Chapter 35

Question 1

Usually forms in the heart, but a roughened atheromatous plaque in any artery also can lead to thrombus formation

If a thrombus breaks loose, it becomes an embolus and travels through the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion

Thrombi from the right side of the heart lodges in the lungs causing a PE

Thrombi from the left side of the heart usually affects the legs

Answer 1

Arterial emboli

Question 2

Signs and symptoms of arterial emboli

Answer 2

Severe, acute pain
Gradual loss of sensory and motor function in the affected areas
Pain aggravated by movement or pressure
Absent distal pulses
Pallor and mottling (irregular discoloration)
Sharp line of color and temperature demarcation: tissue beyond the obstruction is pale and cool

Question 3

Medical and surgical treatment for arterial emboli

Answer 3

Intravenous anticoagulants and thrombolytic agents

Embolectomy

Question 4

When should anticoagulant not be used

Answer 4

Active internal bleeding
Cardiovascular accident
Recent major surgery
Uncontrolled hypertension
pregnancy

Question 5

Arterial embolism dx/intervention

Answer 5

Inadequate tissue perfusion
Stress
Immobility
Skin breakdown
Inadequate self care

Question 6

common sites of occlusion for peripheral arterial disease

Answer 6

Common sites for arterial occlusion are the distal superficial femoral and the popliteal arteries

Question 7

Hypoxia affects all tissues distal to the occlusion in what condition

Answer 7

Peripheral arterial disease

Question 8

Signs and symptoms of peripheral artery disease

Answer 8

Intermittent claudication (classic sign)
Absence of peripheral pulses below occlusive area
Rest pain (persistent and aching)
Shiny, scaly skin
Pale color
Hairlessness
Ulcers with a gray or yellowish hue (tips of toes, foot, lateral malleolus)

Question 9

Medical diagnosis of peripheral artery disease

Answer 9

Plethysmography
Duplex imaging
Angiography (if surgery is indicated)

Question 10

Medical treatment for peripheral artery disease

Answer 10

Lifestyle changes
Smoking cessation
exercise
weight management

Question 11

Drugs for claudification

Answer 11

cilostazol and Plavix are anticoagulant

pentoxifylline which is a blood viscosity reducing agent

Question 12

Nursing diagnosis of peripheral artery disease

Answer 12

Impaired activity tolerance
Pain
Skin breakdown
Altered body image
Inadequate peripheral circulation
Inadequate self-care management
Potential infection
Inadequate cardiac output
Inadequate peripheral circulation
Impaired physical mobility

Question 13

Inflammatory thrombotic disorder of arteries and veins in lower and upper extremities

Answer 13

Thromboangiitis Obliterans aka(Buerger Disease)

Question 14

intermittent claudication, rest pain, skin color/temperature changes in affected areas, cold sensitivity, abnormal sensation, ulceration, gangrene

Answer 14

Signs and symptoms of Thromboangiitis Obliterans

Question 15

What is the most important treatment for Thromboangiitis Obliterans

Answer 15

Most important treatment is smoking cessation

Question 16

affects hands primarily.

Can also affect tips of nose toes

Answer 16

Raynaurds disease

Question 17

Signs and symptoms of Raynaud disease

Answer 17

Chronically cold hands, numbness, tingling, and pallor
Finger involvement is not symmetric and the thumb is typicall not involved
During an arterial spasm, the skin color changes from pallor to cyanosis to redness

Question 18

Based on the signs and symptoms and on the absence of evidence of occlusive vascular disease

Answer 18

Raynaurd disease

Question 19

Nursing diagnosis of Raynaud disease

Answer 19

Pain
Inadequate peripheral tissue oxygenation
stress

Question 20

A dilated segment of an artery caused by weakness and stretching of the arterial wall

