A Group Case Study entitled:

Peripheral Arterial Occlusive

Diseases (PAOD)

Presented to the Faculty of the School of Health and Natural Sciences

Saint Mary’s University
Bayombong, Nueva Vizcaya

In Partial Fulfillment of the Requirements in Care of Older Adult

NCM 114 RLE

October 2021

PATIENT’S INFORMATION
Name: Mr. C
Age: 67 years old
Address: Magsaysay, Bayombong, Nueva Vizcaya
Occupation: Teacher
Nationality & Ethnicity: Filipino
Weight: 73kg
Height: 5’3”
Chief Complaint: Leg pain that does not go away, a marked decrease in the temperature of lower left leg
compared to the other leg, skin discoloration and hair loss on the skin of the leg.
Admitting Facility: R2TMC
Admitting day: October 01, 2021
Admitting Physician: Doctor D
HISTORY OF PRESENT ILLNESS
2 weeks of ache on left-calf whilst strolling for greater than 10 minutes, pain is followed through
paleness of pores and skin on affected part. In addition, pain is relieved in the course of relaxation, pain is
worse at night time whilst snoozing inflicting affected person to awaken. Furthermore, there is a want to dangle
the affected leg at the aspect of the mattress. On October 1, 2021at exactly 8:00AM in the morning an old man
rushed to the hospital with a chief complaint of 2 weeks of ache on his left-calf whilst strolling for greater than
10 minutes and pain is followed through paleness of pores and skin on affected part. In addition, pain is
relieved in the course of relaxation, pain is worse at night time whilst snoozing inflicting affected person to
awaken. Furthermore, there is a want to dangle the affected leg at the aspect of the mattress. He was a 67
year old and working as a teacher in their Barangay. Upon assessment, his Vital signs were RR- PR- BP- T-
Ps02- . The doctor ordered to test him for RAT ready for admission. At 8:30 AM, the nurse took a blood sample
for the CBC, Urinalysis and Blood Glucose Test the results of her lab was- . He turns out to be negative on
RTPCR and he was admitted to the Geriatric Ward in Room 12.
PAST ILLNESSES
The patient was diagnosed with Type II Diabetes mellitus when he was 40 years-old. Furthermore, they
have a family history of hypertension.
FAMILY HEALTH HISTORY
According to Mr. C their family has a history of hypertension.
SOCIAL HEALTH HISTORY
Mr. and Mrs. C is a very kind and generous couple that is loved by their neighbors and friends, they
were always invited to parties, pre-COVID, and that is the reason he drinks and smokes. Furthermore, they
also mentioned that he smokes 6 sticks of cigar a day and drinks at least 4 times a week, Mr. C also loves to
eat meat.
 BRIEF DESCRIPTION OF PATIENT’S CONDITION

DEFINITION

Peripheral Arterial Occlusive Diseases (PAOD) is blockage or narrowing of an artery in the legs (or rarely the
arms), usually due to atherosclerosis and resulting in decreased blood flow. Thrombus or blood clotting also
cause narrowing of the artery. Most cases of arterial thrombosis are caused when a process called
atherosclerosis damages an artery. Fatty deposits build up on the walls of the arteries and cause them to
harden and narrow.

In PAOD patients, the most common affected area is the lower extremities but it can also affect the upper
extremities if worsen. In relation to our patient, Mr. C is experiencing 2 weeks of pain on his left calf when
walking for more than 10 minutes which is one of the reasons why he is diagnose with PAOD.

ETIOLOGY

Atherosclerosis is a common cause of peripheral artery disease, especially to older people wherein it is a
condition in which fatty deposits build up on the inside walls of your arteries, that reduces blood flow, which
becomes more common with aging.

Since Mr. C is classified as an older adult at the age of 67 and had an unhealthy lifestyle because of eating
meat most of the time, he is more prone on developing atherosclerosis which is a common cause of PAOD.
PREDISPOSING FACTORS

Factors that increase your risk of developing peripheral artery disease include:

 Smoking

 Diabetes

 Obesity (a body mass index over 30)

 High blood pressure

 High cholesterol

 Increasing age, especially after age 65 or after 50 if you have risk factors for atherosclerosis

 A family history of peripheral artery disease, heart disease or stroke

 High levels of homocysteine, an amino acid that helps your body make protein and to build and
maintain tissue

People who smoke or have diabetes have the greatest risk of developing peripheral artery disease. When a
person inhales the smoke of a cigarette, nicotine will enter the bloodstream that can cause an impact in to our
brain for within 10 seconds. It will now trigger chemical reaction that produces temporary feeling of pleasure
and concentration. These chemical reactions include the release of catecholamines such as adrenaline, the
"fight or flight" hormone. It will now increase the heart rate and blood pressure of a person. When this happens,
smokers may experience rapid, shallow breathing and they may also feel racing of heartbeat. The adrenalines
also tells the body to dump excess glucose into the bloodstream. So, nicotine also helps to lose weight in other
ways.

