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Peripheral Arterial Disease

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John Anderson

on 11 September 2014

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Transcript of Peripheral Arterial Disease

Peripheral Arterial Disease
Conditions that Interfere with Flow of Blood to Extremities

Symptoms of PAD
Intermittent Claudication-Aching, burning pain that occurs when walking due to lack of blood to legs
Rest Pain- Pain at rest due to lack of O2 to tissues. clients will hang legs over the side of the bed to relieve pain.
Ulcers-Tissues affected by lack of O2 starts to break down
Gangrene-Death of tissues, starts distally, must be surgically removed, amputation
Risk Factors for PAD
Smoking- Most important. Destroys the endothelial lining of vessel. Speeds up atherosclerosis.
Hyperlipidemia- found in half of clients with PAD. Dietary changes and Statins (lipitor) slow progression of PAD
Hypertension- increases rick of claudication. keep BP less than 130/80
Diabetes- Speeds progression to ischemic rest pain and ulceration due to atherosclerosis and high levels of triglycerides. Diabetic with claudication have an amputation rate of 20% and a five year mortality rate of 50%. Keep HBGA1c less than 7%
Diagnostic Tests for PAD
Ankle-Brachial Index (ABI)
Measure BP with doppler of in both arms (brachial)
Measure BP with doppler in posterior tibial in ankles
Divide the systolic BP from each ankle by the highest brachial systolic BP
WNL 0.91-1.30 Mild 0.70-0.90
Moderate 0.40-0.69 severe less than 0.40
Management of risk factors
Stop smoking-decreases mortality by 50%
Walk 30-60 minutes Q day.
Pletal, Plavix & ASA
Warm extremity to decrease vaso-contriction
Weight-controled diet, lower cholesterol
Anti-lipid medication: Statins-lowers cholesterol and triglycerides and increases HDL
Monitor liver enzymes, severs muscle pain (rhabdomyolysis) annual eye exama
Anti-platelet agents-
Cilostazol (Pletal) and Clopidogrel (Plavix)
-inhibits platelet aggregation and dilates blood vessels, improves flow of blood to legs
These medication will help with S/S of intermittent claudication
Contraindicated in CHF
- decreases blood viscosity (thickness) and increase microcirculation
Analgesics for pain

Bypass Graft
Best choice when plaque extends over a long area.
Arterial graft utilizing client's own saphenous vein or may use synthetic material.
Performed to re-route the blood flow around the stenosis or occlusion.
Femoral-to-popliteal graft is used if clot is below the inguinal ligament in the superficial femoral artery.

Arterial Embolism
The 7 P's of assessment
Parasthesuas (numbness)
Poikilothermia (coldness)

PAD: Stenosis of Artery Lumen
Atherosclerosis-plaque formation leading to narrowing, or stenosis, thrombus, aneurysm, ulceration & rupture of artery
Deprive dependent tissues of O2 & nutrients
Causes ischemic necrosis-death of cell due to inadequate blood flow
Stimulates growth of collateral circulation
Can involves the distal aorta and iliac arteries in trunk, femoral, popliteal, & tibial arteries in legs
Upper Extremity PDA
Forearm claudication-pain & fatigue in arms, inability to hold onto objects
Subclavian Steal-reverse flow in vertebral & basilar arteries to provide blood to arms therefore vertigo, ataxia, syncope, or bilateral vision change. Transcranial doppler to evaluate cirulation in brain.
Arm symptoms-coolness, pallor, decreased capillary refill, diminished pulse, BP in one arm will be 20mm more than the other
Assessment of chronic PAD
Intermittent claudication
Dependent rubor-purple & Discoloration of feet when dependent
White, pale when legs elevated
Thick, calcified toenails
Ulcers on feet, decreased hair growth
Diminished pedal pulse
Numbness and tingly in extremity
Slow Cap refill
Decreased activity due to pain
Can lead to gangrene

Duplex Ultrasonography-Non-invasive imagery of tissue, organs, and blood flow. Assess blood flow, velocity using doppler, finds stenosis vs occlusion
Magnetic Resonance Angiography (MRA)
Non-invasive, IV dye used. Produces images of blood vessels. can not test if client has any metal in or outside their body, because of magnetic
Computed Tomography Angiography- Gives 3D images of blood vessel. used more than CT's in angiography in PAD studies
Contrast Angiography- invasive procedure. Catheter is placed in the artery in question. Dye is injected and then filmed by x-ray
Revascularization: Endovascular Procedures
Balloon Angioplasty-Used to dilate narrow or occluded vessels. These stents are coated with medication and are placed immediately post angioplasty
Mechanical Atherectomy-Removal of plaque from artery
Lazer Angioplasty- Vaporizes plaque in arteries
Thrombo-endarterectomy-Removal of clot. Open surical procedure
Nursing Care

