Nursing Process: The Patient Who Has Peripheral Arterial Insufficiency of the Extremities

NURSING PROCESS:THE PATIENT WHO HAS PERIPHERAL ARTERIAL INSUFFICIENCY OF THE EXTREMITIES

Assessment

The nursing assessment includes a complete health and medica-tion history and identification of risk factors for peripheral artery disease. Signs and symptoms detected during the nursing assess-ment may include claudication pain; rest pain in the forefoot; pallor, rubor, or cyanosis; weak or absent peripheral pulses; and skin breakdown or ulcerations.

Nursing Diagnosis

Based on assessment data, major nursing diagnoses for the patient may include the following:

·      Ineffective peripheral tissue perfusion related to compro-mised circulation

·      Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen

·      Risk for impaired skin integrity related to compromised circulation

·      Deficient knowledge regarding self-care activities

Planning and Goals

The major goals for the patient may include increased arterial blood supply to the extremities, promotion of vasodilation, pre-vention of vascular compression, relief of pain, attainment or main-tenance of tissue integrity, and adherence to the self-care program.

Measures used by the patient and members of the health care team to accomplish a single goal must be evaluated in terms of the positive and the negative effects these measures may have on the simultaneous achievement of other goals. An overview of the care of a patient with peripheral arterial problems is provided in the Plan of Nursing Care: The Patient With Peripheral Vascular Problems.

Nursing Interventions

IMPROVING PERIPHERAL ARTERIAL CIRCULATION

Arterial blood supply to a body part can be enhanced by position-ing the part below the level of the heart. For the lower extremities, this is accomplished by elevating the head of the patient’s bed on 15-cm (6-inch) blocks or by having the patient use a reclining chair or sit with the feet resting on the floor.

The nurse can assist the patient with walking or other moder-ate or graded isometric exercises that may be prescribed to pro-mote blood flow and encourage the development of collateral circulation. The nurse instructs the patient to walk to the point of pain, rest until pain subsides, and then resume walking so that en-durance can be increased as collateral circulation develops. Pain can serve as a guide in determining the amount of exercise appro-priate for an individual. The onset of pain indicates that the tis-sues are not receiving adequate oxygen, signaling the patient to rest before continuing activity. However, a regular exercise program can result in increased walking distance before the onset of clau-dication. The amount of exercise a patient can tolerate before the onset of pain is determined to provide a baseline for evaluation.

Not all patients with peripheral vascular disease should exercise. Before recommending any exercise program, the primary health care provider should be consulted. Conditions that worsen with ac-tivity include leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions.

PROMOTING VASODILATION AND PREVENTING VASCULAR COMPRESSION

Arterial dilation promotes increased blood flow to the extremities and is therefore a desirable goal for patients with peripheral arte-rial disease. However, if the arteries are severely sclerosed, inelas-tic, or damaged, dilation is not possible. For this reason, measures to promote vasodilation, such as medications or surgery, may be only minimally effective.

Nursing interventions may involve applications of warmth to promote arterial flow and instructions to the patient to avoid ex-posure to cold temperatures, which causes vasoconstriction. Adequate clothing and warm temperatures protect the patient from chilling. If chilling occurs, a warm bath or drink is helpful.

When heat is applied directly to ischemic extremities, the tem-perature of the heat source must not exceed body temperature. Even at lower temperatures, burn injuries can occur in ischemic extremities. Excess heat may increase the metabolic rate of the ex-tremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.

Nicotine causes vasospasm and can thereby dramatically re-duce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Patients with arterial insufficiency who use tobacco (ie, smoke, chew) must be fully informed of the effects of nicotine on circu-lation and encouraged to stop using tobacco.

Emotional upsets stimulate the sympathetic nervous system, resulting in peripheral vasoconstriction. Although emotional stress is unavoidable, it can be minimized to some degree by avoiding stressful situations when possible or by consistently fol-lowing a stress-management program. Counseling services or re-laxation training may be indicated for people who cannot cope effectively with situational stressors.

Constrictive clothing and accessories such as tight socks, panty girdles, and shoelaces impede circulation to the extremities and promote venous stasis and therefore should be avoided. Cross-ing the legs should be discouraged because it compresses vessels in the legs.

