Care of the Client with Peripheral Artery Disorders

Nursing Interventions for PAD:

*Assess and Promote Circulation* •Monitor pulses, skin color, warmth, sensation, cap refill. (Use Doppler prn to auscultate pulses.) •Position legs *below* heart level •*Provide pain relief* •Encourage walking to improve circulation •Walk to the point of pain. Rest, then continue to walk further. •*Diet teaching* (↓Fat, ↓ CHO, ↓ Na+) •Monitor Carbs •Encourage more protein, vit. C if ulcers present to promote wound healing •*Encourage smoking cessation* (smoking vasoconstricts, thus slowing everything down)

Arterial thrombosis nursing care:

*Monitor for hemorrhage r/t anticoagulants*: •around existing IV's or catheters •prolonged or heavy vaginal bleeding •hemoptysis, hematemesis, hematochezia (bright bloody stools), hematuria •epistaxis, bleeding gums •melana (dark tarry stools) •assess pressure points for bruising Other: •Monitor pulses, assess circulation hourly •Manage pain •Maintain IV fluids prn •Maintain patient on bed rest with extremity level or *slightly dependent* •Avoid heating/cooling pads •Keep limb warm with soft clothing •Use foot cradle

Dissecting Aneurysm:

Critical complication. High mortality rate! Occurs when there is a tear in inner layer causing hemorrhage into middle layer leading to separation of vessel layers. It can happen anywhere in aorta. Causes: HTN rooted in atherosclerosis, Congenital defect, Gender (M>F), Age. Nursing Priority: RECOGNIZE EMERGENCY •Hallmark: quick onset of acute tearing/ripping pain, chest, back, shoulders, abdomen. •HTN then Hypotension •Syncope •Tachycardia •Dyspnea •Pallor •Confusion •Lost sensation and decrease peripheral pulses Hemorrhage is happening!

Surgical management of arterial thrombosis:

Embolectomy: surgical removal of clot from artery.

Aneurysms:

Is ballooning of weakened arterial wall. Named by location: Aortic aneurysm, Thoracic aneurysm, Abdominal Aortic Aneurysm (AAA or Triple A) Cause: HTN Risk factors: Weakened arterial wall r/t arteriosclerosis and HTN. Also r/t smoking, gender, age, genetics, pregnancy.

Risk factors:

Non-modifiable: Age, Genetics, male>women, women after menopause due to ↓ HDL and ↑ LDL, African-American. Modifiable: Smoking, HTN, DM2, Diet, Hyperlipidema, Obesity, Physical inactivity.

PAD:

Peripheral Arterial insufficiency Peripheral Arterial Disease Peripheral Insufficiency (PI) Peripheral Arterial insufficiency (PAI) Peripheral Arterial Occlusive Disease Peripheral Vascular Disease (PVD) Peripheral Atherosclerosis

PAD: what is going on?

Poorly oxygenated blood supply to body. Hemorrhagic or ischemic. Hemorrhagic ->aneurism. Ischemic ->plaque Leading to necrosis/death.

Arterial Ulcers:

Small, circular, deep, dry. Location: toes, balls of feet, shin. Mild/no edema, usually pale base, gangrene, *may lead to amputation*. •Not debrided due to poor circulation •Avoid a bigger non-healing wound •Debridement after revascularization (stents, balloon, bypass)

Arteries

Take oxygenated blood to peripheral organs. These are elastic for pumping large amounts of blood.

Aneurysms Manifestations:

Thoracic: •Back, neck, and substernal pain •Cough •Dyspnea •Dysphagia •Facial edema •Jugular vein distention Abdomen: •Palpate in abdomen: heart beat as pulsating mass. •Peripheral cyanosis: cool extremities •Pain: mid-abdomen to lumbar Critical complication: Rupture

Arterial Thrombi and Embolism:

Thrombosis: clot forms in an area of atherosclerotic plaque Embolism: clot travels through arteries until lodged, blocks blood flow. Origin of arterial clots originate in left side of the heart associated with: -A. fib -MI -Left sided heart failure -Valvular heart disease -Infected heart disease (endocarditis)

Raynaud's disease & Raynaud's phenomenon:

Vasospasms occur in small arteries of fingers maybe toes. Therefore blood flow isn't reaching during spasms. Episodes gradually worsen. Calloused fingers, brittle nails, risk for ulcers. Blue-White-Red= Hypoxic-ischemic-blood return. Pt. teaching: Keep hands warm, wear gloves, increase perfusion, vasodilators, know triggers.

Thromboangiitis Obliterans

Vasospasms with clot formation. Affects all 4 limbs. Autoimmune disease. Intermittent episodes (claudication to rest pain effected limb) Manifestations similar to arterial insufficiency. Medical management : •Vasodilators •Decrease viscosity, increase RBC flexibility Surgery: •bypass graph •*Amputation* Nursing management: •Prevent vasoconstriction, extremities warm •promote tissue perfusion, extremities dependent, monitor for ischemia •Prevent tissue injury •Encourage routine exercise •Medication teaching •Pt. teaching: *Smoking cessation*

More NI for PAD:

•*Prevent arterial constriction*: smoking cessation, avoid tight garments, move hourly, no crossed legs, avoid being in cold water, educate about managing HTN & DM2. •*Maintain tissue integrity*: assess skin daily, apply emollients to prevent skin cracks (not between toes), assess bath water temp before entering tub/shower, *Do not use cooling or heating pads*, avoid too much sun exposure causing burns, Keep arterial ulcers protected and *dry*. •Stringent foot care: inspect feet and legs daily, keep feet warm and protected, always wear appropriate size shoes, never walk barefoot, file nails straight across or refer to podiatry for nail care.

