Week 7: Chp 31: Peripheral Arterial Disease (PAD) Flashcards
(44 cards)
1
Q
Main Contributor to PAD; main risk factor
A
-atherscelrosis
2
Q
Modifiable Risk Factors
A
- smoking
- hypertension
- diabetes
- dyslipidemia
- sedentary lifestyle
- obesity
- ineffective stress management
3
Q
Non-modifiable risk factors
A
- age
- gender
- ethnicity
- family history
- a strong family history of coronary artery disease or PAD is an important predictor of its occurrence and subsequent prognosis
4
Q
Peripheral Arterial Disease
A
progressive and chronic condition, where the obstruction of blood flow through the large peripheral arteries causes a partial or total arterial occlusion
- deprives the lower extremities of oxygen and nutrients; the result of this inadequate tissue perfusion can be ischemia and necrosis, or cell death
- affects the limbs and is a manifestation of systemic atherosclerosis
5
Q
PAD can be caused by?
A
caused by a combination of atherosclerosis, inflammation, stenosis, embolus, and thrombus
6
Q
Clinical Manifestations
A
may be asymptomatic, identified only by a reduced BP in the ankle, or it may manifest symptoms of intermittent claudication, or atypical lower extremity pain
- person with PAD typically experiences profound limitation in exercise capacity and quality of life
- will vary with the tissues involved and the severity of altered blood flow
- early stage–> classic leg pain (intermittent claudication), fatigue and pain in a specific muscle group during exertion
7
Q
Intermittent Caludication
A
muscle pain–ache, cramp, numbness, or sense of fatigue, classically in the calf muscle, that occurs during exercise and is relieved by a short period of rest
8
Q
Atypical Leg Pain
A
limited or painful joints, cold and/ or ulcerated extremities, or painful stretching
-exercised induced and rest relief
9
Q
The vascular assessment for PAD
A
includes pulse palpitation, auscultation for femoral bruits, and inspection of the legs and feet
10
Q
How to confirm Diagnosis of PAD
A
abnormal physical examination findings must be confirmed with diagnostic testing
-other comorbid causes of atypical leg pain should be ruled out before diagnosing
11
Q
Non-invasive testing for PAD
A
-ankle-brachial index (ABI)
-plethysmography
-graded-exercise treadmill test
>provide information about the arterial system with minimal risk
12
Q
Ankle-Brachial Index (ABI)
A
used a doppler probe to compare the BP obtained at the ankle with the pressure obtained at the brachial artery
- BP readings are normally higher in the ankle than those in upper extremities
- test provides a ratio known as ABI; value can be derived by dividing the ankle BP by the brachial BP
- ABI less than 0.9 in either leg is diagnostic of PAD
13
Q
Ankle-Brachial Index Values
A
- Greater than 1.30= non-compressible arteries (stiff arteries)
- 1 to 1.29= normal
- 0.91 to 0.99= borderline PAD
- 0.41 to 0.9= mild to moderate PAD
- 0 to 0.4= severe PAD
14
Q
Plethysmography
A
non-invasive test used to evaluate arterial flow in the lower extremities
- pulse volume recordings are plethysmographical tracings that detect changes in the volume of blood flowing through a limb
- pressure cuffs are placed on the thigh, calf, ankle, or foot
- the pressure cuffs are inflated to 65 mm Hg and a plethysmographical tracing is recorded at the various areas where the cuffs are placed
- a normal pulse volume recording is similar to a normal arterial pulse wave tracing and consists of a rapid systolic upstroke and rapid downstroke with a prominent dicrotic notch.
