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NURS3313 Adult Health > Chapter 26 Assessment & Management of Patients w/ Vascular Disorders & Problems of Peripheral Circulation > Flashcards

Chapter 26 Assessment & Management of Patients w/ Vascular Disorders & Problems of Peripheral Circulation Flashcards

1
Q

Where does the right side of the heart pump blood to?

A

This side of the heart pumps blood through the lungs into pulmonary circulation

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2
Q

Where does the left side of the heart pump blood to?

A

This side of the heart pumps blood to all other body tissues via systemic circulation

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3
Q

Function of the Vascular System

A

Supplies circulatory needs of tissues

Maintains blood flow & BP

Capillary filtration and reabsorption:
-Hemodynamic resistance
-Peripheral vascular regulating
mechanisms

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4
Q

What is the driving force that moves blood through the vascular system?

A

Ventricular contraction

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5
Q

Pathology of Peripheral Vascular Disorders

A

Pump failure = inadequate peripheral blood flow
* Heart Failure with reduced ejection fraction (HFrEF or systolic HF)
* Causes accumulation of blood in the lungs, reduced CO, and inadequate arterial blood flow to tissues
* Heart Failure with preserved ejection fraction (HFpEF or diastolic HF)
* Causes systemic venous congestion and reduced CO

Alterations in blood and lymphatic vessels (reducing flow)
* Arterial - damage or blockage to vessels by atherosclerotic plaque, thromboembolus, infection or inflammatory process, etc.
* Venous – thromboembolus obstructing vein, incompetent venous valves, or reduced effectiveness of surrounding muscles
* Lymphatic – tumor, damage from mechanical trauma, or inflammatory process

Circulatory insufficiency of the extremities
* Most disorders results in ischemia and produces symptoms of pain, skin changes, diminished pulses, and possible edema

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6
Q

Disorders & Diseases Seen in Peripheral Arterial Disease

A

Aneurysms

Aortic dissection

Embolism & Thrombosis

Raynaud’s phenomenon

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7
Q

Disorders & Diseases Seen in Peripheral Venous Disease

A

Venous Thromboembolism (VTE)
Venous Insufficiency or Postthrombotic Syndrome
Leg Ulcers
Varicose Veins

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8
Q

Physical Assessment of PAD

A

Areas to assess: Skin color, temperature, pulses

Expected Assessment Findings
-Cool & pale extremities
-Rubor
-Cyanosis
-Loss of hair, brittle nails, dry or scaling skin, atrophy & ulcerations
-Edema
-Gangrenous changes w/prolonged severe ischemia

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9
Q

Where do arteries distribute blood?

A

Distributes oxygenated blood from the LT side of the heart to the tissues

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10
Q

Arterioles

A

The smallest arteries that are generally embedded w/in the tissues

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11
Q

Function of Arterioles

A

Regulate volume & pressure in arterial system

Regulate blood flow to the capillaries

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12
Q

Arteries & Arterioles Wall Composition

A

3 layers: The intima, media, & adventitia

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13
Q

The Intima

A

Inner endothelial layer of arterial wall

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14
Q

Function of the Intima

A

Provides a smooth surface for contact w/moving blood

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15
Q

The Media

A

Middle layer made up of smooth muscle & elastic tissue

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16
Q

Function of the Media

A

Gives the vessel considerable strength

Allows to constrict & dilate to accommodate the blood ejected from the heart during each cardiac cycle (stroke volume)

Maintain an even steady blood flow

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17
Q

The Adventitia

A

Outer layer of connective tissue

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18
Q

Function of the Adventitia

A

Control diameter of the blood vessel via contracting & relaxing

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19
Q

How do arterioles offer resistance to blood flow?

A

Altering their diameter

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20
Q

Capillary Wall Composition

A

Lack smooth muscle & adventitia

Single layer of endothelial cells

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21
Q

What effect does the thin wall composition of capillaries have on circulation?

A

Permits rapid & efficient transport of nutrients to the cells & removal of metabolic wastes

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22
Q

What effect does a capillary wall’s diameter (5-10 mcm) have on red blood cell passage?

A

RBCs must alter their shape in order to pass through this blood vessel

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23
Q

As blood passes through tissue capillaries…

A

…O2 is removed & CO2 is added

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24
Q

What influences a capillary wall’s diameter?

A

Changes are passive

Influenced by contractile changes in the blood vessels that carry blood to and from the capillary

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25
Q

Precapillary Sphincter

A

A cuff of smooth muscle (located near arterioles end of capillary) that is responsible for controlling capillary blood flow (along w/arteriole)

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26
Q

What is the name of the larger blood vessel that capillaries join to form?

A

Venule

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27
Q

Where do veins distribute blood?

A

Carries deoxygenated blood from the tissues to the RT side of the heart

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28
Q

Venous System Equivalents of Arteriolar Vessels

A

Venules: Arterioles

Veins: Arteries

Vena cava: Aorta

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29
Q

Key Differences in Venous Wall Composition

A

Walls are thinner & less muscular

Layers are not as well-defined

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30
Q

How does the venous wall being thinner & less muscular affect blood flow?

A

Allows for the vessel to distend more than arteries

Greater distensibility & compliance allows for larger volumes of blood to remain in the veins under low pressure

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31
Q

SNS Stimulation Effect on Venous Blood Flow

A

Venoconstriction can reduce venous volume & increase volume of blood in the general circulation

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32
Q

Venoconstriction

A

Constriction of the veins

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33
Q

What happens when skeletal muscle contraction occurs in the extremities?

A

Creates the primary pumping action to facilitate venous blood flow back to the heart

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34
Q

Function of Lymphatic Vessels

A

Collects lymphatic fluid from tissues and organs & transports the fluid to the venous circulation

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35
Q

What are the two main structures of the lymphatic vessel system?

A

The thoracic duct & the right lymphatic duct

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36
Q

Where does the right lymphatic duct primarily convey lymph?

A

Conveys lymph primarily from the RT side of the head, neck, thorax, & upper arms

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37
Q

Where does the thoracic duct primarily convey lymph?

