BLOK 8 KARDIOVASKULER, PSIK FKIK UMY Skenario 4

A. Blood Vessels Structure and Function

The walls of blood vessels, except the very smallest, are composed of three distinct
layers:
- Tunica externa (adventia); an outer of loosely woven collagen tissue which is
composed of loose connective tissue
- Tunica media; a middle layer which is consists primarily of circumferentially
arranged layers of smooth muscle cells and elastic fibers.
- Tunica intima; an inner layer which consists of a single layer of endothelial cells
that line the lumen of the vessels and the underlying subendothelial connective
tissue.

There are five main types of blood vessels which are arteries, arterioles, capillaries, venules and veins.

Arteries
Arteries are blood vessels that carry blood away from the heart. The majority of arteries carry oxygenated blood. Arteries have a large internal diameter and thus offer
little resistance to the flow of blood. The wall of an artery has the three layers of a typical blood vessel, but has a thick muscular-to-elastic tunica media. Due to their
plentiful elastic fibers, arteries normally have hit compliance, which means that their walls stretch easy or expand without tearing in response to a small increase in
pressure. Arteries also have a smooth muscular layer that functions to regulate the flow of blood through the artery. Muscular arteries possess the ability to constrict
and dilate in order to accommodate the metabolic needs of the moment.

Arterioles
Arterioles are smaller arteries that carry blood from larger arteries to the capillary bed where gas exchange will occur. Arterioles have a thin tunica interna with a thin,
fenestrated internal elastic lamina that disappears at the terminal end. The tunica media consists of one to two layers of smooth muscle cells having a circular
orientation in the vessel wall. The terminal end of the arteriole, the region called the metarteriole, tapers toward the capillary junction. At the metarteriole-capillary

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junction, the distal-most muscle cell forms the precapillary sphincter which monitors the blood flow into the capillary, the other muscle cells in the arteriole regulate
the resistance to blood flow.

Venules
Group of capillaries within a tissue reunite to form small vein called venules. Venules are attached to the capillary and merge together to form larger blood vessels
known as veins. Unlike their thick-walled arterial counteparts, venules have thin walls that do not readily maintain their shape. Venules drain the capillary blood and
begin the return flow of blood back toward the heart.

Veins
Veins are the blood vessels that convey blood from tissue back to the heart or venules in turn merge to form progressively larger blood vessels. Veins have three layers
but very poorly developed. Tunica externa usually several times thicker than tunica media. The lumens are larger than corresponding arteries. While veins do show
structural changes as they increase in size from small to medium to large, the structural changes are not as distinct as they are in arteries. Veins , in general, have very
thin walls relative to their total diameter. They range in size from 0.5 mm in diameter for small veins to 3 cm in the large caval veins entering the heart.

Capillaries
Capillaries are the smallest and most numerous of blood vessels. Capillaries function as the site of exchange of
nutrients and wastes between blood and tissues. The anatomy of capillaries is well suited to the task of efficient
exchange. Capillary walls are composed of a single layer of epithelial cells surrounded by a basement layer of
connective tissue. The thin nature of the walls facilitates efficient diffusion of oxygen and carbon dioxide. Most
capillaries also have pores between cells that allow for bulk transport of fluid and dissolved substances from the
blood into the tissues and visa versa.

B. Definition of Peripheral Arterial Disease

PAD is the preferred clinical term for describing stenosis or occlusion of upper- or lower-extremity arteries due to atherosclerotic or thromboembolic disease

Classification
Peripheral artery occlusive disease is commonly divided in the Fontaine stages, introduced by René Fontaine in 1954 for chronic limb ischemia:
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 Stage I: Asymptomatic, incomplete blood vessel obstruction
 Stage II: Mild claudication pain in limb
 Stage IIA: Claudication when walking a distance of greater than 200 meters
 Stage IIB: Claudication when walking a distance of less than 200 meters
 Stage III: Rest pain, mostly in the feet
 Stage IV: Necrosis and/or gangrene of the limb
A classification introduced by Robert B. Rutherford in 1986 and revised in 1997 consists of four grades and seven categories:
 Grade 0, Category 0: Asymptomatic
 Grade I, Category 1: Mild claudication
 Grade I, Category 2: Moderate claudication
 Grade I, Category 3: Severe claudication
 Grade II, Category 4: Rest pain
 Grade III, Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
 Grade IV, Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene

C. Etiology and Risk Factors of Peripheral Arterial Disease

Etiology of PAD is atherosclerosis (a condition in which a material called plaque builds up on the inner walls of the arteries).
Risk factors of PAD:
 Smoking - tobacco use in any form is the single most important modifiable cause of PVD internationally. Smokers have up to a tenfold increase in relative risk for
PVD in a dose-related effect. Exposure to second-hand smoke from environmental exposure has also been shown to promote changes in blood vessel lining
(endothelium) which is a precursor to atherosclerosis.Smokers are 2 to 3 times more likely to have lower extremity peripheral arterial disease than coronary artery
disease. More than 80%-90% of patients with lower extremity peripheral arterial disease are current or former smokers. The risk of PAD increases with the number
of cigarettes smoked per day and the number of years smoked.
 Diabetes mellitus - causes between two and four times increased risk of PVD by causing endothelial and smooth muscle cell dysfunction in peripheral arteries. The
risk of developing lower extremity peripheral arterial disease is proportional to the severity and duration of diabetes. Diabetics account for up to 70% of
nontraumatic amputations performed, and a known diabetic who smokes runs an approximately 30% risk of amputation within 5 years.
 Dyslipidemia (high low density lipoprotein [LDL] cholesterol, low high density lipoprotein [HDL] cholesterol) - elevation of total cholesterol, LDL cholesterol,
and triglyceride levels each have been correlated with accelerated PAD. Correction of dyslipidemia by diet and/or medication is associated with a major
improvement in rates of heart attack and stroke. This benefit is gained even though current evidence does not demonstrate a major reversal of peripheral and/or
coronary atherosclerosis.
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 Hypertension - elevated blood pressure is correlated with an increase in the risk of developing PAD, as well as in associated coronary and cerebrovascular events
(heart attack and stroke).Hypertension increased the risk of intermittent claudication 2.5- to 4-fold in men and women, respectively.

D. Manifestations of Arterial Disease (LeMone & Burke, 2008)

- Pain is the primary symptom of PAD (acute arterial occlusion)
- Intermittent claudication is a cramp-like pain felt in the calf, thigh or buttock during walking or other exercise. It is caused by lack of oxygen to the muscles because of a poor
blood supply and is relieved by rest. Proximal arterial obstruction leads to decreased blood flow to exercising muscle, resulting anaerobic muscle metabolism.
Claudication is an ischemic pain, which means it occurs when the arterial blood supply does not meet the metabolic demand of the muscles. It is often described as
a cramping-type pain. The pain is localized to the hip or buttock and the calf.
Fontaine’s clinical classification: Stage I (asymptomatic), IIa (mild claudication), IIb (moderate-severe claudication), III (ischemic rest pain), IV (ulceration or gangrene)
- Rest pain. It is often described as a burning sensation in the lower legs. Rest pain increases when the legs are elevated and decreases when the legs are dependent (
e.g., hanging over the side of the bed).
- The legs also may feel cold or numb along with the pain.
- The muscle may atrophy

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- Peripheral pulses may be decreased or absent. A bruit may be heard over large affected arteries, such as the femoral artery and the abdominal aorta
- The legs are pale when elevated, but often are dark red (dependent rubor) when dependent.
- The skin often is thin, shiny, and hairless, with discolored areas. Toenails may be thickened.
- Area of skin breakdown and ulceration may be evident.
- Edema may develop with severe PAD

E. Diagnostic Test
1. ABI (Ankle Brachial Index)
ABI is the ration between the systolic arterial (SAP) obtained in the legs and the SAP of the brachial artery.

2. Doppler is used to auscultate the flow in the dorsalis pedis or posterior tibial artery.
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BLOK 8 KARDIOVASKULER, PSIK FKIK UMY Skenario 4
3. Angiography. Angiografi is the imaging of blood vessels using water-soluble ionic or nonionic X ray contrast media
injected into the blood stream of arteries (arteriography) or veins (venography) . A catheter is inserted into the common
femoral artery and selectively guided to the artery in question. While injecting a radiodense contrast agent an X-
ray is taken. Any flow limiting stenoses found in the x-ray can be identified and treated by atherectomy,
angioplasty or stenting. Contrast angiography is the most readily available and widely used imaging technique.

