[Exam 1] Chapter 30: Assessment and Management of Patients with Vascular Disorders & Problems of Peripheral Circulation (Page 841-861, 868-880) Flashcards
Conditions of vascular system include
arterial disorders, venous disorders, lymphatic disroders, and cellulitisi.
The vascular system consists of two interdependent systems.. what do these do?
Right side of heart pumps blood through the lungs to the pulmonary circulation
Left side of heart pumps blood to all other body tissues through the systemic circulation
What do arteries and veins do?
Arteries carry blood from left side of heart to tissues. Veins carry deoxygenated blood from the tissues to the right side of the heart
Capillary vessels connect the
arterial and venous sytems
Lymphatic vessels transport what and to where?
TRansport lymph and tissue fluids from the interstitial space to systemic veins
Layers of artereis?
Intima (inner endothelial cell layer
Media (middle layer of smooth muscle and eleastic tissue
Adventitia (outer layer of CT)
The intima provides a smooth surface for contact with
the flowing blood
Media composed chiefly of
elastic and connective tissue fibers that give the vessels considerable strength , allowing constriction and dilation
What are arterioles known as?
REsistance vessels, because they offer resistance to blood flow by altering their diameter
Capillaries composed of
a single layer of endothelial cells because they lack msooth muscle
Capillaries thin walled structure permits
rapid and efficient transport of nutrients to the cells and removal of metabolic wastes
Capillary beds in fingertips contain arteriovenous anastomoses through which blood passes directly from teh arterial to teh venous systems . What are these believed to do?
Regulate heat exchange between the body and the external environment
Veins are referred to as what type of vessel?
Capacitance because of the abaility for large volume of blood to remain in the veins under low pressure
How much of total blood volume contained in veins?
75%
What does the sympathetic nervous system do to the veins?
Causes the veins to constrict, thereby reducing venous volume and increasing the volume of blood in general circulation
Veins: Contraction of skeletal muscles in the extremities creates
the primary pumping action to facilitate venous blood flow back to the heart
Some veins have one-way bicuspid valves in the lower extremities which prevents
blood from seeping backward as it is propelled toward the heart
What are Lymphatic Vessels?
Complex neetwork of thin-walled vessels similar to the blood capillaries. Collects lym fluid from tissues and organs and transports fluid to venous circulation
Lymphatic vessels converge into
two main structures, thoracic duct and right lymphatic duct
Lymphatic Vessels: Thoracic and Right Lymphatic Duct empty into
subclavian and the internal jugular veins .
Right conveys for head, neck, and upper arms. Thoracic does rest of body
If the blood vessels fail to dilate in response to the need for increased blood flow, what happens?
Tissue ischemia (deficient blood supply to a body part) results.
What side of the heart does blood exit from
Left side
What causes the unidirectional flow of blood that occurs?
Pressure difference that exists between the arterial and venous systems.
Because artial pressure is greater than venous, fluid flows from higher to lower pressure (arterial to venous)
Turbulent blood flow creates an abnormal sound called
a bruit, which can be heard with a stethoscope
Capillary Filtration and Reabsorption: Fluid exchangeacross the capillary wall is
continuous
Capillary Filtration and Reabsorption: Hydrostatic force is a driving pressure that is generated by
the lood pressure
Capillary Filtration and Reabsorption: What is osmotic pressure?
Pulling force created by plasma proteins.
Capillary Filtration and Reabsorption: High pressure at the arterial end of the capillaries tends to
drive fluid out of the capillary and into the tissue space
Capillary Filtration and Reabsorption: Osmotic pressure tends to pull fluid
back into the cappillary from the tissue space, but this osmotic force cannot overcome high hydrostatic pressure at the arterial end
Capillary Filtration and Reabsorption: However at the venous end of the capillary, osmotic force predominates over the low hydrostic pressure, and there is a net
reabsorption of fluid from teh tissue space back into the capillary
Capillary Filtration and Reabsorption: Under certain abnormal conditions, fluid filtered out of capillaries may greatly exceed the amounts
reabsorbed and carreid away by the lymphatic vessels. Results in damage to capillary walls and subsequent increased permeability, obstruction of lymphatic drainage.
Capillary Filtration and Reabsorption: Accumulation of excess intersitial fluid results from these proccesses called
edema
Hemodynamic Resistance: Most important factor that determiens resistance in vascular system is
the vessel radius
Hemodynamic Resistance: Peripheral vascular resistance is the opposition to
blood flow provided by the blood vessels
Hemodynamic Resistance: A large increase in hematocrit may increase
blood viscosity and reduce capillary blood flow
Peripheral Vascular Regulating Mechanisms: What is the most important factor in reguating the caliber and therefore the blood flow of peripheral blood vessels?
Sympathetic nervous system
Peripheral Vascular Regulating Mechanisms: All blood vessesls are innervated by the
sympathetic nervous system except the capillary and precapillary sphincters
Peripheral Vascular Regulating Mechanisms: Stimulation of the sympathetic nervous syste causes
vasoconstriction
Peripheral Vascular Regulating Mechanisms: What is responsible for sympathetic vasoconstriction?