On the other hand, Diabetes accelerates atherosclerosis by increasing inflammation and decreasing blood
flow. Atherosclerosis, or artery hardening, was formerly thought to occur when too much cholesterol clogged
arteries with fatty deposits known as plaques. Heart attacks and strokes occur when blood arteries become
fully clogged. The immune system's reaction to fatty build-up, rather than the build-up itself, increases the risk
of heart attack.

Mr. C is a smoker, he smokes for approximately 6 times a day which is the greatest of all the cardiovascular
risk factors. They also have family history of hypertension and also an alcohol drinker which also a contributor
to the disease. Mr. C also loves to eat meat wherein it can increase his level of cholesterol. He was also
diagnosed with Type II Diabetes at the age of 55 years old and his present age is also one of the risk factors
which is 67 years old.

SIGNS AND SYMPTOMS

1. Intermittent Claudication
2. Rest Pain
3. Coldness, paleness, and/or numbness of affected extremity
4. Shiny, dry, and atrophic skin
5. Thinning or loss of hair on affected extremity
6. Thickened and opaque nails on the affected extremity
7. Peripheral pulses on the affected extremity is weaker compared to the opposite leg
8. Slow wound healing
9. Gangrene
 10. Ulcerations
11. Bruits
12. Weak or absent peripheral pulse
(explain that item 3 to 10 are due to reduced blood flow)

Claudication is a classical sign of PAOD that results from the narrowing of the artery due to
atherosclerosis or blood clots. It can be characterized by aching, cramping, or inducing fatigue or
weakness on the muscles of the legs, which is triggered by activities such as walking or running. Pain
usually occurs quickly if the person is walks quickly or uphill. However, this type of pain can be easily
relieved with 1 to 5 minutes of rest, in which sitting is not necessary.

The pain usually occurs on the muscle groups that are distal to the area where the blockage
occurs. Most common location where pain occur is on the calf. It can also occur in the buttocks, hips, or
thighs. In rare situations, the pain occurs in the foot.

As the disease progresses, rest pain will occur and the patient will have a decreased ability to
walk the same distance like before. In addition, pain can also be longer in duration or be increased.
This type of pain cannot be relieved by opioid-pain killers and can be disabling.

Rest pain is also worse at night which causes sleep disturbances. Whenever lying down, the
patient must avoid putting the affected leg in an elevated or horizontal position as this positions
increase the pain. Position the affected leg in a dependent position such as hanging it on the side of the
bed, reduces pain.

In relation to our patient Mr. C, he is experiencing Intermittent claudication and experiences rest pain at
night. His affected leg is also cool and pale and the nail beds are pale as well.

EPIDEMIOLOGY
According to Dominguez J. A. (2021), 10% of all 65 year-olds and older, especially those from the
western population, can be affected with atherosclerosis, and by the year 2040, the elderly population is
expected to increase by 22%. Thus, atherosclerosis is expected to increase and have a big impact in the
health and medicine field.

She also added that PAOD has an estimated prevalence of 4.3% in the US alone. In the year 2000,
there were estimated 5 million people in the US who are diagnosed with PAOD and that goes up with age,
which means, as more people age, the number of people who might get affected by PAOD also increases.

DIAGNOSTIC PROCEDURES
PAOD can be diagnosed using multiple different tests which includes Doppler Ultrasound Flow Studies,
Exercise Test, Duplex Ultrasonography, CT Scan, Angiography, MRA/MRI, Contrast Phlebography, and
Lymphoscintigraphy.

1. Doppler Ultrasound Flow Studies

This is a procedure wherein a handheld continuous wave (CW) Doppler ultrasound device is used in
order to detect blood flow in vessels where the pulse cannot be palpated. In this procedure the hand-held
device will emit a continuous signal through the tissues. The signals will then be reflected by the blood cells
which will be received by the device.
 This procedure is a lot more useful with the help of ankle blood pressures or the computation of
Arterial Blood Index (ABI). This procedure uses the ratio of the systolic BP in the ankle and systolic BP in the
arm. It is used to indicate arterial disease by quantifying the degree of occlusion. The narrow the arteries, the
weaker the pulse.

