WEEK 2 (Stacy) Chapter 26 ppt: Assessment and Management of Patients with Vascular Disorders and Problems of Circulation

Question 1

Vascular System

Answer 1

Consists of two interdependent systems
o Right side of the heart pumps blood through
the lungs to the pulmonary circulation
o Left side of the heart pumps blood to all other
body tissues through the systemic circulation
Arteries and arterioles
Capillaries
Veins and venules
Lymphatic vessels

Question 2

Function of the Vascular System

Answer 2

Circulatory needs of tissues
Blood flow
Blood pressure
Capillary filtration and reabsorption
Hemodynamic resistance
Peripheral vascular regulating mechanisms

Question 3

Pathophysiology of the Vascular System

Answer 3

Pump failure
Alterations in blood and lymphatic vessels
Circulatory insufficiency of the extremities

Question 4

Gerontologic Considerations

Answer 4

Aging produces changes in the walls of the blood
vessels that affect the transport of oxygen and
nutrients to the tissues
Changes cause vessels to stiffen and results in:
o Increased peripheral resistance
o Impaired blood flow
o Increased left ventricular workload

Question 5

Assessment of the Vascular System

Answer 5

Health history
o Intermittent claudication,
o “Rest pain”
o Location of the pain
Physical assessment
o Skin (cool, pale, pallor, rubor, loss of hair,
brittle nails, dry or scaling skin, atrophy, and
ulcerations)
o Pulses

Question 6

Diagnostic Evaluation


Answer 6

Doppler ultrasound flow studies
o Ankle-brachial index (ABI)
Exercise testing
Duplex ultrasonography
Computed tomography scanning
Angiography and magnetic resonance
angiography
Contrast phlebography (venography)
Lymphoscintigraphy

Question 7

Continuous wave (CW) Doppler
Ultrasound

Answer 7

Photograph courtesy of Kim Cantwell-Gab, MN, ACNP, ANP.
Handheld ultrasound
device that detects blood
flow, combined with
computation of ankle or
arm pressures
Signals are reflected by
the moving blood cells
Diagnostic technique
helps characterize the
nature of peripheral
vascular disease

Question 8

Assessment of the Patient with Peripheral
Vascular Problems

Answer 8

Health history
Medications
Risk factors
Signs and symptoms of arterial insufficiency
Claudication and rest pain
Color changes
Weak or absent pulses
Skin changes and skin breakdown

Question 9

Planning and Goals for the Patient with
Peripheral Vascular Problems

Answer 9

Major goals include:
o Increased arterial blood supply
o Decrease in venous congestion
o Promotion of vasodilatation and prevention of
vascular compression
o Relief of pain
o Attainment/maintenance of tissue integrity
o Adherence to the self-care program

Question 10

Improving Peripheral Arterial Circulation

Answer 10

Positioning strategies—body part below the level
of the heart
Exercise program and activities: walking, graded
isometric exercises
o Consult primary provider before engaging in
an exercise routine
Temperature; effects of heat and cold
Discourage use of nicotine
Stress reduction

Question 11

Arterial Disorders

Answer 11

Arteriosclerosis and atherosclerosis
Peripheral artery disease
Upper extremity arterial disease
Aortoiliac disease
Aneurysms (thoracic, abdominal, other)
Aortic dissection
Arterial embolism and arterial thrombosis
Raynaud’s phenomenon and other acrosyndromes

Question 12

Arteriosclerosis and Atherosclerosis

Answer 12

Arteriosclerosis
o Hardening of the arteries
o Diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened
Atherosclerosis
o Different process, affecting the intima of large and
medium-sized arteries
o Accumulation of lipids, calcium, blood
components, carbohydrates, and fibrous tissue on
the intimal layer of the artery
o Atheromas or plaques

Question 13

Risk Factors for Atherosclerosis and PAD

Answer 13

Modifiable
Nicotine use
Diabetes
Hypertension
Hyperlipidemia
Diet
Stress
Sedentary lifestyle
C-reactive protein
Hyperhomocysteinemia

Nonmodifiable
Increasing age
Familial
predisposition/genetics

Question 14

Peripheral Artery Disease (PAD)

Answer 14

Hallmark symptom is intermittent claudication
described as aching, cramping, or inducing
fatigue or weakness
Occurs with some degree of exercise or activity
Relieved with rest
Pain is associated with critical ischemia of the
distal extremity and is described as persistent,
aching, or boring (rest pain)
Ischemic rest pain is usually worse at night and
often wakes the patient

Question 15

Pharmacologic Therapy for PAD

Answer 15

Phosphodiesterase III inhibitor
o Cilostazol
Antiplatelet agents
o Aspirin
o Clopidogrel
Statins

Question 16

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

Answer 16

C. Keep the lower extremities in a neutral or
dependent position
Rationale: For patients with PAD, blood flow to the
lower extremities needs to be enhanced; therefore,
the nurse encourages keeping the lower extremities
in a neutral or dependent position. In contrast, for
patients with venous insufficiency, blood return to
the heart needs to be enhanced, so the lower
extremities are elevated. Exercise can be prescribed
to aid in the development of collateral circulation.
Some pain is associated with PAD.

