Chapter 22 - Assessing Peripheral Vascular System, Ch. 22 Vascular System (Prep U), Ch 22 Assessing Peripheral Vascular System, Assessing Peripheral Vascular System (chapter 22), Chapter 22: Assessing Peripheral Vascular system, peripheral vascular s...

main functions of the lymphatic system (3)

(1) *drains* excess fluid and plasma proteins from tissues and returns them to venous system (2) *traps and destroys* microorganisms and foreign materials filtered from lymph (3) *absorbs fats* from small intestine into bloodstream

A nurse is caring for a patient with chronic lymphedema. In preparing a teaching plan for this patient, what would be essential for the nurse to address? A. Treatment B. Body image C. Pathophysiology D. Exercise plan

*Body Image*

The nurse is obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. The nurse is concerned about the possibility of arterial insufficiency and performs the Allen test. What does this mean?

*Checked for patency of the ulnar artery*

Walking contracts the calf muscles and forces blood away from the heart. a) False b) True

*False*

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

*Lymphedema*

A nurse asks a supine client to raise his knee partially. The nurse then places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery?

*Popliteal*

if pt has varicose veins, perform which test

*Trendelenburg test*, to determine competence of saphenous vein valves and retrograde (backward) filling of superficial veins

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

*arterial insufficiency*

peripheral edema can also occur with...

*deep vein thrombosis (DVT)*

inflammation/infection in abdomen would drain into where

*inguinal nodes* located in groin area

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 4-mm depression. How would the nurse document this? a) +1 pitting edema b) +2 pitting edema c) +3 pitting edema d) +4 pitting edema

+2 pitting edema Explanation: Slight pitting edema, with a 2-mm depression is +1. Increased pitting with a 4-mm depression is +2. Deeper pitting with a 6-mm depression is +3 and severe pitting has an 8-mm depression.

because of the high pressure system, the arteries need to have a specific structure to perform their function. Describe some characteristics of arteries:

- arterial walls must be thick and strong - arterial walls contain elastic fibers so they can stretch -

You want to ask subjective data health history questions. Some common or concerning symptoms of PVD might be...

- pain in the arms or legs - intermittent claudication - cold, numbness, pallor, hair loss - welling in the calves, legs, feet - swelling with redness or tenderness

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?

-*Ensure that the client's hand is not opened in exaggerated extension* -Keep both arteries occluded and have the client release the fist -Use the thumbs to occlude the radial and ulnar arteries -Have the client rest the hand palm side up and make a fist

Which of the following clients is most likely at the greatest risk of acute compartment syndrome?

-An obese man who has a 50 pack per year history of smoking -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* -A 31-year-old pregnant client with a history of IV drug use

Functions of Doppler Ultrasound Device

-Assess unpalpable pulses in the extremities -Determine the patency of arterial bypass grafts -Assess tissue perfusion in an extremity

Varicose Veins

-Hereditary - Can develop from increased venous pressure and venous pooling. - Standing for long periods of time

Risk Factors for Venous Peripheral Vascular Disease

-Pregnancy -Prolonged standing -Limited physical activity/poor physical fitness -Congenital or acquired vein wall weakness -Female gender -Increasing age -Genetics (African American) -Obesity -Lack of dietary fiber -Use of constricting corsets/clothes

Patient Education - Peripheral Artery Disease

-Quit smoking -Keep diabetes under control -Lower cholesterol and blood pressure levels -Diet low in saturated fats -Maintain healthy weight

Risk Factors for Deep Vein Thrombosis

-Reduced mobility -Dehydration -Increased viscosity of the blood -Venous stasis

Risk Factors for Arterial Peripheral Vascular Disease

-Tobacco smoking -Age greater than 50 year (less if diabetic) -Family history of hypertension -Coronary -Peripheral vascular disease

Unilateral edema

-characterized by a 1-cm difference in measurements Caused by: -venous stasis due to insufficiency or obstruction -lymphedema -muscular atrophy

Three types of veins

-deep veins -superficial veins -perforator (or communicator) veins

A note! Older Adult Considerations Varicosities are common in the older client.

...

CLINICAL TIP. Bilateral coolness of the feet and legs suggests one of the following: the room is too cool, the client may have recently smoked a cigarette, the client is anemic, or the client is anxious. All of these factors cause vasoconstriction, resulting in cool skin.

...

TIPS OF THE TRADE, BITCHES! Arterial blood flow is not occluded if there are arterial pulses distal to the tourniquet

...

Pulse amplitude 3 means...

... Bounding (unable to obliterate or requires firm pressure)

Pulse amplitude 2 means...

... Normal (obliterate with moderate pressure)

ABI reading of less than or equal to 0.49 means...

....critical ischemia, rest pain, or gangrene

Perform position change test for arterial insufficiency. Why?

...If pulses in the legs are weak, further assessment for arterial insufficiency is warranted. The client should be in a supine position. Place one forearm under both of the client's ankles and the other forearm underneath the knees. Raise the legs about 12 inches above the level of the heart. As you support the client's legs, ask the client to pump the feet up and down for about a minute to drain the legs of venous blood, leaving only arterial blood to color the legs.

Pulse amplitude 1 means...

...Weak, diminished (easy to obliterate)

A hemorrhoid is also known as...

...a varicose vein

ABI reading 0.6-0.8 means...

...borderline perfusion

Pulse amplitude 0 means...

...pulse amplitude is absent

ABI reading of 0.50-0.75 means...

...severe ischemia

Pulse Amplitude

0 - Absent 1+ = Weak, diminished (easy to obliterate) 2+ = Normal (obliterate with moderate pressure) 3+ = Bounding (unable to obliterate or requires firm pressure)

Mechanism of Venous Return

1) Structure - one way values 2) Skeletal muscular contraction 3) Pressure gradient

Functions of Lymphatic System

1) drain excess fluid and plasma proteins from bodily tissues and return them to the venous system. 2) defending the body against microorganisms 3) absorb fats (lipids) from the small intestine into the bloodstream

*pitting edema* is documented as:

1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit; gross edema in extremity

the three mechanisms of venous function that help to propel blood back to the heart

1. one-way valves in the veins (permit blood to pass thru them going back to the heart, prevents blood from returning in opposite direction) 2. skeletal muscle contraction (movement squeezes blood toward heart) 3. pressure gradient produced by inspiration (inspiration dec intrathoracic pressure while inc abdominal pressure -> producing pressure gradient)

An ABI = to ___________ has been considered normal.

1.0

ankle pressure in a healthy person is the same or slightly higher than brachial pressure = ABPI of approx. _.__ or no ________ _____________

1.00; arterial insufficiency

about __% of healthy clients *may not* have a posterior tibial pulse present

15%

correct technique of ABPI involves using a BP cuff __% _____ than diameter of limb being measured, inflating to no more than 20-30 mmHg beyond where last arterial signal was detected and slowly deflating the cuff so as not to miss the highest pressure (p. 466)

20% wider

compression test (cont.) second hand should be placed _ to _ inches above first hand

6 to 8 inches. nurse should feel for pulsation to fingers in the *upper hand*

Doppler device should be held at a __ to __ degree angle and placed lightly on the area to avoid occluding vessel being assessed

60 to 90 degree (if repeated assessments needed -> mark site w/ waterproof pen)

blood from the lower trunk and legs drains upward into the inferior vena cava. the percentage pf the bodys blood volume that is contained in the veins is nearly

70%

Veins hold approximately what percentage of the body's blood?

70%.

return of a pink color to legs after dangling them during a *position change test for arterial insufficiency* should take how long

<10 seconds (normal); >10 (delayed)

Intermittent claudication

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

It may be difficult or impossible to palpate a pulse in an edematous foot. What tool could you use to help find the pulse?

A Doppler ultrasound device may be useful in this situation

Brownish discoloration just above the malleolus suggests chronic venous insufficiency.

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

Warm skin and brown pigmentation around the ankles are associated with venous insufficiency. Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency.

A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?

Pallor of foot occurs with elevation

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?

Lymphedema Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

Check the insertion site for redness. Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

A complete peripheral vascular examination involves...

A complete peripheral vascular examination involves inspection, palpation, and auscultation.

Palpate the client's fingers, hands, and arms, and note the temperature Abnormal?

A cool extremity may be a sign of arterial insufficiency. Cold fingers and hands, for example, are common findings with Raynaud's.

Assist the client to walk as soon and as often as possible. Explanation: Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Severe stenosis leading to ischemia and tissue damage An ABPI of less than 0.3 indicates severe stenosis leading to ischemia and tissue damage. The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately 1.00 or no arterial insufficiency. An ABPI of 0.5 to 1.0 indicates mild to moderate arterial insufficiency.

A nurse determines that a client's ankle-brachial pressure index (ABPI) is 0.2. Which of the following conditions does this reading indicate?

Assess adequacy of blood flow using a Doppler device. Explanation: Arterial insufficiency causes a decrease in the amount of blood flow to an extremity. If the blood flow is diminished significantly, the adequacy of the pulse may also diminish. Therefore, if a pulse cannot be palpated, the nurse's best action is to obtain a Doppler device to assess for adequate blood flow. A Doppler device works by transmitting ultra-high-frequency sound waves in a way that they strike red blood cells in an artery or vein. This rebounding ultrasound waves produces a whooshing sound that is transmitted through the Doppler.

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?

Lightly palpate the client's leg veins for tenderness Explanation: To fully assess for a suspected phlebitis, lightly palpate for tenderness. The client should still be standing from the inspection of the legs.

