Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes depression of the cough reflex. slowed heart rate. diuresis. vasospasm.
vasospasm. Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Clients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop
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 increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." "The older I get the higher my risk for peripheral arterial disease gets." "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
"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.
Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5
1.5 to 2.5 Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give? 20 30 40 50
50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Gradual onset of a frontal headache Numbness and pain of the left arm A ripping sensation in the chest Pain when flexing the neck forward
A ripping sensation in the chest Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.
The nurse explains to a patient that the primary cause of a varicose vein is: Venous occlusion. An incompetent venous valve. Venospasm. Phlebothrombosis.
An incompetent venous valve. Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Outside of the foot just below the heel. Exterior surface of the foot near the heel. Anterior surface of the foot near the ankle joint.
Anterior surface of the foot near the ankle joint. The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.
You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect? Coronary artery disease Aortic aneurysm Raynaud's disease Peripheral artery disease
Aortic aneurysm A pulsating mass may be felt or even seen around the umbilicus or to the left of midline over the abdomen. Options A, C, and D would not present with a pulsating mass near the umbilicus; therefore, they are incorrect.
A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge? Application of graduated compression stockings Methods of keeping the wound area dry Adequate carbohydrate intake Prophylactic antibiotic therapy
Application of graduated compression stockings Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? Trauma Arterial insufficiency Venous insufficiency Neither venous nor arterial
Arterial insufficiency Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.
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 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.
Which of the following assessment results is considered a major risk factor for PAD?
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 15 ml/hour and 2+ hematuria 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 150 ml/hour and heart rate of 45 beats/minute
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.
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: Lack of exercise. Stress. Obesity. Cigarette smoking.
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.
The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: Common iliac artery. Anterior tibial. Posterior tibial. Common femoral artery.
Common iliac artery. Explanation: The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.
A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.) Computed tomography Electroencephalogram Electrocardiogram (ECG) X-ray Transesophageal echocardiography
Computed tomography Transesophageal echocardiograpy X-ray Explanation: Diagnosis of a thoracic aortic aneurysm is principally made by chest x-ray, computed tomography angiography (CTA), and transesophageal echocardiography (TEE).
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 Slow heart rate and high blood pressure Higher than normal blood pressure and falling hematocrit Constant, intense back pain and falling 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 is a characteristic of arterial insufficiency?
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.
The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?
Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.
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. Lower the patient's legs and massage the calf muscles to note any areas of tenderness. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return.
Dorsiflex the foot while the leg is elevated to check for calf pain. Explanation: Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.
Which statement is accurate regarding Raynaud disease? Episodes may be triggered by unusual sensitivity to cold. It is most common in men 16 to 40 years of age. It affects more than two digits on each hand or foot. The disease generally affects the client trilaterally.
Episodes may be triggered by unusual sensitivity to cold Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.
Which class of medication lyses and dissolves thrombi? Platelet inhibitors Fibrinolytic Anticoagulant Factor XA inhibitors
Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: Decreased motor function. Stent dislodgement. Hemorrhage. Thrombosis of the graft.
Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.
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?
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).
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? International normalized ratio (INR) is 2.5. Activated partial thromboplastin time (aPPT) is half of the control value Prothrombin time (PT) is 0.5 times normal. K+ level is 3.5.
International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin are monitored by 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)
Increase Arterial Blood Supply to the Extremities? Keep legs in a dependent position. Increase in physical activity each day. Wear warm clothing in the winter. Do not use of bicotine products. Avoid crossing the legs.
Keep legs in a dependent position. Increase in physical activity each day.
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Very mild arterial insufficiency Tissue loss to that foot Moderate to severe arterial insufficiency No arterial insufficiency
Moderate to severe arterial insufficiency Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.
Aortic dissection may be mistaken for which of the following disease processes? Pneumothorax Angina Myocardial infarction (MI) Stroke
Myocardial infarction (MI) Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?
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.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, warm skin temperature, and redness Swelling, warm skin temperature, and drainage Redness, cool skin temperature, and swelling 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.
Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? Trauma Pacing wires Surgery Obesity
Obesity Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? Pallor Cyanosis Gangrene Ulceration
Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
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. Keep the extremities elevated slightly. Massage the calf muscles if pain occurs.
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.
