PAD

Question 1

PAD what is it?

Answer 1

Thickening of the artery walls. This results in a progressive narrowing of the arteries of the upper and lower extremities. PAD is strongly related to other types of cardiovascular disease CVD and their risk factors. PAD prevalence increases with age

Question 2

PAD Pathophysiology

Answer 2

• Leading cause is atherosclerosis, a gradual thickening of the intima (innermost layer of the arterial wall) and media (middle layer of arterial wall)
• This results from deposits of cholesterol and lipids within the vessel walls and leads to progressive narrowing of the artery
• inflammation and endothelial injury play a major role
• atherosclerosis more commonly affects certain segments of the arterial tree. These include: coronary, carotid, and lower extremity arteries. Clinical symptoms occur when vessels are 60-75& blocked

Question 3

Risk factors for PAD

Answer 3

• Tobacco use (most significant)
• Chronic kidney disease
• Diabetes
• HTN
• Hypercholesterolemia

Question 4

PAD: Lower extremities

- lower extremity PAD may affect the?

Answer 4

Iliac, femoral, popliteal, tibial, or peroneal 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

Question 5

Clinical manifestations of PAD

Answer 5

• Intermittent claudication
• asymptomatic or atypical leg symptoms (burning, hardness, heaviness, knotting, pressure, soreness, tightness, weakness) in atypical locations (ankle, foot, hamstring, hip, knee, shin)
• Paresthesia (numbness/tingling in toes/feet
• Pallor of feet noted in response to leg elevation
• Reactive hyperemia (redness) develops when limb hangs in dependent position (dependent rubor). Skin is shiny and taut with hair loss on lower legs. Pedal, popliteal, or femoral pulses are diminished or absent
• PAD progression involves continuous pain at rest mostly in forefoot or toes and aggravated by limb elevation

Question 6

Define intermittent Claudication

Answer 6

Ischemic muscle pain that is caused by exercise, resolves within 10 minutes or less with resting, and re reproducable

Question 7

Most serious complication of PAD

Answer 7

Nonhealing arterial ulcers and gangrene, and may require amputation

Question 8

PAD Diagnostic Studies

Answer 8

• Doppler US & duplex imaging assess blood flow
• Segmental BPs obtained (using Doppler US & a sphygmomanometer) at the thigh, below the knee, and at ankle level while patient is supine. A drop in segmental BP of >30 mm Hg suggests PAD
• Angiography or magnetic resonance angiography (MRA) delineates location and extent of PAD

Question 9

PAD Interprofessional Care
The first Tx goal is to reduce cardiovascular risk factors. Tobacco cessation is essential. Aggressive lipid management is essential for all patients with PAD. Both dietary interventions and drug therapy are needed

Answer 9

1) Statins & fibric acid derivative lower LDL and triglyceride levels. HTN and diabetes mellitus also need to be controlled
2) Antiplatelet agents are critical for reducing risk of CVD events and death in patients with PAD. Oral antiplatelet therapy should include 75-235 mg/day of aspirin. Aspirin intolerant patients may take 75 mg of clopidogrel (Plavix) daily

Question 10

Treatment of intermittent claudication

Answer 10

• Two drugs: cilostazol (Pletal) and pentoxifylline. Cilostazol, a phosphodiesterase inhibitor, inhibits platelet aggregation and increases vasodilation. Pentoxifylline, a xanthine derivative, improves deformability of RBCs and WBCs and decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity
• Supervised exercise program: 30-45 min/day, @least 3x/week for minimum 3 months. Can be walking or cycling
• Adjust caloric intake so ideal body weight achieved/maintained
• Diet: high in fruits, vegetables, and whole grains. Low in cholesterol, saturated fats, and salt

Question 11

Patients taking antiplatelet agents, NSAIDs, or anticoagulants (warfarin) should consult HCP before taking?

