Peripheral Vascular Disease

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Peripheral Vascular Disease
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• Mr. DeLaRosa is a 79-year-old obese Hispanic man
  who has undergone left total hip arthroplasty
  (THA) secondary to osteoarthritis. He is in his
  fourth day of postoperative recovery.
•  
• Subjective Data
• ?         States pain in his left leg is a 4 to 5
  on a 1 to 10 scale
•  
• Objective Data
• Physical Examination
• ?         Alert and oriented to person, place,
  and time
• ?         Vital signs blood pressure 140/68,
  pulse 64, temperature 98.7? F, respirations 20
• ?         Oxygen saturation 93 on room air
• ?         Lungs clear all lobes
• ?         Bowel sounds are normoactive and
  present in all four quadrants
• ?         Apical pulse 64
• ?         Skin warm to touch bilateral lower
  extremities, slight erythema left lower extremity
• ?         No edema right lower extremity, 2 left
  lower extremity
• ?         Pedal pulses 3 right lower extremity,
  1 left lower extremity
• ?         Calf circumference right, 8 cm left,
  10 cm
• ?         Wound has staples, no signs or symptoms
  of infection
• Postoperative Status

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• Critical Thinking Questions
•   1.      What is the primary nursing
  concern? What data are used to make this
  determination?
•              2.      What is the priority nursing
  care?
•              3.      What are potential
  complications associated with DVT?
•          4.      What diagnostic studies can
  be done to  determine site, location, and
  extent of a DVT?

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• Case Study Progression
• Mr. DeLaRosa has been diagnosed with a DVT in the
  left lower extremity.
•              5.      What is a priority nursing
  diagnosis, etiology, and defining
  characteristics for this patient?
•              6.      What risk factors for
  development of a DVT does Mr. DeLaRosa have?
•              7.    What measures can be taken to
  prevent DVT in a susceptible patient?
•              8.    What is the usual treatment
  for a patient with DVT?

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www.memorialcare.com
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www.azheart.com
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www.rjmatthewsmd.com Peripheral
Vascular Disease
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• Atherosclerosis- occurs from vascular damage,
  involved in coronary and cerebral vascular
  disease
• Stable plaque
• Unstable plaque

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PAD Risk Factors (same as for atherosclerosis)

• Modifiable
• Cigarette smoking
• Obesity
• Diabetes Mellitus
• Physical Inactivity
• High Cholesterol
• High Blood Pressure

• Non- Modifiable
• Personal or family history
• Heart disease
• Hx of stroke
• Age
• Male

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PVD

• Disorders that interfere with natural flow of
  blood through peripheral circulation.
• Patients can have arterial and venous disease.
• Chronic condition
• Systemic manifestation of atherosclerosis

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• Obstructions-
• Inflow located above the inguinal ligament, may
  not cause significant damage
• Outflow- below superficial femoral artery,
  typically cause significant damage

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Patient Assessment

• Blood pressure checks in both arms
• Palpate pulses and compare with opposite side
• Capillary filling time
• Inspect extremities for edema, discoloration,
  loss of hair, temperature differences, ulcers
• Observe for intermittent claudication with
  ambulation

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Stages of PAD

• Stage I- Asymptomatic
• No claudication
• Pedal pulses affected
• Stage II-Claudication
• Pain or burning with exercise but relieved
  with rest
• Symptoms reproducible by exercise

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• Stage III- Resting Pain
• Awakens patient at night
• Numbness or burning quality
• Relieved with extremity in dependent position
• Stage IV- Necrosis/Gangrene
• Gangrenous odor
• Ulcers and necrotic tissue

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Assessment

• Intermittent claudication- pain with ambulation
  that stops with rest
• Inflow disease- discomfort in buttocks, lower
  back and thighs
• Outflow disease- burning or cramping in ankles,
  feet, toes and calves, resting pain

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Diagnostic Exams

• Systolic blood pressure readings
• Exercise tolerance testing
• Plethysmography

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Treatment

• Non-surgical-
• Exercise
• Patient positioning
• Medication
• Angioplasty
• Arthrectomy

• Surgical-
• Bypass (inflow and outflow)

