(Relates to Chapter 38, “Nursing Management: Vascular Disorders,” in the textbook)

2 Ulcer Located Near Ankle

3 What Kind of Peripheral Vascular Disease Ulcer is This?

4 This person also had toe amputations What Type of Ulcers Real Photo

5 Diabetic Foot Ulcer Locations

6 Examples of Diabetic Foot Ulcers

7  To function properly, veins must be patent (open) with competent valves  Vein function also requires the assistance of the surrounding muscle beds to help pump blood toward the heart  If one or more veins are not operating properly, they become distended and clinical manifestations occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

8 Three Health Problems Alter Blood Flow in Veins: 1. Thrombus formation (venous thrombosis) can lead to pulmonary embolism (PE), a life-threatening complication. Venous Thromboembolism is the current term that includes both DVT and PE 2. Defective valves lead to venous insufficiency and Varicose Veins which are not life threatening 3. Skeletal muscles do not contract to help pump blood in the veins. This problem can occur when weight-bearing is limited or muscle tone decreases- problems are occur with prolonged sitting and standing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

9 Venous Insufficiency  occurs as a result of prolonged venous hypertension that stretches the veins and damages the valves.  valvular damage can cause backup of blood and further venous hypertension  results in edema and decreased tissue perfusion.  Stoppage is called venous stasis & results in venous stasis ulcers, swelling, and cellulitis.

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11  The focus of treating venous insufficiency is to decrease edema and promote venous return from the affected leg.  What type of stockings might be used?  Treatment of chronic venous insufficiency is nonsurgical unless it is complicated by a venous stasis ulcer that requires surgical débridement. The desired outcomes of managing venous stasis ulcers are to heal the ulcer, prevent infection, and prevent stasis with recurrence of ulcer formation. Collaborate with the wound care nurse or wound, ostomy, and continence nurse to make recommendations for ulcer care  Nursing: Teach the patient to elevate his or her legs for at least 20 minutes four or five times per day. When the patient is in bed, remind him or her to elevate the legs above the level of the heart

12  Dos and Don'ts For Venous Insufficiency  Elevate your legs for at least 20 minutes four or five times a day. When in bed, elevate your legs above the level of your heart.  Avoid prolonged sitting or standing  Do not cross your legs. Crossing at the ankles is acceptable for short periods  Do not wear tight, restrictive pants. Avoid girdles and garters.

13  Varicose Veins: distended, protruding veins that appear darkened and tortuous  Common in adults older than 30 years whose lives require prolonged standing.  Varicose veins are frequently seen also in patients with systemic problems (e.g., heart disease)  Management: compression stockings & elevating the extremities as much as possible  Patients who have pain or unsightly veins may opt for either sclerotherapy or surgical removal of the vein  Phlebitis is an inflammation of the superficial veins caused by an irritant such as peripheral IV therapy  Patient has a reddened, warm area radiating up the arm. Pain, soreness, and swelling may also occur. Management involves application of warm, moist soaks, which dilate the vein and promote circulation

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15  Peripheral Arterial Disease (PAD)

16 FEATUREARTERIAL ULCERSVENOUS ULCERSDIABETIC ULCERS History Patient reports claudication after walking about 1-2 blocks Rest pain usually present Pain at ulcer site Two or three risk factors present Chronic non-healing ulcer No claudication or rest pain Moderate ulcer discomfort Patient reports of ankle or leg swelling Diabetes Peripheral neuropathy No reports of claudication Ulcer location and appearance End of the toes Between the toes Deep Ulcer bed pale, with even edges Little granulation tissue Ankle area Brown pigmentation Ulcer bed pink Usually superficial, with uneven edges Granulation tissue present Plantar area of foot Metatarsal heads Pressure points on feet Deep Pale, with even edges Little granulation tissue

