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Peripheral Artery Disease

  • Interferes with normal blood flow
  • Affects arteries
  • Results from atherosclerosis that usually occurs in the arteries of the lower extremities and is characterized by inadequate flow of blood
    • Atherosclerosis is caused by gradual thickening of the intima and media of the arteries, ultimately resulting in the progressive narrowing of the vessel lumen
      • Plaques can form on walls making them rough and fragile
      • Progressive stiffening of the arteries and narrowing of the lumen dec blood supply to affected tissues and inc resistance to blood flow
      • Actually a type of arteriosclerosis-->loss of elasticity of arteries overtime due to thickening of their walls
  • Classified as inflow (distal aorta or iliac arteries) or outflow (femoral, popliteal, and tibial arteries) and can range from mild to severe
    • Tissue damage occurs below arterial obstruction


what is included under peripheral artery disease?

  • Buerger’s disease,
  • subclavian steal syndrome,
  • thoracic outlet syndrome,
  • Raynaud’s dz,
  • popliteal entrapment


risk factors for peripheral artery disease

  • HTN
  • Hyperlipidemia
  • DM
  • Smoking
  • Obesity
  • Sedentary lifestyle
  • Familial predisposition
  • Female gender
  • Older clients


expected findings for Peripheral Artery Disease

  • Burning, cramping, and pain in legs-->intermittent claudication
  • Numbness or burning pain primarily in feet when in bed
  • Pain that is relieved by placing legs at rest in a dependent position
  • Physical assessment:
    • Bruit over femoral and aortic arteries
    • Dec cap refill of toes (>3 seconds)
    • Dec or nonpalpable pulses
    • Loss of hair on lower calf, ankle, and foot
    • Dry, scaly, mottled skin
    • Thick toenails
    • Cold and cyanotic extremity
    • Pallor of extremity w/ elevation
    • Dependent rubor (redness) of the extremity
    • Muscle atrophy
    • Ulcers and possible gangrene of toes


list the diagnostics used for Peripheral Artery Disease

  • arteriography
  • exercise tolerance test
  • plethysmography
  • segmental SBP measurements
  • magnetic resonance angiography
  • ankle brachial index (ABI)
  • doppler derived maximal systolic acceleration


explain arteriography as a diagnostic for PAD

  • involves arterial injection of contrast medium to visualize areas of decreased arterial flow on an x ray
  • Usually done only to determine isolated areas of occlusion that can be treated during the procedure with percutaneous transluminal angioplasty and possible stent placement
  • Nursing actions:
    • Observe for bleeding and hemorrhage
    • Palpate pedal pulses to identify possible occlusions


explain exercise tolerance test as a diagnostic for PAD

  • done with or w/o a treadmill w/ measurement of pulse volumes and BP prior to and following manifestations or 5 min of exercise
  • Delays in return to normal pressures and pulse waveforms indicate arterial dz
  • Used to evaluate claudication during exercise


explain segmental SBP measurements

  • doppler probe takes various BP measurements for comparison
    • In the absence of PAD, pressures in the lower extremities are higher than those of upper extremities
    • With PAD, pressures in the thigh, calf, and ankle are lower


explain magnetic resonance angiography as a diagnostic for PAD

  • contrast medium is injected to help visualize blood flow thru peripheral arteries


explain ankle brachial index (ABI) as a diagnostic for PAD

  • ankle pressure is compared to brachial pressure
  • Expected finding is 0.9-1.3
    • ABI less than 0.9 in either leg is diagnostic for PAD


what is nursing care for PAD?

  • encourage client to exercise to build up collateral circulation
  • promote vasodilation and avoid vasoconstriction
  • positioning


what to do to encourage client to exercise to build up collateral circulation to help with PAD?

  • Initiate exercise gradually and inc slowly
  • Instruct client to walk until point of pain, stop, and rest, and then walk a little farther


what to do to promote vasodilation and avoid vasoconstriction as a way to care for client with PAD?

  • Provide a warm environment for the client
  • Have client wear insulated socks
  • Tell the client to never apply direct heat, such as a heating pad, to the affected extremity b/c severity is decreased, and this can cause a burn
  • Avoid exposure to cold which causes vasoconstriction and dec arterial flow
  • Avoid stress, caffeine, nicotine--cause vasoconstriction
    • Vasoconstriction is avoided completely when the client completely abstains from smoking or chewing tobacco
    • Vasoconstriction of the vessels lasts up to 1 hr after smoking or chewing tobacco


how to position a client with PAD

  • Avoid crossing legs
  • Refrain from restrictive garments
  • Tell client to elevate legs to reduce swelling, but not to elevate them above the level of the heart b/c extreme elevation slows arterial blood flow to the feet


what are the 2 classes of meds most often used to tx PAD?