In Doppler ultrasonography, both brachial pressure is assessed and the higher of the two will used to
divide the highest ankle systolic pressure, with that the ABI is computed. Normal results of ABI should be 1.0
or higher but in people with occluded peripheral artery, result is considered abnormal if it’s below 0.90 not
exceeding 0.50 which is considered to be mild to moderate insufficient blood flow. Patients who have ischemic
rest pain usually have a result of below 0.50 and patient with severe ischemia or have tissue loss have an ABI
of 0.40 or less.

Indications:
 Gather baseline ABI data on patients with decreased pulses or patients who are 70 years or older.
 Patients who have history of diabetes and/or tobacco use.
 Patients who underwent arterial interventional surgeries such as the insertion of balloon stent into the
artery
 Patients who had sudden cold or painful limb

Nursing Responsibilities prior to the procedure:

 Educate the patient regarding the indications and procedure of ABI
 Patient should be instructed to not use tobacco products or drink caffeinated beverages for at least two
hours (if procedure is not urgent)
 Tell the patient that there may be some discomfort involved when the cuffs are inflated

2. Exercise Test

This test is done to assess how long a patient can walk until they feel pain and also to measure the
systolic BP in response to walking. Usually the treadmill will be set on a speed of 1.5mph and with a slope or
inclination of 12%, the patient will run for maximum of 5 minutes. If there is no treadmill, the patient will be
asked to walk on the hallway with a specific distance and/or time.

Normal results should be little or no drop of ankle systolic pressure. However, patients with arterial
occlusion, the pressure will decrease of drop.

One nursing responsibility is to educate the patient regarding the procedure and explain that it will not
require running.

3. Duplex Ultrasonography

Duplex ultrasonography is non-invasive procedure and is considered the standard diagnostic test for
lower extremity venous thrombosis. The term duplex refers to two modes of ultrasound is used during the
procedure. The two modes that are used in this procedure are Doppler and B (brightness)-mode. B-mode
presents an image of part being studied. Doppler on the other hand evaluates the velocity and direction of
blood flow in the vessel. Since this procedure will be presenting images, it will be able to locate the affected
vessel.
 Before the procedure, the patient should be educated regarding the procedure and what to expect.
However, patients who will undergo an abdominal vascular duplex ultrasound should be put on NPO for at
least 6 hours.

4. Computed Tomography (CT) Scanning

This procedure provides a cross-sectional image of soft tissues and shows the area of volume changes
to an extremity. Multidetector-computed tomography (MDCT) is a version of CT scan where a spiral CT
scanner and rapid IV infusion of contrast agent is used in order to view even very thin sections of the target
area are also shown, thus with this procedure, even the vessels can be viewed.

MDCT may be contraindicated to pediatric patients and those who have problems in their renal
function. However, they can be scheduled for a pre-procedural treatment in order to avoid contrast-induced
nephropathy. The procedure might also be contraindicated to patients with iodine allergy. However, they can
have the procedure but they will need premedication with steroid and histamine blockers.

Nursing responsibilities prior to the procedure:

 Ask if patient has renal dysfunction

 Explain to the patient the procedure
 Assess for allergies in iodine or seafood

Nursing responsibilities post-procedure:

 Monitor urine output which should be at least 0.5/ml/Kg

 Assess for contrast-induced kidney injury 48 to 96 hours post-procedure

5. Angiography

Angiography or angiogram is a procedure which involves an X-ray imaging in order to preview blood
vessels. This procedure can also be used to confirm the diagnosis of PAOD. This procedure involves an
injection of radiopaque contrast agent directly to the arterial system to visualize the vessels. However, this
procedure has additional risks including vessel injury, acute arterial occlusion, bleeding, or contrast
nephropathy.

As a nurse, it is important to explain to the patient the procedure and what to expect. The nurse should
also ask the patient for allergies in iodine. In case the patient is unaware of the allergy, immediate or delayed
allergic reactions are dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities.
In such event, the nurse should immediately report this to the interventionalist. Treatments include
administration of epinephrine, antihistamines, or corticosteroids.

6. Magnetic Resonance Angiography (MRA)

MRA is a procedure which involves standard Magnetic Resonance Imaging (MRI) scanner and special
software which is programmed to isolate the blood vessels. With this procedure, there will be better imaging of
the vessels because the images can be rotated and viewed from different angles. MRA procedure is somehow
the same with CT Scanning because of the use of contrast dye. Therefore, nursing responsibilities regarding
contrast dye is also applied to MRA procedure.

