Chronic limb ischaemia: case study and clinical literature review.

This article will discuss chronic limb ischaemia as the result of peripheral artery disease (PAD) using a case study. The patient's concurrent diagnosis of metastases meant clinical decision making was complex and treatment options were limited. PAD is the third most common clinical presentation of atherosclerosis after coronary artery disease and stroke. Although advances in radiological technology and biochemical screening offer the potential for earlier intervention and improved survival rates for patients with PAD, a review of the evidence suggests that commitment to more conservative approaches, such as exercise therapy and health promotion, could have more sustainable, longer-term benefits for patients with chronic limb ischaemia. The therapeutic nature of the nurse-patient relationship makes nurses ideally placed for encouraging lifestyle changes and signposting to support services. Active participation from the patient is imperative for any potential modifications, which should be individualised as part of a holistic care plan, to ensure patient engagement and compliance. Therefore emphasis should remain on the management and prevention of modifiable risk factors, for which the nurse's role is an integral part to ensure success.

Úlceras arteriales y venosas. La física de la dinámica de fluidos vasculares como base de la prevención primaria enfermera / Arterial and venous ulcers. The physics of fluid dynamics as a basis for primary nursing prevention

Las úlceras vasculares son lesiones que se producen en las extremidades inferiores provocadas o agravadas por algún problema en el flujo sanguíneo distal, ya sea por el aporte, en el caso de las arteriales, o por el retorno, en el caso de las venosas. El conocimiento del proceso fisiopatológico en la aparición de las mismas ayuda a entender su etiología y proceso de evolución. Además, la comprensión de los mecanismos fisiológicos que las provocan permite escoger entre las diferentes técnicas a llevar a cabo, tanto preventivas como curativas, para establecer las medidas oportunas a poner en marcha. Se consiguen así intervenciones más efectivas dirigidas a la etiología del problema, que evitan que aparezca o se agrave, o, en caso contrario, favorecen una pronta cicatrización y, por lo tanto, una mayor calidad de vida de los pacientes. Enfermería debe conocer el proceso fisiopatológico de dichas lesiones, ya que tiene por objeto fomentar medidas de prevención, así como realizar las curas de manera efectiva, reduciendo las recidivas

Vascular ulcers are wounds in the lower limbs caused or aggravated by a problem in the distal blood flow, either by the supply in the case of arterial ulcers and return in the case of venous ulcers. The knowledge of the physiopathological process behind its etiology helps to understand the cause and evolution of vascular ulcers. In addition, the understanding of the physiological mechanisms that cause them allows to choose the most effective preventive measure or the most appropriate healing treatment. Thus, more effective interventions aimed at the etiology of the problem are achieved. These measures prevent the ulcers from appearing or getting worse, or in the case of presenting them, they promote an early healing, and therefore, a higher quality of life for the patients. The nurses must know the pathophysiological process of such wounds, since it is in charge of promoting preventive measures, as well as performing the cures effectively, reducing recurrences

Mobile educational follow-up application for patients with peripheral arterial disease.

OBJECTIVE: to describe the development of a prototype mobile educational application for nursing follow-up aimed at patients diagnosed with peripheral arterial disease. METHOD: a prototype-based technological production study. The construction followed the contextualized instructional design model using two steps: analysis and design and development. RESULTS: the pedagogical content of the application was based on a survey of needs of patients with Peripheral Arterial Disease and treatments recommended in the literature. The prototype developed contained concepts, risk factors, signs and symptoms, treatment, importance of medications and their side effects, frequent doubts, necessary health care, and follow-up of patients by monitoring the evolution of the cicatricial process of lesions and possible complications, clarification of doubts and stimulus for continuation of treatment. CONCLUSION: the use of health applications is a technological tool with the potential to improve the follow-up of patients regarding the progress of the disease and self-care, monitoring of risk factors, co-participation of the patient in the treatment, family participation, as well as planning of individualized care, and cost reduction for the health system.

Motivators and Barriers to Walking in Older Adults With Peripheral Artery Disease.

The purpose of the current review is to provide, within the context of social cognitive theory, a current description of behavioral, personal, and environmental factors that motivate or prevent an individual with peripheral artery disease (PAD) from participating in activity. A comprehensive review to explore motivators and barriers to walking in older adults with PAD was performed to help guide development of interventions to increase activity. Several databases were used for the literature review, with inclusion criteria being all study designs with samples of older adults with PAD. From the initial yield of 22 abstracts, and additional hand search, eight publications were used for this review. Social cognitive theory provided a context for understanding barriers and motivators to walking experienced by older adults with PAD. Nurses may contribute to walking self-efficacy with support and motivation. [Journal of Gerontological Nursing, 44(1), 43-50.].

Patients' experiences and feelings before undergoing peripheral percutaneous transluminal angioplasty.

