Disorders of peripheral arteries
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Disorders of Peripheral Arteries. Peripheral Arteriosclerosis, Arterial Embolism, & Arterial Thrombosis. Objectives. Describe pathophysiology of commonly occuring peripheral vascular disorders ID lab & diagnostic tests used to identify and assess peripheral vascular disorders

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Disorders of Peripheral Arteries

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Disorders of peripheral arteries

Disorders of Peripheral Arteries

Peripheral Arteriosclerosis, Arterial Embolism, & Arterial Thrombosis


Objectives

Objectives

  • Describe pathophysiology of commonly occuring peripheral vascular disorders

  • ID lab & diagnostic tests used to identify and assess peripheral vascular disorders

  • Explain nursing implications of meds prescribed for treating clients w/…..

  • Provide client/family teaching for clients w/common peripheral vascular disorders

  • Use nursing process as framework to provide individualized care to clients w/ peripheral vascular disorders


Peripheral arteriosclerosis

Peripheral Arteriosclerosis

  • Most common chronic arterial disorder

  • Characterized by thickening, loss of elasticity, & calcification of arterial walls

  • Atherosclerosis is a form of arteriosclerosis in which the thickening and hardening of the arteries are the result of deposits of fat and fibrin

  • In peripheral circulation, these changes result in decreased blood supply to tissues, called peripheral vascular disease (PVD)

  • Manifestations most common in lower extremities; 60 % or more of blood supply is occluded


Risk factors

Risk Factors

  • Over age 50

  • Men > women

  • High-fat diet

  • HTN

  • DM

  • Smoking

  • Obesity

  • Stress


Pathophysiology sites of plaque deposits compromising peripheral circulation

Pathophysiology: Sites of plaque deposits compromising peripheral circulation

  • Femoral/popliteal arteries

  • Common iliac arteries

  • Abdominal aorta

    • Arteriosclerosis in abdominal aorta leads to development of aneurysms as plaque development erodes vessel walls


Manifestations complications pain is primary

Manifestations/Complications: Pain is Primary

  • Intermittent claudication: cramping or aching sensation of calves of legs, thighs, buttocks; often w/limping & weakness; experienced w/activity & relieved by rest

  • Rest pain: often described as burning sensation in lower legs; occurs during period of inactivity; increases w/legs elevated & decreases w/legs dependent

    • C/O cold or numb legs

    • When legs are elevated, skin is pale; when legs are dependent, skin is dark red (dependent rubor)

    • Skin thin & shiny; areas of discoloration/hair loss, thickened toenails

    • Skin breakdown may lead to ulcerations & gangrene

    • Peripheral pulses may be decreased or not palpable


Lab diagnostics occlusive arterial disorders

Lab & Diagnostics: Occlusive Arterial Disorders

  • Primarily imaging & arteriographic studies

  • Few lab tests are performed because interruption of arterial flow has little effect on lab values

  • Diagnostic tests

    • Segmental pressure measurements

    • Stress testing

    • Doppler ultrasonic flow study

    • Duplex Doppler ultrasound

    • Transcutaneous oximetry

    • Angiography or magnetic resonance angiography

    • Renal function studies

    • Oscillometry

    • Plethysmography


Medications

Medications

  • Pharmocologic mgt is less effective than w/CHD

  • Pentoxifylline (Trental) appears to decrease blood viscosity & increase RBC flexibility, increasing blood flow to microcirculation & tissues of extremities

  • Vasodilator prostaglandins may be administered parenterally to decrease pain & promote healing in clients w/ severe limb ischemia

  • Low doses of ASA recommended due to risk for inflammation & blood clot formation; or clopidogrel (Plavix)


Conservative therapy

Conservative Therapy

  • Encourage client to maintain a program of daily walking for fixed periods to promote development of collateral circulation & function. (35-45 min)

  • Instruct: walk to point of experiencing claudication pain, then take a 3-min rest; resume

  • Must stop smoking; nicotine causes vasospasm and decreases blood supply to extremities; SNS

  • Weight loss may decrease pain during activity


Revascularization surgery

Revascularization/Surgery

  • Indicated w/severe intermittent claudication &/or interference w/physical activity; w/rest pain or pregangrenous lesions on foot

    • Nonsurgical: PTA, stent,

      atherectomy

    • Thromboendarterectomy

    • Arterial graft

    • Endovascular surgery


Nursing process assessment

Nursing Process: Assessment

  • Complete History; Fears?

