Peripheral Vascular and Lymphatics

The nurse continues assessment of Lourdes' upper extremities, palpating the brachial and radial pulses. Which approach is best for the nurse to use when assessing for capillary refill? - Observe the nailbed angle. - Depress the client's nailbed. - Place the client's fingertips in a dependent position. - Count the radial pulse for 30 seconds.

Depress the client's nailbed. (To assess capillary refill, the RN first compresses the nailbed for 3 seconds. This results in blanching of the nailbed. The RN then measures the amount of time necessary for return of normal color of the nailbeds: the capillary refill time.)

After ensuring that arterial circulation is present, the nurse next assesses Lourdes' wound. The wound Lourdes mentioned is located on the plantar surface of her right foot, on the ball of the foot. The nurse observes that the wound bed is red and the tissue immediately surrounding the wound is inflamed. The nurse plans to document the stage of the wound. What additional action should the nurse take to correctly stage the wound? - Determine the depth of the wound and underlying tissue damage. - Measure the width of the wound from front-to-back and side-to-side. - Note the amount, color, and character of the wound drainage. - Observe the tissue to determine the phase of wound healing.

Determine the depth of the wound and underlying tissue damage. (Pressure ulcers are staged based on the depth of tissue damage to the dermis and underlying tissues, which may include underlying tendons, joint capsules, bones, and muscles.)

After completing the interview, the nurse continues the assessment, focusing first on the lower extremities.

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Before leaving the room, the supervisor asks the nurse to obtain several venous blood samples for lab work prescribed by the HCP as soon as possible.

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Following completion of the nursing assessment and medical evaluation, Lourdes is given prescriptions to treat her foot ulcer and the cut on her forearm, and for further blood work.

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The HCP prescribes several medications. Lourdes is given an antiplatelet medication to prevent clot formation, antihyperglycemic to control blood sugar, antihypertensive to prevent blood pressure elevation, and the medication cilostazol (Pletal) to help dilate the arteries. The nurse administers Cilostazol (Pletal) tablets 100 mg orally twice daily. Only 50 mg tablets are available. How many 50 mg tablets will the nurse give daily? (Enter numeric value only. If rounding is necessary, round to the whole number.)

100 mg x 2(twice daily)= 200 mg daily only have 50 mg available. 200mg/ 50mg =4 tab daily of 50mg

Lourdes asks the nurse about the function of the lymph nodes. Which is the best answer the nurse can give in response to how the lymphatic system works? - The lymphatic system provides immunity by collecting red blood cells that destroy foreign cells. - Lymph nodes filter useful substances and contain lymphocytes that activate the immune system. - The lymph system carries the lymphocytes throughout the body. They respond to foreign and abnormal substances, and communicate responses to other parts of the body. - Lymph travels through multiple lymphatic channels and nodes before returning to the venous system by the hepatic duct.

- The lymph system carries the lymphocytes throughout the body. (They respond to foreign and abnormal substances, and communicate responses to other parts of the body. This summarizes the function of the lymphatic system most concisely and in the most understandable way.)

Lourdes is admitted to the acute care facility for treatment of cellulitis of her left arm. Her foot ulcer is slowly healing, but further tests confirm diminished peripheral arterial circulation in her lower extremities and the onset of diabetes mellitus.

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Meet the Client: Ms. Lourdes Ramirez. Ms. Lourdes Ramirez is a 48-year-old Hispanic female. She visits the community clinic, reporting to the nurse that her feet feel numb that and she has a small sore on the bottom of her right foot. Ms. Ramirez mentions to the nurse that she underwent surgery for breast cancer 2 years ago.

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After completing the focused assessment of Lourdes' pedal pulses, the wound on the bottom of her foot, and Lourdes' subjective report of numbness, the nurse begins to obtain the client's history, focusing on data related to her peripheral vascular system. To learn about any history of intermittent claudication, what question should the nurse ask? - "When do you first stand up, do you feel dizzy or light-headed?" - Can you feel your pulse pounding after vigorous activity?" - Have you experienced any leg cramping or pain in your legs?" - Do you have an urge to move your legs a lot during the night?"

