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ATI PVD

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John Anderson

on 12 March 2015

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Transcript of ATI PVD

Peripheral vascular disease included Peripheral arterial disease (PAD)and peripheral venous disorder (PVD), both interfere with normal blood flow.
PAD affects the arteries(blood vessels that carry blood away from the heart), and PVD affects the veins( blood vessels that carry blood toward the heart).

PERIPHERAL ARTERIAL DISEASE
(PAD)

PAD

PVD
PVD
PERIPHERAL VASCULAR DISEASE
Overview



PAD results from atherosclerosis that usually occurs in the arteries of the lowers extremities and is characterized by inadequate flow of blood.
Atherosclerosis is caused by gradual thickening of the intima and media of the arteries, ultimately resulting in the progressive narrowing of the vessel lumen. Plaques form on the wall of the arteries making them rough and fragile

OVERVIEW OF PAD



Progressive stiffening of the arteries and narrowing of the lumen decreases the blood supply to affected tissues and increases resistance to blood flow.
Atherosclerosis is a type of arteriosclerosis, which means “hardening of the arteries” and alludes to the loss of elasticity of arteries over time due to thickening of their walls.

OVERVIEW OF PAD



PAD is classified as inflow (distal aorta and iliac arteries) or outflow (femoral, popliteal, and tibial arteries) and may range from mild to severe.
Tissue damage occurs below the arterial obstruction.
Buerger’s disease, subclavian steal syndrome, thoracic outlet syndrome, Raynaud’s disease and popliteal entrapment are examples of PAD

OVERVIEW OF PAD



Hypertension
Hyperlipidemia
Diabetes
Smoking
Obesity
Sedentary lifestyle
Familial predisposition
Age- men over 45 and women who are postmenopausal

Risk Factors



Burning, cramping, and pain in the legs during exercise (intermittent claudication)
Numbness or burning pain primarily in the feet when in bed
Pain is relieved by placing legs at rest in a dependent position


Subjective Data



Thick toenails
Cold and cyanotic extremity
Pallor of extremity with elevation
Dependent rubor
Muscle atrophy
Ulcers and possible gangrenes of toes

Objective Data



Bruit over femoral and aortic arteries
Decreased capillary refill of toes (greater than 3 seconds)
Decreased or non-palpable pulses
Loss of hair on lower calf, ankle, and foot
Dry, scaly, mottled skin

Objective Data

Diagnostic Procedures



Arteriography of the lower extremities involves arterial injection of contrast medium to visualize areas of decreased
Arterial flow on an x-ray
It is done to determine isolated areas of occlusion that can be treated during the procedure with percutaneous transluminal angioplasty and possible stent placement

Arteriography



Observe for bleeding and hemorrhage


Palpate pedal pulse to identify possible occlusion

Nursing Actions



A stress test is done with or without the use of a treadmill with measurement of pulse volumes and blood pressure prior to and following the onset of symptoms or 5 min of exercise.
Delays in return to normal pressures and pulse waveforms indicate arterial disease. It is used evaluate claudication during exercise.

Exercise Tolerance Testing



Is used to determine the variations of blood passing through an artery, thus identifying abnormal arterial flow in the affected limb.
Blood pressure cuffs are attached to the client’s upper extremities and a lower extremity and attached to the plethysmograph machine.
A decrease in pulse pressure of the LE indicates a possible blockage in the leg.

Plethysmography



A Doppler probe is used to take various BP ( thigh, calf, ankle, brachial) for comparison.
If there is no PAD – the pressures in the lower extremities are higher than those of the upper extremities
With arterial disease, the pressures in the thigh, calf, and ankle are lower

Segmental systolic blood pressure measurement

Patient-Centered Care



Encourage the client to exercise to build up collateral circulation
Initiate exercise gradually and increase slowly
Instruct the client to walk until the point of pain, stop and rest, and then walk a little farther

Nursing Care



Instruct the client to avoid crossing the legs
Tell the client to refrain from wearing restrictive garments
Tell the client to elevate the legs to reduce swelling, but not to elevate them above the level of the heart because extreme elevation slows arterial blood flow to the feet

Positioning



Provide a warm environment for the client
Have the client wear insulated socks
Never apply direct heat to extremity- client may not be able to feel and can cause a burn
Avoid exposure to cold (vasoconstriction and decreased arterial flow)
Avoid stress, caffeine, and nicotine (vasoconstrictor) stop smoking or chewing tobacco is the best way to treat PAD

Promote vasodilation and avoid vasoconstriction



Antiplatelet medications
Aspirin (acetylsalicylic acid) (ASA)
Clopidogrel (Plavix)
Pentoxifylline (Trental)
Statins
Simvastain (Zocar) Atorvastatin (Lipitor)
Can relieve manifestations associated with PAD (intermittent claudication)


