Vascular System & Hematology Flashcards
Vascular system:
network of arteries, veins, and capillaries
Hematologic system:
living blood cells
and plasma within the blood vessels.
Lymphatic system:
assists the vascular
system by draining unabsorbed plasma
from tissue spaces and returning this fluid
(lymph) to the heart via the thoracic duct ,
which empties into the left jugular vein
Functions of Blood
Oxygen & carbon dioxide transport
Nutrient & metabolite transport
Hormone transport
Transport of waste products to kidneys & liver
Transport cells & substances involved in immune reactions
Clotting at breaks in blood vessels
Maintenance of fluid balance
Body temperature regulation
Maintenance of acid
base balance
Vascular Examination
History
Inspection
Palpation
Auscultation
Vascular Tests
Diagnostic Studies
Vascular Examination (History)
• Relevant medical history (DM, HTN, hyperlipidemia, syncope or
vertigo, & nonhealing ulcers).
• Relevant social history (exercise, dietary habits, & use of tobacco or
alcohol).
• Pain in arms & legs (visceral pain & arthritis pain may radiate to the
extremities).
• Presence of intermittent claudication . If so, the speed , distance ,
and the site of the pain, should be noted.
• Presence of nocturnal pain (can develop as the vascular occlusion
worsens). Caused by leg elevation & reduced cardiac output.
• History of acute or chronic peripheral edema .
• Precautions (weight bearing or BP parameters after vascular surgery).
Vascular Examination (Inspection)
• Skin color: (discoloration of the distal extremities/nail bed).
• Hair distribution: patchy hair loss on the lower leg may indicate arterial insufficiency
• Venous pattern: dilated veins, particularly in the calf.
• Edema or atrophy:
– Peripheral edema from right sided CHF : bilaterally in dependent
– Edema from trauma, lymphatic obstruction, or chronic venous insufficiency: generally unilateral.
• Presence of cellulitis.
• Presence of petechiae: small, purplish, hemorrhagic spots on the skin.
• Skin lesions: ulcers, blisters, or scars.
• Digital clubbing: poor arterial oxygenation or circulation.
Vascular Examination (Palpation)
- Pain & tenderness
- Strength & rate of peripheral pulses
- BP
- Skin temperature
- Limb girth (if edematous)
Vascular Examination
(Vascular Tests)
Capillary refill time
Elevation pallor
Manual compression test
Allen’s test
Homans’ sign
Ankle
brachial index (ABI)
Capillary refill time
is defined as the time taken for a distal capillary bed to regain its color after pressure has been applied to cause blanching
Manual compression test
if varicose v are seen then occlude the proximal and palpate the distal. If a pulse is felt, then it is a positive test.
Homans’ sign
for people you expect has DVT. Bring pt foot into DF and squeeze at the calf make sure knee is flexed to take away potential of tight hamstrings. Pos if pt feels pain and discomfort.
Allen’s test
used to assess collateral blood flow to the hands, generally in preparation for a procedure that has the potential to disrupt blood flow in either the radial or the ulnar artery.
Modified wells Criteria:
Criteria for predicting the probability of a DVT
If you have more than 2 than you are at risk for DVT
Vascular Examination (Diagnostic Studies)
Noninvasive Lab studies
• Doppler ultrasound
• Plethysmography
• Exercise testing
• CT
• MRI
• Magnetic resonance angiography
(MRA)
Vascular Examination (Diagnostic Studies) Invasive Vascular Studies
Arteriography (Most common)
• Postangiogram care:
– Bed rest for 4 to 8 hours.
– Pressure dressings to the injection site with assessment for hematoma formation.
– Intravenous fluid administration to help with dye excretion.
– Frequent vital sign monitoring with pulse assessments.
Hematologic Examination (History)
• What are the presenting symptoms?
• Was the onset of symptoms gradual , rapid , or associated with trauma or other
disease?
• Is the pt unable to complete daily activities secondary to fatigue
• Hx of anemia or other blood disorders, cancer, hemorrhage, or systemic
infection?
• Hx of blood transfusion
• Hx of chemotherapy , radiation therapy, or other drug
• Night sweats, chills, or fever?
• Easily bruised ? Is wound healing delayed?
Hematologic Examination (Inspection)
• General appearance ( lethargy , malaise , or apathy
• Degree of pallor or flushing of the skin, mucous
membranes, nail beds, and palmar creases.
