Peripheral Vascular Diseases
Peripheral vascular disease is (PAD) is a circulatory problem that causes a decrease in perfusion of the lower extremities. PAD is a prevalent but underdiagnosed manifestation of atherosclerosis (Campia et al., 2019). There is little awareness of its clinical manifestations and the risk of adverse cardiovascular and limb outcomes.
PAD is a chronic progressive disorder that is usually caused by atherosclerosis and mainly affects large and medium-sized vessels. It is primarily driven by the progression of atherosclerosis and leads to microvascular and macrovascular dysfunction (Morley et al., 2018). Blood flow through the arteries is reduced.
Atherosclerosis is a complex inflammatory response. It involves thrombotic factors, vascular cells, cholesterol, and inflammatory molecules. Lipoprotein accumulation in the intimal layer of blood vessels is usually the first step. These develop into more advanced plaques, which accumulate to cause narrowing of arteries.
As narrowing continues, blood flow is gradually obstructed distal to the occluded vessel. Oxygen delivery is unable to match oxygen demand. The most commonly affected vessels are usually the abdominal aorta, iliac arteries, the upper extremities, and the lower limb. The lower extremity vessels are affected more than the upper extremity vessels (Morley et al., 2018).
History and physical assessment findings.
The clinical presentation of PAD is primarily dependent on the presence of comorbid conditions and the severity of arterial insufficiency. Comorbidities may mask or alter the symptoms of the disease. Intermittent claudication is the most classic symptom seen in PAD. It is characterized by a cramping sensation mainly after walking or exercise (Hamburg & Creager, 2017). This is usually associated with fatigue, weakness, and pressure.
Patients may also complain of pain. Elevation of the leg worsens the symptoms and putting the leg in a dependent position relieves the discomfort. Patients may also have paresthesia, lower extremity weakness, and cool extremities. The level of obstruction can be seen one level above the area of discomfort.
Physical examination for PAD begins with inspecting the hands for tar stains on the fingernails. Pallor can be a finding on assessment of the limbs. The pulses can then be examined to check for rate, rhythm, and strength. Diminished pulses on the upper extremities or pulselessness in the lower extremities is an expected finding. Other findings on physical assessment include pallor, muscular atrophy, cyanosis skin, loss of skin hairs, pain on palpation, ulcers, and gangrenous areas.
Around 200 million people are affected by this disease worldwide, with the spectrum of symptoms ranging from none to severe. About 40 -45 million Americans are affected by this disease (Shu & Santulli, 2018). The condition is most common among the elderly, and the prevalence rises with age. It is relatively uncommon among the young population.
The prevalence is more than 20% among individuals who are 80 years and above. The disease was previously perceived to affect men mostly, but recent studies have shown that the prevalence among senior men is equal to the prevalence among senior women. Underdiagnosis is a common issue experienced with PAD as most patients don’t present with the classic symptoms.
Claudication is the stereotypical presentation associated with PAD. (Hamburg & Creager, 2017). Smoking increases the risk of PAD and can increase disease severity. Smokers with PAD have shorter life spans than non-smokers, as smoking contributes to faster progression of the disease.
The standard test for diagnosis is by calculation of the ankle-brachial index. An ankle-brachial index (ABI) is a bedside test used to measure lower extremity arterial perfusion. It compares the systolic blood pressures at the ankle to that of the arm (Firnhaber & Powell, 2019).
Urea, electrolyte, and creatinine test can also be performed. This may reveal impaired kidney function and elevated electrolyte levels. Measurement of inflammatory markers such as CRP can also be done. Other investigations include a coagulation profile, d-dimer tests, ABGs, and INR.
Imaging using a doppler ultrasound is essential to determine the site of blood flow occlusion. It can also be used to measure the flow velocities. CT angiography and MRA can also help determine the site of occlusion (Morley et al., 2018).
Treatment of PAD involves lifestyle modifications, medical therapy, and surgical intervention. Lifestyle modifications focus on the elimination of risk factors. This includes the cessation of smoking, as well as dietary modification.
