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Peripheral disease: Term used to describe a variety of conditions affecting arteries in the neck, abdomen, and extremities. Can be subdivided into occlusive disease, aneurysmal disease, and vasospastic phenomenon. In contrast, venous diseases primarily affect the lower extremities and can be categorized into venous thrombosis and chronic venous insufficiency. PERIPHERAL VASCULAR (Arterial) DISEASE Involves progressive narrowing and degeneration of the arteries of the neck, abdomen, and extremities. Atherosclerosis is the primary reason for PAD. Most significant risk factors: Nonmodifiable: age, esp after 50, history of heart disease, male gender, DM type 1, post-menopausal women, family history of dyslipidemia, PVD, or hypertension Modifiable: CAD, impaired glucose tolerance, dyslipidemia, hypertension, obesity, physical inactivity, smoking or use of tobacco products Other risk factors: obesity, family history, sedentary lifestyle, and stress. Most common areas are those areas of bifurcation. Clinical manifestations occur when the vessel is between 60 and 75% occluded. Arteriosclerosis most common disease of the arteries. It actually means hardening of the arteries. It is the end result of atherosclerosis. Atherosclerosis different process it affects the intima of the blood vessels - these processes usually occur together, and the terms are used interchangeably - atherosclerosis is a process which is usually started as a result of a tear in the intimal lining of the artery (red blood cells stick to the tear) - there becomes a buildup of fatty material over time - arteriosclerosis is the resultant hardening of the artery as a result of that fatty buildup - physicians worry about cross clamping (clamping off blood supply during surgery) in these patients, because they could shatter the aorta Clinical manifestations of peripheral arterial disease: - depend on the organ affected, but can include o kidney (renal)failure o brain (CVA) o cardiac (chest pain and subsequent infarction) - diabetics are at increased risk of developing PAD Disorders of the aorta: 1) Aortic aneurysm: outpouchings or dilations of the arterial wall. a. Etiology and Pathophysiology of Aneurysms i. May involve aortic arch, thoracic aorta, and/or abdominal aorta. 1. most are below the renal arteries 2. occurs over time b. Classification of Aneurysms i. True and false aneurysms 1. A true aneurysm is one in which the wall of the artery forms the aneurysm, with at least one vessel layer still intact. They typically develop over time. True can be further subdivided:
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a. Fusiform circumferential and relatively uniform in shape (can be different sizes and have different symptoms) monitor feet, assess circulation (pedal pulses), respiratory status (lung sounds), usually on anticoagulants if not fixed by surgery b. saccular dilation does not involve the whole aorta; involves its own little sac
Causes of true aneurysms: - the exact cause of true aneurysms are unknown. - It may be atherosclerosis (plague) of the intima diabetics at most risk - Degenerative changes to the media - This leads to weakening and eventual dilation of aorta
2. A false aneurysm is not an aneurysm, but a disruption of all layers of the arterial wall resulting in bleeding that is contained by surrounding structures. c. Clinical manifestations of Aneurysms - Depends on location of aneurysm. - Can be asymptomatic--thoracic aneurysm (above renal arteries) - Can have deep, diffuse chest pain. - Can produce hoarseness, dysphagia, back pain (abdominal aneurysm) d. Complications of Aneurysms: untreated can result in rupture. e. Diagnostic studies for Aneurysms: Chest x-ray, angiography (good picture of aorta), MRI, CT scan f. Collaborative Care for Aneurysms a. Goal: to prevent rupture. Early detection is key i. Conservative treatment of 4 cm or less aneurysm 1. diet 2. watch BP ii. Surgical treatment if aneurysm is 5- 6 cm 1. synthetic graft (Dacron) a. clamp above and below b. patient is on by pass machine c. cut out aneurysm (blood goes everywhere) d. sewn in graft, release clamps, and voila!! Post Op Synthetic Graft Treatment: - blood pressure hypotension and hypertension should be avoided - CV status - monitor for infection (temp, redness, warmth, purulent drainage, CBC) - GI status unusual for paralytic ileus to persist beyond 4th post op day - assess bowel sounds - watch graft patency - incentive spirometer - splinting with pillow if coughing to hold sutures together - encourage deep breathing and coughing (atelectasis can occur if they don't breathe deeply) - stool softener to prevent straining after surgery - activity tolerance, may need oxygen - signs and symptoms of bleeding (BP)