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www.unipv.it Arthrectomy
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http//health.yahoo.com
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• Aortoiliac and aortofemoral bypass
• Axillofemoral bypass

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Preoperative Care

• Prepare for general anesthesia
• Document vital signs and mark pulses
• Prepare patient with IV, Foley catheter and
  education

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Post operative care

• Graft occlusion complication in first 24 hours.
• Observe extremity closely and very frequently
• Assess vital signs closely and frequently
• Determine quality of pain
• Incentive spirometer
• Notify surgeon IMMEDIATELY with any changes
• Assess for infection

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Patient Education

• Examine feet daily
• Report worsening symptoms to healthcare provider
• NEVER walk barefoot
• Well fitting shoes
• QUIT smoking
• Regular exercise
• Low fat, low cholesterol, high fiber diet

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Acute peripheral arterial occlusion

• Embolus is most common cause
• Affects both upper and lower extremities
• HX of recent MI or a-fib
• Severe pain even resting
• Temperature cool, mottled and no pulse
• six Ps of ischemia
• Immediate intervention needed to prevent loss of
  extremity

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• Treatment- thrombectomy
• Must observe extremity for improvement of
  condition also for complications

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www.merck.com Aneurysms
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Aneurysms - Abdominal Aortic

• Dilation of an artery
• Fusiform or saccular
• True or false
• Most originate below the renal artery and can
  extend into the common iliac artery.
• Asymptomatic- found on routine physical exam by
  pulsating area on abdomen.
• Symptomatic- abdominal or lower back pain. Low
  grade fever, elevated ESR, smokers.
• Ruptured- severe back, abdominal or flank pain,
  hypotension.

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• Imaging-
• Abdominal US for screening and monitoring
  progression.
• Abdominal CT scan to specifically measure size
  and its relationship with the renal arteries.

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• Treatment-
• For gt5cm surgical intervention with graft
  replacement.
• If symptomatic surgical treatment must be
  immediate irregardless of size
• Preoperatively- cardiac evaluation must be done.
• Cardiac interventions may need to be done before
  repair of aneurysm
• Stent grafts are treatment.
• Inserted through common femoral arteries. Less
  than 2 hours, minimal blood loss.
• May need more complicated repair depending on
  patient condition.

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• Complications-
• Myocardial infarction, bleeding, limb ischemia,
  bowel infarction, renal insufficiency, stroke.
• Graft infection and graft fistulas can occur.
• Endoleak
• Some patients will develop another aneurysm in
  another location.

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Aneurysm- Thoracic Aorta

• Vasculitis, syphilis, traumatic (automobile
  accidents), collagen vascular disease (Marfan's
  syndrome), smoking
• S/S depend on size and rate of growth.
• Substernal pain, dyspnea, neck or back pain.

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• Imaging-
• Must be differentiated from other diagnoses (lung
  neoplasm, mediastinal masses).
• CT scan and MRI very sensitive to assess.
• Treatment-
• Controlling HTN and Beta Blockers may slow
  growth.
• Surgery is for patients that have symptoms, gt5cm,
  or rapidly expanding size.
• Morbidity and Mortality higher than with AAA

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Popliteal and Femoral

• Popliteal make up approximately 85 of peripheral
  artery aneurysms.
• Symptoms due to arterial thrombosis, peripheral
  embolus, compression of adjacent structures.
• US used for diagnosis and measurement
• Surgery- gt2cm if asymptomatic and for all
  symptomatic regardless of size.

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• Femoral-
• Pulsatile groin masses.
• Same problems as popliteal.

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AAA resection

• General anesthesia
• Bowel preparation
• Assess and mark peripheral pulses
• If emergency will require large amounts of IV
  therapy
• Operative-
• Aneurysm removed and graft inserted

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• Post-operative-
• Critical care unit
• Assess for complications
• Assess for cardiac dysrhythmia
• Assess vital signs closely and frequently
• Assess for paralytic ileus
• Assess respiratory status

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Thoracic Aneurysm Repair

• Depends on type and location
• Cardiopulmonary bypass required
• Thoracotomy or median sternotomy incision
• Graft goes over the aneurysm
• Postoperatively-
• Same as AAA repair
• Also assess extremities for movement and sensation

