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
Common Sites of Atherosclero6c Lesions
• Risk Factor: – Tobacco use – Chronic kidney disease – Diabetes mellitus – Hypertension – Hypercholesterolemia – Obesity – Sedentary Lifestyle
2 Fall 2019 -‐ Spring 2020
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Peripheral Vascular Disease
23 Fall 2019 -‐ Spring 2020