• Presence of petechiae ecchymosis (bruising).
• RR.
Laboratory Studies
(CBC)
- Decreased Hgb levels can reduce oxygen transport capacity -> reduce O2 supply -> ↓endurance level.
- Be aware of S&S of hypoxia to major organs : brain, heart, & kidneys
• Hct may be falsely high w/ dehydration & falsely low w/ fluid overload
• Low Hct -> weakness, dyspnea, chills, ↓activity tolerance, or exacerbate
angina.
Pancytopenia
Significant ↓in RBCs, all types of WBCs, & platelets
Neutropenia
An abnormal decrease in WBCs, particularly neutrophils.
Leukocytosis
High level of WBC
Thrombocytopenia
A significant decrease in platelets.
Thrombocytosis
An abnormal increase in platelets.
Laboratory Studies (ESR)
• A measurement of how fast RBCs fall in a sample of
blood.
• Normal values:
– Males: up to 15 mm/hour
– Females: up to 20 mm/hour
• ESR may be elevated in systemic infection , collagen
vascular disease, and HIV.
– Disease worsens -> ↑ESR
– Disease improves -> ↓ESR
Laboratory Studies (Coagulation Profile)
• Coagulation tests assess the blood’s ability to clot.
– Prothrombin time (PT) (11 12.5 seconds)
– International normalized ratio (INR) (0.8 1.1)
– Partial thromboplastin time (PTT) (60 70 seconds)
• Activated PTT ( aPTT ) (30 40 seconds)
• Used in clinical conditions in which an increased risk
of thrombosis is present ( DVT)
Laboratory Studies (D-Dimer)
• Provides measurement of the amount of fibrin
degradation fragment.
• Accurately identifies pts w/ DVT (high negative
predictive value):
– Negative -> patient has a very low likelihood of having DVT.
– Positive -> less helpful (multiple conditions).
Arterial Disorders
Atherosclerosis, Aneurysm, Aortic Dissection, Hypertension, Raynaud’s Disease, Chronic Regional Pain Syndrome, Compartment Syndrome.
Venous Disorders
• Varicose Veins, Venous Thrombosis, Pulmonary Embolism, Chronic Venous Insufficiency.
Combined Arterial & Venous Disorders
Arteriovenous Malformations
Hematologic Disorders
• Anemia, Polycythemia, Thrombocytic Disorders.
Lymphatic Disorders
Lymphedema
Atherosclerosis
- Deposition of plaques of fatty material on their inner walls ↓blood perfusion past the area.
- A 50% to 60% reduction in blood flow is necessary for pts to present w/ symptoms (e.g., pain).
- The underlying cause of ~ 90% of all MI and a large proportion of strokes.
Atherosclerosis Risk Factors
– Reversible: HTN, DM, HLD, cigarette smoking, obesity.
– Irreversible: male gender, family history, genetic.
Atherosclerosis S & S
Reduced to absent peripheral pulses
Coolness & pallor skin, more w/ elevation
Ulcerations, atrophic nails, & hair loss
Increased BP
Burning pain in LE, more w/ elevation
Pain at rest?
Severe (80% 90%) occlusion
Calf cramp
↑by walking & ↓by rest
Artherosclerosis Ambulation
• The distance a person can walk before the
onset of pain indicates the degree of
circulatory inadequacy:
- ≥2 blocks: mild
- 1 block: moderate
- ≤½ block: severe
Aneurysm
• Localized dilatation or outpouching of the vessel.
• Common places:
– Abdominal aorta or iliac arteries, popliteal, femoral, & carotid.
• ~ 80% of the aneurysms are identified incidentally.
Aortic Dissection
• Caused by an intimal tear, which allows creation of
a false lumen between the media and adventitia.
• Twice as frequently in men than in women.
Aortic Dissection S&S
– Sudden pain in upper back migrates to the neck,
abdomen, or groin.
– Cardiogenic or hypovolemic shock.
– Syncope.
– Hypertension.
– Reduced or absent pulses.
– Pleural effusions
– Neurological manifestations (CVA).
Aortic Dissection Clinical Tip
– pain can mimic that of myocardial ischemia
Hypertension
- Elevated arterial blood pressure, both systolic & diastolic, that is abnormally sustained at rest.
- Frequently asymptomatic.