A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next?

Body image Clients with chronic lymphedema may experience disfigurement that affects their body image and self-esteem. It is essential for nurses to address these areas that affect quality of life. Addressing exercise, treatment, and pathophysiology is not considered as essential for the nurse to address in teaching as are body image and self-esteem.

A nurse is caring for a client with chronic lymphedema. In preparing a teaching plan for this client, what would be essential for the nurse to address?

Cool skin

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

Lower arm and hand for erythema and swelling Explanation: The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy.

A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?

Abdomen, noting any organ enlargement or tenderness

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?

Legs should be elevated for 15 seconds When 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 performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Firmly compress the lower portion of the varicose vein

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

Question 11 of 20 Which of the following wounds is most likely attributable to neuropathy? A painless wound on the sole of the client's foot, which is surrounded by calloused skin A painful wound in the client's shin, which is surrounded by apparently healthy skin A wound on a client's highly edematous ankle that is surrounded by pigmented skin A moderately painful wound on the lateral aspect of the client's ankle

A painless wound on the sole of the client's foot, which is surrounded by calloused skin

Which of the following wounds is most likely attributable to neuropathy?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

Epitrochlear Lymphatics from the ulnar surface of the forearm drain first into the epitrochlear nodes, which are located on the medial surface of the arm approximately 3 cm above the elbow. Lymphatics from the rest of the arm drain into the lateral and central axillary nodes and a few may drain directly into the infraclavicular nodes.

A patient has developed an infection of the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area?

Risk for peripheral neurovascular dysfunction Explanation: Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction. The other options are distracters to the question.

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

Palpate the dorsalis pedis pulse. abNormal findings?

A weak or absent pulse may indicate impaired arterial circulation. Further circulatory assessments (temperature and color) are warranted to determine the significance of an absent pulse

brachial pulse.

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

lymphedema

An abnormal accumulation of tissue fluid (potential lymph) in the interstitial spaces. Results from blocked lymphatic circulation. Effects one extremity, causing induration and nonpitting edema.

What is an ABI?

Ankle brachial index

Observe arm size and venous pattern; also look for edema. If there is an observable difference, measure bilaterally the circumference of the arms at the same locations with each re-measurement and record findings in centimeters What's normal?

Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning.

How do you Palpate the femoral pulses?

Ask the client to bend the knee and move it out to the side. Press deeply and slowly below and medial to the inguinal ligament. Use two hands if necessary. Release pressure until you feel the pulse. Repeat palpation on the opposite leg. Compare amplitude bilaterally.

How do you palpate the popliteal pulse?

Ask the client to raise (flex) the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse. It is usually detected lateral to the medial tendon

How to Inspect for varicosities and thrombophlebitis?

Ask the client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. As the client is standing, inspect for superficial vein thrombophlebitis. To fully assess for a suspected phlebitis, lightly palpate for tenderness. If superficial vein thrombophlebitis is present, note redness or discoloration on the skin surface over the vein.

pitting edema

Associated with -systemic problems such as congestive heart failure, or hepatic cirrhosis -local problems such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting.

Why are veins walls much thinner than those of arteries?

Because blood in the veins is carried under much lower pressure than in the arteries, the vein walls are much thinner

Make sure the temperature in the room is comfortable.

Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?

Inspect legs for edema. Abnormal findings?

Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as congestive heart failure, or a local problem, such as lymphedema (abnormal or blocked lymph vessels) or prolonged standing or sitting (orthostatic edema). Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema (see Abnormal Findings 22-2, p. 471). A difference in measurement between legs may also be due to muscular atrophy. Muscular atrophy usually results from disuse due to stroke or from being in a cast for a prolonged time.

70%. Explanation: Blood from the lower trunk and legs drains upward into the inferior vena cava. The veins contain nearly 70% of the body's blood volume.

Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body's blood volume that is contained in the veins is nearly

____________________ are small blood vessels that form the connection between the arterioles and venules and allow the circulatory system to maintain the vital equilibrium between the vascular and interstitial spaces

Capillaries

Palpate to assess capillary refill time. Normal?

Capillary beds refill (and, therefore, color returns) in 2 seconds or less.

Palpate to assess capillary refill time. Abnormal?

Capillary refill time exceeding 2 seconds may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.

Shape

Characteristics of Arterial and Venous Insufficiency: Arterial: Circular Venous: Irregular border

Depth of ulcer

Characteristics of Arterial and Venous Insufficiency: Arterial: Deep, often involving joint space Venous: Superficial

Skin Characteristics

Characteristics of Arterial and Venous Insufficiency: Arterial: Dependentg rubor - elevation pallor of foot, dry, shiny skin, cool-to-cold temperature, loss of hair over toes and dorsum of foot, nails thickened and ridged Venous: Pigmentation to gaiter area (area of medial andlateral, skin thickened and tough, may be reddish blue, frequently associated dermatitis

Pulses

Characteristics of Arterial and Venous Insufficiency: Arterial: Diminished or absent Venous: Present, but may be difficult to palpate through edema

Pain

Characteristics of Arterial and Venous Insufficiency: Arterial: Intermittent claudication to sharp, unrelenting and constant; significant _______ Venous: aching, cramping; minimal ______ if superficial or may be very _______

Leg edema

Characteristics of Arterial and Venous Insufficiency: Arterial: Minimal unless extremity kept in dependent position constantly to relieve pain Venous: Moderate to severe

Ulcer base

Characteristics of Arterial and Venous Insufficiency: Arterial: Pale to black and dry gangrene Venous: Granulation tissue - beefy red to yellow fibrinous in chronic long-term ulcer

Ulcer Characteristics Location

Characteristics of Arterial and Venous Insufficiency: Arterial: Tips of toes, toe webs, heel or other pressure areas if confined to bed Venous: Medial malleolus, infrequently lateral malleolus or anterior tibial area

Question 16 of 20 During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find? Cool leg on one side Cold fingers and hands Cool legs bilaterally Capillary refill less than 2 seconds SUBMIT ANSWER

Cold fingers and hands

Observe coloration of the hands and arms. Normal?

Color varies depending on the client's skin tone, although color should be the same bilaterally

Temperature

Comparison of Arterial and Venous Insufficiency: Arterial: Cool, cold Venous: Warm

Pulse

Comparison of Arterial and Venous Insufficiency: Arterial: Decreased or absent Venous: Present

Sensation

Comparison of Arterial and Venous Insufficiency: Arterial: Leg pain aggravated by exercise and relieved with rest; pressure or cramps in buttocks or calves during walking paresthesia Venous: Leg pain aggravated by prolonged standing or sitting, relieved by elevation of legs, lying down or walking; also relieved with use of support hose

Edema

Comparison of Arterial and Venous Insufficiency: Arterial: None Venous: Present

Color

Comparison of Arterial and Venous Insufficiency: Arterial: Pale on elevation, dusky rubor on dependency Venous: Pink to cyanotic, brown pigment at ankles

Skin

Comparison of Arterial and Venous Insufficiency: Arterial: Shiny skin, thick nails, absence of hair, ulcers on toes, gangrene may develop Venous: Ulcers on ankles, discolored, scaly

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

Cool foot temperature and ulceration on the client's great toe 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.

Question 15 of 20 A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency? Bilateral radial pulses of 2+ Epitrochlear lymph nodes not palpable Capillary refill time of 2 seconds Cool skin SUBMIT ANSWER

Cool skin

Bilateral edema

Detected by: Absence of visible veins, tendons, or bony prominences Indicates: -Systemic problem such as congestive heart failure, or local problem -prolonged standing or sitting (orthostatic edema)

A note about capillary refill: Inaccurate findings may result if the room is cool, if the client has edema, has anemia, or if the client recently smoked a cigarette.

Don't smoke!

For pulses unable to palpate, how would you measure the pulse?

Doppler ultrasound device

Palpate the dorsalis pedis pulse. Normal findings?

Dorsalis pedis pulses are bilaterally strong. This pulse is congenitally absent in 5%-10% of the population.

How do you palpate the dorsalis pedis pulse?

Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. The pulses of both feet may be assessed at the same time to aid in making comparisons. Assess amplitude bilaterally

Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus.

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

Cold fingers and hands Raynaud's is exhibited by cold fingers and hands. Cool extremities could be due to a cool room or arterial insufficiency. A capillary refill of less than 2 seconds is normal.

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find?

Venous insufficiency

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?

Palpate the epitrochlear lymph nodes abNormal?

Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm, or they may occur with generalized lymphadenopathy. Enlarged lymph nodes may also occur because of a lesion in the area

For male clients: Have you experienced a change in your usual sexual activity? Describe.

Erectile dysfunction (ED) may occur with decreased blood flow or an occlusion of the blood vessels such as aortoiliac occlusion (Leriche's syndrome). Men may be reluctant to report or discuss difficulties achieving or maintaining an erection.

Question 8 of 20 Walking contracts the calf muscles and forces blood away from the heart. False True

False

T/F - With aging, lymphatic tissue is gained, resulting in larger but fewer lymph nodes

False. With aging, lymphatic tissue is lost, resulting in smaller and fewer lymph nodes

Palpate the femoral pulses. Normal?

Femoral pulses strong and equal bilaterally.

How do you Palpate the superficial inguinal lymph nodes?

First, expose the client's inguinal area, keeping the genitals draped. Feel over the upper medial thigh for the vertical and horizontal groups of superficial inguinal lymph nodes. If detected, determine size, mobility, or tenderness. Repeat palpation on the opposite thigh

Palpate bilaterally for temperature of the feet and legs Abnormal?