Answer 11

Any dietary or herbal supplements, because of potential interactions and bleeding risks

Question 12

Critical limb ischemia

Answer 12

• Chronic ischemic rest pain lasting more than 2 weeks, arterial leg ulcers or gangrene of the leg as a result of PAD
• Management goals: protecting extremity from trauma, decreasing ischemic pain, preventing/controlling infection, maximizing perfusion. Inspect, cleanse, and lubricate both feet to prevent cracking of the skin and infection

Question 13

PAD: Interventional radiology catheter-based procedures are alternatives to open surgical approaches for Tx of lower extremity PAD

Answer 13

1) Percutaneous transluminal angiogplasty: catheter w/cylindric balloon at tip. End of catheter advanced to stenotic (narrowing) area of artery. Balloon is inflated, compressing atherosclerotic intimal linging
2) Stents: expandable metallic devices that keep artery open after balloon angioplasty. May be covered w/Dacron or a drug-eluting agent to reduce restenosis by limiting amount of new tissue growth into stent
3) Atherectomy: removes obstructing plaque. Directional atherectomy device uses high-speed cutting disk that cuts long strips atheroma. Laser atherectomy uses UV energy to break apart atheroma
4) Peripheral arterial bypass operation w/autogenous (native) vein or synthetic graft material to bypass or carry blood around the lesion
5) Endarterectomy (opening artery and removing obstructing plaque) and patch graft angioplasty (opening artery, removing plaque, and sewing a patch to the opening to widen the lumen)
6) Amputation required if tissue necrosis is extensive, gangrene or osteomyelitis, or other major arteries are occluded, precluding possibility of successful surgery

Question 14

PAD Goals

Answer 14

-Patient w/lower extremity PAD will have adequate tissue perfusion, relief of pain, increased exercise tolerance, and intact, healthy skin on extremities

Question 15

PAD Nursing interventions:

After surgical or radiologic intervention what should the nurse do?

Answer 15

Check the operative extremity every 15 minutes initially then hourly for color, temp. cap refill time, presence of peripheral pulses or a change in the doppler sound over a pulse. Immediately contact HCP

Question 16

PAD Nursing interventions:

After the patient leaves the recovery area, the nurse should continue to monitor what?

Answer 16

1) Perfusion of extremities and assess for complications such as bleeding, hematoma, thrombosis, embolization, and compartment syndrome. Does so by checking VS
2) Dramatic increase in pain, loss of previously palpable pulses, extremity pallor or cyanosis, decreasing ankle brachial index (ABI) on serial measurements, numbness or tingling, or cold extremity suggests blockage of graft or stent. Report to HCP

Question 17

PAD Nursing interventions:

What should be avoided and done in a patient with PAD

Answer 17

• Knee flexed positions (except for exercise)
• Turn patient frequently & position pillows to support incision
• Starting postop day 1 pt should get out of bed several times and walk even if it is short distances
• discourage prolonged sitting with leg dependency because 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 above the heart level

Question 18

PAT Education

Answer 18

• Encourage supervised exercise training after successful revascularization
• Teach foot care to all pt’s with PAD, especially diabetics
• Inspect legs and feet daily for mottling, changes in skin color or texure, and reduction in hair growth. Show pt’s how to check temp and cap refill and palpate pulses
• Wear clean, all cotton or all wool socks and comfortable shoes with rounded toes and soft insoles. Lace shoes loosely and break in new shoes gradually

Question 19

INTER PROFESSIONAL CARE RISK FACTOR MODIFICATION

Answer 19

• Tobacco cessation
• Glycosylated hemoglobin <7.0% for diabetics
• Aggressive treatment of hyperlipidemia
• BP maintained <140/90

Question 20

INTER PROFESSIONAL CARE DRUG THERAPY
ACE inhibitors
– Ramipril (Altace)

Answer 20

• ↓ Cardiovascular morbidity
• ↓ Mortality
• ↑ Peripheral blood flow
• ↑ABI
• ↑ Walking distance

Question 21

INTER PROFESSIONAL CARE DRUG THERAPY

• Antiplatelet agents

Answer 21

– Aspirin

– Clopidogrel (Plavix)

Question 22

INTER PROFESSIONAL CARE DRUG THERAPY

• Drugs prescribed for treatment of intermittent claudication

Answer 22

– Cilostazol (Pletal)
• Inhibits platelet aggregation
• ↑ Vasodilation

– Pentoxifylline (Trental)
• Improves deformability of RBCs and WBCs
• Decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity

Question 23

INTER PROFESSIONAL CARE NUTRITIONAL THERAPY

Answer 23

• BMI <25 kg/m2
• Waistcircumference<40inchesformenand<35inchesforwomen
• Recommend reduced calories and salt for obese or overweight persons

