Chap. 22: peripheral vascular system

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1.Out-of-bed activities as desired 2.Bed rest with the affected extremity kept flat 3.Bed rest with elevation of the affected extremity 4.Bed rest with the affected extremity in a dependent position

3.Bed rest with elevation of the affected extremity

A postpartum client with femoral thrombophlebitis has developed sudden shortness of breath and appears very anxious. What is the nurse's priority action for this client? 1.Check the client's blood pressure immediately. 2.Elevate the head of the bed to 30 to 45 degrees. 3.Initiate an intravenous line if one is not already in place. 4.Administer oxygen by face mask as per protocol at 8 to 10 L/min.

4.Administer oxygen by face mask as per protocol at 8 to 10 L/min.This client is at increased risk for pulmonary embolus and is exhibiting symptoms. Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Although the remaining options may be implemented, none of these is the priority nursing action.

The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning? Thigh Knee Calf Ankle

Calf

Best positioning for PVD vs. PAD

PVD eleVate vs. PAD hAng

A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency? Pallor of foot occurs with elevation Ulcer located on medial malleolus Reports of aching, cramping pain Irregular-shaped ulcer on the inner aspect of the ankle

Pallor of foot occurs with elevation

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include? To avoid sitting for long periods Signs and symptoms of DVT How to apply a nonelastic hose To walk at least 2 miles/day

To avoid sitting for long periods

T or F. The radial pulse is palpated over the lateral flexor surface.

True

A nurse performs the Allen test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test?

avoid overextending the hand after fist is made

How do oral controceptives effect cardiac health?

hypertension, increased thrombus, and edema

How would cigarette smoke affect PVD assessment?

hypertensive response increases pulse

what is the first sign of PVD

intermittent claudicaiton

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

venous thromboembolism. Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism. Arterial occlusion is characterized by pain with exercise. Neuropathy is characterized by no pain. Symptoms of a venous occlusion would include edema.

How does exercise affect intermittant claudication?

worsens with exercise

Endovenous laser treatment (EVLT) is done on a client with varicose veins. Which interventions should the nurse include in the postprocedure plan of care? 1.Inform the client that the EVLT procedure ensures closure of the treated vein. 2.Assess color and temperature of the affected limb to determine vascular status. 3.Teach the client the importance of using graduated compression stockings (GCSs) during the day. 4.Inform the client that circulation impairment and nerve damage is expected to occur following the procedure.

2.Assess color and temperature of the affected limb to determine vascular status.

A client presents with pitting edema to the left foot, which a nurse observes as a noticeably deep pit when the area is depressed and the extremity looks larger than the right. How should the nurse accurately document this amount of edema? 3+ 2+ 1+ 4+

3+

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3.An arterial ulcer

he nurse is caring for a postpartum client with a diagnosis of deep vein thrombosis who is receiving a continuous intravenous infusion of heparin sodium. Review of which laboratory result is the most important by the nurse? 1.Platelet count 2.Prothrombin time (PT) 3.International normalized ratio (INR) 4.Activated partial thromboplastin time (aPTT)

4.Activated partial thromboplastin time (aPTT)

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding? Attempt to palpate the posterior tibial pulse. Assess adequacy of blood flow using a Doppler device. Obtain an order for ankle brachial index test to be performed. Check the extremity for findings of decreased blood flow.

Assess adequacy of blood flow using a Doppler device.

A client has a pulse that suggests diminished pulse pressure. What nursing action is mostappropriate to determine the cause of this condition? Assess for physical signs of anemia. Ask about a history of hyperthyroidism. Assess for an elevated temperature. Assess for bleeding.

Assess for bleeding.

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching? Report any changes in skin or hair appearance to health care provider. Check feet daily for cuts or pressure areas. Wear compression stockings at all times. Disfigurement is common in clients with peripheral arterial disease.

Check feet daily for cuts or pressure areas.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Legs should be elevated for 15 secondsWhen performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg

A nurse recognizes that what change is considered normal in the lymphatic system of the elderly? Lymph nodes are smaller and fewer in number. Irregularity of shape and size increase with age. Swelling occurs more frequently and lasts longer. Tenderness is common, especially in the lower extremities

Lymph nodes are smaller and fewer in number.

Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results? Ensure proper lighting in the room. Allow client to empty the bladder. Make sure the temperature in the room is comfortable. Place the client in a position of comfort for the entire exam.

Make sure the temperature in the room is comfortable.

pitting vs non pitting edema

Pitting = vascular; Non-pitting = lymphatic

Which statement made by a student nurse concerning how to test a client for a paradoxical pulse would indicate that the nurse needs further education? "Inflate the blood pressure cuff to a pressure higher than the client's usual systolic pressure." "The difference between the pressures at the two levels is normally no greater than 5 mm Hg." "Drop the pressure until that point where sounds can be heard throughout the respiratory cycle." "Note the pressure level at the point where the first sounds can be heard."

The difference between the pressures at the two levels is normally no greater than 5 mm Hg.

The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer? The client voices pain related to the ulcer. The extremity is without a pulse. The ulcer is superficial and pale. The ulcer is necrotic.

The ulcer is superficial and pale.

A nurse is working with a patient who has been confined to bed rest in the hospital for the past 2 weeks. Which areas of the body are most likely to develop ulcers due to arterial insufficiency? Select all that apply.

Tips of toes Toe webs Heels

A nurse is working with a patient who has been confined to bed rest in the hospital for the past 2 weeks. Which areas of the body are most likely to develop ulcers due to arterial insufficiency? Select all that apply. Toe webs Tips of toes Medial ankle Heels Anterior tibial area

Toe webs Tips of toes Heels medial malleous and tibial area are venous insuff.

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the patient? Allen test Venous occlusion test Ankle-brachial index test Trendelenburg test

Trendelenburg test

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the patient? Venous occlusion test Ankle-brachial index test Allen test Trendelenburg test

Trendelenburg test

Signs of arterial and venous insufficiency in legs

cold and clammy toes, heels, ; warm with brownish pigmentation in medial malleous&anterior tibial=venous

The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg? saphenous posterior tibial femoral dorsalis pedis

femoral

intermittent claudication

pain in the leg, calf, and buttock muscles due to PAD that occurs is exacerbated by exercise and sometimes, depending on the severity, relieved by rest.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?

popliteal

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?

tobacco use is #1 risk for PVD

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the primary health care provider (PHCP) will most likely prescribe which option? 1.Maintain activity level as prescribed. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

1.Maintain activity level as prescribed. Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level, which could be bed rest or ambulation. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1.Soak the feet in hot water daily. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

2.Be careful not to injure the legs or feet. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet. Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1.Bilateral edema 2.Increased calf circumference 3.Diminished distal peripheral pulses 4.Coolness and pallor of the affected limb

2.Increased calf circumference lso known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication

A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1."Apply warm packs to the leg." 2."Keep the leg elevated as much as possible." 3."Your primary health care provider needs to be contacted to report this problem." 4."This normally occurs after surgery and will subside when the edema goes down."

3."Your primary health care provider needs to be contacted to report this problem."A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1.Use nail polish to protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands. 3.Stop smoking because it causes cutaneous blood vessel spasm. 4.Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

3.Stop smoking because it causes cutaneous blood vessel spasm. Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements and indicate that the teaching has been effective.

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? 1.Monitor oxygen saturation with pulse oximetry. 2.Assess activity tolerance before and after exercise. 3.Observe the client's cardiac rhythm with telemetry. 4.Assess peripheral pulses with an ultrasonic Doppler device

4.Assess peripheral pulses with an ultrasonic Doppler device. Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although the remaining options may be components of the assessment, they are not the priority.

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1.Checking for a rash on the digits 2.Observing for softening of the nails or nail beds 3.Palpating for a rapid or irregular peripheral pulse 4.Palpating for diminished or absent peripheral pulse

4.Palpating for diminished or absent peripheral pulse. Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.

