PVD Part 2 Fall 2015

Peripheral artery disease (PAD) involves thickening of artery walls,

which results in a progressive narrowing of the arteries of the upper and
lower extremities.

The leading cause of PAD is atherosclerosis, a gradual thickening of the

intima (the innermost layer of the arterial wall) and media (middle layer
of the arterial wall), which leads to progressive narrowing of the artery
lumen: 4 stages of PAD:

Stage I: Asymptomatic

Stage II: Claudication

Stage III: Rest Pain

Stage IV: Necrosis/Gangrene

Lower extremity(LEAD) PAD may affect the iliac, femoral, popliteal,

tibial, or peroneal arteries, or any combination of these 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. In advanced PAD, multiple levels of occlusions are
found.

Clinical Manifestations

Generally, the severity of the clinical manifestations depends on the

site and extent of the blockage and the amount of collateral
circulation. The classic symptom of lower extremity PAD is
______________________________, which is ischemic muscle pain that is
caused by _______________, resolves within 10 minutes or less with rest,
and is reproducible. The ischemic pain is a result of the buildup of
lactic acid from anaerobic metabolism. Once the patient stops
exercising, the lactic acid is cleared and the pain subsides. Patients
with ____________________ have discomfort in the lower back, buttocks,
or thighs. (located above the inguinal ligament)

Patients with _____________________ describe burning or cramping in the

calves, ankles, feet, and toes. (femoral, popliteal, and tibial arteries
and are below the superficial femoral artery (SFA) Instep or foot
discomfort indicates an obstruction below the popliteal artery

________________ or numbness or tingling, in the toes or feet

may result from nerve tissue ischemia. True peripheral
neuropathy occurs more often in patients with diabetes and
in those with long-standing ischemia. Neuropathy produces
severe shooting or burning pain in the extremity. It does not
follow particular nerve roots and may be present near
ulcerated areas. Gradual, reduced blood flow to neurons
produces loss of both pressure and deep pain sensations.
Thus patients may not notice lower extremity injuries.

_____________________________________provides important information

about blood flow. The skin becomes thin, shiny, and taut, and hair
loss occurs on the lower legs. Pedal, popliteal, or femoral pulses are
diminished or absent. Pallor (blanching of the foot) develops in
response to leg elevation (___________________). Conversely, reactive
hyperemia (redness of the foot) develops when the limb is in a
dependent position (___________________)
Wounds are located ________________________________. Wound beds are
often pale or necrotic with minimal exudate. Regular wound edges.
Delayed wound healing
Even small or shallow wounds do not heal because of the lack of
arterial blood flow.
Unilateral, localized edema
As PAD progresses and involves multiple arterial segments,
continuous pain develops at rest. Rest pain most often occurs in the
foot or toes and is aggravated by ___________________ Rest pain occurs
when blood flow is insufficient to meet basic metabolic requirements
of the distal tissues. Rest pain occurs more often at night because :
Patients often try to achieve pain relief by dangling the leg over the
side of the bed or sleeping in a chair. This allows gravity to maximize
blood flow.

The patient with chronic rest pain, ulceration, or gangrene has

_________________
Which may lead to amputation if untreated. Every attempt is made to
save the limb with surgical or endovascular revascularization. If a
patient is not a candidate for revascularization and/or if
revascularization is not technically possible, medical treatment is
required.

Complications
Lower extremity PAD progresses slowly. Prolonged ischemia leads to:
atrophy of the skin and underlying muscles. Even minor trauma to
the feet (e.g., stubbing one's toe, blister from shoes) can result in
delayed healing, wound infection, and tissue necrosis, especially in
the diabetic patient. Arterial (ischemic) ulcers most often occur over
bony prominences on the toes, feet, and lower legs Wound located at
ankle or below laterally. Round punched out appearance, deep,
decrease exudate, pale or necrotic wound bed
_________________ arterial ulcers and _______________ are the most
serious complications.
Amputation may be needed if adequate blood flow is not restored or
if severe infection occurs.

