Peripheral arterial occlusive disease (PAD) is an arterial insufficiency of the extremities found more often in men and predominantly in the legs. The age of onset and the severity are influenced by the type and number of atherosclerotic risk factors present. Obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below the renal arteries to the popliteal artery.
The diagnosis of PAD may be made using continuous wave (CW) Doppler and ankle-brachial index (ABI) tests, treadmill testing for claudication, duplex ultrasonography, or other imaging studies previously described.
- Walking programs help to reduce symptoms and improve walking durations.
- Weight reduction and smoking cessation further improve activity tolerance.
- Arm-ergometer exercise training effectively improves physical fitness, central cardiorespiratory function, and walking capacity in patients with PAD claudication symptoms.
Pharmacologic Therapy
- Pentoxifylline (Trental) and cilostazol (Pletal) are approved for the treatment of symptomatic claudication. Despite its physiologic effects, however, there has been no positive effect on ABIs at rest or post exercise in multiple trials; therefore, its usefulness is questionable in treatment of PAD.
- Antiplatelet agents such as aspirin or clopidogrel (Plavix) are used to prevent the formation of thromboemboli.
- Statin therapy can be used in some patients to reduce the incidence of new intermittent claudication symptoms and also to help increase walking distance in patients with claudication; however, statin therapy has not improved overall mortality rates in patients without known vascular risks.
Endovascular Management
- Radiologic interventional (endovascular) management can include a balloon angioplasty, stent, stent graft, or an atherectomy.
- These revascularization procedures are less invasive than conventional surgery; their objective is to establish adequate inflow to the distal vessels.
- Nursing care for the patient who has had endovascular revascularization procedures mostly mirrors the care of patients who have had endovascular repair to aortic aneurysms. The patient who has had an endovascular procedure may be discharged home the day of the procedure, or by the following day.
Surgical Management
Surgery is reserved for treatment of severe and disabling claudication or when the limb is at risk for amputation because of tissue necrosis and may include endarterectomy, bypass grafts (synthetic or autologous), and vein grafts.
Outline
Maintaining Circulation Postoperatively
The primary objective in postoperative management of patients who have had vascular procedures is to maintain adequate circulation through the arterial repair.
- Check pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity and compare with those of the other extremity; record values initially every 15 minutes and then at progressively longer intervals.
- Perform Doppler evaluation of the vessels distal to the bypass graft for all patients after vascular surgery because it is more sensitive than palpation for pulses.
- Monitor ABI every 8 hours for the first 24 hours and then once daily until discharge.
- Notify surgeon immediately if a peripheral pulse disappears; this may indicate thrombotic occlusion of the graft.
Monitoring and Managing Potential Complications
- Monitor urine output (more than 30 mL per hour), central venous pressure, mental status, and pulse rate and volume to permit early recognition and treatment of fluid imbalances.
- Monitor for bleeding at the surgical site and the area of anastamosis.
- Instruct patient to avoid leg crossing and prolonged extremity dependence.
- Educate patient to perform leg elevation and to exercise limbs while in bed to reduce edema.
- Monitor for compartment syndrome (severe limb edema, pain, and decreased sensation).
Quality and Safety Nursing Alert
| Before surgery and for 24 hours after surgery, the patient's arm is kept at heart level and protected from cold, venipunctures or arterial sticks, tape, and constrictive dressings. |
Promoting Home- and Community-Based Care
- Assess patient's ability to manage independently or, if necessary, the availability of a support network (family and friends) to assist with daily activities.
- Determine patient's motivation to make lifestyle changes needed with chronic disease.
- Assess patient's knowledge and ability to assess for postoperative complications, such as infection, occlusion of graft, and decreased blood flow.
- Inquire whether patient wants to stop smoking and encourage all efforts to do so; provide local resources to assist the patient's smoking cessation.
For more information, see Chapter 30 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Outline