Norepinephrine. Occurs in response to physiolgoic and psychological stressors
Peripheral Vascular Regulating Mechanisms: What does Epinephrine do?
Acts like norepinephrine in constricting peripheral blood vessels in most tissue beds. In low concentrations however, causes vasodilation in skeletal muscles of heart.
Inadequate peripheral blood flow occurs when
the heart’s pumping action becomes inefficient. Left-sided heart failure causes an accumulation of blood in the lungs and reduction in forward flow or cardiac output.
Peripheral Vascular Regulating Mechanisms: Right sided heart fialure causes
systemci venous congestion and a reduction in forward flow
Alterations in Blood and Lymphatic Vessels: Decreased venous blood flow results in
increased venous pressure, a subsequent increase in capillary hydrostatic pressure, net filtration out of a capilary into interstitial space
Circulatory Insufficiency of the Extremities: Although many types of peripheral vascular diseaes exist, most result in and produce these symptoms
Ischemia , and produce symptoms like pain, skin changes, diminished pulse, possible edema
Circulatory Insufficiency of the Extremities: Peripheral vascular disease is categorized as
arterial, venous, or lymphatic
Assessmenet of the Vascular System - Health History: a muscular , cramp-type pain , discomfort, or fatigue in teh extremities consistently reproduced with the same degree of exercise or activity and relieved with rest is experienced in patients with
peripheral arterial insufficiency. This pain is known as Intermittent Claudication
Assessmenet of the Vascular System - Health History: Intermittent Claudication is caused by
inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients
50% of arterial lumen or 75% of cross-secctional area must be obstructed before this happens
Assessmenet of the Vascular System - Health History: Persistent pain in the forefoot when the patient is resting indicates
a severe degree of arterial insufficiency and a critical state of ischemia. This is known as rest pain
Assessmenet of the Vascular System - Health History: Rest pain is often worse at
night and may interefere with sleep .
Extremity must be lowered to a dependent position to improve perfusion
Assessmenet of the Vascular System - Health History: The site of arterial disease can be deduced form the location of claudication because pain occurs in muscle groups…
distal to the diseased vessel
Assessmenet of the Vascular System - Health History: Calf pain may accompany reduced blood flow through the
superficial femoral or popliteal artery
Assessmenet of the Vascular System - Health History: Pain in the hip or buttock may result from reduced blood flow in the
abdominal aorta or comon iliac
Assessmenet of the Vascular System - Physical Assessment: What is important in the diagnosis of arterial disorders?
Through assesment of patients skin color and temperature and character of peripheral pulses
Assessmenet of the Vascular System - Physical Assessment: Inadqueate blood flow results in
cool and pale extremities. Further reduction occurs when extremity elevated
Assessmenet of the Vascular System - Physical Assessment: What is Rubor?
A reddish-blue discoloration of the extremities that may be observed 20 seconds to 2 minutes after the extremity is placed in the dependent positon
Assessmenet of the Vascular System - Physical Assessment: Rubor suggests
severe peripheral arterial damage in which vessels that can not constrict remain dilate
Assessmenet of the Vascular System - Physical Assessment: To prevent palpating your own pulse, examiner should use
light touch and avoid using only the index finger for palpitation because this finger has the strongest arterial pulsation of all the fingers. Thumb for the same reason
Assessmenet of the Vascular System - Physical Assessment: Absence of pulse may indicate
that the site of stenosis (narrowing or constriction) is proximal to that location
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: This can be used when
pulses cannot be reliable palpated. Used to detect blood flow in vessels
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Signals are reflected by
the moving blood cells and are received by the device . Then transmitted to loudspeaker where it can be heard
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: The lower the frequency, the
deeper the tissue penetration
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: To evaluate the lower extremities, the patient is placed in the
supine postion with HOB elevated 20-30 degrees. Legs externally rotated to access medial mallelous. Gel applied.
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Tip of Doppler transducer positioned at what degree
45-60 degrees
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Continuous Wave Doppler is more useful as a
clinical tool when combined with ankle blood pressures
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: What is ABI?
Ratio of the systolic blood pressure in the ankle to the systolic blodo pressure in the arm.
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: In ABI, increasing degrees of arterial narrowing, there is a progressive decrease in
systolic pressure distal to the involved sites
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: First step to determine the aBI is to have the patient
rest in supine position for 5 minutes as cuff aplied to ankle. Systolic pressures obtained while listening to doppler.