"Have you experienced any leg cramping or pain in your legs?" (Claudication is cramp-like calf pain, associated with diminished blood supply to the leg muscles. When this pain occurs only at specific times, such as during activities, it is referred to as intermittent claudication.)

A client reports that she often experiences leg cramps, usually after walking around the park. What follow-up question by the nurse provides the best information about the client's claudication distance? - "When did you first notice you were having leg cramps?" - "How long have you been walking this same distance?" - "On a 10-point scale, how would you rank your pain?" - "How far do you walk before the leg cramps begin?"

"How far do you walk before the leg cramps begin?" (Claudication distance refers to the distance, such as blocks walked, or stairs climbed, that produces pain.)

The nurse has already observed that both of Lourdes' feet are cool and pale. What questions should the nurse ask Lourdes to obtain additional supporting data? - "Do your toes or toenails ever look blue." - "After a bump, do you bruise easily?" - "Are any of your veins bulging or crooked?" - "Have you ever had a blood clot?" - "Do you feel tingling, numbness, or burning sensations in your legs and feet?"

- "Do your toes or toenails ever look blue." (Cool skin temp. and pallor are signs of diminished arterial circulation. Cyanosis, a bluish color, of the tips of the toes or nail beds, is also an indicator of decreased arterial circulation.) - "Do you feel tingling, numbness, or burning sensations in your legs and feet?" (Cool skin temp., paresthesia, and pallor are signs of diminished arterial circulation. Cyanosis, a bluish color of the tips of the toes or of the nail beds is also an indicator of decreased arterial circulation. )

Which question that Lourdes ask the nurse, indicate that more teaching needs to be done? - "Should I use sunblock and avoid extreme temperatures?" - "Will I receive a diuretic for the swelling?" - "Should I elevate my affected limb while sleeping?" - "Is it possible that I will have to wear a compression sleeve?"

- "Will I receive a diuretic for the swelling?" (This answer requires more teaching because diuretics should not be used to help lymphedema. They draw off water in the interstitial spaces, and once the diuretic is out of the system, it will pull more water into the affected area.)

The nurse next palpates the axillary nodes. Using the pads of the fingers, the nurse moves over the node area in a circular motion. Two nodes are palpable and are easily movable. What actions should the nurse take in response to this finding? - Document the assessment as within normal limits in the assessment record. - Note the amount of pressure needed to occlude the nodes and prevent movement. - Apply pressure more firmly until all the nodes in the area can be palpated. - Assess the nodes further for consistency and any palpable matting. - Ask Lourdes if any there is any tenderness upon palpation of the nodes.

- Assess the nodes further for consistency and any palpable matting. (If lymph nodes are palpable, the nurse should assess for mobility, size, shape, consistency, and whether the nodes are discrete or matted. These findings should then be documented in the assessment record.) - Ask Lourdes if any there is any tenderness upon palpation of the nodes. (If lymph nodes are palpable, the nurse should assess for tenderness. This finding should then be documented in the assessment record.)

Which nursing diagnoses are a priority when developing Lourdes' plan of care? - Impaired physical mobility. - Disturbed body image. - Risk for infection. - Risk for impaired skin integrity. - Chronic lymphedema related to status post breast cancer surgery.

- Impaired physical mobility. (Lymphedema can make mobility difficult, especially lower extremity lymphedema. It is important to assess the client and refer to physical therapy for exercises and activity restrictions.) - Disturbed body image. (A client with lymphedema may have a disturbed body image from such things as wearing over-sized clothes or two different sized shoes. It is important to address these things with the client.) - Risk for infection. (Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis.) - Risk for impaired skin integrity. (Skin on the affected arm may be more dry than normal. Good skin care is essential to prevent infection; wraps and compression stockings may retain moisture against the skin.)

