Peripheral Artery Disease
Approximately 1.5 million people live in 17,000 nursing homes within the United States. Ninety percent are 65 years or older and 24 percent are 85 years or older. It is estimated that by 2030, more than 8 million seniors will reside in nursing homes or long-term care facilities. Reports show that with the advance in years comes an increase in sedentary lifestyles. This decline in mobility combined with a decrease in circulation gives rise to circulatory problems such as stroke, heart attacks and peripheral vascular disease, also known as peripheral artery disease (PAD).
Physical activity is undoubtedly an important health benefit. Research shows that physical activity can reduce the risk of certain chronic diseases, relieve symptoms of depression, help maintain independent living, and enhance the overall quality of life. Data from the National Center for Health Statistics show the most common types of exercise among older Americans were light to moderate activities such as walking, gardening, and stretching. More than 21 percent of the older population reported that they would like to be doing more while 63.9 percent felt they were doing enough and 2.3 percent thought they were doing too much.1
ஐﻬ WHAT IS PAD?
PAD occurs because of a decrease in oxygen-rich blood flow to the blood vessels or arteries that supply the legs. This decrease in circulation is usually caused by a narrowing or blockage in the blood vessels.1 As you know, arteries are blood vessels that carry blood away from the heart to the rest of the body, always under a great deal of pressure. The artery wall has three layers: the intima, the media and the adventitia. The intima consists of epithelial cells and is the innermost layer, which is closest to where blood flows through the artery. The media is the middle layer, consisting of elastic connective tissue and smooth muscle tissue, which are surrounded by a network of collagenous, elastic fibers. The outermost layer of the arterial wall consists of fibrous connective tissue.
Arterial walls lose some of their elasticity and vasomotor tone with normal aging. It is now thought that vascular aging may occur at different rates and to varying degrees in different individuals and among races and societies. The artery has difficulty complying with the changes in the body's needs and therefore cannot meet the demand. Increased peripheral vascular resistance elevates blood pressure along with an increase in vasopressor, which increases systolic and diastolic pressures. 2
Atherosclerosis is a major contributor to PAD. Atherosclerosis comes from the Greek words athero meaning paste and sclerosis meaning hardness. This hardening and narrowing of the arteries builds up plaque in the walls of the artery. Plaque is the deposit of fats, cholesterol and other substances. This plaque formation can reduce the blood flow through an artery or completely block it.
ஐﻬ WHO IS AT RISK?Promoting a healthy endothelium, the inner lining of your blood vessels, may be the key to maintaining strong blood vessels and preventing atherosclerosis and other circulatory problems. Identifying the risk factors is the first step in tackling PAD.
• Cigarette smokers: May be diagnosed with PAD 10 years earlier than non-smokers.
• Obesity: Diets high in saturated fats and cholesterol increase the risk of cardiovascular problems.
• Diabetes mellitus: People with type 2 diabetes have 3-4 times the normal risk for PAD. They also tend to develop PAD at earlier ages and to have more severe cases.
• Hypertension: High blood pressure almost doubles the chances of developing PAD.
• Pulse pressure greater than 70 mm Hg: The difference between the systolic (top) number of the blood pressure and diastolic (bottom) number is called the pulse pressure. Normal range is between 30 and 50 mm Hg. The higher the number, the greater the damage or stiffening of blood vessels.
• Hypercholesterolemia: The risk of PAD is increased by at least 10 percent with every 10 mg/dl increase in total cholesterol levels. These patients also tend to have lower high-density lipoprotein (HDL, or good cholesterol) and high triglyceride levels.
• Elevated C-reactive protein levels: These elevated levels are indicators of persistent inflammation in the arteries, which is now known to cause significant damage in blood vessels. This inflammatory damage is associated with PAD.
• Physical inactivity: Decreased exercise can exacerbate chronic diseases, increase the risk of osteoporosis and increase the risk of cardiovascular events. 3
ஐﻬ SIGNS & SYMPTOMSA client may have no symptoms at all or may report a cramping pain, tiredness in the legs, thighs, calves or hip muscles while exercising, walking or climbing stairs. This pain is referred to as an intermittent claudication and usually occurs with exercise but goes away with rest. The pain occurs because of the lack of blood flow to the extremity.4 The muscles need more blood flow when they are being used. If the blood supply does not meet the demand, the patient has pain. Calf muscles may become withered and reddish in color when in a dependent position but pale when elevated. The skin will have an absence of hair, and may appear smooth and shiny while the nails become hardened and brittle. In advanced PAD, black, painful ulcers may develop; they do not bleed.