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Doppler Ultrasonography is used to measure
brachial pressures in both arms. Arms elevated because patient may have asymptomatic stenosis in the subclavian artery
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: To calculate ABI, highest ankle systolic pressure is divided by
the higher of the two brachial systolic pressures
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: In general, systolic pressure in the ankle of a healthy person is the same or slightly higher than the
brachial systolic pressure resulting in ABI of about 1.0
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Nurse should perform baseline ABI on any patient with
decreased pulses or any patient 70 years or older
Assessmenet of the Vascular System - Diagnostic Evaluation, Doppler Ultrasound Flow Studies: Prior to ABI, patients should be instructed to
avoid use of tobacco or caffeinated beverages for at least 2 hours before testing
Assessmenet of the Vascular System - Diagnostic Evaluation, Exercise Testing: Used to determine
how long a patient can walk and to measure the ankle systolic blood pressure in response to walking
Assessmenet of the Vascular System - Diagnostic Evaluation, Exercise Testing: Most patients can complete the test unless they have
severe cardiac, pulmonary, or orthopedic problems or a physical disability
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: What does this involve??
B-Mode grayscale imaging of the tissue, organs and blood vessels and permits estimation of velocity changes by use of a pulsed DOppler.
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: Color flow techniques may be used to
shorten the examination time
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: May be used to determrine
the level and extend of venous disease as well as chronicity of the disease
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: Using B mode and doppler, it is possible to image and assess
blood flow, evaluate flow of the distal vessels, locate the disease and determine anatomic morphology and hemodynamic significant of plaque causing stenosis
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: Prep for test?
It is non invasive and requires no patient prep.
Assessmenet of the Vascular System - Diagnostic Evaluation, Duplex Ultrasonography: Patients who undergo abdominal vascular duplex ultrasound prep
NPO for at least 6 hours prior to the examination to decrease production of bowel gas that cna interfere with the examination
Assessmenet of the Vascular System - Diagnostic Evaluation, Computed Tomography SCanning (CT): This provides
cross-sectional images of soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes take place
Assessmenet of the Vascular System - Diagnostic Evaluation, Computed Tomography SCanning (CT): What happens in Multidetector-computed tomography (MDCT),
a spircal CT scanner and rapid intravenous infusion of contrast agent are used to image very thin sections of the target area and results are configured in three dimensions so that the image can be rotated and viewed from multiple angles
Assessmenet of the Vascular System - Diagnostic Evaluation, Computed Tomography SCanning (CT): In MDCT< patient is exposed to
xrays and a contrast agent to visualize the blood vessels
Assessmenet of the Vascular System - Diagnostic Evaluation, Computed Tomography SCanning (CT): Patients with impaired renal function scheduled fo rMDCT may require
preprocedural treatment to prevent contrast induced nephropathy. This may include oral or IV hydration 6-12 hours before preprocedure
Assessmenet of the Vascular System - Diagnostic Evaluation, Computed Tomography SCanning (CT): In MDCT, nurse should montior
the patients urinary output post procedurally.
Assessmenet of the Vascular System - Diagnostic Evaluation, Angiography: Arteriogram produced by this may be used to confirm diagnosis of occlusive arterial disease… this involves what?
Injecting a radiopaque contrast agent directly into the arterial system to visualize the vessels
Assessmenet of the Vascular System - Diagnostic Evaluation, Angiography: What does the patient experience when contrast agent injected
Temporary sensation of warmth and local irritation may occur at the injection site
Assessmenet of the Vascular System - Diagnostic Evaluation, Angiography: Manifestations include
dyspnea, nausea , and vomiting, sweating, tachycardia, and numbness.
May require antihistamines or corticosteroids
Assessmenet of the Vascular System - Diagnostic Evaluation, Magnetic Resonance Angiography: MRA performed with MRI scanner to isolate
blood vessels. Resulting images can be rotated and viewed from multiplea angles
Assessmenet of the Vascular System - Diagnostic Evaluation, Magnetic Resonance Angiography: MRA contraindicated in patients with any
metal implants or devices like pacemakers.
Assessmenet of the Vascular System - Diagnostic Evaluation, Magnetic Resonance Angiography: Patient should beinstructed that they may hear
noises including banging and popping sounds.
Assessmenet of the Vascular System - Diagnostic Evaluation, Magnetic Resonance Angiography: MRA procedure require the use of
IV dyes. Therefore nursing implications following MRA same as MDCT
Assessmenet of the Vascular System - Diagnostic Evaluation, Contrast Phlebography (Venography): What does this involve?
Injecting a radiopaque contrast agent into the venous system.
Assessmenet of the Vascular System - Diagnostic Evaluation, Contrast Phlebography (Venography): If thrombus exists, X-Ray reveals
unfilled segment of vein in an otherwise completely filled vein
Assessmenet of the Vascular System - Diagnostic Evaluation, Contrast Phlebography (Venography): Injection of contrast may cause beief but painful
inflammation of the vein
Assessmenet of the Vascular System - Diagnostic Evaluation, Contrast Phlebography (Venography): What is the standard for diagnosing lower extremity venous thrombosis?
Duplex Ultrasonography
Assessmenet of the Vascular System - Diagnostic Evaluation, Contrast Phlebography (Venography): What should patient know before receiving contrast?