Diagnostic Studies
Doppler ultrasound with duplex imaging maps blood flow throughout
the entire region of an artery.The Doppler ultrasound can determine
the degree of blood flow.
Segmental blood pressures (BPs) are obtained (using Doppler
ultrasound and a sphygmomanometer) at the thigh, below the knee,
and at ankle level while the patient is supine. A drop in segmental BP
of greater than 30mm Hg suggests PAD
 The ankle-brachial index (ABI) is a PAD screening tool. It is performed
using a hand-held Doppler. The ABI is calculated by dividing the ankle
systolic BPs by the higher of the left and right brachial systolic BPs.
ABI <0.9 is diagnosed PAD. In very elderly patients and those with
diabetes, the arteries often are calcified and noncompressible.

Exercise tolerance testing (by chemical stress test or treadmill) may

give valuable information about claudication (muscle pain) without rest
pain.

Collaborate with interdisciplinary health care team members when

providing care for patients with PAD
Cardiovascular disease risk factor modification:

Treatment of hyperlipidemia and hypertriglyceridemia:

Treatment of claudication symptoms:

Nutrition therapy

Proper foot care:

Percutaneous transluminal balloon angioplasty with or without stent
Peripheral artery bypass surgery: The most common with an
autogenous (native) vein or synthetic graft to bypass, or carry blood
around, the lesion
Thrombolytic therapy or mechanical clot extraction therapy (for
acute ischemia only)
Amputation: may be required if tissue necrosis is extensive, gangrene
or osteomyelitis develops, or all major arteries in the limb are
blocked, precluding the possibility of successful surgery.
Nursing Management Lower Extremity Peripheral Artery Disease

Acute Intervention.

Compare all assessment findings with the patient's baseline

and with findings in the opposite limb
Assess for potential complications such as bleeding,
hematoma, thrombosis, embolization, and compartment
syndrome. A dramatic increase in pain, loss of previously
palpable pulses, extremity pallor or cyanosis, decreasing ABIs,
numbness or tingling, or a cold extremity suggests blockage
of the graft or stent.

Prerenal failure can develop for several reasons. The kidney

can sustain ischemia from decreased aortic blood flow,
decreased cardiac output, emboli, inadequate hydration

Emboli can also develop and lodge in the arteries of the lower
extremities or mesentery. Clinical manifestations include
those of acute occlusion in the leg.

Bowel necrosis is exhibited as fever, leukocytosis, ileus,

diarrhea, and abdominal pain.

The spinal cord can also become ischemic, resulting in

paraplegia, rectal and urinary incontinence, or loss of pain and
temperature sensation. Spinal cord ischemia tends to occur
more commonly when an abdominal aortic aneurysm has
ruptured.

Changes in sexual function may also develop following repair

of an abdominal aortic aneurysm. Retrograde ejaculation
occurs in about two thirds of male clients, and loss of potency
occurs in one third of males who have undergone repair of
abdominal aortic aneurysm

Avoid placing the patient in a knee-flexed position except for

exercise. Turn the patient and position frequently with pillows
to support the incision. Discourage prolonged sitting with leg
dependency, since 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. Walking even short distances is desirable.

Surgical site infection (SSI) after lower extremity

revascularization occurs in about 11% of cases.

VENOUS DISORDERS

__________________________ is thrombophlebitis of the deep

veins. DVT is a common disorder, more so in women than in
men, and among hospitalized clients.
______________________________ is the preferred terminology
and represents the spectrum of pathology from DVT to
pulmonary embolism

Etiology and Risk factors

Thrombus formation is usually attributed to Virchow's triad:

Venous stasis is usually caused by _________________ or lack of

use of the ____________________. Other conditions that may
cause stasis are age older than 40 years, surgery, prolonged
travel, stroke, obesity, pregnancy, paralysis, and heart
disease such as heart failure, myocardial infarction, and
cardiomyopathy. Some of the highest risk clients are those
having ______________________.

Hypercoagulability often accompanies : _________________,

_______________ and _______________. Oral contraceptives and
hematologic disorders may also increase the coagulability of
the blood.

Conditions that may cause vein wall trauma are intravenous

injections; fractures and dislocations; severe blows to an area;
chemical injury from sclerosing agents, contrast x-ray studies,
or certain antibiotics (such as chlortetracycline); and
Buerger's disease

Clinical manifestations of DVT are less distinctive; about

half of clients are asymptomatic. The most common clinical
manifestation is _____________ _____________. Other clinical
manifestations include pain, redness or warmth of the leg,
dilated veins, and low-grade fever. The first clinical
manifestation may be _______________.

