UNIT 9 Oxygen-arterial insufficiency PDF

**[UNIT 9 ]** **HEALTH NEED**: Oxygen **HEALTH PROBLEM:** Decreased Circulating Oxygen/Arterial Insufficiency **PURPOSE**: The purpose of this unit is to assist the student in acquiring the knowledge necessary to care for a patient and family faced with problems related to peripheral arterial dis...

**[UNIT 9 ]** **HEALTH NEED**: Oxygen **HEALTH PROBLEM:** Decreased Circulating Oxygen/Arterial Insufficiency **PURPOSE**: The purpose of this unit is to assist the student in acquiring the knowledge necessary to care for a patient and family faced with problems related to peripheral arterial disease (PAD). **UNIT OBJECTIVES**: At the conclusion of this unit the student will be able to: 1. define and describe peripheral arterial disease (PAD), including identifying both modifiable and non-modifiable risk factors. a. **Peripheral artery disease** refers to any disease process that affects the arteries. Various PAD's result in ischemia and produce these signs and symptoms below. The type and severity of symptoms depends partly on the type, stage, and extent of the disease process and on the speed with which the disorder develops. PAD is one manifestation of atherosclerosis; thus systemic diseases that affect arteries of the brain, heart, kidneys, mesentery, and limbs should be suspected. Atherosclerosis involves changes of the intima consisting of an accumulation of lipids, calcium, blood components, complex carbs, and fibrous tissue. Atherosclerosis causes arterial stenosis, obstruction by thrombosis, aneurysm, ulceration, and vessel rupture. i. Signs and symptoms 1. The hallmark symptom for PAD in the lower extremity is intermittent claudication (cramp-like pain in the muscle that occurs with the same degree of exercise activity, and is relieved with rest) 2. Structural changes resulting from chronic lack of O2 and nutrient delivery to tissues a. Hair loss distal to the occlusion b. Thick, opaque nails; shiny, dry skin c. Skeletal muscle atrophy 3. Skin color changes d. Elevational pallor e. Dependent rubor (red color when limb dependent from dilated damaged vessels) 4. Pulse changes f. Pulses diminished or absent below area of stenosis/obstruction-pedal, posterior tibial, popliteal, femoral g. Cool extremity distal to occlusion h. Bruits may be auscultated with a stethoscope just distal to arterial stenosis, indicating turbulent blood flow with vessel stenosis. 5. Sensation changes i. Paresthesia j. Numbness k. Tingling of extremities 6. Ulcers or gangrene located at tips of toes, over areas of pressure (heels or shin); defined punched out (circular) necrotic/yellow ulcer base, dry, pale in appearance, usually very painful; poor healing of injuries on extremities b. Risk factors ii. Age of onset and severity is influenced by the type and number of atherosclerosis risk factors iii. Modifiable 7. Diet: 8. BMI of 30 or greater 9. Stress 10. lack of exercise 11. Smoking and tobacco use is the most important because nicotine decreases blood flow, increases HR and BP, and increases risk for clot formation by increasing platelet aggregation. iv. Nonmodifiable 12. Rage 13. Age v. Coronary artery disease vi. Cerebral artery diseases vii. Diabetes mellitus viii. Hypertension ix. Higher total cholesterol is associated with increased risk (but higher HDL is associated with a [decreased] risk) x. Clotting disorders xi. Homocysteine is a protein that promotes coagulation, and is associated with elevated thrombotic risk, however elevated levels have only weakly predicted cardiovascular risk. It is associated with genetic factors and a diet LOW in folic acid, vitamin B6 and B12. xii. Elevated C-reactive protein (CRP) levels are strongly associated with development of PAD 2. describe the rationale for the following tests used to assess vascular blood flow in the peripheral arteries: c. **Doppler ultrasound** xiii. Evaluation of arterial signals xiv. Blood pressure measurement in the limbs xv. Assessment of vessel size and compressibility xvi. Assessment for presence of thrombus xvii. Assessment of valve function d. **duplex ultrasonography** xviii. Localization of vascular obstruction xix. Evaluation of stenosis xx. Assessment for vascular reflux xxi. Provides both image and audible signal e. **angiography** xxii. Confirmation of occlusive arterial disease when considering interventions xxiii. Patient may report the sensation of warmth during injection and may have immediate or delayed allergic reaction to the iodine in the contrast agent