of  pressure  and  deep  pain  sensa6ons  

–  Injuries  o^en  go  unno6ced  by  pa6ent  

•  “Pain”  at  rest  –  As  PAD  progresses  –  Occurs  in  feet  or  toes  –  Aggravated  by  limb  eleva6on  

–  Occurs  from  insufficient  blood  flow  

–  Occurs  more  o^en  at  night  

5  Fall  2019  -­‐  Spring  2020  

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Clinical  Manifesta6ons  

•  Thin,  shiny,  and  taut  skin  •  Loss  of  hair  on  lower  legs  •  Diminished  or  absent  

pedal,  popliteal,  or  femoral  pulses  

•  Pallor  of  foot  with  leg  eleva6on  

•  Reac6ve  hyperemia  of  foot  with  dependent  posi6on  

6  Fall  2019  -­‐  Spring  2020  

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Cri0cal  Limb  Ischemia  (CLI)  

•  Characterized  by:  – Chronic  ischemic  rest  pain  las6ng  more  than  2  weeks  

– Arterial  leg  ulcers  or  gangrene  

•  Urgent/Emergent  revasculariza6on  to  save  limb  *How  will  this  be  done?  

Fall  2019  -­‐  Spring  2020   7  

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Complica6ons  

•  Atrophy  of  skin  and  underlying  muscles  

•  Delayed  healing,  wound  infec6on,  6ssue  necrosis    

•  Arterial  (ischemic)  ulcers  –over  boney  prominences  on  toes,  feet  and  lower  legs  

•  Nonhealing  arterial  ulcers  and  gangrene  are  most  serious  complica6ons  

•  May  result  in  amputa6on    –  If  adequate  blood  flow  is  not  restored  

–  Collateral  circula6on  in  chronic  PAD  

–  If  severe  infec6on  occurs  (osteomyeli6s)    

Fall  2019  -­‐  Spring  2020   8  

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Diagnos6c  Studies  

•  Doppler  ultrasound  •  Ankle-­‐brachial  index  (ABI)  

•  Angiography  and  magne6c  resonance  angiography  

•  Duplex  imaging  

What  studies  will  be  done  if  surgical  interven6on  is  an6cipated  for  a  78  y.o.  pa6ent,  PMH:  CAD,  HTN,  DM  2?  

Fall  2019  -­‐  Spring  2020   9  

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Nursing  Management  Nursing  Diagnoses    

•  Ineffec6ve  peripheral  6ssue  perfusion  •  Ac6vity  intolerance  •  Chronic  pain  •  Ineffec6ve  health  management  

*What  will  be  evaluated  to  know  goals  are  met?  

10  Fall  2019  -­‐  Spring  2020  

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Nursing  Management  Planning    

•  Overall  goals  for  pa6ent  with  PAD  – Adequate  6ssue  perfusion  – Relief  of  pain  –  Increased  exercise  tolerance  –  Intact,  healthy  skin  on  extremi6es  –  Increased  knowledge  of  disease  and  treatment  plan    

11  Fall  2019  -­‐  Spring  2020  

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Interprofessional  Care    Risk  Factor  Modifica6on    

•  Tobacco  cessa6on  •  Glycosylated  hemoglobin  <7.0%  for  diabe6cs  •  Aggressive  treatment  of  hyperlipidemia    •  BP  maintained  <140/90  

12  Fall  2019  -­‐  Spring  2020  

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Interprofessional  Care    Drug  Therapy  

•  ACE  inhibitors  –  Ramipril  (Altace)    

•  ↓  Cardiovascular  morbidity/mortality    •  ↑  Peripheral  blood  flow  •  ↑  ABI  •  ↑  Walking  distance    

•  An0platelets/An0coagulants    – Aspirin  –  Clopidogrel  (Plavix)  – Heparin  IV  

 

13  Fall  2019  -­‐  Spring  2020  

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Interprofessional  Care    

EXERCISE  THERAPY  •  Exercise  improves  oxygen  

extrac6on  in  legs  and  skeletal  metabolism  

•  Walking  is  most  effec6ve  exercise  for  individuals  with  claudica6on  –  30  to  45  minutes  daily,  3  

6mes/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  

Fall  2019  -­‐  Spring  2020   14  

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Interprofessional  Care    Leg  With  Cri0cal  Limb  Ischemia    

 

•  Conserva6ve  Treatment:  –  Improve  arterial  perfusion  •  Intravenous  Heparin  drip  (25,000  units/500ml  NS,  D5W)  

– Protect  from  trauma  – Decrease  ischemic  pain  – Prevent/control  infec6on    

15  Fall  2019  -­‐  Spring  2020  

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25,000  Units/500ml  0.9%  NS  :  Bolus  4000  units,  start  at  500  unit/hr  How  many  ml/hr  will  be  set  on  the  infusion  pump?    