Which of the following clients is most likely at the greatest risk of acute compartment syndrome? A 31-year-old pregnant client with a history of IV drug use An obese man who has a 50 pack per year history of smoking A 17-year-old who has just been fitted with an arm cast following a fracture of his radius A 79-year-old man who is immobilized due to a recent cerebrovascular accident

A 17-year-old who has just been fitted with an arm cast following a fracture of his radius Application of a cast that is too tight is a central risk factor for the development of compartment syndrome. Immobility and smoking are not key to the development of compartment syndrome, while pregnancy and IV drug use constitute a risk of thrombosis.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

DVT. Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphlococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

On questioning a client with peripheral edema during an interview, the nurse learns that the client has a sedentary job and drinks little water throughout the day. What underlying condition is the client most likely to have, based on these findings? Systemic bacterial infection Deep vein thrombosis Varicose veins Peripheral artery disease

Deep vein thrombosis Peripheral edema (swelling) results from an obstruction of the lymphatic flow or from venous insufficiency from such conditions as incompetent valves or decreased osmotic pressure in the capillaries. It may also occur with deep vein thrombosis (DVT). Risk factors for DVT include reduced mobility, dehydration, increased viscosity of the blood, and venous stasis, such as would occur with a sedentary job. Neither a systematic bacterial infection nor peripheral artery disease would result in peripheral edema, nor would they be associated with the risk factors listed. Varicose veins are associated with the risk factors listed but, by themselves, do not result in peripheral edema.

A finding on palpation that suggests venous insufficiency is: Diminished sensations of dorsum of right foot Cool lower legs and feet Diminished dorsalis pedis pulse in an edematous foot Ulcerations on toes of left foot

Diminished dorsalis pedis pulse in an edematous foot. Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish. Arterial would not have as much edema.

A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding? Pain in the calf muscles Pallor of the leg on elevation Tenderness on plantar flexion Cramping pain in both thighs

Pain in the calf muscles Clients undergoing vascular surgery are at increased risk for the development of deep vein thrombosis. The Homan's test has traditionally been used to detect the presence of a blood clot within a vessel. Homan's sign is positive if the client experiences tenderness or pain in the calf muscles on flexing the knee, and aching or cramping on dorsiflexion of the foot. Cramping pain in thighs may not be elicited by Homan's sign. Pallor of the leg on elevation is not elicited by Homan's test. Tenderness on plantar flexion of foot indicates negative Homan's sign.

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client? Venous disease Neuropathy secondary to diabetes Peripheral arterial disease Advanced chronic arterial occlusive disease

Peripheral arterial disease

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

cool foot temperature. Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

To screen for deep vein thrombosis, you would:a. measure the circumference of the ankle.b. check the temperature with the palm of the hand.c. compress the dorsalis pedis pulse, looking for blood return.d. measure the widest point with a tape measure.

d. measure the widest point with a tape measure.

Patients with PAD need to understand why it is important to monitor blood urea nitrogen levels Na+ and K+ levels creatinine levels triglyceride levels

triglyceride

The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing thrombophlebitis. intermittent claudication. varicose veins. edema.

intermittent claudication.

A client presents with pitting edema to the left foot, which a nurse observes as slight pitting when the area is depressed. How should the nurse accurately document this amount of edema?

1+

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Encourage coughing with deep breathing. 2.Place in high-Fowler's position for eating. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables

1.Encourage coughing with deep breathing 3.Encourage increased oral intake of water daily 4.Place thigh-length elastic stockings on the client. The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high-Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify health care provider as suspected DVT

Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency? Skin temperature of the leg is normal. Ulceration is noted on the great toe of the affected foot. Skin is cyanotic when the leg is in a dependent position. Leg pulses are normal but difficult to assess because of edema.

Ulceration is noted on the great toe of the affected foot.

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

Upper torso Head Upper extremities

Intermittant claudication is caused by

arterial ischemia especially WITH ACTIVITY (rest reduces). located in lower body except feet

A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding? Head and neck for recent ear infection or sore throat Lower arm and hand for erythema and swelling Abdomen, noting any organ enlargement or tenderness Cervical lymph nodes for tenderness and swelling

Abdomen, noting any organ enlargement or tenderness. This is upstream from inguinal

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

Allen test

PAD vs. PVD

both narrowing of vessels and cause pain. PAD more severe pain.

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

brachial pulse; work upstream

toes,heel&:artery:pallor/cold::___:vein:___

feet; warm