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Post Op Graft Interventions - watch for infection (WBC count) - Monitor Input and Output - usually NPO after procedure Minimally invasive procedure: - must meet criteria- don't use if affects renal arteries - can leak - graft dysfunction grafts don't work really well Aortic Dissection - tear in intima of the artery-> blood goes between intima and media (creates its own little lumen) creating a false lumen of blood flow - each systolic pulsation causes increased pressure to the damaged area - occludes major branches of aorta and cuts off blood supply to organs - develops over time - cause of dissection is unknown - symptoms of aortic dissection: sudden, severe pain; can mimic MI pain - if blood goes into pericardial sac (lining around heart), it can cause cardiac tamponade (squeezes heart; heart can't pump), which can lead to asystole - most common occurs in the thorax Aortitis rare and involves inflammation of the aorta almost always secondary to another disease process (i.e.,, syphilis) treat with NSAIDS, corticosteroids patient will have fever, pain
Aortoiliac disease - narrowing of iliac arteries - decreases blood flow to lower extremities - occurs at bifurcations - common in diabetics - primary symptom: intermittent claudication (pain below level where occlusion is) Causes and risk factors of Aortoiliac disease o atherosclerosis o smoking o hypertension o high cholesterol o diabetes o age Recommended Treatment for Aortoiliac Disease - angioplasty (blow up balloon) - stenting (to keep vein open) put on anti-coagulant after - atherectomy catherization (catheter with an attached drill or laser removes plaque within the artery) - bypass surgery (take vein or artery and bypass area of blockage) like to use mammary artery o veins are put in upside down because they have valves
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Arterial Vs Venous Insufficiency - Arterial Insufficiency oxygen blood flow to the tissues is diminished; intermittent claudication is the presenting symptom - dangle feet - don't cross legs - Venous insufficiency blood reaches the tissues; the difference is that it is not returned to the right side of the heart in an efficient matter. Therefore, edema begins to develop o Elevate extremities Peripheral Arterial Disease of the Lower Extremities: Manifestations: Depends on site and extent of obstruction. - Classic symptoms of PAD of the lower extremities = intermittent claudication (ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible). - The physical appearance of the limb provides important information about the adequacy of blood flow. - The skin becomes shiny, and taut, loss of hair. - Diminished or absent pulses. Pallor in response to elevation (keep extremity dangled) - As the disease progresses, rest pain develops. - Thick nails - Ulcers: painful, circular - Rarely have edema - Usually develops slowly and collateral circulation can develop Diagnostic studies for Peripheral Arterial Disease: - Doppler ultrasound detect pulses, and can show where blood flow is occluded - Ankle-brachial index (0 to 0.41 = severe PAD). Normal is 0.90 to 1.30. Calculated by dividing the ankle systolic blood pressure by the highest brachial SBP. Angiography Pre Care: - NPO - Assess peripheral pulse - Baseline vitals - Allergy to dye Post Care - check for bleeding - compare vitals to baseline vitals - lay flat, extremity straight, keep still - monitor for infection to site - pain - assess dressing (if hematoma develops, hold pressure firmly over) - monitor I and O - encourage fluids Collaborative Care:
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- Risk Factor Modification - Drug Therapy for Arterial Disease - Antiplatelet drugs (may be on Heparin first) o Ticlid o Plavix Monitor for thrombocytopenia (below 5), neutropenia (platelets, and WBC count) Drugs for intermittent Claudication o Trental increases erythrocyte flexibility and reduces blood viscosity o Pletal inhibits platelet aggregation and increases vasodilation Side effects: headache and diarrhea
Exercise Therapy of Arterial Disease - Walking improves oxygen extraction in the legs and skeletal muscle metabolism - Walk to the point of pain, stop, and rest, resume walking until discomfort recurs to promote collateral circulation - Usually walk 30-40 minutes per day for at least 3-4 days a week - Dangle feet, don't' cross legs Nutritional Therapy for Arterial Disease - goal is to maintain ideal body weight - cholesterol < 200 mg/day - decrease saturated fat intake - reduce sodium to < 2 gm per day Other important nursing care for Arterial Disease: - inspect feet daily - stop smoking - arterial blood supply can be enhanced by positioning body part below level of heart - no crossing legs - heat sources (don't take hot baths) - test water with elbow - put heat on abdomen to still get affects (more SQ tissue, less chance of burning; heat will flow to lower extremities) Interventional Radiologic Procedures - balloon inflated Surgical Therapy - femoral-popliteal bypass: the saphenous vein is grafted from above to below the occluded portion of the artery to provide continuous blood flow - most common surgery - assess peripheral pulses - monitor I and O - monitor BP - assess for bleeding - monitor infection: temperature, CBC - assess lung sounds (if breathing shallow, incentive spirometer) - turn, and cough, deep breath
