peripheral vascular diseases edited

PERIPHERAL VASCULAR DISEASE

OVERVIEW OF ANATOMY AND PHYSIOLOGY

STRUCTURE & FUNCTION OF BLOOD VESSELS

BLOODVESSELSchannels

blood distributed to body tissues

WALLS OF AN ARTERY OR VEIN 3 LAYERS

1- tunica intima2-tunica media3-tunica adventitia

the pressure a vessel must endure determine– thickness of the walls – amount of connective

tissue – smooth muscle

DIVIDED INTO THE ARTERIAL & VENOUS SYSTEM

ARTERIAL SYSTEMhigh pressure vessels, – Aorta- largest

branch into arterioles

less than 0.5 mm in diameter

functions • to deliver blood to

various tissues for nourishment

• contribute to tissue temperature regulation

VENOUS SYSTEM

• large diameter

• thin walled vessels

• less pressure

• Leg veins– contain valves

• regulate one-way flow

1.MUSCULAR PUMP– Milking action of

skeletal muscle contraction

2.RESPIRATORY PUMP– Changes in

abdominal and thoracic pressures occur with breathing

Functions • to return blood

from the capillaries to the right atrium

– for circulation

– acts as a reservoir for blood volume

CAPILLARIES • Connects arterioles and venules

• Permeable to gases and molecules exchanged between blood and tissue cells

• Found between in interwoven networks

• Filter and shunt blood from terminal arterioles to postcapillary venules

B. CIRCULATION AND DYNAMICS OF BLOOD FLOW

BLOOD FLOW• amount of fluid

• per unit of time

• through a vessel, organ or throughout the entire circulatory system

• Systemic circulation–supplies nourishment

to all of the tissue located throughout your body, • with the exception of

the heart and lungs because they have their own systems.

• Systemic circulation–major part of the

overall circulatory system.

• The blood vessels (arteries, veins, and capillaries) – delivery of oxygen and

nutrients to the tissue.• Oxygen-rich blood

– enters the blood vessels– through the heart's main

artery -- the aorta. – The forceful contraction of

left ventricle • forces the blood into the aorta

which • then branches into many

smaller arteries • which run throughout the

• inside layer of artery – very smooth,

• allowing quick blood flow• outside layer of an artery

– very strong, • allowing forceful blood flow.

• The oxygen-rich blood – enters the capillaries where

• oxygen & nutrients are released. • The waste products are

collected • waste-rich blood

– flows into the veins • to circulate back to the heart• Where pulmonary circulation

– will allow the exchange of gases in the lungs.

• During systemic circulation,– blood passes through the

kidneys• renal circulation

– During this phase• the kidneys filter much of the

waste from the blood. – Blood also passes through

the small intestine during systemic circulation.

• portal circulation. – During this phase

• the blood from the small intestine collects in the portal vein

• passes through the liver. • The liver filters sugars from the

blood, storing them for later.

BLOOD FLOW THROUGH THE HEART

• 1. deoxygenated blood – returning from the body enters the heart– through the superior vena cava and

inferior vena cava.

• 2. blood passes into – the right atrium and right ventricle

• 3. right ventricle – pushes the blood – through the pulmonary arteries

• 4. blood passes – through the lungs

• where it loses carbon dioxide • picks up oxygen

• 5. this oxygenated blood – returns to the heart – via the pulmonary veins

• 6. blood enters – the left atrium and left ventricle

• 7. the left ventricle – pushes the blood out

• through the main artery,– the aorta

• 8. blood travels to all parts of the body– where it delivers oxygen – picks up carbon dioxide

FACTORS AFFECTING ARTERIAL CIRCULATION • 1. BLOOD VOLUME

– Volume of blood transported in vessel, organ or throughout entire circulation in a given period of time

FACTORS AFFECTING ARTERIAL CIRCULATION

• 2. PERIPHERAL VASCULAR RESISTANCE [PVR]– Opposing forces or impedance to

blood flow as arterial channels are more distant from heart

– Determined by 3 factors• Blood viscosity-thickness of blood

– Greater viscosity the greater resistance to moving & flowing

• Length of vessel– Longer the vessel the greater the

resistance to blood flow• Diameter of vessel

– Smaller the diameter of vessel, the greater the friction against the walls of the vessel and greater impedance to blood flow

• 3. BLOOD PRESSURE– Force exerted against the walls of

arteries by blood

– Mean arterial pressure –MAP• Highest pressure

– Peak of venticular contraction or systole– SYSTOLIC BLOOD PRESSURE

• Lowest pressure– Exerted during ventricular relaxation– DIASTOLIC BLOOD PRESSURE

– MEAN ARTERIAL PRESSURE [MAP]:MAP= CO [cardiac output] X PVR

– Estimated clinical calculation of MAP• DBP + 1/3 OF PULSE PRESSURE

(DIFFERENCE BETWEEN SYSTOLIC AND DIASTOLIC BLOOD PRESSURE)

• 3. BLOOD PRESSURE• OTHER FACTORS

REGULATING BP

– 1. SYMPATHETIC AND PARASYMPATHETIC NS

• SYMPATHETIC stimulation

– Vasoconstriction of arterioles– Increasing BP

REGULATING BP– 1. SYMPATHETIC AND

PARASYMPATHETIC NS

• PARASYMPATHETIC stimulation

– Vasodilation of arterioles– Lowering BP

REGULATING BP– 1. SYMPATHETIC AND

PARASYMPATHETIC NS

• BARORECEPTORS & CHEMORECEPTORS (in aortic arch, carotid sinus and other large vessels

– Sensitive to pressure and chemical changes causing

» REFLEX SYMPATHETIC STIMULATION

vasoconstrictionincreased HR & BP

REGULATING BP– 2. ACTION OF KIDNEYS TO

EXCRETE OR CONSERVE SODIUM AND WATER

• Kidneys initiate renin-angiotensin mechanism in response to decrease in BP

– Release of aldosterone from adrenal cortex

– Sodium ion reabsorption & water retention

• Kidneys reabsorb water in response to pituitary release of antidiuretic hormone

• Increase in blood volume – Increase CO & BP

REGULATING BP– 3. TEMPERATURE

• Cold – Vasoconstriction

• Warmth– Vasodilation

– 4. CHEMICALS, HORMONES, DRUGS

• Vasoconstriction– Epinephrine– Endothelin [chemical fr.bld vsl inn

lining]– Nicotine

• Vasodilation– Prostaglandin– Alcohol & histamine

REGULATING BP– 5. DIETARY FACTORS

• Salt• Saturated fat• Cholesterol

– 6. OTHER FACTORS• Race• Gender• Age• Weight• Time of day• Position• Exercise• Emotional state

DIANOSTIC TEST AND ASSESSMENT

DIAGNOSTIC TESTS AND ASSESSMENT

• DOPPLER ULTRASOUND measures the velocity of

the blood flow through a vessel emits an audible signal

when arterial palpation is difficult or impossible because of occlusive disease

useful in determining blood flow

palpable pulse & Doppler pulse are not equivalent & should not be used interchangeably

PLETHYSMOGRAPHYbiologic changes in volume in a portion of the body – associated with cardiac contractions or in

response to pneumatic venous occlusion

can detect & quantify vascular disease – changes in pulse contour, blood pressure.

or arterial /venous blood flow

A plethysmography test is • performed by placing blood pressure cuffs on

the extremities • to measure the systolic pressure• The cuffs are then attached to a pulse

volume recorder (plethysmograph) – that displays each pulse wave.

