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Peripheral Vascular Disease

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Stage II-Claudication. Pain or burning with exercise but relieved with rest ... Intermittent claudication- pain with ambulation that stops with rest ... – PowerPoint PPT presentation

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Title: Peripheral Vascular Disease


1
Peripheral Vascular Disease
2
  • 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

3
  • 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?

4
  • 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?

5
www.memorialcare.com
6
www.azheart.com
7
www.rjmatthewsmd.com Peripheral
Vascular Disease
8
  • Atherosclerosis- occurs from vascular damage,
    involved in coronary and cerebral vascular
    disease
  • Stable plaque
  • Unstable plaque

9
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

10
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

11
  • Obstructions-
  • Inflow located above the inguinal ligament, may
    not cause significant damage
  • Outflow- below superficial femoral artery,
    typically cause significant damage

12
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

13
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

14
  • 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

15
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

16
Diagnostic Exams
  • Systolic blood pressure readings
  • Exercise tolerance testing
  • Plethysmography

17
Treatment
  • Non-surgical-
  • Exercise
  • Patient positioning
  • Medication
  • Angioplasty
  • Arthrectomy
  • Surgical-
  • Bypass (inflow and outflow)

18
www.unipv.it Arthrectomy
19
http//health.yahoo.com
20
  • Aortoiliac and aortofemoral bypass
  • Axillofemoral bypass

21
Preoperative Care
  • Prepare for general anesthesia
  • Document vital signs and mark pulses
  • Prepare patient with IV, Foley catheter and
    education

22
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

23
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

24
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

25
  • Treatment- thrombectomy
  • Must observe extremity for improvement of
    condition also for complications

26
www.merck.com Aneurysms
27
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.

28
  • Imaging-
  • Abdominal US for screening and monitoring
    progression.
  • Abdominal CT scan to specifically measure size
    and its relationship with the renal arteries.

29
  • 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.

30
  • 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.

31
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.

32
  • 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

33
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.

34
  • Femoral-
  • Pulsatile groin masses.
  • Same problems as popliteal.

35
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

36
  • 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

37
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

38
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

39
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

40
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.

41
  • 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.

42
www.latrobe.edu.au
43
www.australianprescriber.com
44
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

45
www.cardiology.utmb.edu VIRCHOWS TRIAD
46
  • 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.

47
  • 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.

48
  • 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

49
  • 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)

50
www.hksmas.org DVT Filter
51
www.chhs.niu.edu
Sequential Compression Device
52
http//faculty.valencia.cc.fl.us
53
www.vascularprn.com Plexi
Pulse Boots
54
(No Transcript)
55
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

56
  • Treatment-
  • Decrease edema and promote venous return
  • Primarily non-surgical
  • Compression stockings
  • Elevate legs ABOVE heart
  • Unna boot
  • Topical medication

57
  • Surgical-
  • Not usually done
  • Surgical debridement

58
Home Care
  • Avoid standing still
  • Elevate legs while sitting
  • Avoid crossing legs
  • Avoid constricting garments
  • Compression stockings

59
www.vascular.co.nz Arterial
Ulcer
60
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

61
  • Treatment-
  • Treat underlying cause
  • Teach patient to prevent trauma and infection
  • Good foot care

62
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

63
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)

64
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

65
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)

66
Plavix
  • Antiplatelet
  • Irreversible on platelets
  • Contraindications- intracranial hemorrhage,
    active bleeding
  • Education- discontinue one week before having
    surgery
  • Monitor- signs of bleeding, platelet count

67
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

68
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

69
Vit K
  • Antidote for overdose of Coumadin
  • Contraindication- severe liver disease
  • Monitor- patient, PT/INR, Bleeding
  • IV route for emergencies only

70
Protamine sulfate
  • Antidote for heparin overdose
  • Used after stopping heparin
  • Contraindication- hypersensitivity to fish
  • Monitor- patient and vital signs

71
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

72
Chronic Pain
  • Chronic physical and/or psychological disability
  • Pain management
  • Comfort strategies
  • Complimentary therapies
  • Collaboration with healthcare team

73
Acute Pain
  • Physical injury, thrombus
  • Physical assessment
  • Medication
  • Intervention to treat cause

74
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

75
Risk for Injury
  • Chemical, physical
  • Assess environment
  • Monitor closely
  • Review lab data periodically
  • Re-evaluate environment and physical assessment
    frequently

76
Other diagnoses to consider
  • Activity intolerance (unable to complete ADLs)
  • Depression (not able to do same activities)
  • Decision making (surgery, amputation, lengthy
    treatment plan)
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