Focus on Peripheral Artery Disease of the Lower Extremities

Focus on Peripheral Artery Disease of the Lower Extremities
(Relates to Chapter 38, “Nursing Management: Vascular Disorders,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

What caused this problem? What is the blackened area?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peripheral Arterial Disease Description
Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities Peripheral arterial disease (PAD) increases risk for chronic angina, MI, and stroke Affects the legs more frequently than the arms Systemic atherosclerosis is the leading cause in majority of cases. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Flow Obstructions Obstructions are classified as inflow or outflow, according to the arteries involved and their relationship to the inguinal ligament Inflow obstructions involve the distal end of the aorta and the common, internal, and external iliac arteries. They are located above the inguinal ligament Outflow obstructions involve the femoral, popliteal, and tibial arteries and are below the superficial femoral artery (SFA). Gradual inflow occlusions may not cause significant tissue damage. Gradual outflow occlusions typically do. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Sites of Atherosclerotic Lesions
Common anatomic locations of atherosclerotic lesions (shown in yellow) of the abdominal aorta and lower extremities. Fig Common anatomic locations of atherosclerotic lesions (shown in yellow) of the abdominal aorta and lower extremities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Description Peripheral artery disease (PAD) may affect Aortoiliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery The femoral popliteal area is the site most commonly affected in nondiabetic patients. The patient with diabetes mellitus tends to develop PAD in the arteries below the knee, especially the anterior tibial, posterior tibial, and peroneal arteries. In advanced PAD, multiple levels of occlusions are found. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Locations of Flow Obstructions
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Description Typically appears at ages 60s to 80s Largely undiagnosed Risk factors Cigarette smoking Hyperlipidemia Hypertension Diabetes mellitus Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations
Classic symptom of PAD—intermittent claudication Ischemic muscle ache or pain that is precipitated by a constant level of exercise Resolves within 10 minutes or less with rest Pain is reproducible- students what does this mean? As the disease progresses patients can walk only shorter and shorter distances before pain recurs. Ultimately, pain may occur even while at rest. The ischemic pain is a result of the accumulation of end products of anaerobic cellular metabolism, such as lactic acid. Once the patient stops exercising, the metabolites are cleared and the pain subsides. PAD of the aortoiliac arteries produces claudication in the buttocks and thighs, whereas calf claudication indicates femoral or popliteal artery involvement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Manifestations Continued
Rest pain, which may begin while the disease is still in the stage of intermittent claudication, is a numbness or burning sensation, often described as feeling like a toothache that is severe enough to awaken patients at night. Rest pain is usually located in the toes, the foot arches, the forefeet, the heels, and, rarely, in the calves or ankles. Patients can sometimes get pain relief by keeping the limb in a dependent position (below the heart). Students: Think why may pain relieved in this position? Those with rest pain often have advanced disease that may result in limb loss. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflow Disease Manifestations
Patients with inflow disease have discomfort in the lower back, buttocks, or thighs. Patients with mild inflow disease have discomfort after walking about two blocks. This discomfort is not severe but causes them to stop walking. It is relieved with rest. Patients with moderate inflow disease experience pain in these areas after walking about one or two blocks. The discomfort is described as being more like pain, but it eases with rest most of the time. Severe inflow disease causes severe pain after walking less than one block. These patients usually have rest pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Outflow Disease Manifestations
Patients wit outflow diseases describe burning or cramping in the calves, ankles, feet, and toes. Instep or foot discomfort indicates an obstruction below the popliteal artery. Those with mild outflow disease experience discomfort after walking about five blocks. This discomfort is relieved by rest. Patients with moderate outflow disease have pain after walking about two blocks. Intermittent rest pain may be present. Those with severe outflow disease usually cannot walk more than one-half block and usually experience rest pain. They may hang their feet off the bed at night for comfort and report more frequent rest pain than do those with inflow disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chronic Peripheral Artery Diseases Stages