xxiv. Digital subtraction angiography (DSA) has bony structures removed from the image f. **Ankle/Brachial Index (ABI)** xxv. The continuous wave doppler is used to obtain systolic BP in the extremities to calculate the ABI. This ratio compares ankle to arm systolic BPs and is an indicator of perfusion to the lower extremities. xxvi. Patient should rest supine for 10-20 minutes before procedure. Place the ankle BP cuff just above malleoli (above the ankle). xxvii. Calculate an ABI for each leg, the ABI for each lower extremity is calculated by selecting the higher of the two-ankle systolic BP (obtained from both the posterior tibial and dorsalis pedis arteries) and dividing it by the higher of the right and left brachial systolic pressures. xxviii. Ex: the patient's right brachial systolic pressure is 160, and the right posterior tibial systolic pressure is 80. Therefore 80/160= 0.5 ABI xxix. Equation 14. Right ABI= highest pressure in right foot/ highest pressure in both arms xxx. The ankle systolic pressure is normally the same or slightly higher than the brachial systolic pressure, resulting in an ABI of 1- 1.4. An ABI greater than 1.4 suggests a noncompressible calcified vessel, whereas as ABI lower than 0.9 is considered diagnostic of PAD. As PAD progresses, the systolic BP in the ankle of the affected extremity decreases. 15. An ABI of 0.8-0.99 indicates mild PAD 16. 0.5-0.8 indicates moderate PAD (claudication present) 17. Less than 0.5 indicates severe PAD (pain at rest) g. **MRA (magnetic resonance angiography)** xxxi. Detection of changes, aneurysms, DVT xxxii. Useful in poor kidney function or contrast agent allergy xxxiii. Software is programmed to isolate blood vessels and reassemble images into three dimensions h. **CTA (computed tomography angiography)** xxxiv. Demonstration of cross-sectional images of soft tissue xxxv. Diagnoses of abdominal aneurisms, graft infections or occlusions, hemorrhage 3. develop a plan of care following interventions for a patient with peripheral arterial disease: i. **percutaneous transluminal angioplasty** xxxvi. May be performed with or without a stent. Balloons are inserted into the vessels via a catheter and expanded at the stenotic site within the vessel. The expanding balloon cracks the atherosclerotic plaque and opens the vascular lumen. Stents may be inserted to support the vessel wall and maintain patency. xxxvii. Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration. xxxviii. The advantages of angioplasty, stents, and stent-grafts compared to open surgical procedures is the decreased length of hospital stay required for the treatment and more minor physical trauma to the patient than open surgical procedures. Percutaneous catheter procedures may be performed in an outpatient setting, depending on patient's condition j. **Thrombolysis** xxxix. Thrombotic stenosis or occlusion may be treated by thrombolysis. After catheter insertion into the affected vessel, the thrombolytic agent is injected directly into the thrombus. It will lyse the thrombus (clot). The patient is admitted to a special or critical care unit for continuous monitoring. Vital signs are taken frequently, according to facility's protocol. The patient is monitored closely for signs of bleeding, as this is the most common side effect of thrombolytic therapy. The nurse minimizes the number of punctures for IV lines and obtaining blood samples, avoids intramuscular injections, prevents tissue trauma, and applies pressure at least twice as long as usual after any puncture is performed. Patients will have follow up images to determine effectiveness of treatment k. **peripheral arterial bypass surgery** (Example: femoral -- popliteal bypass surgery) xl. The initial treatment goals for ALI are to prevent worsening ischemia and thrombus propagation, manage pain and preserve tissue. Anticoagulation is started immediately upon recognizing acute ischemia. Revascularization or arterial bypass is the first line intervention used in ALI treatment. Vascular surgical procedures are divided into two groups: inflow procedures (which improve blood supply from the aorta into the femoral artery) and outflow procedures (which provide blood supply to vessels below the femoral artery). xli. Bypass grafts are placed to reroute blood flow around the stenosis or occlusion. Grafts below the knee require the use of native vein (patients own vein) to ensure patency; however synthetic grafts may be used for bypass procedures on larger vessels above the knee. l. Nursing