He or she will receieve dye through a vein and will be monitored for 2 hours post venogram
Assessmenet of the Vascular System - Diagnostic Evaluation, Lymphoscintigraphy: What does this involve?/
Injection of a radioactively labaled colloid subcutaneously in the second interdigital space. Extremity rthen exercised to facilitate the uptake of the coloid by lymphatic system
Assessmenet of the Vascular System - Diagnostic Evaluation, Lymphoscintigraphy: What should the nurse inform the patient?
Blue dye may stain ijection site
IF patient has lymphatic leak, there may be blue drainage from incision for a couple a days
Arterial Disorders, what are they?
They can cause ischemia and tissue necrosis. These disorders may occur because of chronically progresive pathologic changes to arterial vasculature
What is Arteriosclerosis?
Most common disease of arteries. Muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickend
What does Atherosclerosis affect?
Affects the intima of large and medium sized arteries
Arterisclerosis and Atherosclerosis consist of
accumulation of lipidis, calciu, blood compoents, and carbohydrates and fibrous tissue on the intimal layer of the artery
Atherosclerosis is a generalized disease of the arteries, and when it is present in the extremities, it is usually peresent
elsewhere in the body
Most common result of atherosclerosis in arteries include
narrowing of the lumen obstruction by thrombosis , aneurysm, ulceration and rupture
Indirect results of atherosclerosis are
malnutrition and subsequent fibrosis of the organs tha the sclerotic arteries supply with blood
Atherosclerosis: Sites for males include
Distal abdominal aorta, common iliac arteries
Orifice of the superfiical femoral and profunda femoris arteries and superfiical femoeral artery
Atherosclerosis: what is the reaction-to-injury theory
Vascular endothelial cell injury results from prolonged demodynamic forces , such as shearing stress and turbulent flow.
Atherosclerosis: Injury to the endothelium increase the
aggregration of platelets and monocytes at the site of the injury . Smooth muscle cells migrate and prolfierate allowing a matrix of collagen and elastic fibers to form
Atherosclerosis: Lesions are of two types
Fattty Streaks and fibrous plaque
Atherosclerosis: What are fattty streaks?
Are yellow and smooth, protude slightly into the luman of the artery and are composed of lipids. Do not cause clincal symptoms
Atherosclerosis: Fibrous plaques composed of
smooth musclecells, collagne fibers, plasma components and lipids. Protude in various degrees into the arterial lumen. Found in abdominal aorta
Atherosclerosis: Gradual narrowing of the arterial lumen stimulates development of
collateral circulation
Atherosclerosis: Collateroal circulation arisis from
pre-exisitng vessels that enlarge to reroute blood flow around a hemodynamially signifcant stenosis or occlusion
Atherosclerosis, Risk Factors: One of the most important risk factors is
tobacco products. Nicotine in tobacco decreases blood flow to extremities and increases HR and BP by stimulating sympathetic nervous system, causing vasoconstriction
Also increases aggregation of platelets
Atherosclerosis, Risk Factors: Evidience shows that smoking decreases what in the body?
HDL
Atherosclerosis, Risk Factors: Amount of toacco used is directly correlated to
extend of the disease and cessation of any type of tobacco product
Atherosclerosis, Risk Factors: Atherosclerosis, Risk Factors: Diabetes increases risk of Peripheral Arterial Disease how much more?
2-4 fold with amputation rates5-10 times higher than in patients without diabetes
Atherosclerosis, Risk Factors: How does diabetes affect the onset and progression?
Multifactorial including incitation of inflammatory processes, derangement of various cell types within vessesl walls, and promiton of coagulation
Atherosclerosis, Risk Factors: What is C-Reactive Protein (CRP)?
Sensitive marker of cardiovascular inflammation both systemically and locally. Slight increases are associated with increased risk of damage in the vasculature
Atherosclerosis, Risk Factors: Hyperhomocysteinemia has been positively correlated with
risk of peripheral, cerebovascular and coronary artery disease and VTE
Atherosclerosis, Risk Factors: What is Homocysteine?
PRotein that promotes coagulation by increasing factor V and XI activity while depressing protein C activation
Atherosclerosis, Prevention: Intermittent claudication is a symptom of , and may be a marker of
symptom of generalized atherosclerosis and may be a marker of occult coronary artery disease
Atherosclerosis, Prevention: What are the first things done to preven thtis?
Test for cholesterol and begin disease prevenetion efforts that include diet modifications
Atherosclerosis, Prevention: Yu shouold reduce the amount of
fats ingested in a healthy diet, sub unsaturated fats or saturated fats and decreasing cholesterol
Atherosclerosis, Prevention: MEdication recommended for first-line use in patients with PAD is
Statins
Atherosclerosis, Prevention: Hypertension is a major risk factor for development of
PAD and may be more significant in women
Atherosclerosis, Prevention: Majority of patients with hypertension require
more than two antihypertensive agents to reach goal blood pressure
Atherosclerosis, Prevention: What is one thing particularly recommended to prevent this?
