University of Bahrain

College of Health and Sport Sciences

Nursing Department
WHO Collaborating Center for Nursing Development

Adult Health I

NUR - 318

Case Study on
Peripheral Arterial Occlusive Disease

Revised- 2018

F: Adult Health 1 – Peripheral Occlusive Arterial Disease

Adult Health - I Case Study NUR - 318

Learning Objective

On completion of this case-study, the students will be able to:

1. Define Peripheral vascular disease (PVD).

2. Classify peripheral vascular disease.

3. Differentiate between arterial and venous insufficiency.

4. Analyze the prevalence of peripheral arterial Occlusive disease

(PAOD) in kingdom of Bahrain and worldwide.

5. Identify the predisposing factors/etiology of peripheral arterial disease.

6. Inference the clinical manifestations of PAOD in relation to its

pathophysiology.

7. Predict the common complications of peripheral arterial Occlusive

disease.

8. Justify the investigations done in a patient with peripheral arterial

Occlusive disease.

9. Explain the pharmacological, surgical, and nursing management of a

client with peripheral arterial Occlusive disease.

9. Design a nursing care plan on the problem of peripheral altered tissue

perfusion in a client with PAOD.

10. Formulate a health education plan for a client with PAOD.

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Content Outline

1. Definition of Peripheral vascular disease

2. Classification of peripheral vascular disease.

3. Characteristics of arterial and venous insufficiency.

4. Incidence of peripheral vascular insufficiency.

5. Predisposing factors/etiology of peripheral arterial disease.

- Modifiable
- Non modifiable

6. Clinical manifestation and it’s related pathophysiology

7. Complications and it’s prevention

8. Diagnostic studies done in PAD

- Blood investigations
- Angiography
- Doppler ultra sound flow studies
- Arteriogram
- Exercise testing
- Segmental blood pressure measurement.

9. Management – (Medical / Nursing)

- Drugs
- Exercise
- Position
- Promoting vasodilation
- Percutaneous transluminal angioplasty
- Atherectomy
- Amputation

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Surgical management – arterial revascularization

Nursing management – Pre-operative care
Post - operative care – nursing care plan on
- peripheral altered tissue perfusion
Post operative complications it’s prevention and action to be performed
in case of it’s occurrence
Graft occlusion
Compartment syndrome
Infection
Thrombosis

10. Emotional support of client with gangrene

11. Discharge instructions

- Diet
- Foot care
- Exercise
- Drugs
- Smoking cessation etc.

Skill:

Physical assessment of peripheral vascular system.

Attitude:

Understand the emotional needs of a patient with PAD and provide

appropriate care.

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Background:

Mr. Fadhel, 65 years Bahraini, widower having 5 children, 3 girls and 2 boys.
All the girls are married. Both his sons are not married and living with him.
His wife died 5 years back of cancer breast. He has a housemaid to help him
in his household work.

He was working in the catering department of Bahrain Airport and is retired for
8 years. He is a chronic smoker and was an alcoholic since his adolescence.

Past medical history shows that he is a known case of diabetes mellitus since
15 years and is on oral hypoglycemia drugs.

Trigger I

Mr. Fadhel came to surgical clinic with complaints of aching pain in the left
foot which increases on walking since 6 weeks.

On physical examination

GI - NAD,
RS - NAD,
CVS - peripheral

Lower extremity – left foot cyanotic, dusky and cold to touch. Peripheral pulse
on lower extremities as given below:

+
+
+

+ +

+ +

+ -
+ _
_ -
_
Provisionally, he was diagnosed as peripheral arterial
_ disease.

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Tasks

1.1 Define and classify peripheral vascular disease.

1.2 Differentiate between arterial and venous insufficiency

1.3 Discuss the incidence of peripheral vascular disease international and

in Kingdom of Bahrain.

1.4 Identify the physical assessment findings in Fadhel related to PAD.

1.5 Discuss the predisposing factors/etiology of PAD and relate it to Mr.

Fadhel.

1.6 Discuss the clinical manifestations in relation to the pathophysiology in

PAD and relate it to Mr. Fadhel.

1.7 Identify the complication fadhel has developed and discuss

other complications of PAD.

Trigger II

Mr. Fadhel was admitted to the vascular surgical ward for further
investigations and management. His investigation results were as follows:

CBC - WBC 9x109/1

RBC 5.5 x 1012/
Hb 11.5gm%
Hct 33 1/1
FBS 6.7 mmol/L
Antibody screening → -ve
Blood gp – B positive
Serum cholesterol – 180mg/dL
Coagulation studies
PT – 14 secs
PT index – 86%
International Ratio → 1:1
A.P.TT 34 secs
ECG - NAD

Doppler test - lower frequency in left foot

Arteriogram - Occlusion in left popliteal artery

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Doctor confirmed his diagnosis as peripheral arterial disease (PAD) and put
him on the following treatment.