4. Computerized tomography (CT) scanners provide direct imaging of the arterial system as an alternative to angiography. CT provides complete evaluation of the
aorta and lower limb arteries without the need for an angiogram's arterial injection of contrast agent.
5. Magnetic resonance angiography (MRA) is a noninvasive diagnostic procedure that uses a combination of a large magnet, radio frequencies, and a computer to
produce detailed images to provide pictures of blood vessels inside the body. The advantages of MRA include its safety and ability to provide high-resolution
three-dimensional (3D) imaging of the entire abdomen, pelvis and lower extremities in one sitting.

F. Pathway of Peripheral Arterial Disease

Atherosclerosis is a condition in which a material called plaque builds up on the inner walls of the arteries. Atherosclerosis is characterized by the development of
atheromatous lesions within the intimal lining of the large and medium sized arteries that produce into and can eventually obstruct blood flow. The development of
atheroscheloris lesions is a progressive process involving
a. Endothelial cell injury. Agents such as smoking, elevated LDL (low-density lipoprotein)levels, immune mechanisms, and mechanical stress share the potential for
causing endothelial injury with adhesion of monocytes and platelets.
b. Migration of inflammatory cells. Early of the development of atherosclerotic lesions, endothelial cells begin to express selective adhesion molecules that bind
monocytes and other inflammatory cells that initiate the atherosclerosis lesions. After monocytes adhere to the endothelium, they migrate between the endothelial
cells to localized in the intima, transform into macrophages, and engulf lipoproteins, largely LDL.
c. Lipid accumulation and smooth muscle proliferation. Although the recruitment of monocytes, their differentiation into mcrophages and subsequent ingestion of
lipids, and their ultimate transformation into foam cells is protective in that it removes excess lipids from the circulation, progressive accumulation eventually
leads to lesion progression. Activated macrophages release toxic oxygen species that oxidize LDL: they then ingest the oxidatized LDL to become foamcells. They
also produce growth factors that contribute to the migration and proliferation of smooth muscle cells.
d. Plaque structure. Atherosclerotic plaques consists of an aggregation of smooth muscle cells, macrophages, and other leukocytes, collagen and elastic fibers,and
intracellular and extracellular lipids.

PAD is mainly caused by atherosclerosis and associated thrombosis within the lower limb arteries leading to end organ ischemia. Other causes include vasculitis and in
situ thrombosis related to hypercoagulable states. The pathophysiology of athero-thrombosis induced PAD is complex, and involves a large number of cells, proteins
and pathways. Important cells contributing to or controlling the development of athero-thrombosis include vascular endothelial cells (ECs), vascular smooth muscle
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cells (SMCs), fibroblasts, platelets, resident stem cells, pericytes and inflammatory cells. The pathophysiology of atherosclerosis has been described in detail in
previous reviews
Under healthy conditions the response to gradually progressive limb ischemia involves the promotion of angiogenesis and arteriogenesis in an attempt to increase the
blood supply to the affected limb. Vascular remodeling, inflammation and apoptotic pathways are also implicated in the ischemic response and these may in part
contribute to the resolution of tissue damage. In patients with CLI these compensatory responses to ischemia are ineffective. As a result, there is on-going inadequate
perfusion of tissue, endothelial dysfunction, chronic inflammation and high levels of oxidative stress. All these changes lead to mitochondrial injury, free radical
generation, muscle fibre damage, myofibre degeneration and fibrosis, and tissue damage, which may present as gangrene.
Arteriogenesis is the process of enlargement of pre-existing collateral arteries to contribute to tissue perfusion. The primary driving force is the increased laminar blood
flow or shear stress associated with redistribution of flow as a result of the reduction in downstream luminal pressure. The increase in shear stress promotes vessel
enlargement, which is stimulated by activation of nitric oxide (NO) signaling and likely other signaling responses to flow.Angiogenesis describes the development of
new capillary networks. An important driving force for angiogenesis is tissue ischemia. In response to local hypoxia in the ischemic limb, sprouting of small
endothelial tubes occurs from pre-existing capillary beds. A number of hypoxia-inducible growth factors play a role in this process, such as vascular endothelial growth
factor (VEGF) and hypoxia inducible factor (HIF)-1α. Potential therapies designed to accelerate arteriogenesis and angiogenesis during ischemia are under intense
investigation although most of these interventions have not developed to a stage that they are ready for widespread clinical use