Check for bleeding at site and VS Q HR
Check peripheral pulses with doppler, cap refill
Keep dressing clean and dry
Bed rest for 6-8 hrs with limb straight. If in the arm, keep arm above heart. Fingers highest.
When circulation returns their may be warmth, redness, and edema to affected limb.
Educate client not to bend hip in daily life, to decrease clot formation.

Post-op Care of Bypass Graft
Check ABI, pedal and post-tibial pulse with doppler.
Check limb for color changes, cap refill, strength of pulse, temp, and pain. Compare to other limb. Increase pain may indicate re-occlusion.
Check BP. If hypovolemic (which will lower BP) the risk of the graft collapsing is increased. If hypertensive, there is a risk of bleeding from sutures.
Graft occlusion- Bad; will happen in first 24 hours. Call MD if any S/S of occlusion, like increased pain, decrease strength of distal pulses, increase pallor or coolness.
Treatment of graft occlusion-Emergency thromectomy with t-PA (tissue plasminogen activator), or an infusion of platelet inhibitor (
) Watch for bleeding.
Compartment Syndrome-Possible serious complication. Tissue pressure within a confined body space can restrict blood flow, resulting ischemia can lead to irreversible tissue damage.
Signs and Symptom are: Numbness/tingling, edema, pain on movement, and unequal pulses.
Call MD NOW!!! Loosen clothing. If not treated client will loose limb. Treatment is Fasciotomy.

Performed when gangrene is present or imminent.
Post-Op Care
Monitor incision for infection.
Keep dressing clean and dry.
Elevate stump to decrease edema.
Avoid pressure ulcers on stump.
Total Occlusion Treatment
Bed rest- Keep extremity level
IV Heparin drip ASAP
Angiography or duplex scan
Lysis (elimination) of clot by injecting a thromolytic agent into the clot
If Lysis unsuccessful, endovascular procedure or bypass
Check for bleeding
Prevent extension of present clot.
Prevent formation of new clots by prolonging blood clotting.
Given prophylacticly to obese and immobile clients with a history of clots.
Inhibits conversion of prothrombin to thrombin.
Given Sub-Q or continuous IV.
Monitor heparin anti-Xa level (0.3-0.7IU/ml) or PTT (1.5-2.5 X baseline).
Protamine Sulfate is antidote.

Prevents Vitamin K from Synthesizing clotting factors in liver.
Given PO( takes 5 days to become therapeutic) and continued at home.
Monitor INR-blood test.
Desired INR is 1.5 -3 or 3-4.5 for clients at high risk.
Aquamephyton (Vitamin K) is antidote
Discharge Teaching For Anticoagulants
Clients will need INR q week until therapeutic.
Check with MD before taking any medication.
Report any sign of bleeding: mucose membranes, urine, or stool.
Use soft tooth-brush to avoid bleeding gums.
Tell all health care providers that you are taking these medication.
Avoid food that are high in vitamin K (Green, leafy vegetable).
Should wear medic-alert tag.
Raynaud's Disease
Raynaud's is an arterial disease that has nothing to do with atherosclerosis.
Affects hands and feet of women between 16-40 years old.
Primary Raynaus's-no underlying disease.
Secondary Rayanaud's- occurs with lupus, rheumatoid arthritis, scleroderma, or trauma.
Can lead to ulcers and gangrene of fingertips

Pathophysiology of Raynaud's
Pallor of hands or feet due to sudden vasoconstrivtion.
Cyanosis-Bluishness due to pooling of de-oxygenated blood during vasospasm.
After vasospam stop, reflow of blood creates red color.
Treatment of Raynaud's
Stop smoking
Avoid extreme cold
Dress warmly in cold weather
Avoid cold air-conditioning

Buerger's Disease
Buerger's is an arterial disease that has nothing to do with atherosclerosis.
Affects extremities of young men.
Inflammation of the small arteries and veins.
Leads to thrombus formation and occlusion of vessels.
Exacerbations and remissions
Physical Signs
Intense rubor-reddish, bluish discoloration of foot, no pedal pulse but normal femoral and popliteal pulses.
If toe's become gangrenous, amputate .
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