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Nursing care of Patient with Peripheral Vascular Disease

Peripheral Arterial Occlusive Disease


Upper extremity arterial occlusive disease
Arterial embolism; arterial thrombosis
Thromboangiitis obliterian (buetgers disease)
Aneurysms: aortic aneurysm, thoracic aneurysm, abdominal
aortic aneurysm, dissecting aorta.
Venous disorders
Deep vein thrombosis aka DVT, thrombophlebitis and
phlebothrombosis
Chronic venous insufficiency
Leg ulcers
Varicose veins
Cellulitis
Peripheral vascular disease
Disorders that alter the natural flow of blood through the arteries
and veins of the peripheral circulation
Affects the lower extremities more than the uppers
A chronic disorder in which partial or total occlusion deprives the
lower extremities of oxygen and nutrients
Tissue damage occurs below the level of the aerial occlusion
Atherosclerosis- most common cause of peripheral arterial
disease
Assessment
Intermittent claudication: Hallmark of the disease
General rule- pain of intermittent claudication occurs one joint
level below the disease process
What is intermittent claudication- a muscular, cramp type
pain in the extremities consistently reproduced with the same
degree of exercise or activity and relieved by rest. Experienced
by patients with peripheral arterial insufficiency.
Rest pain: severe. Persistent pain in the forefoot when the
patient is resting. Indicates severe degree of arterial insufficiency
and a critical state of ischemia. Its often worse at night and may
interfere with sleep. Frequently requires that extremity be
lowered to a dependent position to improve perfusion pressure to
the distal tissues.
Numbness or burning often described as feeling like a toothache,
that is severe enough to awaken a patient in the night
Unrelieved by opioids

Elevating the extremity it placing it in horizontal position


increases the pain, whereas placing the extremity in a dependent
position reduces the pain
In bed, some sleep with affected leg hanging over the side of the
bed
Some patients sleep in a reclining in an attempt to relieve the
pain
Coldness or cold sensitivity- coldness in the feet with exposure to
cold environment, associated with blanching or cyanosis due to
ischemia
**Extremity: cold and pale when elevated, or ruby and
cyanotic when placed in a dependent position.
Nail: thickened and opaque
Skin: shiny, atrophic and dry with sparse hair growth
Comparison of he left and right extremities
Bruits may auscultated with stethoscope
Ulceration and gangrene: may be due to ischemia or trauma.
Impaired tissue perfusion process
Edema: due to severe obstruction
Sexual dysfunction. Occlusion of terminal aorta decreases blood
supply to the penile arteries
Gangrene
Muscle atrophy
Assessment Pulses
Peripheral pulses: important part of assessing arterial
occlusive disease
Unequal pulses between extremities or the absence of
normally palpable pulse is a sign of peripheral arterial disease.
The femoral pulse in the groin and the posterior tibial pulse
beside the medial malleolus are most easily palpated.
Diagnostic findings
Ankle- brachial index
Arteriogram
Exercise tolerance test
Treatment
Increase arterial blood flow
Control hypertension
Positioningdont cross legs to prevent thrombosis
Promote vasodilationkeep patient warm
Skin and foot care
Pentoxifylline aka Trental: increase flexibility of RBCs , decrease
blood viscosity by inhibiting platelet aggregation and decrease
fibrinogen and thus increase blood flow in the extremities.

Foot

Antiplatelet drugs: aspirin, Plavix


Exercise
Stop smoking
Low fat, low cholesterol diet
care for patients with PVD
Keep feet clean
Keep feet dry
Avoid injury
Never go without socks; make sure they fit well; wear cotton
socks
Cut toenails properly straight across
Apply lubricate to feet
No exposure to extreme climate changes
Do not use heat lamps on feet
No smoking
Avoid extended pressure on the feet or ankles
Surgical management
Threatens the loss of limb
Patient can no longer work
Vascular grafting- for patients with severe intermittent
claudication and disabling or when the limb is at risk for
amputation because of tissue loss
Endartectectomy- incision is made into the artery, atheromatous
obstruction is removed, artery is then sutured closed to restore
vascular integrity
Bypass grafts: performed to reroute the blood around the
stenosis or occlusion. The distal outflow vessels must be at least
50% patent for the graft to remain patent.
Femoral to popliteal graft: above-knee, below-knee grafts
Nursing management: maintaining circulation, maintain skin
integrity and prevent infection, monitor and manage potential
complication, promote home and community based care.
Maintaining circulation: Post Op care
Monitor the ff q hour for the first 8 hours and then every 2 hours
for 24 hours
Pulses
Color and temperature of the extremity
Capillary refill
Sensory and motor function of the affected extremities
Compare extremities
Doppler evaluation