Question 24

INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA

Answer 24

• Revascularization via bypass surgery
• Percutaneous transluminal angioplasty (PTA)
• IV prostanoids (iloprost [Ventavis])
• Spinal cord stimulation
• Angiogenesis

Question 25

INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA INTER PROFESSIONAL CARE LEG WITH CRITICAL LIMB ISCHEMIA • ConservativeTreatment

Answer 25

– Protect from trauma – Decrease ischemic pain – Prevent/control infection – Improve arterial perfusion

Question 26

CASE STUDY • B.D. returns for follow-up in 3 months. • His BP and lipid levels are stabilizing, but he complains of increasing leg pain at rest. • His physician determines that it is time to consider an intervention to improve his circulation. What are the interventions?

Answer 26

RADIOLOGY PROCEDURES • Indications – Intermittent claudication symptoms become incapacitating – Pain at rest – Ulceration or gangrene severe enough to threaten viability of the limb 1) Percutaneous transluminal angioplasty (PTA) – Involves insertion of a catheter through femoral artery – Catheter contains a cylindrical balloon – Balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining – Stent is placed 2) Atherectomy – Removal of obstructing plaque – Performed using a cutting disc, laser, or rotating diamond tip 3) Cryoplasty – Combines percutaneous transluminal angioplasty and cold therapy – Liquid nitrous oxide

Question 27

INTER PROFESSIONAL CARE SURGICAL THERAPY | • Most common surgical approach

Answer 27

– Peripheral artery bypass surgery with autogenous vein or synthetic graft to bypass blood around the lesion – PTA with stenting may also be used in combination with bypass surgery

Question 28

INTER PROFESSIONAL CARE SURGICAL THERAPY

Answer 28

* Endarterectomy * Patch graft angioplasty * Amputation

Question 29

NURSING MANAGEMENT NURSING ASSESSMENT • Past health history

Answer 29

``` – Diabetes mellitus – Smoking – Hypertension – Hyperlipidemia – Obesity ```

Question 30

NURSING MANAGEMENT | NURSING ASSESSMENT

Answer 30

* Exercise intolerance * Loss of hair on legs and feet * Decreased or absent peripheral pulses * Intermittent claudication

Question 31

Overall goals for patient with PAD

Answer 31

``` – Adequate tissue perfusion – Relief of pain – Increased exercise tolerance – Intact, healthy skin on extremities – Increased knowledge of disease and treatment plan ```

Question 32

NURSING MANAGEMENT NURSING IMPLEMENTATION • Health Promotion

Answer 32

– Identification of at-risk patients – Diet modification – Proper care of feet – Avoidance of injuries

Question 33

Acute Care after surgery | – Frequently monitor after surgery

Answer 33

* Skin color and temperature * Capillary refill * Presence of peripheral pulses distal to the operative site * Sensation and movement of extremity

Question 34

Acute Care

Answer 34

– Continued circulatory assessment – Monitor for potential complications – Knee-flexed positions should be avoided except for exercise – Turn and position frequently

Question 35

* B.D. is being discharged home. * What will you teach him regarding immediate care and precautions at home? * What patient teaching is essential for him to help manage his disease?

Answer 35

• Ambulatory Care – Management of risk factors – Long-term antiplatelet therapy – Importance of supervised exercise training after revascularization – Importance of meticulous foot care – Daily inspection of the feet – Comfortable shoes with rounded toes and soft insoles – Shoes lightly laced

Question 36

NURSING MANAGEMENT | EVALUATION

Answer 36

``` • Adequate peripheral tissue perfusion • Increased activity tolerance • Effective pain management • Knowledge of disease and treatment plan • Plans for walking program • Increased activity tolerance • Verbalize key elements of – Therapeutic regimen – Knowledge of disease – Treatment plan – Reduction of risk factors – Proper ulcer/foot care ```

Question 37

A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is a. Risk for injury related to decreased sensation. b. Impaired skin integrity related to decreased peripheral circulation. c. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d. Activity intolerance related to imbalance between oxygen supply and demand.

Answer 37

a (Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment.)

Question 38

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a. “I should not use heating pads to warm my feet.” b. “I should cut back on my walks if it causes pain in my legs.” c. “I will examine my feet every day for any sores or red areas.” d. “I can quit smoking if I use nicotine gum and a support group.”

Answer 38

B (Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.)