Imbalance Between Myocardial Supply and Demand Irma B.Ancheta,PhD,RN Peggy McCartt, PhD (c), CCRN, ARNP

Peripheral Vascular Disease (PVD) PVD includes disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation. PVD affects the lower extremities much more frequently than the upper extremities. Generally a client with PVD implies arterial disease (rather than just venous disease)

Assessing for Peripheral Vascular Disease (PVD) Physical Assessment – Assess blood pressure in both arms – Palpate pulses – Listen for a bruit

PVD Laboratory Assessment – Lipid Profile Cholesterol Triglycerides – Homocysteine Amino acid found in the blood homocysteine levels blocks NO dec. elasticity promote plaque build-up

B6 = Pyridoxine (nuts, soybeans, legumes) B9 = Folic acid “folium” B12 = cyanocobalamin (liver,shellfish,salmon)

Interventions Monitor for Metabolic Syndrome Diet Therapy Smoking Cessation Complementary and Alternative Therapies Exercise Drug Therapy  HMG-CoA Mevalonic acid terpenes and steroids (terpenoid lipid) cholesterol  (first enzyme in the metabolic pathway that produces cholesterol and other lipids)  (gene located on the long arm of 5 th chromosome) HMG Co-Reductase inhibitors – Niacin – Fibric Acid Derivatives –

Peripheral Arterial Disease (PAD) PAD is a manifestation of systemic atherosclerosis and is a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients. – Inflow Obstructions- distal end of aorta and the common, internal and external iliac arteries – Outflow obstructions involve infrainguinal arterial segments ( femoral, popliteal, and tibial arteries) and are below the superficial femoral artery.

PAD Risk Factors and Incidence/Prevalence? Physical Assessment Intermittent claudication Arterial ulcers Diabetic ulcers Venous stasis ulcers Radiographic Assessment – Arteriography Other Diagnostic Assessments – Segmental systolic blood pressure measurements with a Doppler – Ankle-brachial index (ABI) – Exercise Tolerance Testing

Int. Claudi. [1] + Pain  Cramping  Burning  Reproducible  Awakened at night  Toes, foot Arched heels (-) calves -(-) ankles Arterial U [1]+ Pain Great Toe  Well def border DM U [1] (-) Pain Plantar foot Venous U [1]min Pain Ankle Foot warm  +Pulse  +discoloration

PAD Interventions Nonsurgical – Exercise – Positioning – Promoting vasodilation – Drug therapy i.e. anti-platelet medications: aspirin and Plavix – Percutaneous Transluminal Angioplasty (PTA)- stents/ laser angioplasty/ atherectomy Surgical Management – Arterial revascularization- bypass grafting with PTFE, Gore- Tex or Dacron

PAD Nursing Diagnoses NICS/NOCS Chronic Pain Ineffective Tissue Perfusion: Peripheral Risk for Injury – NICS- pain management circulatory care: arterial insufficiency surveillance: safety

Pre-operative Care for PAD Surgical Patient General Preoperative Surgical Care as for any surgery patient Postoperative Care- – Assess for Graft occlusion – Assess for Graft Patency Care for Graft occlusion (thrombectomy) – Assess for Infection

Acute Peripheral Occlusion Six “Ps” of Ischemia – Pain – Pallor – Pulselessness – Parathesia – Paralysis – Poikilothermia (coolness)

PAD Home and Community Care Home Care Management Health Teaching Health Care Resources

Aneurysms Abdominal Aortic Thoracic

Abdominal Aortic Aneurysm (AAA) Diagnosis Interventions – Nonsurgical – Surgical AAA Resection Pre and Postoperative Care

Peripheral Venous Disease Pathophysiology Venous Thromboembolism (VTE) Venous Insufficiency (Varicose Veins) Lack of Skeletal Muscle Contractility

Thrombus Definition A thrombus is a blood clot believed to result from an endothelial injury, venous stasis, or hypercoagulability. The thrombosis may not be specifically attributable to one element, or it may involve all three elements. It is often associated with an inflammatory process. When a thrombus develops, inflammation can occur around the clot, thickening the vein wall and consequently leading to embolization (formation of an embolus).

VTE Embolus Thrombophlebitis Phlebothrombosis Deep Venin Thrombophlebitis or Deep Venin Thrombosis (DVT) Pulmonary Embolism Virchos’s triad- stasis of blood flow, endothelial injury, and hypercoagculability

VTE Assessment Look for calf tenderness and pain, and sudden onset of unilateral swelling of the leg. Pain in the calf on dorsiflexion of the foot (positive Homan’s sign) appears in only 10% of clients- many clients(40%) may have no S&S Localized edema Tests Venous Doppler Impedance plethysmography MRI D-dimer