N403 Ch30 Vascular Disorders and Problems of Peripheral Circulation++

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?

"Don't take aspirin while you're taking warfarin."

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my wife look at the soles of my feet each day."

Which of the following observations regarding ulcer formation on the patient's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

Size is large and superficial

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment?

5

A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

A patient admitted to the medical surgical unit with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect."

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

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

complications of PAD

*Chronic tissue ischemia* -infection -cellulitis -tissue breakdown -gangrene *Acute limb ischemia (acute arterial occlusion)* *emergency* S/S (6 P's) -Pain -Paresthesia -Paralysis -Pale -Pulselessness -Poikilothermia (cold)

risk factors for PAD

*smoking* (vasoconstriction) hyperlipidemia diabetes uncontrolled hypertension men over 45 post-menopausal women obesity sedentary lifestyle

A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.)

- Computed tomography - Transesophageal echocardiography - X-ray

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.

- Constant, intense back pain - Decreasing blood pressure - Decreasing hematocrit

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply.

- Hematoma - Embolization - Dissection of the vessel - Bleeding - Stent migration

assessment of PAD

-*intermittent claudication* -decreased capillary refill of toes > 3 seconds -*priority assessment: check pedal pulse* -decreased peripheral pulse -atrophy- decreased muscle tone from lack of O2 -skin and nail changes- thick nails and dry, scaly skin -*pallor of extremity with elevation* -dependent rubor -pain at rest = severe obstruction

treatment for VTE

-*prevention* is best (ambulation/exercise) -mechanical prophylaxis (SCD's/TED hose) -Bedrest is controversial -IVC filters (keeps emboli from reaching heart)

A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm?

Anastomotic

diagnosing PAD

-ankle-brachial index: compares blood pressure in ankle to blood pressure in upper arm (plethysmography) -doppler/ultrasound -exercise tolerance testing or adenosine stress test: evaluates claudication during exercise -C-Reactive protein: levels rise with inflammation (plaque) -arteriogram: most specific but most invasive; involves injection of contrast agent into blood vessel (*check injection site and pulses*)

medications for PAD

-antihypertensive agents (ACE inhibitors) -hemorheological/vasodilator & anti-inflammatory (pentoxifylline (Trental)-phosphodietrase inhibitor) -antiplatelet agents (acetylsalicyclic acid (Aspirin) /clopidogrel (Plavix)) -statins

prevention of varicose veins

-avoid activities that cause venous stasis -avoid crossing legs/standing -walk for several minutes every hour -wear graduated compression stockings

DVT

-blood clot that forms due to venous stasis, endothelial injury, or hypercoagulability -may cause pulmonary embolus and death -VTE (venous thromboembolism)- the disease process that includes DVT and/or PE

coumadin

-dose based on PT/INR results -if clotting is a problem, it needs to be 2 to 2.5 times the normal -usually started while the patient is still on heparin -antidote is vitamin K -client should be taught to not change their consumption of green leafy vegetables- no more than 2-3 times a week

heparin

-dose based on PTT or unfractionated heparin levels (normal PTT- 25-25 seconds) -antidote is protamine sulfate

chronic venous insufficiency patient teaching

-elevate legs several times a day for at least 15-30 minutes -avoid crossing legs or wearing constrictive clothing -should wear elastic compression stockings and apply them after elevating legs and when swelling is at a minimum (in the morning) -avoid trauma to the limbs -proper foot care -daily moisturizer to decrease itching (not between toes) -wound care consult will be needed -eat a diet high in zinc, protein, and vitamins A & C

varicose veins

-enlarged, twisted, superficial veins -may feel heaviness in the legs; aching, tiredness pain -severity and discomfort is not related to the size of the varicosities

intermittent claudication

-hallmark sign of PAD -muscle pain, ache, cramp, numbness, or sense of fatigue, classically in the calf muscle, that occurs during exercise and is relieved by short period of rest -does not occur with venous disorders

medications for VTE

-heparin -lovenox -coumadin

risk factors, signs, symptoms for VTE

-immobility -Virchow's triad -edema/tenderness/warmth -clinical manifestations vary depending on size, location, degree of vessel occlusion and adequacy of collateral circulation

care of patient with PAD

-ineffective peripheral tissue perfusion, risk for impaired skin integrity, chronic pain -dangle arteries -gradual exercise to tolerance (under physician direction) -avoid crossing legs -inspect feet daily -avoid restrictive clothing -no heating pads or ice packs -stop smoking -DASH diet -teach patient to watch for signs of bleeding (overt: epistaxis (nosebleed), hemoptysis, vomiting blood, coffee ground emesis, black tarry stools; covert: abdominal pain, low blood pressure)