A

Conveys lymph from the remainder of the body

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38
Q

Factors that Affect Adequate Blood Flow

A

Efficiency of the heart to work as a pump, the patency & responsiveness of the blood vessels, & adequacy of circulating blood vol

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39
Q

Function of the Vascular System

A

Supplying the circulatory needs of tissue

Maintain blood flow & BP

Providing capillary filtration & reabsorption

Hemodynamic resistance

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40
Q

Factors that Affect The % of Blood Flow Received by Individual Organs

A

Rate of Tissue Metabolism

Availability of Oxygen

Function of the Tissue

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41
Q

When metabolic requirements increase…

A

…blood vessels dilate to increase the flow of O2 & nutrients to the tissues

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42
Q

When metabolic requirements decrease…

A

… vessels constrict & blood flow to the tissues decrease

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43
Q

Activities/Factors that Increase Metabolic Demand

A

Physical activity

Local heat application

Fever

Infection

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44
Q

Activities/Factors that Decrease Metabolic Demand

A

Rest/decreased activity

Local cold application

Cooling of the body

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45
Q

Ischemia

A

Lack of blood supply

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46
Q

What can cause ischemia to occur?

A

Ischemia can be caused if the blood vessels fail to dilate in response to accommodate for increased metabolic needs

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47
Q

Order of Blood Flow

A

LT side of the heart-> aorta-> arteries-> arterioles-> capillaries-> venues-> veins-> vena cava-> RT side of the heart

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48
Q

What is the cause of the unidirectional blood flow?

A

The differences in blood pressure between the arterial & venous system changes

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49
Q

Arterial vs Venous BP

A

Arterial BP: 100mmHg

Venous BP: 40 mmHg

(Fluid flows from an area of higher pressure->lower press)

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50
Q

When resistance increases…

A

…a greater press is req to maintain the same degree of flow

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51
Q

What happens if arterial pressure is chronically elevated?

A

Myocardium atrophies to compensate for the greater contractile force

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52
Q

Factors that Increase Blood Flow

A

Blood viscosity increases

Diameter of the vessels become greater than normal

Segments of the blood vessel are constricted

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53
Q

Bruit

A

Adventitious sound of blood flowing via narrowed portion of an artery

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54
Q

Hydrostatic Force

A

A driving pressure that is generated by the blood pressure

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55
Q

Osmotic Pressure

A

The pulling force created by plasma proteins

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56
Q

Which type of pressure is exerted at the arterial end of the capillary?

A

Hydrostatic pressure

Drives fluid out of the capillary-> tissue space

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57
Q

Which type of pressure is exerted at the venous end of the capillary?

A

Osmotic pressure

Osmotic pressure is greater than hydrostatic pressure->net reabsorption of fluid from the tissue space back into the capillary

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58
Q

Function of the Arterial End of the Capillary

A

Filtration

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59
Q

What happens to the excess filtrated fluid?

A

Enters lymphatic circulation

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60
Q

Edema

A

Accumulation of excess interstitial fluid

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61
Q

Possible Causes of Edema

A

Damage to capillary walls and subsequent increased permeability

Obstruction of lymphatic drainage

Elevation of venous pressure, or a decrease in plasma protein osmotic force

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62
Q

Function of the Venous End of the Capillary

A

Reabsorption

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63
Q

The Critical Factor that Determines Resistance in Vascular System

A

Vessel radius

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64
Q

Which system is responsible for regulating the peripheral vascular system?

A

SNS

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65
Q

Neurotransmitter responsible for SNS vasoconstriction

A

Norepinephrine

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66
Q

Increase in SNS activity causes vasodilation or vasoconstriction?

A

Vasoconstriction

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67
Q

Decrease in SNS activity causes vasodilation or vasoconstriction?

A

Vasodilation

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68
Q

What is formed from the interaction of renin & angiotensinogen?

A

Angiotensin I

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69
Q

Which organ is renin synthesized by?

A

The kidneys

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70
Q

What is angiotensin-converting enzyme (ACE) responsible for?

A

Converting angiotensin I-> angiotensin II

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71
Q

Is angiotensin II a potent vasodilator or vasoconstrictor?

A

It is a potent vasoconstrictor (especially arterioles)

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72
Q

Proinflammatory Cytokines

A

Substances liberated from platelets that aggregate at the damaged vessel site, causing arteriolar vasoconstriction & continued platelet aggregation at injury site

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73
Q

When does inadequate peripheral blood flow occur?

A

This occurs when the heart’s pumping action becomes inefficient

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74
Q

What does heart failure (HF) w/ reduced LT ventricular ejection fraction cause?

A

Causes an accumulation of blood in the lungs & reduction of forward flow (CO) -> inadequate arterial blood flow to the tissues

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75
Q

Which type of heart failure is characterized by a REDUCED LT ventricular ejection fraction?

A

Systolic HF (HFrEF)

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76
Q

What does heart failure (HF) w/ PRESERVED LT ventricular ejection fraction cause?

A

Causes systemic venous congestion & reduced CO (forward flow)

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77
Q

What type of heart failure is characterized by a PRESERVED LT ventricular ejection fraction?

A

Diastolic HF (HFpEF)

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78
Q

Thromboembolus

A

A blood clot that may have been dislodged from the vessel where it originally formed

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79
Q

Effects of a Sudden Arterial Occlusion vs. a Gradual Arterial Occlusion

A

Sudden: Can cause profound and irreversible tissue ischemia & tissue death

Gradual: Less risk of sudden tissue death due to collateral circulation that may develop-> giving the tissue time to adapt to gradually decreasing blood flow

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80
Q

Factors that Reduce Venous Blood Flow

A

Thromboembolus obstructing a vein

Incompetent venous valves

Reduction in the effectiveness of surrounding muscle pumping action

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81
Q

Effects of Reduced Venous Blood Flow

A

Increased venous pressure

Subsequent increase in capillary hydrostatic pressure

Increase of net filtration of fluid out of the capillaries-> interstitial space

Increase in subsequent edema

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82
Q

Gerontological Considerations for Venous Blood Flow

A

Cellular proliferation & fibrosis-> intima thickens

Elastin fibers of media become calcified, thin, & fragmented

Overall changes cause vessels to stiffen-:
- Increased peripheral resistance
- Impaired blood flow
- Increased ventricular workload-> hypertrophy, ischemia, systolic HF

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83
Q

General Arterial Insufficiency Characteristics

A

Pain: Intermittent claudication to sharp, unrelenting, constant pain

Pulses: Diminished/absent

Skin:
-Color: Dependent rubor w/ elevation pallor of foot

-Texture: Shiny, dry skin w/ cool to cold temp

-Hair: Loss os har over toes & dorsum of foot

-Nails thickened & ridged

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84
Q

General Venous Insufficiency Characteristics

A

Pain: Aching, throbbing, cramping

Pulses: Present but may be diff to palpate due to edema

Skin:
-Color: Pigmentation in area of medial & lateral malleolus, may be red & blue (freq associated w/dermatitis)

