Focus on Peripheral Arterial Disease of the Lower Extremities

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Focus on Focus on Peripheral Arterial Peripheral Arterial Disease of the Lower Disease of the Lower Extremities Extremities

(Relates to Chapter 38, (Relates to Chapter 38, “Nursing Management: Vascular Disorders,” “Nursing Management: Vascular Disorders,” in the textbook)in the textbook)


Peripheral Arterial DiseasePeripheral Arterial DiseaseDescriptionDescription

Involves progressive narrowing and Involves progressive narrowing and degeneration of arteries of neck, degeneration of arteries of neck, abdomen, and extremitiesabdomen, and extremities

Atherosclerosis is the leading cause Atherosclerosis is the leading cause of majority of casesof majority of cases


Fig. 38-1Fig. 38-1


Peripheral Arterial DiseasePeripheral Arterial DiseaseDescriptionDescription

Typically appears at ages 60s to 80sTypically appears at ages 60s to 80s Largely undiagnosedLargely undiagnosed Risk factorsRisk factors

Cigarette smokingCigarette smoking HyperlipidemiaHyperlipidemia HypertensionHypertension Diabetes mellitusDiabetes mellitus


Peripheral Arterial DiseasePeripheral Arterial DiseaseClinical ManifestationsClinical Manifestations

Classic symptom of PAD—Classic symptom of PAD—intermittent claudicationintermittent claudication Ischemic muscle ache or pain that is Ischemic muscle ache or pain that is

precipitated by a constant level of precipitated by a constant level of exerciseexercise

Resolves within 10 minutes or less Resolves within 10 minutes or less with restwith rest

ReproducibleReproducible



ParesthesiaParesthesia Pain at restPain at rest

Occurs in the forefoot or toes and is Occurs in the forefoot or toes and is aggravated by limb elevationaggravated by limb elevation

Occurs from insufficient blood flowOccurs from insufficient blood flow May indicate critical ischemiaMay indicate critical ischemia



Thin, shiny, and taut skinThin, shiny, and taut skin Loss of hair on the lower legsLoss of hair on the lower legs Diminished or absent pedal, Diminished or absent pedal,

popliteal, or femoral pulsespopliteal, or femoral pulses PallorPallor


Peripheral Arterial DiseasePeripheral Arterial DiseaseComplicationsComplications

Atrophy of the skin and underlying Atrophy of the skin and underlying musclesmuscles

Delayed healingDelayed healing Wound infectionWound infection Tissue necrosis Tissue necrosis Arterial ulcersArterial ulcers



Nonhealing arterial ulcers and Nonhealing arterial ulcers and gangrene are most serious gangrene are most serious complicationscomplications

May result in amputation if blood May result in amputation if blood flow is not adequately restored or if flow is not adequately restored or if severe infection occurssevere infection occurs



Arterial Ulcers (see table 38-2)Arterial Ulcers (see table 38-2) Small, deep, round “punched out” Small, deep, round “punched out”

appearanceappearance Minimal drainageMinimal drainage Typically occur on tips of toes or feetTypically occur on tips of toes or feet Ulcer tissue may have black eschar or Ulcer tissue may have black eschar or

pale pink granulationpale pink granulation


Peripheral Arterial DiseasePeripheral Arterial DiseaseDiagnostic StudiesDiagnostic Studies

Doppler ultrasoundDoppler ultrasound Segmental blood pressuresSegmental blood pressures

Ankle–brachial index (ABI)Ankle–brachial index (ABI) Done using a handheld DopplerDone using a handheld Doppler

AngiographyAngiography Magnetic resonance angiography Magnetic resonance angiography

(MRA)(MRA)


Collaborative CareCollaborative Care Risk Factor ModificationRisk Factor Modification Smoking cessationSmoking cessation Aggressive treatment of Aggressive treatment of

hyperlipidemia hyperlipidemia Hypertension and diabetes mellitusHypertension and diabetes mellitus BP maintained <130/80BP maintained <130/80 Glycosylated hemoglobin <7.0% for Glycosylated hemoglobin <7.0% for

diabeticsdiabetics


Collaborative CareCollaborative Care Drug TherapyDrug Therapy

Antiplatelet agentsAntiplatelet agents AspirinAspirin Ticlopidine (Ticlid)Ticlopidine (Ticlid) Clopidogrel (Plavix)Clopidogrel (Plavix)

