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Chapter 12 Heart and Peripheral Vascular System Kevin Dobi, MSN, APRN Kevin Dobi, MSN, APRN revised 7/2013 Concept Overview • Perfusion: • Mechanisms that facilitate and impair perfusion of oxygenated blood • All tissues require perfusion of oxygenated blood. • All of these physiologic concepts are interrelated. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 2 Anatomy and Physiology • Cardiovascular system: • • • • Transports oxygen Transports nutrients Transports other substances to body’s tissues Carries metabolic waste products to kidneys and lungs • This dynamic system is able to adjust to changing demands for blood by: • Constricting or dilating blood vessels • Altering cardiac output Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 3 Anatomy and Physiology: The Heart and Great Vessels • Heart is a pump: • Beats 60 to 100 times a minute without rest. • Responds to both external and internal demands. • Each side has two chambers: • Atrium • Ventricle • Right side: • Receives blood from superior and inferior venae cavae. • Pumps blood through pulmonary arteries to pulmonary circulation. • Left side: • Receives blood from pulmonary veins. • Pumps blood through aorta into systemic circulation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 4 Anatomy and Physiology: The Heart and Great Vessels (contd.) • Upper part of heart is base. • Lower left ventricle is apex. • Heart lies behind sternum and above diaphragm in mediastinum. • Lies at an angle so right ventricle makes up most of anterior surface and left ventricle lies left and posteriorly. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 5 Anatomy and Physiology: The Heart and Great Vessels (contd.) • Pulmonary arteries and aorta are termed the great vessels. • Aorta curves upward out of left ventricle and bends posteriorly and downward just above the sternal angle. • Pulmonary arteries emerge from superior aspect of right ventricle near third intercostal space. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 6 7 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Pericardium and Cardiac Muscle • Heart wall has three layers: Pericardium, myocardium, and endocardium. • Heart encased in pericardium, which has a fibrous layer and two serous layers. • Fibrous layer, fibrous pericardium, is fibrous sac of elastic connective tissue shielding heart from trauma and infection. • One of serous layers lies next to fibrous pericardium and other serous layer lies next to myocardium. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 8 Anatomy and Physiology: Pericardium and Cardiac Muscle (contd.) 9 • Pericardial space lies between fibrous pericardium and serous pericardium and contains pericardial fluid to reduce friction as myocardium contracts and relaxes. • Serous pericardium, or epicardium, covers heart surface and extends to great vessels. • Middle layer, or myocardium, is thick muscular tissue that contracts to eject blood from ventricles. • Endocardium lines inner chambers and valves. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 10 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Blood Flow through the Heart – The Cardiac Cycle 11 • Four valves govern blood flow through four chambers of heart: • Tricuspid valve on right. • Mitral valve on left termed atrioventricular (AV) valves because they separate atria from ventricles. • Aortic valve opens from left ventricle into aorta. • Pulmonic valve opens from right ventricle into pulmonary artery; aortic and pulmonic valves are termed semilunar valves because of their half-moon shape. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 12 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Diastole 13 • Diastole: Ventricles relax and fill with blood from left and right atria. • Movement of blood from atria to ventricles is accomplished when pressure of blood in atria becomes higher than pressure in ventricles. • Higher atrial pressures passively open AV valves, allowing blood to fill ventricles. • About 80% of blood from atria flows into relaxed ventricles. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Diastole (contd.) 14 • Diastole: • Contraction of atria forces remaining 20% of blood into ventricles. • This added atrial thrust is termed the atrial kick. • At end of diastole, ventricles are filled with blood. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 15 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Systole 16 • Systole: Ventricles contract creating pressure that closes AV valves, preventing backflow of blood into atria. • Ventricular pressure also forces semilunar valves to open, resulting in ejection of blood into aorta from left ventricle and pulmonary arteries from right ventricle. • As blood is ejected ventricular pressure decreases, causing semilunar valves to close. • Ventricles relax to begin diastole. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 17 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 18 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Electric Conduction • Heart stimulated by electric impulse originating in sinoatrial (SA) node in superior aspect of right atrium and travels in internodal tracts to AV node. • SA node, termed cardiac pacemaker, normally discharges 60 to 100 impulses per minute. • Electric impulses stimulate contractions of both atria and then the flow to AV node in inferior aspect of right atrium. • Impulses are then transmitted through series of branches and Purkinje fibers in myocardium, which results in ventricular contraction. