Most

common affected is femoralpopliteal area in patients who do not

have diabetes

Patients

with diabetes usually develop

in arteries below the knees

http://www.youtube.com/watch?v=I4

jxjWIbWyg

 Intermittent
Define

claudication classic for PAD!

claudication ___________________

Due to waste product _______________________

Define Paresthesia ___________________________

Peripheral Neuropathy _______________________

Claudication (intermittant)

Neuropathy (peripheral)

May need a device to keep

the sheets/blankets from
touching the clients skin
Occurs in diabetic clients

Diminished blood flow

Skin: thin, shiny, taut
Loss of hair growth
Elevation pallor
Dependent rubor
or absent pulses
Pain
pain at night
Ulceration/gangrene

Often in forefoot/toes
Over boney areas

Atrophy: skin & muscles

Delayed healing

Tissue necrosis

Infection

Gangrene

Amputations

While working in the outpatient clinic, the

nurse notes that the chart states that a patient
has intermittent claudication. Which of these
statements by the patient would be consistent
with this information?

a. My fingers hurt when I go outside in cold

weather.
b. Sometimes I get tired when I climb a lot of
stairs.
c. When I stand too long, my feet start to swell
up.
d. My legs cramp whenever I walk more than a
block.

Treatment goal: aggressively modify

cardiovascular risk factors (patients are at
high risk for cardiovascular-related death)

Smoking cessation is essential!

Aggressive treatment of hyperlipidemia

Tight control of diabetes and HTN

Inhibits synthesis of cholesterol in liver

LDL (bad cholesterol) and HDL

Take at night for increased effectiveness

Lower dosages should be Rxd for Chinese people

SE: GI upset, HA, muscle cramps, monitor for liver

damage
Warning: Instruct client to report any muscle
aches/weakness- can lead to rhabdomyolysis

Common Drugs:
A-tor-va-statin (Lipitor)
Prava-statin (Pravachol)
Lova-statin (Mevacor)
Simeva-statin (Zocor)
Meva-statin
Rosu-va-statin (Crestor)

We are Fam-ily

Drugs: Antiplatelet agents, ACE inhibitors, Trental

and Pletal to treat claudication
Exercise: improves oxygen extraction in legs,
muscle metabolism, vascular endothelial function
(walking is most effective)
Nutrition: normal weight, reduced fat & sodium
Alternative: ginkgo biloba and others being used.
Insufficient data on effectiveness. Consult with
physician before using, has side effects and
bleeding risk if used with antiplatelets, NSAIDs,
anticoagulants

Aspirin- BASA or ASA- Watch for GI symptoms

Clopidogrel (Plavix), prasugrel (Effient), ticlopidine (Ticlid)- more

expensive, work better when used in conjunction with other meds

Inhibit platelet adhesion & aggregation

Used to prevent thrombus formation

Stop before surgeries, dental work,

invasive procedures

Bleeding Precautions

A patient with PAD has a new prescription for

clopidogrel (Plavix). Which information should
the nurse include when teaching the patient
about this medication?
a. Call if you notice that your stools are
black or have blood in them.
b. Take the Plavix on an empty stomach as
soon as you get up.
c. Change position slowly to avoid
dizziness while you are taking Plavix.
d. You should not take acetaminophen
while you are taking the Plavix.

When developing a teaching plan for a

patient newly diagnosed with PAD, which
information should the nurse include?
a. Try to keep your legs elevated
whenever you are sitting.
b. Exercise only if you do not experience
pain.
c. It is important to try to stop smoking.
d. Put on support hose early in the day
before swelling occurs.

Critical limb ischemia: protect from trauma,

maximize perfusion
Radiologic procedures: balloon angioplasty,
stents (high rate of re-stenosis)
Surgical therapy:
peripheral arterial bypass to carry blood
around lesion (graft or autogenous vein)
Endarterectomy (open up and take out
plaque)
Amputation may be required

Goals:
Adequate tissue perfusion
Relief of pain
Increased exercise tolerance
Intact, healthy skin on extremities

Health promotion
Assess patients risk factors and teach how to control
Screen for PAD, hyperlipidemia, HTN, obesity, & diabetes
Educate about hazards of tobacco use, importance of

regular physical activity, diet modification, proper care

of feet, avoidance of injury, regular follow-up

Following patient teaching, for a patient with

chronic 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 change my position every hour and
avoid long periods of sitting with my legs down.
c. I will use a heating pad on my feet at night to
increase the circulation and warmth in my feet.
d. I will walk to the point of pain, rest, and walk
again until I develop pain for a half hour daily.

Clot in vein due to inflammation

Superficial Vein Thrombosis (SVT)

Venous Thromboembolism (VTE)

(used to be called DVT)

(used to be called Thrombophlebitis)

Most common cause in upper extremity is IV
therapy

most common in iliac and femoral veins

***Terms can be used interchangeably at this point***

VTE includes DVTs and the potential complication of a PE

 Virchows triad:
venous stasis (pooling)
damage of endothelium (which
activates platelets)
hypercoagulability of blood

In a client diagnosed with Superficial Vein

Thrombosis (Thrombophlebitis) which
intervention would be included in the
clients care
A. cold packs
B. warm packs

The 45-year-old man presents with leg pain,

redness, and warmth of the extremity. He has
recently returned from a business trip to China. He
does not smoke or use illicit drugs. He is married
with two small children. Which factor puts this
client at greatest risk for developing venous
thromboembolism?
A. Age
B. Gender
C. Health habits
D. Immobility

SVT / Thrombophlebitis formation

http://www.youtube.com/watch?v=eLcl
6wbvKjo

VTE / DVT formation

http://www.youtube.com/watch?v=CETf
ozL0cQg&feature=related

May or may not have:

Unilateral leg edema, extremity pain, warm
skin, erythema, temp greater than 100.4
If calf involved, may be tender to palpation
Homans sign is classic but very unreliable sign
If IVC involved, lower extremities may be
edematous and cyanotic
If SVC involved, may be symptoms in arms,
neck, face, back
Most serious complication is PE

Early

mobilization is easiest and

most cost-effective prevention!
TED hose (compression stockings)
done right
Intermittent compression devices
Preventive anticoagulation
Stay hydrated!