Generalized coolness in one leg or change in temperature from warm to cool as you move down the leg suggests arterial insufficiency. Increased warmth in the leg may be caused by superficial thrombophlebitis resulting from a secondary inflammation in the tissue around the vein.

Lack of exercise Overweight Smoking

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

Palpation of the pulses in the peripheral vascular examination is typically to assess amplitude or strength. Pulse amplitude is graded on a 0 to 3- scale, with 3+ being the strongest.

Got it?

Use the following steps to measure ABI:

Have the client rest in a supine position for at least 5 minutes. Apply the blood pressure (BP) cuff to first one arm and then the other to determine the brachial pressure using the Doppler. First palpate the pulse and use the Doppler to hear the pulse. The "whooshing" sound indicates the brachial pulse. Pressures in both arms are assessed because asymptomatic stenosis in the subclavian artery can produce an abnormally low reading and should not be used in the calculations. Record the higher reading. In addition to abnormal ABI findings, reduced or absent pedal pulses, a cool leg unilaterally, lack of hair, and shiny skin on the leg suggests peripheral arterial occlusive disease. Nexøe et al. (2012) caution about false ABI test results, which may occur in general practice settings rather than when performed in specialized vascular centers. Inaccurate readings may also occur in people with diabetes because of artery calcification (Scanlon et al., 2012). Abnormal ABI findings, indicating PVD, are associated significantly with poorer walking endurance (McDermott et al., 2010). Apply the BP cuff to the right ankle, then palpate the posterior tibial pulse at the medial aspect of the ankle and the dorsalis pedis pulse on the dorsal aspect of the foot. Using the same Doppler technique as in the arms, determine and record both systolic pressures. Repeat this procedure on the left ankle (Fig. 22-24).

Inspect legs for edema. Normal findings?

Identical size and shape bilaterally; no swelling or atrophy.

Why would you auscultate the femoral pulse?

If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits

How do you auscultate the femoral pulse?

If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits. Repeat for other artery

How do you Palpate for edema?

If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.

Nontender, mobile, and 1 cm in diameter Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

If palpable, superficial inguinal nodes are expected to be:

What is the Trendelenburg test?

If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The client should lie supine. Elevate the client's leg 90 degrees for about 15 seconds or until the veins empty. With the leg elevated, apply a tourniquet to the upper thigh. Assist the client to a standing position and observe for venous filling. Remove the tourniquet after 30 seconds, and watch for sudden filling of the varicose veins from above.

What happens if one of the three mechanisms of venous blood return are malfunctioning?

If there is a problem with any of these mechanisms, venous return is impeded and venous stasis results

Question 9 of 20 The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development? Hypertension Immobility Smoking Obesity

Immobility

Question 7 of 20 A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? Fear of Loss of Extremity Risk for Skin Breakdown Imbalanced Nutrition Impaired Skin Integrity SUBMIT ANSWER

Impaired Skin Integrity This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented.

Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength. AbNormal?

Increased radial pulse volume indicates a hyperkinetic state (3+ or bounding pulse). Diminished (1+) or absent (0) pulse suggests partial or complete arterial occlusion (which is more common in the legs than the arms). The pulse could also be decreased from Buerger's disease or scleroderma

arterial insufficiency

Indicated by: -pallor, especially when elevated, and rubor when dependent -loss of hair on legs, often thin and shiny

How do you Inspect legs for edema?

Inspect the legs for unilateral or bilateral edema. Note veins, tendons, and bony prominences. If the legs appear asymmetric, use a centimeter tape to measure in four different areas: circumference at mid-thigh, largest circumference at the calf, smallest circumference above the ankle, and across the forefoot. Compare both extremities at the same locations

Question: Do you experience pain or cramping in your legs? If so, describe the pain (aching, cramping, stabbing). How often does it occur? Does it occur with activity? Is the pain reproducible with same amount of exercise? If you have pain with walking, how far and how fast do you walk prior to the pain starting? Is the pain relieved by rest? Are you able to climb stairs? If so, how many stairs can you climb before you experience pain? Does the pain wake you from sleep? Rationale?

Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD; American College of Cardiology Foundation/American Heart Association [ACCF/AHA], 2011). Most clients with PAD are asymptomatic until more advanced disease is present (Mann, 2013). Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

What if you can't feel the popliteal pulse? What else should you do then?

It is not unusual for the popliteal pulse to be difficult or impossible to detect, and yet for circulation to be normal. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. Cyanosis may be present yet more subtle in darker-skinned clients

What is the primary function of the lymphatic system?

Its primary function is to drain excess fluid and plasma proteins from bodily tissues and return them to the venous system.

A note!!! Hair loss on the lower extremities occurs with aging and is, therefore, not an absolute sign of arterial insufficiency in the older client

Just because gpa aint got the hair no more don't mean he got that there arterial insufficiency

Explain stage 3 lymphadema. Reversible or irreversible?

LE has progressed to the lymphostatic elephantiasis stage, at which the limb is very large. Affected area is nonpitting, often with permanent eczema. Skin is firm and thick, with hard (fibrotic) underlying tissue having an unresponsive feel. Skin folds develop. At increased risk for recurrent cellulitis, infections (lymphangitis), or ulcerations. Affected limb may ooze fluid. Elevation will not alleviate symptoms. irreversible.

Inspect for lesions or ulcers. Normal?

Legs are free of lesions or ulcerations

Question 13 of 20 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 seconds Have the client stand upright after tourniquet removal Tourniquet should be put on before leg elevation Ensure that the client's legs are over the side of the bed SUBMIT ANSWER

Legs should be elevated for 15 seconds

The posterior tibial pulse

Located in the groove between the medial malleolus and Achilles tendon.

Inspect distribution of hair on legs. AbNormal?

Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well.

What is lymph?

Lymph is the fluids and proteins absorbed into the lymphatic vessels by the microscopic lymphatic capillaries.

Palpate the superficial inguinal lymph nodes. Abnormal?

Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy

Question 17 of 20 The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? Varicose veins Peripheral arterial disease Venous stasis Lymphedema

Lymphedema

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.

Observe arm size and venous pattern; also look for edema. If there is an observable difference, measure bilaterally the circumference of the arms at the same locations with each re-measurement and record findings in centimeters What's abnormal?

Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Prominent venous patterning with edema may indicate venous obstruction

Why is it important to keep an examining room at around 72 degrees F?

Make sure that the room is a comfortable temperature (about 72°F), without drafts. This helps to prevent vasodilation or vasoconstriction

A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?

Measure the diameter of the calves The nurse should complete the inspection process before going on to the other physical assessment techniques. After inspecting asymmetry of the legs, the nurse should measure the calves to determine the exact difference in diameter. Then the nurse can palpate for edema and temperature and notify the health care provider with the information once it is all gathered.

Palpate for edema. Normal finding?

No edema (pitting or nonpitting) present in the legs.

Explain stage 0 lymphadema.

No obvious signs or symptoms. Impaired lymph drainage is subclinical. Lymphedema (LE) may be present for months to years before progressing to later stages. Edema is not evident.

Trendelenburg test. Normal?

No pulsation is palpated if the client has competent valves. Saphenous vein fills from below in 30 seconds. If valves are competent, there will be no rapid filling of the varicose veins from above (retrograde filling) after removal of tourniquet.

If palpable, superficial inguinal nodes are expected to be: Fixed, tender, and at 2.5 cm in diameter Discrete, tender, and 2 cm in diameter Nontender, mobile, and 1 cm in diameter Fixed, nontender, and 1.5 cm in diameter

Nontender, mobile, and 1 cm in diameter

Palpate the superficial inguinal lymph nodes. Normal?

Nontender, movable lymph nodes up to 1 or even 2 cm are commonly palpated.

You can also palpate the brachial pulses if you suspect arterial insufficiency Normal? Abnormal?

Normal - felt equally bilaterally abnormal - Brachial pulses are increased, diminished, or absent

Question 3 of 20 When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? Possible lymphoma Normal finding Atherosclerosis No lymphedema

Normal finding

Palpate the epitrochlear lymph nodes Normal?

Normally, epitrochlear lymph nodes are not palpable

arterial disease

Older clients with _______________ may not have the classic symptoms of intermittent claudication, but may experience coldness, color change, numbness, and abnormal sensations.

Trendelenburg test Explanation: If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The ABPI is considered an accurate objective assessment for determining the degree of peripheral arterial disease. The position change test is done to further assess for arterial insufficiency in the legs following the determination of weak pulses. The Allen test evaluates patency of the radial or ulnar arteries. It is implemented when patency is questionable or before such procedures as a radial artery puncture.

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?

arterial insufficiency

Painful wounds surrounded by healthy skin are associated with _______________ ________________

Observe skin color while inspecting both legs from the toes to the groin. AbNormal findings?

Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency. Cyanosis when dependent suggests venous insufficiency. A rusty or brownish pigmentation around the ankles indicates venous insufficiency

Where is the posterior tibial pulse?

Palpate behind and just below the medial malleolus (in the groove between the ankle and the Achilles tendon)

Question 6 of 20 A nurse palpates a weak left radial artery on a client. What should the nurse do next? Document the finding in the client's record. Palpate both radial arteries for symmetry. Assess the left hand for pallor and coolness. Palpate the left ulnar artery

Palpate both radial arteries for symmetry

Why should you palpate both posterior tibial pulses at the same time?