Eliminate use of nicotine products
Atherosclerosis, Medical Management: Management includes
modification of RF
Controlled exercise program to improve circulation
Medication therapy
Interventional or surgical graft procedures
Atherosclerosis, Medical Management, Surgical Management: Vascular surgical procedure divided into two groups..
Inflow procedure 0 improve blood supply from teh aorta into femeral artery
Outflow procedure - provide blood supply to vessels below the femoral artery
Atherosclerosis, Medical Management, Surgical Management: Inflow procedures described with diseases of the
aorta
Atherosclerosis, Medical Management, Surgical Management: Outflow procedures described with diseases of the
peripheral arterial occlusive disease
Atherosclerosis, Medical Management, Radiologic Interventions: If an isolated lesions or lesions identified during the arteriogram, what is done?
Angioplasty performed.
Atherosclerosis, Medical Management, Radiologic Interventions: What happens during Angioplasty
After anesthetic agenete, balloon-tipped catheter manuvered across area of stenosis . Improves blood flow by overstretching the elastic fibers.
Atherosclerosis, Medical Management, Radiologic Interventions: What does an Antherectomy reduce?
PLaque buildup within ana rtery using a cutting devide or laser
Atherosclerosis, Medical Management, Radiologic Interventions: Complication from Angioplasty or Antherectomy?
Dissection (separation of the intima) of the vesse and vleeding
Atherosclerosis, Medical Management, Radiologic Interventions: To reduce risk of reocclusion, what is put in palce?
Stents may be inserted to support walls of blood vessels
Atherosclerosis, Medical Management, Radiologic Interventions: Complciations assiocated with stents include
distal embolization, intimal damage and dislodgement
Atherosclerosis, Medical Management, Improving PEripheral Arterial Circulation: Arterial blood supply to a body part can be enhanced by what for the upper extremity
positioning the part below the level of the heart
Atherosclerosis, Medical Management, Improving PEripheral Arterial Circulation: Arterial blood supply to the heart can be enhanced for the lower extremity by
Elevating head of patietns bed or having patient use reclining chair
Atherosclerosis, Medical Management, Improving PEripheral Arterial Circulation: Conditions that worsen with exercise include
leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions
Atherosclerosis, Medical Management, Promoting Vasodilation and Preventing Vascular Compression: Arterial dilation promotes
increased blood flow to the extremities and is therefore a goal for patietns with PAD
Atherosclerosis, Medical Management, Promoting Vasodilation and Preventing Vascular Compression: Nursing interventions for dilation include
applications of wamrth to promote arterial flow and instructions to the patient to avoid exposure to cold temperature, which causes vasoconstriction
Atherosclerosis, Medical Management, Promoting Vasodilation and Preventing Vascular Compression: For those with vasospastic disorders, where may the heat be applied?
May be applied directly to ischemic extremities using a warmed or electric blanket
Atherosclerosis, Medical Management, Promoting Vasodilation and Preventing Vascular Compression: Nicotine from any tobacco product causes vasopasm and can thereby reduce
circulation to the extremities
Atherosclerosis, Medical Management, Relieving Pain: What can be prescribed to relieve pain?
Analgesic agents such as hydrocodone.
Atherosclerosis, Medical Management, Gerontologic Considerations: What may be the first sign of disease for those who are inactive?
Limb ischemia or gangrene
Peripheral Arterial Occlusive Disease: In PAD, obstrucive lesions are predominatly confined to segments of
the arterial system extending from the aorta below the renal arteries to the popliteal artery
Peripheral Arterial Occlusive Disease, Clinical Manifestations: Hallmark symptom is
intermittent claudication described as aching, crmaping, or inducing fatigue or weakness that occurs with some degree of exercise or activity. COmmonly occurs in muscle groups distal to the area of stenosis.
Peripheral Arterial Occlusive Disease, Clinical Manifestations: Ischemic rest pain is usually worse at
night and often wakes the patient
Peripheral Arterial Occlusive Disease, Clinical Manifestations: Elevating the extremity or placing it in a horizontal position does what?
Increases the pain but placing limb in dependent positon reduces the pain
Peripheral Arterial Occlusive Disease, Assessment and Diagnostic Findings: Examination of peripheral pulses is an important part of assessing because
unequal pulses between the extremities or absence of a normlly palpable pulse is a sign of PAD
Peripheral Arterial Occlusive Disease, Assessment and Diagnostic Findings: Diagnosis of disease may be made using
CW Doppler and ABIs, treadmill testing for claudication, duplex ultrasonography or other imaging studies
Peripheral Arterial Occlusive Disease, Medical management: Patients feel better after they participate in
an exercise program.
Peripheral Arterial Occlusive Disease, Medical management: Studies show that for those who walk from house versus wiht an instructor
have no difference. Home-based progrm may be viable then
Peripheral Arterial Occlusive Disease, Medical management: Patients can pair walking programs with what?
