Med-Surg - Cardiovascular System, part 17: Peripheral Arterial Disease, Peripheral Bypass Graft

Hi, I'm Cathy with Level Up RN. In this video, I'm going to talk about peripheral arterial disease, or PAD, as well as a peripheral bypass graft. At the end of the video, I'm going to give you guys a little quiz to test your understanding of some of the key concepts I'll be covering in this video. So definitely stay tuned for that, and be sure to pull out your Level Up RN medical surgical nursing flashcards so you can follow along with me.

With peripheral arterial disease, or PAD, we have inadequate blood flow to the extremities. So blood is having a hard time getting down into the legs. This is different than peripheral venous disease, where blood is having no problem getting into the extremities, but it's having issues getting back up to the heart.

So with peripheral arterial disease, or PAD, this is caused by atherosclerosis, which either partially or totally occludes the blood vessels, which impairs blood flow down into the extremities. And this deprives the extremities of the oxygen and the nutrients that they need.

Risk factors include hypertension, diabetes, smoking, obesity and hyperlipidemia.

Signs and symptoms include intermittent claudication. So this means that the patient is going to have leg pain that is worse with exertion, like when they're walking, and it will feel better when they dangle their legs in a dependent position. So I once had a patient with severe PAD who definitely had this intermittent claudication, and the only position that he was comfortable in was laying in his hospital bed with his legs kind of draped over the side of the bed, so dangling. So in order to do wound care on his wounds on his legs, I had to sit on the floor to take care of those wounds, which was kind of a bummer.

Other signs and symptoms of PAD include delayed capillary refill, as well as decreased pedal pulses. In addition, the patient will likely have lack of hair on their calves, and the skin over that area will be cool and shiny. In addition, when they elevate their legs, they will become pale so they'll have pallor. And that makes sense, right? Because if we already have decreased blood flow into the extremities, if you lift those up, elevate the legs, that's going to decrease blood flow even more, which is why they turn pale. And then when they dangle their legs in a dependent position, they will turn red. The blood flow will go down there, so we'll have dependent rubor.

In addition, patients who have PAD often have wounds on their feet. They usually occur on the toes, and these wounds will be dry and necrotic, typically filled with eschar. And they will also have delayed wound healing because in order for a wound to heal, it needs oxygen and it needs nutrients. And we're not getting those because of that impaired blood flow.

So patients with PAD will have delayed wound healing, if those wounds heal at all.

In terms of diagnosis, we can do what's called an ankle brachial index, or ABI. That's where we compare the patient's ankle blood pressure to their arm blood pressure. And if their ankle blood pressure is greatly decreased, then that's indicative of PAD. We can also do a Doppler ultrasound to assess for blood flow into the extremities.

Treatment of PAD includes medications such as statins and antiplatelets. Surgical procedures that can be used include an angioplasty. So that attempts to open up those arteries to restore blood flow to the lower extremities. We can also do a peripheral bypass graft, which we're going to talk more about here in a minute.

In terms of patient teaching, because intermittent claudication is an issue with PAD, when your patient experiences pain while walking, they should stop and rest a little bit until that pain subsides and then walk a little more. We also want to advise our patient to avoid restrictive clothing and crossing their legs because that can impair blood flow to the lower extremities, and we definitely don't want to do that. We also want them to maintain a warm environment and wear socks, so we don't want those legs getting cold because if they get cold, that's going to cause a vasoconstriction, which is definitely not what we want. We also want to advise our patient to avoid nicotine and caffeine because those substances can also cause vasoconstriction.

So if your patient requires a peripheral bypass graft - this is where we reroute blood flow around the occluded artery - after the surgery, you're going to want to closely monitor your patients' pedal pulses as well as their capillary refill, skin color, and temperature. And then in all likelihood, they will need to keep their legs straight for 24 hours after the procedure.

As the nurse, you're going to want to monitor for complications, which include a graft occlusion. So the signs and symptoms of this include pallor, decreased pedal pulses, decreased temperature. So if your patient's skin suddenly feels cold, that's a warning sign. And then if your patient has a sudden increase in pain, that is also a sign of graft occlusion.

You also want to monitor for compartment syndrome. So compartment syndrome is where we have increased pressure inside a muscle compartment due to swelling that can impair blood flow. And it's very serious, so it can block blood flow altogether. So signs and symptoms of this complication include numbness, severe pain with even passive movement, as well as edema and taut skin. So if you notice any of these things with your patient's extremity, you definitely want to alert the provider right away, as this is a very serious complication.

Okay, time for quiz. I have three questions for you. First question. A patient with PAD will have decreased pain when their extremity is elevated. True or false? The answer is false. It will feel better-- they will have decreased pain when their extremity is in a dependent position, so dangling.
Question number two. Pallor with elevation and dependent rubor are indicative of PAD. True or false? The answer is true.
Third question. Edema, taut skin, numbness, and severe pain are indicative of what complication following a peripheral bypass graft? The answer is compartment syndrome.

Okay. Hopefully, you did well there on the quiz. If not, be sure to review the flashcards because it takes repetition to remember all of these different facts. I appreciate you watching. Be sure to like this video and leave me a comment. Take care and good luck studying.
To closely monitor their legs for-- hold up the [inaudible]. [laughter] Okay, let's try again.