  • antiplatelet meds
  • statins


antiplatelet meds for PAD

  • aspirin, clopidogrel, pentoxifylline
    • Reduce blood viscosity by decreasing blood fibrinogen levels, enhancing erythrocyte flexibility, and inc blood flow to the extremities
  • Pentoxifylline: less common--may be used to help with intermittent claudication
  • Client edu:
  • Effects may not be apparent for several weeks
  • Monitor for evidence of bleeding: abdominal pain, coffee ground emesis, black, tarry stools


statins for PAD

  • simvastatin, atorvastatin
    • Can relieve manifestations of PAD (intermittent claudication)


therapeutic procedures for PAD

  • percutaneous transluminal angioplasty and laser assisted angioplasty
  • mechanical rotational abrasive atherectomy
  • arterial revascularization surgery


explain percutaneous transluminal angioplasty and laser assisted angioplasty as a therapeutic procedure for PAD

  • Percutaneous transluminal: invasive intraarterial procedure using a balloon to help maintain the patency of the vessel
  • Laser assisted: invasive procedure in which a laser probe is advanced thru a cannula to the site of stenosis
    • Laser can vaporize atherosclerotic plaque and open the artery
  • Nursing considerations:
    • Priority action: to observe for bleeding at puncture site
    • Monitor V/S, peripheral pulses, cap refill
    • Keep client on bed rest with limb straight for 2-6 hours before ambulation
    • Anticoag therapy used during procedure, followed by antiplatelet therapy for 1-3 mos


explain rotational abrasive atherectomy as a therapeutic procedure for PAD

  • uses a rotational device to scrape plaque from the inside of the client’s peripheral artery
    • Device is designed to cause minimal damage to the surface of the artery
  • Nursing considerations:
    • Priority action: to observe for bleeding at puncture site
    • Monitor V/S, peripheral pulses, cap refill
    • Keep client on bed rest with limb straight for 2-6 hours before ambulation
    • Anticoag therapy used during procedure, followed by antiplatelet therapy for 1-3 mos


explain arterial revascularlization surgery as a therapeutic procedure to help with PAD: what is it and nursing implications

  • used with clients who have severe claudication and/or limb pain at rest, or with clients who are at risk for losing a limb due to poor arterial circulation
    • Bypass grafts are used to reroute the circulation around the arterial occlusion
    • Grafts can be harvested from client or made from synthetic materials
  • Nursing:
    • Priority: to maintain adequate circulation in the repaired artery
    • Location of the pedal or dorsalis pulse should be marked, and its pulsatile strength compared to the contralateral leg on a scheduled basis using a doppler
    • Color, temp, sensation, and cap refill should be compared w/ contralateral extremity on scheduled basis
    • Assess for redness, warmth, edema as a result of inc blood flow in affected limb
    • Monitor for pain
    • Monitor BP
      • hypoTN can result in an inc risk of clotting or graft collapse
      • HTN inc the risk for bleeding from sutures
    • Instruct client to limit bending at hip/knee to dec risk of clot formation


explain arterial revascularlization surgery as a therapeutic procedure to help with PAD: client education

  • Avoid crossing or raising legs about heart
  • Wear loose clothing
  • Instruct client on wound care if revascularization surgery was done
  • Discourage smoking and cold temps
  • Foot care: keep feet clean and dry, wear good shoes, never go barefoot, cut toenails straight across


what are possible complications with PAD?

  • graft occlusion
  • wound or graft infection
  • compartment syndrome


explain graft occlusion as a complication of PAD

  • serious complication of arterial revascularization and often occurs w/in first 24 hours after surgery
  • Nursing:
    • Notify surgeon of manifestations of occlusion, such as absent or reduced pedal pulses, inc pain, change in extremity color or temp
    • Be prepared to assist with tx, which can include thrombectomy (removal of clot), local intra-arterial thrombolytic therapy with a tissue plasminogen activator, infusion of platelet inhibitor, or combo
      • Assess for indications of bleeding


explain wound or graft infection as a complication of PAD

  • Nursing actions:
    • Use sterile technique when changing dressing or providing wound care
    • Indications of infection: localized induration, warmth, tenderness, erythema, edema, purulent drainage, elevated WBC


explain compartment syndrome as a complication of PAD

  • medical emergency
  • Tissue pressure w/in a confined body space can restrict blood flow, and the resulting ischemia can lead to irreversible tissue damage
  • Nursing actions:
    • Manifestations:
      • Tingling
      • Numbness
      • Worsening pain
      • Edema
      • Pain on passive movement
      • Unequal pulses
    • Loosen dressings
    • Prepare to assist with fasciotomy


what is an aneurysm and what are the 2 types?

  • A weakness in a section of a dilated artery that causes a widening or ballooning in the wall of the blood vessel is called an aneurysm
    • Can be saccular (only affecting 1 side of the artery) or fusiform (involving both sides)


health promotion and dz prevention of aneurysms

  • Promote smoking cessation
  • Maintain appropriate weight for height and body frame
  • Encourage a healthy diet and physical activity
  • Control BP w/ regular monitoring and medication if needed


risk factors for aneurysms

  • Male gender
  • Atherosclerosis: MOST COMMON CAUSE
  • Uncontrolled HTN
  • Tobacco use
  • Hyperlipidemia
  • Family hx
  • Blunt force trauma
  • Hx of syphilis
  • w/ age, arterial stiffening caused by loss of elastin in arterial walls, thickening of intima of arteries, and progressive fibrosis of media occurs
    • Older clients are more prone to aneurysms and have a higher mortality rate from aneurysms than younger individuals


expected findings with an abdominal aortic aneurysm (AAA)

  • Most common, related to atherosclerosis
    • Constant gnawing feeling in abdomen
    • Flank or back pain
    • Pulsating abdominal mass (do not palpate-->can cause rupture)
    • Bruit over the area of the aneurysm
    • Elevated BP (unless in cardiac tamponade or rupture of aneurysm)