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SOUTH FLORIDA COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
MEDICAL SURGICAL II
PERIPHERAL VASCULAR SYSTEM
(Peripheral Arterial Disease)
*Not sure about 6 through 8 … are they pertaining to ALL the disorders in chapter
38 or just one? If just one … then where are the answers?
OBJECTIVES: Upon completion of this unit the student should be able to:
1.
Review the normal A & P.
2.
Review the physiologic changes that occur with aging.
- Loss of elasticity in something or other.
3.
Explain the etiology and symptoms of peripheral vascular disease.
- PAD involves progressive narrowing and degeneration of the arteries of the
neck, abdomen and extremities. Regardless of anatomic location, atherosclerosis
is responsible for the majority of cases.
- The leading cause of PAD is atherosclerosis, a gradual thickening of the intima
and media of arteries, which leads to progressive narrowing of the vessel lumen.
- Clinical manifestations occur when the vessel is between 60% and 75%
occluded.
4.
Discuss the risk factors for peripheral vascular disorders.
- The four most significant risk factors for PAD are cigarette smoking,
hyperlipidemia, hypertension, and diabetes mellitus, which the most important
being cigarette smoking. Other risk factors include obesity, hypertriglyceridemia,
hyperuricemia, family history, sedentary lifestyle and stress. Additional risk
factors under investigation include serum levels of C-reactive protein (CRP),
fibrinogen, ferritin, homocysteine and lipoprotein (a).
5.
Explain methods of preventing arterial and venous disorders.
- To prevent these disorders, one must look at the risk factors for developing these
problems. If you maintain a healthy weight, eat a well balanced diet, get regular
exercise, do not abuse alcohol, do not smoke and control diabetes one is at
significantly lower risk for developing these problems.
6.
Describe the differentiating characteristics of arterial and venous disorders.
7.
Explain the purpose and nursing intervention of diagnostic tests for peripheral
vascular disorders.
8.
Discuss the medication used in treatment of peripheral vascular disorders
(including dosage, mechanism of action, nursing intervention, and antagonist).
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9.
Describe the surgery techniques and their purpose in treatment of peripheral
vascular disorders.
- Various surgical approaches can be used to improve arterial blood flow beyond
a stenotic or occluded artery. The most common is a peripheral arterial bypass
operation with autogenous (native) vein or synthetic graft material to bypass or
carry blood around the lesion.
- Endarterectomy is opening the artery and removing the obstructing plaque
- Patch graft angioplasty is opening the artery, removing the plaque and sewing a
patch to the opening the widen the lumen
10.
Compare advantages of BK and AK amputations.
11.
Explain nursing care and teaching for the patient pre and post amputation.
Chapter 63 Page 1659
Preoperative Management
- Before surgery, the nurse should reinforce information that the patient and
family have received about the reasons for the amputation, the propped prosthesis
and the mobility-training program. Also, warn the patient of phantom limb
sensation which is if the patient experienced pain in the limb before amputation,
they will feel it occasionally after amputation…
Postoperative Management
- Nursing care must be individualized on the patient’s general state of health, the
reason for the amputation and the patient’s age.
- Prevention and detection of complications are important nursing responsibilities
during the postoperative period.
- If prosthesis had been applied, the nurse must monitor vital signs.
12.
Describe intermittent claudication.
- Intermittent claudication, the classic symptom of PAD, is an ischemic muscle
ache or pain that is precipitated by a consistent level of exercise, resolves within
10 minutes or less with rest, and is reproducible.
13.
Explain the Doppler technique.
- Doppler ultrasound consists of a probe transducer containing a crystal that
directs high frequency sound waves toward the artery or vein being examined.
The sound waves bounce off the blood cells at a rate that corresponds with the
velocity (or speed) of blood flow. This emits an audible signal.
14.
Discuss the educational issues important in preventing exacerbation of symptoms
of arterial disease.
