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Flashcards in PAD Deck (38)
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1

PAD what is it?

Thickening of the artery walls. This results in a progressive narrowing of the arteries of the upper and lower extremities. PAD is strongly related to other types of cardiovascular disease CVD and their risk factors. PAD prevalence increases with age

2

PAD Pathophysiology

-Leading cause is atherosclerosis, a gradual thickening of the intima (innermost layer of the arterial wall) and media (middle layer of arterial wall)
- This results from deposits of cholesterol and lipids within the vessel walls and leads to progressive narrowing of the artery
- inflammation and endothelial injury play a major role
- atherosclerosis more commonly affects certain segments of the arterial tree. These include: coronary, carotid, and lower extremity arteries. Clinical symptoms occur when vessels are 60-75& blocked

3

Risk factors for PAD

-Tobacco use (most significant)
-Chronic kidney disease
-Diabetes
- HTN
-Hypercholesterolemia

4

PAD: Lower extremities
- lower extremity PAD may affect the?

Iliac, femoral, popliteal, tibial, or peroneal arteries. The femoral-popliteal area is the most common site in nondiabetic patients. Patients with diabetes tend to develop PAD in the arteries below the knee

5

Clinical manifestations of PAD

-Intermittent claudication
-asymptomatic or atypical leg symptoms (burning, hardness, heaviness, knotting, pressure, soreness, tightness, weakness) in atypical locations (ankle, foot, hamstring, hip, knee, shin)
-Paresthesia (numbness/tingling in toes/feet
-Pallor of feet noted in response to leg elevation
-Reactive hyperemia (redness) develops when limb hangs in dependent position (dependent rubor). Skin is shiny and taut with hair loss on lower legs. Pedal, popliteal, or femoral pulses are diminished or absent
-PAD progression involves continuous pain at rest mostly in forefoot or toes and aggravated by limb elevation

6

Define intermittent Claudication

Ischemic muscle pain that is caused by exercise, resolves within 10 minutes or less with resting, and re reproducable

7

Most serious complication of PAD

Nonhealing arterial ulcers and gangrene, and may require amputation

8

PAD Diagnostic Studies

-Doppler US & duplex imaging assess blood flow
-Segmental BPs obtained (using Doppler US & a sphygmomanometer) at the thigh, below the knee, and at ankle level while patient is supine. A drop in segmental BP of >30 mm Hg suggests PAD
-Angiography or magnetic resonance angiography (MRA) delineates location and extent of PAD

9

PAD Interprofessional Care
The first Tx goal is to reduce cardiovascular risk factors. Tobacco cessation is essential. Aggressive lipid management is essential for all patients with PAD. Both dietary interventions and drug therapy are needed

1) Statins & fibric acid derivative lower LDL and triglyceride levels. HTN and diabetes mellitus also need to be controlled
2) Antiplatelet agents are critical for reducing risk of CVD events and death in patients with PAD. Oral antiplatelet therapy should include 75-235 mg/day of aspirin. Aspirin intolerant patients may take 75 mg of clopidogrel (Plavix) daily

10

Treatment of intermittent claudication

-Two drugs: cilostazol (Pletal) and pentoxifylline. Cilostazol, a phosphodiesterase inhibitor, inhibits platelet aggregation and increases vasodilation. Pentoxifylline, a xanthine derivative, improves deformability of RBCs and WBCs and decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity
-Supervised exercise program: 30-45 min/day, @least 3x/week for minimum 3 months. Can be walking or cycling
-Adjust caloric intake so ideal body weight achieved/maintained
-Diet: high in fruits, vegetables, and whole grains. Low in cholesterol, saturated fats, and salt

11

Patients taking antiplatelet agents, NSAIDs, or anticoagulants (warfarin) should consult HCP before taking?

Any dietary or herbal supplements, because of potential interactions and bleeding risks

12

Critical limb ischemia

-Chronic ischemic rest pain lasting more than 2 weeks, arterial leg ulcers or gangrene of the leg as a result of PAD
-Management goals: protecting extremity from trauma, decreasing ischemic pain, preventing/controlling infection, maximizing perfusion. Inspect, cleanse, and lubricate both feet to prevent cracking of the skin and infection

13

PAD: Interventional radiology catheter-based procedures are alternatives to open surgical approaches for Tx of lower extremity PAD

1) Percutaneous transluminal angiogplasty: catheter w/cylindric balloon at tip. End of catheter advanced to stenotic (narrowing) area of artery. Balloon is inflated, compressing atherosclerotic intimal linging
2) Stents: expandable metallic devices that keep artery open after balloon angioplasty. May be covered w/Dacron or a drug-eluting agent to reduce restenosis by limiting amount of new tissue growth into stent
3) Atherectomy: removes obstructing plaque. Directional atherectomy device uses high-speed cutting disk that cuts long strips atheroma. Laser atherectomy uses UV energy to break apart atheroma
4) Peripheral arterial bypass operation w/autogenous (native) vein or synthetic graft material to bypass or carry blood around the lesion
5) Endarterectomy (opening artery and removing obstructing plaque) and patch graft angioplasty (opening artery, removing plaque, and sewing a patch to the opening to widen the lumen)
6) Amputation required if tissue necrosis is extensive, gangrene or osteomyelitis, or other major arteries are occluded, precluding possibility of successful surgery

14

PAD Goals

-Patient w/lower extremity PAD will have adequate tissue perfusion, relief of pain, increased exercise tolerance, and intact, healthy skin on extremities

15

PAD Nursing interventions:
After surgical or radiologic intervention what should the nurse do?