- with increasing severity of PAD, the waveforms are decreasing or flattening depending on the degree of occlusion
15
Q
Treadmill Test
A
give valuable information about the degree of peripheral arterial narrowing in patients who experience intermittent claudication
- once the resting pressure and pulse volumes are obtained, the patient is asked to walk on a treadmill at a constant speed, either at a constant grade or with a variable incline (lasts for 5 minutes)
1. confirms the diagnosis of intermittent claudication and PAD
2. demonstrates the objective functional limitation of PAD
3. documents the effect of therapy on initial and absolute claudicating distances
4. uncovers previously unrecognized coronary artery disease
16
Q
Duplex Ultrasound
A
uses the detection of sound waves to measure the velocity of blood flow
-used to detect and localize vascular lesions and quantify the amount and severity of damage through blood flow velocity criteria
17
Q
Stages of PAD
A
- Stage I: Asymptomatic PAD
- Stage II: claudication
- Stage III: Rest Pain
- Stage IV: Necrosis or gangrene
18
Q
Stages of PAD: Stage I: Asymptomatic PAD
A
- no claudication/ pain is experienced by patient
- bruit may be heard
- pedal pulses are decreased or absent
19
Q
Stages of PAD: Stage II: Claudication
A
- muscle pain, burning and cramping are experienced with exercise and are relieved by rest
- pain is reproducible with the same amount of exercise
20
Q
Stages of PAD: Stage III: Rest Pain
A
- pain is experienced at rest
- pain often awakens patient at night
- pain is described as numbness and burning and usually occurs in the distal portion of the extremity
- pain is often relieved by putting the extremity in the dependent position
21
Q
Stages of PAD: Stage IV: Necrosis or gangrene
A
- ulcers and blackened tissue occur on the toes, the forefoot, or the heel of the foot
- gangrenous odor may be present
22
Q
Computed tomography angiography (CTA)
A
is a CT scan that requires contract material to visualize blood vessels
- it displays the roadmap of the vasculature which identifies the issues and is sometimes essential for determining interventional strategies
- Advantages: quick non-invasive testing, wide availability, high resolution, and 3D imaging
- Disadvantages: lack of hemodynamic data, exposure to radiation, use of contrast agents
23
Q
Magnetic Resonance Angiography (MRA)
A
magnetic resonance test that focuses on the study of the vasculature
- uses contrast and non-contrast techniques when imaging the peripheral arteries
- Non-contrast MRA has inferior resolution and may contain artefacts that limit interpretation, but is a valuable alternative for use in patients with mild to moderate chronic kidney disease for whom se of contrast agents is not recommended
- vascular calcification can be underestimated by MRA and may affect revascularization procedures
24
Q
Angiography
A
consists of arteriography of the lower extremities
- done to quantify the narrowing of the occluded vessels
- arteriography involves injecting contrast medium into the arterial circulation through a small sheath in the groin
- treatment options can be derived and refined via arteriography; one treatment option is balloon angioplasty for the occluded vessel with stent placement
- angiography can also provide a better visual for refinements for planned peripheral bypass surgery
25
Treatment
goal is to provide relief of symptoms, prevent the progression of arterial disease and cardiovascular complications, improve quality of life, and provide education about the disease
- medications and non-surgical and surgical interventions are options
- non-pharmacological interventions such as weight reduction, smoking cessation, exercise, and adherence to a low-fat diet are first line actions
26
Medications
target the risk factors driving the progression of atherosclerosis in PAD
- antihypertensive, antiplatelet, and statin agents
- Beta blockers can be used for BP control
27
Medications: Antiplatelet
```
acetylsalicylic acid (aspirin) and clopidogrel (Plavix) are prescribed in patients with chronic PAD
-inhibit platelet aggregation, therefore decreasing the probability of vascular events
```
28
Medications: Lipid-Lowering Statins
successfully reduce total cholesterol in most patients when used for extended period
-Achieve target LDL-C level of less than 100 mg/dL
29
Nonsurgical Management
consists of positioning or promoting vasodilation by having limb in a dependent position
- exercise; to increase blood flow to affected limb by increasing collateral circulation
- percutaneous transluminal angioplasty, laser-assisted angioplasty, rotational atherectomy
30
Nonsurgical Management: Percutaneous transluminal angioplasty
nonsurgical, minimally invasive method of improving arterial blood flow
- a cannula is inserted into or above an occluded or stenosed artery
- the occluded artery is then dilated with a balloon catheter
- success is proven when it opens the vessel and restores or improves arterial blood flow