PERIPHERAL ARTERIAL DISEASE

Complete occlusion of proximal Etiology

Nursing Intervention left superficial artery Hypertension, diet (salty food),
- Assessment of wound smoking 10 years (2 packs per day).
- Wound dressing
- Don not elevate the legs above the level of heart.
Determine the size and depth of the wound and
classify ulcer. Monitor peripheral pulses Intolerance activity signed by
Decreased blood flow to Intermittent claudication
(Ackley & Ledwig, 2004)
the foot

Signs & symptoms

Reduce lower extremity Supply-demand mismatch
- PAD classification
perfusion
- Type of wound
Tissue hypoxia Signs & symptoms
- Negative pulses on popliteal,
Impaired skin/tissue integrity Ulcer Ischemic of muscle dorsalis pedis & posterior tibia
- Result of Angiogram 7
- ABI score
BLOK 8 KARDIOVASKULER, PSIK FKIK UMY Skenario 4

Produce chemical; bradikinin, histamine, etc Anaerob metabolism

Dorsal Horn Nociceptic

Ineffective tissue perfusion r/t
Spinal Cord Brain decreased arterial blood flow

Pain Nursing Intervention

- Assess level & type of pain Reducing Pain
Signs & symptoms - Give education about pain
- Pain level - Nonpharmachology: music
- Continuous pain therapy, mindfulness, exercise
G. Treatment of Peripheral Arterial Disease
- Intermittent Claudication - Collaboration: analgetic:
Dependent on the severity of the disease, the following steps can be taken:
 Smoking cessation
 Management of diabetes.
 Management of hypertension.
 Management of cholesterol
 Regular exercise for those with claudication helps open up alternative small vessels (collateral flow) and the limitation in walking often improves. Treadmill exercise (35 to 50
minutes, 3 to 4 times per week has been reviewed as another treatment with a number of positive outcomes including reduction in cardiovascular events and improved quality of
life.
 Medication with aspirin, clopidogrel and statins, which reduce clot formation and cholesterol levels, respectively, can help with disease progression and address the other
cardiovascular risks that the patient is likely to have. Prescribing medication especially anticoagulants. Anticoagulants such as low-molecular-weight heparin (LMWH) increase
the action of antithrombin and inhibit a number of coagulation proteins.
 Cilostazol or pentoxifylline treatment to relieve symptoms of claudication.
 Recommendations for Antiplatelet and Antith-rombotic Drugs. is indicated for individuals with asymptomatic lower extremity PAD to reduce the risk of adverse cardiovascular
ischemic events. Antiplatelet therapy is indicated to reduce the risk of MI, stroke, and vascular death in individuals with symptomatic atherosclerotic lower extremity PAD,
including those with intermittent laudication or CLI prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia.
 Patient with claudication. Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the AbI,the AbI should
be measured after exercise if the resting index is normal.
After a trial of the best medical treatment outline above, if symptoms remain unnacceptable, some treatments can be done:

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 Angioplasty/ PTA
Angioplasty is an angiographic procedure for elimination of areas of narrowing in the blood vessels. Balloon angioplasty inflation and deflation of a
balloon catheter inside an artery, stretching the intima and leaving a ragged interior surface, triggering a healing response and breaking up of plaque.
Balloon angioplasty, the expanded balloon pressing against a stenotic site in an artery.
Percutaneous transluminal angioplasty (PTA) is the mechanical recanalization of an occluded or stenotic artery by displacement of the obstructing
material within like atherosclerosis plaque or predilation and sizing of the mecenteric artery prior to stent placement. A type of balloon angioplasty
in which the catheter is inserted through the skin and through the lumen of the vessel to the site of the narrowing.
 Bypass grafting. Bypass grafting is needed to circumvent a seriously stenosed area of the arterial vasculature.
Bypass surgery is surgery to reroute the blood supply around a blocked artery in one of your legs by creating a new pathway for blood flow using a
graft. An incision in the groin and thigh to expose the affected artery above the blockage, and another incision to expose the artery below the
blockage. This surgery is performed when the buildup of fatty deposits (plaque) in an artery has blocked the normal flow of blood that carries oxygen
and nutrients to the lower extremities. Bypass surgery reroutes blood from above the obstructed portion of an artery to another vessel below the
obstruction.
 When gangrene of the toes has set in, amputation is often a last resort to stop infected dying tissues from causing septicemia.