Contraindications:
  Metal Implants (e.g. pacemakers)
 Old tattoos

Nursing Responsibilities:

 Educate the patient regarding what to expect during and after the procedure
 Patient should be notified about lying on a cold, hard table that will slide into an enclosed small tube
 Instruct patient that they will hear noises
 Patients with history of claustrophobia may be prescribed a sedative before the procedure
 Patient should be educated to close their eyes before entering the tube, and to keep them closed for
this may help decrease claustrophobia symptoms
 Reassure patient that a panic button will be provided that they may press if they feel a need to stop the
procedure.

7. Contrast Phlebography (Venography)

Venography is a procedure which shows veins of a patient through an X-ray. Typically, veins cannot be
seen on a normal X-ray, which is why this procedure involves the use of injecting a radiopaque contrast agent
into the venous system. With this procedure, it can show any problems or abnormalities in the blood vessels. In
this procedure, if there is a presence of blockage in the vessels, x-ray images will reveal an unfilled or
completely filled vein.

Types of Venography are the following:

 Ascending venography – used to see the location of DVT or occlusion in the legs
 Descending venography – measures the function of the valves in the deep veins
 Upper extremity venography – allows the physician to identify presence of occlusions or vascular
abnormalities in the neck and arms
 Vena cavography – used to assess the ability of the inferior vena cava to bring blood to the heart

Contraindications:

 Congestive heart failure

 Pulmonary hypertension
 Allergy to contrast dye, iodine, or seafood
 Obesity
 Diabetes
 Taking metformin
 Swelling of limbs

Nursing responsibilities:

 Assess patient for allergies in seafood

 Educate the patient regarding the procedure
 Tell patient what to expect during the procedure

Other nursing care following venography is similar to the nursing care for MDCT.

5. Lymphoscintigraphy

This is a procedure that evaluates the body’s lymphatic system for any presence of disease such as
blockages in the lymphatic system. This procedure uses a blue dye that is radioactively labelled colloid or also
called radiotracers, which is injected subcutaneously in the second interdigital space. After the injection of the
radiotracers, the extremity will be exercised to facilitate uptake. During the procedure, the radiotracers
travelling through the extremity being examined will give off energy in forms of gamma rays which can be
detected by a special camera and computer to create images of the inside of the body.

One disadvantage of lymphoscintigraphy is that it’s time consuming. Radiotracers can take several
hours or days to accumulate in the area of interest and imaging can also take hours to perform.

Nursing responsibilities prior to the procedure:

 Contraindicated to pregnant women

 Assess allergies
 Ask patient to remove jewelries or accessories because this may interfere with the procedure
 Educate the patient regarding the procedure and what to expect such as the staining of the radiotracers
in the injection site.

Surgical Procedures
Treatment includes both surgical and non-surgical
Non-surgical Procedure
Patients with peripheral arterial disease are treated using risk factor management, which depending on
symptoms and blockage could include:

 Aspirin Regimen
 Improve Diet
 Smoking Cessation
 Controlling high blood pressure, High cholesterol or Diabetes
Surgery for Patients with Severe PAD Symptoms and Complications
Surgery is reserved for patients who have the most severe symptoms and complications.
In the most extreme cases, when a leg has gangrene (when body tissue dies) and cannot be saved,
amputation may be recommended. In many cases even when gangrene is present, amputation can be
avoided. The following are surgical procedures that may be used to treat peripheral arterial disease:
Balloon Angioplasty/Stenting – Angioplasty uses a balloon-tipped catheter to open a blocked blood vessel
and improve blood flow.
Procedure of Balloon Angioplasty/Stenting

 The balloon and stent are positioned in the narrowed part of the artery
 The balloon inflated and the stent expands, pushing the plaque back against the artery wall
 The balloon is the deflated and removed, leaving the stent propping open the artery
 The widened artery improves blood flow to the heart
Advantage

 It can be performed during a life-threatening heart attack to restore blood flow to your heart and
potentially save your life.
 It can relieve and reduce the symptoms of heart disease.
 It may reduce your risk of future stroke.
 It can improve your overall kidney function.
 It can prevent gangrene by promoting blood flow to the legs.
Disadvantage

 Some patients may experience an allergic reaction to their stent.