Weight reduction and cessation of tobacco use to further improve their activity tolerance
Peripheral Arterial Occlusive Disease, Pharmacologic therapy: What was approved for treatment of symptomatic claudication?
Pentoxifylline and Cilostazol
Peripheral Arterial Occlusive Disease, Pharmacologic therapy: What does Pentoxifylline do?
Increases erythrocyte flexibility, lowers blood fibrinogen concentrations and inhibits neutrophil adhesion and activaiton
Peripheral Arterial Occlusive Disease, Pharmacologic therapy: What does Cilostazol do?
IS a direct vasodilator that inhibits platelet aggregation. Plays role in decreasing intimal hyperplasia after angioplasty and stenting
PAtients report pain free walking within 4-6 weeks
Peripheral Arterial Occlusive Disease, Pharmacologic therapy: Antiplatelets agents such as apirin prevent
formation of thromboemboli, which can lead to MI and stroke
Peripheral Arterial Occlusive Disease, Pharmacologic therapy: Statins improve
endothelial function in patietns with PAD.
They improve symptoms of intermittent claudication and also increase walking distance
Peripheral Arterial Occlusive Disease, Endovascular Management: This can include
Ballon angioplasty, stend, stent graft, or an atherectomy
Peripheral Arterial Occlusive Disease, Endovascular Management: ,Subject of these surgeries are to
Establish adequate inflow to the distal vessels
Peripheral Arterial Occlusive Disease, Surgical Management: Reserved for treatment of
severe and disabling claudication or when the limb is at risk for amputation because of tissue necrosis
Peripheral Arterial Occlusive Disease, Surgical Management: Bypass sgrafts performed to
reroutethe blood flow around the stenosis or occlusion. Before surgery, surgeron determines where the distal anastomosis (site where the vessels are surgically joined)
Peripheral Arterial Occlusive Disease, Nursing Management, Maintaining Circulation: ABI monitored every
8 hours for 24 hours and then once each day until discharge
Peripheral Arterial Occlusive Disease, Nursing Management, Maintaining Circulation: Typical hospital stay is
3-5 days postoperatively
Upper Extremity Arterial OCclusive Disease: Not as common as
lower, due to upper circulation being the better
Upper Extremity Arterial OCclusive Disease, Clinical Manifestations: Stenosis and occlusons in the upper extremity result from
atherosclerosis or trauma
Upper Extremity Arterial OCclusive Disease, Clinical Manifestations: Stenosis usually occurs iat the origin of the
vessel proximal to the vertebrl artery
Upper Extremity Arterial OCclusive Disease, Clinical Manifestations: Patient typically complains of
arm fatigue and pain with exercise, inability to hold objects and difficulty driving
Upper Extremity Arterial OCclusive Disease, Clinical Manifestations: Patient may develop subclavian steal syndrome which is characterzed by
reverse flow in the vertebral and basilar characterized by reverse flow in the vertebral and basilar arteries to provide blood flow to the arm
Upper Extremity Arterial OCclusive Disease, Assessment and Diagnostic Findings: Assessment findings include
coolness and pallor of the affected extremity, decreased capillary refill, and a different in arm blood pressures
Upper Extremity Arterial OCclusive Disease, Assessment and Diagnostic Findings: Noninvasive studies performed to evaluate for upper extremity arterial occlusions incldude
upper and forearm blood pressure determinations and duplex ultrasonography to identify the anatomic location of the lesion
Upper Extremity Arterial OCclusive Disease, Medical Management: If short focal lesion is identified, in an upper extremity artery what is done?
A PTA with possible stent or stent graft placement may be performed
Venous Thromboembolism: What are the three factors known as Vorchow Triad that are beleived to play a significant role in its development?
Endothelial Damage, Venous Stasis, And Altered Coagulation
Venous Thromboembolism: Damage to the intimal lining of blood vessels creates a site for
clot formation
Venous Thromboembolism: Venous Stasis occurs when
blood flow is reduced as in heart fiailure or shock
When veins are dilated, and
when skeletal muscles contraction is reduced
Venous Thromboembolism: Altered coagulation occurs with patients who
have had their anticoagulation medications abruptly withdrawn
Venous Thromboembolism: Formation of thrombus frequently accompanies
Phlebitis, which is an inflammation of the vein walls.
Venous Thromboembolism: When thronus develops initially in the veins as a rsult of stasis or hypercoagulability but without inflammation, process referred to as
phelbothrombosis
Venous Thromboembolism: Most frequently affected upper segment is in the
subclavian vein .
Venous Thromboembolism: Upper Extremity VTE more common in patients with
IV catheters or in patients with an underlying disease that cuases hypercoagulability
Venous Thromboembolism: Effort Thrombosis , also known as PAget-Schroetter Syndrome, of the upper extremity is caused by
repeptive motion (competitivev swimmers) that irritates the vessel wall cusing inflammation and subsequent thrombosis and is a manifestion of venous thoracic outlet syndrome where they become distorted and narrowed
Venous Thromboembolism: Propagating Venous thrombosis is dangerous because
parts of the thrombus can break off and occldude the pulmonary blood vvessels
Venous Thromboembolism, Clinical Manifestations: Difficulty with this is that S&S are
nonspecific.