H. Nursing Care of Peripheral Arterial Disease

1. Assessment
- Health history: complains of pain, its relationship to exercise or rest, timing, associated symptoms, and relief measures; history of coronary heart disease,
peripheral vascular disease, hyperlipidemia, hypertension, or diabetes, current medications; smoking history, usual diet, and activity patterns.
- Physical examination: Vital signs, strength and equality of peripheral pulses of all extremities; capillary refill time; skin color, temperature, hair distribution,
presence of any discolorations or lesions; movement and sensation of lower extremities.
- Assessment intermittent claudication: hallmark of the disease rest pain: severe is a numbness or burning, often described as feeling like a toothache, that is
severe enough to awaken clients at night. it may be so excruciating that it is unrelieved by opioids. elevating the extremity or placing it in a horizontal position
increases the pain, whereas placing the extremity in a dependent position reduces the pain. In bed, some sleep with affected leg hanging over the side of the bed.
Some patients sleep in a reclining chair in an attempt to relieve the pain.
- Assessment Coldness or cold sensitivity – Coldness in the feet with exposure to a cold environment, associated with blanching or cyanosis due to ischemia
extremity Cold and pale when elevated or ruddy and cyanotic when placed in a dependent position nails : thickened and opaque Skin: shiny, atrophic, and dry,
with sparse hair growth. comparison of the right and left extremities. Bruits may be auscultated with a stethoscope
- Assessment Ulceration and gangrene. May be due to ischemia ot trauma. Impaired tissue perfusion inhibits healing process Edema. Due to severe obstruction
Sexual dysfunction. Occlusion of terminal aorta decreases blood supply to the penile arteries Gangrene muscle atrophy
- Assessment peripheral pulses: important part of assessing arterial occlusive disease. Unequal pulses between extremities or the absence of a normally palpable
pulse is a sign of peripheral arterial disease. The femoral pulse in the groin and the posterior tibial pulse beside the medial malleolus are most easily palpated.

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BLOK 8 KARDIOVASKULER, PSIK FKIK UMY
No Nursing Diagnose
1 Acute/ chronic pain related to
tissue damage
2 Ineffective tissue perfusion on
foot related to decrease of
blood supply to the right foot
(Arterial occlusion of popliteal
artery in the right foot)
3 Activity intolerance
4 Impaired skin/tissue integrity
Skenario 4
Nursing Intervention
Outcomes/Goals
- Reduced pain 1. Assess and document the intensity, character,
- Patient look relax onset, duration, and aggravating and relieving
- Patient can control pain factors of pain
by herself 2. Determine the client’s current medication use
3. Support and teach the patient use of
nonpharmacological methods to help control pain,
music therapy
4. Collaboration analgetic drug: fentanyl IV
Adequate tissue perfusion 1. Monitor peripheral pulses
- Palpable peripheral 2. Encourage exercise such as walking
pulses, 3. Conduct massage in lumbosacral, pelvic and lower
- Warm and dry skin limb
4. Don not elevate the legs above the level of heart
5. Keep the patient warm and support to use socks
6. Collaboration: PTA
1. Assist with care activities as needed
2. Unless contraindicated, encourage gradual
increases in duration and intensity ofexercise
3. Assess peripheral pulses, pain, color, temperature,
and capillary refill every 4 hours and as needed.
Use Doppler device if pulses are not palpable. Use
pulse locations with an indelible marker.
4. Provide position with extremities dependent.
5. Advice patient to do exercise.
Gangrene/ arterial ulcer: 1. Observe and report signs of infection
- Remain free from 2. Measure pulse on popliteal, dorsalis pedis,
signs and symptoms of posterior tibia
infection 3. Monitor the status of the skin around the wound
Rational
1. The initial assessment and documentation provide direction for the pain
treatment plan (JCAHO, 2000 as cited in Ackley & Ledwig, 2004).
2. To aid in planning pain treatment, obtain a medication history (Acute
Pain Managemnet Guideline Panel, 1992 as cited in Ackley & Ledwig,
2004).
3. Music intervention contributed to significantly reducing chronic pain
(Guetin, 2011)
4. Fentanyl, is an opioid (morphine-like) drug, that has been demonstrated
to be an effective pain-killer medication by the i.v. and transdermal
(through skin) routes (Sinatra, Jahr, Watkins-Pitchford, 2010)
1. Pulses is one symptoms that make sure the cause of arterial occlusion
2. Exercise training can reverse age-related peripheral circulatory problems
in otherwise healthy older man (Beere et al, 1999)
3. Massage influence blood flow in foot and increase foot oxygen saturation
( Castro-Sanchez et al, 2011)
4. Leg elevation decreases arterial blood supply to the legs
5. Keep extremities warm to maintain vasodilatation and blood supply
6. PTA is the mechanical recanalization of an occluded or stenotic artery by
displacement of the obstructing material within like atherosclerosis
plaque or predilation and sizing of the mecenteric artery prior to stent
placement.
Gradual increases in the duration and intensity of exercise promote
development of collateral circulation
Assessment data provide a baseline for evaluating the effectiveness of
interventions and identifies changes in arterial blood flow.
Gravity promotes arterial flow to the dependent extremity, increasing tissue
perfusion and relieving pain.
Exercise promotes development of collateral circulation to ischemic tissues
and slows the process of etherosclerosis.
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 BLOK 8 KARDIOVASKULER, PSIK FKIK UMY Skenario 4
4. Determine the size and depth of the wound
5. Wound dressing one time a day
6. Mobilization every 2 hours
7. Encourage a balanced diet
8. Collaboration : antibiotics