-Texture: Skin thickened & tough

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85
Q

Arterial Insufficiency Ulcer Characteristics

A

Location: Tip of toes, web spaces, heel or other pressure points if pt is immobile

Pain: Very painful

Depth of ulcer: Deep, often involving joint space

Shape: Circular

Ulcer base: Pale to black & wet to dry gangrene

Leg edema: Minimal unless kept in dependent position constantly to relieve pain

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86
Q

Venous Insufficiency Ulcer Characteristics

A

Location: Medial malleolus, lateral malleolus, or anterior tibial area

Pain: Minimal to very painful

Depth: Superficial

Shape: Irregular border

Ulcer base: Granulation tissue
-Beefy red to yellow fibrinous in chronic long-term ulcer

Leg edema: Moderate to severe

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87
Q

Intermittent Claudication

A

Pain, discomfort, or fatigue is caused by the inability of the arterial system to provide adequate blood flow to the tissues in face of increased demands for nutrients & O2 during exercise
-Described as aching, cramping, or inducing fatigue or weakness that occurs w/some degree of activity

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88
Q

What position can help alleviate intermittent claudication pain?

A

Placing the extremity in a dependent position reduces the pain
-Some patients may sleep w/affected leg hanging over the side of the bed or sleep in a reclining chair

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89
Q

What is known as the hallmark symptom of PAD?

A

Intermittent claudication

90
Q

As the tissues are forced to complete the energy cycle w/out adequate nutrients & O2…

A

…muscle metabolites & lactic acid are produced

-Muscle metabolites aggravate nerve endings-> causes pain

91
Q

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?

A

~50% of the arterial lumen or 75% of the cross-sectional area must be obstructed

92
Q

What helps alleviate intermittent claudication pain?

A

Rest (decreases metabolic needs of muscles)

93
Q

Rest Pain

A

Persistent pain in the foot or digits when the patient is resting

94
Q

What does the presence of rest pain indicate?

A

Rest pain indicates a severe degree of arterial insufficiency & critical state of ischemia

95
Q

What can be done to increase perfusion to distal tissues in the presence of rest pain?

A

Lowering the extremity to a dependent position

96
Q

How can the site of arterial disease be deduced from the location of claudication?

A

It can be deduced because pain occurs in muscle groups distal to the diseased vessel

97
Q

If the patient is experiencing calf pain, where would the site of claudication be?

A

Insufficient blood flow through either the superficial or popliteal artery

98
Q

Rubor

A

Reddish-blue discoloration of the extremities
-May be observed w/in 20secs-2mins after extremity is placed in dependent position

99
Q

Cyanosis

A

Bluish tint of the skin that is manifested when amount of oxygenated hemoglobin contained in the blood is reduced

100
Q

Nursing Considerations for Pulse Palpation

A

Palpation is subjective

Use light touch & more than just the index finger for palpation (strongest pulse) to avoid mistaking their own pulse for the pt’s pulse
-Same for thumb

Occlusive arterial diseases impairs blood flow & can reduce/obliterate palpable pulses in the extremities

Palpate bilaterally & simultaneously
Symmetry in:
-Rate
-Rhythm
-Quality

101
Q

Handheld Continuous Wave (CW) Doppler Ultrasound

A

Used to detect blood flow when pulses cannot be reliably palpated

102
Q

What determines at what depth where blood flow can be detected by a Doppler?

A

The frequency it produces
-The lower the frequency, the deeper the tissue penetration

103
Q

Nursing Considerations for Doppler Ultrasound Flow Studies

A

Place the pt in supine position, elevate HOB 20 to 30 degrees to evaluate the lower extremities
-Externally rotate the legs, if possible, to permit access to medial malleolus

Apply acoustic water soluble gel to pt’s skin

Avoid excessive pressure (severely diseased arteries can collapse w/min pressure)

104
Q

Ankle-Brachial Index (ABI)

A

Ratio of the systolic BP in the ankle to the systolic BP in the arm

105
Q

What is the ABI used to determine?

A

The ABI is used to quantify the degree of stenosis

106
Q

Steps to Determine ABI

A

1) Have patient lay in supine position for 5 mins

2) Apply appropriate-sized BP cuff to the patient’s ankle above the malleolus

3) After ID’ing an arterial signal of the posterior tibial & dorsalis pedis arteries, systolic pressures are obtained while listening to the Doppler signal for both arteries
-Diastolic pressures cannot be obtained via Doppler

107
Q

Nursing Considerations for Obtaining ABI

A

Use correctly sized BP cuffs

Document cuff sizes used

Use sufficient inflation
-Do not inflate too rapidly

Suspect medial calcific sclerosis:
- Anytime the ABI is 1.20 or greater
- Ankle pressure is more than 250 mmHg

Be weary of arterial pressures recorded at less than 40 mmHg (venous signal was confused for arterial signal)

108
Q

ABI >1.40

A

Abnormal, indicates non-compressible arteries
-Follow w/ toe-brachial index (TBI)

109
Q

ABI of 1.00-1.40

A

Normal

110
Q

ABI of 0.91-0.99

A

Borderline

111
Q

ABI of less than or equal to 90

A

Abnormal

112
Q

ABI of 0.50-0.90

A

Moderate to mild insufficiency
-Seen in pts w/claudication

113
Q

ABI of <0.50

A

Found in patients w/ischemic rest pain

114
Q

ABI of or less than 40

A

Found in pts w/ischemia or severe tissue loss

115
Q

Nursing Considerations for Diagnostic Evaluations

A

Perform baseline ABI on any pt w/decreased pulses or any pt 65 yrs or older (especially hx of diabetes & nicotine use)

Pts who undergo arterial interventions should have ABIs performed per hospital protocol

Prior to Procedure: Educate pts about the indications of ABI and what to expect

Avoid nicotine use & caffeine prods for at least 2 hrs prior to testing

116
Q

Exercise Testing

A

Used to determine how long a patient can walk & to measure the the ankle systolic BP in response to walking

117
Q

Contraindications for Exercise Testing

A

Patients w/:
- Significant arterial insufficiency
- Severe cardiac, pulmonary, or orthopedic problems
- Physical disability

118
Q

How is exercise testing performed?