  • Physical Exam of lower extremities

    • Skin integrity

    • Decreased leg hair

    • Capillary refill of toes

    • Pedal pulses/Doppler ultrasound

    • Skin temperature

    • Any discolorations/infections of leg or foot

    • Pain assessment


Nursing diagnosis

Nursing Diagnosis

  • Ineffective peripheral tissue perfusion: Peripheral

  • Pain

  • Impaired skin integrity

  • Activity Intolerance


Ineffective tissue perfusion peripheral

Ineffective Tissue Perfusion: Peripheral

  • Assess extremities for peripheral pulses, pain, color, temp, & capillary refill at least q4hrs & PRN; May need Doppler

  • Teach client importance of keeping extremities in a dependent position (gravity)

  • Keep extremities warm using lightweight blankets, socks, & slippers

  • Encourage change of position at least q 1 hr & avoid leg crossing

  • Provide thorough leg & foot care daily, using mild soap & moisturizers


Pain r t interrupted arterial blood flow

Pain r/t interrupted arterial blood flow

  • Assess pain level using scale of 1-10

  • Evaluate bilateral peripheral pulses at least q 4 hrs & more often PRN

  • Keep client’s extremities warm, using socks, slippers, warm blankets

  • Teach methods for reducing pain & relieving stress


Impaired skin integrity

Impaired Skin Integrity

  • Assess the skin of extremities at least once per shift & PRN. Document findings/changes

  • Provide meticulous daily skin care; keep skin clean, dry, supple

  • Apply bed cradle


Activity intolerance

Activity Intolerance

  • Assist with ADLs

  • Diversional activities w/bedrest

  • Frequent position changes/Active ROM


Teaching for home care

Teaching for Home Care

  • Give clients info about conservative measures that will help them manage their conditions

  • Teaching includes information r/t

    • Stress reduction

    • Smoking cessation

    • Medications:: Remember Anticoagulants

    • Methods of keeping extremities warm

    • Signs of excessive bleeding

  • Provide list of resources

    • Support groups

    • Public health & other community agencies

  • Teach leg & foot care to all family members (p. 1004)


Arterial thrombus or embolism

Arterial Thrombus or Embolism

  • Occurs most often as complication of another disease process

  • Both often result in occlusion

  • Manifestations depend on artery involved, tissue supplied by occluded artery & degree to which collateral circulation developed

  • Thrombosis is usually managed w/medical tx, whereas an embolism requires immediate surgery

  • Focus of care: relieve obstruction & preserve extremity


Clinical manifestations arterial thrombosis

Clinical Manifestations: Arterial Thrombosis

  • Pain in the region of the affected vessel

  • Numbness in the affected extremity

  • Pallor or mottling of skin (affected area)

  • Muscle spasms

  • No pulses distal to blockage

  • Possible paralysis


Clinical manifestations arterial embolism

Clinical Manifestations: Arterial Embolism

  • Pain in the extremity (sudden or insidious)

    • Worsens w/increased extent of occlusion

  • Numbness in extremity

  • Coldness of extremity

  • Tingling of extremity

  • No pulses distal to blockage

  • Pallor or mottling of extremity

  • Muscle weakness

  • Paralysis

  • Line of demarcation, w/pallor, cyanosis, & cooler skin distal to the blockage


Lab diagnostics

Lab & Diagnostics

  • Conducted to determine any underlying cause for thrombois or embolism & to confirm the presence of obstruction

  • Cardiac enzyme studies (MI?)

  • Blood cultures (Organism?)