ACE inhibitorsACE inhibitors


Collaborative CareCollaborative Care Drug TherapyDrug Therapy

Drugs prescribed for treatment of Drugs prescribed for treatment of intermittent claudicationintermittent claudication Pentoxifylline (Trental)Pentoxifylline (Trental)

↓ ↓ Blood viscosityBlood viscosity

Cilostazol (Pletal)Cilostazol (Pletal) ↑ ↑ Vasodilation Vasodilation


Collaborative CareCollaborative Care Exercise TherapyExercise Therapy

Exercise improves oxygen Exercise improves oxygen extraction in the legs and skeletal extraction in the legs and skeletal metabolism metabolism

Walking is the most effective Walking is the most effective exercise for individuals with exercise for individuals with claudicationclaudication 30 to 60 minutes daily30 to 60 minutes daily


Collaborative CareCollaborative Care Nutritional TherapyNutritional Therapy

Dietary cholesterol <200 mg/dayDietary cholesterol <200 mg/day Decreased intake of saturated fatDecreased intake of saturated fat Soy products can be used in place Soy products can be used in place

of animal proteinof animal protein


Collaborative CareCollaborative Care Care of Leg with Critical Limb IschemiaCare of Leg with Critical Limb Ischemia

Protect from trauma Protect from trauma Reduce vasospasm Reduce vasospasm Prevent/control infectionPrevent/control infection Maximize arterial perfusion Maximize arterial perfusion Other strategiesOther strategies

Immune modulation therapy Immune modulation therapy Angiogenic gene therapyAngiogenic gene therapy


Collaborative CareCollaborative Care Interventional Radiologic ProceduresInterventional Radiologic Procedures

IndicationsIndications Intermittent claudication symptoms Intermittent claudication symptoms

become incapacitating become incapacitating Pain at restPain at rest Ulceration or gangrene severe enough Ulceration or gangrene severe enough

to threaten viability of the limbto threaten viability of the limb


Collaborative CareCollaborative Care Interventional Radiologic ProceduresInterventional Radiologic Procedures

Percutaneous transluminal balloon Percutaneous transluminal balloon angioplastyangioplasty Involves the insertion of a catheter Involves the insertion of a catheter

through the femoral arterythrough the femoral artery

Balloon is inflated dilating the vessel Balloon is inflated dilating the vessel by cracking the confining by cracking the confining atherosclerotic intimal shellatherosclerotic intimal shell


Collaborative CareCollaborative Care Surgical TherapySurgical Therapy

Most common surgical approachMost common surgical approach A peripheral arterial bypass A peripheral arterial bypass

operation with autogenous vein or operation with autogenous vein or synthetic graft material to bypass synthetic graft material to bypass blood around the lesionblood around the lesion


Fig. 38-7Fig. 38-7


Collaborative CareCollaborative Care Surgical TherapySurgical Therapy

EndarterectomyEndarterectomy Patch graft angioplastyPatch graft angioplasty Amputation Amputation


Nursing ManagementNursing ManagementNursing AssessmentNursing Assessment

Past health historyPast health history Diabetes mellitusDiabetes mellitus SmokingSmoking HypertensionHypertension Hyperlipidemia Hyperlipidemia ObesityObesity


Nursing ManagementNursing ManagementNursing AssessmentNursing Assessment

Exercise intoleranceExercise intolerance Loss of hair on legs and feetLoss of hair on legs and feet Decreased or absent peripheral Decreased or absent peripheral

pulsespulses


Nursing ManagementNursing ManagementNursing DiagnosesNursing Diagnoses

Ineffective tissue perfusion Ineffective tissue perfusion (peripheral)(peripheral)

Impaired skin integrityImpaired skin integrity Activity intoleranceActivity intolerance Ineffective therapeutic regimen Ineffective therapeutic regimen

managementmanagement


Nursing ManagementNursing ManagementPlanningPlanning

Overall goals for patient with PADOverall goals for patient with PAD Adequate tissue perfusionAdequate tissue perfusion Relief of painRelief of pain Increased exercise toleranceIncreased exercise tolerance Intact, healthy skin on extremities Intact, healthy skin on extremities


Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation

Health PromotionHealth Promotion Identification of at-risk patientsIdentification of at-risk patients Community involvementCommunity involvement Diet modification Diet modification



Acute InterventionAcute Intervention Frequently monitor after surgery Frequently monitor after surgery

Skin color and temperatureSkin color and temperature Capillary refillCapillary refill Presence of peripheral pulses distal to Presence of peripheral pulses distal to

the operative sitethe operative site Sensation and movement of extremity Sensation and movement of extremity