Palpating both posterior tibial pulses at the same time aids in making comparisons. Assess amplitude bilaterally

Question 14 of 20 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? Peripheral arterial disease Venous disease Neuropathy secondary to diabetes Advanced chronic arterial occlusive disease SUBMIT ANSWER

Peripheral arterial disease

Question 2 of 20 When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause? Peripheral arterial disease Arterial aneurysm Venous insufficiency Chronic lymphedema

Peripheral arterial disease

Question 2 of 20 When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause? Peripheral arterial disease Arterial aneurysm Venous insufficiency Chronic lymphedema SUBMIT ANSWER

Peripheral arterial disease

Question 5 of 20 A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? Peripheral vascular problems Calcium deficiency Obstruction in the femoral artery Diabetes mellitus

Peripheral vascular problems

Ask the client to lie supine. Then drape the groin area and place a pillow under the client's head for comfort. Observe skin color while inspecting both legs from the toes to the groin. Normal findings?

Pink color for lighter-skinned clients and pink or red tones visible under darker-pigmented skin. There should be no changes in pigmentation.

Perform the Allen test. Normal?

Pink coloration returns to the palms within 3-5 seconds if the ulnar artery is patent. Pink coloration returns within 3-5 seconds if the radial artery is patent.

Palpate for edema. Abnormal findings?

Pitting edema is associated with systemic problems, such as congestive heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema). A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe

Question 4 of 20 What pulse is located in the groove between the medial malleolus and the Achilles tendon? Popliteal Posterior tibial Femoral Dorsalis pedis

Posterior tibial

Question 12 of 20 The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate? "Quitting smoking and keeping good control of your blood sugar levels are important." "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD." "If you develop swelling in your ankles or feet, then you should seek emergency care." "It's critical that you come to get screening tests twice annually." SUBMIT ANSWER

Quitting smoking and keeping good control of your blood sugar levels are important

Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength. Normal?

Radial pulses are bilaterally strong (2+). Artery walls have a resilient quality (bounce)

Question: Have you noticed any color, temperature, or texture changes in your skin? Rationale?

Rationale: Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles are associated with venous insufficiency.

A client seeks medical attention for the condition shown. What finding does the nurse anticipate? (white fingers)

Raynaud's disease is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours. Venous insufficiency, deep vein thrombosis, and arterial insufficiency all affect the blood vessels of the lower extremities.

Observe coloration of the hands and arms. Abnormal?

Raynaud's disorder is sometimes referred to as a disease, syndrome, or phenomenon (National Heart, Lung, Blood Institute, 2011). It is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours. Raynaud's affects about 5% of the population and can often be controlled with minor lifestyle changes

Smoking

Risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm.

Hypertension

Risk factor for arterial disease and abdominal aortic aneurysm.

Obesity and Smoking

Risk factors for the development of arterial and venous disease.

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive?

Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill. The other options are distracters to the question.

Question 1 of 20 What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply. Cardiac output Intraluminal valves Skeletal muscle contraction Activity level Respiration

Skeletal muscle contraction Respiration Intraluminal valves

Palpate the client's fingers, hands, and arms, and note the temperature Normal?

Skin is warm to the touch bilaterally from fingertips to upper arms.

Explain stage 2 lymphadema. Reversible or irreversible?

Skin tissue is firmer. Skin may look tight, shiny, and tissue may have a spongy feel. Pitting may or may not be present as tissue fibrosis (hardening) begins to develop. Elevation does not completely alleviate the swelling. Hair loss or nail changes may be experienced in affected extremity. Assistance will be needed to reduce edema Spontaneously reversible

Stage 3

Stage of Lymphedema: Lymphedema has progressed to the lymphostatic elephantiasis stage, at which the limb is very large. Affected area is nonpitting, often with permanent eczema. Skin is firm and thick, with hard (fibrotic) underlying tissue having an unresponsive feel. Skin folds develop. At increased risk for recurrent cellulitis, infections (lymphangitis, or ulerations. Affected limb may ooze fluid. Elevation will not alleviate symptoms.

Stage 0

Stage of Lymphedema: No obvious signs or symptoms. Impaired lymph drainage in subclinical. Lymphedema may be present for months before progressing to later stages. Edema is not evident.

Stage 2

Stage of Lymphedema: Skin is firmer. Skim may look tight, and tissue may have a spongy feel. Pitting may or may not be present as tissue fibrosis (hardening) begins to develop. Elevation dos not completely alleviate the swelling. Hair loss or nail changes may be experienced in affected extremity. Assistance will be needed to reduce edema. (Spontaneously irreversible)

Stage 1

Stage of Lymphedema: Swelling is present. Affected area pits with pressure. Elevation relieves swelling. Skin texture is smooth. (Spontaneously reversible)

Explain stage 1 lymphadema. Reversible or irreversible?

Swelling is present. Affected area pits with pressure. Elevation relieves swelling. Skin texture is smooth. Spontaneously reversible.

Numbness Color change Pain

Symptoms of complete arterial occlusion include which of the following? Select all that apply.

peripheral artery disease (PAD)

Symptoms: -intermittent claudication (pain in the leg when walking) - most common -numbness -weakness -coldness -sores on toes -change in skin color of legs -hair loss or slow growth on legs -shiny skin -slow growing toe-nails -diminished pulses in legs and feet - erectile dysfunction

T / F - Older clients with arterial disease may not have the classic symptoms of intermittent claudication, but may experience coldness, color change, numbness, and abnormal sensations

TRUE

How do you Palpate the epitrochlear lymph nodes?

Take the client's left hand in your right hand as if you were shaking hands. Flex the client's elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles (Fig. 22-12). If nodes are detected, evaluate for size, tenderness, and consistency. Repeat palpation on the opposite arm.

What does the Allen test evaluate? How do you perform the Allen test?

The Allen test evaluates patency of the radial or ulnar arteries. It is implemented when patency is questionable or before such procedures as a radial artery puncture. The test begins by assessing ulnar patency. Have the client rest the hand palm side up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries. Continue pressure to keep both arteries occluded and have the client release the fist Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand. To assess radial patency, repeat the procedure as before, but at the last step, release pressure on the radial artery.

When assessing temperature of the skin, which portion of the hand should the examiner use?

The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. The nurse may have difficulty detecting subtle differences without using the backs of the fingers.

Arterial occlusion

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

Check feet daily for cuts or pressure areas.

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

During an assessment, the nurse first performs the action shown. (legs up) After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

The color change test is to check for arterial insufficiency. With the patient supine, the legs are elevated about 30 cm (12 in.) above the level of the heart. Then when have the patient sit up and dangle the legs. Color should return to the feet and toes within 10 seconds. The superficial veins of the feet fill within 15 seconds. Return of color taking longer than 10 seconds or persistent dependent rubor indicates arterial insufficiency. This is not a technique to assess lymphedema, the femoral pulse, or intermittent claudication.

What nodes are located approx 3 cm above the elbow on the inner aspect of the arm?

The epitrochlear nodes are located approximately 3 cm above the elbow on the inner (medial) aspect of the arm.

Major provider of blood to the legs?

The femoral artery is the major supplier of blood to the legs. Its pulse can be palpated just under the inguinal ligament.

brachial arteries

The largest arteries of the upper extremities are the

The ______________ _____________, an integral and complementary component of the circulatory system, is a complex vascular system composed of lymphatic capillaries, lymphatic vessels, and lymph nodes.

The lymphatic system

Calf Pain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot depending on the level of the obstruction. Absence of this pain does not rule out significant vascular disease, actually, the minority of these clients are symptomatic.

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?

intermittent claudication Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity

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

getting regular exercise Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, decreasing the risk for developing PVD.

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by

Elevate the legs on pillows. Explanation: Common complaints of venous ulcer pain include: aching pain and feeling of heaviness which is relieved with elevation of the legs.

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?

Smoking Family history Hypertension

The nurse is discussing risk factors of an aneurysm. What should be included? Select all that apply.

Immobility Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis.

The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

To avoid sitting for long periods Explanation: Patients with lymphatic disorders have several issues that you must address. As with venous disease, edema in the extremities is the primary symptom of lymphedema. Suggest that the patient avoid sitting or standing for long periods.

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?

Quitting smoking and keeping good control of your blood sugar levels are important.

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?

Quitting smoking and keeping good control of your blood sugar levels are important. Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests.

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?

Venous insufficiency

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?

What veins connect the superficial veins with the deep veins?

The perforator veins connect the superficial veins with the deep veins

Allen test Prior to the cannulation of the radial artery, an Allen test should be performed to assess the patency of collateral circulation.

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

knee

The popliteal artery can be palpated at the

nurse assessing pulse- posterior tibial

The posterior tibial pulse is located in the groove between the medial malleolus and Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament. The popliteal pulse is located behind the knee lateral to the medial tendon. The dorsalis pedis pulse is located halfway up the foot, immediately lateral to the extensor tendon of the great toe.

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

Palpate the posterior tibial pulses Normal?

The posterior tibial pulses should be strong bilaterally. However, in about 15% of healthy clients, the posterior tibial pulses are absent

This is cool. The radial and ulnar arteries join to form what just below their pulse sites?

The radial and ulnar arteries join to form two arches just below their pulse sites. The superficial and deep palmar arches provide extra protection against arterial occlusion to the hands and fingers

Where you palpate the radial pulse?

The radial pulse can be palpated on the lateral aspect of the wrist

True

The radial pulse is palpated over the lateral flexor surface.