Check the operative extremity every 15 minutes initially then hourly for color, temp. cap refill time, presence of peripheral pulses or a change in the doppler sound over a pulse. Immediately contact HCP

16

PAD Nursing interventions:
After the patient leaves the recovery area, the nurse should continue to monitor what?

1) Perfusion of extremities and assess for complications such as bleeding, hematoma, thrombosis, embolization, and compartment syndrome. Does so by checking VS
2) Dramatic increase in pain, loss of previously palpable pulses, extremity pallor or cyanosis, decreasing ankle brachial index (ABI) on serial measurements, numbness or tingling, or cold extremity suggests blockage of graft or stent. Report to HCP

17

PAD Nursing interventions:
What should be avoided and done in a patient with PAD

-Knee flexed positions (except for exercise)
-Turn patient frequently & position pillows to support incision
-Starting postop day 1 pt should get out of bed several times and walk even if it is short distances
-discourage prolonged sitting with leg dependency because it may cause pain and edema, increase the risk of venous thrombosis, and place stress on the suture lines.
-If edema develops, position the patient supine and elevate the leg above the heart level

18

PAT Education

-Encourage supervised exercise training after successful revascularization
-Teach foot care to all pt's with PAD, especially diabetics
-Inspect legs and feet daily for mottling, changes in skin color or texure, and reduction in hair growth. Show pt's how to check temp and cap refill and palpate pulses
-Wear clean, all cotton or all wool socks and comfortable shoes with rounded toes and soft insoles. Lace shoes loosely and break in new shoes gradually

19

INTER PROFESSIONAL CARE RISK FACTOR MODIFICATION

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

20

INTER PROFESSIONAL CARE DRUG THERAPY
ACE inhibitors
– Ramipril (Altace)

• ↓ Cardiovascular morbidity
• ↓ Mortality
• ↑ Peripheral blood flow
• ↑ABI
• ↑ Walking distance

21

INTER PROFESSIONAL CARE DRUG THERAPY
• Antiplatelet agents

– Aspirin
– Clopidogrel (Plavix)

22

INTER PROFESSIONAL CARE DRUG THERAPY
• Drugs prescribed for treatment of intermittent claudication

– Cilostazol (Pletal)
• Inhibits platelet aggregation
• ↑ Vasodilation

– Pentoxifylline (Trental)
• Improves deformability of RBCs and WBCs
• Decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity

23

INTER PROFESSIONAL CARE NUTRITIONAL THERAPY

• BMI <25 kg/m2
• Waistcircumference<40inchesformenand<35inchesforwomen
• Recommend reduced calories and salt for obese or overweight persons

24

INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA

• Revascularization via bypass surgery
• Percutaneous transluminal angioplasty (PTA)
• IV prostanoids (iloprost [Ventavis])
• Spinal cord stimulation
• Angiogenesis

25

INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA
INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA
• ConservativeTreatment

– Protect from trauma
– Decrease ischemic pain
– Prevent/control infection – Improve arterial perfusion

26

CASE STUDY
• B.D. returns for follow-up in 3 months.
• His BP and lipid levels are stabilizing, but he complains of increasing
leg pain at rest.
• His physician determines that it is time to consider an intervention to improve his circulation. What are the interventions?

RADIOLOGY PROCEDURES
• Indications
– Intermittent claudication symptoms become incapacitating
– Pain at rest
– Ulceration or gangrene severe enough to threaten viability of the limb
1) Percutaneous transluminal angioplasty (PTA)
– Involves insertion of a catheter through femoral artery
– Catheter contains a cylindrical balloon
– Balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining
– Stent is placed
2) Atherectomy
– Removal of obstructing plaque
– Performed using a cutting disc, laser, or rotating diamond tip
3) Cryoplasty
– Combines percutaneous transluminal angioplasty and cold therapy
– Liquid nitrous oxide

27

INTER PROFESSIONAL CARE SURGICAL THERAPY
• Most common surgical approach

– Peripheral artery bypass surgery with autogenous vein or synthetic graft
to bypass blood around the lesion
– PTA with stenting may also be used in combination with bypass surgery

28

INTER PROFESSIONAL CARE SURGICAL THERAPY

• Endarterectomy
• Patch graft angioplasty
• Amputation

29

NURSING MANAGEMENT
NURSING ASSESSMENT
• Past health history

– Diabetes mellitus
– Smoking
– Hypertension
– Hyperlipidemia
– Obesity

30

NURSING MANAGEMENT
NURSING ASSESSMENT

• Exercise intolerance
• Loss of hair on legs and feet
• Decreased or absent peripheral pulses
• Intermittent claudication