Medication therapy involves the management of comorbidities that might contribute to the pathogenesis and progression of the disease. This includes the management of diseases such as hypertension, hyperlipidemia, and diabetes (Bevan & White Solaru, 2020). Also, therapies that reduce platelet aggregation should be used. Surgical intervention includes the use of stents, angioplasty, and bypass surgery.
Patients with PAD, especially women below the age of 65, are at an increased risk of experiencing depressive symptoms (Ramirez et al., 2018). The depressive symptoms are accompanied by higher rates of smoking. Depression leads to worse functional outcomes and poorer quality of life.
Nursing Care Plan
Nursing Diagnosis: Ineffective tissue perfusion.
- To maintain maximum tissue perfusion to vital organs.
- To make lifestyle changes
- the patient will have adequate perfusion to organs. This will be evidenced by strong peripheral pulses, warm skin, and normal vitals. The patient will show an increased tolerance to exercise. The patient will also be able to move appropriately without pain and discomfort.
- The patient will also eliminate the risk factors that may accelerate the progression of the disease by making lifestyle changes such as cessation of smoking and exercising.
- Assess for signs of decreased tissue perfusion. This includes the presence of cold extremities, absent peripheral pulses, and skin color changes. Evaluation for decreased perfusion allows the nurse to make future comparisons to the initial findings.
- Review laboratory data such as electrolytes and coagulation profiles. Monitoring the coagulation profile is essential before the commencement of anticoagulants and antiplatelet agents. Knowing the initial baseline ranges is vital to stay within therapeutic levels.
- Monitor peripheral pulses. Loss of pulses can indicate arterial obstruction and can result in limb ischemia.
- Encourage smoking cessation. Smoking increases the risk of PAD by up to four times
- Encourage exercise. this enhances the development of collateral circulation.
- Encourage the patient not to elevate the legs. This decreases the blood supply to the legs.
Peripheral vascular disease leads to narrowing of vessels distal to the arch of the aorta. The most common symptom is claudication. It can also lead to limb ischemia. Intermittent claudication is characterized by pain on the muscle triggered by exercise. Physical exam findings include absent or abnormal pedal pulses, bruits on the femoral artery, delayed venous filling time, and abnormal skin color.
The disease is hard to diagnose because it often has subtle signs and symptoms. The standard test for diagnosis is by calculation of the ankle-brachial index. Treatment of the disease involves lifestyle modifications, medical therapy as well as surgical intervention.
Bevan, G. H., & White Solaru, K. T. (2020). Evidence-Based Medical Management of Peripheral Artery Disease. Arteriosclerosis, Thrombosis, And Vascular Biology, 40(3), 541–553. https://doi.org/10.1161/ATVBAHA.119.312142
Campia, U., Gerhard-Herman, M., Piazza, G., & Goldhaber, S. Z. (2019). Peripheral Artery Disease: Past, Present, and Future. The American Journal Of Medicine, 132(10), 1133–1141. https://doi.org/10.1016/j.amjmed.2019.04.043
Firnhaber, J. M., & Powell, C. S. (2019). Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. American Family Physician, 99(6), 362–369.
Hamburg, N. M., & Creager, M. A. (2017). Pathophysiology of Intermittent Claudication in Peripheral Artery Disease. Circulation Journal: Official Journal of the Japanese Circulation Society, 81(3), 281–289. https://doi.org/10.1253/circj.CJ-16-1286
Morley, R. L., Sharma, A., Horsch, A. D., & Hinchliffe, R. J. (2018). Peripheral artery disease. BMJ (Clinical Research ed.), 360, j5842. https://doi.org/10.1136/bmj.j5842
Ramirez, J. L., Drudi, L. M., & Grenon, S. M. (2018). Review of biologic and behavioral risk factors linking depression and peripheral artery disease. Vascular Medicine (London, England), 23(5), 478–488. https://doi.org/10.1177/1358863X18773161
Shu, J., & Santulli, G. (2018). Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis, 275, 379–381. https://doi.org/10.1016/j.atherosclerosis.2018.05.033