                 What  is  the  nursing  management  for  a  pa6ent  on  a  heparin  g[?  

Fall  2019  -­‐  Spring  2020   16  

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Interprofessional  Care    Leg  With  Cri0cal  Limb  Ischemia    

                                                                           A,  Femoral-­‐popliteal  bypass  gra^  around  an  occluded  superficial  femoral  artery.  B,  Femoral-­‐posterior  6bial  bypass  gra^  around  occluded  superficial  femoral,  popliteal,  and  proximal  6bial  arteries.    

 

•  Percutaneous  transluminal  angioplasty  (PTA)  

•  Atherectomy/Endarterectomy  

•  Peripheral  artery  bypass  surgery  

•  Patch  graW  angioplasty  •  Amputa0on      *All  require  pre-­‐opera2ve  and  post-­‐opera2ve  nursing  management  specific  to  procedure  done  *Think  about  nursing  management    

Fall  2019  -­‐  Spring  2020   17  

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Nursing  Management  Nursing  Implementa6on  

•  Acute  Care  – Frequently  monitor  a^er  surgery  

•  NEUROVASCULAR  CHECKS  (Q15  min,  Q1-­‐2  hours)  –  Palpa6on,  doppler  

•  Skin  color  and  temperature  •  Capillary  refill  •  Presence  of  peripheral  pulses  distal  to  the  opera6ve  site  •  Sensa6on  and  movement  of  extremity    

18  Fall  2019  -­‐  Spring  2020  

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Nursing  Management  Nursing  Implementa6on  

•  Acute  Care  – Con6nued  circulatory  assessment  – Monitor  for  poten6al  complica6ons  – Knee-­‐flexed  posi6ons  should  be  avoided  except  for  exercise  

– Turn  and  posi6on  frequently    

19  Fall  2019  -­‐  Spring  2020  

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Nursing  Management  Nursing  Implementa6on  

•  Ambulatory  Care  – Management  of  risk  factors  

–  Long-­‐term  an6platelet  therapy  

–  Importance  of  supervised  exercise  training  a^er  revasculariza6on  

•  Importance  of  me6culous  foot  care  –  Daily  inspec6on  of  the  feet  

–  Comfortable  shoes  with  rounded  toes  and  so^  insoles  

–  Shoes  lightly  laced  

Fall  2019  -­‐  Spring  2020   20  

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Nursing  Management  Nursing  Implementa6on  

Foot  Care:    •  Carefully  inspect,  cleanse,  and  lubricate  feet  to  prevent  

cracking  of  the  skin  and  infec6on  •  If  ulcera6on  is  present,  keep  affected  foot  clean  and  dry.  

Cover  ulcers  with  a  dry,  sterile  dressing  to  maintain  cleanliness  

•  Deep  ulcers  can  be  treated  with  a  variety  of  wound  care  products,  but  healing  is  unlikely  without  increased  blood  flow.  Systemic  an6bio6cs  are  used  in  pa6ents  with  CLI,  skin  ulcera6ons,  and  limb  infec6on  

•  Encourage  the  pa6ent  to  select  so^,  roomy,  and  protec6ve  footwear  and  avoid  extremes  of  heat  and  cold  

21  Fall  2019  -­‐  Spring  2020  

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The  nurse  teaches  a  pa6ent  with  peripheral  arterial  disease.  The  nurse  determines  that  further  teaching  is  needed  if  the  pa6ent  makes  which  statement?  a.  “I  should  not  use  hea6ng  pads  to  warm  my  feet.”  b.  “I  should  cut  back  on  my  walks  if  it  causes  pain  in  my  legs.”  c.  “I  will  examine  my  feet  every  day  for  any  sores  or  red  areas.”    d.  “I  can  quit  smoking  if  I  use  nico6ne  gum  and  a  support  

group.”  

22  

Audience  Response  Question  

Fall  2019  -­‐  Spring  2020  

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Peripheral  Vascular  Disease  

23  Fall  2019  -­‐  Spring  2020  


Coronary artery, cerebrovascular and peripheral … guidelines/Dialysis/acceptance...Coronary artery, cerebrovascular and peripheral vascular disease Date written: December 2008 Final

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