VASCULAR STRESSORS

ANATOMY &
PHYSIOLOGY
ARTERIES WALLS ARE
THICKER DUE TO GREATER
SMOOTH MUSCLE, HENCE
STRONGER & CAN
WITHSTAND HIGH PRESSURE

ANATOMY &
PHYSIOLOGY
PHYSICAL PRINCIPLES THAT
DETERMINE BLOOD FLOW
1.
2.

PRESSURE CREATED BY
PUMPING OF HEART
RESISTANCE OF BLOOD
PUMPED (PVR) PERIPHERAL
VASCULAR RESISTANCE
(CHANGE IN VESSEL RADIUS)

ARTERIAL DISORDERS
SUSTAINED HIGH ARTERIAL PRESSURE
INCREASES THE EFFECTS OF INJURY AND
DISEASE
EFFECTS OF ARTERIAL DISEASE CAUSES
TISSUE ISCHEMIA DEATH OF TISSUE
SEVERITY OF SYMPTOMS IS DEPENDENT
UPON METABOLIC RATE & TISSUE NEEDS
SURGERY MAY RE-ESTABLISH CIRCULATION

ARTERIAL
ASSESSMENT
PURPOSE: TO DETERMINE
ADEQUATE TISSUE PERFUSION
GUIDE LINES
1. COMPARE UPPER & LOWER
2. COMPARE BILATERALLY
3. COMPARE DISTAL & PROXIMAL
4. SUPINE (VS) DEPENDENT
CHANGES

ARTERIAL
ASSESSMENT

1.
2.
3.

MAJOR AREAS OF
ASSESSMENT
CIRCULATION PULSE MEANS
PERFUSION
MOTION MUSCLES NEED
OXYGEN
SENSATION PAIN, BURNING,
PROPRIOCEPTION, NUMBNESS

ARTERIAL
ASSESSMENT

CIRCULATION

CHECK PULSE POINTS

CAROTID
RADIAL
FEMORAL
DORSALIS PEDIS
POSTERIOR TIBIAL
CAPILLARY REFILL

ARTERIAL
ASSESSMENT
PULSES ARE BASED ON A SCALE
0 to 4+
0 = NO PULSE
1+ = THREADY PULSE
2+ = NORMAL PULSE
3+ = BOUNDING PULSE
4+ = ANEURYSM

ARTERIAL
ASSESSMENT

ARTERIAL INSUFFICIENCY

1.

SKIN COOL, SHINY THIN, ONION

LIKE
PAIN /W COLD
PALE /W ELEVATION
DISTAL PULSES OR ABSENT
DECREASED OR ABSENT HAIR
ISCHEMIC ULCERS
THICK NAILS

2.
3.
4.
5.
6.
7.

COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
DUPLEX ULTRASOUND
HELPS Dx NARROWING OR
OCCULUSION OF INTERNAL
CAROTIDS or DVT
FALSE (+) DUE
NO PATIENT PREP TO
PAINLESS & SAFE CALCIFICATION
OF VESSELS
SUPINE POSITION

COMMON DIAGNOSTIC
VASCULAR TESTS
NON-INVASIVE TECHNIQUES
SEGMENTED ARTERIAL PRESSURE
MONITORING
MEASURES PRESSURE DIFFERENCE
BETWEEN EXTREMITIES AT DIFFERENT
LEVELS
USES B/P MONITOR & DOPPLER

ANKLE/BRACHIAL
INDEX
EXAMPLE:
BRACHIAL PRESSURE =120mmHg
ANKLE PRESSURE = 96mmHg
ABI = 96 / 120 = 0.8

NORMAL

0.9 - 1.2

RISK IS LOW

VASCULAR
DISEASE

0.6 0.9

SEVERE
DISEASE

< 0.5

MODERATE
RISK EXISTS
VERY HIGH
RISK EXISTS

ARTERIAL
ASSESSMENT

CLAUDICATION
INTERMITTANT CRAMPING OF
SKELETAL MUSCLES WITH
EXERCISE
STANDARD ABLE TO WALK ONE
CITY BLOCK W/O PAIN
(+) = PAIN WITH AMBULATION,
PAIN WITH ELEVATION, RELIEF
WITH DEPENDENT POSITION
Tx: pentoxyphylline (Trental)
cilostazol (Pletal)

ACUTE ARTERIAL
INSUFFICIENCY
THE 5 Ps
WHEN PRESENT = SURGICAL
EMERGENCY!
1. PAIN
2. PALLOR
3. PULSELESSNESS
4. PARALYSIS
5. PARESTHESIA