Lourdes' capillary refill is less than 2 seconds, within normal limits. A complete arterial circulation assessment includes a Modified Allen's Test. Which approach is best for the nurse to use to conduct this test? - Instruct Lourdes to make a fist several times for about 30 seconds. - Place the client's hand in a dependent position. - Obliterate the ulnar and radial pulses. - Instruct Lourdes to flex all of her fingers. - Document that the test results show inadequate circulation to the hand if pinkness fails to return within 6 seconds.

- Instruct Lourdes to make a fist several times for about 30 seconds. (Making a fist several times causes the hand to blanch during the Modified Allen's Test.) - Obliterate the ulnar and radial pulses. (The ulnar and radial arteries are obliterated by holding pressure for a few seconds until pallor in the hand occurs.) - Document that the test results show inadequate circulation to the hand if pinkness fails to return within 6 seconds. (A blanched hand or pallor in the fingernails greater than 6 seconds after releasing ulnar pressure indicates inadequate circulation.)

The clinic supervisor enters Lourdes' room, and the nurse gives the supervisor a brief report, based on the assessment completed up to this point. It is most important to report which finding to the supervisor? - Lack of dependent rubor. - Location of varicose veins. - Stage 2 pressure ulcer. - Bilateral cyanosis in both legs. - Ankle brachial index of .94.

- Stage 2 pressure ulcer. (A stage 2 pressure ulcer in a client with diminished sensation and circulation requires intervention and should be immediately reported to the supervisor.) - Bilateral cyanosis in both legs. (Bilateral cyanosis with diminished sensation and circulation requires intervention and should be immediately reported to the supervisor.)

While the nurse assesses the wound, Lourdes mentions that she found a stone in her shoe and that she thinks that the stone caused the sore on her foot. She states she never felt the stone in her shoe. The nurse questions Lourdes further about the onset of loss of sensation in her feet, and proceeds with the client interview.

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Lourdes asks the nurse approximately how many lymph nodes an adult has. Which is the most factual answer the nurse can provide to the client about lymph nodes? - 25. - 2,000,000. - 650. - 150.

650. (A healthy adult has approximately 600 to 700 lymph nodes.)

When reporting to the supervisor, the nurse tells the supervisor that the client's pressure sore developed because the client had a stone in her shoe that she couldn't feel. How should the nurse summarize this initial report by the client? - Foot paralysis bilaterally. - Discomfort in both feet. - Numbing pain in her feet. - Bilateral paresthesia in the feet.

Bilateral paresthesia in the feet. (Paresthesia refers to abnormal sensation, such as numbness or tingling, so this is the best terminology to describe the client's report of numbness and lack of feeling in her feet.)

The nurse next plans to determine the client's ankle brachial index. What equipment should the nurse obtain prior to completing this measurement? - Measuring tape. - Blood pressure cuff. - Pulse oximeter. - Tourniquet.

Blood Pressure cuff. (A blood pressure cuff along with a Doppler probe is used to obtain the systolic blood pressure in the lower extremity. To calculate the ankle branchial index (ABI), this value is compared with eth systolic blood pressure in the upper extremity.)

What is the best way for Lourdes to identify the affected or at risk extremity? - Tie a string around the affected extremity. - Put the affected extremity in a sling or brace. - Carry a wallet card or ID bracelet that identifies the affected extremity. - Have the HCP call first.

Carry a wallet card or ID bracelet that identifies the affected extremity. T(his is the most effective way to remind HCP to avoid venipunctures, blood pressures, and fingersticks on the affected extremity.)

Although there is no visible swelling, Lourdes' legs are large, so the nurse gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the nurse take next? - Document the presence of non-pitting edema. - Note that there is currently no edema present. - Ask the client to elevate her legs and repeat. - Compress the tissue more firmly for 5 seconds.