 Blood vessels may become damaged wherever the catheter is inserted.
 An artery may collapse or close.
 Blood clots can form inside stents.
 The more major arteries that are involved, the greater the risk of fatal heart attack or stroke during the
procedure.
 Repeat procedures may become necessary if scar tissue grows within the stent.
 If angioplasty is not adequate, a coronary bypass surgery may be necessary.
  Some patients may experience side effects to the medications given following the procedure.
Nursing Considerations
Post Operation
If you're having a planned coronary angioplasty, you'll probably be discharged from the hospital the same day
or the following day. Before you leave the hospital, do note:

 Any medication you need to take

 Changes you need to make to your diet and lifestyle
 Wound care and hygiene advice
 Your follow-up appointment with the doctor
Post Discharge

 Take Your Medication

 Dial Down the Activities
 Avoid Driving
 Quit Smoking
 Change Your Diet
Cryoplasty- is therapy that uses pressure and cold to open blocked or narrowed arteries. Arteries are blood
vessels that carry blood with oxygen from your heart to another part of the body. They can become clogged by
plaques that decrease blood flow in the artery.
Procedure is similar to angioplasty

 Vascular surgeon inserts a balloon catheter into a blocked artery to repair an obstruction within the
vessel.
 Once the balloon catheter reaches the site of the blockage, it is filled with liquid nitrous oxide, which
immediately evaporates into a gas, causing the balloon to inflate and freeze the surrounding tissue,
promoting the dilation or opening of the artery while minimizing the potential for growth of new scar
tissue, and reduces the likelihood that the blockage in the treated location will reoccur.

Percutaneous or Laser Atherectomy- is a minimally invasive procedure designed to allow the damaged
blood vessel to dilate, increasing blood flow and providing for the necessary oxygenation of the tissues
involved. This procedure is particularly helpful in treating arterial blockages in smaller branches of blood
vessels.

Procedure

 Vascular surgeon inserts a specialized catheter into a blocked artery to remove a buildup of
atherosclerotic plaque from within the vessel.
 The catheter contains a sharp rotating blade, grinding bit, or laser filament, as well as a collection
system that permits the surgeon to remove the plaque from the wall of the vessel and collect or suction
any resulting debris.

Before

 Pre-procedure tests may be performed to ensure that it is safe to continue with the procedure.
 Discontinue certain medications before the procedure.
After

 You can usually begin normal activities again several days after the atherectomy.
 Your doctor will provide specific guidelines for your recovery.
Medical Management
Past intake of drugs
EMPAGLIFLOZIN METFORM HCI

 used with proper diet and exercise to treat high blood sugar levels caused by type 2 diabetes.
 It is also used to lower the risk of death in patients with type 2 diabetes and heart or blood vessel
disease.
  The dosage is based on your medical condition, response to treatment, and other medications you may
be taking.
Nursing Considerations

 Metformin is the drug of choice for overweight patients for whom dieting has not controlled diabetes.
Can also be used in patients who are not overweight and when diabetes cannot be controlled with
sulphonylurea treatment.
 Advantages include lower incidence of weight gain.

Present intake of drugs

ASPIRIN

 also known as acetylsalicylic acid, is a medication used to reduce pain, fever, or inflammation.
 If you have recently had surgery on clogged arteries (such as bypass surgery, carotid endarterectomy,
coronary stent), your doctor may direct you to use aspirin in low doses as a "blood thinner" to prevent
blood clots.
Nursing Considerations

 Assess pain and/or pyrexia one hour before or after medication.

 In long-term therapy monitor renal and liver function and ototoxicity.
 Assess other medication for possible interactions - especially warfarin which is a special hazard.
ROSUVASTATIN

 It's used to lower cholesterol if you have been diagnosed with high cholesterol and to increase levels of
"good" cholesterol (high-density lipoprotein, or HDL), also to lower triglycerides (a type of fat in the
blood).
 It's also taken to prevent heart and blood vessel disease, heart attacks and strokes.
Nursing Considerations

 Assess any joint pain or muscle pain, tenderness, or weakness, especially if accompanied by fever,
malaise, and dark-colored urine.
 Advise patient that these symptoms may represent drug-induced myopathy, and that myopathy can
progress to severe muscle damage (rhabdomyolysis)

Nursing Management
Nursing Diagnosis

 Ineffective peripheral tissue perfusion related to compromised circulation.

Nursing Intervention

 Administer nitroglycerin (NTG) sublingually for complaints of angina

 Maintain oxygen therapy as ordered.

Evaluation

 Protects extremities from exposure to cold.