– The test compares the systolic blood pressure of the lower extremity to the upper extremity,

• to help rule out disease that blocks the arteries in the extremities

DIGITAL INTRAVENOUS ANGIOGRAPHY

utilizing computer technology

visualization of blood vessels – occurs after IV injection of

contrast material

allows for small peripheral venous injections of contrast medium, compared with large doses that must be injected via arterial cannulation

DIGITAL INTRAVENOUS ANGIOGRAPHY

VENOGRAPHYinjection of radiopaque dye

into veins serial x-rays are taken to

detect deep vein thrombosis and incompetent valves

ANGIOGRAPHYinjection of radiopaque dye

into arteries to detect plaques,

occlusions, injury, etc…

ANKLE-BRACHIAL INDEXmost commonly used parameter for – overall evaluation of

extremity status

ankle pressure normally is the same or slightly higher than brachial systolic pressure

expected ABI is 0.8 to 1.0

ANKLE-BRACHIAL INDEX

gives the ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery of the arm

COMPUTED TOMOGRAPHY

allows for visualization – of the arterial wall and its

structures

used in the diagnosis of abdominal aortic aneurysm [AAA]

and postoperative vascular complications– graft occlusion – hemorrhage

MAGNETIC RESONANCE IMAGING [MRI]

uses magnetic fields rather than radiation

used with angiography to detect abnormalities

especially in people who are unable to have dye injected

COMMON NURSING TECHNIQUES AND PROCEDURES: BLOOD PRESURE MEASUREMENT

A. BLOOD PRESSUREis primarily a function of cardiac output and systemic vascular resistance

B. ARTERIAL BLOOD PRESSURE=CARDIAC OUTPUT X SYSTEMIC VASCULAR RESISTANCE

1. Client seated – with arm bared, – supported and at heart level

2. Client should not have smoked or ingested caffeine – 30 minutes prior

3. BP – taken in both arms initially

4. Appropriate sized cuff must be used– rubber bladder should

encircle the arm by 80%

C. PROPER TECHNIQUE

5. After palpating the brachial or radial pulse, – inflate the cuff 30 mmHg above the level

at which the pulse disappears

6. Record systolic and diastolic sounds---Korotkoff sounds the disappearance of sound is the

diastolic reading

7. Two or more readings – 2 minutes apart - average

8. If the client’s arms are inaccessible, – thigh or calf, – auscultating the popliteal or posterior

tibial arteries,

cuff size must be adjusted for larger extremity

PATIENTS WITH PERIPHERAL

VASCULAR DISEASE

PERIPHERAL VASCULAR DISEASE

• Disease of blood vessels

• In the periphery– Especially those

supplying to meet the needs to the tissues

IMPAIRED CIRCULATION:PATHOLOGIC CHANGES

• Coldness• Pallor

– Decrease in color– Reduced

oxyhemoglobin– Decrease blood

flow• Buccal mucosa

• Rubor– Redness– Reddish blue color– Superficial vessels

injured– Anoxia– Coldness – dilated

• Cyanosis– Blueness– Seen in areas –least

pigmentation• Lips• Nailbeds• Palpebral conjunctiva• Palms

• Pain– Intermittent

claudication• Tropic changes

– Dryness– Scaling of skin– Brittle toenails

GENERAL NURSING CARE

• Increased arterial blood Increased arterial blood flow and venous returnflow and venous return– Proper positioning– ARTERIAL

• Blood flow towards their legs and feet

• Because they suffer from a deficit of oxygenated blood to their extremities

– VENOUS• Elevate legs above the level of

the heart• Suffer from a pooling of

deoxygenated blood in the extremities and poor venous return to the heart

• Elevate 6 inches block

GENERAL NURSING CARE– Prescribe exercise

• Short walks• Buerger-Allen routine

– Feet up from ½ to 3 minutes

– Sit on edge of bed– Do foot exercise for 3

minutes– Lie down for 5 minutes

• Oscillating bed– If cannot do Buerger-Allen

• Circoelectric bed– To change position– Improve circulation

GENERAL NURSING CARE– Patient Education

• Avoid obesity– Extra pounds exhaust the

heart– Decreases circulation &

increases congestion– DIET: high in protein &

decrease in saturated fat» Prevents breakdown of

tissues» Promote healing of

vascular ulcer– DIET: high vitamin B comp.

» Maintain N health of bld vsl

– DIET: vitamin C» Healing» Prevent bleeding

GENERAL NURSING CARE– Patient Education

• Avoid standing in any position—long period

– Promotes venous stasis• Never wear constricting

clothes– Garters– Girdles– Tight belts– Tight shoe laces– Never cross legs at the

knee» Constricts the popliteal

vessels

GENERAL NURSING CARE– Promote Vasodilation

• Warmth– Home thermostat 70-72°F

» Not to exceed 37.8°C– Apply hot water bottle to abdomen

» Cause reflex dilatation of arteries in extremities» Peripheral nerve degeneration---lessen sensitivity to

heat---resulting to burns– Use of hot water bottles, heating pads and hot foot soaks

» CONTRAINDICATED– Applying heat to extremities

» dangerous

• Prevent vasoconstriction– Nicotine

» Cause vasospasm– High emotion

» Stimulates sympathetic nervous system

– Chilling• Vasodilators

– Cilostazol (Pletaal)» MOA: inhibits pletelet

aggregation & allows vasodilation

» Nsg Resp: minimal side effects, take with meals

• Vasodilators– Pentoxifylline (Trental)

» MOA: decreases viscosity----increased bld flow to microcirculation

» Nsg Resp: take with meals, minimal side effects

– Alcohol» 30-60 ml 3-4 x a day

• Sympathectomy– Surgical procedure– Sympathetic nerve fibers– Severed– Causing relaxation of the

arterioles– Better blood flow

GENERAL NURSING CARE– Prevent and Treat Vascular

Obstruction– Low cholesterol diet– Exercise– Control obesity– Avoid tobacco– Calm & rational attitude

• Venous thrombosis—caused by venous stasis, hypercoagulability of blood, injury to venous wall

– Preventive measures» Avoid prolonged bed rest» Fluids---to prevent

dehydration & hypercoagulability

» Proper positioning» Use anticoagulants &

fibrinolytics

GENERAL NURSING CAREANTICOAGULANTS• Action: prolong clotting time of

blood– Won’t dissolve clots already formed– Prevent extension of clot– Inhibit formation of new clots

• Heparin– ACTION: prevents activation of

thrombin• Inhibits thromboplastin formation

– Hypersensitivity:• Mild fever, urticaria, rhinitis, burning

sensation in the feet

– Parenterally• Destroyed by gastric

secretions • NOT absorbed from GIT

– Effect immediate• Ceases after 3-4 hours

– 50 mg –ave. dose (5000 “μ”)

– IV q 3-4 hrs through heparin lock

– Monitor PTT (partial thromboplastin time) value

• 1.5-2.5 x the control• Therapeutic value

GENERAL NURSING CAREANTICOAGULANTS• Bishydroxycoumarin

(Dicumarol)– ACTION: suppresses the act.

