| Patho | Signs & symptoms | Risk factors & diagnosis | Treatment & management | Nursing Process |
|---|---|---|---|---|
|
Atherosclerosis: the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as plaques, found predominantly in the abdominal aorta and the coronary, popliteal, and internal carotid arteries.
Define atherosclerosis.
|
Leg pain, aching, cramping, fatigue, or weakness particularly when walking or exercising, which disappears after a few minutes of rest
What is intermittent claudication?
|
Modifiable: Diabetes, Hyperlipidemia, Nicotine use, Hypertension, Obesity, Sedentary lifestyle
Non-modifiable: Male gender, Heredity, Age >50
Name 5 risk factors for PAD. Are they modifiable or non-modifiable?
|
• Angioplasty: a procedure in which a balloon tipped catheter is inserted and threaded into an artery; then the balloon is inflated, opening the narrowed artery. A stent, may be left in place to help keep the artery open.
• Endarterectomy: an incision is made into the artery, and the atheromatous obstruction is removed. The artery is then sutured closed to restore vascular integrity • Artery bypass graft: a procedure in which a blood vessel is taken from another part of the body and is attached to reroute the blood flow around the stenosis or occlusion. It is sometimes necessary to provide the palliative therapy of primary amputation rather than an arterial bypass.
Name and describe 2 surgical procedures which can be used in the treatment of PAD? Which did tony receive?
|
• Ineffective peripheral tissue perfusion related to compromised circulation
• Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen • Risk for impaired skin integrity related to compromised circulation • Deficient knowledge regarding self-care activities
Name 3 nursing priority problems related to PAD.
|
|
Dyslipidemia: characterized by elevated triglycerides, low high-density lipoprotein, and very low-density lipoprotein in the circulation. These eventually deposit into the lumen of arterial vessels, causing plaque formation.
Tony: Cholesterol: 7.1 (4.2-5.2), LDL: 6.0 (2.2-3.4), TG's: 3.4 (0.6-2.3)
Which of the following terms refers to abnormal concentrations of serum lipoproteins such as lipids, phospholipids, cholesterol, and triglycerides bound to carrier proteins?
A. Dyslipidemia B. Lipoprotemia C. Phospholipidemia Did Tony have abnormal cholesterol, LDL and triglycerides? |
They would heal more slowly due to decreased arterial blood flow, infections may become very serious.
How would PAD affect wound healing and infections?
|
The ankle brachial index (ABI): compares the blood pressure in the ankle to the blood pressure in the arm. If the blood pressure in the lower leg is lower than the pressure in the arm, it may be indicative of PAD.
What is the ankle brachial index (ABI) and how is it used to diagnose PAD?
|
Correct answer: A
(current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.)
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?
A. Statins B. Vitamins C. Thrombolytics D. Anticoagulants |
Correct answer: B
(Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.)
When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information should the nurse include?
A. "Exercise only if you do not experience any pain." B. "It is very important that you stop smoking cigarettes." C. "Try to keep your legs elevated whenever you are sitting." D. "Put on support hose early in the day before swelling occurs." |
|
Hyperglycemia: high glucose concentrations in the vessels damages the endothelial cells and causing inflammation.
Insulin resistance: leads to hyperinsulinemia, increasing the synthesis of LDL's, and triglycerides, accelerating the development of atherosclerosis.
How do hyperglycemia and insulin resistance in diabetes contribute to the pathogenesis of PAD?
|
Left leg pale and cool to touch from below knee to foot. Right foot warm to touch.
Left dorsalis pedis and posterior tibial pulses faintly audible by Doppler. Both pulses+3 in right foot. Paresthesia present in all left toes but negative in right foot. Capillary refill 12 seconds left great toe and 1 second right great toe. No complaints of pain at rest at present but complained of severe cramp-like pain when walking to the nurses’ station (8/10)
Describe Tony's signs and symptoms of PAD. (Hint: look under Cardiovascular and Peripheral Vascular System assessment)
|
Arteriogram, MRI, ultrasound
Tony: Duplex ultrasound and arteriogram
What kinds of imaging can be used to view if arteries are narrowed or blocked? Which were used for Tony?
|
Correct Answer: B
(PAD occurs as a result of atherosclerosis, and the risk factors are the same as for other diseases associated with atherosclerosis, such as CAD, cerebral vascular disease, and aneurysms. Major risk factors are hypertension, cigarette smoking, and hyperlipidemia. The risk for amputation is high in patients with severe occlusive disease, but it is not the best approach to encourage patients to make lifestyle modifications)
When teaching the patient with peripheral artery disease about modifying risk factors associated with the condition, the nurse emphasizes that...
