Peripheral vascular disease

Peripheral vascular disease (PVD) is a slow and progressive disease that affects the peripheral circulation. Narrowing, blockage, or spasms in a blood vessel are some contributing factors that can cause PVD. Peripheral vascular disease can disturb any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain and legs, may not get adequate blood flow for suitable function. However, the legs and feet are generally affected. Peripheral vascular disease is also known peripheral arterial disease (PAD). Atherosclerosis is the most common cause of PAD, which is the buildup of plaque inside the artery wall. Plaque reduces the volume of blood flow to the extremities. It also decreases the oxygen and nutrients supply to the tissue. Deep vein thrombosis (DVT) may form on the artery walls, which could resolute in blockage of major arteries.
Assessment
Correct assessment allows a management strategy to be developed with the goal of revising cardiovascular risk, managing symptoms, and preventing major amputation if possible. It is essential that the patient is fully assessed and asked several questions. During the assessment, it is important for the nurse to determine if the patient is exhibiting symptoms of chronic artery insufficiency or chronic venous insufficiency. If there is evidence of edema, ankle flare, atrophie blanche, brown discolored pigmentation, and ulcer in gaiter area, feeling of heaviness in legs or aching, the patient is experiencing peripheral venous insufficiency. Instruct the patient to elevate that extremity to facilitate comfort. The assessment findings for peripheral artery insufficiency is opposite and you want to educate the patient that relief is facilitated when dangling legs. In PAD the patient may experience capillary refill time of fewer than three seconds, a cold foot, pale colored leg, gangrene on toes, loss of hair on the leg, loss of pedal pulses, muscle wasting in calf or thigh and intermittent claudication (Geraghty, 2015).
People with intermittent claudication or with wounds on their legs or feet that are not healing, or unexplained leg pain, should be assessed, particularly if they also have diabetes. The legs and feet should be examined for evidence of skin discoloration or ulceration, and femoral, popliteal and foot pulses should be taken, along with measurement of the ankle brachial pressure index, preferably while the person is resting and lying flat (Linden, 2013).
When assessing the patient’s home as a nurse it is important to look for any safety hazard that could cause further injury. Also assess for swimming pools, tile flooring, signs of smoking, and adequate powders or/and moistures. Patients may be given compression stocking to help facilitate healing. Those compression stocking can cause patients to slip. It is important the patient does not slip and fall causing more injury. Educate the patient on the importance of wearing non-slip socks or house slippers. Foot and leg care for patients with PVD includes applying moisturizing cream to feet and legs daily as well as drying between the toes after showering. The patient should use powder on the feet to keep feet dry. When swimming, water should be warm because cool water causes vasospasm, which can worsen the patient’s condition. Cigarette smoking is by far the most potent risk factor for developing atherosclerosis and intermittent claudication, increasing the risk at least threefold (Furlong, 2015). The goal is to always provide safe efficient care.
Interventions
When dealing with peripheral vascular disease there are some important interventions that the patient must implement in order to see improvement and/or prevent further complications. An important intervention is to teach and have the patient implement healthy lifestyle changes to prevent the condition from worsening. If the patient smokes, a healthy lifestyle change would be to quit smoking. Smoking cessation is essential for slowing down peripheral artery disease which is a form of PVD (Berti-Hearn, 2018). Smoking causes vasoconstriction which decreases the blood flow. Another healthy lifestyle change is having the patient exercise and set realistic goals depending on their condition. Walking is the most effective exercise (Berti-Hearn, 2018). The idea of exercising is that it will encourage the development of collateral circulation that will bypass any blockage (Warren, 2013). If the patient’s diet is high in calories and fats, the nurse should encourage a healthier diet for the patient. Being overweight puts the patient at risk because it affects the way the body deals with glucose and because it increases the blood pressure and cholesterol (Warren, 2013).
Another important intervention would be teaching the patient about proper foot care. Proper foot care is imperative because with having peripheral vascular disease you have insufficient perfusion to the extremities which puts you at risk for infection and possible amputation. You should teach the patient how to inspect the foot for any impaired tissue integrity such as ulcers and to look for any abnormal coloring of the skin which may indicate poor perfusion. It is recommended to wear compression stockings to prevent venous thromboembolism (VTE) which is associated with PVD (Muñoz-Figueroa ; Ojo, 2015).
Medications
Patients with PVD will most likely be prescribed medication to help improve blood flow. Some medications used when dealing with peripheral vascular disease are vasodilators, anticoagulants, and platelet aggregation inhibitors (Kaplan, 2017). Anticoagulants are used to prevent clot extension and formation. Some examples of anticoagulants are warfarin and heparin. Anticoagulants thin out the blood, when taking these medications you should avoid anything invasive that could cause bleeding. It is important to teach the patient to report any symptoms of unusual bleeding or bruising to health care professional immediately (Vallerand, Sanoski ; Deglin, 2017).
Vasodilators are medicines the open the blood vessels so that the blood can flow more sufficiently. An example of a vasodilator which is also known as an antihypertensive drug is nifedipine. Nifedipine helps lower blood pressure, the patient should monitor their blood pressure for it can cause hypotension. Also, the patient should be taught to change positions slowly to minimize orthostatic hypotension (Vallerand, Sanoski ; Deglin, 2017).