- Causes: genetic predisposition, smoking, type A personality, obesity, DM, atherosclerosis.
- Hypertensive crisis is a medical emergency.
Hypertention (Brain)
• Cerebrovascular accident
Hypertension (Eyes)
• Blurred or impaired vision
Hypertension (Heart)
- Myocardial infarction
- Congestive heart failure
- Myocardial hypertrophy
- Dysrhythmias
Hypertension (Kidneys)
- Renal insufficiency
- Renal failure
Hypertension
(PT Considerations)
- HTN is a risk factor for heart attack, stroke, & kidney failure
- Women typically have lower BP than men until after menopause
- Physical exertion increases BP acutely & decreases resting BP over time
- Knowledge of medication schedule may facilitate activity tolerance
- Review & clarify strict BP parameters by physician
- BP is high? check cuff size, take in the opposite side, then notify the team
- If contraindicated in the UEs, take it in the LE
Raynaud’s Disease
Symptoms that occur to exposure to cold and or emotional stress
Fingertip color change (white -> Blue-> Red) due vasoconstriction or occlusion
Raynaud’s Phenomenon: comes from other systemic disease like lupus. May not be able to be changed or reverse. Which can lead to atrophy, gangrene.
Complex Regional Pain Syndrome
- A disorder of the extremities characterized by autonomic & vasomotor instability.
- Constant, extreme pain after the healing phase of minor or major trauma, fractures, surgery.
Complex Regional Pain Syndrome Stages
Stage 1 (hrs to days): Pain, tenderness, edema, & temperature
Stage 2 (3 to 6 mo): Pain beyond the area, loss of hair & dystrophic nails, muscle wasting, osteoporosis, & ↓ROM.
Stage 3 (6 mo): Atrophy, functional impairment, & irreversible damage.
Compartment Syndrome
The circulation within a closed compartment is compromised by an increase in pressure within the compartment.
Causes necrosis of muscles & nerves and eventually of the skin.
Compartment Syndrome if left untreated can lead to …
–> Volkmann ischemic (necrotic muscle & nerve replaced w/ fibrous tissue).
Compartment Syndrome Cases/ Causes
– Fractures, crush injuries, hematomas, penetrating injuries,
circumferential burn injury, & electrical injuries.
– External factors: casts & circular dressings that are too constrictive.
Pressure that can cause Compartment Syndrome
Pressures of 32 to 37 mm Hg can cause compression of capillaries.
Normal pressure: 0-8 mmHg
Compartment Syndrome Permanent Damage time frame
– Muscles: after 4 to 12 hours.
– Nerves: after 8 hours.
Compartment Syndrome (PT Considerations)
- Edu on proper positioning
- When compartment syndrome is present
- Elevation most be discontinued
- Circumferential bandages must be removed
Venous Thrombosis
- Deep veins (femoral or iliac veins) or superficial (saphenous vein).
- Result from: venous stasis ( immobility ), endothelial injury, and hypercoagulability (inflammation, malignancy).
• Usually occurs in LE
Venous Thrombosis S&S
– Pain & swelling distal to the site of thrombus
– Redness & warmth in the area around the thrombus
– Dilated veins
– Low grade fever
– Dull ache or tightness in the region of DVT
How is Venous Thrombosis identified?
Ultrasonography
Venous Thrombosis Clinical Tip
PT intervention for pts w/ suspected DVT should be withheld until cleared by the medical surgical team.
Ways to prevent DVT
- Recommendations to prevent DVT:
- Early mobilization: low risk individuals.
- Anticoagulants: moderate to high risk.
- Postoperatively:
- Early ambulation, good hydration, calf muscles exercise
- Routine use of elastic stockings.
DVT Treatment
– Low molecular weight heparin (e.g., lovenox)
– If cannot be anticoagulated –> inferior vena cava (IVC) filter
Pulmonary Embolism
Moving DVT
A primary complication of venous thrombosis, emboli originating in the LE (75% to 90%).
Pulmonary Embolism S&S
- dyspnea
- CP
- hemoptysis
- tachypnea.
Pulmonary Embolism Clinical Tip
PT intervention should be discontinued immediately if the S&S of an acute PE arise during session.
Arteriovenous Malformations
Involve shunting (via arteriovenous fistula) of blood directly from the artery to the vein, bypassing the capillary bed.
Where do Arteriovenous Malformations occur?