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Endarterectomy - removal of the plaque from the artery - complications: clot Cryoplasty angioplasty on ice - cold is thought to inhibit cells in artery from forming scar tissue Amputation (last effort) - teaching Pre-op o self image o phantom limb pain o teach about contracture formation o don't let patient sit in high fowler's (they need to be in low fowler's position) less pressure o lie prone on stomach for periods of time o wrap very tightly (to prevent swelling) teaching Post-op o prevent contractures o lie prone on stomach for periods of time o wrapped tightly o sit in low fowler's position
Complications of Peripheral Artery Disease - Asses 5 P's o Pain o Pallor o Pulselessness o Paresthesia o Paralysis Assess for bloody stools and urine Treatment: Anti-coagulant or thrombolytic (Streptokinase) agents (dissolve all clots risk of GI bleed, stroke)
Thromboangiitis Obliterans (Buerger's Disease): Recurring inflammation of the intermediate and small arteries and veins of the lower and upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by its microscopic appearance. Thought to be autoimmune, cause is unknown; affects small and medium sized arteries Clinical Manifestations of Buerger's Disease: Pain, foot cramps after exercise (especially in the arch) outstanding symtpom Pain relieved by rest and is aggravated by emotional disturbances, nicotine, or chilling. Treatment for Buerger's disease Same as for atherosclerotic peripheral arterial disease. (walking to the point of pain, rest, restart, thrombolytics) Stop smoking
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Raynaud's Disease: - Episodes of arterial spasms/vasoconstriction and digital ischemia - Mainly occurs in the hands bilaterally. - Caused by exposure to cold and stress. - Caused by underlying disease (Rheumatoid arthritis, systemic lupus, trauma) - Prognosis varies - Avoid stimuli (cold) - Calcium channel blockers may be effective in relieving symptoms - Sympathectomy may help some patients (interrupting the sympathetic nerves by removing the sympathetic ganglia or dividing their branches to help prevent pain) - First it blanches (lack of blood flow), then turns blue (vessles dilate to keep blood in tissues), then back to red (blood flow returns) (West Baton Rouge) when stimulated Pathophysiology of Raynaud's Disease: Skin on fingers and toes is numb and blanches (vasoconstriction) Numb areas turn cyanotic Finally skin turns red Patient may experience pain and throbbing. Management of Venous Disorders: Venous Thrombosis, Deep Vein Thrombosis, Thrombophlebitis, and Phlebothrombosis: - These terms do not represent the same process; for clinical reasons they are used interchangeably Venous thrombosis: exact cause is unknown; however, 3 factors (known as Virchow's triad) are believed to play a significant role in its development: Virchow's triad: Stasis of blood (venous stasis) maybe due to heart failure or shock; or immobility Vessel wall injury fractures or dislocations, diseases of the veins, chemical irritation which occurs from IV therapy Altered blood coagulation oral contraceptive use can lead to hypercoagulability. - Formation of a thrombus usually accompanies thrombophlebitis (inflammation of the vein walls). When a thrombus develops initially in the veins as a result of stasis or hypercoagulability but without inflammation, the process is referred to as phlebothrombosis. - Venous thrombosis usually occurs in veins of the lower extremities. Clinical manifestations of venous thrombosis: - Signs and symptoms can be nonspecific. Signs of deep vein obstruction: Edema and swelling of the extremity because of the outflow of venous blood is inhibited. Measurements taken of the extremity may indicate changes. (measure girth and calf distance) Affected extremity may be warm and the veins may appear prominent. Tenderness, redness Homan's Sign not a good indicator (can throw clot) pulmonary embolus is the most severe complication feels warm
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Nursing Interventions and Considerations - on bed rest - on blood thinners - heparin first - then Coumadin to prevent blood clot in brain - Coumadin for rest of their life Medication Management of Venous Thrombosis: Anticoagulation Therapy: o Unfractionated heparin: SC or IV usually for 5 to 7 days to prevent the extension of a thrombus. Oral anticoagulants are usually given with heparin therapy. o Low-Molecular-Weight Heparin: take longer to reach therapeutic levels Longer half life SC (QD or BID) More expensive Thrombolytic Therapy: o Causes the thrombus to lyse and dissolve in 50% of the cases; o Examples: TPA o Advantages: less long term damage to the venous valves o Disadvantages: can cause severe bleeding.
