CLI is a dangerous condition that’s clouded by many patients being ill-informed. Nurses say they advocate for this patient population by communicating effectively.
Jancy Rose Joseph, CRNP, doesn’t like to mince words when it comes to discussing the drastic consequences associated with critical limb ischemia (CLI). “I tell them, we may not be able to save your limb,” said the 10-year nurse who works on staff in the vascular surgery department at Temple University Hospital in Philadelphia. Stern and to the point, it’s the only way she knows how to communicate with a patient population that continues to grow in number as the United States population ages and remains increasingly uneducated about the condition that they live with, not to mention the comorbidities that surely played a role in the development of CLI. Characterized by the Centers for Disease Control and Prevention (CDC) as the most severe manifestation of peripheral artery disease (PAD), a condition that’s on the rise in its own rite and an especially dangerous situation for older adults, CLI exposes patients to increased risk of heart attack, stroke, and amputation, a fear-invoking reality that certainly tends to grab people’s attention. Compassionately careful to also assure patients that all potential measures will be taken in an attempt to preserve their limbs when informing them of the risks that they face related to amputation, Joseph has found that revealing the potential scary outcomes upfront has helped her to help her patients cope with the severity of a condition that she says most people simply remain uninformed despite the rise in incidence and the common comorbidities connected to it, particularly diabetes and hypertension. Still, she and her peers remain up against a challenge to help this subgroup of patients who represent “the most challenging population to manage medically, surgically, and endovascularly” among those diagnosed with PAD, according to one study.1 From socioeconomic issues and inadequate education in the general sense to cultural differences among patients and an outright distrust of the healthcare industry, the obstacles to caring for this patient cohort are many. Often, it is the nurses who will find themselves in the precarious position of trying to help this high-risk population avoid or endure the life-altering changes that so many will encounter.
Educating & Enlightening
For many reasons, the genuine distrust of the healthcare industry is a real problem that Joseph sees among her patients, also at an increasing level. “There is just a lack of trust in healthcare among our patients – those who are elderly as well as those who are younger,” she said. “It may be due to poor outcomes [that they previously had]. Another challenge is the socioeconomic conditions. It can be very difficult to help our patients understand that they have a problem. Also, with cultural preferences, some people just don’t believe in healthcare. They say the home remedies and other approaches will heal wounds or revascularize the areas where they don’t have adequate blood flow – the healthcare system doesn’t exist in their culture. And many of these patients don’t want a healthcare provider in their house. But it’s my job as the healthcare provider to get that trust back.”
She said her best chance of accomplishing this is to foster education, of course on top of helping to facilitate the myriad of allied healthcare services that will be required if her patients are going to have any clinical chance of healthy living, including podiatry, physical therapy, infectious disease, cardiology, nephrology, and wound care. All interventions are introduced within two days of patient admission, said Joseph, who estimates that about 50 percent of her inpatients will experience CLI.
At the University of California Davis Medical Center in Sacramento, Stefanie Generao MSN, FNP-BC, a nurse on the vascular surgery unit, described a similar role that she and her fellow nurses hold for their CLI patients. The nurse’s role is to identify and educate on the significance of the disease, the devastating progression, and the necessity of prevention,” said Generao. “Lifestyle modification and chronic disease management are also key in the nurse’s role.”
Generao also discussed similar approaches to how communication should occur among her patients. “The nurse needs to make the patients aware of the risk,” she said. Nurses need to enroll patients in smoking cessation programs and they need to know different pharmacologic and non-pharmacologic options.” Strategies that nurses can consider to benefit their patients also include Medicare-covered supervised therapies and cardiac rehab programs, home-walking programs that motivate patients to be as independent as possible, and proper skin washing and moisturizing. All PAD patients should also be on a statin and antiplatelet medication, and diet and blood sugar control will also remain very important components of the education, Generao said. Patients who live with diabetes will also be taught to employ good foot care, and the nurse’s presence here remains essential to encouraging patients to participate in their self-care.
“Studies have shown that patients who are more engaged in their care have improved outcomes, and nurses can improve patient engagement through individualized, tailored interventions that focus on education and follow up,” Generao said.
Amputation & Prosthetics
According to a 2017 study, the risk of amputation is particularly high during the first six months following revascularization for CLI2 and the rate of limb loss and death increase as patients live longer with PAD and CLI. When surgery and subsequent life with an artificial limb are necessary, particular tact must be taken to not only impact the quality of life but to continue to encourage patients to practice self-care.
“When surgery is required, the patient’s level of understanding of the procedure in detail is important, as is explaining the risks and benefits of surgery, post-operative care of the surgical site, and pain management,” Joseph said. “Nurses should also explain the importance of early ambulation, the rehab phase, prosthesis training, and life after amputation. If it’s the case of a peripheral bypass, then we will have education about the prevention of limb loss.”
The level of expected compliance is often not very high despite best efforts, Generao said. Unfortunately, this population struggles with compliance,” she continued. “PAD patients are often older, of a lower socioeconomic group, with limited resources and access to care. Patients may not exhibit symptoms of worsening PAD, like intermittent claudication, because they simply walk less to avoid pain when they should be walking more. It is a struggle to convince patients that walking is as effective as an endovascular intervention to improve blood flow to the extremity in the absence of tissue loss.
It’s not all negative, however, for these nurses and their patients. “The goal is to prepare the patients for prosthesis so that they can have improved quality of life,” said Joseph, who also recounted a recent experience with a patient who was recently informed that the need for amputation might be avoided. For those who do not avoid limb loss, Joseph said the education emphasis is placed on wound healing of the surgical site to successfully promote the wearing of a prosthesis the ongoing rehab effort, and the fitting of a prosthesis as well as the needed training and maintenance.
“We have a newly admitted patient who is a kidney transplant candidate, he has extensive wounds to his lower extremities, he’s diabetic, end-stage renal – so I had to tell him and his family that there’s about an 80 percent chance that he’s going to lose his leg. That kind of communication, when it’s upfront, they know what to expect and there are no surprises if anything [negative] happens,” she said. “But I always sit with my patients and tell them that we will try everything possible. I tell them that I care about them as much as I would care for a family member. And when patients hear that I think patients are more likely to listen to you, more likely to follow instructions, more likely to follow up for their appointments, and more likely to take their medications.”
- Dua A, Lee CJ. Epidemiology of peripheral arterial disease and critical limb ischemia. Tech Vasc Interv Radiol. 2016;19(2):91-5.
- Baubeta Fridh E, Andersson M, Thuresson M, et al. Amputation rates, mortality, and pre-operative comorbidities in patients revascularised for intermittent claudication or critical limb ischaemia: a population based study. Eur J Vasc Endovasc Surg. 2017;54(4):480-6.