 Avoids all tobacco products
 COMPREHENSIVE GERIATRIC ASSESSMENT FORM

Date of Assessment: October 1, 2021

A. PERSONAL DATA ASSESSMENT

Advanced Health Directive Planning
DNR Directive: None
Living Will: None
Medical Power of Attorney: None
Financial Health Planning
Primary source of healthcare: R2TMC
Financial resources related to illness: Philhealth

B. MEDICAL ASSESSMENT Justification/ Pathophysiological basis

Vital Signs
Temperature As we age our vital signs may change depending on
Rate: 36.8 degrees Celsius how healthy we are and also some medical can
Route: Axilla cause changes in our vital signs. Normal body
temperature does not change much with aging but
as you get older it becomes harder our body to
control its temperature. A decrease in the amount of
fat below the skin makes it harder to stay warm.

Blood pressure
Rate: 130/80 mmHg there is abnormal sounds such as crackles or
wheezing are auscultated and since the patient had
diabetese
Peripheral pulse
Rate: 55 bpm -lower peripheral pulse rate in the of lower left leg
Rhythm: irregular due to pain and other sign and symptoms of patient
Location: popliteal pulse that shows and this could lead to arterial peripheral
Pulse amplitude: abnormal disease
Apical pulse -
Rate: 65 bpm
Rhythm: normal
Murmurs: none
Respirations
Rate: 18 cpm - The normal respiratory rate for elderly individuals
Rhythm: normal living independently is 12-18 breaths per minute .
Use of accessory muscles: none
Lung sounds: normal breath sound like
sound of air
General appearance:
Allergic reactions on
Medication: -patient doesn’t have any allergies and reactions to
Food: medications, food and environment
Environment:

Vaccinations:
1. Sinovac Covid Vaccine
2. Influenza Vaccine
3.Pneumococcal Vaccine
4. Tetanus-Diphteria-pertussis
(Tdap)
Health promotion activities:
1.Diet Eating smaller portion, maintaining healthy diet and
2.Physical Activities regular physical activities can help control weight,
3. supervised exercise program and blood glucose levels. The patient should
4. smoking cessation undergo aggressive control of blood pressure, sugar
intake. Quitting smoking are better able to manage
blood sugar level

Long term conditions:

1. Type II Diabetes Mr. C was diagnosed with Type II Diabetes at the
2. age of 40 years old
3.
Regular clinics and therapies:
1. Geriatric ward
2. Barangay Health Center
3.
Surgical history:
1. There is no surgical history of
the patient
2.
3.
Eyes/ Vision
Eyes: -Dark brown round eyes, PERLLA all assessed as
Pupil: normal. Pupils are equally round and react to light
Use of glasses: and accommodation. The patient does not use
glasses

Ears/ Hearing
Hearing: -there were no lesions, or unusual secretion noted
Hearing aid: on both ears, does not use any hearing aid , and as
patient say he’s hearing is a bit impaired as he get
older but still hear clear

Skin integrity
Scar/s: -there is no presence of scars, wounds and surgical
Wound/s: incisions to patient
Surgical incision/s:
Mucous membranes: dry and thinner The normal mucous membrane is moist and intact
but as with aging the skin becomes drier with more
tendencies to crack, becomes thinner and more
fragile.

Airway clearance -
Mouth: moist and intact
Nose: moist and intact
Color
Skin: paleness There is paleness and coolness in the skin usually
Nails: pale in the calf of affected legs of the patient. Also nail
Lips: pink beds are pale as well because Mr.C experiencing
intermittent claudication and rest pain.

Capillary refill: pink tone returns 1-2
seconds to blanched nail beds when
pressure is released
As regards assessment of CRT, Champion
suggested a maximum refill time of 2 seconds, while
Schrigger and Barraf differentiated the cut off
values, based on age and gender, in healthy
patients. The refill times they identified as normal do
not exceed 1.9 seconds for males and 2.9 for
females aged 18 to 64, and 1.8 seconds in both
genders aged 65 or more.

Oxygen therapy: 96% A normal oxygen saturation level is 97-100% but

older adults typically have lower levels than younger
adults. If an individual is older than 70, a normal
oxygen level for elderly adults may be about 95%,
which is acceptable.