The _________________ _________________ __________________ consist of two groups: a horizontal and a vertical chain of nodes. The horizontal chain is located on the anterior thigh just under the inguinal ligament, and the vertical chain is located close to the great saphenous vein. These nodes drain the legs, external genitalia, and lower abdomen and buttocks

The superficial inguinal nodes consist of two groups: a horizontal and a vertical chain of nodes. The horizontal chain is located on the anterior thigh just under the inguinal ligament, and the vertical chain is located close to the great saphenous vein. These nodes drain the legs, external genitalia, and lower abdomen and buttocks

Which nodes are the only lymph nodes accessible to examination?

The superficial lymph nodes are the only lymph nodes accessible to examination.

What are the two superficial veins of the legs?

The superficial veins are the great and small saphenous veins. The great saphenous vein is the longest of all veins and extends from the medial dorsal aspect of the foot, crosses over the medial malleolus, and continues across the thigh to the medial aspect of the groin, where it joins the femoral vein. The small saphenous vein begins at the lateral dorsal aspect of the foot, travels up behind the lateral malleolus on the back of the leg, and joins the popliteal vein

The two deep veins in the legs are?

The two deep veins in the leg are the femoral vein in the upper thigh and the popliteal vein located behind the knee. These veins account for about 90% of venous return from the lower extremities.

Question: Do you, or does your family, have a history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated cholesterol or triglyceride levels? Rationale?

These disorders or abnormalities tend to be hereditary and cause damage to blood vessels. An essential aspect of treating PVD is to identify and then modify risk factors.

What do the epitrochlear nodes drain?

These lymph nodes drain the lower arm and hand.

Why is it important to evaluate aspects of the client's lifestyle and health factors that may impair peripheral vascular health?

These questions provide the nurse with an avenue for discussing healthy lifestyles that can prevent or minimize peripheral vascular disease (PVD). Some of the history questions may overlap those asked when assessing the heart and the skin because of the close relationship between systems.

Why is it important for the nurse to ask about personal and family history of vascular disease?

This information provides insight into the client's risk for a recurrence or development of problems with the peripheral vascular system.

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction. The other options are distracters to the question.

How do the veins propel blood back to the heart with their low pressure, no force system?

Three mechanisms of venous function help to propel blood back to the heart. one-way valves. These valves permit blood to pass through them on the way to the heart and prevent blood from returning through them in the opposite direction. muscular contraction. Skeletal muscles contract with movement and, in effect, squeeze blood toward the heart through the one-way valves. creation of a pressure gradient through the act of breathing. Inspiration decreases intrathoracic pressure while increasing abdominal pressure, thus producing a pressure gradient.

Palpate bilaterally for temperature of the feet and legs. Use the backs of your fingers. Compare your findings in the same areas bilaterally (Fig. 22-16). Note location of any changes in temperature. normal?

Toes, feet, and legs are equally warm bilaterally.

T / F - With disorders of the peripheral vascular system, severe symptoms may not occur until there is extensive damage

True

The radial pulse is palpated over the lateral flexor surface. a) False b) True

True

T / F - Disorders of the peripheral vascular system may develop gradually

True.

T / F - a third function of the lymphatic system is to absorb lipids (fats) from the small intestine into the blood stream.

Truth! A third function of the lymphatic system is to absorb fats (lipids) from the small intestine into the bloodstream.

T / F - Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease.

Truth.

Question: Do you have any sores or open wounds on your legs? Where are they located? Are they painful? Rationale?

Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle

Inspect for lesions or ulcers. AbNormal?

Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle result from venous insufficiency

What is unilateral edema and how's it characterized? How would you test for unilateral edema?

Unilateral edema is edema on one leg more than the other. It is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. Measure the ankles/calves and if a difference of 1 cm at ankle or 2 cm at calves, there is unilateral edema.

Question: Do you have any leg veins that are rope-like, bulging, or contorted? Rationale?

Varicose veins are hereditary but may also develop from increased venous pressure and venous pooling (e.g., as happens during pregnancy). Standing in one place for long periods of time also increases the risk for varicosities

Inspect for varicosities and thrombophlebitis Abnormal?

Varicose veins may appear as distended, nodular, bulging, and tortuous, depending on severity. Varicosities are common in the anterior lateral thigh and lower leg, the posterior lateral calf, or anus (known as hemorrhoids). Varicose veins result from incompetent valves in the veins, weak vein walls, or an obstruction above the varicosity. Despite venous dilation, blood flow is decreased and venous pressure is increased. Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted

Varicose veins result from...

Varicose veins result from incompetent valves in the veins, weak vein walls, or an obstruction above the varicosity.

Raynaud's Disease

Vascular disorder caused by vasoconstriction or vasospasm of the fingers and toes. Usually occurs bilaterally. Characterized by: rapid changes in color, swelling, pain, numbness, tingling, tenderness,burning, throbbing, and coldness

Inspect for varicosities and thrombophlebitis. Normal?

Veins are flat and barely seen under the surface of the skin.

Superior vena cava

Veins of the arms, upper trunk, head and neck carry blood to the _____________, where it passes into the right atrium

What is venous stasis?

Venous stasis, or venostasis, is a condition of slow blood flow in the veins, usually of the legs. Venous stasis is a risk factor for forming blood clots in veins (venous thrombosis), as with the deep veins of the legs (deep vein thrombosis or DVT

Palpate the femoral pulses. AbNormal?

Weak or absent femoral pulses indicate partial or complete arterial occlusion

Posterior tibial

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Peripheral arterial disease

When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause?

Normal finding Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Venous thromboembolism Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

Upper torso Head Upper extremities The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium. The lower extremities and lower torso drain into the inferior vena cava.

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

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain.

Which of the following wounds is most likely attributable to neuropathy?

Brachial pulse The brachial pulses are located at approximately the inner third of the antecubital fossa when the palm is held up. It is not usually necessary to palpate the ulnar pulse, which is difficult to locate.

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward?

malignancy. Explanation: Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy.

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with

Thin, shiny, atrophic skin

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

Perform the Allen test. Abnormal findings?

With arterial insufficiency or occlusion of the ulnar artery, pallor persists. With arterial insufficiency or occlusion of the radial artery, pallor persists

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

You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

Inspect distribution of hair on legs. Normal?

You got the hair! Hair covers the skin on the legs and appears on the dorsal surface of the toes.

Trendelenburg test. Abnormal?

You will feel a pulsation with your upper fingers if the valves in the veins are incompetent. Filling from above with the tourniquet in place and the client standing suggests incompetent valves in the saphenous vein. Rapid filling of the superficial varicose veins from above after the tourniquet has been removed also indicates retrograde filling past incompetent valves in the veins.

Hair loss

__________ on the lower extremities occurs with aging and is, therefore, not an absolute sign of arterial insufficiency in the older client.

Superficial veins

___________ are the great and small saphenous veins.

Deep veins

________of the leg: the femoral vein and popliteal vein.

What is the ABI?

a screening tool used to detect asymptomatic arterial disease in the legs to prevent progression to claudication or limb ischemia and detect individuals at high risk of cardiovascular events.

If palpable, superficial inguinal nodes are expected to be: a) Nontender, mobile, and 1 cm in diameter b) Fixed, nontender, and 1.5 cm in diameter c) Fixed, tender, and at 2.5 cm in diameter d) Discrete, tender, and 2 cm in diameter

a) Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with a) malignancy. b) localized infection. c) arterial insufficiency. d) systemic infection.

a) malignancy.

The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. the nurse should a. apply K-Y jelly to the client's skin b. place the client in a supine position with the head flat c. place the tip of the probe in a 30 degree angle to the artery d. apply gel used for ECG to the client's skin

a. apply K-Y jelly to the client's skin

The popliteal artery can be palpated at the a. knee b. great toe c. ankle d. inguinal ligament

a. knee

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for a. lymphedema b. Raynaud disease c. poor peripheral pulses d. bruits over the radial artery

a. lymphedema

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that tthe client may be experiencing a. venous insufficiency b. arterial occlusive disease c. venous ulcers d. ankle edema

a. venous insufficiency

leg pain that awakens a pt from sleep is often associated with what disease

advanced chronic arterial occlusive disease

determines the patency pf the radial and ulnar arteries

allen test

What is a long-term complication of peripheral vascular disease?

amputation Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of patients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation.

peripheral edema results from what

an obstruction of lymphatic flow or venous insufficiency (caused by incompetent valves or dec osmotic pressure in capillaries)

The pulse can be felt by lightly compressing a superficial artery against what?.

an underlying bone.

the posterior tibial pulse can be palpated at the

ankle

If the patient has risk factors for peripheral artery disease, an _________-____________ _________ screening should be performed.

ankle brachial index

the nurse is preparing to use a doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. the nurse should

apply K-Y jelly

a cool extremity (hands/fingers) may be a sign of what

arterial insufficiency

although loss of hair can be a normal finding in an elderly pt, nurse should perform further assessment before making this judgement; loss of hair is also seen with...

arterial insufficiency

cold, pale, clammy skin on extremities and thin, shiny skin w/ hair loss esp over lower legs are associated with what insufficiency

arterial insufficiency

the position change test is done to further assess for ________ _____________ in the legs following determination of weak pulses

arterial insufficiency

while assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the clients legs. the nurse suspects that the client may be experiencing

arterial insufficiency

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

arterial insufficiency Manifestations of arterial insufficiency include intermittent claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin in cool to cold in temperature and there is a loss of hair over the toes and dorsum of the foot.

nurse should assess ulnar artery pulses to determine what

arterial insufficiency (hands would have pallor and coolness)