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Endovascular Repair

• For high risk surgery patients
• Before aneurysm reaches diameter for elective
  surgery
• Inserted through femoral artery
• Decreased length of stay in hospital
• Still need monitoring for complications

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Patient Education

• Look for s/s of abdominal, back pain, shortness
  of breath, difficulty swallowing
• No lifting of heavy objects
• No driving for several weeks
• Wound site care

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Varicose Veins

• Dilated, tortuous superficial veins of the lower
  extremities
• Symptomatic or asymptomatic- Symptoms do not
  always correspond to the number and size of
  varicosities
• Female, family history, prolonged sitting or
  standing (NURSES)
• Dull aching feeling after long periods of
  standing
• Complications include ulceration, stasis
  dermatitis, superficial venous thrombosis and
  thrombophlebitis.

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• Treatment includes compression stockings worn all
  day and removed at night.
• Periodic elevation of legs and exercise are
  recommended.
• Surgery is for patients that have persistent,
  disabling pain, ulceration, superficial
  thrombophlebitis.
• Sclerotherapy can be used for small varicosities.
  More than one treatment may be needed.
• This is chronic disease and requires continued
  stockings, rest and exercise.

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www.latrobe.edu.au
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www.australianprescriber.com
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VTE - Venous Thromboembolism

• Thrombus- a blood clot in a blood vessel
• Embolism- a clot that travels and blocks a vessel
• DVT (deep vein thrombosis)- is serious because it
  can cause a pulmonary embolism
• DVT are most common in legs but can occur in the
  upper extremities also
• Thrombus formation is associated with Virchows
  Triad

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www.cardiology.utmb.edu VIRCHOWS TRIAD
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• Patients that have hip, knee or prostate surgery
  are at highest risk for DVT.
• Other patients that are vulnerable are pregnant
  women, heart failure, ulcerative colitis and
  immobile patients.
• People who sit for long periods of time or have
  altered mobility are at risk for DVT. Others are
  people with severe infections, SLE, OC users,
  trauma, cancer, IV (central or peripheral)
  therapy.

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• Patients who have had DVT are always at higher
  risk for another DVT.
• Precautions and interventions are essential to
  prevent DVT.
• Avoid OC, drink adequate amounts of fluid, leg
  exercises, ambulation to avoid long periods of
  sitting or standing.
• Post surgical interventions include TED hose, SCD
  or Plexi boots, ambulation and patient education.

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• S/S- may be symptomatic or asymptomatic.
• Calf pain, unilateral leg swelling, pain
  unrelieved by pain medication, tightness or dull
  ache in calf when walking, groin pain can be
  signs of DVT.
• Homans sign- pain in calf on dorsiflexion of
  foot. Not always accurate indicator of DVT.
• Venography, duplex ultrasound, doppler flow
  studies and plethysmography are used for
  diagnosis.
• D-Dimer test- blood test that is useful for
  diagnosis

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• Treatment- Primarily to prevent further
  complications from DVT.
• Non-surgical-
• Rest
• Medication (heparin, lovenox, coumadin, t-PA)
• Elevation of extremity
• Surgical-
• Thrombectomy, ligation or external clips, filter
  (to prevent PE)

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www.hksmas.org DVT Filter
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www.chhs.niu.edu
Sequential Compression Device
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http//faculty.valencia.cc.fl.us
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www.vascularprn.com Plexi
Pulse Boots
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(No Transcript)
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Venous leg ulcer

• Take long time to treat and heal
• Venous insufficiency
• Stasis dermatitis
• Stasis ulcer
• Over the malleolus (more medial than lateral)
• If not controlled they can lose extremity

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• Treatment-
• Decrease edema and promote venous return
• Primarily non-surgical
• Compression stockings
• Elevate legs ABOVE heart
• Unna boot
• Topical medication

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• Surgical-
• Not usually done
• Surgical debridement

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Home Care

• Avoid standing still
• Elevate legs while sitting
• Avoid crossing legs
• Avoid constricting garments
• Compression stockings

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www.vascular.co.nz Arterial
Ulcer
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Arterial Ulcers

• Claudication after walking short distance
• Pain at ulcer site
• Between or top of toes
• Cold feet
• Decreased or absent pulses
• Possible gangrene
• Atrophy of skin

