Exam 2- Peripheral & Vascular Flashcards
What does the right side of the heart do?
Pumps blood through the lungs to the pulmonary circulation
What does the left side of the heart do?
Pumps blood to all other body tissues through the systemic circulation
What is included in the vascular system?
Heart
Arteries and arterioles
Capillaries
Veins and venules
Lymphatic vessels
Functions of the vascular system (6)
Circulatory needs of tissues
Blood flow
Blood pressure
Capillary filtration and reabsorption
Hemodynamic resistance
Peripheral vascular regulating mechanisms
Pathophysiology of the vascular system
- Pump failure (not effectively squeezing the blood)
- Alterations in blood and lymphatic vessels (decreased healing)
- Circulatory insufficiency of the extremities
What produces changes in the walls of the blood vessels that affect the transport of oxygen and nutrients to the tissues?
Aging
Aging changes cause vessels to stiffen. This results in…
- Increased peripheral resistance
- Impaired blood flow
- Increased left ventricular workload
When doing an assessment of the vascular system, what health history do we need to obtain?
- Intermittent claudication
- “Rest pain”
- Location of the pain
When doing an assessment of the vascular system, what physical assessment do we need to obtain?
- Skin (cool, pale, pallor, rubor, loss of hair, brittle nails, dry or scaling skin, atrophy, and ulcerations)
- Pulses: life or limb
Diagnostic evaluation of peripheral vascular system (7)
- Doppler ultrasound flow studies
- Exercise testing
- Duplex ultrasonography
- Computed tomography scanning
- Angiography magnetic resonance angiography
- Contrast phlebogrphy (venography)
- Lymphoscintigraphy
What test do we do for ankle-brachial index (ABI)?
Doppler ultrasound flow studies
What diagnostic do we use dye for?
Contrast phlebography (venography)
Which testing is good for findings on the ankle, brachial, or index?
Computed tomography scanning
Continuous wave (CW) doppler ultrasound is used for…
Vascular
Handheld ultrasound device that detects blood flow, combined with computation of ankle or arm pressures
Continuous wave (CW) doppler
In a CW doppler ultrasound, signals are reflected by…
The moving blood cells
What helps us characterize the nature of peripheral vascular disease?
Diagnostic technique
What do we obtain in an assessment of patients with peripheral vascular problems? (8)
- Health history
- Medications
- Risk factors
- S/S of arterial insufficiency
- Claudication and rest pain (red flag)
- Color changes
- Weak or absent pulses (red flag)
- Skin changes and skin breakdown
Medications for patients with peripheral vascular problems (3)
- Aspirin
- Plavix
- Statin
Major goals for patients with peripheral vascular problems (6)
- Increased arterial blood supply
- Decrease in venous congestion
- Promotion of vasodilation (open up hose, let blood flow go) and prevention of vascular compression
- Relief of pain
- Attainment/maintenance of tissue integrity (making sure no further wounds)
- Adherence to the self-care program
Ways to improve arterial circulation
- Positioning strategies (body part below the level of the heart) (easier to pump downhill than uphill)
- Exercise program and activities
- Temperature; effects of heat and cold (frostbite: gangrene)
- Discourage use of nicotine
- Stress reduction
Arterial disorders (7)
- Arteriosclerosis and atherosclerosis
- Peripheral artery disease
- Aortoiliac disease
- Aneurysms
- Aortic dissection
- Arterial embolism and arterial thrombosis
- Raynaud’s phenomenon
What is arteriosclerosis?
Hardening of the arteries
Example of a common aneurysm
Thoracic abdominal
Diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened
Arteriosclerosis
What affects the intima of large and medium-sized arteries
Atherosclerosis
Atherosclerosis is an accumulation of…
Lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery
Atheroma or plaque build up results in…
Atherosclerosis
Modifiable risk factors for atherosclerosis and PAD (9)
- Nicotine use
- Diabetes
- HTN
- Hyperlipidemia
- Diet
- Stress
- Sedentary lifestyle
- C-reactive protein
- Recreational drug use
Nonmodifiable risk factors for atherosclerosis and PAD (3)
- Increasing age
- Familial/genetics
- Hyperhomocysteinemia
Hallmark symptom of PAD
Intermittent claudication
PAD is relieved with what?
Rest
PAD occurs with…
Some degree of exercise or activity
PAD pain is associated with…
Critical ischemia of the distal extremity
PAD pain is described as…
- Persistent
- Aching
- Boring (rest pain)
When is ischemic rest pain the worst?
