Arterial disorders that may lead to arterial obstruction include arteriosclerosis obliterans, thromboangiitis obliterans, arterial embolism, and an aneurysm of the lower extremity. A sudden occlusion usually causes tissue ischemia and death, whereas a gradual blockage allows for the development of collateral vessels. Usually, Arterial occlusive diseases are only part of a complex disease syndrome that affects the entire body. Complications include severe ischemia, skin ulceration, gangrene, leg amputation, and sepsis.
Causes of Arterial Occlusive Disease
Arteries can become occluded by atherosclerotic plaque, thrombi, or emboli. The most common cause of acute arterial insufficiency is embolization, with cardiac sources accounting for more than 70% of emboli. Subsequent obstruction and damage to the vessels can follow chemical or mechanical trauma and infections or inflammatory processes. Arteriosclerosis obliterans is marked by plaque formation on the intimal wall of medium-sized arteries, causing partial occlusion. In addition, there is calcification of the media and a loss of elasticity that predisposes the patient to dilation or thrombus formation. Thromboangiitis obliterans (Buerger disease), which is characterized by an inflammatory infiltration of vessel walls, develops in the small arteries and veins (hands and feet) and tends to be episodic. Risk factors include hyperlipidemia, hypertension, and smoking.
Nursing care plan assessment and examination
Elicit a history of previous illnesses or surgeries that were vascular in nature; ask if the patient has been diagnosed with arterial occlusive disease in the past. Determine if a positive family history exists for hypertension or vascular disorders in first-order relatives. Ask if the patient smokes cigarettes; eats a diet high in fats; leads a sedentary lifestyle; or is subject to emotional stress, anxiety, or ulcers. Determine if the patient has experienced any pain, swelling, redness, or pallor. Establish a history of signs and symptoms that may point to the site of occlusion.
Determine if the patient has experienced any transient ischemic attacks (TIAs) because of reduced cerebral circulation. Elicit a history of such signs and symptoms as unilateral sensory or motor dysfunction, difficulty in speaking (aphasia), confusion, difficulty with concentration, or headaches, all of which are signs of possible carotid artery involvement. Ask if the patient has experienced signs of vertebrobasilar artery involvement, such as binocular visual disturbances, vertigo, dysarthria, or episodes of falling down. Determine if the patient has experienced lameness in the right arm (claudication), which is a sign of possible innominate artery involvement.
The specific finding in PAOD is intermittent claudication. The pain is insidious in onset, occurring with exercise and relieved by resting for 2 to 5 minutes; determining how much physical activity is needed before the onset of pain is crucial. The onset of pain is often related to a particular walking distance in terms of street blocks, helps to quantify patients with some standard measure of walking distance before and after therapy.
Determine if the patient’s mesenteric artery is involved by asking if he or she has experienced acute abdominal pain, nausea, vomiting, or diarrhea. Ask the patient if she or he has experienced numbness, tingling (paresthesia), paralysis, muscle weakness, or sudden pain in both legs, which are all signs of aortic bifurcation occlusion. Determine if the patient has experienced sporadic
claudication of the lower back, buttocks, and thighs or impotence in male patients, all of which are indicators of iliac artery occlusion. Elicit a history of sporadic claudication of the patient’s calves after exertion; ask if the patient has experienced pain in the feet—these are signs of femoral and popliteal artery involvement.
Observe both legs, noting alterations in color or temperature of the affected limb. Cold, pale legs may suggest aortic bifurcation occlusion. Inspect the patient’s legs for signs of cyanosis, ulcers, or gangrene. Limb perfusion may be inadequate, resulting in thickened and opaque nails, shiny and atrophic skin, decreased hair growth, dry or fissured heels, and loss of subcutaneous tissue in the digits. Check the patient’s skin on a daily basis.
The most important part of the examination is palpation of the peripheral pulses. Absence of a normally palpable pulse is the most reliable sign of occlusive disease. Comparison of pulses in both extremities is helpful. Ascertain, also, whether the arterial wall is palpable, tortuous, or calcified. Auscultation over the main arteries is useful, as a bruit (sound produced by turbulent flow of blood through an irregular or stenotic lumen) often indicates an atheromatous plaque. A bruit over the right side of the neck is a possible indication of innominate artery involvement.
Occlusive diseases are chronic or lead to chronic illness. They are usually slow in onset, and much irreversible vascular damage may have occurred before symptoms are severe enough to bring the patient for treatment. Treatment is often long and tedious and brings additional concerns regarding finances, curtailment of usual social outlets, and innumerable other problems. Assess the patient’s ability to cope with a chronic illness.
Primary Nursing Diagnosis of this Nursing care plan: Altered tissue perfusion (peripheral) related to decreased arterial flow.
Nursing care plan intervention and treatment
Emphasize to the patient the need to quit smoking or using tobacco and limit caffeine intake. Recommend maintaining a warm environmental temperature of about 21°C (70°F) to prevent chilling. Teach the patient to avoid elevating the legs or using the knee Gatch on the bed, to keep legs in a slightly dependent position for periods during the day, to avoid crossing the legs at the knees or ankles, and to wear support stockings. Explain why the patient needs to avoid pressure on the affected extremity and vigorous massage, and recommend the use of padding for ischemic areas.
Stress the importance of regular aerobic exercise to the patient. Explain that activity improves circulation through muscle contraction and relaxation. Exercise also stimulates collateral circulation that increases blood flow to the ischemic area. Recommend 30 to 40 minutes of activity with warm-up and cool-down activities on alternate days. Also suggest walking at a slow pace and performing ankle rotations, ankle pumps, and knee extensions daily. Recommend Buerger-Allen exercises, if indicated. If intermittent claudication is present, stress to the patient the importance of allowing adequate time for rest between exercise and of monitoring one’s tolerance for exercise.
Provide good skin care, and teach the patient to monitor and protect the skin. Recommend the use of moisturizing lotion for dry areas, and demonstrate meticulous foot care. Advise the patient to wear cotton socks and comfortable, protective shoes at all times and to change socks daily. Advise the patient to seek professional advice for thickened or deformed nails, blisters, corns, and calluses. Stress the importance of avoiding the application of direct heat to the skin. The patient also needs to know that arterial disorders are usually chronic. Medical follow-up is necessary at the onset of skin breakdown such as abrasions, lesions, or ulcerations to prevent advanced disease with necrosis.
Nursing care plan discharge and home health care guidelines
To prevent arterial occlusive disease from progressing, teach the patient to decrease as many risk factors as possible. Quitting cigarette smoking and tobacco use is of utmost importance and may be the most difficult lifestyle change. Behavior modification techniques and support groups may be of assistance with lifestyle changes.
Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and need for routine laboratory monitoring for anticoagulants.
Ensure that the patient understands that the condition is chronic and not curable. Stress the importance of adhering to a balanced exercise program, using measures to prevent trauma and reduce stress. Include the patient’s family in the plans.