n325 peripheral vascular student version

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  • 1. ArterialVenousLymphatic

2. Arterial Occlusive Disease (PAD-peripheralarterial disease) Narrowing of arterial lumen Stenosis or occlusion May include intimal liningdamage Usually affects lower extremitiesand areas with bifurcations(when a blood vessel splits,common for plaque to build up.Common in iliac and femoralartery 90% of all PAD secondary toathrosclorosis Can cause CAD, stroke and carotidartery disease Poor public and physicianawareness of diseaseepidemiology!!!!!!!!!!!! (ACC/AHA, 2011) 3. Incidence 8 12 million Americansare affected Greater incidence in AA Compared to Non-hispanicwhites Worst outcomes indiabetic women b/c Common/preventable; poorly recognized Independent risk factor forCV morbidity/mortality PAD tends to be lessintensively managed 4. Pathophysiology: atheroschlerosis,vasospasm, inflammation 5. Etiology and Risk Factors of ArterialDisease Atherosclerosis Embolism Thrombosis Trauma Spasm Inflammation Obesity **Smokingdoubles riskof amputation; at least of all with PAD smoke!! **Diabetes Stress Hyperlipidemia,Tgl HTN **> 60 Age Sedentary lifestyle Chronic kidney disease Homocystine- high levels 6. Clinical Manifestations of PAD Pain with walkingclaudication*; or at rest ischemia (moresevere/advanced disease) can be in the calf, thigh, buttox, or foot Cramps/pain at night, relieved when hanging down Dependent rubor, blanched on elevation Cool extremity Weak or absent pulse Hypertrophic changes of nails Tissue atrophy, ulceration, gangrene Paresthesias Impotence in males Critical limb ischemia-pain at rest, non-Healing wounds, gangrene 7. What is the Patho? Ischemia---anaerobic----lactic acid----pain due todecreased blood supply Vasodilation Pain, increases blood flow distally when legs are hungdown Collateral circulation- body compensates in other waysto get blood to where it needs to go by makingalternative blood vessels 8. Arterial vs Venous AssessmentArterial VenousPulses Decreased/0 presentCap refill > 3 sec < 3 secABI- ankle brachialindex, looks atpulses and pressure< 0.75 > .90Edema 0 +Hair 0 Present or 0Ulcer Tips toes, heel, latankleMedial ankleSkin color Rubor, elevationpallorBrown varicoseveinsSkin texture Thin, shiny Thick, hardened 9. Arterial Ulcer 10. Compare PAD with Venous Ulcer 11. Name that disease! Namesigns/symptoms 12. Assessment FindingsIs IT PAD or VenousDisease? Pulses Capillary refill Edema Hair Skin Ankle/brachial index Doppler- ultrasound Duplex scan- involves botharterial and venous Arteriogram- invasiveprocedure that injects dye tolook for blockages 13. When would the nurse use thedoppler at the bedside? 14. What is the ABI? What is a normalmeasurement? Abnormal? 15. Doppler Ultrasound 16. Name Nursing Diagnoses,Outcomes,and Interventions for Patients withPAD 17. Nursing Diagnoses: Impaired Tissue PerfusionOutcome: Patient will have palpable pulses,pink/warm dry skin, cap refill < 3 secondsInterventions: Assess & monitor tissue perfusion- specify Prevent limb ischemia Avoid knee flex positions Reverse trendelenberg positioning- head up, feet dwn will increaseperfusion Balance activity with rest, bedrest if ulcers present Avoid constrictive clothing, crossing legs Prevent vasoconstriction Avoid tobacco, stress, cold- leads to vasoconstriction Provide protective clothing, relaxation exercises, administervasodilating drugs, eg. Pletal as ordered and assess response 18. Tissue Perfusion Continued:Pharmacologic therapy Antiplatelet agents Aspirin Ticlodipine (Ticlid) Clopidogrel (Plavix) Cilostazol (Pletal) also vasodilates Decrease blood viscosity Pentoxifylline (Trental) 19. Tissue Perfusion Continued Thrombolytic therapyWhat is the rationale for thesemedications? What are indications? What arepotential complications? Streptokinase, urokinase Tissue plasminogen activator (TPA)- clot buster drug Not used for old calcified blockages Side effect could be major bleeding 20. Medication Management-ClinicalReasoning Questions?What is the nurse monitoring when the patent is receivingthe following?Anticoagulant therapyHeparinEnoxaparin (Lovenox )Warfarin (Coumadin)Low-molecular weight heparinWhy might the patient be on Heparin and Coumadin atthe same time?What safety precautions and patient teaching must thenurse perform when caring for patients receiving thesemeds?? 21. Nursing Diagnosis: Impaired Tissue IntegrityOutcome: Patients skin will remain intact or the woundthat is present will not increase in size, redness, drainageand will demonstrate s/s of granulation tissue growthInterventions: Regular skin care (specify) and assess Prevent pressure-float heels Monitor tops of toes, medial malleolus Foot cradle Foot care Provide roomy protective footwear Prevent injuryWound care if skin breakdown present 22. What Do We Teach Our PatientsAbout Foot Care? 23. Nursing Diagnosis: Imbalanced NutritionOutcome: Patient will maintain weight of ____;albumin levels will remain at least 3mg/dlInterventions: Dietary consult for weight control and nutrition plan Lipid control no more than 30% daily calories fromfat and no more than 7% from saturated and trans-fats. Limit sodium (Na) to no more than 2,400 mg (2.4 g)per day 24. Diagnosis: Alteration in Comfort: PainOutcome: Pain will be < 4/10Interventions: Appropriate positioning Avoid standing for more than a few minutes Avoid leg crossing Assess for edema Antiplatelet and vasodilating drugs as ordered Chronic pain management- gabapentin- seizuremedication used for chronic pain along with lyrica andsometimes antidepressants 25. Nursing Diagnosis:Activity IntoleranceOutcome: Patient will be able to walk at least 10 feet without pain;rest pain will be < 4/10 (different for every patient depending ondisease severity)Interventions: Careful history to identify activities that are poorlytolerated PT, structured walking program Clients who should not exercise include thosewith: Ulcers Deep vein thrombosis Pain at rest Cellulitis Gangrene 26. Medical Management of PAD Slow progression of disease Promote arterial blood flow to relieve symptoms,savage limbs, and improve functional status Prevent a CV event: MI, stroke, vascular death(ACC/AHA, 2011) 27. To Summarize:Interventions forArterial diseaseWeight lossBMI 18.5-24.9 Structured gradual exercise-EB Smoking cessation Proper positioning Glucose control in diabetes Low fat, low cholesterol diet-LDL