1. Peripheral Arerial Diseases PAD

2. Key points PAD results from atherosclerosis in the arteries of the lower extremities and is characterized by inadequate flow of blood (mild, moderate, severe) PAD is classified as: ▫ inflow (distal aorta, iliac arteries) ▫ outflow (femoral, popliteal, and tibial artery) Tissue damage occurs below the arterial obstruction. Acute arterial occlusion ; Acute arterial occlusion ; is a sudden occlusion of an artery by an embolus/ thrombus (more common in lower extremities). Acute occlusion may cause severe ischemia (S&M loss).

3. Key points Examples of peripheral arterial diseases: ▫ Buerger’s disease ▫ Raynaud’s disease and ▫ Raynaud’s phenomenon. The most common cause of PAD is atherosclerosis.

4. Risk Factors Hypertension Hyperlipidemia Diabetes mellitus Cigarette smoking Obesity Familial predisposition Age Male gender In acute arterial occlusion, the origin of the embolus is most often from the heart (recent MI, atrial fibrillation). The history includes: sudden onset of severe pain, coldness, numbness, and pallor in an extremity with absent pulses distal to the obstruction.

5. Diagnostic Procedures and Nursing Interventions Arteriography of lower extremities (injection of contrast medium to visualize areas of decreased arterial flow on an x-ray). Exercise Tolerance Testing: Stress test or treadmill (pulse volumes & BP 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. Used to evaluate claudication without rest pain.

6. Diagnostic Procedures and Nursing Interventions Plethysmography: Used to determine the variations of blood passing through an artery, thus identifying abnormal arterial flow in the affected limb. Segmental Systolic Blood Pressure (BP) Measurements: The use of a Doppler probe to take various BP measurements (thigh, calf, ankle, brachial) for comparison. With arterial disease, the pressures in the thigh, calf, and ankle are lower than brachial pressures (normally higher).

7. Therapeutic Procedures and Nursing Interventions Percutaneous Transluminal Angioplasty (PTA): intra-arterial procedure using a balloon and stent to open and help maintain the patency of the vessel. Laser-Assisted Angioplasty: a laser probe is advanced through a cannula to the site of stenosis. The laser is used to vaporize atherosclerotic plaque and open the artery. Observe for bleeding at the puncture site postop, since anticoagulant therapy is used during the operative procedure, followed by antiplatelet therapy for 1 to 3 months following the procedure Atherectomy: a high-speed rotary metal burr to scrape plaque out of affected arteries and improve blood flow to ischemic limbs. Arterial revascularization surgery is used when the severity threatens the loss of a limb or for clients with severe pain at rest or claudication interfering with their ability to work. Bypass Grafts:

8. Assess/Monitor Peripheral pulses Fluid status Coagulation status Pain Exercise tolerance

9. NANDA Nursing Diagnoses Chronic pain Ineffective tissue perfusion (peripheral) Risk for injury Risk for peripheral neurovascular dysfunction

10. Nonsurgical Nursing Interventions Encourage exercise to build up collateral circulation – initiat gradually, increase slowly. Positioning: ▫Avoid crossing legs. ▫Refrain from wearing restrictive garments. ▫Elevate to reduce swelling but not above the level of the heart Promote vasodilation and avoid vasoconstriction. ▫Provide warm environment. ▫Wear insulated socks. ▫Never apply direct heat to the affected extremity as sensitivity is decreased and the client may inadvertently be burned. ▫Avoid exposure to cold (causes vasoconstriction and decreased arterial flow). ▫Stop smoking, and avoid stress, caffeine, and nicotine, which also cause vasoconstriction.

11. Nonsurgical Nursing Interventions Administer medications as prescribed. ▫Hemorheologic drugs, such as pentoxifylline (Trental), to increase the RBCs flexibility & to decrease blood viscosity, thus increasing blood flow in the extremities. ▫Antiplatelet agents, such as aspirin (acetylsalicylic acid) and clopidogrel (Plavix). ▫Antihypertensives to improve tissue perfusion by maintaining pressures that are adequate to perfuse the periphery but not constrict the vessels.

12. Postoperative Nursing Interventions Immediately postoperative, mark the site where the distal pulse is best palpated or heard by Doppler. Assess the extremity and compare to the contralateral extremity (every 15 min for the first hour, then hourly) for changes in color, temperature, pulse intensity, circulatory refill, and pain Warmth, redness, and edema of the affected limb are expected outcomes of surgery as a result of increased blood flow. Monitor for pain. Monitor blood pressure (Hypotension may indicate hypovolemia, which can increase the risk of clotting or graft collapse/ HTN causes bleeding from sutures). Limit ROM of the affected limb (bending of hip and knee is contraindicated) to decrease the risk of clot formation.