COMMON DIAGNOSTIC
VASCULAR TESTS

ANGIOGRAPHY (ANGIOGRAM)
INVASIVE TECHNIQUE USED
WHEN SURGICAL INTERVENTION
IS BEING CONSIDERED
USED TO DIAGNOSE
EMBOLI, THROMBOSIS, TRAUMA,
ANEURYSM, BUERGERS DISEASE,
ARTERIOSCLEROSIS

ARTERIAL DISORDERS
ARTERIAL SYSTEM PROBLEMS
CAN BE CONTROLLED BY
MODIFYING RISK FACTORS:
SMOKING
DIET
GLUCOSE CONTROL
ACTIVITY LEVEL
HYPERLIPIDEMIA
BP (DOUBLES RISK)

WHEN ARTERIES
BECOME OCCLUDED
HEALTHY ARTERIES ARE BLOOD
VESSELS WHICH ARE FLEXIBLE,
STRONG & ELASTIC
THEIR INSIDE LINING IS
SMOOTH SO BLOOD CAN FLOW
WITHOUT RESTRICTION
Risk Factors cause arteries to
become occluded.

Progression of Occlusion

PLAQUE DEPOSIT
ORIGINAL DIAMETER

ARTERIAL DISORDERS
PERIPHERAL ARTERIAL
INSUFFICIENCY / OCCLUSION
ASSESSMENT:
WEAK/ ABSENT PULSES
PAIN /W LEG ELEVATION
SKIN COOL TO TOUCH
PALE SKIN COLOR
THICKENED TOENAILS

ARTERIAL DISORDERS
GOALS:
1. IMPROVE PERIPHERAL
ARTERIAL CIRCULATION WITH
EXERCISE
REGULAR EXERCISE SUCH AS
WALKING INCREASES
CIRCULATION

ARTERIAL DISORDERS
GOALS:
2. PREVENT VASCULAR
COMPRESSION
AVOID RESTRICTIVE CLOTHING,
CROSSING LEGS, SITTING FOR
PROLONGED PERIODS

ARTERIAL DISORDERS
GOALS:
3. RELIEVE PAIN
CONSIDER ANALGESICS SO
PATIENT CAN PARTICIPATE IN
ACTIVITIES

ARTERIAL DISORDERS
GOALS:
4. MAINTAIN TISSUE INTEGRITY

AVOID TRAUMA, WEAR

CORRECT
SHOE GEAR (NO
BARE FEET!)
TEST WATER TEMP WITH HAND
NOT FOOT!
REGULAR PODIATRY CARE
GOOD NUTRITION

ANGIOPLASTY

BALLOON
ANGIOPLASTY
CATHETER
INSERTED
THROUGH AN
ARTERY
BALLOON IS
INFLATED AND
COMPRESSES
LESION

USED FOR
INSERTION OF
STENTS

ANGIOPLASTY

MEDICAL
MANAGEMENT
THROMBOLYTIC THERAPY
USED TO DISSOLVE CLOTS:
Retavase, streptokinase, tPa
SURGICAL MANAGEMENT
1. GRAFTING BYPASS SURGERY
2. ENDARTERECTOMY REMOVAL
OF ATHEROSCLEROTIC PLAQUE
3. AORTO/FEMORAL/TIBIAL BYPASS

NURSING DX/ ARTERIAL

DISORDERS & GOALS
1.

2.

ALTERED PERIPHERAL TISSUE

PERFUSION
( ARTERIAL BLOOD FLOW)
GOAL: MAXIMIZE TISSUE
PERFUSION
ACTIVITY INTOLERANCE
VASCULAR SUPPLY CAN NOT KEEP
UP WITH TISSUE DEMANDS
GOAL: MANAGE ACTIVITY WITHIN
LIMITATIONS

NURSING DX/ ARTERIAL

DISORDERS & GOALS
3.

ANTICIPATORY GRIEVING RELATED

TO POTENTIAL LOSS OF LIMB
GOAL: EXPRESS CONCERNS

4.

BODY IMAGE DISTURBANCE AS

RELATED TO LOSS OF BODY PART
GOAL: DISCUSS IMAGE & OPTIONS

NURSING DX/ ARTERIAL

DISORDERS & GOALS
5.

6.

IMPAIRED TISSUE INTEGRITY

AS RELATED TO CIRCULATION
GOAL: MAINTAIN TISSUE
INTEGRITY
KNOWLEDGE DEFICIT OF SELF
CARE ACTIVITIES
GOAL: EDUCATE PATIENT

NURSING DX/ ARTERIAL

DISORDERS & GOALS
7.

PAIN DUE TO ISCHEMIA

8.