Each heartbeat forces blood through the arterial vessels under high pressure, creating a surge. This surge of blood is the

arterial pulse or simply a person's pulse

usually occur on the tips of toes, metatarsal heads and lateral malleoli; ulcers have pale ischemic base well defined edges and no bleeding

arterial ulcer

clients with ulcers due to ________ insufficiency usually present as what, are located where, and are what shape

arterial; *deep ulcers* that often involve *joint space* located on *tips of toes, toe webs, heels, or other pressure areas* if bed-ridden; they are *painful* and *circular*

What are the blood vessels that carry oxygenated, nutrient rich blood from the heart to the capillaries?

arteries

peripheral arteries

arteries of the arms and legs that are accessible to examination.

rigid peripheral vessels; occur more commonly in older adults

arteriosclerosis

when using a Doppler, listen for a *whooshing* sound when echoing from an...

artery

a nurse experiences *difficulty with palpation* of dorsalis pedis pulse in pt w/ *arterial insufficiency*, what is an appropriate action based on this finding (p. 456)

assess adequacy of blood flow using *Doppler device*

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

assist the client to walk as soon and as often as possible Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

While assessing the legs of your patient you note that the legs and feet are cool to the touch. What would you know is most often the cause of bilateral coolness? a) DVT b) Anxiety c) Embolism d) Inadequate arterial circulation

b) Anxiety

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? a) Obtain an order for ankle brachial index test to be performed. b) Assess adequacy of blood flow using a Doppler device. c) Check the extremity for findings of decreased blood flow. d) Attempt to palpate the posterior tibial pulse.

b) Assess adequacy of blood flow using a Doppler device.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis? a) Raise the foot of the bed for an hour and then lower it. b) Assist the client to walk as soon and as often as possible. c) Assist in active range-of-motion exercise of the upper body. d) Massage lower extremities vigorously every 6 hours.

b) Assist the client to walk as soon and as often as possible.

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment? a) Education on nonmodifiable risk factors b) Identification of cardiovascular risk factors c) Plan for modifying risk factors d) History related to grandparents' health

b) Identification of cardiovascular risk factors

A nurse is working with a client who demonstrates venous stasis in his legs. The nurse understands that there must be a problem with one of the mechanisms of venous function that help to propel blood back to the heart. Which of the following are included among these mechanisms? Select all that apply. a) Gravity b) One-way valves in the veins c) Pumping action of the heart d) Pressure gradient produced by inspiration e) Skeletal muscle contraction

b) One-way valves in the veins e) Skeletal muscle contraction d) Pressure gradient produced by inspiration

Which vessels return the lymph fluid to circulation? a) Epitrochlear ducts b) Thoracic ducts c) Internal jugular ducts d) Infraclavicular ducts

b) Thoracic ducts

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

b) Trendelenburg test

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 a. varicose veins b. intermittent claudication c. edema d. thrombophlebitis

b. intermittent claudication

popliteal pulse can be palpated where

behind the knee -> this artery divides below knee into anterior and posterior branches

Where do you Palpate the popliteal pulses?

behind the knee.

As mentioned previously, the lymphatic capillaries function to remove any excess fluid left behind in the interstitial spaces. Therefore, the capillary bed is very important in maintaining the equilibrium of interstitial fluid and preventing edema

blah blah blah

Superficial vein thrombophlebitis

blood clots that form in superficial veins Symptoms: redness, thickening and tenderness along the veing. Swelling and inflammation.

Inferior vena cava

blood from the lower trunk and legs drains upward.

veins

blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissue back to the heart, contain 70% of the body's blood volume . -Larger in diameter than arteries and can expand if blood volume increases.

Arteries

blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries. Walls are thick, strong containing elastic fibers.

The ______________ artery is the major artery that supplies the arm

brachial

The largest arteries of the upper extremities are the

brachial arteries

the major artery that supplies blood to the arm is the

brachial artery

Question 20 of 20 After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's brachial pulse. popliteal pulse. tibial pulse. femoral pulse

brachial pulse

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

brachial pulse

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

brachial pulse You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

lymphedema results from blocked lymphatic circulation, which may be caused by ______ surgery

breast; usually affects one extremity, causing *nonpitting edema*

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

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

c) Check feet daily for cuts or pressure areas.

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find? a) Cool leg on one side b) Cool legs bilaterally c) Cold fingers and hands d) Capillary refill less than 2 seconds

c) Cold fingers and hands

Which of the following assessment findings is most congruent with chronic arterial insufficiency? a) Ulceration on the medial surface of the client's ankle b) Brown pigmentation around a client's ankles and shins c) Cool foot temperature and ulceration on the client's great toe d) Thickened and scarred skin on the client's ankle

c) Cool foot temperature and ulceration on the client's great toe

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test? a) Ask the client to sit on a chair for the examination b) Place the second hand 3 to 4 inches above the first hand c) Firmly compress the lower portion of the varicose vein d) Feel for a pulsation to the fingers in the lower hand

c) Firmly compress the lower portion of the varicose vein

A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next? a) Have the client sit down b) Use a Doppler ultrasound device on the client's leg c) Lightly palpate the client's leg veins for tenderness d) Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe

c) Lightly palpate the client's leg veins for tenderness

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's a) femoral pulse. b) popliteal pulse. c) brachial pulse. d) tibial pulse.

c) brachial pulse

The nurse documents a 2+ radial pulse. What assessment data indicated this result? a) bounding pulse b) diminished pulse c) brisk, expected (normal) pulse d) absent (unable to palpate) pulse

c) brisk, expected (normal) pulse

Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body's blood volume that is contained in the veins is nearly a. 50% b. 60% c. 70% d. 80%

c. 70%

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's a. femoral pulse b. popliteal pulse c. Brachial pulse d. tribal pulse

c. Brachial pulse

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the a. degree of arterial occlusion that exists b. pulse of a client with poor elasticity c. competence of the saphenous vein valves d. severity of thrombophlebitis

c. competence of the saphenous vein valves

The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. The nurse should instruct the client to a. assume a supine position b. rest his arm on the examination table c. flex his elbow about 90 degrees d. make a fist with his left hand

c. flex his elbow about 90 degrees

popliteal artery

can be palpated behind the knee

posterior tibial artery

can be palpated behind the medial malleolus of the ankle.

dorsalis pedis artery

can be palpated on the great-toe side of the top of the foot.

radial pulse

can be palpated on the lateral aspect of the wrist.

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

capillary refill greater than 2 seconds The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool.

the time it takes for color to return to the nail beds after they have been blanched by pressure; a good measure of peripheral perfusion and cardiac output

capillary refill time

Vasoconstriction

capillary refill time exceeding 2 seconds may indicate ___________, decreased cardiac output, shock, arterial occlusion, or hypothermia.

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

check feet daily for cuts and pressure areas Because of decreased blood flow, the client needs to check feet daily for cuts or pressure areas so that treatment to prevent arterial ulcers can begin immediately. Compression stockings should not be worn by clients with peripheral arterial disease. Disfigurement is not common in clients with peripheral arterial disease. There will be decreased hair and the skin will be shiny in clients with peripheral arterial disease.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

check the insertion site for redness Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Flushing the ports with saline can assist the nurse in checking patency of the lines.

Brawny changes and skin thickening, especially near the ankle. Ulceration, brownish pigmentation, and edema in the feet are common. Occasionally bilateray. What is this?

chronic venous insufficiency

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

cigarette smoking previous use of hormones high fat diet

active exercise such as having pt ambulate asap will stimulate __________ and ______ ______

circulation and venous return -> reduces possibility of clot formation and prevents venous stasis

diffuse enlargement of terminal phalanges

clubbing

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find?

cold fingers and hands Raynaud's is exhibited by cold fingers and hands. Cool extremities could be due to a cool room or arterial insufficiency. A capillary refill of less than 2 seconds is normal.

Arterial insufficiency

cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair over, especially over lower legs is associated with ___________

Raynaud's disease (cont.), these vasospasms/vasoconstrictions occur in fingers or toes and cause rapid _bilateral_ changes in...

color (pallor, cyanosis, redness)

the nurse is panning to perform the trendelenburg test on an adult client. then nurse should explains to the client that this test is used to determine the

competence of the saphenous vein valves

lymphatic system

complex vascular system composed of lymphatic capillaries, lymphatic vessels, and lymph nodes.

intermittent claudication

condition of too little blood flow during exercise characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. Relieved with rest. May indicate peripheral arterial disease

Bilateral edema usually indicates a systemic problem such as _____________ _______________ __________________ or a local problem such as lymphadema or prolonged standing or sitting.

congestive heart failure

Perforator veins

connect superficial veins with the deep veins.

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

cool skin

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

cool temp and ulceration on clients great toe 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.

Which of the following wounds is most likely attributable to neuropathy? a) A moderately painful wound on the lateral aspect of the client's ankle b) A painful wound in the client's shin, which is surrounded by apparently healthy skin c) A wound on a client's highly edematous ankle that is surrounded by pigmented skin d) A painless wound on the sole of the client's foot, which is surrounded by calloused skin

d) A painless wound on the sole of the client's foot, which is surrounded by calloused skin

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? a) Shortness of breath b) Knee pain c) Chest pressure with exertion d) Intermittent claudication

d) Intermittent claudication

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what? a) Pulmonary embolism b) Deep vein thrombosis c) Varicose veins d) Intermittent claudication

d) Intermittent claudication

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

d) Lower arm and hand for erythema and swelling

A nurse palpates a weak left radial artery on a client. What should the nurse do next? a) Document the finding in the client's record. b) Palpate the left ulnar artery. c) Assess the left hand for pallor and coolness. d) Palpate both radial arteries for symmetry.

d) Palpate both radial arteries for symmetry.