Nonpharmacologic:

if hospitalized,
bedrest, elevate extremity,
anticoagulants, warm compresses
Drugs: anticoagulants can prevent clots,
but once clot is built, goal is to prevent
its growth, any new clots, and
embolization
Anticoagulants dont dissolve clot,
bodys own system initiates fibrinolysis
spontaneously

Warfarin (coumadin)
monitor INR (its a PT prothrombin time, compared

with a control)
Admin PO takes 3-5 days to reach therapeutic levels.
Antidote is Vit K
Patients can take it for 3-6 months after DVT resolved

Heparin (UH and LMWHs)

Measured by aPTT Partial Thromboplastin time.

IV for treatment.
SQ for prevention. Example SQ is Lovenox
Antidote protamine sulfate

The drugs work on different clotting cascades

and are often used together

The health care provider has prescribed the

client sodium warfarin (Coumadin) while he or
she is still receiving intravenous heparin. Which
is the nurses best action?
a. Administer the medications as prescribed.
b. Turn off the heparin drip for 1 hour before
administration of the warfarin.
c. Discontinue the heparin drip completely
before warfarin administration.
d. Hold the dose of warfarin.

Which symptom reported by the

postoperative client with a total hip
replacement is the result of a deep vein
thrombosis (VTE / DVT) and requires
emergency action?
A. Localized swelling of one of the lower
extremities
B. Positive Homan's sign
C. Shortness of breath and chest pain
D. Tenderness and redness at the IV site

Acute: goal is prevent emboli, reduce

edema
Review meds and herbals for interference with

coagulation therapy
Monitor labs
Reduce risk of bleeding (monitor urine and stool,
incisions, avoid IM injections)

Home care: modify risk factors for VTE / DVT

TEDs (2yrs post VTE) , labs, meds, follow-up
Teach: quit smoking, no constrictive clothing, OC

and HRT may be contraindicated, avoid

prolonged standing or sitting, S&S of PE, prevention
of bleeding

 Risk

factors:
Hereditary, females, hormone use, age, obesity,
pregnancy, venous obstruction, prolonged
standing occupations
Pathophysiology:
Superficial veins enlarge, valves stretched and
become incompetent, venous blood flow is
reversed. Back pressure increases, further
venous distention, pressure causes fluid to leave
capillary bed into tissues causing edema

Varicose vein
formation
http://www.youtube.c
om/watch?v=49jUyBu4
M1Q&feature=related

Not

indicated if only cosmetic problem

Sclerotherapy: injection for small veins
Laser therapy/light therapy: heat
hemoglobin, injures endothelium, vessel
scleroses
Surgery: ligation of vein (usually greater
saphenous) and removal of incompetent
tributaries

A 42-year-old service-counter worker

undergoes sclerotherapy for treatment of
superficial varicose veins at an outpatient
center. Before discharging the patient, the
nurse teaches the patient that

a. exercises such as walking or jogging cause

recurrence of varicosities.
b. sitting at the work counter, rather than
standing, is recommended.
c. taking one aspirin daily will help prevent
clotting around venous valves.
d. compression stockings should be applied
before getting out of bed.

 Prevention:

avoid sitting or standing for

long periods, maintain normal body
weight, avoid injury, avoid constrictive
clothing, walk daily
After surgery: deep breathing, check for
color, movement, sensation,
temperature, edema, pedal pulses,
elevate legs, TEDs (remove every 8 hours
for short period then reapply)

 Long-term:

improve circulation,
relieve discomfort, improve
cosmetic appearance, avoid
complications
Teach: cleanliness, put on TEDs
before getting out of bed, elevate
legs, lose weight, change
positions frequently

A 63-year-old patient states, 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. ask about any skin color changes that

occur in response to cold.
b. check for the presence of tortuous veins
bilaterally on the legs.
c. assess for unilateral swelling, redness, and
tenderness of either leg.
d. attempt to palpate the dorsalis pedis and
posterior tibial pulses.

A patient recovering on a general surgical

unit from an aortic valve replacement 1 week
ago develops sudden severe pain,
pulselessness, pallor, and coolness in the left
leg. The nurse should notify the health care
provider and
a. elevate the left leg on a pillow.
b. apply an elastic wrap to the leg.
c. keep the patient in bed in the supine
position.
d. assist the patient in gently exercising the
leg.

The nurse is teaching the young female client

how to prevent venous thromboembolism
specific to her hospital stay after intensive
orthopedic surgery. Which client statement
indicates the need for further teaching?

A. ''I must stop taking my birth control pills.''

B. ''I should drink lots of water so I don't get
dehydrated.''
C. ''I should exercise my legs when I have
been sitting or standing for a long time.''
D. ''If I wear pantyhose, I won't have to wear
the stockings the hospital gives me.''