Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Redness, cool skin temperature, and swelling Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Numbness, cool skin temperature, and pallor

Numbness, cool skin temperature, and pallor Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

The nurse is caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what? Obstructed lymph vessels Sensitivity to antibiotics Excessive lymph is the vascular space Improper anticoagulant use

Obstructed lymph vessels Lymphedema is caused by accumulation of lymph in the tissues and may be a result of obstructed lymph vessels. It is not caused by sensitivity to antibiotics, vascular accumulation of lymph, or improper anticoagulant use.

A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.) A pulsatile abdominal mass Low back pain Decreased bowel sounds Lower abdominal pain Diarrhea

pulsatile abdominal mass low back pain lower abdominal pain Some patients complain that they can feel their heart beating in their abdomen when lying down, or they may say that they feel an abdominal mass or abdominal throbbing. The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. Signs of impending aneurysm rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves.

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "The older I get the higher my risk for peripheral arterial disease gets." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? "Walk to the point of pain, rest until the pain subsides, then resume ambulation." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "As soon as you feel pain, we will go back and elevate your legs." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."

"Walk to the point of pain, rest until the pain subsides, then resume ambulation." The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50

50 Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease

Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? Assess for unilateral swelling and tenderness of either leg. Ask about any changes in skin color that occur in response to cold. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Check for the presence of tortuous veins bilaterally on the legs.

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Avoid fatty foods and exercise. Take over-the-counter decongestants. Avoid situations that contribute to ischemic episodes. Report changes in the usual pattern of chest pain.

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client? Avoid straining during bowel movements and coughing. Wear wool socks and mittens during cold weather. Minimize bowel movements and coughing. Avoid situations that contribute to ischemic episodes.

Avoid straining during bowel movements and coughing. The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. The client with Raynaud's disease is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.

Which of the following assessment results is considered a major risk factor for PAD? Triglyceride level of 150 mg/dL LDL of 100 mg/dL BP of 160/110 mm Hg Cholesterol of 200 mg/dL

BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 15 ml/hour and 2+ hematuria

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency? Is deep, involving the joint space Border of the ulcer is irregular Though superficial, it is very painful Base is pale to black

Border of the ulcer is irregular The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous insufficiency ulcers are usually superficial.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: Cigarette smoking. Obesity. Stress. Lack of exercise.

Cigarette smoking. Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

Pentoxifylline (Trental) is a medication used for which of the following conditions? Elevated triglycerides Claudication Hypertension Thromboemboli

Claudication Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? Constant, intense headache and falling blood pressure Constant, intense back pain and falling blood pressure Higher than normal blood pressure and falling hematocrit Slow heart rate and high blood pressure

Constant, intense back pain and falling blood pressure Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot? Contrast phlebography Air plethysmography Lymphoscintigraphy Lymphangiography

Contrast phlebography When a thrombus exists, an X-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

Which is a characteristic of arterial insufficiency? Superficial ulcer Pulses are present but may be difficult to palpate Diminished or absent pulses Aching, cramping pain

Diminished or absent pulses A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? Dorsiflex the foot while the leg is elevated to check for calf pain. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Lower the patient's legs and massage the calf muscles to note any areas of tenderness.

Dorsiflex the foot while the leg is elevated to check for calf pain. Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Elevate the legs periodically for at least an hour. Elevate the legs periodically for at least 15 to 20 minutes. Avoid foods with iodine. Refrain from sexual activity for a week.

Elevate the legs periodically for at least 15 to 20 minutes. The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? Keep the patient's knees at a 45-degree angle. Elevate the patient's lower extremities. Hang the patient's legs over the side of the bed Keep the patient's legs flat without the knees raised.

Elevate the patient's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within 12 hours Within the first 24 hours In 3 to 5 days In 2 days

In 3 to 5 days Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Decreased pulse rate and blood pressure Increased abdominal and back pain Retrosternal back pain radiating to the left arm Elevated blood pressure and rapid respirations

Increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Ineffective peripheral tissue perfusion related to venous congestion Risk for injury related to edema Excess fluid volume related to peripheral vascular disease

Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking? Orthopnea Intermittent claudication Dyspnea Thromboangiitis obliterans

Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is difficulty breathing and is subjective. Orthopnea is the inability to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger disease.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Acute limb ischemia Dizziness Vertigo Intermittent claudication

Intermittent claudication The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply. A systolic bruit Low back pain Lower abdominal pain Radiating chest pain Hypertension An abdominal pulsatile mass

Low back pain Lower abdominal pain An abdominal pulsatile mass A systolic bruit Chest pain and hypertension, although they may be present, are not indicators of AAA even if present. All other choices are positive.

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs. Keep the extremities elevated slightly.

Participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Peripheral pulses every 15 minutes after surgery Ankle-arm indices every 12 hours Blood pressure every 2 hours Color of the leg every 4 hours

Peripheral pulses every 15 minutes after surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: Internal iliac. Common femoral. Posterior tibial. Popliteal.

Posterior tibial. Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Thrombin Phytonadione (vitamin K) Protamine sulfate Plasma protein fraction

Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? Recent pelvic surgery History of increased aspirin use An active daily walking program A history of diabetes mellitus

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Wear antiembolic stockings daily to assist with blood return to the heart. Keep your feet elevated above your heart. Stop smoking. Do not cross your legs for more than 30 minutes at a time.

Stop smoking. Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for? Warm, pink toes in the inoperative leg Blood on the dressing on the inoperative leg Swelling in the inoperative leg Swelling in the operative leg

Swelling in the operative leg When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low Offer cold applications to promote comfort and to enhance circulation Avoid elevating the area Teach the client how to apply an elastic sleeve

Teach the client how to apply an elastic sleeve In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? The aneurysm may be preparing to rupture. The client is experiencing inflammation of the aneurysm. The client is experiencing normal sensations associated with this condition. The aneurysm has become obstructed.

The aneurysm may be preparing to rupture. Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client's legs awaken him during the night with itching. The client experiences shortness of breath after walking about 50 feet. The client can walk about 50 feet before getting pain in the right lower leg. The client's fingers tingle when left in one position for too long.

The client can walk about 50 feet before getting pain in the right lower leg Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.

Which of the following is the most common site for a dissecting aneurysm? Cervical area Lumbar area Thoracic area Sacral area

Thoracic area The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Ulcers and infection in the edematous area Cyanosis Loose and wrinkled skin Evident scarring

Ulcers and infection in the edematous area In a client with lymphedema, the tissue nutrition is impaired because of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: increases high-density lipoprotein (HDL) level. reduces stress. aids in weight reduction. decreases venous congestion.

decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: forcing blood into the deep venous system. encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood.

forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery. place a heating pad around the affected calf.

keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.