Medications



These meds reduce blood viscosity by decreasing blood fibrinogen levels, enhancing erythrocyte flexibility, and increasing blood flow in the extremities.
ASA and Plavix are the most common
Trental may be given to treat intermittent claudication

Antiplatelet Medications



Inform the client that the medication’s effects might not be apparent for several weeks
Advise the client to monitor for evidence of bleeding such as abdominal pain, coffee-ground emesis or black, tarry stools

Client Education



Percutaneous transluminal angioplasty
Laser-assisted angioplasty
Arterial revascularization surgery

Surgical Intervention



Invasive intra-arterial procedure using a balloon and stent to open and help maintain the patency of the vessel.
It is used for candidates who are not suitable for surgery or in cases where amputation is inevitable

Percutaneous Transluminal Angioplasty



Laser-assisted angioplasty is an invasive procedure in which a laser probe is advanced through a cannula to the site of stenosis
The laser is used to vaporized atherosclerotic plaque and open the artery


Laser-Assisted Angioplasty




The priority action is to observe for bleeding at the puncture site
Monitor the client’s vital signs, peripheral pulse, and capillary refill
If prescribed, keep the client on bed rest with the limb straight for 6-8 hour before ambulation
Anticoagulants are used during the procedure, then antiplatelet for 1-3 months

Nursing Actions



Arterial revascularization surgery is used with clients who have severe claudication and/or limb pain at rest, or with clients who are at risk for losing a limb due to poor arterial circulation
Bypass graft are used to reroute the circulation around the arterial occlusion
Grafts can be harvested from the clients (autologous) or made from synthetic materials

Arterial Revascularization Surgery




The priority action is to maintain adequate circulation in the repaired artery. The location of the pedal or dorsalis pulse should be marke, and its pulsatile strength compared with the contralateral leg on a scheduled basis using a Doppler
Color, temp, sensation, and cap refill should be compared with the good limb on a regular basis

Nursing Actions



Assess for warmth, redness, and possibly edema of the affected limb as a results of increased blood flow
Monitor the client for pain. Pain may be severe due to the reestablishment of blood flow to the limb



Nursing Actions



Monitor the client’s BP. Hypotension may result in an increase risk of clotting or graft collapse, while hypertension increases the risk for bleeding at the sutures site
Instruct the client to limit bending of the hip and knee to decrease the risk of clot formation

Nursing Actions

Complications





Graft occlusion is a serious complication of arterial revascularization and often occurs within the first 24 hours following surgery


Graft Occlusion



Promptly notify the surgeon of manifestations of occlusion, such as absent or reduced pedal pulse, increase pain, change in extremity color, or temperature.
Be prepared to assist with treatment, which may include an emergency thrombectomy (removal of a clot), local intra-arterial thrombolytic therapy with an agent like tissue plasminogen activator, or IV platelet inhibitor.
Check for bleeding

Nursing Actions



Compartment syndrome is considered a medical emergency.
Tissue pressure within a confined body space can restrict blood flow and the resulting ischemia can lead to irreversible tissue damage

Compartment Syndrome



Sign and symptoms include tingling, numbness, worsening pain, edema, pain on passive movement, and unequal pulses.
Report finding STAT
Loosen dressing
Prepare to assist with fasciotomy (surgical opening into the tissues), which may be necessary to prevent further injury and to save limb.

Nursing Actions

PERIPHERAL VENOUS DISORDERS
PVD



Peripheral venous disorders are problems with the veins that interfere with adequate return of blood flow from the extremities
There are superficial and deep veins in the lower extremities that have valves that prevent back flow of blood as it returns to the heart.
Skeletal muscles in the LE when walking promotes venous return

Overview



Three peripheral venous disorders that nurses should be familiar with are:

Venous thromboembolism (VTE)
Venous insufficiency
Varicose veins

Overview



A VTE is a blood clot believed to form as a results of venous stasis, endothelial injury,or hypercoagulability.
Thrombus formation can lead to a pulmonary embolism, which is a life-threatening complication
Thrombophlebitis refers to a thrombus that is associated with inflammation

Overview



Venous insufficiency occurs secondary to incompetent valves in the deeper veins of the LE, which allows pooling of blood and dilation of the veins.
The veins’ inability to carry fluid and wastes from the LE precipitates the development of swelling, venous stasis ulcers, and in advanced cases, cellulitis

Overview



Varicose veins are enlarge, twisted and superficial veins that may occur in any part of the body
They are commonly observed in the lower extremities and in the esophagus

Overview

Assessment of PVD



VTE-associated with Virchow’s triad: hypercoagulability, impaired blood flow,
damage to blood vessels
Hip surgery
Total knee
Open prostate
Heart failure
Immobility
Pregnancy
Oral contraceptives


Risk Factors



Venous insufficiency

Sitting or standing in one position for a long time
Obesity
Pregnancy
Thrombophlebitis