13. Complications and Nursing Implications Graft occlusion Compartment syndrome Acute arterial occlusion Ulcer formation

14. Peripheral Venous Disease PVD

15. Key points PVD is a disease of the veins that interferes with adequate flow of blood from the extremities. This includes both venous thromboembolism (VTE) and venous insufficiency. Three reasons alter blood flow in veins: ▫thrombus formation, ▫Defective valves, and ▫lack of skeletal muscle contractility. VTE is the blocking of a blood vessel by a thrombus that moved from a different place (including : DVT and PE). A thrombus (thrombosis) is a blood clot believed to result from an endothelial injury, venous stasis, or hypercoagulability (Virchow’s triad).

17. Key points Thrombus formation can lead to PE, a life- threatening complication Thrombophlebitis refers to a thrombus that is associated with inflammation. This can occur in any vein, but most frequently occurs in deep veins in lower extremities. DVT and thrombophlebitis present a greater risk of PE. PE is when a dislodged blood clot travels to the pulmonary artery. It is a life-threatening situation.

18. Key points Venous insufficiency occurs as a result of prolonged venous HTN, which stretches the veins and damages the valves. Defective valves lead to venous insufficiency and varicose veins, which are problematic but not life- threatening. Treatment for venous stasis focuses on decreasing edema and promoting venous return Varicose veins are enlarged, twisted superficial veins that may occur in any part of the body, but are most commonly observed in the lower extremities and in the esophagus.

19. Risk Factors Risk Factors of Venous Thromboembolism ▫Hip surgery, total knee replacement, open prostate surgery ▫Heart failure ▫Immobility ▫Pregnancy Risk Factors of Venous Insufficiency ▫Sitting or standing in one position for a long period of time ▫Obesity ▫Pregnancy ▫Thrombophlebitis

20. Risk Factors Risk Factors: Varicose Veins ▫Older than 30 with an occupation requiring prolonged standing ▫Pregnancy ▫Obesity ▫Systemic diseases (for example, heart disease) ▫Family history

21. Diagnostic Procedures and Nursing Interventions: DVT and Thrombophlebitis Venous duplex ultrasonography & Doppler flow studies, are noninvasive procedures that can confirm a DVT If the above tests are negative but a DVT is still suspected, a venogram may be needed for accurate diagnosis. MRI scan is noninvasive and useful for finding DVTs in inferior vena cava or pelvic veins. A D-dimer test; a negative D-dimer test can exclude a DVT without an ultrasound.

22. Diagnostic Procedures and Nursing Interventions: Varicose Veins The Trendelenburg test assists with a diagnosis of varicose veins. ▫Place the client in a supine position with legs elevated. ▫When the client sits up, the veins will fill from the proximal end if varicosities are present (veins normally fill from the distal end).

23. Therapeutic Procedures and Nursing Interventions: Varicose Veins Sclerotherapy; a solution is injected into the vein, followed by the application of a pressure dressing. An incision and drainage of the trapped blood in the sclerosed vein are preformed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hr.

24. Therapeutic Procedures and Nursing Interventions: Varicose Veins Vein Stripping; Varicose veins are removed if they are larger than 4 mm in diameter or if they are in clusters. Preoperatively ▫Evaluate pulses as baseline for comparison postoperatively. Postoperatively ▫Maintain elastic bandages on the client’s legs. ▫Monitor the groin and leg for bleeding through the elastic bandages. ▫Monitor the extremity for edema, warmth, color, and pulses. ▫Elevate the legs above the level of the heart. ▫Encourage ROM exercises of the legs. ▫Instruct the client to elevate the legs when sitting and avoid leg dangling or chair sitting. ▫Emphasize the importance of wearing elastic stockings after bandage removal.

25. Therapeutic Procedures and Nursing Interventions: Varicose Veins Application of Radiofrequency (RF) Energy: The vein is heated from the inside by the RF and shrinks. Collateral veins take over. Laser Treatment: Endovenous laser treatment uses a laser fiber to heat and close the main vessel that is contributing to the varicosity.

