Peripheral Vascular Diseases

1
Peripheral Vascular Diseases

• Arterial Manifestations
• Diminished or absent pulses
• Smooth, shiny, dry skin, no hair
• No edema
• Round, regularly shaped painful ulcers on distal
  foot, toes or webs of toes
• Dependent rubor
• Pallor and pain when legs elevated
• Intermittent claudication
• Brittle, thick nails

• Venous Manifestations
• Normal pulses
• Brown patches of discoloration on lower legs
• Dependent edema
• Irregularly shaped, usually painless ulcers on
  lower legs and ankles
• Dependent cyanosis and pain
• Pain relief when legs elevated
• No intermittent claudication
• Normal nails

2
Peripheral Arterial Occlusive Disease (830)

• Pathophysiology Narrowing and sclerosis of
  large arteries (femoral, iliac, popliteal)
  especially at bifurcations due to plaque
  formation
• Risk factors smoking, obesity, sedentary
  lifestyle, HTN, DM, hyperlipidemia, Fa hx
• S/S see previous slide. May also have bruit
  over femoral or popliteal doppler area
• Dx Tests US, exercise testing (822), pulse
  volumes, angiography (823), Trendelenberg test
  (see Assessment text)

3
Treatment of PAOD

• Meds-antiplatelets, antilipidemics, vasodilators,
  Trental (misc.)
• Good skin and foot care-podiatrist for probs
• Avoid standing for long periods, crossing legs,
  tobacco
• Low fat diet, lose weight
• Exercise to point of pain Buerger-Allen
  exercises
• Surgery-fem-pop bypass, endardarectomy, amputation

4
Nursing Management of PAOD

• Administer and monitor meds
• Patient education
• Meds
• Good skin and foot care
• Avoiding pressure, tobacco
• Diet and exercise
• S/S of acute occlusion
• Pre and postop care if indicated

5
Nursing Management of Pt. with Fem-Pop Bypass
(832-3)

• Preop Goal Prevent trauma and maintain
  circulation
• Keep leg level or slightly dependent
• Protect leg from trauma
• Administer anticoagulants
• Assess and monitor VS and NV status
• Assess and monitor anxiety
• Education on above and on what to expect after
  surgery

6
Nursing Management of Fem-pop Bypass contd

• Postop Goal Maintain adequate circulation
  through graft (saphenous, umbilical, Gore-Tex)
• ICU at first
• Assess VS, pulse ox, IO, PT, PTT, lytes, BUN,
  creat
• Monitor NV status (6 Ps) q1h x 8, then q2h x 24
  using doppler. Compare to other extremity.
• Assess ankle-brachial index (ABI) q8h x 24
• Administer anticoags, analgesics
• TEDs for some surgeons, no leg crossing, or
  prolonged extremity dependency
• Pt education on meds, activity, how to recognize
  vascular complications

7
Nursing Management contd

• Notify surgeon immediately for
• Absence of pulse
• Abnormal ABI
• Abnormal VS
• Hemorrhage
• Severe edema with pain and ltsensation (may
  indicate compartment syndrome)

8
Acute Arterial Occlusive Disease (arterial
embolism-840)

• Pathophysiology blood clots from arteries, left
  ventricle, or trauma suddenly break loose and
  become free flowing, lodge in bifurcations,
  causing obstruction distally with acute and
  sudden symptoms
• Assessment 6 Ps (pain, pallor, pulselessness,
  paresthesia, paralysis, poikilothermia), ABIlt1,
  US, MRI, or angiography

9
Management of Arterial Embolism

• Medical
• Anticoagulants-heparin bolus then 1000U/hr
• Thrombolytics
• Surgical (depends on occlusion time)
• Embolectomy (840)
• Bypass
• Angioplasty with stent placement
• Nursing
• Administer and monitor anticoag or thrombolytic
  tx
• If surgery, then monitor for postop angioplasty
  and stent placement, bypass, or embolectomy
  (similar to bypass except no ICU and hospital
  time is less).

10
Buergers Disease (thromboangiitis obliterans-834)

• Pathophysiology obstructive and inflammatory
  disease of small and medium sized arteries and
  veins. Believed to be autoimmune. Has
  exacerbations and remissions. Smoking is very
  high risk factor.
• Assessment pain and instep claudication,
  intense rubor, absence of distal pulses (pedal,
  radial, ulnar), paresthesias segmental limb
  blood pressures, US, angiography

11
Management of Buergers Disease

• Medical/Surgical
• Pain meds
• Stop smoking
• Treatment of infection and gangrene
• Sympathectomy (removal of sympathetic ganglia or
  branches-causes permanent vasodilation
• Amputation
• Nursing
• Support stopping smoking
• Administer pain meds
• Education regarding protection extremities from
  cold and trauma.

12
Raynauds Disease (841)

• Pathophysiology arterial spasms of small
  cutaneous vessels of fingers and toes. May have
  too many alpha 2 receptors leading to
  vasoconstriction and not enough beta receptors.
  Aggravated by cold and stress.
• Assessment classic tri-color symptoms-pallor,
  cyanosis, rubor, pain, and paresthesia.
  Bilateral and symmetric.

13
Management of Raynauds Disease

• Medical/Surgical
• Avoiding cold, stress, nicotine
• Ca channel blockers (particularly nifedipine)
  especially for acute vasospasm
• sympathectomy
• Nursing
• Avoid stress, take stress mgmt classes
• Avoid cold and trauma
• Teach about nifedipine (can cause orthostatic
  hypotension)

14
Hypertension (855)

• Definitions and Etiology
• SBP gt 140 and DBP gt 90 at least 3 times.
• Affects 20-25 of population. 90-95 have
  primary or essential HTN (unknown etiology).
  Other 5-10 have secondary, meaning there is a
  disease process causing it (i.e., thyrotoxicosis,
  renal artery stenosis, pheochromocytoma).
  Hypertensive crisis-DBP gt 120. Malignant
  HTN-rises rapidly. White coat HTN-increased BP
  when patient goes to MD.
• Risk factors are similar to CAD
• Classifications p. 855, Table 32-1

15
Assessment of HTN

• S/S
• Usually absent unless severe or advanced
• If symptoms they include HA, blurred vision,
  dizziness, nosebleeds
• BP gt 140/90
• S4 gallop rhythm

• Dx Tests
• BP readings
• CBC, UA, lytes, lipids, glucose, renal and liver
  functions
• ECG
• CXR
• Echo

16
Management of HTN

• Monitoring of BP recommendations for F/U on p.
  856, Table 32-2.
• Algorithim p. 859. Lifestyle changes and meds.
• Lifestyle changes include wt reduction, heart
  healthy diet, no nicotine, regular exercise.
• Meds 50-1 90-2. Stepped approach with
• Diuretics
• Beta and alpha blockers
• Vasodilators
• ACEIs and Angiotensin receptor blockers
• Ca channel blockers

17
Management of HTN contd

• Treat complications
• Angina, MI
• CHF-from LV hypertrophy
• CRF
• CVA
• Retinal hemorrhages

18
Nursing Management of HTN

• History assess for all risk factors
• Physical assessment heart sounds, pulses, VS,
  lungs, carotid bruit, retina, thyroid, abd, neuro
• Pt education lifestyle modifications, monitor
  BP and daily wts and keep a record, keep appts,
  safety r/t hot showers and environments,
  orthostatic BPs, first dose syncope, meds, dont
  stop meds suddenly, OTC meds, keep list of meds,
  interacting meds-BCPs, steroids, NSAIDs, some
  antidepressants, antihistamines, nasal
  decongestants