Acute InterventionAcute Intervention Continued circulatory assessmentContinued circulatory assessment Monitor for potential complicationsMonitor for potential complications Knee-flexed positions should be Knee-flexed positions should be

avoided except for exerciseavoided except for exercise Turn and position frequently Turn and position frequently



Ambulatory and Home CareAmbulatory and Home Care Management of risk factorsManagement of risk factors Importance of meticulous foot careImportance of meticulous foot care Importance of gradual physical Importance of gradual physical

activity after surgeryactivity after surgery



Ambulatory and Home CareAmbulatory and Home Care Daily inspection of the feetDaily inspection of the feet Comfortable shoes with rounded toes Comfortable shoes with rounded toes

and soft insolesand soft insoles Shoes lightly lacedShoes lightly laced


Nursing ManagementNursing ManagementEvaluationEvaluation

Identify activities that promote Identify activities that promote circulation circulation

Maintain adequate peripheral Maintain adequate peripheral tissue perfusiontissue perfusion

Experience intact skin, free of Experience intact skin, free of infection, on lower extremities infection, on lower extremities


Nursing ManagementNursing ManagementEvaluationEvaluation Plans for walking programPlans for walking program Increased activity toleranceIncreased activity tolerance Verbalize key elements of Verbalize key elements of

therapeutic regimen, knowledge of therapeutic regimen, knowledge of disease, treatment plan, reduction disease, treatment plan, reduction of risk factors, and proper of risk factors, and proper ulcer/foot careulcer/foot care


Venous disordersVenous disorders


Venous ThrombosisVenous ThrombosisFactors in venous thrombosis (38-7)Factors in venous thrombosis (38-7)

1. Venous stasis1. Venous stasis

2. Endothelial damage2. Endothelial damage

3. Hypercoagulability3. Hypercoagulability


Superficial ThrombosisSuperficial Thrombosis

ManifestationsManifestations Palpable cordPalpable cord Red, warm , tender skinRed, warm , tender skin Mild temperature elevationMild temperature elevation Possible edemaPossible edema

CareCare ElevationElevation Heat,Heat, AnalgesicsAnalgesics


Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT) ManifestationsManifestations

Unilateral edemaUnilateral edema PainPain Warm skinWarm skin FeverFever Positive Homan’s sign Positive Homan’s sign (caveat)(caveat) May be minimally symptomaticMay be minimally symptomatic


DVTDVT

Potential ComplicationsPotential Complications Pulmonary embolismPulmonary embolism Chronic venous insufficiencyChronic venous insufficiency

DiagnosisDiagnosis DopplerDoppler


DVTDVT

Prevention oand prophylaxisPrevention oand prophylaxis AnticoagulationAnticoagulation

Prevention AND treatmentPrevention AND treatment Lovenox, heparin, fondaparinuxLovenox, heparin, fondaparinux CoumadinCoumadin


DVTDVT Nursing InterventionsNursing Interventions

Management and teaching related Management and teaching related anticoagulation anticoagulation SafetySafety MonitoringMonitoring DietDiet Minimization of bleeding riskMinimization of bleeding risk

Education about signs/symtpoms of PE Education about signs/symtpoms of PE


Chronic Venous InsufficiencyChronic Venous Insufficiency

A condition in which the valves of A condition in which the valves of the veins are damaged---> the veins are damaged---> retrograde blood flow, pooling of retrograde blood flow, pooling of blood in the legs.blood in the legs.

May lead to venous stasis ulcersMay lead to venous stasis ulcers



ManifestationsManifestations Brawny skin, possible eczemaBrawny skin, possible eczema Edema , possible severeEdema , possible severe Venous ulcersVenous ulcers

Tend to occur above medial malleolusTend to occur above medial malleolus Weepy, - extensive drainageWeepy, - extensive drainage shallow, irregular shapedshallow, irregular shaped Larger than arterial ulcersLarger than arterial ulcers



Care of ulcersCare of ulcers Compression of venous insufficiencyCompression of venous insufficiency

*avoid if concurrent PAD*avoid if concurrent PAD

Moist dressingsMoist dressings

Balanced diet with adequate protein, Balanced diet with adequate protein, vitamins A/Cvitamins A/C

Antibiotics if infection is presentAntibiotics if infection is present

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Focus on Peripheral Arterial Disease of the Lower Extremities