17 Other assessment findings ARTERIAL Cool or cold foot Decreased or absent pulses Atrophy of skin Hair loss Pallor with elevation Dependent rubor Possible gangrene When acute, neurologic deficits noted VENOUS Ankle discoloration and edema Full veins when leg slightly dependent No neurologic deficit Pulses present May have scarring from previous ulcers DIABETIC Pulses usually present Cool or warm foot Painless Treatment Treat underlying cause (surgical, revascularization) Prevent trauma and infection Patient education, stressing foot care Long-term wound care (Unna boot, damp-to-dry dressings) Elevate extremity Patient education Prevent infection Rule out major arterial disease Control diabetes Patient education regarding foot care Prevent infection

18  Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities  Atherosclerosis is the leading cause in majority of cases.

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20  Typically appears at ages 60s to 80s  Largely undiagnosed  Risk factors Cigarette smoking Hyperlipidemia Hypertension Diabetes mellitus

21  Peripheral artery disease (PAD) may affect Aortoiliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery

22  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

23  Paresthesia Numbness or tingling in the toes or feet Produces loss of pressure and deep pain sensations Injuries often go unnoticed by patient

24  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

25  Pain at rest Occurs in the forefoot or toes Aggravated by limb elevation-Critical Thinking-Why? Occurs from insufficient blood flow Occurs more often at night

26  Atrophy of the skin and underlying muscles  Delayed healing  Wound infection  Tissue necrosis  Arterial ulcers

27  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

28  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.

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

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

31  Although chronic peripheral arterial disease (PAD) progresses slowly, the onset of acute arterial occlusions may be sudden and dramatic  An embolus (piece of clot that travels and lodges in a new area) is the most common cause of peripheral occlusions, although a local thrombus may be the cause  Occlusion may affect the upper extremities, but it is more common in the lower extremities. Emboli originating from the heart are the most common cause of acute arterial occlusions  Most patients with an embolic occlusion have had an acute myocardial infarction (MI) and/or atrial fibrillation within the previous weeks.

32  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.

33  Antiplatelet agents Aspirin Clopidogrel (Plavix) What is nursing assessment of patient taking any anticlotting medications?

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

35  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.

36  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.

37  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

38  Revascularization via surgery  Protect from trauma  Reduce vasospasm  Prevent/control infection  Maximize arterial perfusion  Other strategies Hyperbaric oxygen therapy Angiogenesis

39  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.

40  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.

41  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.

42  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.

43 Fig 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.

44  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.

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

46  Past health history Diabetes mellitus Smoking Hypertension Hyperlipidemia Obesity

47  Exercise intolerance? Claudication?  Loss of hair on legs and feet?  Skin integrity? Ulcers?  Decreased or absent peripheral pulses?  Cool skin temperature/cyanosis?  Rubor when legs dependent position?  Paor llwhen legs elevated?

48  Ineffective tissue perfusion (peripheral)  Impaired skin integrity  Activity intolerance  Ineffective self-health management

49  Overall goals for patient with PAD Adequate tissue perfusion Relief of pain Increased exercise tolerance Intact, healthy skin on extremities

50  Health promotion Identification of at-risk patients Diet modification Proper care of feet Avoidance of injuries

51  Acute intervention Frequently monitor after surgery.  Skin color and temperature  Capillary refill  Presence of peripheral pulses distal to the operative site- critical thinking-why?  Sensation and movement of extremity

52  Acute intervention Continued circulatory assessment Monitor for potential complications. Knee-flexed positions should be avoided except for exercise. Turn and position frequently.

53  Ambulatory and home care Management of risk factors Importance of meticulous foot care Importance of gradual physical activity after surgery

54  Ambulatory and home care Daily inspection of the feet Comfortable shoes with rounded toes and soft insoles Shoes lightly laced

55  Identify activities that promote circulation.  Maintain adequate peripheral tissue perfusion.  Experience intact skin, free of infection, on lower extremities.

56  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

57 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

58 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.

59  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.

60  He feet have increased pain when elevated  Angiography reveals nearly obstructed vessels in lower extremities.  He is diagnosed with peripheral artery disease.

61 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?