- The four most significant risk factors for PAD are cigarette smoking,
hyperlipidemia, hypertension, and diabetes mellitus, which the most important
being cigarette smoking.
- To prevent these disorders, one must look at the risk factors for developing these
problems. If you maintain a healthy weight, eat a well balanced diet, get regular
exercise, do not abuse alcohol, do not smoke and control diabetes one is at
significantly lower risk for developing these problems.
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15.
Describe factors that contribute to thrombus formation.
- Localized platelet aggregation and fibrin entrap RBCs, WBCs and more platelets
to form a thrombus.
- Three important factors (called Virchow’s triad) in the etiology of venous
thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of
the vein), and (3) hypercoagulability of the blood.
16.
Explain the manifestations and complications of thrombophlebitis.
- The patient with superficial thrombophlebitis may have a palpable, firm,
subcutaneous cordlike vein. The area surrounding the vein may be tender to the
touch, reddened and warm. A mild temperature systemic elevation and
leukocytosis may be present.
- The patient with DVT may or may not have unilateral leg edema, extremity
pain, warm skin, erythema and a systemic temperature greater than 100.4° F. If
the calf is involved, tenderness may be present on palpation.
- The most serious complications of DVT are PE, chronic venous insufficiency
and phlegmasic cerulean dolens.
17.
Discuss the pathophysiology and symptoms of varicose veins.
- Superficial veins in the lower extremities become dilated and tortuous, with
increased venous pressure. As the veins enlarge, the valves are stretched and
become incompetent, allowing venous blood flow to be reversed. As back
pressure increases and the calf muscle pump (muscle movement that squeezes
venous blood back to the heart) fails, further venous distention results.
- Discomfort from varicose veins varies dramatically among people and tends to
be worsened by superficial thrombophlebitis. The most common symptom of
varicose veins is an ache or pain after prolonged standing, which is relieved by
walking or elevating the limb. Some patients feel pressure or a cramp like
sensation in the legs. Swelling may accompany the discomfort. Nocturnal leg
cramps in the calf may occur.
18.
Describe the treatment of thrombophlebitis and varicose veins.
Thrombophlebitis
- The treatment of superficial thrombophlebitis includes elevation of the affected
extremity to promote venous return and decrease the edema and the application of
warm, moist heat.
- If lower extremity thrombophlebitis has occurred, elastic compression stockings
are recommended once the acute thrombophlebitis has resolved.
- NSAIDs such as Motrin have been used to treat inflammatory process and
accompanying pain.
Varicose Veins
- Treatment usually is not indicated if varicose veins are only a cosmetic problem.
If incompetency of the venous system develops, collaborative care involves rest
with the affected limb elevated, compression stockings, and exercise, such as
walking.
19.
Explain the diagnostic test for venous disorders.
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20.
Discuss the teaching topics for increasing perfusion and measures to prevent
recurrences in venous disorders.
- Patient and family teaching should include avoidance of trauma to the limbs,
proper skin care measures, application and regular placement of prescribed
compression stockings and appropriate activity and limb positioning.
- Proper leg and foot care is essential to avoid additional trauma. Daily
moisturizing of the skin decreases itching and prevents cracking.
- Patient should be instructed to avoid standing or sitting with the feet dependent
for long periods because this has been shown to decrease periulcer skin blood
perfusion and oxygen levels. Patients should also elevate their legs above the
level of the heart to reduce edema. Once ulcers are healed, a daily walking
program is encouraged.
21.
Describe the pathophysiology of leg ulcers (arterial ulcers and venous ulcers) and
the methods of treatment.
- The basic dysfunction is incompetent valves of the deep veins. As a result,
hydrostatic pressure in the veins increases and serous fluid and RBCs leak from
the capillaries and venules into the tissue, resulting in edema. Enzymes in the
tissue eventually cause a brownish skin discoloration. Over time, the skin and
subcutaneous tissue around the ankle are replaced by fibrous tissue, resulting in
thick, hardened, contracted skin.