Question 17

Aneurysms

Answer 17

Localized sac or dilation formed at a weak point in
the wall of the artery
Classified by its shape or form
Most common forms of aneurysms are saccular
and fusiform
o Saccular aneurysm projects from only one
side of the vessel
o When an entire arterial segment becomes
dilated, a fusiform aneurysm develops

Question 18

Raynaud’s Phenomenon

Answer 18

Intermittent arterial vasoocclusion, usually of the
fingertips or toes
o Raynaud’s disease: primary or idiopathic
o Raynaud’s syndrome: associated with other
underlying disease such as scleroderma
Manifestations: sudden vasoconstriction results in
color changes, numbness, tingling, and burning pain
Episodes brought on by a trigger such as cold or stress
Occurs most frequently in young women
Protect from cold and other triggers. Avoid injury to
hands and fingers

Question 19

Venous Disorders

Answer 19

Venous thromboembolism (VTE) condition
o DVT and PE
Chronic venous insufficiency/postthrombotic
syndrome
Leg ulcers
Varicose veins

Question 20

Venous Thromboembolism

Answer 20

Pathophysiology
Risk factors
Endothelial damage
o Venous stasis
o Altered coagulation
Manifestations
o Deep veins
o Superficial vein

Question 21

Preventive Measures

Answer 21

Early ambulation and leg exercises
Graduated compression stockings
Intermittent pneumatic compression devices
Subcutaneous heparin or LMWH
Lifestyle changes
o Weight loss
o Smoking cessation
o Regular exercise

Question 22

Question #2
Which patient is at highest risk for venous
thromboembolism?
A. A 50-year-old postoperative patient
B. A 25-year-old patient with a central venous
catheter in place to treat septicemia
C. A 71-year-old otherwise healthy older adult
D. A pregnant 30-year-old woman due in 2 weeks

Answer 22

Answer to Question #2
B. A 25-year-old patient with a central venous
catheter in place to treat septicemia
Rationale: Some risk factors for venous
thromboembolism include but are not limited to age
older than 65 years, patients undergoing surgery,
central venous catheter placement, septicemia, and
pregnancy. The client in this question with two risk
factors is the 25-year-old with a central venous
catheter in place to treat septicemia. All other
patients only have one risk factor.

Question 23

Assessment of the Patient with Leg Ulcers

Answer 23

History of the condition
Assess pain, peripheral pulses, edema
Treatment depends on the type of ulcer
Assess for presence of infection
Assess nutrition

Question 24

Medical Management of the Patient with
Leg Ulcers

Answer 24

Anti-infective therapy depends on the infecting
agent
o Oral antibiotics are usually prescribed
Compression therapy
Débridement of wound
Dressings
Other

Question 25

Collaborative Problems and Potential
Complications of the Patient with Leg Ulcers

Answer 25

Infection
Gangrene

Question 26

Nursing Interventions for the Patient with
Leg Ulcers

Answer 26

 Restoring skin integrity
o Cleansing wound; positioning; avoiding trauma; avoid
heat sources
 Improving physical mobility
o Physical activity initially restricted to promote healing;
gradual progression of activity
o Activity to promote blood flow; encourage patient to
move about in bed and exercise upper extremities
o Diversional activities
o Analgesic agents before scheduled activities
 Promoting adequate nutrition
o Protein; Vitamins C and A; Iron; Zinc

Question 27

Varicose Veins

Answer 27

Prevention
o Avoid activities that cause venous stasis (wearing
socks that are too tight at the top or that leave
marks on the skin, crossing the legs at the thighs,
and sitting or standing for long periods)
o Elevate the legs 3 to 6 inches higher than heart
level
o Encourage to walk 30 minutes each day if there
are no contraindications
o Wear graduated compression stockings
o Overweight patients should be encouraged to
begin weight reduction plans

Question 28

Lymphatic Disorders

Answer 28

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
o Primary: congenital
o Secondary: acquired obstruction

Question 29

Question #3
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 the sun

Answer 29

B. Constant elevation of the affected extremity
Rationale: Constant elevation of the affected
extremity and observation for complications are
essential. After surgery, antibiotics may be
prescribed for 3 to 7 days. The patient is instructed
to avoid the application of heating pads or exposure
to sun to prevent burns or trauma to the area.

Question 30

Cellulitis

Answer 30

S&S: localized swelling or redness, fever, chills,
sweating
Treat with oral or IV antibiotics based on severity
Nursing
o Elevate affected area 3 to 6 inches above
heart level
o Warm, moist packs to site every 2 to 4 hours
o Educate regarding prevention of recurrence
o Reinforce education about skin and foot care

Question 31

Peripheral Arterial Occlusive Disease (PAD)

Answer 31

▶ Hallmark Sign: Intermittent Claudication
▶ Elevation Pallor and Dependant Rubor
▶ Symptomatic Claudication
▶ Pentoxifylline and Cilostazol
▶ Antiplatelets
▶ Statins

Question 32

Diagnostics Review:

