deleting bone and soft tissue, so that only contrast-filled arter-ies appear.
Magnetic resonance imaging: Demonstrates vessels in
mul-tiple projections and can be used with or without contrast. It
is used widely but is more expensive and not suitable for all
patients. Implanted metal (e.g., pacemakers, automatic
defi-brillators) and prosthetic joint replacements preclude this
study from being performed.
Chronic Pain
Atherosclerotic Arterial Occlusive Disease141
Cardiovascular Care Plans
PART I: Medical-Surgical Nursing
Nursing Diagnosis:
Impaired Tissue Integrity
related to altered arterial circulation occurring with atherosclerotic process
Desired Outcome:
Over a period of days or weeks, the patient’s lower extremity circulation improves and perfusion is maximized as evidenced by palpable pulses, decreased leg pain, and improvement in mobility and sensation.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess legs, feet, and between the toes for ulcerations. Ulcerations can occur with decreased arterial circulation. A decrease in circulation significantly decreases oxygen delivery to the tissues and subsequently impairs healing of even the most minor break in the skin. A baseline assessment enables timely interventions.
Teach the importance of walking and range-of-motion (ROM) exercises for the hip, knee, and ankle.
Walking is the best activity and patients can be instructed to walk until they have pain, rest until recovery, and then resume walking.
Walking and exercise improve collateral circulation. This is especially useful for patients who claudicate, along with other risk factor modifications. Activity may be contraindicated for some patients with severe disease.
Determine the allowed activity and exercise with the health care team, and discuss this with the patient.
Exercise promotes circulation.
Note: Bedrest without exercise may be prescribed in acute, severe cases to decrease oxygen demand to the tissues, which optimally will decrease pain.
Teach the patient how to assess peripheral pulses, warmth, sensation, and color of the lower extremities (LE). Encourage daily foot inspections by the patient or family members if the patient’s vision or assessment ability is compromised.
Monitoring status of the LE is essential for early identification of breaks in skin integrity, because early identification and care may prevent serious problems.
Encourage cessation of smoking and other tobacco use. Provide smoking and tobacco cessation literature. Discuss with the health care provider use of medication for smoking cessation.
Stopping tobacco use helps prevent increased vasoconstriction and severity of the circulation deficit, as well as the effects of nicotine on the lungs and other body organs.
Discuss the importance of keeping the feet warm and protected by wearing socks when walking or in bed.
Decreased circulation because of vasoconstriction results in decreased blood flow to the LE, which promotes hypothermia. Keeping warm promotes vasodilatation and a more optimal blood supply.
Caution the patient about using heating pads. Heating pads increase metabolism and may promote ischemia if circulation is limited. Also, the patient’s sensitivity to temperature is often decreased and burns may result.
Discuss the importance of nightlights being placed in bedrooms and bathrooms.
Nightlights promote visibility and may help avoid tissue trauma at night when getting up.
Caution the patient to avoid pressure over areas of bony prominence. Pressure increases the risk of skin breakdown; areas over bony prominence are particularly susceptible.
Caution the patient to cover all exposed areas when going outside in cooler weather.
This action helps prevent hypothermia, to which patients with decreased circulation may be susceptible. Cold temperatures cause vasoconstriction, which further results in decreased tissue perfusion.
Nursing Diagnosis:
Chronic Pain
related to reduced circulation and ischemia
Desired Outcome:
Over several days or weeks, following nonsurgical interventions to improve
perfusion, the patient’s pain decreases as documented by pain scale.
PART I: Medical-Surgical Nursing
Assess for the presence of pain on initial contact and periodically throughout care, using a pain scale from 0 (no pain) to 10 (worst pain).
This assessment helps determine the degree and trend of pain.
Administer pain medications as prescribed. Usually mild analgesics are given to reduce pain. Opioids may be given for perioperative pain. Opioids may not be effective in some patients for rest pain, and must be used cautiously in older adults.
Document pain relief obtained using the pain scale. This documentation helps determine effectiveness of the medication.
Teach the patient to rest when claudication (severe, cramping pain) occurs.
If claudication occurs at rest, encourage the patient to position legs so that they are dependent, and ensure warmth with socks and blankets, as appropriate.
Intermittent claudication from activity is relieved by rest. Claudication at rest implies severe circulatory compromise; measures such as leg dependency and warmth may reduce pain.
Explore alternative methods of pain relief, such as visualization, guided imagery, biofeedback, meditation, relaxation exercises, or music.
Because the pain may be chronic and continuous, pain relief should be augmented with nonpharmacologic methods, which do not have side effects.
Institute measures to improve circulation, such as dependence of extremities, ensuring warmth, walking, and use of medications (see Impaired Tissue Integrity, p. 141) as directed by the health care provider.
These measures increase circulation to ischemic extremities, which optimally will increase the patient’s comfort level.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the potential for infection and impaired tissue integrity caused by decreased arterial circulation
Desired Outcome:
Following teaching, the patient verbalizes knowledge about the potential for infection and impaired tissue integrity, as well as measures to prevent these problems.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
Teach how to assess for signs of infection or breaks in skin integrity, and to report significant findings to the health care provider.
This information facilitates understanding of symptoms that occur with infection or impaired skin integrity and describes symptoms that should be reported for timely intervention. This includes any new or enlarging wound or ulceration, redness, swelling, increased pain, or drainage.
Caution about the increased potential for easily traumatizing skin (e.g., from bumping lower extremities).
Decreased circulation in the legs diminishes the healing process after tissue trauma.
Instruct the patient to inspect both feet each day for any open wounds or bruises. If necessary, suggest the use of a long-handled mirror to see bottoms of the feet. Advise the patient to report any open areas to the health care provider.
Decreased circulation in the legs diminishes sensation, and therefore careful inspection is important to identify breaks in skin integrity.
Open wounds can lead to infection, which should be reported promptly for timely intervention.
Stress the importance of wearing shoes or slippers that fit properly without areas of stress or friction.
Improper fit can lead to traumatized tissues. Bare feet in an individual with decreased sensation can lead to trauma.
Instruct the patient to cut toenails straight across or have them cut by a podiatrist.
Ingrown toenails can lead to infection.
Advise the patient to cover corns or calluses with pads. Protection helps prevent further injury.