- Compression is essential to the management of CVI, venous ulcer healing and
prevention of ulcer recurrence. Moist environment dressings are the mainstay of
wound care. Nutritional status and intake should be evaluated in a patient with a
venous leg ulcer.
22.
Identify nursing interventions to prevent phlebitis.
- Early mobilization is the easiest and most cost-effective method to decrease the
risk of DVT. Patients on bed rest need to be instructed to change position,
dorsiflex their feet and rotate their ankles every 2 to 4 hours.
- Antiembolism stockings (e.g., TED hose) have long been part of DVT
prevention. These stockings increase venous blood flow, prevent venous dilation
and stimulate endothelial fibrinolytic activity.
- Intermittent compression devices (ICDs) are used for hospitalized patients at
moderate, high or very high risk for DVT. The compression pushes blood from
the superficial veins into the deep veins, thus decreasing venous stasis. The
compression also decreases venous distention, this lowering the risk of
endothelial damage.
- Anticoagulants are used routinely for DVT prevention and treatment.
23.
State the purpose of elastic stockings and discuss the proper use of them.
- Antiembolism stockings (e.g., TED hose) have long been part of DVT
prevention. These stockings increase venous blood flow, prevent venous dilation
and stimulate endothelial fibrinolytic activity.
- To be effective, the nurse must measure the patient’s legs, obtain the appropriate
stocking size and apply the stockings properly. The toe hole needs to be under the
toes and the heel patch needs to be over the heel, there should be no wrinkles
present, and the thigh gusset needs to be on the inner thigh. Venous return is
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impeded by Antiembolism stockings if the top elastic band is too tight or if the
stockings are rolled down.
24.
Discuss the manifestations of lymphademia and its treatment.
25.
Explain the pathophysiology of hypertension.
- There is still much uncertainty about the pathophysiology of hypertension. A small
number of patients (between 2% and 5%) have an underlying renal or adrenal disease as
the cause for their raised blood pressure. In the remainder, however, no clear single
identifiable cause is found and their condition is labeled "essential hypertension". A
number of physiological mechanisms are involved in the maintenance of normal blood
pressure, and their derangement may play a part in the development of essential
hypertension.
26.
Define hypertension in children and adults. (Know the normal BP range for each
age group.)
- HTN in adults is defined as a persistent systolic blood pressure (SBP) ≥ 140 mm
Hg, diastolic blood pressure (DBP) ≥ 90 mm Hg, or current use of
antihypertensive medications.
Age
Boys
Normal
Girls
High
Normal
High
1
< 103/54 >= 106/58 < 103/56 >= 107/60
2 to 3
< 109/63 >= 113/67 < 106/65 >= 110/69
4 to 5
< 112/70 >= 116/74 < 109/70 >= 113/74
6 to 7
< 115/74 >= 119/78 < 113/73 >= 116/77
8 to 10
< 119/78 >= 123/82 < 118/76 >= 122/80
11 to 12 < 123/79 >= 127/83 < 122/78 >= 133/90
13 to 14 < 128/80 >= 132/84 < 125/80 >= 136/92
15 to 17 < 136/84 >= 140/89 < 128/82 >= 132/86
Over 18 same as adults
27.
State the risk factors for hypertension.
- Age, alcohol, cigarette smoking, diabetes mellitus, elevated serum lipids, excess
dietary sodium, gender, family history, obesity, ethnicity, sedentary lifestyle,
socioeconomic status and stress.
A:ADNII/MED SURGII/Objectives: Peripheral Vascular
28.
Discuss prevention methods for primary and secondary hypertension.
- The things that cause primary hypertension are mostly modifiable and it’d be a
good idea to prevent those from happening (e.g., obesity, smoking, alcohol abuse,
high cholesterol diet, sedentary lifestyle, high blood pressure, high stress).
-Secondary hypertension is brought on about more complex medical problems
and even a family history of cardiac defects. Page 765
29.