Risk Factors



Varicose Veins
Sex (women)
Older than 30 with and job requiring prolong standing
Pregnancy
Obesity
Systemic diseases (heart disease)
Family history

Risk Factors



Limb pain


Aching pain and feeling of fullness or heaviness in the legs after standing

Subjective Data



Deep vein thrombosis (DVT) and thrombophlebitis
Client asymptomatic
Calf or groin pain, tenderness, and a sudden onset of edema in extremity
Warmth, edema, and induration and harness over the blood vessel
Changes in leg circumferences, edema over affected area
SOB and CP, which could mean that the embolus has moved to the lungs. (PE)



Objective Data



Venous Insufficiency
Stasis dermatitis is a brown discoloration along the ankles that extends up the calf relative to the level of insufficiency
Edema
Stasis ulcers (typically found around ankles)

Objective Data




Varicose Veins


Distended, superficial veins that are visible just below the skin and are tortuous in nature

Clients often report muscle cramping and aches, pain after sitting, and pruritus

Objective Data



D-dimer test measure fibrin degradation products present in the blood produced
from fibrinolysis

A positive test indicates that thrombus formation has possibly occurred

Laboratory Tests



DVT and Thrombophlebitis
Venous duplex ultrasonography uses high-frequency sound waves to provide a real time picture of the blood flow through a blood vessel
Impedance plethysmography can be used to deterring the variation of blood passing through a vein thus identifying abnormal venous flow in the affected limb
If the above tests are negative for DVT, but one is still suspected, a venogram, which uses contrast material, or MRI may be needed for accurate diagnosis

Diagnostic Procedures



Varicose Veins-Trendelenburg test
Nursing Actions
Place the client in a supine position with legs elevated
When client sets up, the veins will fill from the proximal end if varicosities are present.

Veins normally fill from the distal end

Diagnostic Procedures

PATIENT-CENTERED CARE



DVT and Thrombophlebitis
Encourage the client to rest
Facilitate bed rest and elevation of extremity above the heart.
Avoid using a knee gatch or pillow under knees
Intermittent or continuous warm compresses
Do not massage the affected limb
Thigh-high compression or antiembolism stocking
Prepare client for inferior vena cava interruption surgery(a filter traps emboli and stops them from reaching the heart) as indicated


Nursing Care



Venous Insufficiency
Elevate legs many times a day for 15-30 min
Elevate feet approximately 6 inches at night
Instruct client not to cross legs and wear constrictive clothing or stocking
Instruct client to wear elastic compression stocking and apply them after the legs have been elevated and when edema is at a minimum

Nursing Care



DVT and Thrombophlebitis
Unfractionated heparin is given IV to prevent formation of other clots and to prevent enlargement of the existing clot
It has significant adverse effects and must be given in the facility
Prior to discharge, the client will be converted to oral anticoagulation therapy with warfarin (Coumadin)


Medications



Nursing Actions
Monitor aPTT to allow for adjustment of heparin dosage
Monitor platelet count for heparin induced thrombocytopenia
Ensure that protamine sulfate, the antidote for heparin is available for excessive bleeding
Monitor for hazard and adverse effects associated with anticoagulant therapy

Medications



Low-molecular weight heparin is given sub-Q and is based on a client’s weight
Enoxaparin (Lovenox) is used for the prevention and treatment of DVT
It is usually given in the facility, but the twice daily injection can be given in the home setting

Medications



Nursing Actions
Instruct the client to observe for evidence of bleeding

Instruct the client on bleeding precaution that should be taken (use electric instead of bladed razor and brush teeth with a soft toothbrush)


Medications



Warfarin (Coumadin) inhibits synthesis of the four vitamin K-dependent clotting factors.
The therapeutic effect take 3-4 days to develop, so administration of the medication is begun while the client is still on heparin
The antidote for warfarin is vitamin K

Medications



Nursing Actions

Monitor the client for bleeding
Monitor the client’s PT and INR
Ensure Vit K is available for excessive bleeding
Avoid foods high in Vit K (green leafy vegetables) and avoid fluctuation in the amount and frequency of consumption
Bleeding precautions that should be taken(use electric instead of bladed razor and brush teeth with a soft toothbrush)

Medications



This therapy dissolves clots that have already developed. Must be started within 5 days after the development of the clot. Tissue plasminogen activator, a thrombolytic agent, and platelet inhibitor like abciximab (ReoPro), and eptifibatide (Integrilin) can help dissolve a clot or prevent new clots during the first 24 hr. Inject these meds directly into the clot

DVT and Thrombophlebitis



Nursing Actions

Monitor the client for bleeding (intracerebral)

Bleeding precautions that should be taken(use electric instead of bladed razor and brush teeth with a soft toothbrush)



DVT and Thrombophlebitis



Venous Insufficiency
Care of venous stasis ulcers requires long term management

Consultation with a dietitian and wound care specialist will facilitate the healing process