Venous Thromboembolism, Clinical Manifestations: A large DVT creates
severe and sudden venous hypertension that leads to tissue ischemia with resultant translocation of fluid into the intersittial space
Venous Thromboembolism, Clinical Manifestations, Deep Veins: signs include
Edema and sweling because outflow of venous blood is inhibited. May feel warmer and superficial veins may appear more prominent
Venous Thromboembolism, Clinical Manifestations, Superficial Veins: Thrombosis of superficial veins produces
pain or tenderness, redness, and warmth in the involved area
Venous Thromboembolism, Clinical Manifestations, Superficial Veins: Can be treated
At home with bed rest, elevation of the leg, analgesic agents and possibly anti-inflammatory medication
Venous Thromboembolism, Assessment and Diagnostic Findings: Key concerns include
limb pain, a feeling of heaviness, functional impairment, ankle engorement and edema
Venous Thromboembolism, Prevention: Preventive measures include
application of graduated compression stockings , the use of intermittent pneumatic compression devices and encouragement of early ambulation
Venous Thromboembolism, Medical Management: Objectives to treatment are
to prevent the thrombus from growing and fragmenting.
Venous Thromboembolism, Medical Management: Anticoagulants prevent
the formation of a thrombus in postoperative patients and forestall the extension of thrombus after it has formed.
Venous Thromboembolism, Pharmacologic Therapy, Unfractionated Heparin: Given subcutaneously to prevenet
Development of DVT or given by intermittent or continuous IV wth Vit K antagonist for 5-7 days to prevent the extension of a thrombus
Venous Thromboembolism, Pharmacologic Therapy, Low-Molecular-Weight Heparin: Why to use this?
Longer half lives so doses cna be given in one or two inejctions each day
Venous Thromboembolism, Pharmacologic Therapy, Low-Molecular-Weight Heparin: Prevent the extension of
a thrombus and development of new thrombi and they are associated with fewer bleeding complications and lower risk of heparin induced thrombocytopenia than unfractionated heparin
Venous Thromboembolism, Pharmacologic Therapy, Oral Anticoagulants: Warfarin is a Vitamin K Antagonist that is indicated for
extended anticoagulant therapy.
Venous Thromboembolism, Pharmacologic Therapy, Factpr Xa and Direct Thrombin Inhibitors: Given how and when
Subcutaneously at a fixed dose and has a half-life of 17 hours.
Venous Thromboembolism, Pharmacologic Therapy, Thrombolytic Therapy: Given within first
3 days after acute thrombosis
Venous Thromboembolism, Pharmacologic Therapy, Thrombolytic Therapy: What is this?
Catheter-directed thrombolyitc therapy that lyses and dissolves thrombi in 50% of patients
Venous Thromboembolism, Endovascular Management: Necessary for DVt when
anticoagulant or thrombolytic therapy is contraindicated the danger of PE is extreme, or venous drainge is compromised
Venous Thromboembolism, Endovascular Management: Mechanical method of clot removal may involve using
intraluminal catheters with a balloon or other devices. Some of these spint o break the clot and other use oscillation to facilitate removal
Venous Thromboembolism, Endovascular Management: Ultrasound assisted thrombolysis uses
bursts or continuous high-frequency ultrasound waves emanating forom the catheters to cause cavitations of the thrombus
Venous Thromboembolism, Endovascular Management: Vena cava filter may be placed at the time of thrombectomy which
traps large emboli and prevents PE
Venous Thromboembolism, Nursing Management: If receiving anticoagulant therapy, nurse monitors
aPTT, PT, INR, ACt, Hemoglobin, and Hematocrit Valuves
Venous Thromboembolism, Assessing and Monitoring Anticoagulant Therapy: To prevent inadvertent infusion of large volumes, Unfractionated Heparin always given by
continuous IV
Venous Thromboembolism, Monitoring and Managing Potential Complications. Bleeding: Principal complication of anticoagulant therapy is
spontaneous bleeding
Venous Thromboembolism, Monitoring and Managing Potential Complications. Bleeding: To reverse effects of heparin, what is done
IV injections of protamine sulfate may be given
Venous Thromboembolism, Monitoring and Managing Potential Complications. Drug Interactions: Because oral anticoagulants, particularly warfarin, interact with many other drugs, what has to be done?
Close evaluation of the patitns medications is necessary
Venous Thromboembolism, Providing Comfort: What can be done?
Elevation of affected extremity , graduated compression stockings, and analgesic agents for pain relief . Help improve circulation and increase comfort
Venous Thromboembolism, Providing Compression Therapy, Stockings: Graduated compression stocks Usually prescribed for patients with
venous diseases
Venous Thromboembolism, Providing Compression Therapy, Stockings: Graduated COmpression stocks are desgiend to apply
100% of the prescribed pressure gradient at the ankle and then decrease along the length of the stocking
Venous Thromboembolism, Providing Compression Therapy, Intermittent Pneumatic Compression Devices: What are these?