Sliding insulin scale < 180mg nil

181 – 240mg – 5U
241 – 350mg – 10U
351 – 450mg –15 U
> 451mg 20U
Tab. Trental 400mg bd PO
1500 calories Diabetic Diet

He was posted for left popliteal bypass under spinal anaesthesia.

Pre-op medication
Tab. Valium 10mg hs and 5mg 6am
Inj. Rocephine 2gm IV stat (preop).
Tasks

2.1 Analyse the investigations done for Mr. Fadhel.

2.2 Identify the specific investigations done to confirm Fadhel’s diagnosis.

2.3 What are the other investigations done in a client with PAD that is not
performed for Mr. Fadhel.

2.4 Discuss the non-surgical management done in PAD and relate it to

Fadhel and its rationale.

Trigger III

Fadhel was brought back to the ward after undergoing left popliteal – tibial
Bypass graft under spinal anesthesia. He was fully awake; VS stable IV NS
on flow. Opsite intact with one hemovac. He was moving both lower limbs.

Post – operative orders:

IV NS 1.5 L for 24 hors
NPO – 4 –6 hours
Elevate left leg
Inj. Perfalgan 1 gm/PRN
Continuous bladder drainage
Continue insulin sliding scale
Inj. Clexene 4000 IU SC – 6am
6pm
Repeat CBC U/E, PT, PTT by 8pm
Monitor intake/output
Assess left lower limb for skin temperature, color capillary and pulse
hourly for 8 hrs then 2 hrs for 24 hrs.

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On the 2nd post operative day, Mr. Fadhel was seen by surgeon, ordered to
discontinue IVF and CBD.

On the 3rd post operative day the hemovac was removed. There was slight
bleeding on the opsite. Pressure dressing applied. He was advised
ambulation

Post operative lab results

CBC - WBC 12.1 x 109/L
RBC 3.5 x 1012/1
Hb - 8mg%
Platelet count 449 x 109/1
Urea - .5 mmol/L
Na - 139 nnol/L
K- 3.9 mmol/L
Cl - 102 mmol/L
HCO3 - 26 mmol/L
PT 15 secs
PT Index 80%
INR 1:3
A.P.TT 34 secs

Tasks:

3.1 Discuss the surgical management of PAD and relate it to Mr. Fadhel's
management.

3.2 Discuss the specific post – operative treatment in Fadhel and write
rationale for the above post – operative treatment.

3.3 Discuss importance of the above investigations done in Mr. Fadhel post
operatively.

3.4 Identify the actual/potential problems in Fadhel and formulate nursing

care plan in relation to PAD

3.5 Discuss the post – operative complications Fadhel may develop and
measures to prevent each one. Actions to be taken for each
complication in case of it’s occurrence.

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Trigger IV

After 1 week, he was seen by doctor and advised discharge. He was told that
he may have to undergo amputation of the toes with gangrene, after 2 weeks.

Mr. Fadhel looked worried and he asked “Now you will remove my toes, later
you may even cut my leg also”. Doctor reassured him and explained his
condition.

His discharge treatment includes the following:

Tab. Diamicron 30mg OD

Cap. Fefol one OD
Tab Aspirin 81mg OD
Lipitor 20mg HS
Low fat low carbohydrate diet
Follow up appointment after 1 week

4.1 As a nurse what would be your response to Fadhel’s comments. How

can you help Fadhel accept the amputation?

4.2 Prepare a health teaching plan for Fadhel to maintain his arterial
circulation and prevent further PAD?

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References

1. Brunner & Suddarth’s Text book of medical - surgical nursing, 14th

edition, 2018,Lippincot. Raven publishers.

2. Donna D. ignata vicious. M. Linda Workman. Mary A. Misbler medical -

surgical nursing a nursing process approach, 4th edition, 2001, W.B.
Saunders Company.

3. Sandra M. Nettina “The Lippincot manual of nursing practice, 6th

edition, 1996. Lippincot - Raven publishers.

4. Sharon Mantik Lewis,”Medical - Surgical Nursing assessment and

management of clinical problems”, 5th edition, 2000, McGraw - Hill,
Inc.

5. Lawrence M. Tierncy/current medical diagnosis Stephen J. Mc. Phec

and Rx. 36 edition Maxine A. papadake, 1997, Appleton & lange.

6. Phipps sands Marek , Medical – surgical Nursing Concepts &

Clinical Practice – 6th edition 1999 by Mosby, Inc.

F: Adult Health 1 – Peripheral Occlusive Arterial Disease