  • Electrocardiography (ID changes of MI)

  • Arteriography or MRI (acute embolism)

  • Echocardiography (ID source of embolism)


Pharmacology

Pharmacology

  • If no tissue necrosis arterial embolism or thrombosis may be treated w/thrombolytic tx using streptokinase, urokinase, or tissue plasminogen activator

  • Tx cannot be used if client is bleeding, has had recent surgery, uncontrolled HTN, or is pregnant

  • Arterial embolism may also tx w/ IV heparin as an anticoagulant


Surgery

Surgery

  • Surgical tx of acute arterial embolus involves emergency embolectomy to prevent gangrene & to ensure adequate arterial blood flow to adjacent structures

    • Typical time frame is 4 to 6 hrs after embolic episode

    • To expedite when embolus is in extremity, may use local anesthesia

    • Once embolus is removed,

    • the area is explored for additional

      emboli & thrombi

    • Higher risk for delays >12 hrs:

    • Acute respiratory distress or acute

    • Renal failure


Nursing care

Nursing Care

  • Nursing care for client w/arterial thrombosis is essentially the same as for client w/arterial obstruction due to arteriosclerosis

  • Nursing Diagnoses (embolectomy or arterial reconstruction)

    • Anxiety

    • Ineffective Tissue Perfusion

    • Altered Protection


Anxiety

Anxiety

Trembling, palpitations, restlessness, dry mouth, helplessness, inability to relax, irritability, forgetfulness, lack of awareness of surroundings


Anxiety1

Anxiety

  • Assess level of anxiety at least once per shift & or more. Intervene to reduce current level of anxiety.

  • Provide opportunities for clients to verbalize anxiety, offer reassurance & support/Spend time!

  • Implement measures to decrease sensory stimuli.

    • Speak slowly and clearly

    • Avoid interruptions

    • Give concise directions

    • Focus on here and now

    • Diffuse anxiety via simple tasks


Ineffective tissue perfusion

Ineffective Tissue Perfusion

  • Monitor lower extremities for perfusion, comparing bilaterally

    • Take pulses q 2-4 hrs

    • Take T & color of skin q 2-4 hrs

    • Assess capillary refill (toes) q 2-4 hrs

    • Be alert to c/o pain, esp if unrelieved by meds

  • Maintain IV fluid replacement as prescribed

  • Keep extremity horizontal or lower than heart

  • Use bed cradle to keep pressure off extremity

  • NO cold or heat application


Ineffective tissue perfusion1

Ineffective Tissue Perfusion

  • Avoid activities

    • Raising knee gatch, placing pillows under knees, avoid 90 degree hip flexion

  • Provide measures to promote tissue perfusion

    • Maintain knee of operated leg in slightly flexed position

    • Elevate FOB 15 degrees if lower extremity is edematous

    • Encourage ankle & leg exercises q 1-2 hrs while awake

    • Place bed cradle over lower half of bed

    • Keep client/environment warm


Altered protection

Altered Protection

  • Assess for & report

    • Excessive bloody drainage from incision

    • Continuous oozing from injection sites

    • Bleeding gums

    • Bleeding from nose

    • Hematuria

    • Petechiae, purpura, ecchymoses

  • Monitor APTT if taking heparin parentarally and PT for oral anticoagulants. Report values over target range

  • Monitor older adults more carefully (may require lower maintenance dose)


Teaching for home care1

Teaching for Home Care

  • Depends on type of care needed to resolve health care problem

  • Preoperative teaching PRN

    • Pre-intra-& post op courses of therapy

    • Postop interventions such as meds, activity restrictions,dietary modifications, strategies for reducing atherosclerosis progression/stress reduction

    • D/C instructions to include S/S wound infection

  • Medical Mgt: conservative measures to promote peripheral circulation & maintain tissue integrity


Sample questions

Sample Questions

  • A 62-yr old client is being evaluated for a complaint of leg cramping during walking. Which of the following additional data is consistent w/intermittent claudication?

    • Relieved by rest

    • Superficial stasis ulcer over the medial ankle

    • Pain increases when legs are dependent

    • Lower leg edema


Sample questions1

Sample Questions

  • Teaching for the client w/peripheral arteriosclerosis should include instructions to

    • Go barefoot as much as possible

    • Avoid excessive walking

    • Trim toenails weekly

    • Avoid tight-fitting hose or socks


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