Med Surg Exam 3

• Peripheral Vascular Disease


  A group of disorders in which there is either an incomplete (stenosis) or complete (occlusion) disruption of the flow of blood and lymph thought the veins, arteries or lymphatic systems
• Peripheral Vascular System


  The system of blood vessels that carry blood to and from the body's peripheral tissues

  
• Arteriosclerosis


  Hardening of arteries, calcification of arteries of all sizes, loss of elasticity of arterial walls

  
• Atherosclerosis


  Fibrous "plaque", thickening of inner coat (intima), fatty degeneration of middle layer (media)

  
• Arteriosclerosis Obliterans


  • Disease of large and medium sized arteries, associated with high blood pressure, hyperlipidemia, arterial occlusion particularly at bifurcations

  
• Other examples of peripheral artery disorders

  • Diabetes
  • Vasculitis
  • Sickle cell disease
• Peripheral Artery Disease (PAD)


  A set of disorders of the arterial, venous, and lymphatic systems that cause disruption to the blood flow, leading to ischemia and tissue necrosis

  
• Comprehensive Vascular Examination


  • Pulse examination, bilateral arm blood pressure, cardiac examination, palpation of abdomen for aneurysmal disease, auscultation for bruits, examination of legs and feet
• PAD is very common and affects about 10 million individuals in the US
• PAD is common in older adults, affecting 15%-20% of persons older than 70 years of age
• Early detection, diagnosis, and management of PAD is important because if plaque has built up in the arteries of the legs then it is likely that plaque has also built up in the arteries of the heart or neck, and this can lead to an MI or stroke

  
• Causes of Peripheral Artery Occlusion

  • Atherosclerosis, embolism, thrombosis, vasospasm, edema

  
• Risk Factors for Peripheral Artery Disease

  • Gender: male
  • Age: older
  • Smoking
  • Diabetes: hyperglycemia
  • Hypertension
  • Dyslipedemia (total chol., HDL, LDL, triglycerides)
  • Hyperchromocysteinemia (alteration in metabolism of homocysteine)
  • Inflammatory markers: CRP, fibrinogen and alterations in the hemorrheologic properties of the blood
• Factors that increase the risk of occlusion

  • Obesity
  • Sepsis
  • Hypotension
  • Low cardiac output
  • Aneurysms
  • Aortic dissection
  • Bypass grafts

  
• Factors that increase the risk of ischemia

  • Emboli
  • Atrial fibrillation
  • Proximal atheroma
  • Tumor
  • Foreign bodies
• Clinical Manifestations of Peripheral Artery Disease

  • Intermittent claudication, rest pain, decreased pulses, delayed wound healing

  
• Intermittent claudication


  Tightening pain, sharp cramp, burning, or pressure in calf or buttocks related to decreased blood flow during walking and disappears at rest
• Peripheral signs of PVD (the classic 6 P's)

  • Pulselessness
  • Paralysis
  • Paraesthesia (tingling, tickling, prickling, pricking, or burning)
  • Pain
  • Pallor
  • Perishing cold (Polikilothermia)
• Ankle-Brachial Index (ABI)


  Ratio of systolic blood pressure at the ankle to the systolic blood pressure in the arm, used to diagnose PAD

  
• Ankle-Brachial Index (ABI) Interpretation


  • No blockage (1.0 to 1.4) Normal
  • Borderline (0.9 to 0.99)
  • Mild blockage (0.8 to 0.89)
  • Moderate blockage (0.5 to 0.79)
  • Severe blockage (less than 0.5)
  • Rigid arteries (more than 1.4)

  
• Doppler Ultrasound


  Noninvasive diagnostic test used to evaluate peripheral artery disease
• Treatments for Peripheral Artery Disease