A

Patients walk on a treadmill at 1.5 mph w/ 12% incline for at least 5 mins
or
Walks w/gradual increase in speed & incline to the point of claudication

119
Q

Normal Exercise Testing Result

A

Little or no drop in ankle systolic BP after exercise

120
Q

Patient w/ True Vascular Claudication Exercise Testing Result

A

Ankle pressure drops

121
Q

Duplex Ultrasonography

A

Combine B-grade grayscale imaging of tissues, organs, & blood vessels w/capabilities of estimating velocity changes via pulsed Doppler use

122
Q

What would duplex ultrasonography be used for?

A

Used to determine the level & extent of venous disease and how chronic it is

123
Q

Nursing Considerations for Duplex Ultrasonography

A

Non-invasive

Patients who undergo abdominal vascular ultrasound need to be NPO status for at least 6hrs prior to exam
-Gas released from food can interfere w/ exam

Portable

124
Q

Computed Tomography (CT) Scanning

A

Provides cross-sectional images of soft tissues & visualize area of volume changes to an extremity & the compartment where changes take place

125
Q

Nursing Implications for CT Scan

A

Patients w/impaired renal function may req preprocedural treatment to avoid contrast-induced nephrotoxicity
-May include oral/IV hydration 6-12 hrs preprocedure or sodium bicarbonate admin

Nurse should encourage fluids & monitor patient’s urinary output post-procedure
-Should be at least 0.5 kg/mL/h

Contrast-induced acute kidney injury may occur 48-96 hrs post-op
-Notify & follow-up w/provider if this occurs

Screen for iodine & shellfish allergies
-Might be given steroids & histamine blockers ahead of time

126
Q

What does sodium bicarbonate do?

A

Alkalinizes urine & protects against free radical damage

127
Q

Angiography

A

May be used to confirm diagnosis of occlusive arterial disease when surgery/other interventions are considered

128
Q

Aneurysm

A

Abnormal dilation of blood vessel

129
Q

Nursing Considerations for Angiography

A

Patient experiences temporary wam sensation as contrast agent is injected & local irritation may occur at injection site

May have an immediate or delayed allergic response to the iodine present in the contrast agents

Any reaction must be reported IMMEDIATELY!!

Risks include: vessel injury, acute arterial occlusion, bleeding, or contrast nephropathy

130
Q

Clinical Manifestations of Contrast Agent Induced Allergic Reaction

A

Dyspnea

N/V

Sweating

Tachycardia

Numbness of the extremities

Any of these signs MUST be reported IMMEDIATELY!!

131
Q

Treatment for Contrast Agent Induced Allergic Reaction

A

Admin of epinephrine, antihistamines, or corticosteroids

132
Q

Nursing Implications for Magnetic Resonance Angiography

A

Contraindicated in patients w/metal implants

Assess for presence of any incompatible devices:
-Aneurysm clips
-Old tattoos: May contain trace elements (newer ones may contain nitinol & titanium which are compatible)
-Med patches
-Cardiac implantable electronic devices
-> MUST be screened to determine if they can safely undergo a MRI

Inform pt that:
-They will be in a small, enclosed space
- May hear periodic banging sounds
-They will lay on a cold, hard table

Ask for pts to close their eyes and keep them closed during procedure to decrease symptoms of claustrophobia

Reassure patients that they will be provided a panic button to press if they feel they need to stop the procedure

Assess for claustrophobia: May be prescribed a sedative prior to procedure

MRA procedures use contrast: Use the same precautions as you would w/contrast angiogram

133
Q

Contrast Phlebography (Venography)

A

Involves injecting a radiopaque agent into venous system
-If thrombus is present, x-ray will reveal an unfilled segment of vein in otherwise completely filled vein

134
Q

Arteriosclerosis

A

Hardening of the arteries due to muscle fibers & endothelial lining of walls of small arteries & arterioles becoming thickened

135
Q

Atherosclerosis

A

Inflammatory process involving accumulation of lipids, calcium, blood components, carbs, & fibrous tissue on the intimal layer of a large-or medium-sized artery

136
Q

Which is more common: arteriosclerosis or atherosclerosis?

A

Arteriosclerosis

137
Q

Risk Factors for Atherosclerosis

A

Modifiable Risk Factors:
-Nicotine use
-Hyperlipidemia
-Diet (contributing to hyperlipidemia)
-Hypertension
-Diabetes
-Obesity
-Stress
-Sedentary lifestyle
-C-reactive protein: Protein found in liver, indicative of inflammation (typically specific to cardiovascular conditions-increase)
-Hyperhomocysteinemia: Increase in protein that
promotes coagulation

Nonmodifiable Risk Factors:
-Age
-Gender
-Familial predisposition & genetics

138
Q

Progression of Atherosclerosis

A

Asymptomatic-> Claudication-> Ischemic Rest Pain-> Gangrene (limb loss)

139
Q

Nursing Actions/Considerations for Atherosclerosis

A

Provide patient education on disease prevention/management
* Dietary modifications
* Self-care programs
* Foot and leg care

Medication education
* HMG-CoA (statins): 1st line of therapy
* Long-term therapy requires close monitoring

Encourage elimination of all modifiable risk factors,
particularly nicotine use

140
Q

Gerontological Considerations for Atherosclerosis

A

Symptoms of PAD may be more pronounced
-May have adjusted their lifestyle to accommodate the limitations imposed by the disease
-Limb ischemia or gangrene may be first sign of disease in inactive patients
-May not walk enough to develop symptoms of claudication due to other comorbid conditions (e.g., COPD, HF)

Decreased circulation, although may not be apparent until trauma occurs

Intermittent claudication may occur more quickly, with shorter distance or slight incline

Cognitive impairment may prevent some from verbalizing symptoms such as pain

141
Q

1st Line of Therapy for Atherosclerosis

A

Statins

142
Q

Medical/Surgical Interventions for Patients w/ PAD Atherosclerosis

A

Modifications of risk factors
Controlled exercise program

Medication therapy
* Cilostrazol (Pletal)
* Aspirin or Clopidogrel (Plavix)
* Statins

Surgical management
* Reserved for treatment of rest pain, severe and disabling claudication, or when limb is at risk for amputation due to tissue necrosis. Include:
* Inflow and outflow procedures
* Bypass grafting
* Amputation