GOAL: RELIEVE PAIN

POTENTIAL FOR INJURY DUE TO
SENSATION
GOAL: EDUCATE PATIENT TO INSPECT
FOR INJURY, WATCH FOR TRAUMA

9.

SLEEP PATTERN DISTURBANCE DUE TO

REST PAIN
GOAL: MAXIMIZE SLEEP

NURSING
INTERVENTIONS
1.

RISK FACTOR MODIFICATION

SMOKING (Most significant RISK
FACTOR)
NICOTINE CAUSES VASOSPASMS
WEIGHT LOSS
REDUCES WORKLOAD IN
EXTREMITIES
LOW FAT DIET WILL RETARD
PROGRESSION OF ATHEROSCLEROSIS
CONTROL HTN

NURSING
INTERVENTIONS
2.

PAIN MANAGEMENT
INTENSITY IS VARIABLE
MANAGEMENT- RTC
PAIN MEDICATION
(MAY NOT BE EFFECTIVE)
DEPENDENT POSITION MAY

COMFORT

NURSING
INTERVENTIONS
3.

MAINTAIN FLUID VOLUME

IN SEVERE STENOSIS PATIENT MUST
MAINTAIN SUFFICIENT BLOOD
PRESSURE TO AVOID COMPLETE
OCCLUSION

NURSING
INTERVENTIONS
4.

ACTIVITY
MONITOR CLAUDICATION
TEACH PATIENT PAIN IS NOT
HARMFUL, BUT A BODY SIGNAL FOR
NEED TO REST
EMPHASIZE: EXERCISE INCREASES
COLLATERAL CIRCULATION
CHECK WITH DOCTOR ABOUT ANY
EXERCISE
PROGRESSION SHOULD BE GRADUAL

NURSING
INTERVENTIONS
5.

MAINTAINING TISSUE INTEGRITY

CHANGE POSITION FREQUENTLY
AVOID CROSSING LEGS
& CONSTRICTIVE CLOTHING
METICULOUS FOOT CARE
(PODIATRIST)
PROTECT FROM INJURY
KEEP EXTREMITIES WARM
(NO HEATING BLANKET OR HOT WATER
BOTTLES!)

SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY- Postop
NEUROVASCULAR ASSESSMENT
COMPLICATIONS

GRAFT OCCLUSION:THROMBOSIS
COMPARTMENT SYNDROME
GRAFT INFECTIONS
FISTULA/ULCER FORMATION

EDUCATE PATIENT TO

REPORT PAIN UNRELIEVED BY MEDS

STOP SMOKING
ID NORMAL HEALING PROCESS

SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY
POSITIONING
KEEP LOWER EXTREMITY LEVEL
AND AVOID CONSTRICTION
AVOID DEPENDENT POSITION
WHICH s EDEMA , PAIN &
HEALING
MOBILITY IS PROGRESSIVE

ARTERIAL DISEASES
BUERGERS DISEASE
[TAO]
(aka: Thromboangiitis Obliterans)
1. DISEASE IS LINKED DIRECTLY TO
SMOKING (REQUIRED HX FOR DX)
2. POSSIBLE IMMUNOPATHOGENESIS
3. INFLAMMATION PRODUCES CRITICAL
LIMB ISCHEMIA
4. DISEASE CAN PROGRESS PROXIMALLY

Raynauds Disease
VASOSPASTIC DISORDERS:
1. BLOOD VESSELS (FINGERS & TOES)
GO INTO SPASM
2. EXTREME SENSITIVITY TO TEMP
CHANGES (ESPECIALLY COLD)
3. MORE COMMON FEMALE > MALE
4. Color changes are Red/White/Blue

RAYNAUDS
CLASSIFIED:
1. RAYNAUDS DISEASE = WHEN
SYMPTOMS ARE THE ONLY
PRESENTING FACTOR
2. RAYNAUDS PHENOMENON = WHEN
SYMPTOMS ARE SECONDARY TO
ANOTHER CONDITION
EX: RA, SCLERODERMA, LUPUS, CARPAL
TUNNEL SYDROME, THORACIC OUTLET
SYNDROME

RAYNAUDS
DX:
1. BILATERAL
2. OCCURS X 2 YEARS
3. NO OTHER CAUSE

Prevention:
1. PROTECT FROM COLD EXPOSURE
2. AVOID EXCESSIVE EMOTIONAL
STRESS

ANEURYSM
ANEURYSM = AN
LOCALIZED
ABNORMAL
DILATION OF A
BLOOD VESSEL
HIGH RISK
IN
MARFANS
SYNDROME

Abdominal Aortic
Aneurysm:Pathophysiology
Aneurysm-permanent localized
dilation of an artery
-enlarges to 2x normal
diameter
-middle layer of artery is
weakened
-HTN produces more
tension and enlargement within
the artery

