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Med Surg Ch. 38 Vascular Disorders
Terms in this set (59)
What are some problems of the vascular system?
disorders of the arteries, veins, and lymphatic vessels. Arterial disorders are classified as atherosclerotic, aneurysmal, and nonatherosclerotic vascular diseases.
What is atherosclerotic vascular disease divided into?
Atherosclerotic vascular disease is divided into coronary, cerebral, peripheral, mesenteric, and renal artery disease.
What is PAD?
Peripheral artery disease (PAD) involves thickening of artery walls, which results in a progressive narrowing of the arteries of the upper and lower extremities.
What is the age risk for PAD? When do people have PAD symptoms?
The risk for PAD increases with age; it usually become symptomatic in the sixth to eighth decades of life. In persons with diabetes mellitus, PAD occurs much earlier.
What do pts that have PAD have a higher risk for?
have a significantly higher risk of mortality (in general), CVD mortality, and major coronary events
What is the leading cause of PAD?
atherosclerosis, a gradual thickening pf the intima (the innermost layer of the arterial wall) and media (middle layer of the arterial wall)
Why does the gradual thickening of the intima and media happen?
it results from deposits of cholesterol and lipids within the vessel walls and leads to progressive narrowing of the artery.
What plays a major role in arteriosclerosis?
inflammation and endothelial injury
What are significant risk factors for PAD?
tobacco use, diabetes, hyperlipidemia, elevated C-reactive protein, and uncontrolled hypertension, with the most important being tobacco use. Other risk factors include family history, hypertriglyceridemia, increasing age, hyperhomocysteinemia, hyperuricemia, obesity, sedentary lifestyle, and stress
Woman and men risks for PAD?
Woman with low lifetime recreational activity are at greater risk for PAD than similar men
What arteries do lower extremity PAD affect?
Lower extremity PAD may affect femoral, popliteal, tibial, or peroneal arteries, or any combination of these arteries.
What is a common site for PAD in non-diabetic pt.s?
The femoral popliteal area is the most common site in nondiabetic patients.
Where do diabetic patients tend to develop PAD?
in the arteries below the knee. In advanced PAD, multiple levels of occlusions are found.
What is a classic symptom of lower extremity PAD?
intermittent claudication, which is ischemic muscle pain that is caused by exercise, resolves within 10 minutes or less with rest, and is reproducible. The ischemic pain is a result of the buildup of lactic acid from anaerobic metabolism.
Why does paresthesia happen?
Paresthesia, or numbness or tingling, in the toes or feet may result from nerve tissue ischemia.
When does true peripheral neuropathy happen?
occurs more often in patients with diabetes and in those with long-standing ischemia.
What happens to pts skin, hair, color, and pulses on the lower extremities with PAD?
The skin becomes thin, shiny, and taut, and hair loss occurs on the lower legs. Pedal, popliteal, or femoral pulses are diminished or absent. Pallor (blanching of the foot) develops in response to leg elevation (elevation pallor). Conversely, reactive hyperemia (redness of the foot) develops when the limb is in a dependent position (dependent rubor)
When does rest pain more often occur?
at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart.
What patients have critical lim ischemia?
The patient with chronic rest pain, ulceration, or gangrene
Does PAD progress slow or fast?
Lower extremity PAD progresses slowly.
What does prolong ischemia lead to?
Prolonged ischemia leads to atrophy of the skin and underlying muscles.
what can minor trauma do?
Even minor trauma to the feet (e.g., stubbing one's toe, blister from shoes) can result in delayed healing, wound infection, and tissue necrosis, especially in the diabetic patient.
Where do arterial (ischemic) ulcers most often occur?
over bony prominences on the toes, feet, and lower legs. Nonhealing arterial ulcers and gangrene are the most serious complications. Amputation may be needed if adequate blood flow is not restored or if severe infection occurs.
What are indicators that an amputation is needed?