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 19 Anatomy and Physiology: Electric Conduction (contd.) • AV node prevents excessive atrial impulses from reaching ventricles. • If SA node fails to discharge, AV node can generate ventricular contraction at slower rate of 40 to 60 impulses per minute. • If both SA and AV nodes are ineffective, bundle branches may contract, but at very slow rate of 20 to 40 impulses per minute. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 20 21 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Peripheral Vascular System • Arteries, capillaries, and veins provide blood flow to and from tissues. • Tough and tensile arteries; their smaller branches, arterioles, are subjected to remarkable pressure generated from myocardial contraction. • They maintain blood pressure by constricting or dilating in response to stimuli. • PVR- Peripheral Vascular Resistance. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 22 Anatomy and Physiology: Peripheral Vascular System (contd.) • The more passive veins and smaller branches, venules, are less sturdy, but more expansible, enabling them to act as reservoir for extra blood, if needed, to decrease workload on heart. • Pressure within veins is low, compared with arterial circulation. • Valves in each vein keep blood flowing in a forward direction toward heart. (IV Issues) Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 23 24 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Lymph System • Lymph system works in collaboration with peripheral vascular system in removing fluid from interstitial spaces. • As blood flows from arterioles into venules, oxygen and nutrient-rich fluid is forced out at arterial end of capillary into interstitial space, and then into cells. • Waste products from cells flow through interstitial spaces to venous end of capillary. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 25 Lymphatics Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 26 Anatomy and Physiology: Lymph System (contd.) • Excess fluid left in interstitial spaces is absorbed by lymph system and carried to lymph nodes throughout body. • Lymphatic fluid is clear, composed mainly of water and a small amount of protein, mostly albumin. • Lymph nodes are tiny oval clumps of lymphatic tissue, usually located in groups along blood vessels. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 27 Anatomy and Physiology: Lymph System (contd.) • In peripheral vascular system, lymph node locations of interest are arm, groin, and leg. • Epitrochlear nodes on medial surface of arm above elbow are palpable. • These nodes receive fluid via radial, ulnar, and median lymph vessels. • In upper thigh, inguinal lymph nodes are superficial; they receive most of lymph drainage from great and small saphenous lymphatic vessels in legs. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 28 Anatomy and Physiology: Lymph System (contd.) • In men, lymph from penile and scrotal surfaces drains to inguinal nodes, but nodes of the testes drain into abdomen. • In posterior surface of leg, behind knee, are popliteal nodes, which receive lymph from medial portion of lower leg. • Ducts from lymph nodes empty into subclavian veins. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 29 30 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 31 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Assessment Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 32 General Health History: Present Health Status • Do you have any chronic illnesses such as diabetes mellitus, renal failure, chronic hypoxia, or hypertension? • Are you taking medications? • What are you taking, and when did you start? • Have you experienced any side effects? • Do you take medications as prescribed? • What over-the-counter drugs do you take? • Do you take an aspirin on a regular basis to help thin your blood? • Do you take herbal medications? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 33 General Health History: Family Health Status • Is there anyone in your family with a history of diabetes mellitus, renal failure, chronic hypoxia, or hypertension? • If so, who? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 34 General Health History: Personal and Psychosocial History • Do you use cocaine? • Other street drugs? • How often do you use drugs? • Do you exercise? • What kind of exercise? • How often? • How would you describe your personality type? • How do you deal with stress? • How often do you take time to relax? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 35 General Health History: Personal and Psychosocial History (contd.) • Describe your usual eating habits: • How often do you eat red meat? • Do you monitor your fat and salt intakes? • Do you eat whole grains each day? • Do you drink alcoholic beverages? • What type of alcohol do you drink? • How much? How often? • Do you consume caffeine? • Do you smoke, or have you been a smoker in past? • Are you interested in quitting smoking? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 36 General Health History: Past Medical History • During childhood did you have “growing pains,” unexplained joint pains? • Rheumatic fever? • Heart murmur? • Have you been told you have high levels of cholesterol or elevated triglycerides? • Have you ever had surgery on heart? • On blood vessels? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 37 Problem-Based History: Chest Pain • • • • Where are you feeling the chest pain? What does it feel like? Sharp, dull, ache? Does pain radiate to any location? When did pain start? • Is pain intermittent or constant? • What symptoms have you noticed with pain? • • • • • • Sweating? Turning pale or gray? Heart skipping beats or racing? Shortness of breath? Vomiting? Anxiety? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 38 Problem-Based History: Chest Pain (contd.) • What factors preceded pain? • • • • Exercise? Rest? Highly emotional situations? Sexual intercourse? • What makes pain worse? • What relieves pain? • Rest? • Nitroglycerin? • How many nitroglycerin tablets does it take to relieve chest pain? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 39 Problem-Based History: Shortness of Breath • How long have you had shortness of breath? • Do you feel short of breath now? • When does shortness of breath happen? • How often? • How long does it last? • Does shortness of breath interfere with your daily activities? • Do you have other symptoms with shortness of breath (e.g., do your feet swell during day)? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 40 Problem-Based History: Shortness of Breath (contd.) • What makes shortness of breath worse? • Walking upstairs? • Lying down? • How many pillows do you require when you lie down to sleep? • Do you sleep in recliner? • When episodes of shortness of breath occur, what do you do to breathe more easily? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 41 Problem-Based History: Cough • When did your cough start? • How often do you cough? • Do you cough up anything? (productive or nonproductive?) • What does it look like? • Is cough associated with position? • More coughing when lying down? • With anxiety? • Talking or activity? • What makes it worse? • What actions do you take to relieve cough? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 42 Problem-Based History: Urinating During the Night • For how long have you been getting up during night to urinate? • How many times a night do you get up to urinate? • What have you done to prevent this from happening? • How successful have your efforts been? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 43 Problem-Based History: Fatigue • When do you notice fatigue? • Was onset sudden or gradual? • Is it worse in morning or evening? • Are you too tired to take part in normal activities? • Do you take iron pills? • Do you eat foods with iron, such as green leafy vegetables and liver? • For women: Do you have heavy menstrual flow? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 44 Problem-Based History: Fatigue (contd.) • Have you had any other symptoms associated with fatigue? • Rapid heart rate? • Headache? • Pale skin? • Have you noticed any unusual feelings in your feet and hands, muscle weakness, or trouble thinking? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 45 Problem-Based History: Fainting • What were you doing just before you fainted? • Did you feel dizzy? • Did you lose consciousness? • Has this happened to you before? • Was fainting preceded by any other symptoms? • • • • • Nausea? Chest pain? Headache? Rapid heart rate? Confusion? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 46 Problem-Based History: Swelling of Extremities • Where is swelling located? • Arms or legs? • Unilateral or bilateral? • What makes swelling go away? • Does elevating your arms or feet reduce swelling? • Does swelling disappear after night’s sleep? • Are there any symptoms associated with swelling? • Shortness of breath? • Weight gain? • For women: Is swelling associated with your menstrual period? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 47 Problem-Based History: Leg Cramps or Pain • Describe pain and its location. • What makes pain worse? • What relieves the pain? • Have you noticed any changes in skin of your legs? • • • • • • Coldness Pallor Hair loss Sores Redness or warmth over the veins Visible veins Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 48 PE: Physical Examination Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 49 Examination: Procedures with Normal Findings • Assess general appearance. • Inspect patient for general appearance, skin color, and breathing effort. • Palpate temporal and carotid pulses for amplitude. • Inspect jugular vein for pulsations. JVD • Measure blood pressure. Auscultate • Inspect and palpate upper extremities for skin turgor and symmetry. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 50 Examination: Procedures with Normal Findings (contd.) 51 • Inspect and palpate upper extremities for: • • • • Symmetry Skin integrity Color and temperature Capillary refill • Palpate brachial and radial pulses for: • • • • Rate Rhythm Amplitude Contour • Inspect and palpate lower extremities for skin turgor and symmetry. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 52 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Apical Impulse Palpate over the Apex: 5th-6th ICS at MCL (left side) Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 53 54 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Examination: Procedures with Normal Findings (contd.) 55 • Inspect and palpate lower extremities for symmetry, skin integrity, color and temperature, hair distribution, capillary refill, color and angle of nail beds, tenderness, and superficial veins. • Palpate lower extremities for femoral, popliteal, posterior tibial pulses, and dorsalis pedis pulses for amplitude. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Examination: Cardiac Assessment • Inspect anterior chest wall for: • • • • • Contour Pulsations Lifts Heaves Retractions • Auscultate S1 and S2 heart sounds for: • • • • Rate Rhythm Pitch Splitting Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 56 Heart Sounds: S1 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. S2 57 Landmarks Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 58 Landmarks 59 • Aortic: 2nd-3rd ICS at left sternal border • Pulmonic: rd 2nd3 ICS at right sternal border • Tricuspid: 5th ICS at left sternal border • Mitral: 5th ICS and left MCL (apex) Copyright © 2013 by Mosby, an imprint of Elsevier Inc. • All • Patients • Take • Meds Examination: Special Circumstances or Advanced Practice • Peripheral vascular system: • Auscultate carotid artery for bruits. • Estimate jugular venous pressure for pulsations. • Palpate epitrochlear lymph nodes for size, consistency, mobility, borders, tenderness, and warmth. • Palpate inguinal lymph nodes for size, consistency, mobility, borders, tenderness, and warmth. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 60 Examination: Special Circumstances or Advanced Practice (contd.) • Peripheral vascular system: 61 • Calculate the ankle brachial index to estimate arterial occlusion. • Perform Trendelenburg’s test to evaluate competence of venous valves in patients who have varicose veins. • APRNs----Don’t worry about this technique Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Examination: Special Circumstances or Advanced Practice (contd.) • Cardiac assessment: • Palpate precordium for pulsations, thrills, lifts, and heaves. • Percuss heart borders for heart size……NO! Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 62 Age-Related Variations: Infants, Children, and Adolescents • There are several differences in assessment of cardiovascular system for infants and young children: • Equipment used to measure blood pressure is smaller, sequence of exam may be different, and findings may differ based on anatomic differences. • Assessment of older child and adolescent follows same procedures and reveals similar expected findings. • One exception in exam is electrocardiography, which is not typically performed. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 63 Age-Related Variations: Older Adults • Assessing cardiovascular status of older adults usually follows same procedures as for all adults. • Expected variations may be found in heart rate and blood pressure. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 64 Common Problems and Conditions: Cardiac Disorders – Valvular Heart Disease 65 • Valvular heart disease (VHD) is an acquired or congenital disorder of heart valve characterized by: • Stenotic valve, which does not open completely. • Incompetent valve, which does not close completely. • Rheumatic fever and endocarditis account for most cases of acquired VHD. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Angina Pectoris • Angina pectoris is chest pain due to ischemia of myocardium. 66 • Usually caused by atherosclerosis within coronary arteries. • Can occur during activity, stress, or exposure to intense cold because of an increased demand on heart. • Can also occur during rest as result of spasms of coronary arteries. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Angina Pectoris (contd.) 67 • Clinical findings: Patients describe pain as squeezing, suffocating, or constricting. • May be significant hypertension, but hypotension may also occur. • The duration of angina is important to determine: • If precipitated by exertion and patient rests promptly, may last less than 3 minutes. • If it follows heavy meal or caused by anger, may last 15 to 20 minutes. • Angina lasting more than 30 minutes is unusual, may indicate developing myocardial infarction. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Myocardial Infarction 68 • Myocardial infarction occurs when myocardial ischemia is sustained, resulting in death of myocardial cells (necrosis). • Left ventricle more commonly affected, but right ventricle may also be affected. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Myocardial Infarction (contd.) 69 • Clinical findings: Patients describe pain as worst chest pain ever experienced, pain lasts longer than 5 minutes. • May radiate to left shoulder, jaw, arm, or other areas of chest; it is not relieved by rest or nitroglycerin. • Dysrhythmias are common; heart sounds may be distant with a thready pulse. • Women report different symptoms; they report pain or discomfort in center of chest and shortness of breath, cold sweat, nausea, vomiting, or lightheadedness. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Heart Failure • Heart failure occurs when either ventricle fails to pump blood efficiently into aorta or pulmonary arteries. • Heart failure may occur in left or right ventricle or both. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 70 Common Problems and Conditions: Cardiac Disorders – Heart Failure Left Ventricular Failure 71 • Left ventricular failure is caused by : • Increased resistance that occurs with aortic stenosis or hypertension, when ventricle can no longer compensate for increased workload, or • Weakening of left ventricular contraction occurring after myocardial infarction when death of myocardial cells may result in an ineffective contraction. • Because left ventricle cannot pump sufficient blood forward, some blood backs up into left atrium and eventually into pulmonary capillaries, causing pulmonary edema. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Left Ventricular Failure (contd.) • Clinical findings: Patient complains of fatigue and shortness of breath, including orthopnea, dyspnea on exertion, and paroxysmal nocturnal dyspnea. • Findings may reveal precordial movement, displaced apical pulse, palpable thrill, S3, and systolic murmur at apex. • In acute phase, patient usually has crackles bilaterally from pulmonary edema. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 72 Common Problems and Conditions: Cardiac Disorders – Right Ventricular Failure 73 • Right ventricular failure caused by hypertrophy from pulmonary hypertension or from necrosis from myocardial infarction. • Failure of right ventricle to pump blood into pulmonary arteries causes a backflow of blood into inferior and superior venae cavae. • Right ventricular failure caused by pulmonary disease is termed cor pulmonale. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Right Ventricular Failure (contd.) • Clinical findings: 74 • Findings may include precordial movement at xiphoid or left sternal border, elevated jugular venous pressure, dependent peripheral edema, S3 at lower left sternal border, systolic murmur, and weight gain. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Ineffective Endocarditis 75 • Infective endocarditis is infection of endothelial layer of heart, including cardiac valves: • Develops when endocardial surface is damaged by turbulent blood flow as result of valvular heart disease, congenital lesions, or direct injury from intravenous lines or injections, cardiac catheterization, or artificial valves. • Clinical findings: • Heart sounds normal during early infection; in late infection, murmur is heard if valve damage occurs. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 76 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Pericarditis 77 • Pericarditis is inflammation of parietal and visceral layers of pericardium and outer myocardium. • May be idiopathic or the result of myocardial infarction, uremia, cancer, trauma, infections, cardiac surgery, or autoimmune reaction. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Cardiac Disorders – Pericarditis (contd.) 78 • Clinical findings: Two classic findings are pericardial friction rub and chest pain. • Pericardial friction rub develops as inflamed layers of pericardium move against each other. • Friction rub is best heard with patient leaning forward so that heart is closer to chest wall. • Listen in second, third, or fourth intercostal spaces at left sternal border or at apex; louder during inspiration. • Pain described as sharp pleuritic pain aggravated by deep breathing, lying supine, or coughing. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 79 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Peripheral Vascular Disease Hypertension 80 • Hypertension is diagnosed on the basis of mean of two or more properly measured seated blood pressure readings on each of two or more occasions above 120/80 mm Hg in an adult over 18 years of age. • Pressure in arteries can become elevated due to constriction of blood vessels or fluid volume overload or both. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Peripheral Vascular Disease – Hypertension (contd.) 81 • Clinical findings: Hypertension • Normal blood pressure values are less than 120 mm Hg systolic and less than 80 mm Hg diastolic. • Because there are no specific symptoms of hypertension, periodic screening is important. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Peripheral Vascular Disease – Venous Thrombosis and Thrombophlebitis 82 • Venous thrombosis occurs when a thrombus (clot) develops within a vein. • Thrombophlebitis is inflammation of vein that may or may not be accompanied by clot. • Triad of venous stasis, damage to inner layer of veins, and hypercoagulability are usually responsible for both. • Either may occur in lower extremity, usually in deep veins. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Peripheral Vascular Disease – Thrombosis and Thrombophlebitis (contd.) 83 • Clinical findings: Thrombosis • Sometimes recognized by dilated superficial veins, edema and redness of involved extremity, and increased circumference of involved leg. • In upper extremity, venous thrombosis and thrombophlebitis may occur in superficial veins and are recognized by redness, warmth, and tenderness over affected area. (can happen from IV therapy) • Veins may be visible and palpable. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 84 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Common Problems and Conditions: Peripheral Vascular Disease – Aneurysm • Aneurysm is localized dilation of artery caused by weakness in arterial wall. • Can occur anywhere along aorta and iliac vessels. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 85 Common Problems and Conditions: Peripheral Vascular Disease – Aneurysm (contd.) 86 • Clinical findings: • Depend on location of aneurysm. • Abdominal aortic aneurysms are most common. • Thoracic, usually asymptomatic with deep, diffuse chest pain reported by some patients. • Aorta and aortic arch aneurysms can produce hoarseness from pressure on laryngeal nerve or dysphagia from pressure on esophagus. • A pulsatile mass may be palpated in periumbilical area. • A thrill or bruit may be noted over aneurysm. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Question 1 A patient has been admitted to the medical-surgical unit for exacerbation of congestive heart failure. The nurse notes bilateral +2 pitting edema and dry scaling skin. As the nurse assesses the dorsalis pedis pulse, the nurse is unable to detect it and notes that both feet are warm. What is the best action for the nurse to take? A. B. C. D. Call the physician immediately. Assess skin turgor over the clavicle. Use a Doppler and assess capillary refill. Use a Doppler and assess for renal artery stenosis. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 87 Question 2 In the cardiac unit, a patient awaits surgery for mitral valve repair. As the nurse auscultates the patient’s heart, the nurse will expect to hear a murmur that is: A. B. C. D. Most pronounced at the base of the heart. Most pronounced over the carotid arteries. Heard best at the left sternal border. Heard best over the left midclavicular line. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 88 The End Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 89