Collaborative Care
Prevention and Prophylaxis.

VTE prophylaxis is a core measure of high-quality health care

in hospitalized surgical patients. The Joint Commission's
developed core measures for the care of patients with VTE In
addition, it is recommended that hospitals have a
thromboprophylaxis policy that addresses VTE prevention on
admission of all adult patients. As many as 60% of patients at
risk for VTE do not receive appropriate thromboprophylaxis.

___________________________________________________________
(e.g., thromboembolic deterrent ________ hose) are a part of
VTE prevention in hospitalized patients. When fitted correctly
(both size and length) and worn properly and consistently
from admission until discharge or full mobility, these stockings
decrease VTE risk. Proper use means the toe hole is under the
toes, the heel patch is over the heel, the thigh gusset is on
the inner thigh (thigh length only), and there are no wrinkles.
The stockings are not to be rolled down, cut, or otherwise
altered. Thigh-length stockings prevent proximal VTE better
than knee-length stockings. If the stockings are not fitted and
worn correctly, venous return is impeded. This may promote
the development of VTE and skin breakdown. VTE prevention
is enhanced if elastic compression stockings are used along
with anticoagulation.

____________________________________________________(_____) are
inflatable garments wrapped around the legs. They apply
external pressure to the lower extremities by means of an
electric pump. SCDs may or may not be used with elastic
compression stockings. Like elastic compression stockings,
ensure correct fit by accurately measuring the extremities.
SCDs will not be effective if they are not applied correctly; if
the fit is incorrect; or if the patient does not wear the device
continuously except during bathing, skin assessment, and
ambulation. SCDs are not worn when a patient has an active
VTE because of the risk of PE. VTE prevention is enhanced if
SCDs are used along with anticoagulation.

Anticoagulant therapy is designed to prevent initiation or

extension of thrombi by inhibiting the synthesis of clotting
factors or by accelerating their inactivation. Anticoagulant
agents do not break up or dissolve clots; they prevent new
clots from forming.

Unfractionated Heparin Therapy

The Patient Receiving Anticoagulant Therapy nursing

management and teaching:
Surgical Therapy.

Surgical options include open venous thrombectomy and inferior

vena cava interruption. Venous thrombectomy involves the removal
of a thrombus through an incision in the vein. Anticoagulant therapy
is recommended after venous thrombectomy.

___________________________ is a condition that develops when

leg veins and valves fail to keep blood moving forward. This
results in ambulatory venous hypertension. CVI can lead to
venous leg ulcers (formerly called venous stasis ulcers or
varicose ulcers).

Etiology and Pathophysiology

As a result of ambulatory venous hypertension, serous fluid

and RBCs leak from the capillaries and venules into the tissue.
This produces edema and chronic inflammatory changes.
Enzymes in the tissue eventually break down RBCs, causing
the release of hemosiderin, which causes a brownish skin
discoloration.

Clinical Manifestations and Complications

In individuals with CVI the skin of the lower leg is leathery,

with a characteristic brownish or brawny appearance from
the hemosiderin deposition. Edema usually has been
persistent for a prolonged period. Eczema, or stasis
dermatitis, is often present, and itching is a common
complaint

Venous ulcers classically are located _____________________ The

ulcer is often quite painful, particularly when edema or
infection is present. Pain may be worse when the leg is in a
dependent position. Severe complications can include
osteomyelitis and malignant changes. On rare occasions,
severe CVI with long-standing nonhealing venous ulcers may
result in the need for amputation.

Collaborative Care

____________________ is essential for CVI treatment, along with

topical wound care for stasis ulcers. Before starting
compression therapy, assess the arterial status to make sure
that PAD is not also present.

Evaluate the nutritional status of a patient with a venous

ulcer.

Routine use of antibiotics is not indicated.

Daflon: Pharmacological and clinical studies demonstrated the

comprehensive mode of action of Daflon 500 mg: it increases
venous tone, it improves lymph drainage, and it protects the
microcirculation.