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Terms in this set (47)
what is PAD
Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities
what is the leading cause of PAD?
Atherosclerosis is the leading cause in majority of cases, a gradual thickening of the intima (the innermost layer of the arterial wall) and media (middle layer of the arterial wall). This results from the deposit of cholesterol and lipids within the vessel walls and leads to progressive narrowing of the artery. Although the exact cause(s) of atherosclerosis are unknown, inflammation and endothelial injury play a major role
when is PAD seen? What are the risk factors?
-Typically appears at ages 60s to 80s
Cigarette smoking: VC, reduces O2, increases viscosity
prevalence is highest in who?
PAD prevalence is higher in women, and non-Hispanic African Americans.
The classic symptom of lower extremity PAD is...
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. Once the patient stops exercising, the lactic acid is cleared and the pain subsides.
when does intermittent claudication stop? What is significant about it?
-Resolves within 10 minutes or less with rest
PAD of the iliac arteries produces
claudication in the buttocks and thighs
Calf claudication indicates
femoral or popliteal artery involvement.
what will the skin look like?
loss of hair, thin and shiny
what happens as the disease progresses? why does this happen?
rest pain develops...most often occurs in the foot or toes and is aggravated by limb elevation. Rest pain occurs when blood flow is insufficient to meet basic metabolic requirements of the distal tissues.
what time of day does rest pain most often occur? how do pts try to fix it?
Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve pain relief by dangling the leg over the side of the bed or sleeping in a chair. This allows gravity to maximize blood flow.
Prolonged ischemia from PAD leads to whaT?
Prolonged ischemia leads to atrophy of the skin and underlying muscles...delayed healing, wound infection, and tissue necrosis, especially in the diabetic patient.
what happens over bony prominences?
ischemic arterial ulcers
what are the most serious complications? what can this result in?
Nonhealing arterial ulcers and gangrene are most serious complications.
May result in amputation if blood flow is not adequately restored, or if severe infection occurs
how to DX it?
Doppler ultrasound: looks at blood flow
Segmental blood pressures: drop in 30=PAD
Ankle-brachial index (ABI)
Done using a hand-held Doppler
Bidirectional, color Doppler
Magnetic resonance angiography (MRA)
FIRST to treat modify what risk factors?
• Regular physical exercise
• Achieve or maintain ideal body weight
• Follow Dietary Approaches to Stop Hypertension (DASH) diet
• Tight glucose control in diabetics
• Tight blood pressure control
• Treatment of hyperlipidemia and hypertriglyceridemia
• Antiplatelet agent (aspirin or clopidogrel [Plavix])
• ACE inhibitor
where do I want the PAD patient's BP?
BP maintained <140/90
Glycosylated hemoglobin for diabetic PAD patients?
Glycosylated hemoglobin <7.0% for diabetics
What collaborative therapy can be used for caludication treatment? x2
• Structured walking or exercise program
• Cilostazol (Pletal)
what drug would I give my patients to help with LDL levels?
Antiplatelet therapy for PAD? how much for asymptomatic patients and symptomatic?
critical for reducing the risks of CVD events and death in PAD patients.
-Oral antiplatelet therapy should include 75 to 100 mg/day of aspirin for patients with asymptomatic PAD
-75 to 325 mg/day of aspirin for patients with symptomatic PAD.
-Aspirin-intolerant patients may take clopidogrel (Plavix) daily.
Ramipril aka and MOA
↓ cardiovascular morbidity
↑ peripheral blood flow
↑ walking distance
Drugs prescribed for treatment of intermittent claudication x2
↑ erythrocyte flexibility
↓ blood viscosity
↑ walking distance
The primary nondrug treatment for intermittent claudication is...
The primary nondrug treatment for intermittent claudication is tobacco cessation in combination with a formal, supervised exercise training program.
Lack of exercise and impaired walking ability in PAD patients is related to...
Lack of exercise and impaired walking ability in PAD patients is related to low quality of life
exercise therapy? most effective exercise? how long?
-Exercise improves oxygen extraction in the legs and skeletal metabolism.
-Walking is the most effective exercise for individuals with claudication.
-30 to 60 minutes daily
-BMI < 25 kg/m2
-Waist circumference <40 inches for men and <35 inches for women
-Dietary cholesterol <200 mg/day
-Decreased intake of saturated fat
-Sodium <2 g/day
Critical limb ischemia is a condition characterized by what?
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
Care of Leg With Critical Limb Ischemia
Revascularization via bypass surgery: optimal
Protect from trauma
Maximize arterial perfusion
Hyperbaric oxygen therapy
Interventional Radiologic Procedures indications
-Intermittent claudication symptoms become incapacitating.
-Pain at rest
-Ulceration or gangrene severe enough to threaten viability of the limb
what is Interventional radiology catheter-based procedures. determining which intervention to use depends on what?
-Interventional radiology catheter-based procedures are alternatives to open surgical approaches for treatment of lower extremity PAD. These procedures take place in a catheterization laboratory.
-Determining which intervention to use depends on blockage location and lesion type and severity.
Percutaneous transluminal balloon angioplasty
-Involves the insertion of a catheter through the femoral artery
-Catheter contains a cylindrical balloon.
-Balloon is inflated dilating the vessel by cracking the confining atherosclerotic intimal shell.
-Stent is placed.
what is atheroectomy?
-Removal of the obstructing plaque
-Performed using a cutting disc, laser, or rotating diamond tip
Most common surgical approach?
-A peripheral artery bypass operation with autogenous vein or synthetic graft material to bypass blood around the lesion
-Synthetic grafts typically used for long bypasses
-Balloon angioplasty with stenting used in combination with bypass surgery
what should the past health history include when I do my assessment?
Past health history
possible Nursing DX for those 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
goals for pt with PAD
(1) adequate tissue perfusion; (2) relief of pain; (3) increased exercise tolerance; and (4) intact, healthy skin on the extremities.
nursing implementation: health promotion
Identification of at-risk patients
Proper care of feet
Avoidance of injuries
as a nurse what should I be monitoring after surgery x4
-Skin color and temperature
-Presence of peripheral pulses distal to the operative site
-Sensation and movement of extremity
how often should I check the operated extremity? what do I do if the pt loses their pulse?
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.
Avoid placing the patient how after surgery?
Avoid placing the patient in a knee-flexed position except for exercise.
how do I position the patient after surgery?
Turn the patient and position frequently with pillows to support the incision.
what do I do on post-op day 1? What do I discourage in the patient?
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.
Long-term therapy with ___ or ___ is recommended for patients after surgery.
Long-term therapy with aspirin or clopidogrel(plavix) is recommended for patients after surgery.
how should exercise be after surgery?
foot care after surgery? (implementation)
-Daily inspection of the feet
-Comfortable shoes with rounded toes and soft insoles
-Shoes lightly laced
-Identify activities that promote circulation.
-Maintain adequate peripheral tissue perfusion.
-Experience intact skin, free of infection, on lower extremities.
-Plans for walking program
-Increased activity tolerance
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