AORTIC ANEURYSMS
Location: Thoracic
Abdominal aortic aneurysms
Etiology:
Atherosclerosis (+HTN & smoking)
Syphillis
Marfan Syndrome
Ehlers-Danlos syndrome

AAA Assessment
Upper abdomen pulsation, left of
midline
+ bruit over mass
Abdominal, flank or back
pain- if leaking or ruptured
Abd Xray- Eggshell Calcification
Cat scan
Aortic angiography
Ultrasonography

Interventions
Nonsurgical
Surgical- AAA Resection
- Endovascular stent graft

Post-op care of the AAA patient:

VENOUS
ANATOMY &
PHYSIOLOGY
VEINS HAVE THIN WALLS
(LESS SMOOTH MUSCLE)
ALLOW VESSELS TO
DISTEND MORE THAN
ARTERIES

Venous System
ANATOMY &
PHYSIOLOGY
BLOOD FLOWS AGAINST
GRAVITY BECAUSE:
VALVES ONE WAY VALVES
PREVENT BACKFLOW. (VALVE
COMPETENCY DEPENDS UPON
INTEGRITY OF VEIN WALL)
MUSCLE CONTRACTION MILKS
BLOOD THROUGH VESSELS

VENOUS ASSESSMENT

VENOUS INSUFFICIENCY

DRY, FLAKY
(BROWN & BLOTCHY)
2. PURPLE DEPENDENT
3. ELEVATION s DEPENDENT
EDEMA
4. EDEMA MAY OBLITERATE PULSES
5. VENOUS STASIS ULCERS
6. PARESTHESIAS
1.

Disorders of Venous
Circulation

PHLEBITIS-Vein
inflammation

THROMBOPHLEBITIS
INFLAMMATION OF
WALLS OF VEINS WITH
CLOT FORMATION

PHLEBOTHROMBOSIS
CLOT DEVELOPS DUE
TO VENOUS STASIS
OR THICK BLOOD
HYPERCOAGUABILITY
& INFLAMMATION

DVT- Deep Vein

Thrombosis

VENOUS DISORDERS
VIRCHOWS TRIAD
PREDISPOSING FACTORS
a)
b)

c)

VENOUS STASIS Bedrest, BP,

HYPOVOLEMIA,
HYPERCOAGULABILITY
CANCER,SMOKING, POLYCYTHEMIA,
SURGERY, SEPSIS, OC
ENDOTHELIAL DAMAGE STIMULATES
PLATELET AGGREGATION, VENOUS
INFLAMMATION

VENOUS DISORDERS
Other Risk Factors
d)
e)

f)
g)
h)
i)
j)
k)

IMMOBILIZATION PARALYSIS, PROLONGED

BEDREST, LONG PLANE OR CAR RIDES
DISEASE PROCESSES SEPSIS,
SLE,HEMATOLOGICAL DISORDERS,
MS,MALIGNANCY, CHF, MI, ULCERATIVE COLITIS
PRESSURE OBESITY, PREGNANCY, TUMOR
TRAUMA FRACTURES, VENIPUNCTURE
CLOTTING DYSFUNCTION
SURGICAL PROCEDURES HIP, GYN &
UROLOGICAL & in age >40
OC use- especially in women who smoke
OTHER DEHYDRATION, ADVANCED AGE

VENOUS DISORDERS
DEEP VENOUS THROMBOSIS
(DVT)
1. PATHOPHYSIOLOGY DEEP VEIN
CLOT MOST COMMON IN LOWER LEG
(CALF)
UNDIAGNOSED DVT OCCURS IN 50%
OF PATIENTS WITH PULMONARY
EMBOLI

Assessment of DVT
S&S
-Calf or groin tenderness
-Pain that can be dull or aching, especially when
walking
-Sudden onset of unilateral swelling of the leg
-Cyanosis of the affected extremity
-Slightly elevated temp
-General malaise

Assessment of DVT
Homans Sign-pain on dorsiflexion of foot
NO LONGER ADVISED-can increase the risk
of detaching the thrombus as the calf
muscle contract
Coag studies
D Dimer-increased values with venous
thrombosis, PE, DIC and Malignancy
Duplex Scan

INTERVENTIONS
*Bedrest and leg elevation
*Warm moist soaks may be ordered
*Evaluate for PE
*Anti-inflammatory drugs for superficial
thrombophlebitis ASA or NSAIDS
*Heparin therapy
*Warfarin (Coumadin)