ABI: at least once every 8 hours for the 1st 24 hours and then OD
until discharge.
** Disappearance of pulse that was present may indicate
thrombotic occlusion of the graft.. Notify surgeon STAT
Warm environmental temperature
Place leg in slight dependency to promote arterial flow
Avoid pressure on affected extremity; use padding for support
Avoid vigorous massage of extremities
Avoid: chilling and exposure to cold, avoid contractive clothing,
crossing legs
Quite smoking
Do not go barefooted
Trim toenails straight
Avoid scratching or rubbing feet
Acute arterial occlusion
Happens suddenly
Occlusion may affect upper extremities, but it more common in
the lower extermties
Most common cause: embolus or local thrombus
Risk factors: AMI within the preceding weeks, atrial fibrillation,
infective endocarditis, chronic heart failure
Assessment
Severe pain below level of the occlusion
Occurs even at rest
Affected extremity: cool or cold, pulseless, and mottled
Minute area on the toes may be blackened or gangrenous
Six Ps of ischemia: pain, pallor, pulselessness, paresthesia,
paralysis, coolness of the involved extremity
** HESI hints: decreased blood flow results in diminished sensation in
the lower extremities. Any heat source can cause severe burns before
the patient realize the damage is being done. **
Intervention
Anticoagulant therapy aka Heparin: bolus of up to 10,000 units
Buergers disease
Occlusive inflammatory disease strongly associated with smoking
Raynauds disease (think hands)
Form of intermittent arteriolar vasoconstriction that results in
coldness, pain, and pallor of the fingertips or toes
Triggered by extreme heat or cold
Occur bilaterally, ages 17 and 50 years, more common in women
Aortic aneurysm aka AAA

Atherosclerosis: most common cause


Most occur below the renal arteries
Untreated, the eventual outcome may be rupture and death
Abnormal dilation of the arterial wall caused by localized
weakness and stretching in the medial layer or wall of artery
Localized sac or dilation formed at a weak point in wall or aorta
Can be located anywhere along the aorta
Saccular aneurysm- projects from one side of the vessel
Fusiform aneurysm- entire arterial segment become dilated
Pathophysiology
Damage medial layer of the vessel
After an aneurysm develops it tends to enlarge
Clinical manifestation
Often asymptomatic
Found on examabdominal pulsation
Rapid expansion: co sudden onset of lower back pain.. serious
aneurysm can rupture
Shock, N/V, diaphoresis
Feel heart beating in their abdomen when laying down
Feel abdominal mass or abdominal throbbing
Pulsatile mass in middle and upper abdomen** most important
diagnostic indication**
Systolic bruit over mass
Of associated with thrombus, a major vessel may be occluded or
smaller distal occlusion may result from emboli
A small cholesterol platelet, or fibrin emboli may lodge or digital
arteries, causing blue toes.


DX: abdominal X-rayeggshell, CT scanassess size and location,
ultrasonographycan also identify size and location
** HESI hint: a client is admitted with severe chest pain and states that
he feels a terrible sensation in his chest. He is diagnosed with
dissecting aortic aneurysm. What assessments should the nurse obtain
in the first few hours? Vital signs every hour, neurologic vital sign,
respiratory status, urinary output, and peripheral pulses.
*During aortic aneurysm repair, the large arteries are clamped for
period of time, and kidney damage can result. Monitor daily BUN and
normal creatine levels. Normal BUN is 10 to 20 mg/dl and normal
creatinine is 0.6 to 1.2 mg/dl. The ratio of BUN to creatine is 20:1.
When this ratio increases or decreases, suspect renal problems.*
Signs of impending rupture
Severe back pain or abdominal pain. May be persistent or
intermittent localized in the middle or lower abdomen to the left
midline
Low back pain- because of pressure of the aneurysm on the
lumbar nerves
Lower back pain is a serious symptom, usually indicating that the
aneurysn is expanding rapidly and it is about to rupture
Indications of a rupturing AAA: constant, intense back pain,
falling BP, decreasing hematocrit
What the difference between true and false aneurysm
True includes all three tunica layers
False- entire wall is injured blood escapes between tunica layer
and they separate. The blood is contained by the surrounding

tissues, with eventual formation of a sac communicating with the


artery or heart. If the separation continues, a clot may form,
resulting in a dissecting aneurysm.
Risk factors
Atherosclerosismost common cause
Hypertension
Obesity
Stress
Aging
Trauma
Syphilis, marfan syndrome, ehler-danlos syndrome
Surgery complications
MI
Graft occlusion
Graft rupturehemorrhagedeath
Hypervolemiarenal failure
Respiratory comprise
Paralytic ileus
AAA Post OP
PA line, A linemonitor hemodynamic status
Possible ventextubate early
Assess pulsesmonitor for graft occlusion/ rupture
Assess capillary refill
Fluid status I&O , urine output of less than 50 cc/hr
Labs: H&H, Lytes, BUN, Creat, ABG, Pulse oxygen
NGT
Pain management-opioids for pain
OOB24 hours post extubation