Discuss the therapeutic management of mild to severe hypertension in children
and adults.
- HTN in children not on exam.
- The goal in treating a patient with hypertension is to control BP and reduce
overall cardiovascular risk.
Collaborative Therapy
Periodic monitoring of BP
 Home BP monitoring
 Ambulatory BP monitoring (if indicated)
 Every 3-6 months by health care provider once BP is
stabilized
Nutritional Therapy
 Restrict sodium
 Reduce weight (if indicated)
 Restrict cholesterol and saturated fats
 Maintain adequate intake of potassium
 Maintain adequate intake of calcium and magnesium
Regular, moderate physical activity
Cessation of smoking
Moderation of alcohol consumption
Stress management
Antihypertensive drugs (see Table 33-8)
Patient teaching
30.
Describe the long term effects of undiagnosed hypertension.
- See number 31.
31.
Discuss the complications that may occur with hypertension.
- The most common complications of hypertension are target organ diseases
occurring in the heart (hypertensive heart disease), brain (cerebrovascular
disease), peripheral vasculature (PVD), kidney (nephrosclerosis) and eyes (retinal
damage).
- Hypertensive Heart Disease
 CAD: HTN is a major risk factor for CAD. Arteriolar changes result in a
stiffened arterial wall and a narrowed internal lumen, and account for a
high incidence of CAD and the resulting problems of angina and MI.
 Left Ventricular Hypertrophy: Sustained high BP increases the cardiac
workload and produces left ventricular hypertrophy.
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
Heart Failure: Heart failure occurs when the heart’s compensatory
adaptations are overwhelmed and the heart can no longer pump enough
blood to meet the metabolic needs of the body.
 The patient may complain of shortness of breath on exertion, paroxysmal
nocturnal dyspnea and fatigue.
- Cerebrovascular Disease
 Atherosclerosis is the most common cause of cerebrovascular disease.
HTN is a major risk factor. Portions of the atherosclerotic plaque may
break off and travel to intracerebral vessels, producing a
thromboembolism. The patient may experience transient ischemic attacks
or a stroke.
- Peripheral Vascular Disease
 HTN speeds up the process of atherosclerosis in the peripheral blood
vessels, leading to the development of peripheral vascular disease, aortic
aneurysm and aortic dissection.
 Intermittent claudication is a classic symptom of PVD.
- Nephrosclerosis
 HTN is one of the leading causes of end-stage renal disease, especially
among African Americans. Renal dysfunction is the direct result of
ischemia caused by the narrowed lumen of the intrarenal blood vessels.
 Common laboratory indications of renal dysfunction are
microalbuminuria, proteinuria, microscopic hematuria and elevated BUN
and serum creatinine levels. The earliest manifestation of renal
dysfunction is usually nocturia.
- Retinal Damage
 The appearance of the retina provides important information about the
severity and duration of the hypertensive process. The retina is the only
place in the body where the blood vessels can be directly visualized.
Manifestations of severe retinal damage include blurring of vision, retinal
hemorrhage and loss of vision.
32.
Define hypertensive crisis and explain the treatment of this emergency.
- Hypertensive crisis is a severe and abrupt elevation in BP, arbitrarily defined as
DBP >140 mm Hg. The rate of rise of BP is more important than the absolute
value in determining the need for emergency treatment.
- The initial treatment goal is to decrease the mean arterial pressure (MAP) by no
more than 25% within minutes to one hour. If the patient is stable, the target goal
of BP is 160/100 to 110 mm HG over the next 2 to 6 hours. Lowering the BP
excessively may decrease cerebral, coronary or renal perfusion and could
precipitate a stroke, acute MI or renal failure.
- IV drugs used for hypertensive emergencies include vasodilators (e.g., sodium
nitroprusside [Nitropress], nitroglycerine [Tridil]), adrenergic inhibitors (e.g.,
phentolamine [Regitinel]) and the ACE inhibitor enalaprilat (Vasotec IV).
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