Majority of AVMs occur in the trunk & extremities, (may present in the cerebrovascular region).
Arteriovenous Malformations Signs
– Skin color changes (erythema or cyanosis)
– Edema
– Limb deformity
– Skin ulceration
– Pulse deficit
– Bleeding
Anemia
- A significant reduction in the mass of circulating RBCs.
- Resulting in diminishing O2 binding capacity of blood.
Post
hemorrhagic Anemia
• Rapid blood loss from traumatic artery severance.
Post
hemorrhagic Anemia Percentage Loss
20% - 30% blood loss: Dizziness, hypotension, tachycardia w/ exertion.
30% - 40% blood loss: Thirst, dyspnea, diaphoresis, cold & clammy skin, hypotension, tachycardia, ↓urine output, clouding or LOC.
40% - 50% blood loss: Severe state of shock & potential death.
Post
hemorrhagic Anemia Management
control of bleeding, IV & oral fluid, blood transfusion, & supplemental O2.
Iron
Deficiency Anemia
Iron loss exceeds iron intake –> deplete body’s iron stores –> insufficient
iron for normal Hgb production.
The most common cause of anemia.
Iron
Deficiency Anemia S&S
– Easy fatigability , tachycardia, palpitations, & dyspnea on exertion.
– Dizziness, headache & irritability, dysphagia.
– Softening & spooning of nails, pale earlobes, & palms.
– May develop pica (craving to eat unusual substances, ex,
Iron
Deficiency Anemia Causes
deficient diet, pregnancy, lactation, menstrual, blood donation.
Iron
Deficiency Anemia Management
iron supplementation or nutritional counseling.
Polycythemia
- A chronic disorder characterized by excessive production of RBCs.
- Increase in blood volume, blood viscosity, and Hgb concentration –> excessive workload for the heart and congestion of some organs.
Polycythemia S&S
– Headache, dizziness, blurred vision, & vertigo.
– Venous thrombosis.
– Bleeding: nose, GI, & spontaneous bruising.
– Fatigue.
– Paresthesia in the hands and feet.
– Splenomegaly.
Polycythemia Management
phlebotomy (every 2 to 4 days, 250 - 500 ml)
Thrombocyte Disorders
Disseminated Intravascular Coagulation
Hemophilia
spontaneous bleeding
Thalassemia
Less than normal amount of hemoglobin. This can develop into clots
Thrombocytopenia
reduced amount of platelets
Heparin-Induced Thrombocytopenia
bleed easily
**Lymphedema
When venous is not able to work properly this will cause lymphatic system to be affected and causing fluid to stay stationary
Types of Lymphedema
- Primary (idiopathic) lymphedema
- Secondary (acquired) lymphedema.
Lymphedema S&S
– Swelling (usually not relieved by elevation)
– Pitting edema in early stages and nonpitting edema in later stages
– Fatigue & heaviness, tightness, tingling, & numbness
– Fibrotic changes in the skin
– Increased circumferential limb girth & loss of ROM
The International Society of Lymphology Scale
(lymphedema grade)
- Stage 0: Lymph transport capacity is reduced; no clinical edema is present. Pts may begin to feel heaviness in limb.
- Stage 1:
- Accumulation of protein rich pitting edema
- Reversible w/ elevation ; area affected may be normal in the
- Increases with activity, heat, & humidity.
- Stage 2:
- Accumulation of protein rich nonpitting edema w/ connective & scar tissue.
- Irreversible (does not resolve overnight; increasingly more difficult to pit)
- Clinical fibrosis is present
- Skin changes present in severe stage 2
- Stage 3:
- Accumulation of protein rich edema w/ significant ↑in connective & scar tissue
- Severe nonpitting fibrotic edema
- Atrophic changes (hardening of dermal tissue, skin folds, skin papillomas
Lymphedema Management
- Manual Lymphatic drainage: decreasing pressure as you go more proximal. Improves lymph transport capacity
- Lymphedema bandaging: multiple layers for supportive structure. Used in b/w manual lymphatic drainage
Anticoagulation Therapy
Heparin: prevent change in fibrin to fibrinogen. APPT- 30-40 sec. 60- 80 secs. Fast affect
Coumadin or warfarin: vit k antagonist to prevent clotting factors. INR- 2-3
Subtherapeutic
subtherapeutic: likely to clot / risk for thrombus
* Supertherapeutic
Likely to bleed/ hemorrhage. Pt needs to be given Vit k
Blood Product Transfusion
Blood & blood products are transfused to replenish blood volume, maintain O2 delivery , or maintain proper coagulation.