Endovascular management
* Angioplasty
* Atherectomy
* Stent or Stent Graft placement

143
Q

Endovascular Therapies for Patients w/ PAD/Atherosclerosis: Angioplasty

A

AKA: Percutaneous Transluminal Angioplasty (PTA) and atherectomy

-Atherectomy reduces the plaque buildup using a cutting device or laser
-Complications of both include hematoma formation, embolus, dissection, acute arterial occlusion & bleeding

144
Q

Endovascular Therapies for Patients w/PAD/Atherosclerosis: Stent or Stent Graft Placement

A

Reduces risk for restenosis

Complications include: distal embolization, dissection, and dislodgement

Can be drug-eluting: Candidates must
take antiplatelet meds for 6 months post
procedure

145
Q

Nursing Implications for PAD

A

Improving peripheral arterial circulation

Promoting vasodilation and preventing vascular compression

Relieving Pain

Maintaining tissue integrity

Post-op Care: Primary objective is to maintain circulation within arterial repair
-Pulses, Doppler assessment, color and temperature, cap refills, and sensory and motor function of affected extremity are checked can compared to other extremity
- Observation are every 15mins initially, then a progressively longer when stable
-Complete Doppler evaluation of vessel distal to bypass graft

ABI monitored every 8hrs for first 24hrs then once daily until discharge
* Not usually assessed with pedal artery bypasses due to risk of compression of anastomosis
-Absent pulses may indicate thrombotic occlusion of graft ->Notify surgeon immediately

Monitor and manage potential complications
* Fluid imbalances, bleeding, thrombosis, edema, and compartment syndrome

146
Q

Compartment Syndrome

A

Dangerous complication where elevated tissue pressures in non-expansible space
-Impedes capillary perfusion

MEDICAL EMERGENCY: CALL PROVIDER!!!

147
Q

Nursing Interventions for Compartment Syndrome

A

Limb flat, in neutral position at the level of the heart

Do not elevate or cross legs

Remove anything restricting limb

148
Q

Treatment to Relieve Compartment Syndrome

A

Fasciotomy

149
Q

Discharge Planning & Patient Education for PAD

A

Assess the patient’s ability to manage ADLs independently & patient’s support system

Modifications in diet, activity, & hygiene (skin care)
-Lose weight & adopt low-fat diet
-Slightly elevate feet at rest but not above heart level
-Keep feet dependent to increase blood flow to legs (as tolerated, avoid prolonged dependency)
-Inspect feet daily, keep clean & dry, go to professional for foot care
-Wear proper fitting shoes, avoid walking barefoot
-Begin and maintain walking program

Monitor for s/s of infection, occlusion of artery or graft, or decreased blood flow:
-Encourage plan to stop use of tobacco products
-Adherence with medications

150
Q

Aneurysm

A

Localized sac or dilation formed at a weak point in the wall of the artery

151
Q

Saccular Aneurysm

A

Projects from only 1 side of the vessel

152
Q

Fusiform Aneurysm

A

An entire arterial segment becomes dilated

153
Q

Mycotic Aneurysm

A

Very small aneurysms due to localized infections

154
Q

Thoracic Aortic Aneurysm

A

Approximately 70% of all cases caused by atherosclerosis

Occur most frequently in hypertensive men between 50-70 years old.

Most common site for a dissecting aneurysm
-Can develop in ascending, transverse or descending aorta

Diagnostic testing include chest Xray, CTA, MRA, or transesophageal echocardiography (TEE)

155
Q

Clinical Manifestations of Thoracic Aortic Aneurysm

A

Chest pain/ Upper back pain: May be more severe in supine position

Cough, dyspnea (result of pressure of the aneurysm sac against the trachea), hoarseness, and dysphagia

Patient may be asymptomatic

156
Q

Assessment Findings for Thoracic Aortic Aneurysm

A

Superficial veins of chest, neck, or arms become dilated

Edematous areas on chest wall

Cyanosis

Unequal pupils: Due to pressure against the cervical sympathetic chain

157
Q

Abdominal Aortic Aneurysm (AAA)

A

Most common site for formation is below the renal arteries

Most common cause is atherosclerosis

Prevalence:
* 2-6x more common in men than women
* 2-3x more common in white men than black men
* Most prevalent in patients >65yrs of age

Outcome may be rupture and death if left untreated

More than half of patients with aneurysms have HTN
-Rupture coexists with HTN and aneurysm >6cm

Diagnostic Testing includes duplex ultrasonography or
CTA

158
Q

Clinical Manifestations of Abdominal Aortic Aneurysm (AAA)

A

40% of patients are symptomatic

Signs of HF or loud bruit may suggest rupture into vena cava

Abdominal pain often localized in the middle or lower abdomen to the left of the midline

Persistent or intermittent severe back or abdominal pain: sign of impeding rupture

May extend to impinge on the renal, iliac, or mesenteric arteries

Cyanosis and mottling of toes (“trashing” or “trash toes”)

159
Q

Expected Assessment Findings for Abdominal Aortic Aneurysm (AAA)

A

Pulsatile mass in the middle and upper abdomen palpable during exam

Sensitivity depends on size, abdominal girth, and skill of examiner; more
difficult to palpate in obese patient

Systolic bruit heard over mass

Constant, intense back pain, decrease BP and hematocrit =
____________

160
Q

Treatment & Management of Aneurysm Patients

A

Based on whether patient is symptomatic, aneurysm is expanding, contains a dissection, or involves branch vessels

Control BP: Maintain SBP at 90-120 mm Hg for MAP of 65-75 mm Hg, pre-op
* Thoracic: Beta-blockers, angiotensin receptor blockers (ARBs), hydralazine, and Nitroprusside
* Aortic - Diuretics, beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers

IV fluid and/or blood administration to maintain graft patency

Open surgical repair or endovascular grafts
* > or equal to 5.5cm (2 inches)
* Grafts preferred
* Lumbar spinal drains used to decrease spinal cord ischemia and paraplegia w/ endovascular repairs

Cerebrospinal fluid drained to decrease the arterial to cerebral spinal fluid gradient, thereby improving spinal perfusion
* Keep cerebrospinal fluid pressure < 10 mm Hg (14 cm H2O) and keep MAP > 90 mm Hg for the first 36 to 48 hours, post-op to prevent neuro deficits

Assessments should be focused on anticipation of rupture
* System-based assessments
* Promptly implement medical therapies to stabilize physiologic function