Type of exercise based on evidence based

Author/year/title Method/Sample/setting Intervention Result

Tebbut, Robinson, Todhunter, - RCT
& Jonker, (2010)
A plantar flexion device
exercise programme for
patients with peripheral
arterial disease: a randomised
prospective feasibility study
Aim: to determine if the use of
a plantar flexion device (Step It
pedal) in a newly developed
exercise programme is of
benefit to patients
with peripheral arterial disease.
Gardner, et al. (2005). The - RCT
effect of exercise intensity on - 31 patients in low intensity exercise and 33 patients in high
the response to exercise
rehabilitation in patients with
intermittent claudication
Aim: to compare the efficacy
of a low intensity exercise
rehabilitation programs vs high
- 42 patients( 18 in the control group, 24 patients in the
experimental group)
Inclusion criteria;
Patients have calf pain upon walking and an ABI <0.90. Adult
patients with symptomatic intermittent claudication due to
peripheral arterial disease who were capable of giving
informed consent
exclusion criteria:
unstable cardio/respiratory condition, such as uncontrolled
hypertension, cardiovascular accident or myocardial infarction
within the last 2 months; surgery within 6 weeks of enrolment;
major
amputation of one or more lower limbs; and blood glucose
level >13 mmol/l (i.e. uncontrolled diabetes)
- Physiotherapy Department at Cumberland Infirmary, Carlisle,
UK
intensity exercise.
Inclusion criteria; a history of intermittent claudication,
exercise tolerance, ABI <0.90 and ability to live
independently at home.
Exclusion criteria: absence of PAD, asymptomatic PAD, rest
pain PAD, exercise tolerance limited by factors other than
the control group - Claudication distance and maximum walking
(standard care) or the distance:
intervention group (standard the control group
care plus the median distance reduced from 260 m (IQR
use of the Step It pedal) for 100 to 325 m) to 210 m (IQR 140 to 430 m).
a period of 12 week (3 times the intervention group, the median maximum
per week) distance walked improved from 160 m (IQR
the pattern: 2 minutes 103 to 274 m) to 200 m (IQR 110 to 308 m)
exercise/2 minutes rest, 10 - ABI remained virtually unchanged in both
times, to equal 20 minutes groups. the intervention group (baseline: 0.64,
of exercise in total IQR 0.51 to 0.87; 12 weeks: 0.63, IQR 0.54 to
0.73) control group (baseline: 0.73, IQR 0.56 to
1.00; 12 weeks: 0.74, IQR 0.61 to 0.97)
- Low intensity: walking - Initial claudication distance increased by 109%
duration; 15 minute (1st in the low intensity group (P<.01), by 109% in
month) progressively by 5 the high intensity group (P<.01)
minutes per month until s - Claudication distance increased by61%
total minutes. (P<0.01) and 63% (P<.01) in the low intensity
- High intensity: duration (12, and high intensity groups.
17, 21, 26, 30 and 35 - Both exercise programs elicited improvements
minutes) during 6 months. (P< .05) in peak oxygen uptake, ischemic
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Author/year/title Method/Sample/setting Intervention Result
intensity program in changing claudication, active cancer, renal disease or liver disease, window, and health related quality of life.
physical function, peripheral current use of pentoxifylline or cilostazol.
circulation, and health related - At three Maryland veterans affairs institutional review.
quality of life in peripheral
arterial disease patients.