Amputation

Removal of part of the body


Levels: toes, mid-foot, syme, below the knew, above the knee
Post-OP management
Assessment of tissue perfusion (primary responsible)
Pain management: distinguish between phantom limb vs.
incisional pain
PLP: other meds besides opioidscalcitonin, beta blockers,
anticonvulsants, antspasmotics
Positioning and ambulation.
Plan pre-op
Prevention of flexion contractures: prone patients Q 3-4 hours for
20-30 min each day
Neurovascular status and function of affected extremity or
residual limb and of unaffected extremity
Signs and symptoms of infection
Diagnosis
Acute pain
Risk for disturbed sensory perception
Disturbed body image
Ineffective coping
Risk for anticipatory or dysfunctional grieving
Self care deficit
Impaired physical mobility
Complications
Hemorrhage
Infection
Phantom lim pain
Hazard of immobility
Neuroma
Flexion contractures
What is phantom limb pain

Frequent complication of amputation


Patient complain of pain at the site of the removed body part,
most often shortly after the surgery
Pain is intense, burning feeling, crushing sensation or cramping
Some patient feel that removed body part is in distorted position
Opioids do not help with this pain
Exercise after amputation
ROM to prevent flexion contractures, particulay in the hip and
knee
Trapeze and overhead frame
Firm mattress
Prone position every 3 to 4 hours
Elevation of lower leg residual limb controversial
Thrombophlebitis
Inflammation of deep veins
Associated with thrombus formation
Can lead to DVT or pulmonary embolism
Virchows triadinflammatory process caused by endothelial
injury, venous stasis, hyper coaguability
Causes : surgery, pregnancy, ulcerative colitis, heart failure,
immobility
(sitting for extended time)
S&S
Swelling and increase diameter of calf and thigh
Vein tract reddened, hard, warm to touch, aka edema
May not have S&S when superficial veins affected
Do mot assess for homans sign
Test
Venogram
Venous Doppler
MRI
**hesi hints: heparin prevents conversion fibrinogen to fibrin and
prothrombin to thrombin, thereby inhibiting clot formation. Because
the clotting mechanism is prolonged, do not cause tissue trauma,
which may lead to bleeding when giving heparin subcutaneously. Do
not massage area or aspirate; give in the stomach between the pelvic
bones 2 inches from umbilicus; rotate sites.
Treatment
ACUTE PHASE
BR
ELEVATE EXT.
WARM MOIST HEAT
ACE WRAP IMPORTANT IF POSITIVE DVT NOOOO TEDSSS!

MEDS
UNFRACTIONATED HEPARIN GTT COUMADIN
ASA
LOW-MOLECULAR WT HEPARIN LOVENOX
Prevention
Start moving
Keep hydrated
No smoking
Leg exercises
Avoid contraceptives
TEDS
Venous compression boots

VENOUS INSUFFICIENCY
VENOUS CONGESTION FROM HTN DAMAGE VENOUS
VALVES
INC. EDEMA PRESENT
CELLULITIS DEVELOPS
STASIS ULCERS DEVELOP
BROWN DISCOLORATION OF SKIN NOTED STASIS
DERMATITIS
MANAGEMENT
GOALS
DECREASE EDEMA
PROMOTE VENOUS RETURN
MANAGING EDEMA
WEAR ELASTIC OR COMPRESSION STOCKINGS
ELEVATE LEGS
ELEVATE LEGS ABOVE HEART LEVEL
GENERAL
AVOID PROLONGED STANDING OR SITTING
DO NOT CROSS LEGS
NO RESRICTIVE CLOTHING PANTS, GIRDLES,
GARTERS, KNEE-HIS

MANAGEMENT
STASIS ULCERS
CHRONIC & RECURRENT
DRESSING TYPES
OXYGEN PERMEABLE
OXYGEN IMPERMEABLE:
DUODERM
UNNA BOOT
USED FOR AMBULATORY PT.

ZINC OXIDE MOISTENED


GAUZE
APPLIED FROM TOES TO
KNEE
WRAPPED W/ ACE
HARDENS LIKE CAST
IN PLACE FOR ONE WEEK