1. By:Ariel Fisher RNS & Janel Canty RNS (Osborn, 2010)

2. Objectives Distinguish causes, incidence, and risk factors Determine signs and symptoms Learn treatment and methods Learn prevention methods

3. What is Peripheral Arterial Disease? Multiple vascular disorders that interfere with the function of all arteries, except coronary arteries Narrowed arteries that decrease the blood flow to extremities A condition that can cause partial or complete obstruction of blood flow to or from the arteries outside the chest (Ali & Carmon, 2012) (Nursing Central, 2012)

4. Pathophysiology of PAD (Osborn, 2010)

5. Most common Causes Smoking Diabetes Hypertension Hyperlipidemia (Osborn, 2010)

6. Signs/Symptoms of PAD Intermittent claudication ◦ Muscle ischemia during exercise, results in pain that resolves with rest. ◦ Femoral or Popliteal results in calf pain. ◦ Iliac Artery pain in buttocks and thighs. ◦ Will progress to rest pain with severe disease. Neuropathy ◦ Especially in diabetics. ◦ Nerve damage results in numbness, tingling and or shooting burning pain. Diminished pulses ◦ Dorsalis pedis and popliteal pulses may be diminished or absent Tropic changes ◦ Skin thin pale shiny. No hair growth Arterial ulcers ◦ Minor trauma may lead to difficult to heal ulcers. Gangrene ◦ Tissue ischemia and necrosis may lead to amputations (Osborn, 2010)

7. Nursing assessment Failure of injuries to heal Necrotic skin patches Pressure sores Extremities are cold, numb, and pale Peripheral pulses are weak or absent (Osborn, 2010)

8. Prevalence 3-10% in all ages Increases to 15-20% in patients over 70 years old 1 in 5 patients who are at least 65 years old have symptomatic or asymptomatic peripheral artery disease (Simmons, Steffen, and Sanders, 2012)

9. Diagnostic test Arterial Duplex ◦ Non invasive ultrasound that determines that degree of arterial blood flow and can determine the location of blockages Ankle-brachial index (ABI) ◦ Ratio of the ankle blood pressure to the highest brachial blood pressure  Normal is 0.9 to 1.3  Mild to moderate is 0.4-0.9  Severe is less than 0.4 (Osborn, 2010)

10. Diagnostic test cont. Angiography ◦ This is an invasive study, dye is injected and x- rays are taken ◦ This will determine the definite degree of disease and the location of the stenosis ◦ This is done if surgery is planned CT ◦ This looks at the carotid arteries for stenosis (Osborn, 2010)

11. What population is at risk? Males have a greater chance of having PAD then women ◦ 2:1 ratio Predominant age is greater then 40 years old (Nursing central, 2012)

12. Prognosis Patients who suffer from symptomatic PAD have a 5 year mortality rate of 30% Increased likelihood of a vascular event risk (Simmons, Steffen, & Sanders, 2012)

13. Medical Interventions Medication treatment ◦ Statins and antiplatelet  These inhibit platelet accumulation and promote vasodilation Angioplasty with a stent placement ◦ These patients after stent placement must be on an antiplatelet Bypass surgery Amputation ◦ This is done for when disease is severe (Osborn, 2010)

14. Nursing Interventions Education on risk factor modifications ◦ Smoking cessation ◦ Control of blood pressure ◦ Control of lipids ◦ Control of diabetes Education on exercise ◦ Teach to exercise to the point of pain then stop. This helps improve tissue oxygen utilization Education on checking feet daily, we need to protect the feet from injury! ◦ May refer to a podiatrist (Osborn, 2010)

15. Patient Scenario Mr. C is a 68 year old male who presented to the ED on 2/14/2013 for “pain in legs.” Mr. C stated the pain is an 8 out of 10. Mr. C smokes a pack a day and has type 2 diabetes and has not been taking his medication for the past couple of months. He states that pain started when he was walking around the grocery store, but then stopped when he rested.