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for:

3 to 5 days. It takes 3 to 5 days for a therapeutic international normalized ratio (INR) to be achieved. Therefore, Coumadin is given concurrently with heparin until a therapeutic level is established, usually within 72 hours.

lovenox

-low molecular weight heparin -subcutaneous -anti-xa: therapeutic level of lovenox

diagnosing VTE

-pre-risk assessment -D-dimer: blood test, if it is elevated you need more testing -Ultrasound- gold standard for DVT -CT and contrast venography

peripheral arterial disease

-progressive and chronic condition where the obstruction of blood flow through the large peripheral arteries causes a partial or total arterial occlusion -lower extremities are deprived of oxygen and nutrients -> ischemia/necrosis -*atherosclerosis*: thickening of arteries (plaque) -*arteriosclerosis*: hardening of the arteries -thrombus

varicose vein interventions

-sclerotherapy -vein stripping -endovenous/laser treatment -radiofrequency energy

manifestations of PE

-shortness of breath -cough -dropping O2 sat -hemoptysis -sharp chest pain -sweating -hypotension

bleeding precautions

-use electric razor -soft toothbrush -avoid aspirin products unless ordered by doctor -avoid injury (contact sports, head injury) -avoid blowing nose forcefully or straining with bowel movement

The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? 0.10 0.25 0.35 0.50

0.50 After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control. A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.

Virchow's Triad

3 categories of factors that contribute to thrombosis -blood stasis -vessel injury -blood coagulation

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

50

Which of the following medications is considered a thrombolytic?

Alteplase Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Alteplase.

The nurse explains to a patient that the primary cause of a varicose vein is:

An incompetent venous valve. Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:

Anterior surface of the foot near the ankle joint.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.

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

Atherosclerosis

A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Bluish urine Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient?

Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches. Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

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

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

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

Cigarette smoking.

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

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

Pentoxifylline (Trental) is a medication used for which of the following conditions?

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

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

In 3 to 5 days

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress The most common trigger for Ray-naud's phenomenon is cold and stress. Vibration can be an irritant that should be minimized or eliminated.

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the:

Common iliac artery. The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?

Computed tomography angiography (CTA)

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse?

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate how to apply and remove elastic support stockings.

A woman has sought care from her nurse practitioner for the treatment of a wound on her lower leg that has been slow to heal. When planning this patient's care, what action should the nurse first perform? -Cleanse the wound bed with normal saline and apply a hydrocolloid dressing. -Take a culture and sensitivity swab from the wound bed. -Determine whether the ulcer results from arterial insufficiency or venous insufficiency. -Prescribe the woman a course of broad-spectrum antibiotics.

Determine whether the ulcer results from arterial insufficiency or venous insufficiency. When planning the treatment of wounds to the lower extremities, it is imperative to determine whether the wound has a venous or arterial etiology. This must precede wound care and is more important than culture and sensitivity testing or beginning oral antibiotics.

Which of the following are characteristics of arterial insufficiency?

Diminished or absent pulses

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

Which of the following aneurysms results in bleeding into the layers of the arterial wall?

Dissecting

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?

Elevate the legs periodically for at least 15 to 20 minutes.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

Epinephrine

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

Epinephrine Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.

Which of the following medication classifications lyses and dissolves thrombi?

Fibrinolytic

Which class of medication lyses and dissolves thrombi?

Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

Hemorrhage. All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homans' A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Hyperbaric oxygen Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

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

Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?

Intermittent claudication

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

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

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

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent. Lowering the extremity to a dependent position improves perfusion to the distal tissues.

A nurse is completing an assessment on a patient and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which of the following terms?

Lymphadenitis

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Moderate to severe arterial insufficiency

Aortic dissection may be mistaken for which of the following disease processes?

Myocardial infarction (MI)

Which of the following are risk factors for venous disorders of the lower extremities?