At night and often wakes the patient
What pharmacologic therapy is used for PAD? (3)
- Phosphodiesterase III inhibitor (Cilostazol)
- Antiplatelet agents (Aspirin, Clopidogrel)
- Statins (Reduce cholesterol)
The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What should be included in the teaching plan?
A) Elevate the lower extremities
B) Exercise is discouraged
C) Keep the lower extremities in a neutral or dependent position
D) PAD should not cause pain
C) Keep the lower extremities in a neutral or dependent position
Localized sac or dilation formed at a weak point in the wall of the artery
Aneurysm
How are aneurysms classified?
By their shape or form
Most common forms of aneurysms
Saccular and fusiform
Which type of aneurysm projects from only one side of the vessel?
Saccular
When an arterial segment becomes dilated, what happens?
A fusiform aneurysm develops
What is Raynaud’s phenomenon?
Intermittent arterial vasoocclusion, usually of the fingertips or toes
Difference between Raynaud’s disease and Raynaud’s syndrome
Raynaud’s disease has no underlying health issues, while Raynaud’s syndrome occurs due to an underlying health condition
Manifestations of Raynaud’s phenomenon
Sudden vasoconstriction that results in
- Color changes
- Numbness
- Tingling
- Burning pain
Raynaud’s phenomenon episodes are brought on by…
Triggers such as cold or stress
Raynaud’s phenomenon is most common in who?
Females
Venous disorders (4)
- Venous thromboembolism (VTE) condition (DVT and PE)
- Chronic venous insufficiency/post thrombotic syndrome
- Leg ulcers
- Varicose veins
Venous thromboembolism pathophysiology
Endothelial damage, venous stasis, and altered coagulation (Virchow’s Triad) - blood is getting stuck (valves not working or blood just not moving up)
Venous thromboembolism risk factors
- Trauma
- Surgery
- Age >65
- Immobilized
- Obesity
- Clotting disorders
(due to sepsis, cancer, genetics, etc.)
Venous thromboembolism manifestations
- Pain or tenderness, swelling, redness, warmth, edema (generally unilateral)
What type of vein is less severe and can treated at home?
Thrombosis of superficial vein
S/S of PE may be first sign of…
Venous thromboembolism
Virchow’s Triad
- Venous stasis
- Vessel trauma
- Hypercoagulopathy
Venous thromboembolism preventative measures
- Pneumatic compression devices
- Subq Heparin or LMWH, warfarin (Coumadin) for extended therapy
- Positioning (periodically elevate lower extremities)
- Exercises (active and passive)
- Early ambulation
- Avoid sitting for a long time (walk for 10 mins every 2 hours)
Venous thromboembolism gold standard preventative measure
Doppler
Diagnostic tests for venous thromboembolism
- Venous flow studies (venous duplex ultrasonography)
- MRI
- D-dimer
Nonsurgical management for venous thromboembolism
- Rest
- Drug therapy
- Preventive measures
Drug therapy for venous thromboembolism
- Unfractionated heparin therapy
- Low molecular weight heparin
- Warfarin therapy (long term min 3-6 months)
- Thrombolytic therapy (EKOS- with ultrasound)
New generations of Warfarin
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
- Dabigatran (Pradaxa)
What do we need to monitor for venous thromboembolism?
aPTT
PT
INR
ACT
Hgb
Platelet count
Fibrinogen levels
IV heparin is always administered via…
Infusion pump
What do we monitor with IV heparin? And what is the goal?
Monitor with aPTT
Goal: 1.5 x control
What precaution should nurses take with venous thromboembolism?
Bleeding precautions!
What do we need to monitor with oral anticoagulants? And what is the goal?
PT/INR
Goal: INR 2-3
What do we do for comfort management for venous thromboembolism?
Pain meds and elevation of the affected extremity
What do you do for compression therapy as a nurse for venous thromboembolism?
Stockings
Intermittent pneumatic compression device
Why should we not use SCDs or pump with venous thromboembolism?
Because massaging leg will break up the clot and send it elsewhere in the body
What do nurses do for positioning someone with a venous thromboembolism?
- Feet above heart level when in bed
- Walk 10 min every hour
Which patient is at highest risk for venous thromboembolism?
A) A 50 yo postoperative pt
B) A 25 yo pt with a central venous catheter in place to treat septicemia
C) A 71 yo otherwise healthy older adult
D) A pregnant 30 yo women due in 2 weeks
B) A 25 yo pt with a central venous catheter in place to treat septicemia
(They have two risk factors and the rest have one)
What is included in an assessment of a patient with leg ulcers?