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? a) Advanced chronic arterial occlusive disease b) Venous disease c) Neuropathy secondary to diabetes d) Peripheral arterial disease

d) Peripheral arterial disease

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease? a) Normal temperature b) Marked edema c) Normal pulsation d) Thin, shiny, atrophic skin

d) Thin, shiny, atrophic skin

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) iliofemoral b) communicating c) saphenous d) popliteal

d) popliteal

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing a) venous ulcers. b) ankle edema. c) arterial occlusive disease. d) venous insufficiency.

d) venous insufficiency

The posterior tibial pulse can be palpated at the a. great toe b. knee c. top of the foot d. ankle

d. ankle

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. the nurse suspects that the client may be experiencing a. venous stasis b. varicose veins c. thrombophlebitis d. arterial insufficiency

d. arterial insufficiency

The major artery that supplies blood to the arm is the a. radial artery b. ulcer artery c. posterior artery d. brachial artery

d. brachial artery

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk facets by a. eating a high-protein diet b. resting frequently c. drinking large quantities of milk d. getting regular exercise

d. getting regular exercise

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, contender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with a. localized infection b. systemic infection c. arterial insufficiency d. malignancy

d. malignancy

While inspecting the skin color of a male client's legs, the nurse observes that the client's legs are slightly cyanotic while he is sitting on the edge of the exam table. The nurse should refer the client to a physician for possible a. arterial insufficiency b. congestive heart failure c. Raynaud disease d. venous insufficiency

d. venous insufficiency

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

deep vein thrombosis 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.

There are three types of veins:

deep veins, superficial veins, and perforator (or communicator) veins.

ankle-brachial pressure index (ABPI) determines what

degree of peripheral arterial disease

how do you calculate ABI (p. 467)

divide higher ankle pressure for each foot by the higher brachial pressure (result is a right foot and left foot ABI)

used to detect a weak peripheral pulse to monitor blood pressure in infants or children and to measure blood pressure in the lower extremity, it magnifies pulse sounds from the heart and blood vessels

doppler ultrasound probe

The dorsalis pedis artery and posterior tibial artery form the_____________ __________, which, like the superficial and deep palmar arches of the hands, provides the feet and toes with extra protection from arterial occlusion

dorsal arch

anterior branch descends down the top of the foot -> becomes

dorsalis pedis artery (can be palpated on the great toe side of the top of the foot)

*dorsiflexing* pt's foot and applying *light pressure* along *extensor tendon of the big toe* are done when palpating for what pulses

dorsalis pedis pulses

swelling caused by excess fluid

edema

What is orthostatic edema?

edema caused by prolonged standing or sitting.

when performing the Allen test, what precaution should nurse take to prevent a false-positive test

ensure pt's hand is not opened in exaggerated extension -> this may cause persistent pallor giving a false-positive

A patient has developed an infection of the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area?

epitrochlear Lymphatics from the ulnar surface of the forearm drain first into the epitrochlear nodes, which are located on the medial surface of the arm approximately 3 cm above the elbow. Lymphatics from the rest of the arm drain into the lateral and central axillary nodes and a few may drain directly into the infraclavicular nodes.

ulnar artery

extends down the little-finger side of the arm, provides blood to the hand.

radial artery

extends down the thumb side of the arm, provides blood to the hand.

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

extent of tobacco use and exposure

Walking contracts the calf muscles and forces blood away from the heart.

false

T / F - arterial network is a low-pressure system.

false. that shit is high pressure!

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?

femoral artery Since the nurse is unable to palpate the popliteal artery, the femoral artery should be palpated to determine if there is blood flow in the extremity. The dorsalis pedis and posterior tibial arteries are located in the foot. If the popliteal artery cannot be felt, it is likely that these two arteries will not be palpable either. Saphenous is a vein and is not routinely palpated to determine blood flow in an extremity.

major supplier of blood to the legs

femoral artery (can be palpated just under inguinal ligament) -> travels down front of thigh then crosses to back of thigh where it is termed *popliteal artery*

for a pt w/ *peripheral vascular disease*, teach them to inc dietary _____ intake, eat a low-___ diet, and to get regular ________

fiber; fat; exercise

lymph nodes

filters that trap and destroy microorganism, foreign materials, dead blood cells, and abnormal cells.

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

firmly compress the lower portion of the varicose vein The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

when performing Trendelenburg test, nurse should do what

first elevate pt's leg for 15 seconds to empty veins -> tourniquet should be put on after leg elevation -> client stands upright w/ tourniquet on leg

the nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. the nurse should instruct the client to

flex his elbow about 90 degrees

lymph

fluids and proteins absorbed into the lymphatic vessels by the microscopic lymphatic capillaries become __________

Veins differ from arteries in that there is no __________ that propels forward blood flow; the venous system is a ____-_____________ system

force low-pressure

hydrostatic force

generated by blood pressure, the primary mechanism by which the interstitial fluid diffuses out of the capillaries and enters the tissue space.

Question 18 of 20 The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by drinking large quantities of milk. resting frequently. getting regular exercise. eating a high-protein diet

getting regular exercise

the nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. the nurse should instruct the client to reduce her risk factors

getting regular exercise

*cervical lymph nodes* drain the ____ and ____

head and neck

blood from legs and lower trunk must flow upward w/ no help from pumping action of the _____ or from _______

heart or from gravity

Which nursing assessment findings support a medical diagnosis of acute lymphangitis? Select all that apply.

history of animal bite red streak noted on skin fever is present Acute lymphangitis presents with red streak(s) on the skin, with tenderness, enlarged, tender lymph nodes, and fever. Bacteria is often introduced by a animal bite. Compartment syndrome presents with pressure and numbness.

The unique filtering mechanism of the lymph fluid through the lymph nodes allows the fluid to be filtered and works hand in hand with the body's __________________ system.

immune

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?

impaired skin integrity This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented.

enlargement of *epitrochlear nodes* indicate infection where

in hand or forearm or may occur with generalized lymphadenopathy

epitrochlear nodes are located where

in the upper inside of the arm

Blood from the lower trunk and legs drains upward into the____________________ _________________ __________________.

inferior vena cava

a condition that indicates vascular deficiencies in peripheral vascular system (reduced blood flow to veins and arteries) is called...

intermittent claudication

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 experiening

intermittent claudication

Hydrostatic force, generated by blood pressure, is the primary mechanism by which the___________________ ________________ diffuses out of the capillaries and enters the tissue space

interstitial fluid

deficient supply of oxygenated arterial blood to a tissue; caused by obstruction of a blood vessel

ischemia

What does the lymph system do?

it removes excess fluid from tissue spaces.

the popliteal artery can be palpated at the

knee

in the case of an acute obstruction (ex: DVT)...

leg pain would persist even when client stops walking/is at rest

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 seconds When 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. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

the low pressure characteristic of veins is of special concern for the veins in the legs. Why?

legs. Blood from the legs and lower trunk must flow upward with no help from the pumping action of the heart.

to fully assess for suspected phlebitis, what do you do

lightly palpate pt's veins for tenderness; pt should be standing during inspection of legs

ulnar pulse

located on the medial aspect of the wrist, a deeper pulse, not easily palpated.

venous system is a ___-pressure system

low

when performing a _compression test_ to assess competence of valves in a pt's varicose veins, firmly compress the _____ portion of varicose vein with ___ hand

lower; one. nurse should ask pt to *stand*, not sit, on a chair during examination

Lymphatic capillaries join to form larger vessels that pass through filters known as______________ ____________, where microorganisms, foreign materials, dead blood cells, and abnormal cells are trapped and destroyed

lymph nodes

what change is considered normal in the lymphatic system of the elderly

lymph nodes are smaller and fewer in number b/c lymphatic tissue is lost w/ advancing age

Edema is soft in early stages, then becomes indurated, hard and nonpitting. Skin is markedly thickened; ulceration is rare. There is no pigmentation. Edema is found in extremities, often bilaterally. This develops when lymp channels are obstructed by tumor, fibrosis, or inflammation, or when lymph nodes have been resected.

lymphedema

Question 19 of 20 A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for Raynaud disease. poor peripheral pulses. lymphedema. bruits over the radial artery

lymphedema

a client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. the nurse should assess the client for

lymphedema

brachial artery

major artery that supplies the arm

femoral artery

major supplier of blood to the legs, can be palpated just under the inguinal ligament.

before beginning an assessment of the peripheral vascular system, a nurse should take what action to best facilitate exam and ensure accurate results

make sure temp in the room is comfortable

while assessing the inguinal lymph nodes on an older adult client the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. then nurse should refer the client to a physician because these findings are generally associated with

malignancy

after inspecting *asymmetry of legs*, the nurse should do what first

measure calves to determine exact difference in diameter (this completes inspection process first) -> then nurse can palpate for edema and temp -> notify provider

Severity of pitting edema

measured on a 1+ to 4+ scale, with 4+ being most severe

ABI reading of < or equal to 0.9

mild ischemia

ABPI of 0.5-1.0 indicates what

mild to moderate arterial insufficiency

venous ulcers

moderately painful ankle wounds surrounded by pigmented skin are often associated with ________________ _________________.

a lack of pain sensation may signal what

neuropathy (in diabetes)

veins differ from arteries in that there is...

no force that propels forward blood flow

If palpable, superficial inguinal nodes are expected to be:

nontender, mobile, 1 cm in diameter

ABI reading of 1.0 means

normal

A nurse assists the client to perform the position change test for arterial insufficiency. While dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test?

normal Return of a pink color to the legs after elevation should take less than 10 seconds. This test does not demonstrate arterial insufficiency. Delayed would be greater than 10 seconds for color to return.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

normal finding Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

Palpate the ulnar pulses normal? abnormal

normal: The ulnar pulses may not be detectable. abnormal: Obliteration of the pulse may result from compression by external sources, as in compartment syndrome. Lack of resilience or inelasticity of the artery wall may indicate arteriosclerosis.