The use of interventional radiology as treatment has increased dramatically and peripheral arterial disease (PAD) is now a common indication for vascular interventions such as percutaneous transluminal angioplasty (PTA).(1) PAD seriously impairs quality of life, and patients experience a lack of control over the disease. The aim of this study was to identify patients who are predominantly anxious or calm before PTA treatment and to explore reasons for these feelings. The study includes both individual interviews, a shortened version of a Swedish Mood Adjective Check List (MACL), and an overall assessment of the perceived degree of calmness-anxiety. Forty-two patients were included in the study. The 'anxious' group showed a significantly lower mood in all scales of the MACL compared with the 'calm' group. Reasons for feeling calm were a sense of being safe and high expectations. Reasons for feeling anxious were represented by a sense of despair and apprehension about the PTA. The main reason for feeling calm was related to trust in their caregivers and an ability to foresee upcoming events. The main reason for feeling anxious before the PTA was fear of a negative outcome and being unsure of treatment options. Greater knowledge and a better understanding of their disease and treatment options would support patients' ability to accept reasons for waiting before using invasive treatment. Moreover, this could decrease their anxiety and increase their feeling of being in control of their situation.

An integrative review: application of self-efficacy instruments for walking in populations with peripheral arterial disease.

OBJECTIVE: The study objective was to identify which self-efficacy measurement instruments are being used for walking in patients with peripheral arterial disease (PAD), the psychometrics of these instruments, and recommendations for use in research on patients with PAD. BACKGROUND: PAD is a common problem for individuals with similar risk factors as cardiovascular disease (CVD). Experts recommend a supervised walking program with incremental increases in speed and distance as an initial treatment for patients with intermittent claudication. Because patients may experience pain while walking, there is a tendency to be nonadherent with exercise therapy, and many limit or avoid walking all together, resulting in a sedentary lifestyle. Self-efficacy plays a role in determining a person's confidence in his or her ability to participate in an exercise program. Data sources for this study were PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and the Cochrane database. METHODS: The integrative review method described by Wittemore and Knafl was used for this review (Wittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52:546-53.). Publications were retrieved electronically and reviewed for inclusion on the basis of studies that measured self-efficacy for walking in populations with PAD, peripheral vascular disease, and CVD. The analysis consisted of 9 publications. RESULTS: Only 2 studies were specific to the population with PAD. The remaining studies addressed self-efficacy issues in CVD or congestive heart failure. The analysis identified 4 instruments based on Bandura's Social Cognitive Theory that were used to assess self-efficacy: (1) the Self-Efficacy Expectation Scale, (2) the Self-Efficacy for Managing Chronic Disease Scale, (3) the Performance-Based Efficacy Scale, and (4) the Barriers Self-Efficacy Scale. The Self-Efficacy Expectation Scale was most frequently used in these studies. CONCLUSIONS: The use of the Self-Efficacy Expectation Scale instruments for walking in patients with PAD is limited because reliability and validity have been demonstrated in an older, mostly white population with CVD and congestive heart failure. Instruments that encompass the key constructs of self-efficacy, including physical, personal, and environmental aspects, would allow full evaluation with identification of potential explanations for success or failure for the chosen outcome. This should be taken into consideration in future studies when using instruments of self-efficacy.

A service pathway for patients at risk of peripheral arterial disease.

Every year in the UK 100,000 people are diagnosed with peripheral arterial disease (PAD) (Belch at al, 2007). Those who are diagnosed are likely to suffer from cardiovascular complications and are six times more likely to die within 10 years, compared with people without PAD (Belch et al, 2007). This medical condition gives no symptoms at early stages and can develop manifesting itself through various degrees of intermittent claudication. This critical analysis will focus on the literature describing peripheral vascular problems with associated symptoms. It will also analyse current understanding of the quality of the vascular assessment within the primary care sector. As a natural consequence this piece of work will aim to highlight the role and significance of Healthcare Professionals within a new service pathway design for the community.

Implementing a home-based exercise prescription for older patients with peripheral arterial disease and intermittent claudication: a quality improvement project.

A Nurse Practitioner-led quality improvement project was implemented in a vascular surgical care clinic to facilitate home-based exercise for patients diagnosed with peripheral arterial disease (PAD) and intermittent claudication (IC). The primary goal of the project was to develop an information brochure about PAD and the benefits of exercise, as well as, a written prescription for home-based exercise program. These materials are used in the care of patients with PAD and IC to augment verbal recommendations normally provided by the healthcare provider. The project's secondary goal was to determine the impact of these materials on the frequency of home-based exercises among participating patients. After implementation of the project, 70% of the patients who received the exercise brochure and prescription reported exercising at least four times per week. Prior to implementing the project, 7 (47%) of the patients in the project reported exercising at least four times a week. Additionally, on the follow-up survey 16 (94%) patients reported participating in some form of exercise and only 1 (6%) patient did not report exercising. Before the project was implemented, 7 (41%) patients reported no regular exercise, and 10 (59%) patients reported exercise. After the project, there was a 35% increase in reported exercise among the patient population. This was a statistically significant finding in the project. This suggests the prescription could have caused the change in the patient reports.

A PAD service led by nurses and podiatrists.