Heparin Therapy
1.Prior to initiation of therapy:
Hx of bleeding disorders
CBC w/ platelet count
UA
Stool for occult blood
Creatinine level
PTT,PT, INR baseline
2. Heparin bolus is given IVP (100u/kg)
followed by continuous infusion and protocol
3. Goal is to attain aPTT level 1.5-2.5x normal

Heparin therapy
4. Assess for signs and symptoms of bleeding
5. Monitor platelet counts- can lead to heparin induced
thrombocytopenia.
6. Antidote available- protamine sulfate
Other Options:
LMWH-Longer half-life and more predictable
Lovenox- 1mg/kg Adjust for renal pts
Fragmin
Coumadin- started while pt is on heparin
-takes 3-4 days to be therapeutic
-monitor INR/PT
-antidote-Vitamin K

VENOUS DISORDERS
TREATMENT
a)

PREVENTIVE
i.
ii.
iii.

EARLY AMBULATION
EXTERNAL COMPRESSION (VCB)
PROPHYLACTIC ANTICOAGULANTS
LOW DOSE HEPARIN
LOW MOLECULAR WT. HEPARIN (FRAGMIN)

b)

WHEN DVT EXISTS

i.
ii.
iii.

BR TO CHANCE OF EMBOLI
ELEVATION TO VENOUS RETURN & EDEMA
ANTICOAGULANTS PREVENT CLOTS FROM
INCREASING (THEY DO NOT DISSOLVE THEM!)

VENOUS DISORDERS
AMBULATION PERMITTED WHEN EDEMA .
BELOW KNEE TEDS USED IF NO ARTERIAL
DISEASE
(TEDS MAY INTERFERE WITH ARTERIAL FLOW)
THROMBECTOMY SURGICAL TREATMENT OF
CHOICE WHEN ARTERIAL FLOW IS AFFECTED
BY DVT
(GREENFIELD FILTER PREVENTS SHOWER
OF PULMONARY EMBOLI) INSERTED IN
INFERIOR VENA CAVA

GREENFIELD FILTER

Inserted into
Inferior Vena
Cava
Filters out
clots as blood
returns to the
right side of
the heart

GREENFIELD FILTER

READILY
IDENTIFIED ON
X-RAY

VENOUS DISORDERS
Health Teaching
Safety and comfort measures
Balance rest and activity
Need for follow up
Importance of taking drugs and not missing doses
Medi-alert bracelet
Avoid OTC meds
Avoid hi fat and hi Vitamin K foods- cabbage,
cauliflower,broccoli, asparagus, spinach, kale, fish
and liver
Patient teaching re: LMWH injections

CHRONIC VENOUS
INSUFFICIENCY
1.

PATHOPHYSIOLOGY & EPIDEMIOLOGY

OCCURS IN 10% OF POPULATION /W DVT
Stasis of blood in lower extremity-due to
prolonged standing, sitting in one position,
pregnancy, and obesity
INCOMPETENT VALVES IN DEEP VEINS

VENOUS PRESSURE IMPEDES CAPILLARY

PERFUSION
PROTEINS LEAK INTO INTERSTITIAL TISSUES
EDEMA IS CHRONIC ULCERS & SCARRING

CHRONIC VENOUS INSUFFICIENCY

Venous Stasis Ulcers

SIGNS & SYMPTOMS INDURATION
HYPERPIGMENTATION, STASIS DERMATITIS &
ULCERATIONS, EDEMA
GOALS: Decrease edema and Promote venous
return
INTERVENTIONS:

2.

3.
4.

a)
b)
c)
d)
e)
f)
g)

COMPRESSION STOCKINGS OR DRESSINGS

ULCERS TREATED WITH TOPICAL AGENTS-Unna,Accuzyme
AVOID TRAUMA
AVOID SITTING FOR LONG PERIODS
EXERCISE TO MUSCLE ACTIVITY
Platelet derivative growth factor ointments-Regranex
Apligraf-type of skin graft

Varicose Veins

Protruding veins that are

darkened/tortuous are caused by
weak vein walls, increased venous
pressure & incompetent valves
Common in patients that stand for
long periods
Pregnancy
Obesity
Family hx of varicose veins
Systemic problems-heart disease

Assessment- S & O Data

Severe, aching pain in leg

Leg fatigue and heaviness
Itching over the affected leg (statis
dermatitis)
Feelings of heat in the leg
Visibly dilated veins
Thin, discolored skin above the ankles
Increased incidence of PE and
thrombophlebitis

Diagnostic Tests
Tourniquet test
Trendelenberg test
Doppler ultrasound/ angiography

