Med-Surg: Peripheral Artery Disease

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation." The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.

complications of PAD

*Chronic tissue ischemia* -infection -cellulitis -tissue breakdown -gangrene *Acute limb ischemia (acute arterial occlusion)* *emergency* S/S (6 P's) -Pain -Paresthesia -Paralysis -Pale -Pulselessness -Poikilothermia (cold)

risk factors for PAD

*smoking* (vasoconstriction) hyperlipidemia diabetes uncontrolled hypertension men over 45 post-menopausal women obesity sedentary lifestyle

assessment of PAD

-*intermittent claudication* -decreased capillary refill of toes > 3 seconds -*priority assessment: check pedal pulse* -decreased peripheral pulse -atrophy- decreased muscle tone from lack of O2 -skin and nail changes- thick nails and dry, scaly skin -*pallor of extremity with elevation* -dependent rubor -pain at rest = severe obstruction

treatment for VTE

-*prevention* is best (ambulation/exercise) -mechanical prophylaxis (SCD's/TED hose) -Bedrest is controversial -IVC filters (keeps emboli from reaching heart)

diagnosing PAD

-ankle-brachial index: compares blood pressure in ankle to blood pressure in upper arm (plethysmography) -doppler/ultrasound -exercise tolerance testing or adenosine stress test: evaluates claudication during exercise -C-Reactive protein: levels rise with inflammation (plaque) -arteriogram: most specific but most invasive; involves injection of contrast agent into blood vessel (*check injection site and pulses*)

medications for PAD

-antihypertensive agents (ACE inhibitors) -hemorheological/vasodilator & anti-inflammatory (pentoxifylline (Trental)-phosphodietrase inhibitor) -antiplatelet agents (acetylsalicyclic acid (Aspirin) /clopidogrel (Plavix)) -statins

prevention of varicose veins

-avoid activities that cause venous stasis -avoid crossing legs/standing -walk for several minutes every hour -wear graduated compression stockings

DVT

-blood clot that forms due to venous stasis, endothelial injury, or hypercoagulability -may cause pulmonary embolus and death -VTE (venous thromboembolism)- the disease process that includes DVT and/or PE

coumadin

-dose based on PT/INR results -if clotting is a problem, it needs to be 2 to 2.5 times the normal -usually started while the patient is still on heparin -antidote is vitamin K -client should be taught to not change their consumption of green leafy vegetables- no more than 2-3 times a week

heparin

-dose based on PTT or unfractionated heparin levels (normal PTT- 25-25 seconds) -antidote is protamine sulfate

chronic venous insufficiency patient teaching

-elevate legs several times a day for at least 15-30 minutes -avoid crossing legs or wearing constrictive clothing -should wear elastic compression stockings and apply them after elevating legs and when swelling is at a minimum (in the morning) -avoid trauma to the limbs -proper foot care -daily moisturizer to decrease itching (not between toes) -wound care consult will be needed -eat a diet high in zinc, protein, and vitamins A & C

varicose veins

-enlarged, twisted, superficial veins -may feel heaviness in the legs; aching, tiredness pain -severity and discomfort is not related to the size of the varicosities

intermittent claudication

-hallmark sign of PAD -muscle pain, ache, cramp, numbness, or sense of fatigue, classically in the calf muscle, that occurs during exercise and is relieved by short period of rest -does not occur with venous disorders

medications for VTE

-heparin -lovenox -coumadin

risk factors, signs, symptoms for VTE

-immobility -Virchow's triad -edema/tenderness/warmth -clinical manifestations vary depending on size, location, degree of vessel occlusion and adequacy of collateral circulation

care of patient with PAD

-ineffective peripheral tissue perfusion, risk for impaired skin integrity, chronic pain -dangle arteries -gradual exercise to tolerance (under physician direction) -avoid crossing legs -inspect feet daily -avoid restrictive clothing -no heating pads or ice packs -stop smoking -DASH diet -teach patient to watch for signs of bleeding (overt: epistaxis (nosebleed), hemoptysis, vomiting blood, coffee ground emesis, black tarry stools; covert: abdominal pain, low blood pressure)

lovenox

-low molecular weight heparin -subcutaneous -anti-xa: therapeutic level of lovenox

diagnosing VTE

-pre-risk assessment -D-dimer: blood test, if it is elevated you need more testing -Ultrasound- gold standard for DVT -CT and contrast venography

peripheral arterial disease

-progressive and chronic condition where the obstruction of blood flow through the large peripheral arteries causes a partial or total arterial occlusion -lower extremities are deprived of oxygen and nutrients -> ischemia/necrosis -*atherosclerosis*: thickening of arteries (plaque) -*arteriosclerosis*: hardening of the arteries -thrombus

varicose vein interventions

-sclerotherapy -vein stripping -endovenous/laser treatment -radiofrequency energy

manifestations of PE

-shortness of breath -cough -dropping O2 sat -hemoptysis -sharp chest pain -sweating -hypotension

bleeding precautions

-use electric razor -soft toothbrush -avoid aspirin products unless ordered by doctor -avoid injury (contact sports, head injury) -avoid blowing nose forcefully or straining with bowel movement

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control. A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.

Virchow's Triad

3 categories of factors that contribute to thrombosis -blood stasis -vessel injury -blood coagulation

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for:

3 to 5 days. It takes 3 to 5 days for a therapeutic international normalized ratio (INR) to be achieved. Therefore, Coumadin is given concurrently with heparin until a therapeutic level is established, usually within 72 hours.

The nurse explains to a patient that the primary cause of a varicose vein is:

An incompetent venous valve. Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient?

Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches. Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Bluish urine Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:

Cigarette smoking. Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

Pentoxifylline (Trental) is a medication used for which of the following conditions?

Claudication Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress The most common trigger for Ray-naud's phenomenon is cold and stress. Vibration can be an irritant that should be minimized or eliminated.

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse?

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

Epinephrine Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.

Which class of medication lyses and dissolves thrombi?

Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

Hemorrhage. All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homans' A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Hyperbaric oxygen Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent. Lowering the extremity to a dependent position improves perfusion to the distal tissues.

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:

Posterior tibial. Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose appoximately 99% of bleeding disorders on the basis of PT and PTT values.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply a graduated compression stocking.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply an elastic sleeve In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

The aneurysm may be preparing to rupture. Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

The nurse is assessing a hospital client who has low albumin levels due to liver disease. What assessment finding should the nurse attribute to the client's low albumin levels?

There is severe edema to the client's legs and abdomen. Albumin helps to keep fluids within the vascular space. Deficiencies, as a result, cause the release of fluid into interstitial spaces, causing edema. Hypoalbuminemia does not cause excessive bleeding, reduced energy or respiratory difficulties.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

medical interventions for PAD

angioplasty/stents arterial re-vascularization -assess 5 P's -*watch for hypo or hypertension* -*graft occlusion is a serious complication that usually occurs in the first 24 hours post-op*

phlebitis

arteries bring blood to area-> veins can't take it away-> blood stagnates and begins to irritate the tissue

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography. When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

Buerger's diesase

inflammation and thrombosis in small and medium-sized blood vessels, typically in the legs and leading to gangrene associated with smoking males

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

chronic venous insufficiency

occurs due to incompetent valves in the deeper veins of the lower extremities

Raynaud's disease

vasospasm of the small vessels in the hands caused by exposure to cold females wear gloves