Stage I: Asymptomatic No claudication is present. Bruit or aneurysm may be present. Pedal pulses are decreased or absent. Stage II: Claudication Muscle pain, cramping, or burning occurs with exercise and is relieved with rest. Symptoms are reproducible with exercise. Stage III: Rest Pain Pain while resting commonly awakens the patient at night. Pain is described as numbness, burning, toothache-type pain. Pain usually occurs in the distal portion of the extremity (toes, arch, forefoot, or heel), rarely in the calf or the ankle. Pain is relieved by placing the extremity in a dependent position. Stage IV: Necrosis/Gangrene Ulcers and blackened tissue occur on the toes, the forefoot, and the heel. Distinctive gangrenous odor is present. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Paresthesia Numbness or tingling in the toes or feet Produces loss of pressure and deep pain sensations Injuries often go unnoticed by patient Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Thin, shiny, and taut skin Loss of hair on the lower legs Diminished or absent pedal, popliteal, or femoral pulses Pallor of foot with leg elevation Reactive hyperemia of foot with dependent position Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pain at rest Occurs in the forefoot or toes Aggravated by limb elevation Occurs from insufficient blood flow Occurs more often at night Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Complications Nonhealing arterial ulcers and gangrene are most serious complications. May result in amputation if blood flow is not adequately restored, or if severe infection occurs If PAD has been present for an extended period, collateral circulation may prevent gangrene of the extremity. Unmanageable pain and severe, spreading infection are indicators that an amputation is required in individuals who are not candidates for revascularization. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Studies Doppler ultrasound Segmental blood pressures Ankle-brachial index (ABI) Done using a hand-held Doppler Duplex imaging Bidirectional, color Doppler When palpation of a peripheral pulse is difficult because of severe PAD, the Doppler can determine the degree of blood flow. A palpable pulse and a Doppler pulse are not equivalent, and the terms are not interchangeable. A drop in segmental BP of >30 mm Hg suggests PAD. The ABI is calculated by dividing the ankle systolic BPs by the higher of the left and right brachial systolic BP. A normal ABI is 0.91 to 1.30 and indicates adequate BP in the extremities. An ABI between 0.71 and 0.90 indicates mild PAD, between 0.41 and 0.70 indicates moderate PAD, and <0.40 indicates severe PAD. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Peripheral Arterial Occlusion
Those with acute arterial insufficiency often present with the “six P’s” of ischemia: pain pallor pulselessness paresthesia paralysis Poikilothermia This is an emergency- patient needs Heparin, thrombectomy Another emergency is compartment sybdrome- pressure within confined space of tissue occludes circulation-example? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Invasive Non-Surgical Procedures
A nonsurgical but invasive method of improving arterial flow is percutaneous transluminal angioplasty (PTA) This procedure requires an arterial puncture in the patient's groin. One or more arteries are dilated with a balloon catheter advanced through a cannula, which is inserted into or above an occluded or stenosed artery. When the procedure is successful, it opens the vessel and improves arterial blood flow. Patients who are candidates for PTA must have occlusions or stenoses that are accessible to the catheter. The physician often uses this procedure for those who are poor surgical candidates, who cannot tolerate general anesthesia, or who need an amputation. Reocclusion may occur after PTA, and the procedure may be repeated. Some patients are occlusion-free for up to 3 to 5 years, whereas others may experience reocclusion within a year Arthrectomy is another technique to improve blood flow to ischemic legs- plaque is scraped from the artery with a device that minimizes damage to the vessel Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Care-Post-Procedures
The priority for nursing care following a PTA or athrectomy is to observe for bleeding at the arterial puncture site, which is usually sealed with special collagen plugs. Monitor for manifestations of impending hypovolemic shock, including a decrease in blood pressure, increased pulse rate, and decreased urinary output. Perform frequent checks of the distal pulses in both legs to ensure adequate perfusion and oxygenation Patients who undergo surgical aorto-femoral or iliac bypass surgery are NPO x1 day to prevent N & V which increases intra-abdominal pressure, lower extremities bypass may have clear liquids post op day 1 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Safety-Critical Assessment Post-Procedures & Surgery
Graft occlusion (blockage) is a postoperative emergency that can occur within the first 24 hours after arterial revascularization. Monitor the patient for and report severe continuous and aching pain, which may be the first indicator of postoperative graft occlusion and ischemia. Many people experience a throbbing pain caused by the increased blood flow to the extremity. Because this sensation is different from ischemic pain, be sure to assess the type of pain that is experienced Pain from occlusion may be masked by patient-controlled analgesia (PCA). Some patients have ischemic pain that is not relieved by PCA Emergency thrombectomy (removal of the clot), which the surgeon may perform at the bedside, is the most common treatment for acute graft occlusion. Thrombectomy is associated with excellent results in prosthetic grafts Graft or wound infections can be life-threatening- sterile techniques should be used for incisional care and wound assessment Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Risk Factor Modification