Health Promotion and Risk Factor Management
* Controlling BP, smoking cessation, increasing physical activity, maintaining healthy body weight & serum lipids, and regular monitoring of smaller aneurysms

161
Q

Pre-Op Management of Aneurysm Patients

A

Baseline labs and peripheral vascular assessments

Preoperative teaching, emotional support, prophylactic antibiotics, reinforcing NPO status, and bowel preparation

162
Q

Post-Op Management of Aneurysm Patients

A

Supine position for 6hrs; HOB elevated up to 45 degrees after 2hrs

Assess access site, VS & pulses; doppler assessment q15mins initially, and temperature q4hrs

Monitor for complications:
-Bleeding or hematoma formation, infection, distal ischemia or embolization, dissection or perforation of aorta, post implantation syndrome, arterial occlusion, kidney injury or erectile dysfunction

Fluid maintenance

163
Q

Aortic Dissection

A

MEDICAL EMERGENCY! CALL PROVIDER!!
Clinical Manifestations:
-Symptoms usually sudden
-Severe and persistent pain: Described as tearing or ripping; in anterior chest or back and extends to shoulder, epigastric area, or abdomen
-May be mistaken for an acute myocardial infarction (MI)
-Pale, diaphoresis, or tachycardia
-BP elevated or markedly different from one arm to the other if dissection involves the orifice of the subclavian artery on one side

164
Q

Assessment & Management of Aortic Dissection

A

Assessment: Arteriography, multidetector-computed tomography angiography (MDCTA), TEE, duplex ultrasonography, and MRA
-Medical/surgical treatment and nursing management same as mentioned with aneurysms

165
Q

Arterial Embolism & Thrombosis

A

May result from invasive catheters, illicit IV drug use or traumas (fracture, compartment syndrome…)
* Embolic or Thrombotic

Symptoms depend on size and organ involvement
* 6 Ps of pain: Pain, Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia

Treatment of thrombosis depends on cause; embolic occlusion usually requires surgery; 4–6-hr window to restore blood flow & prevent irreversible tissue death:
* t-PA and heparin
* Embolectomy and Thrombectomy - Percutaneous or open surgery

166
Q

The 6 Ps of Arterial Embolism & Thrombosis Pain

A

1) Pain
2) Pallor
3) Paresthesia
4) Pulselessness
5) Paralysis
6) Poikilothermia: Inability to regulate core body temperature

167
Q

Nursing Actions for Arterial Embolism & Thrombosis

A

Assess for therapy contraindications:
-Active internal bleeding
-Cerebrovascular hemorrhage
-Recent major surgery
-Uncontrolled HTN
-Pregnancy

Protect affected extremity from trauma & minimize punctures

Obtain accurate weight (heparin drug admin)

Monitor VS – q15mins, then progressively longer when stabilize, pulses, doppler signals, ABI, and motor/sensory functions q4hrs for first 24hrs

Monitor for complications of arterial occlusion (acute kidney injury, compartment syndrome, etc.) and therapy (bleeding/systemic hemorrhage)

168
Q

Raynaud’s Phenomenon

A

Form of intermittent arteriolar vasoconstriction

169
Q

Raynaud’s Disease

A

Primary or Idiopathic Raynaud’s (w/out underlying disease)

170
Q

Raynaud’s Syndrome

A

Secondary Raynaud’s (underlying disease, such as systemic lupus erythematosus, RA, or scleroderma trauma, etc.)

171
Q

Triggers for Raynaud’s Phenomenon

A

Triggered by emotional factors, stress, or by unusual sensitivity to cold

172
Q

Clinical Manifestations of Raynaud’s Phenomenon

A

Coldness, pain, and pallor of fingers and toes

Rubor, cyanosis, numbness, tingling, and burning pain; symptoms bilateral and symmetrical

173
Q

Nursing Management of Raynaud’s Phenomenon

A

Provide patient education
* Avoid stimulus that provokes vasoconstriction – cold, stress, nicotine

No drugs with vasoconstrictive effects - decongestants and other OTC sympathomimetics
* Calcium channel blockers (nifedipine, amlodipine) effective in relieving symptoms
* Vasodilator; first line therapy
* Education about orthostatic hypotension

Analgesics for pain

174
Q

Which type of meds are 1st line therapy for patients w/Raynaud’s phenomenon?

A

Vasodilators

175
Q

Venous disorders cause a reduction in blood flow…

A

…results in stasis of blood

176
Q

Virchow’s Triad

A

1) Endothelial damage
2) Hypercoagulation
3) Venous stasis

177
Q

Risk Factors for Deep Vein Thrombosis & PE

A

Endothelial Damage:
-Central venous catheters
-Dialysis Access catheters
-Local vein damage
-Pacing wires
-Repetitive motion injury, surgery, & trauma

Venous Stasis:
-Age: Older than 65 yrs old
-Bed rest /immobilization
-HF
-History of varicosities
-Obesity
-Spinal cord injury

Altered Coagulation:
-Pregnancy
-Cancer
-Polycythemia
-Septicemia
-Oral contraceptive use

178
Q

Deep Venous Thrombosis (DVT)

A

Thrombus formation in the deep veins in thigh, calf, and sometimes arms (patients with PICC lines)

Important predictor of Postthrombotic syndrome is lack of recanalization w/in first 6 months after DVT

179
Q

DVT Assessment

A

Clinical Manifestations:
-Pain, warmth, tenderness, edema of extremity ->obstruction of venous flow
-Large circumference of the thigh or calf; compare to unaffected extremity
-Many cases are asymptomatic - Assess for high risk factors!