Diagnostic Procedures for PAD:

•Angiogram •Aortagram Make sure to stop metformin 48 hrs prior and after for DM2.

Nursing Assessment for PAD:

•Ankle-to-Brachial artery index (ABI's) 1. Measure systolic pressure in arms. 2. Measure systolic pressure in legs. 3. Divide ankle pressure by brachial pressure. Normal: almost equal or ankle slightly higher. Should be 1.0. Lower ratio means less blood flow.

Causes:

•Arteriosclerosis: harding of plaque •Atherosclerosis: plaque buildup The result is stiffening and narrowing of lumen. HTN, Smoking, Chronic infection, Diabetes, (Central)Obesity, Chronic inflammation.

Pre-Op nursing interventions for Surgery on aneurysm:

•Bed rest with legs flat •Maintain calm environment •Monitor VS frequently- monitor for ↑BP •Monitor UOP (urine output) •O2 prn •Prevent straining at stool or holding breath •Give beta blockers, antihypertensive (keep BP↓ prior to surgery)

Surgical management for PAD:

•Bypass graft •Endartectomy •Stents •Angioplasty Pt.'s will need to be on Plavix or Clavix for rest of life

Atherosclerotic Diseases:

•CAD or Coronary Artery Disease: arrhythmias, MI, HF •PAD or Peripheral Artery Disease: stroke, claudication in legs, aneurysm. Both of these diseases decrease the amount of blood flow to the heart. Oxygen and nutrients aren't being delivered.

Aneurysms: Diagnostic Tests:

•Chest x-ray •Abdominal US and CT •Transeophageal echocardiogram (TEE) •Duplex ultrasound •Angiography

Aneurysms: Priority Medical Tx:

•Control BP and HR -Beta 1 blockers (↓HR, ↓BP) -Calcium cannel blockers (↓HR, ↓BP) •Avoid direct acting peripheral vasodilators such as hydralazine to reduce risk of rupture, take nothing acting on artery. •Post-op: initiate anticoagulant therapy indefinitely for better flow and lower risk of another one.

Arterial thrombosis/embolism diagnostic evaluation:

•Duplex and Doppler ultrasound •Angiography Echocardiogram •*Diagnostics: underlying cardiac disease* •Echocardiogram •Transesophageal echo (TEE) •EKG •Chest x-ray

Manifestations of PAD:

•Hallmark sign of PAD= *Intermittent claudication* (leg involvement, cramping, burning, pain. You may see Pt. dangle leg off bed). •Rest pain •Paresthesia (numbness/tingling pain) •Diminished or absent peripheral pulses •Pallor •Dependent Rubor (redness, loss of elasticity. No blood flow or opening up, blood is flowing down, may be unilateral). •Thickened nails •Hairless •Impaired skin (shiny, dry, thin) •Potential for ulcerations

Post-op nursing care:

•Monitor VS •Manage Pain •Monitor incision or puncture site for drainage, bleeding, infection. •*Assess circulation*: pulses, cap refill, sensation, temp, color, movement, edema.

Arterial thrombus/embolism nursing care:

•Monitor aPTT, PTT -Heparin inactivates clotting factor 2 (prothrombin) -Therapeutic level :1.5-2.5 times control value in seconds -Notify MD if levels are above or below therapeutic range -*Antidote: protamine sulfate* -Monitor hgb, hct, plt count.

Post-op Nursing Interventions for aneurysm:

•Monitor circulation distal to graft every 15 mins •Monitor for signs of graft occlusion •Maintain normal BP •TCDB

6 P's of Peripheral Artery Thrombosis:

•Pain •Pallor •Poikilothermic (temp variation=cool) •Pulselessness •Paresthesia •Paralysis No blood flow, all from tissue ischemia.

Recognizing CVA:

•Sudden change in mental status •Hemiplegia, hemiparesis (one-sided) •Change in LOC •Difficulty swallowing, speaking or understanding speech •Sudden severe headache •visual disturbances (*Usual source of clot is due to left side of heart from a.fib*).

Aneurysm: Surgical Tx:

•Symptomatic or expanding aneurysm require operative repair •Rupturing aneurysm requires immediate surgery (50% mortality) •Elective surgery AAA 6 cm or > •Endovascular stent grafts •Open repair- excised and replaced.

Arterial thrombosis/embolism medical management:

•Thrombolytic agents (clot busters): infused directly into clot, takes several hours to dissolve clot, tissue plasminogen activator. •Anticoagulants: heparin continuous IV infusion, not dissolve clots but prevent from further growth The most potential complication is *BLEEDING*!

Drug therapy for PAD:

•Vasodilators (open) •Anti-platelet aggregators (slippery PLT) •Platelet inhibitor •Drugs to reduce blood viscosity and increase RBC flexibility •Lipid lowering agents (reduce plaque) •Anticoagulants