Of liver in formation of prothrombin

– 12-24 hrs to take effect– Persist for 24-72 hrs– 25-100 mg/day p.o. –

maintenance dose– 10-30% normal or 1 ½ to 2 ½

times (18-30 seconds) the normal activity time

– [N 11-13 seconds-controls]

• Warfarin sodium (Coumadin)– Used widely– ACTION: depresses

liver synthesis of prothrombin & factor VII, IX, & X

– Monitor INR value– N 0.75-1.25– Therapeutic level-

2.0-3.0

GENERAL NURSING CAREANTICOAGULANTS• Ethyl Biscoumacetate

(Tromexan)– ACTION: similar to Dicumarol– Acts more quickly– Effects lasts for a shorter time

NURSING RESPONSIBILITIES

• Careful regulation – Amount & continuity of dose

• Drugs that potentiate anticoagulants– Indocin, salicylates, dilantin, noctec,

antibiotics, quinidine, adrenocorticosteroids

• Inhibit anticoagulant effect– Oral contraceptives, barbiturates, lasix

• ANTIDOTE– 1.Protamine Sulfate to heparin

• Acts immediately• Effect persist for 2 hours• 1 % IV

– 2.Vitamin K (Synkavit or aquamephyton) to Dicumarol IV or p.o.

• ANTIDOTE– IM NOT DONE---large painful

hematomas• 2.1Fibrinolytics

– Used to dissolve fibrinous materials & purulent accumulation by direct enzyme action

– Eg. Streptokinase---& Fibrinuclease (Elase)• 2.2Dextran

– Plasma expander- IV– Hasten resolution– Prevent propagation of thrombus– Administered as 500 ml of a 6% solution of NaCl

GENERAL NURSING CARE– Relieve ischemic pain

• By increasing circulation to the extremities

– Prevent tissue damage & infection & promote healing of existing lesions

• Avoid injury– Check bath water with bath

thermometer –instead of toes– Wear shoes to avoid injury to feet– Vigorous rubbing is always avoided

• Leather shoes– Give good support to feet

• Rubber shoes– Not advised– Retard evaporation– Contribute to development of fungal

infection

DISEASES OF THE ARTERIES AND

1.ARTERIOSCLEROSIS

• Thickening and hardening of the arteries

• Involving the intimal layer

• Leading to hypertension

1.ARTERIOSCLEROSIS

• Raises systolic pressure– By decreasing arterial

distensibility– By decreasing lumen

diameter• Narrowing• Decreased elasticity• Elevated Diastolic blood

pressure

1.ARTERIOSCLEROSIS• ATHEROSCLEROSIS

– Is a form of arteriosclerosis– Leading contributor of

coronary artery disease [CAD] & cerebrovascular disease [CVD]

– An inflammatory disease– Begins with endothelial injury

• Smoking, hypertension, diabetes [insulin resistance]

– Progresses through several stages

• Become fibrotic palque

1.ARTERIOSCLEROSIS• ARTERIOSCLEROSIS

– Plaque• Can rupture

– Clot formation– Instability– Vasoconstriction

» Obstruction of the lumen

» Inadequate oxygen delivery to tissues

HYPERTENSION

HYPERTENSION• Elevation of

systemic arterial blood pressure

• Resulting from increases in cardiac output or total peripheral resistance or both

HYPERTENSION

• PRIMARY– Without a

known cause

• SECONDARY– Caused by a

primary disease

HYPERTENSION • RISK FACTORS– Family history [+]– Male– Advancing age– Black race– Obesity– High sodium intake– Low magnesium,

potassium or calcium intake

– DM– Labile BP– Cigarette smoking– Heavy alcohol

consumption

HYPERTENSION• PATHOPHYSIOLOGY

– Damage and inflammation of the vessel walls

• Thick• Hard • Narrow

– Vasoconstriction– Increased permeability of vessel

wall» Influx of sodium, calcium,

water, plasma proteinsincreases smooth muscle contraction

HYPERTENSION• PRIMARY

HYPERTENSION– Unknown etiology

• Overactivity of sympathetic nervous system

• Overactivity of renin-angiotensin-aldosterone system

• Sodium and water retention by the kidneys

• Hormonal inhibition of sodium-potassium transport across the cell walls

• Complex interactions involving insulin resistance and endothelial function

HYPERTENSION– CLINICAL

MANIFESTATIONS– Damage of organs and tissues

outside the vascular system• Heart disease• Renal disease• Central nervous system• Musculoskeletal dysfunction

1. Subjective dataa. past history

– of cardiovascular, – cerebrovascular, – renal or thyroid diseases, – diabetes, – smoking – or alcohol use

b. family history – of hypertension – or cardiovascular disease

c. possible absence of symptoms

d. reports – of fatigue, – nocturia, – dyspnea on exertion, – palpitations, – angina, – headaches, – weight gain, – edema, – muscle cramps – or blurred vision

symptoms caused by target organ damage

2.OBJECTIVE DATAa. BP consistently >140 mmHg systolic and >90 mmHg diastolicprehypertension category of at risk population is systolic BP > 130 or diastolic > 85

b. peripheral edema, retinal vessel changes, diminished/ absent peripheral pulses, bruits, murmurs and S3 and S4 heart sounds

ORTHOSTATIC HYPOTENSION

• Drop in blood pressure

• Occurs on standing• Compensatory

vasoconstriction• Response to

standing is replaced by marked vasodilation

ORTHOSTATIC HYPOTENSION

• ACUTE– Caused by delay in

the normal regulatory mechanisms

• CHRONIC– Secondary to a

specific disease – idiopathic

ORTHOSTATIC HYPOTENSION • CLINICAL

MANIFESTATIONS– Fainting– Cardiovascular

symptoms– Impotence– Bowel and bladder

dysfunction

HYPERTENSION– MANAGEMENT

• Pharmacologic• Nonpharmacologic

E. PLANNING AND IMPLEMENTATION

1. Tell client the numeric blood pressure readings so he or she can keep an on-going record

2. Inform client that hypertension is usually asymptomatic, and symptoms will not reliably indicate BP levels

3. Explain that long-term followup and therapy will be necessary

4. Accurately record intake and output and daily weights of hospitalized clients

MEDICATION THERAPY

1. no one primary drug is used

a combination of drugs are used until desired

blood pressure is achieved with the fewest side effects

2. medications used include diuretics, beta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors [ACE] inhibitors. Angiotensin II receptor blockers [ARBs] and vasodilators

3. the stepped care approach is often used to guide treatmentthis protocol begins with lifestyle changes and adds medications based on response to previous therapy

PERIPHERAL ARTERIAL DISEASE

PERIPHERAL ARTERIAL DISEASEinterrupt or

impede arterial peripheral blood flow

• due to – vessel

compression,– Vasospasm– structural

defects in the vessel wall

ETIOLOGY AND PATHOPHYSIOLOGY

1. primarily caused by atherosclerosis

local accumulation of lipid and fibrous tissue – intimal layer of an artery

• may also be caused by – trauma, – embolism, – thrombosis, – vasospasm, – inflammation – autoimmunity