Venous duplex studies: Veins larger than normal, incompressible, and dilated

Lab studies:
-Baseline complete blood count (CBC),
-Coagulation studies: prothrombin time (PT), activated partial thromboplastin time (aPTT),
and international normalized ratio (INR)

180
Q

Preventative Measures for DVT

A

Lifestyle modifications - smoking cessation, weight loss, and regular exercise

Graduated compression stockings

Intermittent pneumatic compression devices
* Early ambulation of hospitalized patients
* SQ unfractionated heparin or low-molecular-weight heparin (LMWH)

181
Q

DVT Management Goal

A

Objectives are to prevent the thrombus from extending and fragmenting (thus risk of PE), recurrent thromboemboli, and postthrombotic syndrome

182
Q

Pharmacological Management of DVT

A

Anticoagulant Therapy

Unfractionated Heparin (SQ or IV): Prevents extension of thrombus & development of new thrombus

Low-Molecular Weight Heparins (e.g., Lovenox)

Oral Anticoagulants (e.g., Coumadin)

Oral Direct Factor Xa Inhibitors (e.g., Apixaban)

183
Q

Nursing Considerations for Unfractionated Heparin

A

Can be admin either SQ or intermittent/continuous IV
-IV dose is based on weight

Req aPTT & platelet count monitoring

Assess for bleeding

Admin protamine sulfate for overdose
-Monitor for hypotension & bradycardia if admin

184
Q

Nursing Considerations for Low-Molecular Weight Heparins (Lovenox)

A

Can be admin either 1X daily or twice a day SQ

Associated w/fewer bleeding complications than unfractionated heparin

Admin protamine sulfate for OD: Less effective in reversing low-molecular weight heparin OD than unfractionated heparin

Can be used in pregnancy, IF clearly indicated
-Monitor for bleeding

185
Q

Nursing Considerations for Oral Coagulants (Coumadin)

A

Vitamin K antagonist

Effects occur 12-24 hrs after dose admin
-Admin 1X day, at the same time each day

Req PT & INR monitoring
-PT goal: 1.5-2 times normal
-INR goal: 2.0-3.0

Req admin w/heparin during drug initiation until the desired effect is achieved

Assess pt for bleeding

Admin Vitamin K, fresh-frozen plasma, or prothrombin complex concentrate to reverse OD effects

CONTRAINDICATED FOR PREGNANCY!!!

186
Q

Nursing Considerations for Oral Xa Inhibitors (Apixaban)

A

Admin 2X a day

Assess renal function

Alter dose for obese pts

Admin activated charcoal to reverse OD effects

187
Q

Endovascular Management of DVT

A

For recurrent or extensive thrombi, high risk for pulmonary embolism, or when anticoagulants or thrombolytic therapy is contraindicated

Thrombectomy or Vena Cava Filter:
Assess and monitor anticoagulant therapy
Monitor and manage potential complications
* Bleeding, thrombocytopenia, signs of PE, and drug-drug interactions
* Be familiar with meds approved to reverse effects of various anticoagulants
Reduce discomfort/Pain Management
* Elevate affected extremity, graduated compression stockings, analgesic, or warm packs
Position the body and encourage exercise
* Periodic elevation of extremity and early ambulation

188
Q

Pulmonary Embolism (PE)

A

Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originate(s) somewhere in the venous system or in the right side of the heart

189
Q

Clinical Manifestations of PE

A

Depends on size of thrombus and the area occluded

Dyspnea and tachypnea
* Most frequent symptoms
* Duration and intensity of dyspnea depends on extent of embolization

Chest pain: Common; usually sudden and pleuritic; may be substernal and mimic angina

Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope

Few s/s in many cases; others may mimic other cardiopulmonary disorders (e.g., pneumonia, heart failure)

190
Q

Assessment & Diagnostic Findings Associated w/PE

A

Chest Xray: Usually normal; useful in excluding other possible causes

ECG: Sinus tachycardia and nonspecific ST-T wave abnormalities

Pulse oximetry

Arterial blood gas analysis: Hypoxemia and hypercapnia from tachypnea or may be normal

D-dimer assay

Multidetector Computer Tomography (MDCT) and Pulmonary arteriogram (angiogram)
* MDCT standard for diagnosing; angiogram reasonable alternative to MDCT

  • V/Q scan: Not as accurate as the MDCT or pulmonary angiogram
191
Q

Medical Management for Unstable PE

A

Medical emergency

Thrombolytic therapy with t-PA or other agents
* Contraindications: a stroke in the past 2 months, other active intracranial processes, active bleeding, surgery within 10 days of thrombotic event, recent labor and delivery, trauma, or severe HTN
* Baseline INR, aPTT, HCT, Plt count needed
* Other anticoagulants are discontinued
* Only essential invasive procedures during therapy

Embolectomy

Inferior Vena Cava (IVC) filter

192
Q

Medical Management for Stable PE

A

Immediate anticoagulation to prevent recurrence or extension of thrombus
* May continue for 10 days
* Long-term therapy indicated for 6 months; critical in preventing recurrence; extended indefinitely for high-risk patients
* Initial anticoagulant same as for DVT
* DOACs often prescribed for
outpatient therapy
* Long-term treatment options are warfarin and the DOACs.
-Regular blood draws and higher bleeding risk with warfarin
-DOACs don’t require regular blood testing, more costly

Choice of warfarin vs DOACs: Depends on risk of bleeding, cost, presence of comorbidities, and provider preference

193
Q

General Nursing Considerations for PE

A

Monitor Thrombolytic Therapy: Monitor pt’s response to therapy, INR, or aPTT q3-4 hrs after start of thrombolytic infusion
-Maintain BR, frequent VS, & invasive procedure

Manage Pain: Place in Semi-Fowler’s Position (makes it more comfortable to breathe)
-Usually pleuritic chest pain than cardiac in origin

Manage O2 Therapy: Assess frequently for signs of hypoxemia
-Nebulizer therapy/percussion & postural drainage may be used for the management of secretions

Relieve Anxiety
-Encourage pt to talk about fears and concerns
-Answer patient and family questions concisely and accurately, explain therapy, and describe how to recognize untoward effects early

Monitor for cardiogenic shock or right ventricular failure

Monitor UOP, s/s of infection, maintain BP at level that supports perfusion
-Elevates foot of bed, encourages isometric exercises, SCD, and walking when permitted prevents peripheral venous stasis and edema of lower extremities
-Educate patient about preventing recurrence and reporting s/s

Monitor adherence to treatment plan and reinforce instructions and importance of keeping follow-up appointments for coagulation tests and with primary provider

194
Q

Chronic Venous Insufficiency/Postthrombotic Syndrome

A

20-50% of patient with DVT develop Postthrombotic syndrome
Results from obstruction of the venous valves in the legs or a reflux of blood through the valves

Characterized by chronic venous stasis:
* Edema
* Altered pigmentation
* Pain
* Stasis dermatitis

Symptoms less in morning and more in the evening

Superficial veins may be dilated

Disorder is longstanding, difficult to treat, and often disabling

Increased risk for injury and infection

Venous ulceration is the most serious complication

Cellulitis and dermatitis can complicate care

195
Q

Clinical Manifestations of Chronic Venous Insufficiency/ Postthrombotic Syndrome

A

Stasis ulcers develop as a result of rupture of small skin veins and subsequent ulcerations