Platelet aggregation inhibitors prevent the formation of blood clots in the blood vessels by stopping the platelets from sticking together. Clopidogrel or aspirin is commonly used when treating this disease, these medications reduce the occurrence of cardiovascular events such as stroke and myocardial infarction. The patient should notify health care professional of any adverse effects such as fever, weakness, and chills occur.
Long-term Complications
Peripheral vascular disease (PVD) impacts the way people function in their everyday lives. PVD is a lifelong chronic medical condition and is one of the most frequent causes of pain in the lower extremity (Ustundag ; Gul ; Findik, 2016). The same risk factors that cause atherosclerosis are the same risk factors for PVD. Cigarette smoking speeds up the progression of the disease.
A careful care plan for patient includes clinical evaluation by a healthcare provider who specializes in vascular disorders. After the patient have been hospitalized or diagnosed with PVD the patient needs to be educated about postoperative complications, knowledge of the disease, compliance with medication, and clinic follow-ups. Nurses need to take every opportunity to assess the patient’s learning needs, and choose ways to educate. Ongoing care focuses on cardiovascular risk reduction with physical and medical therapy. Patients with PVD must optimize functional status with structured exercise, and, when indicated, revascularization (Herman & Gornik, 2017). Care plans are customized depending on the patient and must be taken into consideration the level of treatment needed. Nurses can evaluate the patient’s progress by either in the home or at follow-up sessions. Each follow-up the nurse should evaluate the patient’s commitment, physical improvement, and knowledge. Continuous assessments of labs, tissue integrity checks, circulation and pain assessments are possible in home programs available to patients, to decrease further damage to wounds and extremity pain.
After specialized treatments and procedures are performed, ongoing management is required to prevent complications (Herman & Gornik, 2017). A good quality of life can be achieved through different treatments and lifestyle changes. These treatments are set in place to improve the survival rate in patients diagnosed with this type of chronic disease. Patients suffering from PAD generally suffer from pain caused by walking, or claudication. If claudication is left untreated, the patient’s quality of life will be negatively impacted due to decreased ability to walk. Managing PAD can start with the nurse to patient education by stressing lifestyle changes. Patients must be made aware that smoking leads to progression of PAD and increases the risk for cardiovascular problems (Ustundag, Gul ; Findik, 2016).
Unmanaged hypertension and diabetes increase challenges of cardio and renal functions. These, in turn, increases the risk of developing peripheral vascular disease. Patients can decrease complications by adhering to supervised exercise programs. These programs are recommended to improve functional status and to minimize complications from leg symptoms. The nurse can assist the patient with walking or completing a set of isometric exercises. Without proper treatment and management, patients with claudication can progress to chronic limb ischemia (CLI).
Revascularization can help prevent the progression involved with claudication which impacts the activities of daily living (Herman ; Gornik, 2017). Patients with CLI are at risk for amputations and cardiovascular ischemic episodes (Herman ; Gornik, 2017). Unmanaged PAD could lead to complications with tissue loss due to wounds and foot infections. Wound healing therapies are put in place, to minimize tissue loss, completely heal wounds, and preserve a functional foot (Herman ; Gornik, 2017). Patients with primary diseases such as diabetes should be educated about self-foot exams and foot care to prevent complications associated with amputations (Herman ; Gornik, 2017). Nurses or nutritionist can provide in-home education involving a diet high protein, vitamin C and A, iron, and zinc to promote healing of wounds.
Costs
There are many factors that may impact the cost of vascular interventions (Herman ; Gornik, 2017). The cost associated with PVD can vary widely depending on the resources required, and the extent and severity of the vascular damage which also has a substantial impact on the price of treatment (Herman ; Gornik, 2017). Hospitalization and drug treatments are considered cost related treatment. The cost of medication is based on the patient’s individual needs; many medications are used in combinations to achieve a therapeutic goal. Because treatment of vascular disease also includes the use of platelet aggregation inhibitors, blood pressure lowering medication, glucose-lowering medications, and cholesterol-lowering medications, treatments cost skyrocket (Fanari & Weintraub, 2015). The use of antiplatelet agents was effective in reducing the risk of vascular occlusion (Fanari & Weintraub, 2015).
Many of the costs of a specific therapeutic/invasive procedure; for example, the prices for angioplasty are much higher for patients with critical ischemia and tissue necrosis than for patients with disabling claudication which can be due to higher complication rates and more extended hospital stays (Fanari & Weintraub, 2015). Other matters to consider are that amputation has been shown to be about twice as expensive as a limb salvage with either interventional or surgical (Fanari & Weintraub, 2015). For patients with intermittent claudication pain, the cost can range up to an average of $650 per year, while patients with critical leg ischemia, the cost of treatments can range up to an average of $4,478 per year. Similarly, patients with ischemic tissue necrosis cost of therapy can cost an average of $9,353 per year (Fanari & Weintraub, 2015).
The cost for patients who need noninvasive therapy procedures; for example, exercise therapy, an effective treatment to increase walking distance along with improving symptoms; can range up to an average of $2,124 per year (Fanari & Weintraub, 2015). This test includes a 12-month treadmill test. Cost-effectiveness of different therapies in PVD should be considered with the patient in mind with the overall goal to improve quality of life.
Peripheral vascular disease is a very expensive drag on today’s healthcare system, and the cost will only continue to go up. This disease is preventable. Patient’s must be educated in simple lifestyle changes as preventive measures, like quitting smoking, controlling diabetes, controlling blood pressure, and controlling cholesterol. Too many patients take these simple practices for granted.