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Surgical Management: Necessary if thrombolytic or anticoagulant therapy are contraindicated. - Thrombectomy (removal of the thrombus) is the procedure of choice. - A vena cava filter may be placed to trap large emboli and prevent pulmonary emboli. - put green filter into femoral artery surgically, which adheres to the wall of the artery (it has netting) - the purpose of it is to catch clots in extremities - patient is usually on anti-coagulants with these procedure Nursing Management: Monitor blood levels: - Coumadin: PT/INR - Heparin: PTT (usually sliding scale) - Hgb/Hct: To check for bleeding - Platelet: Heparin may decrease platelet count and cause platelet induced thrombocytopenia after about 7-10 days after Heparin therapy - Apply elastic compression stockings: Be careful that they are not too tight. Intermittent Pneumatic Compression Stockings Signs of superficial vein obstruction:(Superficial Thrombophlebitis) Palpable, firm, subcutaneous cordlike vein Pain or tenderness, redness, warmth Most dissolve spontaneously and do not form pulmonary embolus. Treated with bed rest, elevation of the extremity, analgesics, and possibly anti-inflammatory medications
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Chronic Venous insufficiency results from obstruction of the venous valves in the legs or a reflux of blood back through the valves due to prolonged increase in venous pressure. Thus there is a backflow of blood in the veins. o Venous valves are incompetent
Manifestations of Chronic Venous Insufficiency: o Chronic venous stasis resulting in edema o Altered pigmentation o Pain o Stasis dermatitis o Symptoms may be less in the morning and worse in the evening o Stasis ulcers may develop usually in the lower part of the extremity (medial malleolus) o Skin dry, cracks, itches o Potential for infection Management of Chronic Venous Insufficiency - Compression stockings, elevate extremity (at least 15 to 20 minutes every 2 hours). Avoid prolonged sitting or standing; avoid crossing legs. Nursing Diagnoses: - Impaired skin integrity related to vascular insufficiency - Impaired physical mobility related to activity restrictions of the therapeutic regimen and pain Nursing Interventions for Chronic Venous Insufficiency: 1. Venous insufficiency elevate the extremity. 2. Protective boots to avoid trauma. 3. Daily foot bathing: wash b/w toes with mild soap and lukewarm water, then rinse and pat dry (do not rub). 4. Avoid sunburn, heating pads, and hot tubs. 5. Inspect feet daily with mirror for redness, dryness, cuts, blisters. 6. Trim nails straight across. 7. No thong sandals. 8. No cream between toes. 9. Do not cross legs. Varicose Veins: - Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves (mostly in lower extremities). o Primary without involvement of deep veins o Secondary resulting from obstruction of deep veins - A reflux of venous blood in the veins results in venous stasis. Symptoms of Varicose Veins o Dull aches, muscle cramps, and increased muscle fatigue in the lower legs. o Ankle edema may occur o Nocturnal cramps are common. o Legs feel heavy Prevention of Varicose Veins
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exercise control weight don't cross legs while sitting support stockings
Medical Management of Varicose Veins - Surgery requires that the deep veins be patent and functional. - Sclerotherapy solution injected into vein, the vein swells, and turns to scar tissue o The same vein may need to be treated more than once Laser Therapy usually for spider veins only Endovenous Technique catheters placed in vein, radiofrequency waves shrink and seal the vein walls
Cellulitis o Common infectious cause of limb swelling. Symptoms of Cellulitis - swelling, localized redness, pain, fever, chills, and sweating. Medical Management of Cellultis - Antibiotic therapy (either inpatient or outpatient depending on severity) - analgesics Nursing Management of Cellulitis - Elevate, apply warm compresses every 2 to 4 hours (caution with Diabetes and circulatory impairment) Lymphangitis and Lymphadenitis Lymphangitis acute inflammation of the lymphatic channels. Usually from a focus of infection in an extremity. Lymphedema long standing condition - treat lymphedema with compression stockings - manual lymph drainage is commonly referred to as M-L-D. This specialized massage technique is performed by the lympedema therapist to stimulate the flow of the lymphatic system
Comparison of Arterial and Venous Leg Ulcers
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Assessment Peripheral Pulses Capillary Refill ABI Edema Hair Ulcer location Ulcer margin Ulcer drainage Pain Nails Skin color Arterial Decreased or absent Greater than 3 seconds Less than 0.75 No edema Loss of hair on legs, feet, toes Tips of toes, foot, or lateral malleolus Rounded, smooth, looks punched out Minimal Intermittent claudication or rest pain in foot; ulcer may or may not be painful Thickened; brittle Dependent rubor Cool Venous Present; may be difficult to palpate with edema Less than 3 seconds Greater than0.90 Lower leg edema Hair may be present or absent Near medial malleolus Irregularly shaped Moderate to large amount Dull ache or heaviness in calf or thigh; ulcer often painful Normal or thickened Bronze-brown pigmentation Warm
Arterial Ulcers: (Dot Com) D deep O ouch T tips of toes more commonly C circular O ooo it's black M minimal edema