Brownish discoloration of tissues, also known as hemosiderin staining, usually in lower part of extremity, medial malleolus of the ankle

Skin dry, cracked, and itchy

Subcutaneous tissues fibrose and atrophy

196
Q

Chronic Venous Insufficiency/Postthrombotic Syndrome Management Goal

A

Goal is to reduce venous stasis and prevent ulceration

197
Q

Management of Chronic Venous Insufficiency/Postthrombotic Syndrome

A

Protect extremities from trauma

Report signs of ulceration immediately to provider for
treatment and follow-up

Increase venous blood flow
* Compression of superficial veins: compression therapy
-Graduated compression stockings (not anti-embolism stockings/TED stockings), bandages, external or intermittent pneumatic compression devices
-Reduces the pooling of venous blood, enhances venous return to the heart and recommended for people with venous insufficiency

198
Q

Varicose Veins

A

Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
-May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)

199
Q

What class of medication lyses & dissolves thrombi?

A

Fibrinolytic

200
Q

Which medications are specifically indicated for claudication treatment?

A

Pentoxifylline (Trental) & Cilostazal (Pletal)

201
Q

Normal PTT Level Range

A

Between 21-35 secs

202
Q

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

A

1.5 to 2.5 times the baseline control

203
Q

What is the antidote for heparin?

A

Protamine sulfate

204
Q

Varicose Veins

A

Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
-May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)

205
Q

Assessment Findings for Varicose Veins

A

Symptoms may include: dull aches, muscle cramps, increased muscle fatigue in lower legs, ankle edema, and heaviness in legs; nocturnal cramps

Edema, pain, pigmentation, and ulcerations are s/s of chronic venous insufficiency when deep venous obstruction occurs

206
Q

Nursing Considerations for Varicose Veins

A

Provide appropriate post-procedural care and patient education regarding post-op care and/or prevention and proper skin care
* Gently pat dry, do not rub the incision
* Use sunscreen; avoid skin lotion until completely healed

Provide comfort/pain management

Monitor for bleeding and s/s of infection

Assess for temporary/permanent nerve injury
* Reported sensation of “pins and needles”

207
Q

Prevention of Varicose Veins

A

Avoid activities that cause venous stasis

Change position frequently, elevate the legs 3 to 6 inches higher than heart level when tired, and getting up to walk for several minutes of every hour promote circulation
Graduated compression stockings, especially knee-high stockings

Overweight patients should be encouraged to begin a weight reduction plan

208
Q

Management of Varicose Veins

A

Thermal ablation – targeted heat to seal veins
Microphlebectomy – removal of superficial vein w/ small incisions
Sclerotherapy – chemical injection
Ligation/stripping – surgical removal of deep veins

209
Q

Lymphangitis

A

Inflammation or infection of the lymphatic
channels

210
Q

Lymphadenitis

A

Inflammation or infection of the lymph nodes

211
Q

Acute Lymphadenitis

A

Lymph nodes that are enlarged, red, and
tender

212
Q

Suppurative Lymphadenitis

A

Lymph nodes that have become necrotic
and form an abscess

213
Q

Lymphedema

A

Tissue swelling related to obstruction of lymphatic flow
-Especially marked when extremity in dependent position
-Edema initial soft and pitting; as it progresses, it becomes firm, non-pitting and unresponsive to treatment

Frequent bouts of acute infections (high fever & chills) and increased residual edema are seen with chronic swelling
* Leads to chronic fibrosis, thickening of the subcutaneous tissues, and hypertrophy of the skin
* This specific type of lymphedema is known as elephantiasis in which chronic swelling of the extremity recedes only slightly with elevation

214
Q

Primary Lymphedema

A

Congenital Malformations
- Most common
-Usually seen in women

215
Q

Secondary Lymphedema

A

Acquired obstruction
-Axillary node dissection (breast cancer)
-Leg in association w/ varicose veins or chronic thrombophlebitis
-> Usually caused by chronic lymphangitis

216
Q

Lymphedema Treatment Goal

A

Goal of therapy is to reduce and control edema and prevent infection

217
Q

Medical Management of Lymphedema

A

Manual lymphatic drainage by specially trained therapists

Diuretic furosemide

Antibiotic therapy when lymphangitis or cellulitis is present for 3-7 days

Surgical management

218
Q

Nursing Management of Lymphedema

A

Constant elevation of affected extremity

Active and passive exercises

External compression devices; Custom-fitted graduated compression stockings or sleeves

Monitor for complications:
* Flap necrosis
* Hematoma
* Abscess under the flap
* Cellulitis

Patient/Family Education
* Inspect dressing daily
* Report any inflammation or unusual dressing
* Expected loss of sensation in surgical area
* Avoid use of heating pads or exposure to sun
* Skin care

219
Q

Cellulitis

A

Occurs when a microbe enters through broken skin and release their toxins in the subcutaneous tissues, typically, staph or strep

220
Q

Clinical Manifestations of Cellulitis

A

Localized swelling or redness, warmth and pain frequently associated with systemic symptoms fever, chills, and sweating
* Redness may not be uniform; develops a pitting “orange-peel” appearance

221
Q

Nursing Management of Cellulitis

A

Treat with oral or IV antibiotics based on severity

Elevate affected area 3-6 inches above heart level
* Warm, moist packs to site every 2 to 4 hours
* Patients with sensory/circulatory deficits should use caution to avoid
burns
* Educate regarding prevention of recurrence
* Reinforce education about skin and foot care

222
Q

Match Items Appropriately

Assessment Findings:
1) Dilated superficial veins in the chest, neck, or arms; edema in the chest wall

2) Intermittent claudication

3) Pain is described as aching or heavy

4) Ulcerations on the side of the foot over the metatarsal are painless

5) 6 Ps of Pain

6) Pulsatile mass in the abdominal wall

7) DVT

8) Small, circular, deep ulcerations on the tips of toes or web spaces between toes

Disorder
a) Peripheral Artery Disease

b) Peripheral Venous Disease

c) Arterial Ulcers

d) Venous Ulcers

e) Abdominal Aortic Aneurysm

f) Thoracic Aortic Aneurysm

A

1) f

2) a & c

3) d

4) d

5) a

6) e

7) b

8) c

NURS3313 Adult Health (27 decks)

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