Teamwork and Collaboration




Varicose Veins- sclerotherapy
A sclerosing irritating chemical solution is injected into the varicose vein to produce localized inflammation, which will, close the lumen of the vessel over time. For larger vessels, an incision and drainage of trapped blood in a sclerosed vein may need to be performed 2-3 weeks after the injection. Pressure dressing are applied for about a week after each procedure to keep the vessel free of blood

Therapeutic Procedures




Client Education

Instruct the client to wear elastic stocking for prescribed time


Mild analgesics like acetaminophen (Tylenol) can be taken for discomfort

Therapeutic Procedures




Varicose Veins-vein stripping

The removal of large varicose veins that cannot be treated with less-invasive procedures


Surgical Interventions



Nursing Actions
Preoperatively:

Assist the provider with vein marking

Evaluate the client’s pulse as baseline for postoperative comparison


Surgical Interventions


Postoperatively:

Maintain elastic bandage on the legs
Monitor groin and legs for bleeding
Monitor extremity for edema, warmth, color, and pulses
Elevate legs above the heart
Engage in range of motion exercise of the legs
Elevate legs when sitting, and avoid dangling them over the side of the bed

Surgical Interventions



Varicose Veins

Emphasize the importance of wearing elastic stocking after bandage removal

Client Education



Varicose veins-endovenous laser treatment
This treatment uses a laser fiber that is inserted into the vessel proximal to the area to be treated and then threaded to the involved area where heat from the laser is used to close the dilated vein

Therapeutic Procedures

Complication

Ulcer Formation
Venous stasis ulcers often form over the medial malleolus. Venous ulcers are chronic, hard to heal and often recur. They can lead to amputation and/ or death

Clients who have neuropathy may not feel as much discomfort from the ulcers as its appearance may warrant


Therapeutic Procedures



Help to improve circulation (wound vacuum, hyperbaric chamber)
Assess and treat pain as prescribed

Apply oxygen-permeable polyethylene films to superficial ulcers
Apply occlusive, hydrocolloid dressing on deeper ulcers to promote granulation tissue and reepithelialization

Nursing Actions


Leave dressing on for 3-5 days

If a wound needs chemical debridement, apply topical enzymatic agents to debride the ulcer, eliminate necrotic tissue, and promote healing

Administer systemic antibiotics as prescribed

Nursing Actions



Recommend a diet high in zinc, protein, iron, and vitamins A and C

Instruct client on use of compression stockings

Client Education



A pulmonary embolism (PE) occurs when a thrombus is dislodged, and becomes an embolus, and lodges in a pulmonary vessel.

This can lead to obstruction of pulmonary blood flow, decreased systemic oxygenation, pulmonary tissue hypoxia, and possible death

Pulmonary Embolism



Manifestations include sudden onset dyspnea, pleuritic chest pain, restlessness and apprehension, feeling of impending doom, cough and hemoptysis

Finding include tachypnea, crackles, pleural friction rub, tachycardia, S3 or S4 heart sounds, diaphoresis, low grade fever, petechiae over chest wall and axillae, and decreased arterial oxygen saturation

Nursing Actions



Notify the provider immediately, reassure the client, and assist to a position of comfort with the head of the bed elevated


Prepare for oxygen therapy and blood gas analysis while continuing to monitor and assess the client for other manifestations

Nursing Actions

RAYNAUD DISEASE
Raynaud's is a arterial disease that has nothing to do with atherosclerosis
Affects hands and feet of women between 16-40 years old
Can lead to ulcers and gangrene of fingertips
vasospasm reduces blood flow to the finger and toes, causing decrease tissue prefusion
Pathophysiology of Raynaud's
White-Blue-Red
Pallor of hands or feet due to sudden vasoconstrivtion
Cyanosis- Bluishness due to pooling of de-oxygenated blood during vasospram
After vasospam stop, reflow of blood creates red color

Treatment of Raynaud's
Stop smoking
Avoid extreme cold
Dress warmly in cold weather
Avoid air-conditioning

BURGER'S DISEASE
Burger'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
Exacerbation and remissions
Physical Signs
Intense rubor-reddish, bluish discoloration of feet
No pedal pulse but normal femoral and popliteal pulse
If toes become gangrenous, amputate
Management
STOP SMOKING!!!!!!!!

ASSESSMENT OF PAD


Objective Data

Venous Insufficiency
Stasis dermatitis is a brown discoloration along the ankle that extends up the calf relative to the level of insufficiency
Edema
Stasis ulcers (typically found around the ankle)
Therapeutic Procedures

Varicose Veins-application of radio frequency energy

This treatment use a small catheter with a radio frequency electrode, instead of a laser, that is inserted into the vessel proximal to the area to be treated that scars and closed a dilated vein
Medications
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