RELIEVING PAIN

Frequently, the pain associated with peripheral arterial insuffi-ciency is chronic and continuous. It limits activities, affects work and responsibilities, disturbs sleep, and alters patients’ sense of well-being. Patients are often depressed, irritable, and unable to exert the energy necessary to execute prescribed therapies, mak-ing pain relief even more difficult. Analgesics such as oxycodone plus acetylsalicylic acid (Percodan) or oxycodone plus acetamin ophen (Percocet) may be helpful in reducing pain to the point where the patient can participate in the therapies that can increase circulation and ultimately relieve pain more effectively.

MAINTAINING TISSUE INTEGRITY

Poorly nourished tissues are susceptible to damage and infec-tion. When lesions develop, healing may be delayed or inhib-ited because of the poor blood supply to the area. Infected, nonhealing ulcerations of the extremities can be debilitating and may require prolonged and often expensive treatments. Am-putation of an ischemic limb may eventually be necessary. Mea-sures to prevent these complications must be a high priority and vigorously implemented.

Trauma to the extremities must be avoided. Advising the pa-tient to wear sturdy, well-fitting shoes or slippers to prevent foot injury and blisters may be helpful, as may be recommending neu-tral soaps and body lotions to prevent drying and cracking of skin. Scratching and vigorous rubbing can abrade skin and create a site for bacterial invasion; therefore, feet should be patted dry. Stock-ings should be clean and dry. Fingernails and toenails should be carefully trimmed straight across and sharp corners filed to follow the contour of the nail. If nails are thick and brittle and cannot be trimmed safely, a podiatrist must be consulted. Corns and calluses need to be removed by a health care professional. Special shoe in-serts may be needed to prevent calluses from recurring. All signs of blisters, ingrown toenails, infection, or other problems should bereported to health care professionals for treatment and follow-up. Patients with diminished vision may require assistance in periodi-cally examining the lower extremities for trauma.

Good nutrition promotes healing and prevents tissue break-down and is therefore included in the overall therapeutic program for patients with peripheral vascular disease. Eating a well-balanced diet that contains adequate protein and vitamins is nec-essary for patients with arterial insufficiency. Key nutrients play specific roles in wound healing. Vitamin C is essential for colla-gen synthesis and capillary development. Vitamin A enhances epithelialization. Zinc is necessary for cell mitosis and cell prolif-eration. Obesity strains the heart, increases venous congestion, and reduces circulation; therefore, a weight-reduction plan may be necessary for some patients. A diet low in lipids may be indi-cated for patients with atherosclerosis.

PROMOTING HOME AND COMMUNITY-BASED CARE

The self-care program is planned with the patient so that activities that promote arterial and venous circulation, relieve pain, and pro-mote tissue integrity are acceptable. The patient and family are helped to understand the reasons for each aspect of the program and the possible consequences of nonadherence. Long-term care of the feet and legs is of prime importance in the prevention of trauma, ulceration, and gangrene. The Plan of Nursing Care describes nurs-ing care for patients with peripheral vascular disease. Chart 31-3 provides detailed patient instructions for foot and leg care.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Demonstrates an increase in arterial blood supply to extremities

a)     Exhibits extremities warm to touch

b)    Has improved color of extremities (ie, free of rubor or cyanosis)

c)     Experiences decreased muscle pain with exercise

d)    Demonstrates an increase in walking distance or duration

2)    Promotes vasodilation; prevents vascular compression

a)     Protects extremities from exposure to cold

b)    Avoids use of tobacco

c)     Uses stress management strategies to minimize emo-tional upset

d)    Wears nonconstricting clothing

e)     Avoids leg crossing

f)      Takes medication as prescribed

3)    Has decrease in severity and duration of pain

4)    Attains or maintains tissue integrity

a)     Avoids trauma and irritation to skin

b)    Wears protective shoes

c)     Adheres to meticulous hygienic regimen

d)    Eats a healthy diet that contains adequate protein, vita-mins A and C, and zinc

e)     Performs self-care activities