2. symptoms appear– vessel is about 75 % narrowed

3. the femoral-popliteal area– nondiabetics

• arteries below the knees– diabetic

4. Chronic • inadequate oxygenation of the

tissues – intermittent claudication

ischemic muscle pain• precipitated by a predictable amount

of exercise • relieved by rest

C. ASSESSMENT

1. Subjectivea. client reports

– aching, – cramping, – fatigue or– weakness in the legs that is relieved by rest [claudication]

this is an early indication of disease

b. client reports rest pain

– while resting – awaken the client at night toes, arch, forefoot, heel relieved when foot is placed in the dependent position

this indicates more advanced disease

c. client compliants of – coldness – numbness in the LE

2. Objectivea. extremities - cool & pale - cyanotic

color on elevationb. bruits may be auscultatedc. peripheral pulses may be diminished

or absentd. nails may be thickened and opaque

[trophic change]e. skin on the legs may be shiny with

sparse hair growth [trophic change]f. ulcers-- LE

reduced circulation -deep pale base, demarcated edges, painful

treated with wet to moist saline dressings or surgical revascularization

3. Diagnostic testing

a. digital subtraction angiography [DSA]

b. angiography

c. doppler ultrasound

d. plethysmography

PRIORITY NURSING DIAGNOSES

Ineffective tissue perfusion

Impaired skin integrity

E. PLANNING AND IMPLEMENTATION1. Goal: ADEQUATE TISSUE PERFUSION

a. assess and record strength of pulsesb. encourage client to stop smoking as nicotine causes vasoconstriction & hypercoagulability of bloodc. teach client to change position at least hourly and avoid crossing the legsd. encourage client to exercise and walk to the point of pain as

this decreases claudication explain to stop walking when pain occurs to decrease

oxygen needs to affected area and to resume when pain has stopped in order to build tolerance to exercise and stimulate growth of collateral circulatione. teach client to avoid restrictive clothing, including girdles, garters and socks

2. Goal: RELIEF OF PAINa. assess pain on a 1 to 10 scale and provide

analgesics as ordered

b. teach relaxation techniques because stress increases vasoconstriction

c. keep feet warm and in a dependent positiondo not elevate feet if pain is present

3. Goal: INTACT, HEALTHY SKIN ON EXTREMITIESa. skin care and daily inspection of feetb. always wear shoes / slippers and

avoid trauma to the feetbath water should be checked with

the hands,not with the feet,to prevent burns to tissue at high risk for injury that may also have decreased sensation

c. toenail care performed by a professional onlyd. if an ulcer develops,

healing will be slow unless arterial blood flow to the affected limb is improved

through a surgical revascularization procedure

4. If surgery is indicated, provide appropriate postoperative carea. angioplasty

1] monitor neurovascular statuscolor, motion, sensitivity, temperature

and presence of distal peripheral pulsesto the affectd extremity every 15 minutes x

4, every 30 min x 4, then q 1-4 hrs after sheath removal

2] notify physician if client experiences weak or thready pulses, coolness, numbness or tingling in the extremity

3] monitor the sheath site for signs of external and subcutaneous bleeding at the same frequency s neurovascular assessment

4] instruct the client to notify the nurse and apply manual pressure to the site should a sensation of warmth or wetness be felt at the site

5] maintain immobilization of affected extremity for at least 6 hours by reminding client to keep extremity still or lightly immobilize ankle with sheet tucked under both sides of mattress

6] maintain a pressure dressing and sand bag [or other occlusive device] at site

b. bypass grafting1] provide standard postoperative

care2] assess for occlusion of graft by assessing for severe ischemic pain, loss of pulses, decreasing ankle-brachial index, numbness / tingling in extremity, coolness of the

extremity

c. Endarterectomyopening the artery and removing

obstructing plaqueor amputation in severe casesuse same principles of care

F. MEDICATION THERAPY1. Aspirin inhibits platelet aggregation

2. Pentoxifylline [Trental] decreases blood viscosity to increase blood flow to the microcirculation and tissues of the extremities

3. Cilostazol [Pletal] inhibits platelet aggregation and enhances vasodilation

4. Clopidogrel [Plavix] inhibits platelet aggregation

G. CLIENT EDUCATION

1. Promote vasodilation-provide warmth [never by direct heat to the limb]-prevent long periods of exposure to cold-avoid use of restrictive clothing

2. Proper positioning-keep feet dependent to increase blood flow to legs-may elevate feet at rest but not above level of the heart-never crosslegs or ankles-following bypass surgery, may keep legs level with rest of the body

3. Stop smoking

4. Meticulous foot care as would be performed by clients with diabetes mellitus

5. Trental and Plavix should be taken with food and any effects may take 6 to 8 weeks to notice

6. Notify caregiver of any platelet aggregate inhibitors before undergoing any invasive procedures

7. Exercise program with weight reduction is helpful

CLIENT & FAMILY EDUCATION FOR PERIPHERAL ARTERIAL DISEASEstop smokinglose weight and eat a low fat dietdo not cross legs while sittingelevate feet at rest, but not above heart leveldo not stand or sit for long periods of timedo not wear restrictive clothingkeep affected extremity warm but never apply direct heatinspect feet daily and keep them clean & dryavoid walking barefoot; wear proper fitting shoesavoid mechanical or thermal injury to the legs and feetbegin and maintain an exercise & walking programnotify healthcare provider of any changes in color, sensation,

temperature or pulses in extremities

ARTERIAL EMBOLISM

DESCRIPTIONarterial emboli usually arise from thrombi that developed in the heart as a result of

atrial fibrillation, myocardial infarction, prosthetic valves orcongestive heart failure

B. ETIOLOGY AND PATHOPHYSIOLOGY

thrombi become detached and are carried from the left side of the heart into the arterial system where they may lodge and cause obstruction

the symptoms may be abrupt and will depend on the size and location of the embolus

ischemia will progress to necrosis and gangrene within hours

C. ASSESSMENT: the six P’s

1- pain

2- pallor [pale color]

3- pulselessness [diminished or absent pulses]

4- paresthesia [altered local sensation]

5- paralysis [weakness or inability to move extremity]

6- POIKILOTHERMIA [body temperature that varies with environment]

D. PRIORITY NURSING DIAGNOSES

Ineffective peripheral tissue perfusion

Impaired protection

E. PLANNING AND IMPLEMENTATION1- assess peripheral pulses and neurovascular status

every 2 to 4 hours

2- place affected extremity in a neutral position with no restrictive bedding / clothing---keep extremity warm

3- assess level of pain using a 1 to 10 scale

4- change position every 2 hours to increase or improve collateral circulation

E. PLANNING AND IMPLEMENTATION5- assess for and report unusual bleeding from

anticoagulant therapy

6- monitor lab vaues, including APTT, PT and INR levels

7- if necrosis is present, surgical treatment is required;---an emergency embolectomy needs to be performed within 4 to 5 hours of embolism to prevent necrosis and permanent damage to the extremity

F. MEDICATION THERAPY

---if no necrosis present

thrombolytic therapy with streptokinase

heparin

warfarin therapy at home

G. CLIENT EDUCATION

1- PRE AND POSTOPERATIVE TEACHING IF EMBOLECTOMY IS PERFORMED

2- MEASURES TO PROMOTE PERIPHERAL CIRCULATION AND MAINTAIN TISSUE INTEGRITY

BUERGER’S DISEASE

[THROMBOANGIITIS OBLITERANS]