26. Assessment Deep Vein Thrombosis and ThrombophlebitisDeep Vein Thrombosis and Thrombophlebitis The client may be asymptomatic. Classic signs are calf or groin pain or tenderness and sudden onset of swelling of the leg. Pain in the calf on dorsiflexion of the foot (positive Homans’ sign) is NOT ADVISED for diagnosis because it only occurs in 10% of cases. May represent false positive. Examine the area, compare the site to the contralateral limb, gently palpate the site, and observe for induration along the blood vessel and for warmth and edema. Measure, record, and compare Rt and Lt calf and thigh circumferences for changes over time; observe for localized edema. Monitor for SOB and chest pain (????)

27. Assessment Venous Insufficiency ▫Stasis dermatitis or brown discoloration along the ankles and extending up to the calf ▫Edema ▫Ulcer formation Varicose Veins ▫Distended, protruding veins that appear darkened and tortuous ▫Pain in legs with dull aching after standing ▫A feeling of fullness in the legs ▫Ankle edema

28. NANDA Nursing Diagnoses Risk for ineffective tissue perfusion (peripheral) Acute pain Risk for injury

29. Nursing Interventions Deep Vein Thrombosis and Thrombophlebitis ▫Encourage REST.  Facilitate bed rest and elevation of the extremity above the level of the heart as ordered.  Administer intermittent or continuous warm moist compresses as ordered (to prevent thrombus from dislodging and becoming an embolus, do NOT massage the affected limb).  Provide thigh-high compression or antiembolism stockings as prescribed to reduce venous stasis.

30. Nursing Interventions Administer medications as prescribed. ▫Anticoagulants  Unfractionated heparin (UFH) IV based on body weight is given to prevent formation of other clots and to prevent enlargement of the existing clot, followed by oral anticoagulation with warfarin (Coumadin).  Monitor activated partial thromboplastin time (aPTT) to allow for adjustments of heparin dosage.  Monitor platelet counts for heparin-induced thrombocytopenia

31. Nursing Interventions Monitor for hazards and side effects associated with anticoagulant therapy. Low-molecular weight heparin (LMWH) is given subcutaneously. Enoxaparin (Lovenox), is approved for the prevention and treatment of DVT. The client must be willing to learn self injection or have family/friend/home care nurse administer the subcutaneous injections. Monitor the client for evidence of bleeding (blood in stools Warfarin works in the liver to inhibit synthesis of the four vitamin K-dependent clotting factors and takes 3 to 4 days before it can exert therapeutic anticoagulation. Heparin is continued until the warfarin therapeutic anticoagulation effect is achieved, then IV heparin may be discontinued. Monitor for bleeding. Ensure that vitamin K (the antidote for warfarin) is available in case of excessive bleeding.

32. Nursing Interventions Thrombolytic Therapy ▫ It must be initiated within 5 days after the onset of symptoms to be most effective. ▫The advantage is the prevention of valvular damage and consequential venous insufficiency, or “postphlebitis syndrome.” ▫It is contraindicated during pregnancy and following surgery, childbirth, trauma, a cerebrovascular accident, or spinal injury. ▫The primary complication of thrombolytic therapy is seriousmbleeding (for example, intracerebral bleeding). Closely monitor the client for bleeding. Analgesics: Administer as ordered to reduce pain.

33. Nursing Interventions Venous InsufficiencyVenous Insufficiency ▫Consult with a dietician and wound care specialist as needed. ▫Instruct the client:  To elevate legs for at least 20 min four to five times a day.  To elevate legs above the level of the heart.  To avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated.  To wear elastic or compression stockings during the day and evening as prescribed.  Put elastic stockings on before getting out of bed after sleep.  Clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down.  Replace worn out compression stockings as needed.

34. Nursing Interventions Varicose Veins Emphasize the importance of anti-embolism stockings as prescribed. Instruct the client to elevate legs as much as possible. Instruct the client to avoid constrictive clothing and pressure on the legs. Complications and Nursing Implications Ulcer Formation: Typically over malleolus, more often medially than laterally. Ulcers are chronic, hard to heal, and recurrence is common. They may lead to amputation and/or death. (Apply occlusive dressings, administer systemic antibiotics as prescribed).

35. Complications and Nursing Implications Pulmonary Embolism: Occurs when a thrombus is dislodged, becomes emboli, and lodges in the pulmonary vessels. Symptoms include sudden onset dyspnea, pleuritic chest pain, restlessness and apprehension, feelings of impending doom, cough and hemoptysis. Signs include, tachypnea, crackles, pleural friction rub, tachycardia, S3 or S4 heart sound, diaphoresis, low-grade fever, petechiae over chest and axillae, and decreased arterial oxygen saturation.