Answer 32

▶ Ankle-Brachial Index
▶ Doppler Ultrasound
▶ Duplex Ultrasonography
▶ Computed Tomography (CT) Scanning
▶ Angiography
▶ Magnetic Resonance Angiography (MRA)
▶ Contrast Phlebography (Venography)
▶ Lymphoscintigraphy

Question 33

PAD Management

Answer 33

▶ Radiologic Intervention
▶ Balloon Angioplasty
▶ Stent
▶ Stent graft
▶ Atherectomy
▶ Surgical Management
▶ Bypass Graft (50% or more occlusion)

Question 34

Critical Limb Ischemia

Answer 34

▶ Severe obstruction
▶ Pain at rest
▶ Non Healing wounds
▶ Gangrene

Question 35

Upper Extremity Arterial Occlusive Disease

Answer 35

▶ Coolness and Pallor
▶ Stent or Stent Graft
▶ Percutaneous Transluminal Angioplasty (PTA)
▶ Bilateral BP Comparison

Question 36

Aortic Aneurysms

Answer 36

▶ Aneurysm
▶ Abdominal
▶ Thoracic

Question 37

Dissecting Aorta

Answer 37

▶ Dissection
▶ Severe pain
▶ Nausea and vomiting
▶ Tearing feeling
▶ Pulsating abdomen

Question 38

Arterial Embolism and Thrombosis

Answer 38

▶ Acute Vascular Occlusion
▶ Arterial Emboli
▶ Acute Thrombosis
▶ Acute Arterial Occlusion
▶ Iatrogenic Causes
▶ IV Drug Use
▶ Trauma

Question 39

Raynaud’s Phenomenon

Answer 39

▶ Microvascular vasoconstriction
▶ Coolness, pain, pallor
▶ Avoid stimuli
▶ Calcium channel blockers

Question 40

Venous Thromboembolism (VTE)

Answer 40

▶ Deep Vein Thrombosis
▶ Pulmonary Embolism

Question 41

Chronic Venous Insufficiency /
Postthrombotic Syndrome

Answer 41

▶ Obstruction of valves
▶ Reflux of blood
▶ Superficial or deep veins
▶ Prolonged venous pressure
▶ Increased risk of infection / injury
▶ Treatment:
▶ Leg elevation
▶ Compression stockings

Question 42

The Six P’s of Acute Arterial Occlusion

Answer 42

▶ Pain
▶ Pallor
▶ Poikilothermia
▶ Pulselessness
▶ Paresthesia
▶ Paralysis
Why are these symptoms occurring?

Question 43

Varicose Veins

Answer 43

▶ Abnormally dilated and tortuous
▶ Primary (no deep vein involvement)
▶ Secondary (obstruction of deep veins)
▶ Ligation and Stripping
▶ Micro Phlebectomy

Question 44

Lymphatic Disorders

Answer 44

▶ Lymphangitis
▶ Lymphadenitis
▶ Lymphedema
▶ Elephantiasis

Question 45

How is a DVT diagnosed?

Answer 45

▶Medical History
▶Physical Exam
▶Test Results

Question 46

Venous Ultrasound RLE

Answer 46

Ultrasound uses high frequency sound waves to
create pictures and measure the amount of
blood flow through your veins.

Question 47

DVT Medications: Why? Priority Assessments?

Answer 47

▶ Anticoagulation:
▶ Heparin Subcutaneous x 5 days
▶Normal vs. Therapeutic Level
▶q 6 hours initially
▶Reversal Agent
▶ Warfarin PO
▶Normal vs. Therapeutic Level
▶Bridge Therapy
▶Reversal Agent

Question 48

Anticoagulation Therapy

Answer 48

Heparin
▶ Test: aPTT
▶ Normal Range: 20 - 39 seconds
▶ Therapeutic Range: 30 - 100 seconds
▶ Reversal Agent: Protamine Sulfate

Warfarin
▶ Test: INR
▶ Normal Range: 1 or less
▶ Therapeutic Range: 2.0 - 3.5
▶ Reversal Agent: Vitamin K

Question 49

Focused Assessment:

Answer 49

▶ BP = 100/64
▶ HR = 110
▶ RR = 24
▶ Bibasilar Crackles on Auscultation
▶ Labored Breathing
▶ Restless in Obvious Distress

Question 50

Nursing Diagnosis

Answer 50

▶ Risk for Impaired Gas Exchange
▶ Altered Peripheral Tissue Perfusion
▶ Knowledge Deficient
▶ Risk for Bleeding
▶ Acute Pain

Question 51

Discharge Education

Answer 51

▶ Medications: Compliance, Risks, Monitoring
▶ Signs & Symptoms of Bleeding (r/t Anticoags)
▶ Signs & Symptoms of Recurrent Pulmonary
Embolism
▶ CP & SOB

Question 52

Let’s recap the risk factors for a DVT/PE

Answer 52

▶ Sedentary Lifestyle
▶ Recent sedentary behavior
▶ Travel
▶ Prolonged bed rest
▶ Surgery
▶ Heart Failure
▶ Birth Control or Hormone Supplementation
▶ Smoking
▶ Obesity
▶ Pregnancy
▶ Cancer
▶ Genetic Clotting Disorders