1. (Relates to Chapter 38, “Nursing Management: Vascular Disorders,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2  Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities  Atherosclerosis is the leading cause in majority of cases. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 Fig. 38-1. Common anatomic locations of atherosclerotic lesions (shown in yellow) of the abdominal aorta and lower extremities.

4. 4  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.

5. 5  Peripheral artery disease (PAD) may affect Aortoiliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6  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 Reproducible Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

7. 7  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.

8. 8  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.

9. 9  Pain at rest Occurs in the forefoot or toes Aggravated by limb elevation Occurs from insufficient blood flow Occurs more often at night Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

10. 10  Atrophy of the skin and underlying muscles  Delayed healing  Wound infection  Tissue necrosis  Arterial ulcers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

11. 11  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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12  Doppler ultrasound Segmental blood pressures  Ankle-brachial index (ABI) Done using a hand-held Doppler  Duplex imaging Bidirectional, color Doppler Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13  Angiography  Magnetic resonance angiography (MRA) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

14. 14  Smoking cessation, including use of nicotine products  Aggressive treatment of hyperlipidemia  BP maintained <140/90  Glycosylated hemoglobin <7.0% for diabetics Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15  Antiplatelet agents Aspirin Clopidogrel (Plavix) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16  ACE inhibitors Ramipril (Altace)  ↓ cardiovascular morbidity  ↓ mortality  ↑ peripheral blood flow  ↑ ABI  ↑ walking distance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17  Drugs prescribed for treatment of intermittent claudication Pentoxifylline (Trental)  ↑ erythrocyte flexibility  ↓ blood viscosity Cilostazol (Pletal)  ↑ vasodilation  ↑ walking distance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

18. 18  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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19  BMI < 25 kg/m 2  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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20  Revascularization via surgery  Protect from trauma  Reduce vasospasm  Prevent/control infection  Maximize arterial perfusion  Other strategies Hyperbaric oxygen therapy Angiogenesis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21  Indications Intermittent claudication symptoms become incapacitating. Pain at rest Ulceration or gangrene severe enough to threaten viability of the limb Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. 22  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.

23. 23  Atherectomy Removal of the obstructing plaque Performed using a cutting disc, laser, or rotating diamond tip Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. 24  Most common surgical approach A peripheral artery bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. 25 Fig. 38-7. 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.

26. 26  Most common surgical approach (cont’d) Synthetic grafts typically used for long bypasses Balloon angioplasty with stenting used in combination with bypass surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

27. 27  Endarterectomy  Patch graft angioplasty  Amputation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

28. 28  Past health history Diabetes mellitus Smoking Hypertension Hyperlipidemia Obesity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

29. 29  Exercise intolerance  Loss of hair on legs and feet  Decreased or absent peripheral pulses Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

30. 30  Ineffective tissue perfusion (peripheral)  Impaired skin integrity  Activity intolerance  Ineffective self-health management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

31. 31  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.

32. 32  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.

33. 33  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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

34. 34  Acute intervention Continued circulatory assessment Monitor for potential complications. Knee-flexed positions should be avoided except for exercise. Turn and position frequently. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35  Ambulatory and home care Management of risk factors Importance of meticulous foot care Importance of gradual physical activity after surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

36. 36  Ambulatory and home care Daily inspection of the feet Comfortable shoes with rounded toes and soft insoles Shoes lightly laced Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

37. 37  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.

38. 38  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.

39. 39 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. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

40. 40 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.” Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

41. 41  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.

42. 42  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.

43. 43 1. What risk factors for peripheral artery disease does he display? 2. What can he do to prevent additional complications? 3. What patient teaching is essential for him to help manage his disease? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.