Medical and Surgical

Interventions for Varicose
Veins

Elevate
extremity
Elastic Stockings
Sclerotherapy-for
small/limited #
of veins

Vein stripping or
ligation
EndoVenous
Laser tx
RF (radio
frequency)
-vein is heated
from inside

Nursing Interventions
Monitor patient postop
Assess circulation
Elevate legs and perform active
ROM
Teach re: avoidance of venous
stasis, compression stockings,
exercise, leg elevation

Lymphatic System
ANATOMY & PHYSIOLOGY
LYMPHATIC SYSTEM WORKS
WITH CIRCULATORY SYSTEM
a)
b)

THORACIC DUCT
b
RIGHT LYMPHATIC DUCT

DRAINAGE:
THORACIC DRAINS ABDOMEN
(R) DRAINS HEAD, NECK & THORAX

ANATOMY &
PHYSIOLOGY
LYMPHATIC FLUID COLLECTS &
RETURNS TO VENOUS CIRCULATION
BY EMPTYING INTO SUBCLAVIAN
VEINS
WHEN INTERSTITIAL FLUID
PRESSURE INCREASES LYMPHATIC
FLOW INCREASES
WHEN DRAINAGE IS IMPAIRED
EDEMA ENSUES (FLUID COLLECTS)

ANATOMY &
PHYSIOLOGY

CAUSES OF LYMPHEDEMA INCLUDE:

LYMPHANGITIS
CELLULITIS
INSUFFICIENT NUMBER OF
VESSELS
SECONDARY FACTORS
MALIGNANCY
TRAUMA
SURGICAL REMOVAL

Assessment

Pain at site of injury

Redness of skin
Fever and chills
Red streak on skin extending toward
the lymph nodes
Lymph nodes enlarged
WBC, Blood & Wound cultures
Lymphangiography-IV dye, Xrays
Lymphoscintigraphy-simple,no SE

INTERVENTIONS

Moist heat
Elevation and immobilization of the
extremity
Elastic stockings
Na restriction
Antibiotics/antifungals for infection
Diuretics
Analgesics

CASE STUDY
MR. CHARLES HORSE WAS ADMITTED
TO THE HOSPITAL TODAY WHERE HE
PRESENTED HIS CHIEF COMPLAINTS
AND RECENT MEDICAL HISTORY.
THIS PATIENT IS A FIFTY-THREE YEAR
OLD WHITE MALE. MR. HORSE IS A
RUGGED INDIVIDUAL WITH AN
EXTENSIVE HISTORY.

HE SMOKES 1 PACK OF CIGARETTES PER DAY

FOR MORE THAN TWENTY
FIVE YEARS. AS A SINGLE LUMBERJACK HIS
DIET HAS RELIED HEAVILY ON FAST FOODS.
OVER THE PAST SEVERAL MONTHS MR.
HORSE REPORTED HE HAD GRADUALLY BEEN
EXPERIENCING PAIN IN THE LEFT LEG. THESE
PAINFUL SYMPTOMS INCREASED TO A POINT
WHERE HE CANNOT WALK MORE THAN TWO
CITY BLOCKS WITHOUT SEVERE CRAMPING
IN HIS LEFT LEG.

HE STATES HE MUST STOP, SIT AND

RUB HIS LEG UNTIL THE CRAMPING
STOPS. MR. HORSE HAS GRADUALLY
ADJUSTED HIS ACTIVITIES AROUND
THESE SYMPTOMS.
THIS MORNING, MR. HORSE AWOKE
FROM A DEEP SLEEP TO SUDDEN,
SEVERE PAIN IN THE LEFT LEG. THE
PAIN DIMINISHED SLIGHTLY WHEN HE
SAT UP AND HUNG HIS LEGS OVER
THE SIDE OF THE BED.

HE NOTICED CHANGES IN SKIN COLOR

AND TEMPERATURE. CONCERNED
ABOUT THE SUDDEN CHANGES, MR.
HORSE HEADED DIRECTLY TO THE
EMERGENCY ROOM.
WHEN YOU ASSESS THIS PATIENT
ATTENTION IS DIRECTED TOWARD HIS
LEFT LEG. THE SKIN IS COOL TO
TOUCH. ASSESSING PERIPHERAL
PULSES YOU NOTE THAT HIS
FEMORAL AND POPLITEAL PULSES
ARE STRONG AND PALPABLE
BILATERALLY.