I. Islamic Revealed Knowledge

- Smoking cessation
“Dan belanjakanlah (apa yang ada pada kamu) kerana (menegakkan) ugama Allah, dan janganlah kamu
sengaja mencampakkan diri kamu ke dalam bahaya kebinasaan (dengan bersikap bakhil) dan baikilah
(dengan sebaik-baiknya segala usaha dan) perbuatan kamu kerana sesungguhnya Allah mengasihi orang-
orang yang berusaha memperbaiki amalannya. (QS. Al Baqarah (2): 195)

(29) ً‫سككمم إحلن ال لهر ركاًرن بحككمم ررححيِمما‬ ‫يِاً أريِينهاً الحذيِن رآمكنوُا رل ترأمكككلوُا أرموُالرككم بنيِننرككم بحاًلمباًحطحل إحلل أرمن ترككوُرن تحجاًرةم رعن ترنرا ض ح‬
‫ض ممنككمم رورل ترنمقتْكنكلوُا أرنَمنكف ر‬ ‫رر م ر‬ ‫م ر م رم م ر‬ ‫ر ر‬ ‫ر ر‬
An Nisa: 29
Wahai orang-orang yang beriman, janagnlah kalian memakan harta-harta kalian di antara kalian dengan cara yang batil, kecuali dengan perdagangan yang kalian saling ridha. Dan janganlah kalian
membunuh diri-diri kalian, sesungguhnya Allah itu Maha Kasih Sayang kepada kalian.
- Sabar: “…Allah mencintai orang-orang yang sabar.” (QS. Al Imran : 146)
“...dan sabarlah sesungguhnya Allah beserta orang-orang yang sabar. (QS Al Anfal : 46)

Al Baqarah; 153..”Wahai orang-orang yang beriman! Mohonlah p e r t o l o n g a n dengan sabar dan shalat; sesung-guhnya Allah adalah beserta orang-orang yang
sabar.

General Learning Objective:

After this tutorial, the student shall be able to understand the pathway and nursing care for clients with vascular disease
Skenario 4

“Pain”
A man 55 years old has a smoking history since 20 years ago, 2 packs per day, and consumed salty and fatty food. He was hospitalized at surgical ward because of wound pain on
12
left leg since 1 week. Physical assessment showed pain scale 8, throbbing pain, small wound on the left big toe, black colour of wound, cool, dorsal pulse on left foot (-),
intermittent claudication (+), and ABI score 0.5. Left femoral angiography showed complete occlusion of left proximal popliteal artery. His diagnose was arterial occlusion
(peripheral arterial disease). Patient received fentanyl and heparin. Nurse plans to give wound and foot care, suggest patient to walk. Doctor will do Percutaneous transluminal
angioplasty (PTA). Nurse suggested the patient and family to be patient
BLOK 8 KARDIOVASKULER, PSIK FKIK UMY Skenario 4
Tutor action Clinical Reasoning Discussion & Learning Topic
Trigger: Indentify cues: Step 1:
Seorang laki-laki, 55 tahun mempunyai riwayat merokok 20 tahun, 2 bungkus setiap hari. Dia dirawat di Anticipated student Discussion point:
bangsal bedah karena nyeri di bagian kaki kirinya sejak 1 minggu yang lalu. Pemeriksaan fisik response:  Adakah istilah yang tidak diketahui?
menunjukkan skala nyeri 8, nyeri, throbbing (berdenyut), luka kecil di jempol kaki kiri, luka berwarna  Penyumbatan pembuluh Intermittent claudication
hitam, kaki teraba dingin, denyut doralis pedis (-), intermittent claudication (+), dan skor ABI 0.5. darah arteri , terdapat ABI
Pemeriksaan angiografi pada femoral kiri menunjukkan penyumbatan komplet pada arteri popliteal kiri. luka Angiografi
Pasien mendapatkan terapi fentanyl dan heparin. Ners merencanakan perawatan luka dan kaki, Heparin
menganjurkan pasien untuk berjalan. Dokter akan melakukan Percutaneous transluminal angioplasty Percutaneous transluminal angioplasty (PTA)
(PTA). Ners menyarankan kepada keluarga agar bersabar. Fentanyl
Intermittent claudication is a cramp-like pain felt in the calf, thigh or buttock during walking or other exercise. It is caused by lack of oxygen to the muscles because of a poor blood supply and
is relieved by rest
ABI(ankle brachial index) is the ration between the systolic arterial (SAP) obtained in the legs and the SAP of the brachial artery.

