Atherosclerotic arterial occlusive disease

16 Atherosclerotic arterial occlusive disease




Overview/pathophysiology


Atherosclerosis is the primary etiology of peripheral artery disease. Damage to the intima of the artery occurs by the pathogenesis of atherosclerosis, which includes inflammation, plaque formation, lipid deposits, and hemorrhage. This process leads to vessel narrowing and hardening, decreasing lumen size and blood flow. Risk factors for atherosclerosis include smoking, heredity, advancing age, hyperlipidemia, hypertension, diabetes, and sedentary lifestyle


Arterial occlusive disease is systemic and progressive and is of grave concern when 75% or more of a cross section of an artery becomes blocked. This disease is often associated with other comorbidities, such as coronary artery disease, hypertension, chronic obstructive pulmonary disease, and diabetes. The complexity of these comorbidities may lead to loss of limb or life in affected patients.



Health care setting


Acute care or primary care



Assessment




Signs and symptoms:


Severe, cramping pain (intermittent claudication) with exercise that is relieved by rest is the classic symptom of ischemia secondary to decreased blood flow. Additionally, decreased sensory or motor function, thin shiny legs, leg or foot ulcers, pallor or dependent rubor, pain, delayed wound healing, and lastly gangrene all may occur.



Physical assessment:


Decreased pulse amplitude, decreased hair distribution, muscle atrophy, and cool, pale or bluish discoloration of the extremities is noted on physical examination. Skin may appear shiny and atrophied while the nails may appear thickened. Audible bruits may be assessed with a stethoscope over partially occluded vessels. Capillary filling will be 2 or more sec (with normal circulation, capillary filling occurs in less than 2 sec); pulse may be diminished and detected only by Doppler examination.



Risk factors:


Cigarette smoking, hypertension, diabetes mellitus, family history of atherosclerotic disease, and hyperlipidemia.



Diagnostic tests




Ankle-brachial index (ABI):


Determines degree of arterial occlusion and subsequent ischemia. Blood pressure (BP) is determined at the ankle (using either posterior tibial or dorsalis pedis pulse) and at the brachial artery. The pressure obtained at the ankle is divided by that at the brachial artery. Normally ABI is greater than 1.0; resting pain occurs with an ABI 0.3 or less.



Doppler flow studies:


Uses a transducer that emits sound waves through a probe to determine amount of blood flow through arteries in which palpable pulses are difficult to obtain. Waveforms also can be assessed similar to an electrocardiogram. The more normal or triphasic waveform looks like a regular heart rhythm. A flatter line with lengthening, called monophasic, indicates more severe disease. Pressures also can be obtained for ABIs.



Duplex imaging:


Uses ultrasound and Doppler to assess arteries for measuring flow and velocities.



Pulse-volume recording:


BP cuffs are placed over the thighs, calves, or feet to obtain pulse-volume recordings and pulse waveforms.



Exercise testing:


Determines amount of exercise that precipitates claudication.



Angiography of peripheral vasculature:


Locates obstruction and reveals extent of vascular lesions by injecting dye into arteries and taking pictures of the arteries in a timed sequence. This imaging study is most useful in patients in whom angioplasty or stenting is planned.



Digital subtraction angiography:


Arteriogram in which the computer subtracts early images from late images, deleting bone and soft tissue, so that only contrast-filled arteries appear.



Magnetic resonance imaging:


Demonstrates vessels in multiple projections and can be used with or without contrast. It is used widely but is more expensive and not suitable for all patients. Implanted metal (e.g., pacemakers, automatic defibrillators) and prosthetic joint replacements preclude this study from being performed.





Nursing diagnosis:


Impaired tissue integrity

related to altered arterial circulation occurring with atherosclerotic process


Desired Outcome: Over a period of days or weeks, patient’s lower extremity tissue improves and perfusion is maximized as evidenced by palpable pulses, decreased leg pain, and improvement in mobility and sensation.





































ASSESSMENT/INTERVENTIONS RATIONALES
Assess legs, feet, and between toes for ulcerations. Ulcerations can occur with decreased arterial circulation. A decrease in circulation significantly decreases oxygen delivery to the tissues and subsequently impairs healing of even the most minor break in the skin. A baseline assessment of a worsening condition enables timely interventions.
Teach patient the importance of walking and range-of-motion (ROM) exercises for hip, knee, and ankle. Walking is the best activity and patients can be instructed to walk until they have pain, rest until recovery, and then resume walking. Walking and exercise improve collateral circulation. This is especially useful for patients who claudicate, along with other risk factor modifications. Activity may be contraindicated for some patients with severe disease.
Determine the allowed activity and exercise with the health care team, and discuss this with the patient.
Exercise promotes circulation.

Note: Bedrest without exercise may be prescribed in acute, severe cases to decrease oxygen demand to the tissues, which optimally will decrease pain.
Teach patient how to assess peripheral pulses, warmth, sensation, and color of lower extremities (LE). Encourage daily foot inspections by patient or family members if patient’s vision or assessment ability is compromised. Monitoring status of the LE is essential for early identification of breaks in skin integrity, because early identification and care may prevent serious problems.
Encourage cessation of smoking and other tobacco use. Provide smoking and tobacco cessation literature. Discuss with health care provider use of medication for smoking cessation. Stopping tobacco use helps prevent increased vasoconstriction and severity of the circulation deficit, as well as the effects of nicotine on the lungs and other body organs.
Discuss importance of keeping feet warm and protected by wearing socks when walking or in bed. Decreased circulation because of vasoconstriction results in cooler blood to the LE and hence hypothermia. Keeping warm promotes vasodilatation and more optimal blood supply.
Caution patient about using heating pads. Heating pads increase metabolism and may promote ischemia if circulation is limited. Also, patient’s sensitivity to temperature is often decreased and burns can result.
Discuss importance of nightlights being placed in bedrooms and bathrooms. Nightlights promote visibility and may help avoid tissue trauma at night when getting up.
Caution patient to avoid pressure over areas of bony prominence. Pressure increases the risk of skin breakdown; areas over bony prominence are particularly susceptible.
Caution patient to cover all exposed areas when going outside in cooler weather. This action helps prevent hypothermia, to which patient with decreased circulation may be susceptible. Cold temperatures cause vasoconstriction, which results in decreased tissue perfusion.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Atherosclerotic arterial occlusive disease

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