Answer 20

Aneurysm

Question 21

Most common type of aneurysm

Answer 21

Atherosclerosis

Question 22

Most common site of aneurysm

Answer 22

Abdominal aorta

Question 23

Sign and symptoms of aneurysm

Answer 23

Thoracic aneurysms usually have no symptoms, though some report deep, diffuse chest pain
If aneurysm puts pressure on the recurrent laryngeal nerve, patient may complain of hoarseness
Pressure on the coronary arteries can cause angina
Pressure on the esophagus may cause dysphagia
Pressure on the superior vena cava may have edema of the head and arms
Pressure on the pulmonary structures may cause airway obstruction

Question 24

Aneurysm post operative care

Answer 24

Mark the pedal pulses
Critical care unit for 24-48 hours
Monitor vital signs, hemodynamic status, renal function, and fluid balance
Inspect and palpate the extremities for color, warmth, and peripheral pulses

Question 25

A small tear in the intima permits blood to escape into the space between the intima and the media Blood accumulates between the layers, causing the media to split lengthwise

Answer 25

Aortic dissection

Question 26

Varicosities are dilated, tortuous, superficial veins, often the saphenous veins in the lower extremities

Answer 26

Varicose vein

Question 27

Dilation of the vessels results from incompetent valves in the veins

Answer 27

Varicose vein

Question 28

Avoid restrictive garments, prolonged standing or sitting, crossing the legs or knees, and injury to compromised areas Weight reduction Support stockings Sclerotherapy, light therapy, or laser therapy Ligation and stripping

Answer 28

Varicose vein

Question 29

Virchow's triad

Answer 29

Stasis of the blood Damage to the vessel walls Hypercoagulability

Question 30

Pain, redness, warmth, or tenderness in the affected area vein that fells firm and cordlike when palpated Area around the vein may be warm, red, and tender.

Answer 30

SVT

Question 31

Edema, pain, warmth, and tenderness at the area of compromise May have slight elevation in the systemic temperature

Answer 31

DVT

Question 32

Medical treatment for venous thrombosis

Answer 32

Anticoagulant or thrombolytic therapy, or both

Question 33

``` Skin breakdown Pain Anxiety Inability to tolerate activity Inadequate peripheral tissue oxygenation Impaired pulmonary oxygenation Inadequate self care ```

Answer 33

Nursing diagnosis of venous thrombosis

Question 34

Culmination of long-standing pressure that stretches the veins and damages the valves

Answer 34

Patho of chronic venous insufficiency

Question 35

Edema around the lower legs, pain, brownish skin discoloration (stasis dermatitis), and stasis ulcerations Heaviness or dull ache in the calf or thigh Skin temperature is warm, and nails are normal Feet and ankles often cyanotic when in a dependent position Peripheral pulses are present, but due to edema, they may be difficult to palpate

Answer 35

Signs and symptoms of chronic venous insufficiency

Question 36

Nursing diagnosis of chronic venous insufficiency

Answer 36

Inadequate peripheral tissue oxygenation Impaired self concept Potential infection Skin breakdown

Question 37

Acute inflammation of the lymphatic channels | The inflammation is the result of an infectious process, usually caused by streptococcus

Answer 37

Lymphangitis

Question 38

Enlargement of the lymph nodes along the lymphatic channel Tenderness as these nodes are assessed Red streak from the infected wound extends up the extremity along the path of the lymphatics Elevated temperature and chills

Answer 38

Signs and symptoms of lymphangitis

Question 39

Diagnosis of lymphangitis

Answer 39

Wound culture and Lymphangiography

Question 40

Antimicrobials Abscess is incised to drain the suppurative material Rest and elevation of the limb; warm, wet dressings; and elastic support hose

Answer 40

Surgical treatment of lymphangitis

Question 41

Analgesics, antimicrobials, and elevation of the extremity to reduce lymphedema Application of warm, moist soaks to the infected areas Elastic support hose

Answer 41

Interventions of lymphangitis

Question 42

Systolic: <120 mm Hg; diastolic <80 mm Hg

Answer 42

Normal Blood Pressure

Question 43

Systolic between 120 and 139; diastolic between 80 and 89

Answer 43

Prehypertension

Question 44

140-159 SBP and 90-99 DBP

Answer 44

Stage 1

Question 45

≥160 over ≥ 100

Answer 45

Stage 2