Compress the tissue more firmly for 5 seconds. (To effectively assess for pitting edema, the RN should firmly depress the tissue for 5 seconds, release, and measure any resultant indentation.)

Lourdes returns to the clinic in 1 week and reports that her arm seems to be more swollen and inflamed. To validate this subjective report, the nurse assesses for edema in Lourdes' arm, noting that 2+ pitting edema is present. During her previous visit, the edema in Lourdes' arm was recorded as 1+. What action should the nurse implement? - Reassure Lourdes that the swelling has decreased slightly. - Confirm that Lourdes' arm is more swollen than previously. - Document that the swelling has doubled since the last assessment. - Note that the indentation is half as deep as the previous assessment.

Confirm that Lourdes' arm is more swollen than previously. (Pitting edema of 1+ indicates mild pitting, or pitting of 2 mm.Pitting edema of 2+ indicates moderate edema, or pitting of 4 mm. This finding reflects that Lourdes' arm is more swollen than during the previous assessment.)

In selecting a site to draw the blood sample, the nurse observes that Lourdes' left forearm is swollen. Lourdes reports that she cut her left forearm a week earlier and reminds the nurse that she had left breast surgery 2 years previously. The nurse draws the blood samples from Lourdes' right arm and then proceeds to assess Lourdes' lymph nodes. To palpate the epitrochlear node, the nurse palpates the area above and behind the medial condyle of the humerus but is unable to palpate the node. What action should the nurse take next? - Palpate the area below the medial condyle. - Ask the client to slowly flex her elbow. - Document that the node is not palpable. - Apply pressure over the antecubital fossa.

Document that the node is not palpable. (The epitrochlear lymph node is located in the groove between the biceps and triceps muscles, above the medial epicondyle of the humerus and is not normally palpable.)

Lourdes' feet are pale and cool to the touch, consistent with the weak, thready pedal pulses palpated by the nurse. The nurse uses a Doppler ultrasound stethoscope to confirm the presence of the dorsalis pedis pulses. After applying gel to the transducer and placing the transducer over the middle of the dorsal surface of the foot, the nurse hears a regular swooshing sound. What action should the nurse take? - Notify the healthcare provider(HCP) immediately of the lack of a pulse. - Move the end of the transducer closer to the toes and listen again. - Remove the excess gel, apply pressure more gently and try again. - Document the presence of the pulse heard by Doppler ultrasound.

Document the presence of the pulse heard by Doppler ultrasound. (A regular swooshing sound indicates that a pulse is heard with the Doppler ultrasound stethoscope. This finding should be documented.)

The nurse asks Lourdes to stand and assesses for the presence of varicose veins. A large, dilated, torturous vein is observed, so the nurse checks for valve competence by placing one hand at the lower end of the vein, and then compressing the vein with the other hand 20 cm higher. While Lourdes is standing, the nurse notes the absence of any dependent rubor. What action should the nurse take in response to this finding? - Document this finding on the physical assessment form. - Immediately help the client sit down and elevate her legs. - Lightly palpate the calves for warmth or tenderness. - Assess for range of motion in the lower legs and feet.

Document this finding on the physical assessment form. (Dependent rubor, a deep blue-red color when the legs are in a dependent position, occurs with severe arterial insufficiency. The absence of dependent rubor is a normal assessment finding, and should be documented in the physical assessment but requires no further intervention.)

The nurse determines that Lourdes' wound is a stage II pressure ulcer. The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the presence of any undermining tracts, what action should the nurse implement? - Note the amount and appearance of any drainage to help determine the depth. - Gently irrigate the wound with sterile saline to determine the depth. - Insert a sterile, cotton-tipped applicator to measure the depth. - Use a sterile forceps to apply sterile packing to help determine the depth.

Insert a sterile, cotton-tipped applicator to measure the depth. (A sterile, cotton-tipped applicator can be gently inserted to measure the depth of the wound and any undermining tracts.)