Angiografi is the imaging of blood Percutaneous transluminal angioplasty (PTA) is a

vessels using water-soluble ionic or procedure that can open up a blocked blood vessel using a
nonionic X ray contrast media injected small, flexible plastic tube, or catheter, with a "balloon" at
into the blood stream of arteries the end of it. When the tube is in place, it inflates to open
(arteriography) or veins (venography) the blood vessel, or artery, so that normal blood flow is
restored.

Heparin or unfractionated heparin, a highly sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological
molecule
Fentanyl (also known as fentanil, brand names Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen, Haldid, Onsolis, Instanyl, [ Abstral,[ Lazanda and others) is a potent, synthetic opioid
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analgesic with a rapid onset and short duration of action. It is a strong agonist at the μ-opioid receptors
Key emphasis of the case: Problem definition: Step 2:
1. Blood Vessels Structure and Function: Arteries, Venous, and Capillaries Discussion point
2. Definition of Peripheral Arterial Disease, classification 1. Penyakit apa yang dialami pasien?
3. Pathway of atherosclerosis and PAD (etiology-mechanism-sign &symptoms, 2. Apakah ada hubungan anatara merokok dengan penyakit pasien?
nursing problem) 3. Apa penyebab nyeri pada pasien tersebut?
4. Diagnostic Test of Peripheral Arterial Disease 4. Apa diagnose keperawatan yang bisa muncul?
5. Treatment of Peripheral Arterial Disease 5. Apa interpretasi ABI 0.5? berapa nilai normal ABI?
6. Nursing Care of Peripheral Arterial Disease and post operative bypass surgery 6. Kenapa pasien diberi heparin?
7. Islamic Revealed Knowledge: Smoking cessation and Patient
8. EBN: exercise for patient with PAD
Step 3: Mahasiswa mendiskusikan problem di step 2 (Brainstorming)
1. Peripheral arterial disease
2. Ya
3. Akibat adanya occlusion (sumbatan) pada daerah femur menyebabkan aliran darah ke eksterimitas kiri bagian bawah menurun. hal ini menyebabkan supali O2 menurun dan
menyebabkan metabolisme anaerob, sehingga produksi asam laktat meningkat, dan akan merangsang nosiceptor
4. Nyeri akut, gangguan perfusi jaringan perifer
5. 0,5= abnormal ( peripheral arterial disease). Nilai normal ABI adalah 1.00-1.40
6. Heparin digunakan untuk mencegah pembekuan darah
Tutor activity: setelah mahasiswa memberikan hipotesis Step 4:
Add information: (diberikan jika diminta oleh mahasiswa, jika tidak 2. Mahasiswa mendiskusikan problem di step 3 secara mendalam kemudian memerikan hipotesis sementara.
diminta tutor mengarahkan) 3. Student activity: (discuss)
Problem yang muncul dan akan didiskusikan lagi oleh mahasiswa setelah memperoleh data tambahan:
1. Anatomi fisiologi pembuluh darah
2. Pathway peripheral arterial disease
Tutor action: Step 5: Formulating Learning Issues (Sesuai dengan LO/ TIK)
 Menginformasikan sumber belajar yang berkaitan dengan scenario Mahasiswa memberikan hipotesis akhir /diagnosis kerja
(pokok) Mahasiswa menentukan learning objective:
 Mengingatkan setiap mahasiswa agar mencari LO. 1. Blood Vessels Structure and Function: Arteries, Venous, and Capillaries
 Hasil pencarian LO akan di cross check pada pertamuan berikutnya 2. Definition of Peripheral Arterial Disease, classification
3. Pathway of atherosclerosis and PAD (etiology-mechanism-sign &symptoms, nursing problem)
4. Diagnostic Test of Peripheral Arterial Disease
5. Treatment of Peripheral Arterial Disease
6. Nursing Care of Peripheral Arterial Disease and post operative bypass surgery
7. Islamic Revealed Knowledge: Smoking cessation and Patient
8. EBN: exercise for patient with PAD
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