A. DESCRIPTION

an inflammatory disease of the small and medium sized veins and arteries

accompanied by thrombi and sometimes vasospasm of arterial segments

may occur in upper or lower extremities but is most common in the leg or foot

ETIOLOGY & PATHOPHYSIOLOGY

1- the cause of Buerger’s disease is unknown

but since it occurs mostly in young men who smoke

it is currently thought to be a reaction to something in cigarettes nd/ or to have a genetic or autoimmune component

2- inflammation occurs

mirothrombi form

these can lead to vasospasm

this process ultimately obstructs blood flow

ASSESSMENT1- bluish cast to a toe or finger and

a feeling ofcoldness in the affected limb

2- nerves alsoinflamedthere may be severe pain & constriction of smal blood vessels controlled by them

rest pain is common

3- overactive sympathetic nervesmay cause the feet to sweat excessively---even they feel cold

C. ASSESSMENT

4- blood vessels become blockedintermittent claudication

other symptoms similar to those of chronic obstructive arteril disease aften appear

5- ischemic ulcers and gangrene common complications of progressive Buerger’s disease

• INEFFECTIVE TISSUE PERFUSION

• PAIN

1- arrest progress of disease by smoking cessation

2- take measures to promote vasodilation [similar to other arteril disorders]

3-provide for pain relief

4-provide emotional support

analgesic pain medications

calcium channel blockersto ease vasospasm

pentoxifylline [Trental]to reduce blood viscosity

G. CLIENT EDUCATION

1- stop smoking

2- take measures to promote peripheral circulation maintain tissue integrity

RAYNAUD’S DISEASE

A. DESCRIPTION

LOCALIZED

INTERMITTENT EPISODES OF VASOCONSTRICTION OF SMALL ARTERIES OF THE HANDS

LESS COMMONLY THE FEET

CAUSING COLOR AND TEMPERATURE CHANGES

B. ETIOLOGY AND PATHOPHYSIOLOGY

1- a vasospastic disorder of unknown origin that primarily affects young women

2- vasospastic attacks tend to be bilateral and manifestations usually begin at the tips of the digits causing pallor, numbness and sensation of cold

3-attacks are triggered by exposure to cold, emotional stress, caffeine ingestion, and tobacco use

C. ASSESSMENT1- symptoms may appear in the

hands after exposure to cold and / or stressbilateral and symmetrical

2- classic triphasic color changes in the hands with accompanying reduction in skin temperaturepallorcyanosisrubor

3- the intensity of pain increases as disease progresses

4- the skin of the fingertips may thicken and nails may become brittle

D. PRIORITY NURSING DIGNOSES

INEFFECTIVE TISSUE PERFUSION

CHRONIC PAIN

1- keep hands warm and free from injury

2- avoid stressful situations

3- in severe cases, a sympathectomy

surgical dissection of the nerve fibers that allows vasoconstriction to

occur-may be performed

to relieve symptoms associated with vasospasm

1- analgesics for pain

2- vasodilators may provide some relief of symptoms, as well as vascular smooth muscle relaxants and calcium channel blockers

G. CLIENT EDUCATION

1- keep hands warm-wear gloves when out of doors, in air-conditioned environments or when handling cold food

2- avoid injury to hands

3- lifestyle changes-stop smoking-employ stress relief---eg. biofeedback

AORTIC ANEURYSM

A. DESCRIPTION

-localized dilation

-outpouching of a weakened area in the aorta

is classified by region as thoracic or abdominal, or s dissecting

B. ETIOLOGY AND PATHOPHYSIOLOGY1- aorta is susceptible to aneurysm formation because of constant

stress on the vessel wall

2- aneurysms occur in men more often than women and their incidence increases with age

3- most aneurysms are found in the abdominal aorta below the level of the renal arteries

4- the growth rate of n aneurysm is unpredictable

5-half of all aneurysms greater than 6 cm in size will rupture within 1 year

6- the major risk factor is atherosclerosis

C. ASSESSMENT1- THORACIC ANEURYSMS

asymptomatic with the first sign being rupture

a- symptomspain in the back, neck and substernal area that may only occur when lying supine

b-client may experiencedysphagiadyspneastridor or coughwhen pressing on the esophagus or laryngeal nerve

C. ASSESSMENT

2- ABDOMINAL ANEURYSMSmay also be asymptomatic until rupture

a- the client may report a “heartbeat” in the abdomen when lying down

b- a pulsating abdominal mass may be present

c- moderate to severe abdominal or lumbar back pain may be presentsevere pain may be a sign of impending rupture

C. ASSESSMENT

2- ABDOMINAL ANEURYSMSd- the client may experience claudication

e- cool or cyanotic extremities may be noted

f- systolic bruit my be heard

3- DISSECTING ANEURYSMSpresent with sudden, severe and persistent pain described as “tearing” or “ripping” in the anterior chest or the back

a- pain may extend to the shoulder, epigastric area or abdomen

b- pallor, sweating and tachycardia will be evidenced

c- initially the client may have an elevated BP that may be different in one arm from the other

d- possible syncope and paralysis of lower extremities may be present

ANXIETY

E. PLANNING AND IMPLEMENTATION1. Diagnostic test that may be ordered

a- chest x-rayb- transesophageal echocardiographyc- aortographyd- ultrasounde- CT scan or MRI

2- The overall goals for a client with an aneurysma- normal tissue perfusionb- intact motor and neurologic functionc- reduction in anxietyd- no complications of surgical repair

3. Surgical care

a- surgical management may be performed on an emergency or elective basissurgery not usually performed on aneurysms less than 4 to 5 cm in size

b- emergency surgery is the only intervention for clients with a ruptured aneurysm

c- hematomas into the scrotum, perineum, flank or penis indicate retroperitoneal rupture

d- once the aorta ruptures anteriorly into the peritoneal cavity, death is almost certain

3. Surgical care

e- surgical technique involves excision of the aneurysm with replacement of the excised segment with a synthetic graft

f- preoperatively the nurse marks and assesses all peripheral pulses for comparison postoperatively

g- postoperatively the nurse assesses for complications, which may include:1- graft occlusion2-hypovolemia / renal failure3- respiratory distress4-cardiac dysrhythmias5- paralytic ileus6- paraplegia / paralysis

1- the goal of nonsurgical management is to maintain blood pressure at a normal level to decrese the pressure on the arterial system and reduce the risk of rupture

2- antihypertensive therapy and diuretics may be prescribed

3- pulsatile flow may be reduced by medications that reduce cardiac contractility

4-postoperatively clients will be placed on anticoagulant therapyheparin while the client is in the hospital and warfarin [Coumadin] when discharged to home

G. CLIENT EDUCATION

1- clients who do not undergo operative repair must be urged to receive routine physical exminations to monitor the status of the aneurysm

2- be aware of signs and symptoms of impending rupture[see assessment of dissecting aneurysms]

3-self monitor blood pressure and report any increases immediately

4-how to self-manage anticoangulant therapy

G. CLIENT EDUCATION

5- for postoperative clients, teach routine postoperative carea- do limited lifting for 4 to 6 weeks after surgery [no heavy lifting at all]

b- monitor the incision site for bleeding / infection

c- assess neurovascular status of the extremities and presence of pulses

d- clients who receive a synthetic graft may require prophylactic antibiotics before invasive procedures