If PAD is present for an extended period, collateral circulation may prevent gangrene of the extremity. Uncontrolled pain and severe, spreading infection are indicators that an amputation is needed in individuals who are not candidates for revascularization.
What is the first treatment goal in treating PAD?
reduce CVD risk factors
What are some diagnostic studies for PAD?
doppler ultrasound studies, segmental BPs, ankle brachial index, Duplex imaging, angiography and magnetic resonance angiography
What are some collaborative therapy?
cardiovascular disease risk factor modification (tobacco cessation, physical exercise, achieve ideal bod weight, DASH, glucose control, BP control etc)
treatment of claudication symptoms (structured walking or excersize program, cilostazol), nutrition therapy, foot care, amputation
What is essential to reduce the risk of CVD events, PAD progression, and death?
What is essential for all patients with PAD?
agressive lipid management
What are statins?
(e.g., simvastatin [Zocor]) lower low-density lipoprotein (LDL) and triglyceride levels and reduce CVD morbidity and mortality risks
What is considered critical for reducing the risks of CVD events and death in PAD patients?
What should oral antiplatelet therapy include?
75 to 100 mg/day of aspirin for patients with asymptomatic PAD and 75 to 325 mg/day of aspirin for patients with symptomatic PAD. aspirin intolerant patients may take clopidogrel (Plavix)
What is not recommenced for the prevention of CVD events in PAD patients?
What are two drugs available to treat intermittent claudication?
cilostazol (Pletal) and pentoxifylline (Trental).
What is the most effective exercise for PAD patients?
What is a BMI goal gor PAD patients?
BMI less than 25
What is critical limb ischemia?
Critical limb ischemia is a condition characterized by chronic ischemic rest pain lasting more than 2 weeks, arterial leg ulcers, or gangrene of the leg as a result of PAD.
What is optimal therapy for critical limb ischemia?
Optimal therapy is revascularization via bypass surgery. If this is not feasible, percutaneous transluminal angioplasty (PTA) is recommended in patients with a life expectancy of 2 years or less. Patients with critical limb ischemia who are not candidates for surgery or PTA may be treated with prostanoids (e.g., iloprost [Ventavis]).
What does conservative management of critical limb ischemia include?
protecting the extremity from trauma, decreasing ischemic pain, preventing and controlling infection, and improving perfusion. Carefully inspect, cleanse, and lubricate both feet to prevent cracking of the skin and infection. Avoid soaking the patient's feet to prevent skin maceration (or breakdown). If ulceration is present, keep the affected foot clean and dry. Cover any ulcers with a dry, sterile dressing to maintain cleanliness. Deep ulcers can be treated with a variety of wound care products, but healing is unlikely without increased blood flow.
What should you instruct the pt to do to manage critical lim ischemia?
Encourage the patient to select soft, roomy, and protective footwear and avoid extremes of heat and cold. Keep the patient's heels free of pressure. You can do this by placing a pillow under the calves so that the heels are off the mattress. Commercially available devices can also provide heel protection. Administering opioid analgesics and placing the bed in the reverse Trendelenburg position may control pain and increase perfusion to the lower extremities.
What is a way to manage pain in critical limb ischemia patients?
Spinal cord stimulation may be helpful in managing pain
What are interventional radiology catheter-based procedures?
alternatives to open surgical approaches for treatment of lower extremity PAD. These procedures take place in a catheterization laboratory rather than in an operating room. Determining which intervention to use depends on blockage location and lesion type and severity.
What is the percutaneous transluminal angioplasty procedure?
uses a catheter that contains a cylindric balloon at the tip. The end of the catheter is moved to the narrowed (stenotic) area of the artery. The balloon is then inflated, compressing the atherosclerotic intimal lining.Stents, expandable metallic devices, are positioned within the artery immediately after the balloon angioplasty is done. The stent acts as a scaffold to keep the artery open.