Obesity

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in a regular walking program.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess?

Peripheral pulses every 15 minutes following surgery

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

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

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate. Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

Protamine sulfate

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

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

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT)

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose appoximately 99% of bleeding disorders on the basis of PT and PTT values.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?

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

Which of the following is the most effective intervention for preventing progression of vascular disease?

Risk factor modification

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy?

Scheduled eye surgery in 1 week

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking.

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

Taking daily walks

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply a graduated compression stocking.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

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

What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis?

Teach the patient how to apply an elastic sleeve

A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the following is the most likely cause?

The aneurysm may be preparing to rupture.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

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

A patient is receiving enoxaparin (Lovenox) and warfarin (Coumadin) therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin (Lovenox) can be discontinued?

The patient's international normalized ratio (INR) is 2.5.

The nurse is assessing a hospital client who has low albumin levels due to liver disease. What assessment finding should the nurse attribute to the client's low albumin levels?

There is severe edema to the client's legs and abdomen. Albumin helps to keep fluids within the vascular space. Deficiencies, as a result, cause the release of fluid into interstitial spaces, causing edema. Hypoalbuminemia does not cause excessive bleeding, reduced energy or respiratory difficulties.

Which of the following is the most common site for a dissecting aneurysm?

Thoracic area

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?

Ulceration

What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue?

Ulcers and infection in the edematous area

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

Which term refers to enlarged, red, and tender lymph nodes? a) Lymphadenitis b) Lymphedema c) Lymphangitis d) Elephantiasis

a) Lymphadenitis Acute lymphadenitis = enlarged, red, and tender lymph nodes Lymphangitis = acute inflammation of the lymphatic channels Lymphedema = swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels Elephantiasis = condition in which chronic swelling of the extremity recedes only slightly with elevation

A community health nurse is providing an educational event at the local seniors' center. The topic the nurse is speaking about is varicose veins. What would the nurse suggest as proactive preventative measure for varicose veins?

Walking for several minutes every hour to promote circulation A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. It is measurable, increases blood return to the heart, and promotes overall wellness. Sitting with crossed legs may promote relaxation but it is contraindicated for patients with or at risk for varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with or at risk for varicose veins; socks that are below the muscles of calf do not promote venous return because the socks simply capture the blood and promote venous stasis.

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

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

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

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

Which aneurysm results in bleeding into the layers of the arterial wall? a) Dissecting b) False c) Saccular d) Anastomotic

a) Dissecting Dissection = rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall - Saccular = collect blood in the weakened outpouching - False = the mass is actually a pulsating hematoma - Anastomotic = occurs as a result of infection at arterial suture or graft sites

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin can be discontinued? a) INR = 2.5 b) PT is 0.5 times normal c) aPTT is half of the control value d) Potassium level is 3.5

a) INR is 2.5

Which term refers to leg pain that is brought on by walking and caused by arterial insufficiency? a) Intermittent claudication b) Thromboangiitis obliterans c) Orthopnea d) Dyspnea

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

A nurse is caring for a client following an arterial vascular bypass graft in the leg. Which should the nurse plan to assess over the next 24 hours? a) Peripheral pulses every 15 minutes after surgery b) BP every 2 hours c) Color of the leg every 4 hours d) Ankle-are indices every 12 hours

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

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

a) Teach the client how to apply an elastic sleeve

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

medical interventions for PAD

angioplasty/stents arterial re-vascularization -assess 5 P's -*watch for hypo or hypertension* -*graft occlusion is a serious complication that usually occurs in the first 24 hours post-op*

phlebitis

arteries bring blood to area-> veins can't take it away-> blood stagnates and begins to irritate the tissue

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

b) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet" The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions - vasoconstriction = decreased arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets

Which diagnostic test is used to quantify venous reflux and calf muscle pump ejection? a) Contrast phlebography b) Air plethysmography c) Lymphoscintigraphy d) Lymphangiography

b) Air plethysmography

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

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

The nurse is assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? a) Superficial ulcer b) Diminished or absent pulses c) Aching, cramping pain d) Pulses that are present but difficult to palpate

b) Diminished or absent pulses

The nurse knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? a) Lymphangiography b) Duplex ultrasound scan c) Lymphoscintigraphy d) Contrast phlebography

b) Duplex ultrasound scan Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? a) Trauma b) Obesity c) Pacing wires d) Surgery

b) Obesity Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE

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

b) Ulcers and infection in the edematous area

The nurse completes discharge teaching for a client following a femoral-to-popliteal bypass graft. What response by the client indicates that the teaching was effective? a) "I can stop the exercises that were started in the hospital once I return home" b) "I can now stop taking my Lipitor because my leg is fixed" c) "I will call if I develop any coldness, numbness, tingling, or pain the surgical leg" d) "It will important for me to sit at the kitchen table to promote better breathing"

c) "I will call if I develop any coldness, numbness, tingling, or pain the surgical leg"

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? a) "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring" b) Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants" c) "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect" d) "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis"

c) "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect" Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5-2 times normal or the INR is 2.0-3.0)

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give? a) 30 b) 20 c) 50 d) 40

c) 50

In a client with a bypass graft, the distal outflow vessel must have at least what percentage of patency for the graft to remain patent? a) 20 b) 30 c) 50 d) 40

c) 50 The distal outflow vessel must be at least 50% patent for the graft to remain patent

Which aneurysm occurs as a result of infection at arterial suture or graft sites? a) False b) Dissecting c) Anastomotic d) Saccular

c) Anastomotic

Which statement is accurate regarding Reynaud disease? a) The disease generally affects the client bilaterally b) It affects more than two digits on each hand or foot c) Episodes may be triggered by unusual sensitivity to cold d) It is most common in men 16 to 40 years of age

c) Episodes may be triggered by unusual sensitivity to cold Episodes of Reynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits

Which class of medication lyses and dissolves thrombi? a) Factor XA inhibitors b) Anticoagulant c) Fibrinolytic d) Platelet inhibitors

c) Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi

A client in the ED has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining the client's history, which symptoms will it be most important for the nurse to ask about? a) Changes in bowel and bladder habits b) Back or lumbar pain c) Hoarse voice and difficulty swallowing d) Abdominal swelling and tenderness

c) Hoarse voice and difficulty swallowing Symptoms are dyspnea, the result of pressure of the aneurysm sac against the trachea, a main bronchus, or the lung itself; cough, frequently paroxysmal and with a brassy quality; hoarseness, stridor, or weakness or complete loss of the voice (aphonia), resulting from pressure against the laryngeal nerve; and dysphagia (difficulty in swallowing) due to impingement of the aneurysm on the esophagus

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

c) Intermittent claudication

Which term refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Ischemia b) Bruit c) Intermittent claudication d) Aneurysm

c) Intermittent claudication

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? a) is deep, involving the joint space b) Base is pale to black c) Large and superficial d) Though superficial, is very painful

c) Large and superficial Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and high exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color

Which is a risk factor for venous disorders of the lower extremities? a) Trauma b) Surgery c) Obesity d) Pacing wires

c) Obesity

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

c) Ulcers and infection in the edematous area In a client with lymphedema, the tissue nutrition is impaired as a result of stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is a) air plethysmography b) lymphangiography c) contrast phlebography d) lymphoscintigraphy

c) contrast phlebography When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein - Air plethysmography quantifies venous reflux and calf muscle pump ejection - Lymphangiography: contrast media are injected into the lymph system - Lymphoscintigraphy = radioactive-labeled colloid is injected into the lymph system

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

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

A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm? a) Saccular b) False c) Dissecting d) Anastomotic

d) Anastomotic

A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge? a) Methods of keeping the wound area dry b) Prophylactic antibiotic therapy c) Adequate carbohydrate intake d) Application of graduated compression stockings

d) Application of graduated compression stockings Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the angle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing the flow in the deep veins

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

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

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

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

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes a) depresses the cough reflex b) causes diuresis c) slows the heart rate d) causes vasospasm

d) causes vasospasm Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system.

Buerger's diesase

inflammation and thrombosis in small and medium-sized blood vessels, typically in the legs and leading to gangrene associated with smoking males

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

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

chronic venous insufficiency

occurs due to incompetent valves in the deeper veins of the lower extremities

Raynaud's disease

vasospasm of the small vessels in the hands caused by exposure to cold females wear gloves