H. EXPECTED OUTCOMES / EVALUATION

1- client has normal tissue perfusion

2- the aneurysm does not rupture

3- for surgical clients, absence of postoperative complications and maintenance of normal tissue perfusion postsurgical grafting

THROMBOPHLEBITIS

A. DESCRIPTION

The formation of a thrombus [CLOT] in association with inflammation of the vein

Classified as superficial or deep

ETIOLOGY & PATHOPHYSIOLOGY1- ETIOLOGY

VIRCHOW’S TRIAD[at least 2 or 3 present for thrombosis to occur]

a-stasis of venous flowb-damage to the inner lining of the vein [endothelial layer]c-hypercoagulability of the blood

2-PATHOPHYSIOLOGYa-RBCs, WBCs and platelets adhere to form a thrombus [usually in valve cusps of veins]

b- as thrombus enlarges it eventually occludes the lumen of the vein

c- if only partial occlusion of the vein occurs, blood flow continues and the thrombotic process stopsif detechment does not occur, it will become firmly organized and attached within 24 to 48 hours

d- it detachment occurs, emboli from which generally flow through the venous system, back to the heart, and into the pulmonary circulation

ASSESSMENT1-SUBJECTIVE:

history of thrombophlebitispelvic/ abdominal surgeryobesityneoplasm [hepatic & pancreatic]congestive heart failureatril fibrillationprolonged immobilitymyocardial infarctionpregnancy & / or postpartum periodIV therapyhypercoagulable states [polycythemia, dehydration / malnutrition]

2- OBJECTIVE-signs vary according to thrombus size, location and adequacy of collateral circulation

a. Superficial-palpable, firm, subcutaneous, cordlike vein

-surrounding area warm, red, teder to the touch

-edema may or may not be present

-most common cause in the arms is IV therapy

in the legs it is often related to varicose veins

B- deep-unilteral edema-pain-warm skin and elevated temperature-if the inferior vena cava is involved, both legs will be edematous-if the superior vena cava is

involved, both upper extremities, neck,

back, and face may become edematous or cyanotic

-if the calf is involved, Homan’s sign may be present [pain on dorsiflexion of the foot, especially when the leg is raised]

DIAGNOSTIC STUDIES

a-venous duplex scanningb-Doppler ultrasonic flowmeterc-D-dimer, a poduct of fibrin degradation,

indicates fibrinolysis [that occurs as a reaction to thrombosis]

d-venography & plethysmography, former “gold standards” for diagnosis are rarely used today

e-MRIF-Lung scan

PRIORITY NURSING DIAGNOSES

RISK FOR IMPAIRED SKIN INTEGRITY

C. PLANNING & IMPLEMENTATION

1-educate client about diagnostic tests that may be performed

2-provide for relief of paina-assess pain on a scale of 1 to 10b-elevate affected leg higher than the heart to promote venous drainagec-provide analgesics as ordered

3-decreased edemaa-apply warm,moist compresses, intermittent or

continuous, to affected extremityb-measure and monitor leg/arm circumference when edema is presentc-monitor status of peripheral pulses

4-prevent skin ulcerationa-keep bed covers from touching affected limb by using an overbed cradleb- do not allow use of restrictive clothing

5-prevent pulmonary embolia-maintain strict bedrest, usually enforced until anticoagulant therapy is therapeuticb-never massage affected extremityc- instruct client to report any pink-tinged sputum and

monitor for tachypnea, tachycardia, shortness of breath, chest pain and apprehension, which may indicate a pulmonary embolismd-prepare client for vena cava filter [greenfield filter] placement

MEDICATION THERAPY1-anticoagulant therapy

a-inhibits clotting factors that would extend thrombus formation

b-will not induce thrombolysis but prevents clot extension

c-heparin: intravenously or subcutaneous while in the hospital

d-warfarin: home therapy for 2 to 4 months

2-thrombolyticsa-dissolve blood clots by imitating natural enzymatic processses

b-approved drugs include streptokinase [streptase] and alteplase [activase]

c-is usually effective in less than 72 hours

d-higher risk for hemorrhage exists than when using heparin therapy

CLIENT EDUCATION

1-preventiona-early ambulation postoperativelyb-use of compression stockings or sequential devicec-low dose anticoagulant therapyd-avoid prolonged standing or sitting

avoid sitting with crossed legse-avoid restrictive clothingf-stop smoking

2-provide education about anticoagulant therapy

VENOUS INSUFFICIENCY

DESCRIPTION

INADEQUATE VENOUS RETURN OVER A LONG PERIOD OF TIME THAT CAUSES PATHOLOGIC CHANGES AS A RESULT OF ISCHEMIA I THE VASCULATURE, SKIN, AND SUPPORTING TISSUES

1- occurs after prolonged venous hypertension, which stretches the veins and damages the valves, preventing blood return

2-occurs after thrombus formation or when valves are not functioning correctly,which may result froma-prolonged standing/ sittingb-pregnancy and obesity

3-with time, stasis results in edema of the lower limbs, discoloration to the skin of the legs & feet, venous stasis ulceration

ASSESSMENT1-subjectivea-past history of thrombophlebitis,

hypertension and varicositiesb-past history oflong periods of sitting and / or standing

2-objectivea-edema of the lower legs,may extend to the kneeb-thick, coarse, brownish skin around the ankles [gaiter area] and the feetc-stasis ulcers, usually in the malleolar area [ruddy base, uneven edges]

PRIORITY NURSING DIAGNOSISIMPAIRED SKIN INTEGRITY

RISK FOR INFECTION RELATED TO SKIN ULCERATIONS

DISTURBED BODY IMAGE

PLANNING & IMPLEMENTATION1- increase venous blood return, decrease venous

pressure-bedrest-keep legs elevated-avoid long periods of standing-wear elastic support or compression stockingsa-apply stockings before getting out of the bed & placing the leg in a dependent position

b-wear stockings during the day & evening, remove at night

c-never push stockings down around the leg—they will further impair circulation

d-handwash stockings daily and air dry; machine washing or drying will damage elastic fibers

2-treat venous stasis ulcer/sa-open lesions are treated with a hydrocolloid dressing and compression wraps; a topical ointment, such as low-dose hydrocortisone, zinc oxide, or an antifungal may also be indicatedb-ulcers may be treated with an Unna Boot or other compression wrap that is changed every 1 to 2 weeks and is usually applied over a base dressing c-severe ulcers may need surgical debridement

MEDICATION THERAPY

1-topical agents to skin ulcers, such as hydrocortisone, antifungals or zinc oxide, may be prescribed

2- oral or IV antibiotics may be prescribed when ulcers become infected or cellulitis occurs

3-sclerosing agents [called sclerotherapy] may be used to occlude blood flow in a vein, causing disappearance of the varicosity, this may be followed up with use of compression bandage for a short period of time