Braden Scale (Pressure Ulcer Risk) Score

Sensory Perception 4
Moisture 4
Activity 3
Mobility 3
Nutrition 4
Friction 3
Total 21
Interpretation For the result the patient is Low risk in developing
pressure ulcer. In the sensory perception of the
patient is normal there was no impairment that was
assess he can respond to verbal commands and
had no sensory deficit. Foe moisture his skin is
usually dry and usually his linen requires changing
at routine intervals. For the degree of physical
activity the patient walks occasionally during day but
for very short distances with or without assistance
because of his problem and affected leg. He feels
pain whenever he walks long distance that is why
he spends majority of each day in his bed or chair.
For the patient ability to change and control body
position was assess as slightly limited because of
his affected leg he have slightly change in body and
his extremity position independently due to pain that
he feel. For the nutrition of the patient was excellent
wherein he eats most of every meal that was given
to him. He also eats total of 4 or more servings of
protein per day and does not require
supplementation. He eats protein rich foods,
vegetables, and fruits and does not refuse a meal.
Lastly for friction and shear problem he moves
feebly or requires minimum assistance due to the
pain that she felt in his leg but still he maintains
relatively good position in chair or bed most of the
time when pain is there.
 DRUG STUDY

NAME OF CLASSIFICATIONS DOCTOR’S ORDER ACTION SIDE EFFECTS ADVERSE EFFECTS NURSING
MEDICATIONS CONSIDERATION
GENERIC NAME: ANTITHROMBOTIC, D.O: Aspirin 1 Tablet, 80 Aspirin disrupts the  Nausea Toxicity 1.Assess baseline vital
ASPIRIN/ASA or ANTIPLATELETS mg, QD, PO production of the  Vomiting Bloody or tarry stools sign of the patient for
Acetylsalicylic Acid prostaglandins  GI irritation Coughing up blood or comparison with future
BRAND NAME: TIME: throughout the body by  Heartburn vomit that looks like value.
SCHEEPRIN AFTER MEAL targeting  Stomach cramps coffee ground 2.The patient’s vital sign
Cycloocygenase-1(COX-  Bleeding Allergic reaction will be monitored.
1) and Cycloocygenase- Severe nausea & 3.Obtain a medical and
DATE GIVEN: ROUTE: 2(COX-2). Prostaglandin Note: This is not a vomiting drug history of the
Per Os by mouth-PO. are potent, irritating complete list of side Severe stomach pain patient.
substances that have effects and others may Seizure 4.Advice the patient to
DATE DISCONTINUED: FREQUENCY: shown to cause occur. report or go to the
October 09, 2021 Once a day-QD headache and pain. Note: This is not a nearest hospital if any
Through the disruption of complete list of side side effect that persist
Note: For Maintenance FORM: the production and effects and others may or worsen.
Medication, October 09 TABLET prevention of release of occur. 5.Self-Administration-
scheduled of checkup for the prostaglandins in Teach the patient in
adjustment of dosage. inflammation, this drug taking medication and
may stop their action at Explain to the patient
pain receptors, the purpose of the
preventing symptoms of medication.
pain or Aspirin blocks 6.Observe the patient for
prostaglandin synthesis sign of bleeding.
to stop the production of 7.If Blood in feces is
pain-causing present– Advice this is
prostaglandins. not common and talk
to a doctor if you see
that the poo is black
and sticky looking, has
red streaks.
8.What happens if he
misses a dose? Advice
to take the missed
dose as soon as he
remembers. Skip the
missed dose if it is
almost time for her
next scheduled dose.
Do not take extra
 medicine to make up
the missed dose.
9.Advice patient to keep
aspirin bottle out of
reach of children.
10. Instruct patient to
take aspirin with food
to prevent GI distress