Smoking cessation, including use of nicotine products Aggressive treatment of hyperlipidemia BP maintained <140/90 Glycosylated hemoglobin <7.0% for diabetics Table 38-3 summarizes the collaborative care for a patient with PAD. Because of the high risk for MI, ischemic stroke, and CVD-related death, the first treatment goal is to aggressively modify CVD risk factors in all patients with PAD regardless of the severity of symptoms. {Tables 12-4, 12-5, 12-6, and 12-7 discuss smoking cessation.} Current guidelines recommend aggressive lipid management for all PAD patients with the following goals: low-density lipoprotein (LDL) <100 mg/dL, triglycerides <150 mg/dL, high density lipoprotein (HDL) >40 mg/dL. In PAD patients with coexistent diabetes mellitus or renal insufficiency, BP <130/80 mm Hg is recommended. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Drug Therapy
Antiplatelet agents Aspirin Clopidogrel (Plavix) better for reducing risk for MI, CVA and vascular death Patients on anti-hypertensives must be monitored for worsening claudication due to adverse med effect-such as beta blockers Guidelines for oral antiplatelet therapy recommend aspirin ( mg/day). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drugs prescribed for treatment of intermittent claudication Pentoxifylline (Trental) ↑ erythrocyte flexibility ↓ blood viscosity Cilostazol (Pletal) ↑ vasodilation ↑ walking distance Cilostazol is recommended as first-line drug therapy for patients with intermittent claudication who do not respond to exercise therapy and are not candidates for surgical or radiologic interventions. One promising approach to claudication treatment under investigation is carnitine, a naturally occurring derivative of the amino acid lysine. Carnitine improves initial and maximal treadmill walking distance and quality of life. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Exercise Therapy
Exercise improves oxygen extraction in the legs and skeletal metabolism. Walking is the most effective exercise for individuals with claudication. 30 to 60 minutes daily A supervised, hospital-based PAD rehabilitation program is an effective means of improving exercise performance. Such programs typically include exercise for 30 to 60 minutes/day, 3 to 5 times/week, for 3 to 6 months. Supervised treadmill exercise training improves walking performance and quality of life in PAD patients, whether or not they have claudication. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Nutritional Therapy
BMI < 25 kg/m2 Waist circumference <40 inches for men and <35 inches for women Dietary cholesterol <200 mg/day Decreased intake of saturated fat Sodium <2 g/day You should recommend a diet high in fruits, vegetables, and whole grains, and low in cholesterol, saturated fat, and salt. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Care of Leg With Critical Limb Ischemia
Revascularization via surgery Protect from trauma Reduce vasospasm Prevent/control infection Maximize arterial perfusion Other strategies Hyperbaric oxygen therapy Angiogenesis Critical limb ischemia is a condition characterized by chronic ischemic rest pain lasting longer than 2 weeks, arterial leg ulcers, and/or gangrene of the leg attributable to PAD. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Interventional Radiologic Procedures
Indications Intermittent claudication symptoms become incapacitating. Pain at rest Ulceration or gangrene severe enough to threaten viability of the limb Preprocedural and postprocedural nursing care is the same as for a diagnostic angiography. Antiplatelet agents are necessary after the procedure to reduce the risk of restenosis. Long-term, low-dose aspirin therapy is recommended postprocedure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Percutaneous transluminal balloon angioplasty Involves the insertion of a catheter through the femoral artery Catheter contains a cylindrical balloon. Balloon is inflated dilating the vessel by cracking the confining atherosclerotic intimal shell. Stent is placed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaborative Care Surgical Therapy
Most common surgical approach A peripheral artery bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion Surgery is indicated in patients with long areas of stenosis or severely calcified arteries. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bypass grafts A, Femoral-popliteal bypass graft around an occluded superficial femoral artery. B, Femoral-posterior tibial bypass graft around occluded superficial femoral, popliteal, and proximal tibial arteries. Fig A, Femoral-popliteal bypass graft around an occluded superficial femoral artery. B, Femoral-posterior tibial bypass graft around occluded superficial femoral, popliteal, and proximal tibial arteries. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Most common surgical approach (cont’d) Synthetic grafts typically used for long bypasses Balloon angioplasty with stenting used in combination with bypass surgery When a person’s own vein is not available, human umbilical vein, cryopreserved vein, and a composite sequential bypass graft are alternatives. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Endarterectomy Patch graft angioplasty Amputation Amputation may be required if tissue necrosis is extensive, infectious gangrene or osteomyelitis (infection in the bone) develops, or all major arteries in the limb are occluded, precluding the possibility of successful surgery. {Amputation is discussed in Chapter 63.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Nursing Assessment