Lourdes then asks the nurse why the lymphatic system is so important. Which instruction is most important for the nurse to give a client who has lymphedema, when teaching about the importance of the lymphatic system? - It circulates blood throughout the body. - It plays a major role in the body's defense against diseases. - It helps to maintain the byproducts of cellular feeding, such as carbon dioxide and sodium in your body. - It moves cancer cells away from the lymph nodes.

It plays a major role in the body's defense against diseases. (The lymph system circulates lymphocytes, such as T, B and NK cells that help prevent disease.)

After assessing the femoral artery, the nurse palpates the inguinal lymph nodes. What technique should be used? - Lightly press the palmar surface of one hand over the inguinal area. - Move the finger pads over the area using a gentle circular motion. - Firmly compress the area until blanching occurs and then release. - Gently press downward with the fingertips until the node is felt.

Move the finger pads over the area using a gentle circular motion. (This technique allows effective palpation of the lymph nodes.)

During the health history, Lourdes reported that her feet and ankles swell occasionally. To assess for edema, what action the nurse take first? - Ask the client to lie down and elevate her feet and legs. - Observe and compare the client's lower extremities. - Gently compress the tissue on the top of the client's feet. - Ask the client to gently dorsiflex each of her feet.

Observe and compare the client's lower extremities. (The RN should first assess for edema by observing a client's legs for any obvious swelling and by comparing the two extremities for differences in size.)

During her initial clinic visit, Lourdes' radial pulse volumes were recorded as 3+ bilaterally. Assessment by the nurse finds that the left radial pulse volume is now 1+ and the right radial pulse volume is 3+. What additional assessment is most important for the nurse to implement? - Observe the appearance of the left hand. - Palpate the rate of the ulnar pulses bilaterally. - Measure the fingernail capillary refill of the right hand. - Compare hand grip strength bilaterally.

Observe the appearance of the left hand. (A 1+ pulse volume indicates diminished circulation, so further assessment of the left hand is a priority. The RN should assess the color, warmth, and capillary refill.)

How should Cilostazole (Pletal) be taken? - With 2 full glass of water or juice. - One hour before, or two hours after a meal. - Prior to driving. - In the morning and before bed.

One hour before, or two hours after a meal. (The medication is most effective if taken on an empty stomach.)

The nurse palpates the dorsalis pedis pulses bilaterally and determines that both pulses are weak and thready. What additional assessment information will validate this finding? - Pale, cool skin. - Flushed, moist skin. - Inflamed, hot skin. - Dry, inelastic skin.

Pale, cool skin. (Weak, thready pulses indicate diminished arterial circulation. Pale, cool skin is also likely to be present when arterial circulation is diminished, validating the finding of weak, thready pulses.

The nurse prepares to complete a history and physical assessment. Ms. Ramirez asks the nurse to call her Lourdes. The nurse reviews Lourdes' initial complaint that her feet feel numb. Which assessment should the nurse perform first? - Locate the inguinal lymph nodes. - Measure toenail capillary refill. - Compare calf circumferences. - Palpate the dorsalis pedis pulses.

Palpate the dorsalis pedis pulses. (Because the client has complained of numbness, it is important to assess for the presence and strength of the pedal pulses, a measure of the arterial circulation to the feet. The acute absence of arterial circulation would require immediate intervention.)

The nurse begins the assessment at the client's inguinal area, assessing the femoral artery and the inguinal lymph nodes. The nurse palpates the femoral artery and notes that it is weak. The nurse decides to assess for the presence of a bruit. What action should the nurse take? - Feel the inguinal area with the back of the hand. - Firmly compress the artery with the fingertips. - Position a stethoscope over the artery. - Observe the site for bulges or swelling.

Position a stethoscope over the artery. (A bruit is a swooshing sound heard when blood flow through an artery is turbulent. It is heard by placing a stethoscope over the artery.)