HOWEVER, HIS POSTERIOR TIBIAL AND

DORSALIS PEDIS PULSES ON THE LEFT
LEG ARE NOT PALPABLE. A DOPPLER
READING INDICATES THERE IS SOME
DEGREE OF CIRCULATION PRESENT.
NAIL BEDS ARE CYANOTIC; CAPILLARY
FILLING IS SLOW (> 3 SECONDS) IN ALL
DIGITS ON THE LEFT FOOT.
ATTEMPTING TO IMPROVE MR. HORSES
COMFORT, THE NURSE ELEVATES HIS
FEET. MR. HORSE REPORTS THE PAIN
IS SIGNIFICANTLY WORSE!

LEFT LEG DISCUSSION

1. WHAT INFORMATION DOES
INSPECTION OF THE PATIENTS LEG
PROVIDE?
PALE
a) COLOR OF SKIN
b) COLOR OF NAIL BEDS

CYANOTIC

2. WHAT CAN PALPATION TELL YOU

ABOUT THIS PATIENTS CONDITION?
a) TEMPERATURE
COOL TO TOUCH INDICATES BLOOD
FLOW, SENSITIVITY
b) PULSES
BLOOD FLOW, WEAK PULSES
(+) FEMORAL, (+) POPLITEAL PULSES
CHECK FLOW WITH DOPPLER

3. WHAT POSITION WOULD BE THE MOST

COMFORTABLE FOR MR. HORSE?
SUPINE OR DANGLE

4. WHAT PROBLEM DO YOU THINK MR.

HORSE HAS WITH HIS LEFT LEG?
ARTERIAL INSUFFICIENCY

5. WHAT WOULD PREDISPOSE MR. HORSE TO

DEVELOPING THIS TYPE OF PROBLEM?
SMOKING, LIPIDS, PROBABLY CAD,
POSSIBLE DAMAGE TO INTIMAL LAYER
OF BLOOD VESSELS
6. WHAT IS THE CLINICAL TERM FOR A
CONDITION CAUSING PERIODIC CRAMPING
BROUGH ON BY WALKING?
INTERMITTANT CLAUDICATION

7. WHAT ARE THE 5 Ps YOU SHOULD

LOOK FOR?
PAIN
PALLOR
PULSELESSNESS
PARALYSIS
PARESTHESIA

THIS IS A
SURGICAL
EMERGENCY!

FOLLOWING A SUCCESSFUL
REVASCULARIZATION PROCEDURE,
MR. HORSE WAS D/Cd TO HOME IN
GOOD CONDITION. HIS LEFT LEG
WAS WARM, PINK IN COLOR AND ALL
TOES WERE MOBILE. MR. HORSE
WAS PLACED ON MEDICATIONS TO
MANAGE HIS CHF, WHICH WAS
DISCOVERED DURING IHIS MEDICAL
HISTORY AND PHYSICAL EXAM. TWO
WEEKS LATER THIS PATIENT
RETURNED TO THE HOSPITAL

PRESENTING WITH DYSPNEA,

ORTHOPNEA AND BILATERAL +3
PITTING EDEMA. MR. HORSE WAS
READMITTED TO THE HOSPITAL WITH A
DX OF CHF. DIGOXIN (A CARDIOTONIC)
WAS STARTED AND LASIX (A DIURETIC)
ALSO WAS ADDED TO HIS MEDICATION
PROFILE. ONCE AGAIN MR. HORSE
WAS D/Cd TO HOME AND PROVIDED
WITH A HOME HEALTH AIDE TO ASSIST
HIM WITH HIS ADLs. HE WAS
INSTRUCTED TO REMAIN ON BED REST

FOR ONE WEEK. HE IS SEEN BY THE

VISITNING NURSE IN HIS HOME ON F/U
TO ASSESS HIS STATUS. THE NURSE
TAKES NOTICE OF MR. HORSES +2
PITTING EDEMA IN HIS RIGHT LEG,
EXTENDING FROM THE FOOT TO THE
LOWER THIGH. SKIN COLOR IS NOTED
TO HAVE A REDDISH/ PURPLE HUE AND
THE SURFACE TEMP IS INCREASED
LOCALLY. THE LIMB IS TENDER TO
TOUCH AND PAIN INCREASES WITH
DORSIFLEXION.

THE NURSE ALSO NOTES THAT

PERIPHERAL PULSES ARE
MODERATELY DIMINISHED ON THE
RIGHT SIDE ONLY. MR. HORSE
COMPLAINS THAT HIS RIGHT LEG
FEELS HEAVY AND THROBS.