A. amputation is the ultimate outcome if the patient does not alter lifestyle behaviors B. modifications will reduce the risk of other atherosclerotic conditions such as stroke C. risk-reducing behaviors initiated after angioplasty can stop the progression of the disease D. maintenance of normal body weight is the most important factor in controlling arterial disease |
Correct Answers: a, b, e
(Warm legs and feet increase circulation. The lower extremities should be assessed at a regular interval for changes. Walking exercise increases oxygen extraction in the legs and improves skeletal muscle metabolism. The patient with PAD should walk at least 30min a day, preferably twice a day. Exercise should be stopped when pain occurs and resumed when pain subsides. Nicotine in all forms causes vasoconstriction and must be eliminated.)
A patient with PAD has a nursing diagnosis of ineffective peripheral tissue perfusion. Appropriate teaching for the patient includes instructions to (select all that apply).
a) keep legs and feet warm b) walk at least 30 min/day to the point of discomfort c) apply cold compresses when the legs become swollen d) use nicotine replacement therapy as a substitute for smoking e) inspect lower extremities for pulses, temperature, and any swelling |
|
Major complications result from ischemic damage caused by atherosclerosis:
- Thrombosis - myocardial infarction leading to heart attack - cerebral infarction leading to strokes
Many people are unaware they have atherosclerosis until they have one of these three medical emergencies...
|
Correct Answer: B
Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.
A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication?
a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position. |
Correct Answer: B
Rationale: Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient?
a Gender b Smoking c Ethnicity d Co-morbidities |
Correct Answers: a, c, d
Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)?
a Ramipril (Altace) b Cilostazol (Pletal) c Simvastatin (Zocor) d Clopidogrel (Plavix) e Warfarin (Coumadin) f Aspirin (acetylsalicylic acid) |
Correct answer: C
(Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.)
When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says,
A. "I should not use heating pads to warm my feet." B. "I will examine my feet every day for any sores or red areas." C. "I should cut back on my walks if they cause pain in my legs." D. "I think I can quit smoking with the use of short-term nicotine replacement and support groups." |
|
1. Inflammatory activation of the vascular endothelium increases the aggregation of platelets, monocytes and macrophages on the vessel walls. Macrophages absorb cholesterol and fat from the blood and they form fatty streaks on the arterial wall.
2. Smooth muscle cells migrate and proliferate, allowing a matrix of collagen and elastic fibers to form. 3. Platelets adhere to these plaques and secrete growth factors. 4. Plaque ends up growing as lipids, fibers and other cells accumulate in the plaque mass.
Describe how atherosclerotic plaques form. (Hint: use handout)
|
a (Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to deep vein thrombosis, DVT)
A patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should
A. attempt to palpate the dorsalis pedis and posterior tibial pulses. B. check for the presence of tortuous veins bilaterally on the legs. C. ask about any skin color changes that occur in response to cold. D. assess for unilateral swelling, redness, and tenderness of either leg. |
Correct answer: c
Rationale: Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.
A 50-year-old woman weighs 95 kg and has a history of tobacco
use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are: a. weight and diet. b. activity level and diet. c. tobacco use and high blood pressure. d. sedentary lifestyle and high blood pressure. |
Correct answer: C
(Oral anticoagulants, warfarin, are not recommended for treatment of peripheral artery disease, but all the other statements are correct in relation to treatment of peripheral artery disease)
Following teaching about medications for PAD, the nurse determines that additional instruction is necessary when the patient says,
a) "I should take one ASA a day to prevent clotting in my legs" b) "The lisinipril (Zestril) I use for my BP may help me walk further without pain" c) "I will need to have frequent blood tests to evaluate the effect of the oral anticoagulant I will be taking." d) "Pletal should help me be able to increase my walking distance and keep clots from forming in my legs" |
Correct answer: B
(Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful)
In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says,
A. "I will have to buy some loose clothing that does not bind across my legs or waist." B. "I will use a heating pad on my feet at night to increase the circulation and warmth in my feet." C. "I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily." D. "I will change my position every hour and avoid long periods of sitting with my legs down." |
Support Us on Ko-fi