- History of condition
- Assess pain, peripheral pulses, and edema
- Treatment depends on the type of ulcer
- Assess for presence of infection
- Assess nutrition
Clinical manifestations for leg ulcers
- Post thrombotic syndrome
- Stasis ulcers
- Complications (infection: cellulitis, venous ulceration)
What does post thrombotic syndrome look like?
- Chronic venous stasis
- Edema
- Altered pigmentation
- Pain
- Stasis dermatitis
What do stasis ulcers look like?
Brownish discoloration of the tissues
Medical management of leg ulcers
- Pharmacologic
- Compression therapy
- Hyperbaric treatment
- Dressings
Pharmacologic treatment for leg ulcers
- Antiseptic agents
- Chlorhexidine
- Silver wound products
- Topical, PO, or IV antibiotics
What debridement treatments do we use for leg ulcers?
- Surgical
- Dressing
- Topical agents
What are nursing interventions for patients with leg ulcers?
- Restoring skin integrity
- Improving physical mobility
- Promoting adequate nutrition
What should nurses do to restore skin integrity for a patient with a leg ulcer?
Cleansing wound; positioning; avoiding trauma; avoid heat sources
To improve physical mobility with leg ulcer, what should nurses do?
- activity initially restricted to promote healing
- Then, activity to promote blood flow
- Diversional activities
- Analgesic agents before scheduled activities
To promote adequate nutrition for a patient with leg ulcers, what should the nurses do?
Give protein; Vitamins A and C; Iron; Zinc
Infection and swelling of skin tissues
Cellulitis
Cellulitis s/s
Pain, swelling, localized redness
Fever, chills, and sweating
Lymphangitis
What do we use to treat cellulitis?
Antibiotics
If severe, IV therapy
Tissue swelling related to obstruction of lymphatic flow
Lymphedema
Primary lymphedema
Congenital (meaning you are born with it)
Secondary lymphedema
Acquired obstruction
Cellulitis nursing management
- Elevate affected area 3-6 inches above heart
- Warm, moist packs to site every 2-4 hours
- Educate regarding prevention of recurrence
- Reinforce education about skin and foot care
Prevention of varicose veins
- Avoid activities that cause venous stasis (wearing socks that are too tight, crossing legs at the thighs, sitting or standing for long periods of time)
- Elevate legs 3-6 inches above heart
- Encourage walk for 30 mins each day if there are no contraindications
- Wear graduated compression socks
- Overweight patients should be encouraged to begin weight reduction plans
Lymphangitis
Inflammation or infection of the lymphatic channels
Lymphadenitis
Inflammation or infection of the lymph nodes
Lymphedema
Tissue swelling related to obstruction of lymphatic flow
Risk factors of lymphedema
- Lymph node removal
- Immobility
- Obesity
- Venous conditions
Prevention of lymphedema
- Protect the skin (avoid infections, cuts, burns, etc.)
- Exercise (maintain a healthy weight)
- Avoid tight clothing (avoid heavy with at-risk limb)
- If lymph node removal, use unaffected arm for blood draws/IVs/BP
Which of the following is an effective strategy used to promote lymphatic drainage and prevent edema in clients with lymphedema?
A) Antibiotic therapy for 14 days
B) Constant elevation of the affected extremity
C) Application of heat therapy twice per day
D) Daily exposure to sun
B) Constant elevation of the affected extremity
The nurse is discussing the risks of cardiovascular disease (CVD) in female clients according to the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Primary Prevention of CVD with a female client. What risk factor(s) will the nurse discuss with the client? Select all that apply.
menopause
family history
nulliparity
late menarche
preeclampsia
Menopause
Family history
Preeclampsia
A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.
Wound is superficial
Wound base is pale in color
Wound has an irregular border
Thick, tough skin around the ankles
Darkened skin around the lower extremities
Wound is superficial
Wound has an irregular border
Thick, tough skin around the ankles
Darkened skin around the lower extremities
A client is recovering from sclerotherapy to treat varicose veins. Which information will the nurse provide to the client after the procedure? Select all that apply.
Increase the amount of time walking at home.
Change the dressings once a day.
Take acetaminophen as prescribed for pain.
Expect a burning sensation in the injected areas for 1 to 2 days.
Wear graduated compression stockings for a week after the procedure.
Increase the amount of time walking at home.
Take acetaminophen as prescribed for pain.
Expect a burning sensation in the injected areas for 1 to 2 days.
Wear graduated compression stockings for a week after the procedure.
The nurse is assessing a client who is experiencing symptoms of an arterial embolism of the right arm. Which assessment findings indicate to the nurse that the client has this condition? Select all that apply.
Pain
Pallor
Paralysis
Palpitations
Pulselessness
Pain
Pallor
Paralysis
Pulselessness