DRUG STUDY

NAME OF CLASSIFICATIONS DOCTOR’S ORDER ACTION SIDE EFFECTS ADVERSE EFFECTS NURSING
MEDICATIONS CONSIDERATION
GENERIC NAME: ANTIHYPERCHOLESTEROL D.O: Rosuvastatin 1 Rosuvastatin works by  headache Severe muscle 1.Assess baseline vital
ROSUVASTATIN tablet 20mg, QD, PO blocking enzymes in  pain in the abdomen problems. Symptoms sign of the patient for
your liver that make (stomach area) can include: comparison with future
BRAND NAME: TIME: cholesterol and it is  muscle pain  unexplained or value.
ROSWIN Anytime used to reduce your  nausea unusual muscle pain 2.The patient’s vital sign
LDL (bad) cholesterol  weakness  weakness will be monitored.
levels and increase  fever 3.Obtain a medical and
DATE GIVEN: ROUTE: your HDL (good) Liver problems. drug history of the
PO cholesterol levels. It Note: This is not a Symptoms can include: patient.
also reduces your levels complete list of side  unexplained or 4.Check urine output if
DATE DISCONTINUED: FREQUENCY: of triglycerides (fats in effects and others may unusual weakness brown or dark color
October 09, 2021 QD your blood). Improving occur.  decrease in appetite urine is present and
your cholesterol level  pain in the abdomen advice the patient to
Note: For Maintenance FORM: helps prevent (stomach area) undergo CPK lab test.
Medication, October 09 Tablet blockages from forming  dark-colored urine 5.Stop Statin if
scheduled of checkup in your arteries. These  yellowing of the skin Symptoms of liver
for adjustment of blockages can cause or the whites of the problem is present and if
dosage. serious problems, eyes the CPK is X10>.
including heart attack or 6.Self-Administration-
stroke. Note: This is not a Teach the patient in
complete list of side taking medication and
effects and others may Explain to the patient
occur. the purpose of the
medication.
 Name of Medication Classification Doctor’s Order Action Side Effects Adverse Effects Nursing Consideration
Generic Name: Sodium-Glucose D.O: Empagliflozin is a potent - Nausea - Lactic acidosis a) Take not of patient’s
Empagliflozin + Cotransporter 2 Empagliflozin + inhibitor of renal SGLT2 - Vomiting - Dehydration current medications and
Metformin HCl (SGLT2) inhibitors Metformin HCl 500 mg, transporters located in - Abdominal pain - Ketoacidosis ask if the patient is
1 tab PO QD every the proximal tubules of - Bitter or metallic taste - UTI allergic to the
morning kidneys and worksto - Diarrhea - Hypoglycemia medication or has any
Brand Name: Time: lower blood glucose - Bloatedness - Kidney problems other allergies
Jardiance Duo every morning levels via an increase in - Anorexia - Vaginal yeast infection
Date Given: Route: glucosuria. - Yeast infection of the b) Monitor urine or
Oral or PO penis serum glucose levels
Date Discontinued: Frequency: Metformin decreases - Hypersensitivity frequently to determine
Once a day blood glucose levels by - Vitamin B12 deficiency effectiveness of drug
Form: decreasing hepatic - Increased cholesterol and dosage
Tablet glucose production, levels in blood
(gluconeogenesis), c) Monitor urine or blood
decreasing the intestinal for glucose and ketones
absorption of glucose, as prescribed
and increasing insulin
sensitivity by increasing d) Advised patient to not
peripheral glucose use alcohol while taking
uptake and utilization the drug

e) Instruct patient to
report fever, sore throat,
unusual bleeding or
bruising, rash, dark
urine, light-colored
stools, hypo or
hyperglycemic reactions

f) Caution patient about

the side effects they
may experience

g) Monitor renal function

and blood pressure for
any effects on
intravascular contraction
NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation
Subjective: Pain r/t impaired ability Peripheral Arterial Short-term goals: Independent: Independent: Short-term goals:
of peripheral vessels to Occlusive Disease Within 8 hours of nursing a) Placed the patient in a) Stress causes a
supply tissues with intervention, the patient complete bed rest during persistent increase in Within 8 hours of nursing
Objective: oxygen will be able to: pain attacks. Educated cortisol levels, which has intervention, goals were
patient on stress been linked to people met as the patient was
Narrowing of arteries a) report relief of pain management, deep with circulatory issues able to:
with a score of ____ breathing exercises, and
relaxation techniques a) report relief of pain
b) exhibit stable v/s AEB a score of ____
Reduce blood flow to the b) Promoted increased b) Enhancement of
limbs c) demonstrate absence circulation through peripheral circulation b) exhibit stable v/s AEB:
of restlessness exercise (e.g. walking increases the oxygen
program, upper extremity supplied to the muscle c) demonstrate absence
exercises) and decreases the of restlessness AEB
Legs and arms do not accumulation of
receive enough blood metabolites that cause
flow to keep up with muscle spasms
demand
c) Promoted diversional c) Diversional activities
activities such as help lessen the pain
listening to music to experienced by patients
Leg pain, especially lessen experience of and promote non-
when walking pain dependency on drugs
(claudication)
d) Elevated head of the d) Keeping the affected
patient’s bed by 4-6 leg below the level of
inches or position heart lessens pain felt by
patient’s affected leg the patient
below the level of the
heart
Dependent:
Dependent:
a) Analgesic agents help
a) Administer analgesic reduce pain and allow
agents as prescribed, the patient to participate
with appropriate nursing in activities and
considerations exercises that promote
circulation
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