Peripheral arterial disease (PAD) is serious but its significance has only recently been reflected in NICE guidance. A trust launched a PAD service led by nurses and podiatrists. The service is cost-effective and ensures that most patients receive treatment in the community, with referrals made to secondary care as appropriate. A care pathway standardises care.

Differences in nutrition status by body mass index in patients with peripheral artery disease.

Peripheral Arterial Disease (PAD) is most prevalent in the elderly and associated with increased cardio vascular disease (CVD) morbidity and mortality. Treatment focuses on improving functional capacity and reducing CVD risk factors. To date, little is understood about dietary habits and weight in this patient population. Nutritional and weight recommendations are based on heart health, and little is known about the unique needs of elderly PAD patients with multiple comorbidities. This prospective study compared 1) the dietary intake of nonobese PAD patients in comparison with those who were obese and; 2) dietary intake of those patients with the Estimated Average Requirement (EAR) based on age, gender and BMI. Nutritional intake was assessed with the Block 98 Food Frequency Questionnaire. Body mass index (BMI) was calculated in accordance with the National Heart, Lung, and Blood Institute (NHLBI) guidelines.The study population was divided into obese (BMI ≥ 30) and nonobese (NO) groups. Comparisons between groups were performed using the Mann-Whitney U test for continuous variables and the Chi-square test for ordinal variables. All tests were two-tailed and P < 0.05 was considered significant. The Estimated Average Requirement (EAR) cut-point method was used to compare nutritional variables with Dietary Reference Intakes (DRI). The study population included 189 NO (BMI < 30) and 111 obese (BMI > 30) individuals. Obese participants reported greater intake of foods containing cholesterol and trans-fatty acids and more frequent intake of B vitamins in comparison with the NO BMI group. Additionally, the nutrient intake of all participants by age, gender and BMI was lower than the EAR for magnesium, folate, and Vitamin E. These results suggest that the nutritional intake of PAD patients differs based on gender and BMI. Additionally, EAR was lower for specific nutrients than recommended. Further investigation is needed to examine the association between nutritional intake and nutrition-related deficits.

Detección precoz de enfermedad arterial periférica. Mediante la determinación del índice tobillo-brazo en atención primaria / Early diagnosis of peripheral arterial. Disease by measuring the ankle-brachial index in patients of nursing consultations in primary health care

Objetivo. Detectar precozmente la enfermedad arterial periférica (EAP) mediante la medición del índice tobillo brazo (ITB) en usuarios de la consulta de enfermería de Atención Primaria (AP) con riesgo cardiovascular medio o alto calculado mediante la escala de Framingham. Método. Estudio descriptivo, observacional, transversal en el que se incluyó pacientes que acudieron a consulta de enfermería programada de un centro de salud de Elche durante el período comprendido entre marzo y abril de 2009 y que presentaban un riesgo cardiovascular medio o alto en la escala de Framingham. A los sujetos incluidos se les realizó la determinación del ITB. Se excluyó a los pacientes previamente diagnosticados de enfermedad coronaria, cerebrovascular o EAP. Resultados. Se midió el ITB en un total de 52 pacientes. La edad media (desviación estándar) de los sujetos fue de 66,5 (8,8) años y el 51,9% era varón. El ITB fue bajo (<0,9) en 13 pacientes. Por lo tanto se detectó EAP en un 25% de los usuarios a estudio. Conclusiones. La consulta de enfermería de AP constituye un contexto idóneo donde realizar la detección precoz de la EAP, mediante la determinación del ITB. Esta debería formar parte de la exploración de los pacientes crónicos que acuden periódicamente a consulta, sobre todo los que presentan un riesgo cardiovascular medio o alto. De este modo se podrían intensificar las medidas preventivas para evitar futuras complicaciones cardiovasculares en estos pacientes(AU)

Objective. The aim of this study was to detect peripheral arterial disease (PAD) by the measurement of the ankle-brachial index (ABI) in patients of nursing consultations in primary health care who presented a moderate or high risk in Framingham risk score. Method. This descriptive, cross-sectional and observational study included patients with a moderate or high risk in Framingham risk score, who went to programmed nursing consultations in a primary health care center in Elche during the period between March and April in 2009. A measurement of ankle-brachial index was performed. No patients were known to have arterial disease. Results. ABI was measured in 52 patients. Mean age (standard deviation) of subjects was 66,5 (8,8) years and 51,9% were male. A low ABI (<0.9) was found in 13 patients.Therefore, PAD was diagnosed in 25% of the sample subjects. Conclusions. Nursing consultations in primary care are a right context to make an early diagnosis of PAD, by measuring ABI. This should be part of the exploration of chronic patients who come periodically to nursing consultations, particularly those ones with a moderate or high cardiovascular risk. In this way, preventive measures could be intensified to prevent future cardiovascular complications in these patients(AU)

Identifying and managing peripheral arterial disease.

Peripheral arterial disease affects a significant number of people over the age of 60, but is often underdiagnosed and suboptimally treated. Nurses are well placed to help identify and manage PAD in its early stages and help to reduce poor outcomes associated with this disease. Part 2, published next week, describes an innovative nurse and podiatrist-led service for PAD.