  • Promote arterial flow: Pentoxifylline (Trental)
  • Lifestyle changes – dietary modification, smoking cessation, and regularly exercising
  • Manage and control comorbidities: diabetes, hypertension, obesity, hypercholesterolemia and hyperlipidemia
  • Blood thinners: anticoagulants (heparin or warfarin) or antiplatelets (aspirin, plavix)
  • Prevention of injury (foot care)
  • Percutaneous Transluminal Angioplasty (PTA)

  
• Nursing Care for Peripheral Artery Disease


  • History taking, physical assessment, promoting arterial flow, pain management, skin care, activity intolerance, education to reduce risk
• Buerger's Test


  Elevating the leg to 45° to look for pallor, then placing the leg in a dependent position at 90° to look for a red flushed foot before returning to normal. Pallor at <20° indicates severe PAD.

  
• Surgical Management of Peripheral Artery Disease

  • Endovascular interventions: angioplasty, atherectomy, and stent placement
  • Arterial bypass: revascularize limbs, reverse the saphenous vein for femoro-popliteal bypass, synthetic prosthesis for aorto-iliac or ilio-femoral bypass

  
• Foot Care Instructions for Peripheral Artery Disease

  • Wash feet everyday with warm water and mild soap, dry feet gently, keep skin soft and smooth, trim toenails straight across and file edges, check feet daily for sores, cuts, bruises, rashes, corns, calluses, blisters, red spots, swelling, ingrown toenails, and pain

  
• Raynaud's Disease


  A rare disorder that affects the arteries, characterized by brief episodes of vasospasms reducing blood flow to the fingers and toes

  
• Types of Raynaud's Disease

  • Primary Raynaud's (Raynaud's disease), cause unknown and less severe
  • Secondary Raynaud's (Raynaud's phenomenon), caused by an underlying disease, condition, or other factor
• Causes of Secondary Raynaud's Disease

  • Connective tissue diseases
  • Diseases of the arteries
  • Carpal tunnel syndrome
  • Repetitive action or vibration
  • Smoking
  • Injuries
  • Medications
• Signs and Symptoms of Raynaud's Disease

  • Affected areas turn pale or white and then blue, feel numb, cold, or painful, turn red, throb, tingle, burn, or feel numb as blood flow returns

  
• Diagnosis of Raynaud's Disease

  Cold stimulation test, nailfold capillaroscopy, assessment for other conditions that may cause Raynaud's phenomenon

  
• Treatments for Raynaud's Disease

  • Lifestyle changes: avoid cold temperatures, emotional stress, workplace/recreational factors, contact with certain chemicals or medicines, physical activity, limit repetitive hand actions
  • Medications: calcium channel blockers, alpha blockers, prescription skin creams, ACE inhibitors

  
• Buerger's Disease


  A rare disease of the arteries and veins in the arms and legs, where blood vessels become inflamed, swell and can become blocked with blood clots

  
• Nailfold Capillaroscopy


  Nailfold capillaries are visualized under the microscope to detect abnormalities
• Assess for other conditions that may cause Raynaud's phenomenon

  1. Antinuclear antibody (ANA) test

  2. Erythrocyte sedimentation rate (ESR) test

  3. C-reactive protein (CRP) blood test

  
• Raynaud's Disease


  A condition where blood vessels in the fingers and toes overreact to cold temperatures or stress

  
• Raynaud's Disease Treatment


  • Lifestyle changes: avoid cold, emotional stress, workplace/recreational factors, chemicals/medicines
  • Educate patient to protect from cold
  • Physical activity
  • Limit repetitive hand actions
  • Medications: calcium channel blockers, alpha blockers, prescription skin creams, ACE inhibitors
• Buerger's Disease


  A rare disease of the arteries and veins in the arms and legs where blood vessels become inflamed, swell and can become blocked with blood clots, damaging or destroying skin tissues and leading to infection and gangrene

  
• Causes of Buerger's Disease

  • Genetic predisposition in Middle East and Far East
  • Unknown
  • Smoking
  • Gum disease
• Buerger's Disease Signs & Symptoms

  • Pain (claudication)
  • Raynaud's phenomenon
  • Open ulcers