Blood Product Transfusion
(PT Considerations)
• You may defer out of bed or vigorous activities until the transfusion
is complete. A blood unit takes 3 to 4 hours.
• Defer PT intervention during the first 15 minutes.
• During a blood transfusion, vital signs are usually taken every 15 to
30 minutes by the nurse.
• After a blood transfusion, it takes 12 to 24 hours for the Hgb & Hct
to increase.
Embolization Therapy
• Purposely occluding a vessel with Gelfoam , coils, balloons, or
polyvinyl alcohol.
• Indications: disorders characterized by inappropriate blood
flow, such as AVMs.
Embolization Therapy Complications
- Tissue necrosis
- unintentional embolization of normal tissues
- Passage of embolic materials through arteriovenous communications
Transcatheter Thrombolysis
Dissolving clot w/ catheter with medicine
Transcatheter Thrombectomy
Transcatheter Thrombectomy: fewer complications catheter that removes or lyses clot
Peripheral Vascular Bypass Grafting
To reperfuse an area that has been ischemic from peripheral vascular disease.
Pts require ~ 24 to 48 hours to become hemodynamically stable, usually monitored in the ICU.
Peripheral Vascular Bypass Grafting Complications
- Hemorrhage
- Thrombosis
- Infections
- Renal failure
Aneurysm Repair & Reconstruction
Aneurysm Repair & Reconstruction Complications
- Hemorrhage
- Thrombosis
- Infection
- Renal Failure
Aneurysm Repair (PT Considerations)
- Inspect incision
- obtain weightbearing activity
*
Aortobifemoral Repair PT management goals
If fatigue is a problem make sure there is a wheel chair w/ you to make sure pt is safe.
PT Management (Vascular disorders)
• If being evaluated for possible aortic dissection , modify or defer
PT intervention until definite diagnosis is established.
• A thorough review of the medical history is needed before any edema management
PT management (Hematologic)
PT should monitor CBC & coagulation profile daily to determine:
- potential risk for bruising and bleeding
- thrombus formation
- altered O2 carrying capacity
PT management (Hematologic Disorders)
To gain insight into the hemostatic condition, determine:
– Whether the abnormal blood lab values are expected or consistent w/ the
pt’s medical surgical status.
– The relative severity (mild, moderate, or severe) of the abnormal laboratory
values.
– The pt’s presentation & clinical symptoms.
PT management Hemaologic Disorders
Monitoring of vital signs & O2 saturation at rest and with activity is crucial in pts with low H&H.
Determine the need to modify or defer PT intervention according to the lab values (particularly Hct , platelet, & PT/INR).
Thrombocytopenia Exercise Guidelines
- <10,000 mm 3
- Spontaneous CNS, GI, and/or respiratory tract bleeding
- <20,000 mm 3
- ADLs, AROM, & ambulation with physician approval
- 20,000 to 50,000 mm 3
- AROM & walking as tolerated, low intensity exercise (no resistance)
- 50,000 to 150,000
- Progressive resistive exercise, ambulation, or stationary bicycling (w/ resistance)
INR Scale
- INR <4
- Regular exercise program if allowed by physician.
- Advancing intensity should wait for the INR therapeutic range.
- INR 4-5
- Resistive exercises should be held (light exercise only).
- Unsteady gait addressed w/ appropriate AD. Precautions to avoid a fall.
- INR >5
- Mobilization depends on 1. pt’s presentation (age, PLOF, functional status, & medical condition). 2. medical intervention for the high INR. 3. institutional guidelines & the risk/benefit of PT.
- INR >6
- Medical team may consider bed rest until the INR is corrected (usually corrected in 2 days).
RBC Count Normal values
Female: 4.2 - 5.4 million/ul Male: 4.7 - 6.1 million/ul
WBC Count Normal values
5,000 - 10,000 uL
Hematocrit Count Normal values
Female: 37 - 47% Male: 42 - 52%
Hemoglobin Count Normal values
Female: 12 - 16 g/100 ml Male: 14 - 18 g/100 ml
Platelet Count Normal values
150,000 - 450,000 uL