RIGHT LEG DISCUSSION

1. WHAT DOES INSPECTION OF HIS
RIGHT LEG REVEAL?
a) SKIN COLOR
DUSKY RED

b) GIRTH / TENSION
(+) SWELLING

2. WHAT DOES PALPATION TELL YOU

ABOUT THE STATUS OF HIS RIGHT
LEG?
a) TEMPERATURE
TEMP INDICATES INFLAMMATION
b) EDEMA
(2+) PITTING EDEMA, VENOUS CONGESTION

3. WHAT DO YOU THINK THE PROBLEM

IS WITH MR. HORSES RIGHT LEG?
(+) DVT

4. WHAT DO YOU THINK CAUSED MR.

HORSES RECENT COMPLICATIONS?
PROLONGED BED REST DUE TO CHF,
INACTIVITY, DEHYDRATION FROM LASIX,
BLOOD VISCOSITY

5. HOW COULD THESE PROBLEMS

HAVE BEEN AVOIDED?
LMWH, VCB, EXERCISE

BONUS QUESTION
LIST EXAMPLES THAT PREDISPOSE A
PATIENT TO DVT

FACTORS

EXAMPLE

IMMOBILIZATION

OPERATING ROOM > 2 HOURS

PARALYSIS

DISEASE PROCESS

CARDIAC
DIABETES MELLITUS
LOWER EXTREMITY EDEMA
SEPTICEMIA
CANCER

PRESSURE

CAST / BRACES
TRACTION

CLOTTING DYSFUNCTION

POLYCYTHEMIA
SHORT CLOTTING TIME

FACTORS

EXAMPLE

SURGICAL PROCEDURES

GYNECOLOGICAL
GENITOURINARY
ANY ABDOMINAL SURGERY
LOWER EXTREMITY FRACTURE

OTHER

OBESITY
PREGNANCY

TRAUMA

TRAUMA TO A VESSEL

NCLEX TIME
Which of the following clients should the nurse assess first?
A.The 76-year-old woman who has had laser-assisted
angioplasty of the right distal femoral artery 30 minutes
ago
B.The 65-year-old man with a history of hypertensive
crisis who is on a labetalol drip and current blood
pressure is 149/80
C.The 60-year-old woman with a history of peripheral
vascular disease who has a venous leg ulcer draining
purulent yellow fluid
D.The 55-year-old man with a history of axillofemoral
bypass 5 years earlier who is currently admitted for a
diagnostic cardiac catheterization

NCLEX TIME
Which of the following statements indicates the caregiver
does not understand proper care of the client with
peripheral arterial disease of the lower legs?
A.The client should drink fluids to decrease risk for
viscous blood.
B.We must remind the client to refrain from wearing
restrictive clothing.
C.The client should apply heat directly to the legs in
order to promote blood circulation.
D.The client should be encouraged to stop smoking
because it increases the vasoconstriction of the arteries.

NCLEX TIME
You are caring for a 75-year-old man admitted to the
hospital for lower leg cellulitis. On admission, the nurse
notes that his blood pressure is 190/100 and notifies the
physician. Of the following orders, which would you have
the LPN implement?
A.Assess cardiac and respiratory status.
B.Administer Clonidine patch for hypertension.
C.Obtain an order from the doctor for dietary consult.
D.Develop plan for discharge and assess homecare needs.

NCLEX TIME
A group of new graduate nurses is in orientation to work on
a cardiothoracic stepdown unit. Which statement, if made
by one of the nurses, demonstrates the need for further
teaching regarding the difference between
arteriosclerosis and atherosclerosis?
A.Arteriosclerosis is a thickening, or hardening, of the
arterial wall.
B.Atherosclerosis is a type of arteriosclerosis that
involves the formation of plaque within the arterial wall
and is the leading contributor to coronary artery and
cerebrovascular disease.
C.Atherosclerosis is caused by vascular damage.
D.Arteriosclerosis happens when platelets aggregate
and then a group of blood lipids accumulate.

NCLEX TIME
Because Mr. Palan's condition has progressed to severe
rest pain that is now threatening loss of his limb, an
arterial revascularization has to be performed. Which
statement, if made by Mr. Palan, demonstrates that
further teaching is needed related to his postoperative
care?
A.I should be concerned if my foot turns blue.
B.I should not get a fever or any drainage after the
surgery.
C.I may get a feeling of tenseness after the surgery.
D.Warmth, redness, and swelling are expected after
surgery.

NCLEX TIME
5.Clara is teaching a young woman ways to
prevent venous thromboembolism during
hospitalization. Which statement, if made by the
client, indicates the need for further teaching?
A.I need to stop taking my birth control pill.
B.I should drink a lot of water so I don't get
dehydrated.
C.I should exercise my legs when I have been
sitting or standing for a long time.
D.If I wear pantyhose, I don't have to wear the
stockings that the hospital gives me.