16. Nursing Interventions for the scenario Educate Mr. C on the benefits of smoking cessation Educate Mr. C to be compliant with diabetic medication Educate Mr. C to exercise regularly

17. Medical interventions Mr. C had an Ankle brachial index (ABI) performed and results showed a.7, which reveals moderate PAD Mr. C was put on Plavix

18. Scenario Outcome Upon discharge Mr. C reported a pain level of 0 out 10. He confirmed his understanding of the importance to quit smoking and to be compliant with his Glyburide. He stated that he was going to look into joining a gym in order to get adequate exercise. Mr. C is going home with a prescription for Plavix and is going to get this filled soon after discharge.

19. Nursing Diagnosis Risk for altered tissue perfusion R/T compromised blood flow Pain R/T artery stenosis AEB pain when walking Risk for pedal ulcer R/T decrease healing abilities Risk for activity intolerance R/T circulatory dysfunction (Osborn, 2010)

20. NCLEX! The nurse evaluates the effectiveness of a regular exercise program for a client with peripheral arterial disease by asking the client about which of the following? A. Progressive decrease in peripheral pulses B. How quickly intermittent claudication occurs C. Extent of ruber-colored lower extremities D. Degree of bilateral edematous ankles (Osborn, 2010)

21. Answer! The nurse evaluates the effectiveness of a regular exercise program for a client with peripheral arterial disease by asking the client about which of the following? A. Progressive decrease in peripheral pulses B. How quickly intermittent claudication occurs C. Extent of ruber-colored lower extremities D. Degree of bilateral edematous ankles (Osborn, 2010) Rationale: Claudication limits activities. Gradual increases in duration and intensity of exercise promotes the development of collateral circulation, and improves exercise tolerance while decreasing episodes of claudication.

22. Nclex Because a client has acute arterial occlusion in the right leg, the nurse assesses for the following most relevant signs/symptoms? All that apply A. Numbness, tingling, and pain B. no pulse felt proximal to the blockage C. pale, cool skin D. swelling, tenderness, and erythema (Osborn, 2010)

23. Answer Because a client has acute arterial occlusion in the right leg, the nurse assesses for the following most relevant signs/symptoms? All that apply A. Numbness, tingling, and pain B. no pulse felt proximal to the blockage C. pale, cool skin D. swelling, tenderness, and erythema Rationale: Manifestations of acute arterial occlusion include pallor or mottling, cool or cold skin, and pulselessness distal to the blockage. Swelling, tenderness and erythema are associated with venous problems.

24. NCLEX A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further instructions if which statement was made by the client? a) I need to eat balanced diet b) a heating pad on my leg will help soothe the leg pain c) I need to take special care of my feet to prevent injury d) I should walk daily to increase the circulation to my legs (Osborn, 2010)

25. Answer! A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further instructions if which statement was made by the client? a) I need to eat balanced diet b) a heating pad on my leg will help soothe the leg pain c) I need to take special care of my feet to prevent injury d) I should walk daily to increase the circulation to my legs Rational ◦ The long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). The application of heat directly to the extremity is contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, the direct application of heat raises the oxygen and nutritional requirements of the tissue even further. (Osborn, 2010)

27. Work cited Osborn, W. W. (2010). Medical Surgical Nursing. New Jersey: Pearson. Jensen, S. (2011). Nursing Health Assessment. Philadeplphia: Lippincott Williams and Wilkins. Nusing Central. (2012,05). Nawaz Ali,,., & Carman, T. L. (2012). Medical Management for Chronic Atherosclerotic Peripheral Arterial Disease. Drugs, 72(16), 2074- 2085. doi:10.2165/11640810-000000000-00000 Simmons, A., Steffen, K., & Sanders, S. (2012). Medical therapy for peripheral arterial disease. Current Opinion In Cardiology, 27(6), 592-597. doi:10.1097/HCO.0b013e328357428a (Osborn, 2010)