ஐﻬ DIAGNOSTIC STUDIESWhen diagnosing PAD, healthcare providers can use several methods.
• Ankle-brachial index (ABI): Compares blood pressure in the feet to that in the arms to determine how well blood is flowing in the artery.
• Doppler and ultrasound imaging: Noninvasive test done to evaluate blood flow in the major veins and arteries.
• Magnetic resonance angiography: Allows the visualization of blood flowing through the cerebral vessels.4
ஐﻬ TREATMENT MODALITIESThere are two primary goals in the treatment plan of PAD. The first goal is to manage the pain of intermittent claudication, improve functioning and prevent progression of the disease that could lead to gangrene or amputation. The second is to reduce the risk of cardiovascular events such as heart attack and stroke. To meet these goals, the provider screens the patient for risk factors, particularly diabetes mellitus, as people with type 2 diabetes have 3-4 times the risk for PAD, heart disease and severe complications in the legs and feet.
Since cigarette smoking may be directly responsible for about 20 percent of all deaths from heart disease, advise patients to stop smoking.
A heart-healthy diet is recommended to maintain appropriate levels of cholesterol and lipids as well as maintain normal blood pressure and weight. Good hydration is important. Some providers may approve a glass of red wine every other day, which is believed to actually help circulation. Patients are normally steered away from alternative or natural remedies because these products are generally not regulated.
Regular exercises like walking or swimming are highly recommended. The exercise plan should include a fair amount of intensity, an established length of time and a frequency of about 3-4 times per week. Weight-bearing exercises are better at building strength and muscle mass and have lifelong benefits for the cardiovascular system.2
Another modality of treatment is the intermittent pneumatic compression device. This cuff-like apparatus encloses the lower leg and exerts pressure in waves to stimulate the natural increase in blood flow during walking.
Medications also may be used in the treatment of PAD to help manage leg pain and improve overall functioning. Aspirin, Plavix (clopidogrel), or Pletal® (cilostazol) are examples of anti-platelet agents given to prevent blood clots and to open blood vessels. Thrombolytics or clot-busters such as Activase® (alteplase) and Retavase® (reteplase) are agents given to break up existing clots. Mevacor®, Pravachol® and Zocor® are statins prescribed to aggressively treat high cholesterol levels. New studies have showed statins also to be beneficial in improving symptoms of intermittent claudication and reducing the risk of heart attack and stroke. Angiotensin converting enzyme (ACE) inhibitors like Capoten (captopril), Vasotec® (enalapril), Accupril® (quinapril) and Lotensin® (benazepril) prevent the conversion of angiotensin I to angiotensin II, a very potent vasoconstrictor. Its action also reduces peripheral vascular resistance and therefore lowers the blood pressure.5
Surgical procedures open obstructed blood vessels by using angioplasty or performing bypass grafts. In a percutaneous transluminal angioplasty, the obstructed blood vessels are opened. The vascular surgeon inserts a wire through the artery in the groin and passes it to the obstructed area. Once in place, a deflated balloon is passed over the wire to the obstruction, then inflated to open the artery.6 This procedure only requires local anesthetic and the patient can usually return to normal activity in 24-48 hours.
When performing a surgical bypass graft, the surgeon uses a natural vein taken from a different location in the leg or one made by synthetic material and re-routes the flow of blood around the obstructed area.2
ஐﻬ THE NURSE'S ROLENursing care should consist of assessing the peripheral vascular system. The nurse will assess:
Pain: Location, characteristics, duration, intensity rated on a scale of 0-10.
Pulse: rate, rhythm and quality. If the nurse is unable to palpate the pedal pulse a Doppler should be obtained to verify circulation is present.
Pallor or cyanosis: Does the skin feel warm, cool or clammy?
Paresthesia and paralysis: Look for signs of edema, which may be unilateral or bilateral, pitting or non-pitting.
Blood pressure: Calculate the pulse pressure after measuring the blood pressure.7
A nursing diagnosis for a client with peripheral vascular disease may include any of the following:
• Altered peripheral tissue perfusion
• Pain related to decrease arterial flow
• Altered nutrition
• Immobility
• Knowledge deficit