management xlii. Providing postoperative care 18. Patients are encouraged to move the involved extremity and be active 19. Maintain adequate circulation 20. Anticoagulant therapy to prevent thrombus of the graft 21. Metabolic abnormalities, kidney failure, and compartment syndrome are potential complications after arterial occlusions or operations 22. Assess for evidence of local complications such as hemorrhage or thrombosis, by performing neurovascular checks of the limb and systemic complications by monitoring vital signs, intake and output, physical assessment parameters (pulmonary, cardiac, PV, GI, mental status) and lab data. xliii. Provide pain relief xliv. Maintaining tissue integrity 23. Teach patients to avoid trauma, wear sturdy, well-fitting shoes or slippers, and use neutral soaps and body lotions. 24. Patients with open arterial or venous ulcers are given detailed wound care instructions 25. Risk factor modification is the most effective intervention for preventing the progression of vascular disease 26. Educate family and patients on environmental and behavioral risk factors associated with ischemia. (ex: excess heat may increase metabolic rate of extremities and increase need for O2 beyond that provided by the reduced arterial flow through the diseased artery. Cold temp is associated with vasoconstriction, which decreases perfusion to the extremities) 27. Emotional upset cause vasoconstriction by stimulating sympathetic nervous system. Stress management is important 28. Constrictive clothing and accessories are avoided, as are heating pads and hot water bottles. Temperature of bathwater should be evaluated and decreased to avoid scalding. Tight socks, panty girdles, belts, and shoelaces are discouraged because they may impede arterial circulation to the extremities and promote venous congestion and edema 4. describe the difference between Buerger's disease and Raynaud's phenomenon. m. **Buerger's disease** (Thromboangiitis obliterans) xlv. Characterized by recurring inflammation of the intermediate and small arteries and veins, resulting in thrombus formation and vessel occlusion. xlvi. Occurs in both upper and lower extremities. It is differentiated from vessel diseases by microscopic appearance xlvii. It is an autoimmune disease. While its etiology is not known, it is believed to be an autoimmune vasculitis (inflammation of a blood vessel). It most often occurs in males between 25-45 and is reported in all races; however prevalence is high in India, Korea, Japan, and Ashkenazi Jewish individuals. xlviii. Tobacco use is a causative factor, and continued use interferes with healing. xlix. Pain is bilateral and symmetric with focal lesions l. Treatment is essentially the same as for atherosclerotic PAD; sympathetic block may dilate vessels and increase blood flow n. **Raynaud's phenomenon** li. Refers to vasospasm that occurs with cold or stress. Patients with scleroderma or systemic lupus erythematosus may have the same signs and symptoms (this is called secondary Raynaud phenomenon) lii. Unknown etiology but may be associated with immunologic disorders. Emotional factors or cold may trigger episodes. liii. Usually occurs in females between 16-40 and it occurs more frequently in cold climates and during the winter. liv. It may cause skin and muscle atrophy lv. Manifestations: patient's skin becomes cyanotic due to vasospasm and then vasodilation causes redness (rubor). Numbness, tingling, and burning pain occurs. Typically, in the fingers, but toes may be affected. Typically, the radial, ulnar, and pedal pulses are normal; fingers and toes may be cool between attacks and may perspire excessively lvi. Generally benign and self-limiting with appropriate patient teaching and lifestyle modification. The patient is instructed to avoid the stimuli (cold, tobacco, etc.) that provoke vasocontraction. Patients are encouraged to dress warmly, wear gloves and mittens, and protect the trunk, head, and feet with warm clothing to prevent cold-induced reflex vasoconstriction. Patients may be prescribed calcium channel blockers to relieve symptoms. Digital sympathectomy (interrupting the sympathetic nerves) may help some patients 5. differentiate the characteristics of arterial wounds and venous stasis ulcers. (SEE LAST PAGE FOR SIDE BY SIDE CHART FROM BOOK) o. Location lvii. Arterial wounds are typically found on the toes, heels, or outer ankle. lviii. Venous ulcers are usually found on the lower leg, particularly above the ankle more on the medial side