Week #5: Peripheral Vascular & Lymphatic Flashcards
The 6-Ps of arterial occlusion include which of the following? Select all that apply.
a) Pulselessness
b) Pain
c) Paresthesia
d) Pilonidal
e) Pilocarpine
f) Pallor
a) Pulselessness
b) Pain
c) Paresthesia
f) Pallor
While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this?
a) 4+ pitting edema
b) 3+ pitting edema
c) 2+ pitting edema
d) 1+ pitting edema
b) 3+ pitting edema
A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?
a) Deep vein thrombosis (DVT)
b) Varicose vein
c) Lymphedema
d) Pulmonary embolism (PE)
a) Deep vein thrombosis (DVT)
What pulse is located in the groove between the medial malleolus and the Achilles tendon?
a) Dorsalis pedis
b) Posterior tibial
c) Popliteal
d) Femoral
b) Posterior tibial
During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that the client described pain at the ulcer site as achy. The nurse suspects the client may have what?
a) Intermittent claudication
b) Hypertrophic changes
c) Arterial insufficiency
d) Venous insufficiency
d) Venous insufficiency
When assessing the lower extremities, its critical that the examiner:
a) Starts at the femoral area
b) Evaluates the venous system and then the arterial system
c) Starts at the feet
d) Compares side to side
d) Compares side to side
The nurse assessing the clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?
a) The extremity has an easily palpable, strong pulse
b) The borders are irregular
c) The ulcer is superficial and pink
d) The ulcer is necrotic
d) The ulcer is necrotic
Maintaining fluid balance is one function of the lymphatic system.
a) True
b) False
a) True
One extremity cooler than the other indicates arterial insufficiency.
a) True
b) False
a) True
A client comes to the clinic reporting pain in her legs while walking. The client states the pain goes away when resting. The nurse suspects the client is experiencing what?
a) Deep vein thrombosis
b) Pulmonary embolism
c) Intermittent claudication
d) Varicose veins
c) Intermittent claudication
Brownish discoloration in the “gaiter” or ankle area.
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
b) Chronic venous insufficiency (CVI)
Ulcer borders are regular
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
a) Peripheral arterial disease (PAD)
Edema in extremity
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
b) Chronic venous insufficiency (CVI)
Pain is relieved when extremity is elevated
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
b) Chronic venous insufficiency (CVI)
Pain is relieved when extremity is in the dependent position
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
a) Peripheral arterial disease (PAD)
Claudication is often seen
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
a) Peripheral arterial disease (PAD)
Extremity normal in size or with apparent atrophy
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
a) Peripheral arterial disease (PAD)
Ulcer borders are irregular
a)Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)
b) Chronic venous insufficiency (CVI)
Pulse found halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament.
Femoral
Pulse best palpated with your fingers braced on the knee, circling your hands around the back of the knee and pressing against the lower edge of the femur. Might be felt immediately lateral to the medial tendon (often difficult to locate).
Popliteal
Pulse found approximately at the inner third of the antecubital fossa when the palm is held upward.
Brachial
Pulse found in the groove between the medial malleolus and Achilles tendon.
Posterior tibial
Pulse found approximately halfway up the foot immediately lateral to the extensor tendon of the great toe.
Dorsalis Pedis
Pulse found on the thumb side of the forearm at the wrist.
Radial
Monthly assessment of the feet is essential for patients with peripheral arterial disease (PAD).
a) True
b) False
b) False
The more distal a vein is, the lower the number of valves, because the pull of gravity is stronger.
a) True
b) False
b) False
Arterioles have more smooth muscle, and it is here that blood pressure is controlled.
a) True
b) False
a) True
Arteriosclerosis is seen more in the older adult.
a) True
b) False
a) True
Venous insufficiency may result in dilated and tortuous veins.
a) True
b) False
a) True
The _____________ maintains fluid and protein balance and functions with the immune system to fight infection.
Lymphatic system
If untreated, ______________ may progress and result in irreversible tissue enlargement.
Fibrosis
___________________, diabetes, and hyperlipidemia are cardiovascular risk factors with strong genetic components.
Hypertension
A blood clot that travels from the legs to the lungs is called a __________________.
Venous Thromboembolism (VTE)
The serum ___________ is assessed in the patient with a possible DVT.
D-dimer
Chronic venous insufficiency, deep vein thrombosis, and lymphedema result in ______________.
Edema
What are the 7-P’s of peripheral artery disease?
- Pain
- Pallor
- Polar
- Paresthesia
- Pulselessness
- Paralysis
- Perfusion
What are 3 signs of a DVT?
Pain, edema, and warmth of an extremity
List the scale for edema and how you would classify edema in each.
+1: slight pitting, 2-mm depression
+2: increased pitting, 4-mm depression
+3: deeper pitting, 6-mm depression; obvious edema of extremity
+4: severe pitting, 8-mm depression; extremity appears very edematous
Pain brought on by exertion and relieved by rest
Intermittent Claudication
Name 3 nursing diagnoses associated with the peripheral vascular system:
- Ineffective peripheral tissue perfusion
- Risk for impaired peripheral neurovascular function
- Activity intolerance
What is the normal ankle-brachial index (ABI) range?
1-1.40: Normal
0.91-0.99: Borderline
Less than 0.90: Abnormal
Greater than 1.40: Noncompressible arteries
