Peripheral Vascular Disease Care Plan Notes

Description

Peripheral artery disease (PAD), also known as peripheral vascular disease (PVD), peripheral artery occlusive disease, andperipheral obliterative arteriopathy, is a form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities.

Risk Factors

Trauma
Thrombosis
Inflammation
Embolism
Atherosclerosis
Autoimmune response
Smoking

Pathophysiology

Narrowing of the arterial lumen nor damage to the endothelial lining can result from such factors as atherosclerotic buildup of lipid deposits or arteriosclerosis obliterans that causes arterial occlusion. This leads to reduced or absent peripheral blood flow, and if unchecked, tissue ischemia and eventual necrosis.

Assessment/Clinical Manifestations/Signs and Symptoms

Pain or loss of sensory nerves secondary to ischemia
Paresthesias and loss of position sense
Polar or coldness
Paralysis
Pallor due to empty superficial vessels (can progress to mottled, cyanotic, and cadaverous cold leg)
Pulselessness
Intermittend claudication – calf muscle pain occurring when muscle is forced to contract without adequate blood supply (e.g. after walking). The calf muscle pain is alleviated with rest.
Resting pain, which is pain at rest when limited blood flow cannot meet very low tissue requirements.
Trophic changes in skin and nails such as dryness, scaling, and thinning of skin; decreased or absent hair growth, brittle and thickened nails and gangrenous changes marking death and decay of tissues.

Laboratory and diagnostic study findings

Doppler ultrasound flow studies reveal that extremity blood pressure measurements in the legs are lower than in the arms.
Angiography may confirm the diagnosis and shows vascular obstructions or aneurysms and the presence of collateral circulation
Digital subtraction angiography visualizes vascular obstructions, aneurysms, narrowing of vessels and atherosclerotic plaque.

Medical Management

Pharmacologic therapy

Pentoxifylline (Trental) and cilostazol (Pleta) are the only medications specifically indicated for the treatment of claudication.
Antiplatelet agents such as aspirin or clopidogrel (Plavix) help prevent the formation of thromboemboli, which can lead to myocardial infarction and stroke.

Surgical treatment.

The choice of the surgical procedure depends on the degree and location of the stenosis or occlusion.

Endarterectomy (incision is made into the artery and the atheromatous obstruction is removed) is the treatment of choice.
Bypass grafts are performed to reroute the blood flow around the stenosis or occlusion. Before the bypass grafting, the surgeon determines where the distal anatomosis (site where the vessels are surgically joined) will be placed.

Nursing Diagnosis

Ineffective peripheral tissue perfusion related to impaired arterial circulation.
Pain related to decreased oxygen supply to tissues.
Risk for impaired skin integrity related to compromised tissue perfusion.
Fear and anxiety related to actual or potential lifestyle changes.

Nursing Management

Provide proper positioning

Place the client’s legs in a dependent position in relation to the heart to improve peripheral blood flow
Avoid raising the client’s feet above heart level unless specifically prescribed by the health care providers
Keep the client in a neutral, flat, supine position if in doubt about the nature of his peripheral vascular problems.

Promote vasodilation.

Provide insulating warmth with gloves, socks and other outerwear as appropriate.
Keep room temperatures comfortably warm.
Instruct the client to warm himself with warm drinks or baths.
Never apply a direct heat source to the extremities. Limited blood flow combined occur with normal circulation.
Teach the client about the vasoconstrictive effects of nicotine and caffeine, emotional stress, and chilling, discuss ways to avoid or minimize these risk factors.
Teach the client to avoid constricting clothes, such as garters, knee-high stockings and belts.
If overreplacement of glucocortiocoid is indicated, inform the client about the purpose of therapy and possible adverse effects such as cushingoid appearance, weight gain, acne, hirsutism, peptic ulcer, diabetes mellitus, osteoporosis, infection, muscular weakness, mood swings, cataracts and hypertension.

Promote activity and mobility.

For a client with decreased arterial function but without activity-limiting tissue damage, encourage a program of balanced exercise and rest to promote development of collateral circulation.

Provide care for a client undergoing angiography or percutaneous transluminal angioplasty.

Before the procedure, provide information related to the procedure, validate that the informed consent has been obtained, mark peripheralpulses, obtain diagnostic data as ordered and withhold food and fluids as prescribed.
After the procedure, maintain bed rest as prescribed, keeping the involved extremity extended, monitor vital signs and assess peripheral pulses and circulation every 15 minutes for 2 hours and then every hour for 4 hours.
Assess for bleeding, hematoma, or edema at the catheter insertion site, encourage oral fluid and monitor urine output.

Provide care for a client receiving an autogenous saphenous vein or a synthetic bypass graft.

Prepare the client for surgery and mark the site of the peripheral pulses
Monitor the client carefully after the procedure (especially for the first 24 hours) for signs of graft occlusion as manifested by decreased arterial perfusion.
Anticipate and take steps to prevent complications of any surgical procedure involving general anesthesia, particularly respiratory problems and infection.

Provide care for a client who has received an axillofemoral or axillobifemoral bypass graft or an endarterectomy (i.e. removal of atheromatous plaque).

Avoid positioning the client on the side of the graft or incision after the procedure
Warn the client not to wear tight clothing which can lead to graft occlusion
Instruct the client on signs and symptoms of infection to report to the health care provider.