CLIENT EDUCATION

1-elevate legs for at least 20 minutes four times a day2-keep legs above the level of the heart when in bed3-avoid prolonged sitting or standing4- do not cross legs when sitting5-do not wear tight, restrictive pants, socks or boots

avoid girdles and garters that restrict circulation in the upper leg

6- wear suppoert stockings as instructed

VARICOSE VEINS

DESCRIPTION

A VEIN OR VEINS IN WHICH BLOOD HAS POOLED, PRODUCING DISTENDED, TORTUOUS AND PALPABLE VESSELS

ETIOLOGY & PATHOPHYSIOLOGY1-one in 5 people worldwide will develop varicosities2-they are more commonin women over 35. those who

are obese, those with a positive family history of varicosities, and those who stand for long periods of time

3-develop from trauma or damages to a vein or valve or from gradual venous distension, which diminishes the action of the muscle pump, and increases the pull of gravity on blood within the legs

4-as the vein swells, increased hydrostatic pressure will push plasma through the stretched vessel walls and edema of surrounding tissue may occur

ASSESSMENT1-subjective

aching, heaviness, itching, swelling and unsightly appearance to the legs

2-objectivea-dilated, tortuous superficial veins will be seen along the upper and lower legb-superficial inflammation c-positive Trendelenburg test [ done to evaluate valve competence]-supine position, elevate legs-as client sits up, the veins would normally fill from the distal end-if [+] varicosities, veins fill from the proximal end

PRIORITY NURSING DIAGNOSIS

RISK FORIMPAIRED SKIN INTEGRITY

RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION

E. PLANNIG & IMPLEMENTATION1-asses and provide pain relief

a-assess pain scale of 1 to 10b-provide analgesics as needed

2-improve venous circulationa-assess pulses and neurovascular status of lower extremitiesb-teach/ apply support stockingsc-avoid prolonged sitting and standing

never cross legs. Walking is encouragedd-elevate feet above heart level when lying downe-avoid restrictive clothing / shoes

3-prevent skin breakdown; teach proper skin care and importance of avoiding trauma to legs

4-teach preoperative and postoperative care if surgery is chosena-sclerotherapy-palliative not curative

-elastic bandage- until 6 weeksb-vein ligation surgery---ligation of the entire vein usually the saphenous and dissection and removal of the incompetent tributaries

-post op-perform hourly circulation checks

-elevate extremity to a15 degree angle to prevent stasis and edema

-apply compression gradient stockings from foot to groin

MEDICATION THERAPY

LOW DOSE ASPIRIN THERAPY—to reduce platelet aggregation and subsequent clot development

CLIENT EDUCATION: PREVENTION1-AVOID SITTING OR STANDING

FOR LONG PERIODS2-CHANGE POSITION OFTEN3-AVOID CONSTRICTIVE CLOTHING4-ELEVATE LEGS WHEN SITTING TO

PROMOTE VENOUS RETURN5-MAINTAIN IDEAL BODY WEIGHT

LYMPHATIC SYSTEM

• Composed of: lymphatic vessels lymphoid organs

• Form network around arterial and venous channels

• Interweave at capillary beds

• Lymph [tissue fluid] leaks from cardiovascular system and accumulates at end of capillary bed

• Fluid returned to heart through lymphatic veins and venules that drain into right lymphatic ductright lymphatic duct and left thoracic ductleft thoracic duct which empty into subclavian vein subclavian vein under the collarbones

• These veins join to form the form the superior vena cavasuperior vena cava, the large vein that drains blood from the upper body into the heart.

• Low pressure system Low pressure system depends on

rhythmic contraction of smooth muscle and muscular and respiratory pumps

• lymphatic system transports fluids throughout the body

• thin-walled lymphatic vessels, lymph nodes, and two collecting ducts

• larger than capillaries

• most are smaller than the smallest veins

Organs of the lymphatic system• LYMPH NODES

– Special cells of immune system

– Remove foreign material, infectious organism, tumor cells from lymph

– Distributed along lymphatic vessels forming clusters in regions of neck, axilla, groin

Organs of the lymphatic system• SPLEEN

– Filters blood by breaking down old red blood cells

– Stores or releases to liver by- products such as iron

– Synthesizes lymphocytes– Stores platelets for blood

clotting– Serves as reservoir for blood

Organs of the lymphatic system

• THYMUS

– Active in childhood

– produces hormones facilitating the immune action of lymphocytes

Organs of the lymphatic system

• TONSILS

– Protect upper respiratory tract

• PEYER’S PATCHES OF SMALL INTESTINE

– Protect digestive tract

• Lymphokinetic motion (flow of the lymph) due to:

• 1) Lymph flows down the pressure pressure gradientgradient.

• 2) Muscular and Muscular and respiratory pumpsrespiratory pumps push lymph forward due to function of the semilunar valvessemilunar valves.

SEMILUNAR VALVES

• either of two crescent-shaped valves in the heart that prevent blood from flowing back into the ventricles.

• The two valves are called the aortic aortic valve and the pulmonary valvevalve and the pulmonary valve

• All lymph passes through strategically placed lymph lymph nodesnodes, which filter filter damaged cells, cancer damaged cells, cancer cells, and foreign particles cells, and foreign particles out of the lymphout of the lymph

• Lymph nodesLymph nodes also produce specialized blood cellsspecialized blood cells designed to engulf and destroy damaged cells, cancer cells, infectious organisms, and foreign particles.

FUNCTIONS OF THE LYMPHATIC SYSTEM

• to remove damaged cells from the body

• to provide protection against the spread of infection and cancer.

• Functions of the lymphatic system:

• to maintain the pressure and maintain the pressure and volume of the extracellular fluidvolume of the extracellular fluid by returning excess water and dissolved substances from the interstitial fluid to the circulation.

• lymph nodes and other lymphoid tissues are the site of clonal of clonal production of production of immunocompetent lymphocytes immunocompetent lymphocytes and macrophages in the specific and macrophages in the specific immune responseimmune response.

ASSESSMENT OF LYMPHATIC SYSTEM

1. SUBJECTIVE DATA

• a. lymph node enlargement

• b. infection or impaired immunityfeverfatigueweight loss

2. PHYSICAL ASSESSMENT

• a. skin over regional lymph node

edemaerythemared streaksskin lesions

1. LYMPHANGITIS

• Inflammation of lymph vessel

red streak with hardness following course of lymphatic collecting duct

2. LYMPHEDEMA• Swelling due to

lymphatic obstruction

congenital anomalytrauma to area as

with surgeryarm lymphedema after radical mastectomy

metastasis

LYMPH NODE ASSESSMENT

• 1.LYMPHADENOPATHY

– Enlargement over 1 cm with or without tenderness indicates inflammation, infection or malignancy of nodes or region drained by nodes

• 2.LYMPHADENITIS [INFLAMMATION]

– Enlargement with tenderness– Bacterial infection – warm , localized swelling

• 3. MALIGNANT OR METASTATIC NODES

– Hard as lymphoma– Rubbery as with Hodgkin’s

disease– Fixed to adjacent structures– Non-tender

• 4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT

– PREAURICULAR AND CERVICAL NODES

• Ear infection• Scalp• Face lesions

– ANTERIOR CERVICAL NODES

• Streptococcal pharyngitis or mononucleosis

– OCCIPITAL NODES• Can occur with brain tumors

– SUPRACLAVICULAR NODES-LEFT

• Suggestive of metastatic disease

– AXILLARY NODES• Associated with breast cancer

– INGUINAL NODES• Lesions of genitals

• 5.PERSISTENT GENERALIZED LYMPHADENOPATHY

– Associated AIDS and AIDS related complex [ARC]