Can be used with elastic or graduated compresseion stockings . Consist of electric controller that is attache dby air hoses to plastic knee-high sleeves. Fill and apply pressure.
Chronic Venous Insufficiency/Postthrombotic Syndrome: Venous insuffiency results from
obstruction of the venous valves in the legs or a reflux of blood through the valves
Chronic Venous Insufficiency/Postthrombotic Syndrome: What happens in this state?
Leaflets of the venous valves are stretched and preented from closing completely causing a backflow or reflux of blodo in the vein s
Chronic Venous Insufficiency/Postthrombotic Syndrome: What confirms the obsturction?
Duplex ultrasonography
Chronic Venous Insufficiency/Postthrombotic Syndrome, Clinical Manifestations: Characterized by
chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis
Chronic Venous Insufficiency/Postthrombotic Syndrome, Clinical Manifestations: Stasis ulcers develops a a result of
the rupture of small skin veins and subsequent ulcerations. When these veins rupture, red bloco cells escape into surrounding tissues and then degernate leaving a brownish discoloration of the tissues
Chronic Venous Insufficiency/Postthrombotic Syndrome, Complications: Venous ulceration is the most sreious complication of chronic venous insufficnecy and can be associated with other conditions affecting the
circulation of the lower extremities
Chronic Venous Insufficiency/Postthrombotic Syndrome, Medical and Nursing Management: Management is directed at
reducing venous stasis and prevent ulcerations.
Chronic Venous Insufficiency/Postthrombotic Syndrome, Medical and Nursing Management: MEasure sthat increase venous blodo flow are
antigravity activites such as elevting the leg, compression of superficial vains with graduated compression vein s
Chronic Venous Insufficiency/Postthrombotic Syndrome, Medical and Nursing Management: Elevaitng legs decreases
edema, promotes venous return and provides symptomatic relief
Leg Ulcers, Arterial Ulcers: Characterized by
intermittent claudication which is pain caused by activity and relieved after a few minutes of rest
Leg Ulcers, Arterial Ulcers: Patient may complain of
digital or forefoot pain at rest
Leg Ulcers, Arterial Ulcers: Arterial Ulcers are typically
small, circular, deep ulcerations on the tips of toes or in the webspace sbetween the toes
Leg Ulcers, Venous Ulcers: Characteried by
pain described as aching or heavy
Leg Ulcers, Venous Ulcers: Ulcerations are in the area of
medial or lateral malleolus and are typically large, superficial, and highly exudative
Leg Ulcers, Pharmacologic Therapy: What is prescribed?
Antiseptic agents that inhibit growth and development of most skin organisms are broad specrum and generate relatively little antimicrobial resistance
Leg Ulcers, Compression Therapy: Adequate compression therapy involves
application of external or coutner pressure to the lower extremity to facilitate venous return to the heart.
Leg Ulcers, Debridement: To promote healing, method of flush is
nromal saline solution or to clean it with noncytotoxic wound cleaning agent
Leg Ulcers, Debridement: Nonselective Debridement can be accomplished by
applying isotonic saline dressing of fine mesh gauze to the ulcer. When dried, it is removed along with debris adhering to it
Leg Ulcers, Debridement: Enzymatic Debridement is
application of enzyme ointments that may be prescribed to trea thte ulcer. Only applied to lesion
Leg Ulcers, Debridement: Calcium alginate dressings may be used for debridement when
absorption of exudate is needed. Dressings changed when exudate seeps through cover dressing sat least every 7 days
Leg Ulcers, Hyperbaric Oxygenation: May be benficial as an adjunct treatment in patients with
diabetes with no signs of wound healing after 30 days of standard would treatment
Leg Ulcers, Promoting Adequate Nutrition: What diet is recommended?
A diet that is high in protein, vitamins C and A, Iron, and Zinc is enouraged to promote healing.
Varicose Veins: What are these?
Are abnormally dilated, tortuous superficial veins caused by incompetent venous valves
Varicose Veins: Occurs most commonly in
lower extremtiies , the saphenous veins, or lower trunk.
Varicose Veins: Most common for people that work in what fields?
Occupations that require prolonged standing such as salespoeple, hair stylists, teachers, nurses, and construction workers
Varicose Veins: Reflux of venous blood results in
venous stasis
Varicose Veins: Symptoms if present include
dull aches, muscle cramps, nincreased muscle fatigue on lower legs, ankle edema, and feeling of heaviness of the legs
Varicose Veins: What symptom is common at night?
Nocturnal crmaps
Varicose Veins: Diagnostic tests include
Duplex ultrasound scan which documents site of reflux and provides a quantitive measure
Varicose Veins, Prevention and MEdical Management: Patient should avoid
activies that cause venous stasis such as wearing socks that are to tight