What is atherectomy?
the removal of the obstructing plaque. A directional atherectomy device uses a high-speed cutting disk that cuts long strips of the atheroma. Laser atherectomy uses ultraviolet energy to break up the atheroma. Orbital or rotational atherectomy catheters have a diamond-coated tip that rotates at a high speed (similar to a dentist drill). These crush the calcium within the atheroma into particles smaller than a blood cell.
What is cryoplasty?
combines two procedures: PTA and cold therapy. A specialized balloon is filled with liquid nitrous oxide, which changes from liquid to gas as it enters the balloon. Expansion of the gas results in cooling to 14° F (−10° C). The cold limits restenosis by reducing smooth muscle cell activity. Preprocedure and postprocedure nursing care is the same as for a diagnostic angiography.
Surgical therapy for PAD?
Various surgical approaches can be used to improve blood flow beyond a blocked artery. The most common is peripheral artery bypass surgery with an autogenous (native) vein or synthetic graft to bypass, or carry blood around, the lesion. Synthetic grafts typically are used for long bypasses such as an axillary-femoral bypass. When a person's own vein is not available, human umbilical vein or a composite sequential bypass graft (native vein plus synthetic graft) is an alternative. PTA with stenting may also be used in combination with bypass surgery.
What are some other surgical options for PAD?
endarterectomy (opening the artery and removing the obstructing plaque) and patch graft angioplasty (opening the artery, removing plaque, and sewing a patch to the opening to widen the lumen).
Amputation and PAD?
Amputation may be required if tissue necrosis is extensive, gangrene or osteomyelitis develops, or all major arteries in the limb are blocked, precluding the possibility of successful surgery. Every effort is made to preserve as much of the limb as possible to improve the potential for rehabilitation.
What are some nursing diagnoses for a patient with PAD?
Ineffective peripheral tissue perfusion related to deficient knowledge of contributing factors
Activity intolerance related to imbalance between oxygen supply and demand
Ineffective self-health management related to lack of knowledge of disease and self-care measures
What are overall goals for the patient who has lower extremity PAD?
(1) adequate tissue perfusion; (2) relief of pain; (3) increased exercise tolerance; and (4) intact, healthy skin on the extremities.
After surgical or radiologic intervention what should you do when the patient is moved to a recovery area for observation?
Check the operative extremity every 15 minutes initially and then hourly for color, temperature, capillary refill, presence of peripheral pulses, and sensation and movement. Loss of palpable pulses or a change in the Doppler sound over a pulse requires immediate notification of the physician or radiologist and prompt intervention. Postoperative ABI measurements are not recommended as they place the patient at risk for graft thrombosis. Compare all assessment findings with the patient's baseline and with findings in the opposite limb.
pain management for patients with PAD?
Many PAD patients have a history of chronic ischemic rest pain and may have developed a tolerance to opioids. Thus aggressive pain management may be needed postoperatively.
What should you do after the patient leaves the recovery area?
continue to monitor perfusion to the extremities. Assess for potential complications such as bleeding, hematoma, thrombosis, embolization, and compartment syndrome. A dramatic increase in pain, loss of previously palpable pulses, extremity pallor or cyanosis, decreasing ABIs, numbness or tingling, or a cold extremity suggests blockage of the graft or stent. Report these findings to the physician immediately.
What position should you avoid?
Avoid placing the patient in a knee-flexed position except for exercise.
Turning the patient with PAD
Turn the patient and position frequently with pillows to support the incision.
What should you do on postop day 1?
On postoperative day 1, assist the patient out of bed several times daily. Discourage prolonged sitting with leg dependency, since it may cause pain and edema, increase the risk of venous thrombosis, and place stress on the suture lines.
What should you do if edema develops?
If edema develops, position the patient supine and elevate the leg above heart level. Occasionally, elastic compression stockings are used to help control leg edema. Walking even short distances is desirable. The use of a walker may be helpful, especially in frail, older patients.
How often does surgical site infection of lower extremity revascularization occur?
occurs in about 11% of cases.
What therapy is recommended for patients after surgery?
Long-term therapy with aspirin or clopidogrel is recommended
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