Chapter 38

Question 1

Taking VS
Auscultating all lung fields
Monitoring O2
Assessing cognition
Checking incisions, body orifices and under the patient for signs of active bleeding
Assessing he skin for bruises and petechiae
Examining all body areas of swelling or discoloration that could indicate internal bleeding

Answer 1

Perform and interpret physical assessment in patients experiencing inadequate oxygenation and tissue perfusion as a result of hypovolemic shock

Question 2

Muscle pain caused by an inadequate blood supply

Answer 2

Claudication

Question 3

uncommon occlusive disease of the arteries and veins in the distal portion of the upper and lower extremities
-often extends into the tissues around the vessels, resulting in fibrosis and scarring that bind the artery, vein, and nerve firmly together

Answer 3

Buerger’s Disease (thromboangiitis Obliterans)

Question 4

permanent localized dilation of an artery which enlarges the artery to at least two times its normal diameter

Answer 4

Aneurysm

Question 5

to evaluate outflow disease compare ankle pressure with brachial pressure

• dividing the ankle blood pressure by the brachial blood pressure
• ABI less than 0.9 in either leg diagnostic of PAD

Answer 5

Ankle-Brachial index (ABI)

Question 6

Classic leg pain usually can only walk only a certain distance before a cramping burning muscle discomfort or pain forces them to stop

Answer 6

Intermittent Claudication

Question 7

involve the femoral, popliteal, and tibial arteries and are below the superficial femoral artery

Answer 7

Outflow Obstructions

Question 8

Involve the distal end of the aorta and the common, internal, and external iliac arteries
-located above the inguinal ligament

Answer 8

Inflow Obstructions

Question 9

Systemic atherosclerosis
-chronic condition in which partial or total arterial occlusion (blockage) deprives the lower extremities of oxygen and nutrients

Answer 9

Peripheral Arterial Disease (PAD)

Question 10

disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation

Answer 10

Peripheral Vascular Disease (PVD)

Question 11

reddish brown discoloration along the ankles, extending up to the calf

Answer 11

Stasis Dermatitis

Question 12

results of prolonged venous hypertension that stretches the veins and damages the valves

Answer 12

Venous insufficiency

Question 13

taking VS 
assessing peripheral pulses
assessing capillary refill 
checking for sensation and temp
completing a pain assessment 
assessing ulcer

Answer 13

Perform and interpret physical assessment

When patient experiencing inadequate oxygenation and tissue perfusion as a result of peripheral vascular disease

Question 14

notifying physician immediately or call RRT if aortic rupture suspected
monitoring VS
giving O2 if aneurysm rupture suspected
starting IV line if aneurysm rupture suspected
documenting abnormal peripheral vascular assessment findings
elevating legs if swollen unless arterial blood flow is poor

Answer 14

Respond to patients experiencing inadequate oxygenation and tissue perfusion as a result of peripheral vascular disease

Question 15

think about how you responded
continue to monitor patient for changes in peripheral blood flow, including pulse assessments
observe patient for decreased report of pain

Answer 15

What should you Reflect on

Question 16

Redness and swelling in lower leg (venous)
pallor cyanosis (darkened), mottling or rubor in lower leg (atrial )
report of pain/ cramping in lower legs or hands (at rest or during activity)
Ulcers on ankles feet or digitis
Pulsating mass in abdomen (abnormal aortic aneurysm)
decreased level of consciousnes (LOC), diaphoresis, decreased urine output (rupturing aortic aneurysm)

Answer 16

Might notice if the patient is experiencing inadequate oxygenation and tissue perfusion as a result of Vascular Problems

Question 17

turbulent swishing sound which can be soft or loud in pitch

-result of blood trying to pass through a narrowed artery

Answer 17

Bruit

Question 18

insufficient supply of blood to an organ, usually due to a blocked artery

Answer 18

Ischemia

Question 19

provider discontinues heparin admin

• platelet count <150,000
• white clot syndrome

Answer 19

Heparin-induced thrombocytopenia (HIT)

Question 20

a type of arteriosclerosis, involves formation of plaque within the arterial wall and is leading factor for CVD

Answer 20

Atherosclerosis

Question 21

thickening or hardening of the arterial wall that is often associated with aging

Answer 21

Arteriosclerosis

Question 22

disturbances in blood flow which result in damage to tissues of the extremities and organs due to ischemia and the excessive accumulation of waste/fluid due to venous/lymphatic stasis
-condition of blood vessels lending to narrowing and hardening of arteries that supply legs/feet

Answer 22

Peripheral Vascular Disease

Question 23

lower blood pressure by interfering with the transmembrane flux of calcium ions

• vasodilation decreasing BP
• Blocks SA and AV node conduction, decreasing HR

Answer 23

Calcium Channel Blockers

Question 24

severe type of elevated blood pressure that rapidly progress

Answer 24

Malignant Hypertension