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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

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