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• Treatment-
• Treat underlying cause
• Teach patient to prevent trauma and infection
• Good foot care

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Aspirin

• Inhibits platelet aggregation---reduces ability
  of blood to clot
• Contraindications- allergy, GI bleed, bleeding
  disorder, children lt18 with viral infection
• Report- Signs of bleeding, petechiae, ecchymoses,
  bleeding gums, black or bloody stools

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Heparin

• Inhibits formation of new clots
• Does not dissolve existing clot but prevents its
  extension
• Contraindications- active bleeding, hemophilia,
  thrombocytopenia, suspected intracranial
  hemorrhage
• Monitor- H/H, platelets (prior and regular
  intervals), PTT
• PROTECT FROM INJURY
• Avoid IM injections
• Report- drop in BP, bleeding
• ANTIDOTE- protamine sulfate 1 sol (heparin
  antagonist)

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Lovenox (low molecular weight heparin)

• Anticoagulant
• Prevention of DVT
• TX of DVT, PE, ACS
• Contraindication- GI bleed, active bleeding,
  bleeding disorder, thrombocytopenia
• Monitor- H/H, platelets
• Report- Signs of bleeding, drop in platelet count

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Coumadin (warfarin sodium)

• Prevents new clots from forming
• Treatment of A-Fib
• Prophylactic if has prosthetic heart valve
• Contraindications- hemophilia, active bleeding,
  esophageal varices, severe hepatic disease
• Antidote- Holding one or more doses, Vit K, blood
  transfusion may be needed
• Monitor- PT, INR
• Report- Bleeding (nose, mouth, gums, urine,
  stool)
• Take at the same time each day
• Maintain consistency in diet with Vit K foods
  (broccoli, cabbage, lettuce, green tea, spinach,
  tomatoes)

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Plavix

• Antiplatelet
• Irreversible on platelets
• Contraindications- intracranial hemorrhage,
  active bleeding
• Education- discontinue one week before having
  surgery
• Monitor- signs of bleeding, platelet count

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TPA

• Thrombolytic
• For CVA patients within 3 hour time frame from
  onset of s/s
• Contraindications- active internal bleeding,
  recent surgery or trauma, bleeding disorder, use
  of oral anticoagulants, uncontrolled HTN
• Monitor- bleeding, neuro checks, cardiac rhythm
• Education- IM contraindicated, no invasive
  procedures, quiet and on bed rest during
  administration

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Trental (pentoxifylline)

• Decreases blood viscosity and improves blood
  flow---results in---reducing tissue hypoxia,
  decreased pain and paresthesias
• Contraindications- intracranial bleed
• Monitor- relief from pain and cramping, improved
  walking tolerance

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Vit K

• Antidote for overdose of Coumadin
• Contraindication- severe liver disease
• Monitor- patient, PT/INR, Bleeding
• IV route for emergencies only

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Protamine sulfate

• Antidote for heparin overdose
• Used after stopping heparin
• Contraindication- hypersensitivity to fish
• Monitor- patient and vital signs

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Reopro

• Inhibits platelet aggregation
• Contraindications- GI/GU bleeding recently, CVA
  in last 2 years, recent major operation or trauma
• Monitor- for bleeding, H/H, platelets, PT/INR
• Avoid ANY unnecessary procedures

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Chronic Pain

• Chronic physical and/or psychological disability
• Pain management
• Comfort strategies
• Complimentary therapies
• Collaboration with healthcare team

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Acute Pain

• Physical injury, thrombus
• Physical assessment
• Medication
• Intervention to treat cause

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Ineffective Tissue Perfusion Peripheral

• Delayed healing
• Interruption of flow, arterial
• Impaired transport of oxygen
• Comprehensive physical assessment
• Extremity in dependent position
• Medication to prevent clots
• Protect extremity from injury
• Proper foot care
• Early intervention

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Risk for Injury

• Chemical, physical
• Assess environment
• Monitor closely
• Review lab data periodically
• Re-evaluate environment and physical assessment
  frequently

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Other diagnoses to consider

• Activity intolerance (unable to complete ADLs)
• Depression (not able to do same activities)
• Decision making (surgery, amputation, lengthy
  treatment plan)