p. Pain lix. Arterial wounds will have claudication. Rest pain; continuous pain worsens with elevation and eases with dependency. lx. venous ulcers may cause a dull ache throughout the entire leg. Aching, throbbing, heaviness. Superficial stinging when open to air during dressing changes. q. Ulcer base lxi. Arterial: dry, pale gray or yellow, may be necrotic lxii. Venous: generally shallow but may be deep. Pink, but may be beefy red with granulation tissue. Ulcer bed usually moist. May have copious drainage r. Shape lxiii. Arterial: border regular and well demarcated lxiv. Venous: irregular border s. Surrounding tissue: lxv. Arteria;: pale; cooler than other skin areas. In longstanding insufficiency, skin is thin lxvi. Venous: darkened color in gaiter area. Temperature higher than other skin areas. Brawny edema. Skin may be thick and fibrotic (woody). May be oozing and crusted t. Edema: lxvii. Arterial: minimal unless leg is dependent often lxviii. Venous: may be severe u. Pulses: lxix. Arterial: may be absent or diminished; often disappears with exercise lxx. Venous: usually present with only venous etiology but may be difficult to palpate with edema v. ABI: lxxi. Arterial: less than 0.9 lxxii. Venous: greater than 0.9 w. Wound treatment: lxxiii. Arterial: moist wound healing after revascularization. Monitor for infection. Keep dry gangrene dry lxxiv. Venous: compression. Elevation above heart. Absorptive dressings x. Appearance lxxv. Arterial ulcers are small and deep with e "punched-out" look, 29. Skin around arterial wounds may appear shiny, hairless, and cool to the touch. lxxvi. while venous ulcers are large and shallow with irregular borders. 30. The skin around venous ulcers may appear warm, discolored, and swollen y. Wound bed lxxvii. Arterial wounds may appear pale or necrotic lxxviii. Venous wounds may appear dark red or fibrinous slough z. Exudate lxxix. Arterial wounds rarely produce exudate lxxx. Venous wounds always produce exudate a. Eschar lxxxi. Arterial wounds commonly have eschar lxxxii. Venous wounds never have eschar 6. identify tasks that can be delegated to assistive personnel (AP) when caring for a patient with arterial disease. b. Observing and reporting changes c. Assist with ADLs such as bathing, dressing, toileting, etc d. Assisting with motion exercises e. Taking and recording vital signs 7. recognize patient situations that require immediate nursing intervention when caring for a patient with arterial disease. (Prioritization) f. New or worsening symptoms like chest pain, dizziness, shortness of breath, irregular pulse, unexplained weight gain g. Difficulty walking can be a sign of a stroke h. Cyanosis or pallor 8. develop and implement an NCP using the PERSON framework for an individual: i. arterial disease j. skin grafting for wound healing k. lower extremity limb amputation l. arterial ulcer 9. develop and implement a teaching plan to meet an identified learning need for an individual with arterial disease. 10. identify healthcare personnel the nurse could collaborate with in providing interdisciplinary care for patients in this population. m. Vascular surgeons n. Interventional radiologists o. Cardiologists p. Podiatrists q. Wound care specialists r. Physical therapists s. Dieticians t. Pharmacists 11. Discuss the role of the nurse in educating the public about risk reduction for developing peripheral artery disease. u. Promoting healthy lifestyle choices lxxxiii. Healthy diet lxxxiv. Regular exercise and movement lxxxv. Avoid smoking!!! v. Teaching self care lxxxvi. Proper foot care lxxxvii. Avoid long periods of sitting or standing (for every 2 hours sitting, walk for 15 minutes) w. Providing guidance on risk factors lxxxviii. Such as high BP lxxxix. High cholesterol xc. Diabetes xci. Obesity xcii. Smoking x. Sharing information about treatments xciii. Such as medications, exercise therapy, and lifestyle changes 12. state the classification, action, indications, routes of administration, adverse effects, and nursing implications for the following medications: y. Classification: Vasodilator xciv. Example: 31. cilostazol (Pletal) z. Classification: Direct thrombin inhibitor xcv. Example: 32. bivalirudin (Angiomax) 33. dabigatran (Pradaxa) a. Classification: Blood viscosity reducing agent xcvi. Example: 34. pentoxifylline (Trental) REQUIRED RESOURCES: Honan Topics: Peripheral Arterial Disease of the Lower Extremities and Arterial Wounds RECOMMENDED: Lippincott Advisor or Davis Drug Guide for Nurses Review listed medications