Peripheral artery disease
Peripheral artery disease (PAD) is defined as arterial insufficiency of the extremities that occurs most often in men and is a common cause of disability. Appropriate nursing actions to increase arterial blood supply to the client's extremities include keeping the legs in a dependent position and encouraging physical activity. Keeping legs in a dependent position enhances arterial blood supply, while exercise promotes blood flow and the development of collateral circulation. Appropriate nursing actions to promote vasodilation and prevent vascular compression include wearing warm clothing when it is cold, discouraging the use of nicotine products, and advising the client to avoid crossing the legs. Warmth promotes arterial flow by preventing vasoconstriction from chilling; nicotine causes vasospasm, which decreases circulation; and crossing the legs causes compression of vessels with the subsequent impediment of circulation, resulting in venous stasis. Keeping warm, discouraging the use of nicotine products, and telling the client to avoid crossing the legs are nursing actions more appropriate to promote vasodilation and prevent vascular compression versus increasing arterial blood supply to the extremities. Keeping the legs in a dependent position and encouraging physical activity daily are interventions that increase arterial blood supply to the extremities versus promoting vasodilation and preventing vascular compression.
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Buerger's disease Peripheral vascular disease Arterial occlusive diseases Raynaud's disease
Raynaud's disease Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.
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 A history of diabetes mellitus History of increased aspirin use An active daily walking program
Recent pelvic surgery Explanation: 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.
Which of the following is the most effective intervention for preventing progression of vascular disease?
Risk factor modification Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Hematemesis Hypertensive crisis Rectal bleeding Severe pain
Severe pain Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Increasing blood pressure and monitoring fluid intake and output Stabilizing heart rate and blood pressure and easing anxiety Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility
Stabilizing heart rate and blood pressure and easing anxiety For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.
What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?
Teach the client how to apply a graduated compression stocking. In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression 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 is diagnosed with a large thoracic aneurysm. Which findings will the nurse expect when assessing this client? Select all that apply. Stridor Aphonia Hoarse voice Reduced radial pulses Brassy cough
Stridor Hoarse voice Brassy cough Aphonia The thoracic area is the most common site for a dissecting aneurysm. Symptoms vary and depend on how rapid the aneurysm dilates and how the pulsating mass affects surrounding structures. Symptoms of this type of aneurysm include stridor caused by pressure of the aneurysm against the trachea. Other symptoms include a hoarse voice, a brassy cough, and aphonia (or loss of voice) caused by pressure on the laryngeal nerve. A thoracic aneurysm does not affect pulses in the arms.
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? Taking daily walks Reducing daily fat intake to less than 45% of total calories Engaging in anaerobic exercise Abstaining from foods that increase levels of high-density lipoproteins (HDLs)
Taking daily walks Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? The aneurysm has become obstructed. The client is experiencing inflammation of the aneurysm. The aneurysm may be preparing to rupture. The client is experiencing normal sensations associated with this condition.
The aneurysm may be preparing to rupture. Explanation: 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.
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: Independent arterial wall activity. Hormonal secretion. The sympathetic nervous system. The influence of circulating chemicals.
The sympathetic nervous system. Explanation: Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the responsible neurotransmitter.
Which of the following is the most common site for a dissecting aneurysm? Lumbar area Cervical area Sacral area Thoracic 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.
The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? Ulceration Rubor Cellulitis Dermatitis
Ulceration Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.
The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client? Veins are tied off and removed. Removal of the small saphenous vein. Veins are tied off and left in the leg. Removal of the great saphenous vein.
Veins are tied off and left in the leg. A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off.
The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply. Altered coagulation Endothelial damage Prominent veins Venous stasis Edematous extremity
Venous stasis Endothelial damage Altered coagulation Explanation: Although the exact cause of venous thromboemboli are unclear, three factors known as Virchow triad are believed to play a role in the development. These factors include venous stasis, endothelial damage, and altered coagulation. Prominent veins and edema of the affected extremity are symptoms associated with deep vein thrombosis.
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? "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "As soon as you feel pain, we will go back and elevate your legs." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "Walk to the point of pain, rest until the pain subsides, then resume ambulation."
Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: 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.
Promote Vasodilation and Prevent Vascular Compression? Keep legs in a dependent position. Increase in physical activity each day. Wear warm clothing in the winter. Do not use of bicotine products. Avoid crossing the legs.
Wear warm clothing in the winter. Do not use of bicotine products. Avoid crossing the legs.
A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply. Wound is superficial Wound base is pale in color Thick, tough skin around the ankles Darkened skin around the lower extremities Wound has an irregular border
Wound is superficial Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities Aching leg pain is a symptom of venous insufficiency. Assessment findings that indicate the client is experiencing a venous ulcer include the wound is superficial with an irregular border. Thick skin around the ankles and darkened skin around the lower extremities are additional symptoms of venous insufficiency. A pale wound base is associated with an arterial ulcer.
The most common site of aneurysm formation is in the:
abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debarked type I aneurysms). Debarked type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debarked type III aneurysms occur in the descending aorta, beyond the subclavian arteries.
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is
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 a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.
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: place a heating pad around the affected calf. elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery.
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.
Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: maintain room temperature at 78° F (25.6° C). keep the client uncovered. keep the client warm. match the room temperature to the client's body temperature.
keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.