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

notify the healthcare provider The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever.

findings of Raynaud's disease include (5)

numbness, tingling, pain, and burning in fingertips; hallmark finding: *color changes*

Allen Test

occludes ulnar and radial artery to assess circulation. Abnormal finding: only half of palm becomes pink other half remains whitish indicates arterial insufficiency or occlusion of artery released.

Where do you find the dorsalis pedis pulse?

on the top of the foot.

A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?

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.

*leg ulcers* due to *arterial insufficiency* would have what finding

pallor of feet when elevated due to poor blood supply

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

palpate both radial arteries for symmetry Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record.

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?

peripheral artery disease Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

if radial arteries/pulses are both weak, this may indicate a problem with...

peripheral circulation

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

peripheral vascular problems The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

Arteries, veins, capillaries, and lymphatics all make up the...

peripheral vascular system

Type of edema that is soft, bilateral, w pitting on pressure, on the anterior tibiae and feet. No ulceration or pigmentation.

pitting edema

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

popliteal Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse.

edema in the feet or ankles may make it difficult or impossible to palpate for which pulse

posterior tibial pulse -> use Doppler

What are some situations that can result in pitting edema?

prolonged standing or sitting, congestive heart failure, nephrotic syndrome, cirrhosis, malnutrition

if unable to palpate popliteal artery w/ pt in supine position, assist pt to assume what position

prone position and then palpate again -> if still unable to palpate, use Doppler (you can also partially raise pt's leg while prone then place fingers deep in the bend of the knee)

if blood flow is diminished significantly, adequacy of _____ may also diminish

pulse

The artery on the thumb side of the lower arm?

radial artery

the Allen test evaluates patency of what two arteries (implemented when patency is questionable or before procedures such as a radial artery puncture)

radial or ulnar arteries

a vasospastic disorder, primarily affects the hands, characterized by color change from pallor, to cyanosis, to rubor; attacks precipitated by cold or emotional upset and relieved by warmth

raynaud disease

enlargement of *cervical lymph nodes* would be due to... (3)

recent ear infection, sore throat, or other upper respiratory tract infection

risk factors for DVT include (4)

reduced mobility, dehydration, inc viscosity of blood, and venous stasis, such as would occur w/ a sedentary job

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct.

venous insufficiency

rusty or brownish pigmentation around the ankles indicates ____________.

ABPI <0.3 indicates what

severe stenosis -> ischemia and tissue damage

extremities should always be assessed ______________ for pulsation symmetry

simultaneously

risk factors for development of peripheral vascular disease includes... (6)

smoking, lack of exercise, high stress, moderate to high alcohol intake, use of oral contraceptives, and a high-fat diet

nurse should encourage pt to stop _______ b/c it causes ________________ (and plaque formation) -> inc complications brought about by *peripheral vascular disease*

smoking; vasoconstriction

The veins of the arms, upper trunk, head, and neck carry blood to the____________ __________ ____________, where it passes into the right atrium.

superior vena cava

How is the ABI measured?

supine patient, using sphygmomanometer and Doppler ultrasound probe. ABI is calculated as the higher pressure at the ankle divided b the higher of the left and right arm pressures.

Arterial pulse

surge of blood as each heartbeat forces blood through the arterial vessels under high pressure.

orthostatic edema

swelling caused by prolonged standing or sitting

The ABI is a ratio of...

systolic blood pressure at the ankle to the systolic BP in the arm.

indications of abnormal lymph nodes (3)

tenderness, swelling, and irregular shape

Collateral circulation

the alternate circulation around a blocked artery or vein via another path, such as nearby minor vessels.

Which is the longest vein in the body?

the great saphenous vein

Review: The Thoracic duct drains the rest of the body's lymph and empties into which vein?

the left subclavian!

SOLVE THE RIDDLE: OHW ma I? these things are somewhat circular or oval. Normally they vary from very small and nonpalpable to 1 to 2 cm in diameter. they tend to be grouped together. They are both deep and superficial, and many are located near major joints.

the lymph nodes

The brachial artery divides near the elbow to become which two arteries?

the radial artery (extending down the thumb side of the arm) and the ulnar artery

after lymph is filtered, it can drain in two places. Which drains the upper right side of the body?

the right lymphatic duct

venous stasis

the temporary cessation or slowing of the venous blood flow

after lymph is filtered, it can drain in two places. Which drains the rest of the body besides the upper right side of the body? This fluid then back into the venous system circulation through the subclavian veins.

the thoracic duct

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

thin shiny atrophic skin

__________________________ is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted

thrombophlebitis

inflammation of a vein associated with thrombus formation

thrombopphlebitis

What is the purpose of the peripheral vascular assessment?

to identify any signs or symptoms of PVD including arterial insufficiency, venous insufficiency, or lymphatic involvement.

Allen test (cont.)

to perform, pt must rest the hand palm side up and make a fist -> use thumbs to occlude radial and ulnar arteries -> while keeping both arteries occluded, have pt release the fist (more on p. 459)

The radial pulse is palpated over the lateral flexor surface.

true

Artery on the pinky side of lower arm?

ulnar artery

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet?

use a doppler to evaluate presence of a pulse Edema in the feet or ankles may make it difficult or impossible to palpate for the posterior tibial pulse. In these cases, a Doppler should be used to assess for adequate circulation. Elevating the feet will not enhance the pulse. Assessing temperature is not an alternative for assessing circulation because this client demonstrates edema, which shows that circulation is compromised. About 15% of healthy clients may not have a posterior tibial pulse present.

swollen, distended, and knotted veins; occur most commonly in the legs

varicose veins

varicosities

varicose veins may appear distended, nodular, bulging, and tortuous, depending on severity. Result from incompetent valves in the veins. weak vein walls, or an obstruction.

Standing in one place for a long ass time increases the risk for the development of what type of veins?

varicose veins.

regular exercise improves peripheral ________ circulation and dec what (3)

vascular; stress, HR, and BP -> dec risk for PVD

if room is too cold ->

vasoconstriction -> dec circulation

if room is too warm ->

vasodilation -> inc circulation

when using a Doppler, listen for a *nonpulsating, rushing* sound when echoing from a...

vein

the blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart

veins

heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with what disease

venous disease

*warm skin* and *brown pigmentation* around the *ankles* are associated with what insufficiency

venous insufficiency

aching and cramping pain present in *irregular-shaped* ulcers located on the *medial malleolus* is caused by what

venous insufficiency

during a physical examination the nurse detects warm skin and brown pigmentation around an adult clients ankles. the nurse suspects that the client may be experiencing

venous insufficiency

while inspecting the skin color of a male clients leg, the nurse observes that the clients legs are slightly cyanotic while he sitting on the edge of the examination table. then nurse should refer the client to a physician for possible

venous insufficiency

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

venous insufficiency Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus.

immobility creates an environment in which clotting (embolism formation) can be caused by what

venous stasis

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

venous thromboembolism Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.

usually occur in medial malleoli; ulcers have bleeding eneven edges

venous ulcer

ulcers due to ______ insufficiency may be located where, have what kind of borders, and are associated w/ what level of edema

venous; located in the *anterior tibial area*, have *irregular borders*, and are associated with *moderate to severe* edema

capillary bed

very important to maintaining the equilibrium of interstitial fluid and preventing edema.

capillaries

very small blood vessels form connecting network between the arterial and venous circulation

what demonstrates correct technique when using Doppler device to locate peripheral pulses

warming the gel will help to avoid *vasoconstriction* at the site; vasoconstriction makes is difficult to obtain a signal

Palpate the posterior tibial pulses Abnormal?

weak or absent pulse indicates partial or complete arterial occlusion

intermittent claudication is characterized by what factors (5)

weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks (rarely in the feet) w/ activity; if quickly relieved by rest -> may indicate *peripheral arterial disease (PAD)*

lymphatic tissue

with aging, __________ is lost, resulting, in smaller and fewer lymph nodes

An older client is hospitalized with pneumonia. The nurse suspects the client is developing severe sepsis based on which assessment findings? (Select all that apply.) a) Temperature 37.8 degrees Celsius b) Pulse 104 beats/minute c) White blood cell count 10,000/mm3 d) Platelet count 90,000 e) PaCO2 30 mmHg

• Platelet count 90,000 • Pulse 104 beats/minute • PaCO2 30 mmHg Explanation: Inital signs of severe sepsis include: heart rate greater than 90 beats/min; platelet count less than 100,000; temperature less than 36 or greater than 38.3 degrees Celsius; PaCO2 less than 32 mmHg; white blood cells greater than 12,000 or leass than 4,000 mm3.

The nurse explains to the client with a diagnosis of peripheral vascular disease her is at risk for what occurring? Select all that apply. a) Hypertension b) Stroke c) Obesity d) Diabetes e) Myocardial infarction

• Stroke • Myocardial infarction