Exercise intolerance Loss of hair on legs and feet Decreased or absent peripheral pulses Palpate all pulses in both legs The most sensitive and specific indicator of arterial function is the quality of the posterior tibial pulse, because the pedal pulse is not palpable in a small percentage of people. The strength of each pulse should be compared bilaterally. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Nursing Diagnoses
Ineffective tissue perfusion (peripheral) Impaired skin integrity Activity intolerance Ineffective self-health management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Planning
Overall goals for patient with PAD Adequate tissue perfusion Relief of pain Increased exercise tolerance Intact, healthy skin on extremities Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Nursing Implementation
Health promotion Identification of at-risk patients Diet modification Proper care of feet Avoidance of injuries Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute intervention Frequently monitor after surgery. Skin color and temperature Capillary refill Presence of peripheral pulses distal to the operative site Sensation and movement of extremity Check the operative extremity every 15 minutes initially and then hourly for color, temperature, capillary refill, presence of peripheral pulses, and sensation and movement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute intervention Continued circulatory assessment Monitor for potential complications. Knee-flexed positions should be avoided except for exercise. Turn and position frequently. After the patient leaves the recovery area, you will continue to monitor perfusion to the extremities and will assess for potential complications such as bleeding, hematoma, thrombosis, embolization, and compartment syndrome. Discourage prolonged sitting with leg dependency as 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 edematous leg above heart level. Walking even short distances is desirable. The use of a walker may be helpful, especially in frail, elderly patients. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory and home care Management of risk factors Importance of meticulous foot care Importance of gradual physical activity after surgery Tobacco use in any form (including environmental smoke) is contraindicated. Encourage physical activity, and explain that it improves a number of CVD risk factors, including hypertension, hyperlipidemia, obesity, and glucose levels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Evaluation
Identify activities that promote circulation. Maintain adequate peripheral tissue perfusion. Experience intact skin, free of infection, on lower extremities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Evaluation
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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Venous Ulcers Chronic- non healing ulcer No claudication or rest pain
Moderate ulcer discomfort Patient reports ankle or leg swelling Often located in ankle area Brown pigmentation Ulcer bed pink, usually superficial with uneven edges Granulation tissue present Ankle discoloration 7 edema Veins are “full” when leg slightly dependent No neurological deficit Pulses Present Treat with long-term wound care, dressings and specialty boot Elevate extremity—Why? Prevent infection STUDENTS –REFER TO CHART 38-4 for Key Features of arterial, venous & diabetic ulcers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question A patient with peripheral vascular disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is: 1. Risk for injury related to decreased sensation. 2. Impaired skin integrity related to decreased peripheral circulation. 3. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. 4. Activity intolerance related to imbalance between oxygen supply and demand. Answer: 1 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says, 1. “I should not use heating pads to warm my feet.” 2. “I will examine my feet every day for any sores or red areas.” 3. “I should cut back on my walks if they cause pain in my legs.” 4. “I think I can quit smoking with the use of short-term nicotine replacement and support groups.” Answer: 3 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study 62-year-old man complains of pain when walking his dog that is relieved with rest. He has a history of hypertension and hyperlipidemia, and smokes one pack of cigarettes per day. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study He has edema in his feet. Angiography reveals nearly obstructed vessels in lower extremities. He is diagnosed with peripheral artery disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What risk factors for peripheral artery disease does he display? What can he do to prevent additional complications? What patient teaching is essential for him to help manage his disease? Smoking, male, and his age Quit smoking, and monitor his diet. Stress the importance of quitting smoking. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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