SPLEEN ASSESSMENT WITH ABNORMAL FINDINGS

• Splenic enlargement

– Associated with • Cancer• Blood dyscrasias• Viral infection

– mononucleosis

LYMPHEDEMA

• Tissue edema • Caused by obstructed lymph

flow in an extremity

• Lymphedema results when the lymphatic system cannot adequately drain lymph from the tissues, causing swelling

• PRIMARY LYMPHEDEMA– Congenital

• Present at birth– Praecox

• Developing early in life• Most common type• Second decade of life• females

– Tardia• Developing late in life

ETIOLOGY• PRIMARY

LYMPHEDEMA– Also known as

lymphedema of unknown origin or idiopathic lymphedema

– May be associated with

• Aplasia-no lymph vessels

• Hypoplasia-smaller or fewer lymph vessels than normal

• Hyperplasia-larger or more numerous lymph vessels

ETIOLOGY• SECONDARY

LYMPHEDEMA– Results from damage

or obstruction of the lymph system by disease or procedure

• Trauma• Neoplasms• Mosquito transmitted

filariasis• Inflammation• Surgical excision of

axillary, inguinal or iliac lymph nodes

• High dose radiation therapy

PATHOPHYSIOLOGY• 1.Collection of lymph distal

to a blocked lymphatic results in [backward flow]– increased intralymphatic

pressures Causing• lymphatic wall dilation• Valve incompetency

– Increased intralymphatic pressure leads to

• Protein accumulation in the interstitial spaces

– Increased colloid osmotic pressure in tissues

» Resulting in fluid retention & edema

PATHOPHYSIOLOGY• 1.Collection of lymph distal

to a blocked lymphatic results in [backward flow]– increased intralymphatic

pressures Causing• lymphatic wall dilation• Valve incompetency

– Increased intralymphatic pressure leads to

• Protein accumulation in the interstitial spaces

– Increased colloid osmotic pressure in tissues resulting in

» fluid retention » edema

PATHOPHYSIOLOGY• 2. Chronic lymph

congestion leads to

– Fibrosis– Formation of dense

connective tissue in subcutaneous tissue

ASSESSMENT FINDINGS

• 1. CLINICAL MANIFESTATIONS– A. PRIMARY

LYMPHEDEMA• Nonpitting edema• Dull, heavy sensation• Absence of pain• Roughened skin without

ulceration of skin or cellulitis• Marked limb enlargement

Grades of Lymphedema

The International Society of Lymphology has graded lymphedma into categories:

• Grade 1 – skin is pressed the pressure will leave

– takes some time to fill back in

– referred to as pitting edema.

– swelling can be reduced by elevating the limb for a few hours.

– little or no fibrosis (hardening)

– so it is usually reversible.

• Grade 2 – swollen area is pressed,

– it does not pit,

– swelling is not reduced very much by elevation.

– If left untreated, the tissue in the limb gradually hardens

– becomes fibrotic.

• Grade 3

– Elephantiasis

– almost exclusively in the legs

– after progressive, long term, and untreated lymphedema

– gross changes to the skin

– protrude and bulge

– leakage of fluid through the tissue in the affected area, especially if there is a cut or sore

– rarely reversible.

ASSESSMENT FINDINGS

• 1. CLINICAL MANIFESTATIONS– A. SECONDARY

LYMPHEDEMA• Secondary lymphedema

related to filariasis – Intermittent high fever with

chills– Malaise and fatigue– Tender regional

lymphadenopathy– Severe muscle pain– erythema with increased

edema and elephatiasis [severe edema]

ASSESSMENT FINDINGS • 1. CLINICAL

MANIFESTATIONS– A. SECONDARY

LYMPHEDEMA• Secondary lymphedema

related to neoplasms – Nonpainful lymph node

enlargement or edema

ASSESSMENT FINDINGS• 2. LABORATORY AND

DIAGNOSTIC STUDY FINDINGS– A. LYMPHANGIOGRAPHY

• Injects a contrast medium • visualized on radiograph• Lymphomatous lymph nodes

retain the contrast agent for up to 1 year

ASSESSMENT FINDINGS• 2. LABORATORY AND DIAGNOSTIC STUDY

FINDINGS– A. LYMPHOSCINTIGRAPHY

• Injects a radiactive colloid subcutaneously• Uptakes into the lymph system• Serial images visualize abnormal lymph nodes

NURSING MANAGEMENT

• 1. ADMINISTER PRESCRIBED MEDICATIONS– Diuretics– Anticoagulants

NURSING MANAGEMENT• 2. ASSESS THE CLIENT’S

NEUROVASCULAR STATUS– By assessing for the 6 P’s on

both extremities• PAIN

– With exercise– With rest– At all times

» Pain scale 1-10» Type of pain

• PARESTHESIA– Sharp or dull

» Use cotton tipped applicator» All five toes, bottom of foot,

up the leg

both extremities• POLOR

– Feel the feet» Warm or cold

• PARALYSIS– Move his toes, ankles and knee– Observe while ambulating

• PALLOR– Assess the color of feet– Positions

» Neutral» Dependent» Elevated

both extremities• PULSES

– Assess lower extremity pulses» Dorsalis pedis» Popliteal» Posterior tibial

– Rating 0[absent]- 4+[bounding]

– Mark with X if difficult to palpate– If unable to assess pulses

» Use Doppler ultrasound

NURSING MANAGEMENT• 3. ASSESS FOR

LYMPHEDEMA– Measure and compare

extremities for enlargement [at risk]

– Assess for coexisting symptoms of lymphedema

• Initially pitting• Then brawny & nonpitting edema• No pain• Absence of infection

– TO RULE OUT VENOUS DISORDER AS THE CAUSE OF EDEMA

NURSING MANAGEMENT• 4. PROMOTE LYMPHATIC

DRAINAGE– Collaborate with physical

therapy • Mechanical or manual squeezing

of tissue followed by specific active and passive exercises

– To press stagnant lymphatic fluid into the blood stream

– Elevate the affected extremity• Elevate the arm on a pillow with

the elbow higher than the shoulder and the hand higher than the elbow

NURSING MANAGEMENT• 4. PROMOTE LYMPHATIC

DRAINAGE– Apply an elastic sleeve or

stocking – Measure the circumference of

the affected extremity • To assess progress

– Prepare the client for excisional removal of edematous subcutaneous tissue

NURSING MANAGEMENT• 5. PROVIDE CLIENT AND

FAMILY TEACHING– Instruct the client and his

family to observe for and report

• red streaks on the affected extremity

• Fever and chills• Penetrating wounds• Enlarged & tender lymph nodes

NURSING MANAGEMENT• 5. PROVIDE EMOTIONAL

SUPPORT– Assist the client with a

diagnosis of neoplastic disease in coping with associated problems

– Encourage the client to express fears and concerns

– Listen actively• Altered body image

– Assist the client • to select concealing clothing • To take other measures to

emphasize positive aspects of body image

THANK YOU

peripheral vascular diseases edited

blood passes

shunt blood

blood travels

deoxygenated blood

blood flow factors

oxygen blood flow

blood pressure force

forceful blood flow

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