- stents may be used to keep vessels open
- transfemoral approach is safest; alternative brachial or axillary
31
Nonsurgical Management: Laser-assisted angioplasty
minimally invasive intervention for patients with PAD
- a laser probe is advanced through a cannula that is inserted into or above an occluded artery
- usually indicated for smaller occlusions in the distal superficial femoral, proximal popliteal, and common iliac arteries
- heat from the laser probe vaporizes the arteriosclerotic plaque to open the occluded or stenosed vessel
32
Nonsurgical Management: Rotational Atherectomy
used to improve blood flow to the ischemic limbs of people with PAD
- more commonly used for very hard, calcified stenotic lesions that are not amenable to balloon angioplasty
- rather than compressing plaque and stretching an artery narrowed by atherosclerotic plaque, the goal is removal of the plaque by breaking it into micro fragments which can pass harmlessly into the circulation
33
Surgical Management
surgical or revascularization is indicated when patients have severe pain at rest or claudication that interferes with ADLs
-arterial revascularization through bypass grafting
-surgical bypass treats narrowed arteries by creating a bypass around a section of the artery that is blocked
(autogenous grafts; patients own saphenous vein or synthetic grafts if patients own vessels are not available)
34
Complications
- Critical Limb Ischemia
| - Acute Limb Ischemia
35
Complications: Critical Limb Ischemia
sustained, severe decrease of arterial blood flow to the affected extremity, which leads to chronic ischemia, rest pain, ulceration, gangrene, and limb loss if left untreated
- obstructive atherosclerotic arterial disease is the most common cause of this
- presents after extended course of PAD
- once PAD progresses to CLI the prognosis is generally poor; infection, cellulitis, and tissue breakdown can occur; all of which increase the requirement for oxygenated blood, which is decreased because of the disease process
- without adequate tissue perfusion, tissue breakdown and ulcers worsen, and gangrene becomes apparent; need revascularization to save the limb
36
Complications: Acute Limb Ischemia
sudden decrease in blood flow to an extremity that threatens tissue viability
-be the first manifestation of PAD in a previously asymptomatic patient or caused by an acute event that leads to symptomatic deterioration in a patient
with lower extremity PAD and intermittent claudication
37
What is the most common cause of peripheral occlusions
-embolus
38
Acute Limb Ischemia Clinical Manifestations
"six Ps"
- pain
- pallor
- pulsenessless
- paresthesia (pins and needles, tingling)
- paralysis
- poikilothermia (cool)
39
Goal of treatment for Acute Limb Ischemia
preserve tissue and save the limb
- initiation of anticoagulation therapy with IV heparin is usually the first intervention to prevent further clot formation
- other interventions: restore blood flow, which relieves pain, helps heal ulcers, and possibly prevents amputation
40
Clinical Manifestations of Severe PAD
- extremity is cold and cyanotic or darkened
- pallor may occur when extremity is elevated and dependent redness may occur when extremity is lowered
- muscle atrophy can also accompany prolonged PAD
41
Nursing Diagnosis
- ineffective peripheral tissue perfusion r/t interruption of arterial blood flow to the peripheral tissue
- risk for impaired skin integrity r/t altered circulation or sensation
- chronic pain r/t decreased peripheral perfusion e/b the inability to walk for prolonged periods of time or having pain at rest
42
Nursing Interventions: Assessment
- assess bilateral BP (increased risk of subclavian artery stenosis. upper arm BP difference greater than 15 to 20 mm Hg is abnormal and suggestive of subclavian stenosis. use bigger BP measurement when calculating ABI and titrating blood pressure medications)
- Palpate pulses in both legs (weak or absent pulses indicate poor blood flow through the extremity)
- Visual Assessment of feet and limbs (signs of ulcer formation, sluggish capillary refill, dry, scaly, dusky, pale, or mottled skin, thickened toenails, loss of hair on lower calf, ankle, and foot indicate poor peripheral blood flow)
- Temperature (cool or cold temp in extremities indicates poor flow)
- Assess bilateral muscle tone (muscle atrophy can accompany prolonged chronic arterial disease)
- Assess pain
43
Nursing Intervetions: Actions
- administer medications as ordered (anti-hypertensives, antiplatelet agents, Cilostazol (has antiplatelet and vasodilation properties that can improve PAD)
- proper positioning (keep extremity dependent)
44
Nursing Interventions: Teaching
- positioning (avoid crossing legs)
- Inspect feet daily
- report chest discomfort or neurological changes
- lifestyle changes consistent with management of atherosclerosis: DASH diet, limit alcohol, smoking cessation, moderate exercise
