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PERIPHERAL CIRCULATORY SYSTEM AND VASCULAR
SYSTEM
ASSESSMENT Health history
Pain and precipitating factors Skin color and temperature Characteristics of peripheral
pulse Physical assessment
Intermittent claudication Is a muscular, cramp–type
pain in the extremities consistently reproduced with the same degree of exercise / activity and relieved by rest (experienced by patients with peripheral arterial insufficiency).
This pain is caused by the inability of arterial
System to provide adequate blood flow to the tissues.
Lactic acid isproduced. Pain is experienced when
metabolites aggravate the
nerve endings of the surrounding tissue.
I.C. will be experienced when 50% of the lumen or 75% of the cross-sectional area is obstructed.
Changes in skin appearance and temperature RUBOR - reddish
discoloration of the extremities. Suggests severe peripheral arterial damage.
Cyanosis - bluish discoloration of the skin.
Gangrenous changes appear after prolonged severe ischemia & represent tissue necrosis.
Adequate blood flow warms the skin & gives a rosy color.
Inadequate blood flow results in cool & pale extremities.
Pulse
DIAGNOSTIC EXAMSI. Doppler ultrasound flow studies
- Type of ultrasound that uses sound waves to measure the flow of blood through a blood vessel
- The test takes several minutes to assess the flow in each blood vessel being tested, If the test shows a decreased amount of blood flow, other testing may be needed.
Interventions: - Supine position, w/ the HOB
elevated 20 to 30 degrees- Acoustic gel isapplied- Doppler
transducerispositionedat a 45 – to 60-degree angle over the expected location of the artery and angle slowly.
It is more useful as a clinicaltoolwhencombined w/ ankleblood pressures, which are used to determine the ankle-brachial index(ABI), alsocalled the ankle arm index (AAI).
Ankle- brachial index (ABI) Ankle- brachial index (ABI) Is the ratio of systolic blood
pressurein the ankle to the
systolic blood pressure in the arm.
Objective indicator of arterial disease that allows the examiner to quantify the degree of stenosis.
Used to measure brachial pressure in both arms.
To calculate ABI: ankle systolic pressure each foot
higher of 2 brachial systolic pressure Right brachial = 160 mmHg Left brachial = 120 mmHg Right posterior tibial= 80 mmHg Right dorsalispedis= 60 mmHg Left posterior tibial = 100 mmHg Left dorsalispedis = 120 mmHg Right ankle = 80 / 160 mmHg =
0.50 ABI Left ankle = 120 / 160 mmHg =
0.75 ABIO
II. Exercise testing- is used to determine how long a
patient can walk- To measure the ankle systolic
blood pressure in response in walking.
- The patient walks on a treadmill at 1.5 mph with a 10% incline for a maximum of 5 minutes.
III. Duplex Utrasonography- involves B-mode gray-scale
imaging of the tissue, organs, and blood vessels and permits estimation of velocity changes by use of a pulsed Doppler.
- It helps determine the level and extent of venous disease.
- Non- invasive, requires no patient preparation.
IV. Computed tomography (CT)- provides cross-sectional images of
soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes take place.
*Spiral CT or helical*Multidetector CT (MDCT) – four
slices or visual Pictures per x-ray tube
rotation.
V. Computed tomographic angiography (CTA)
- a spiral CT scanner and rapid IV infusion of contrast agent are used to image very thin sections of the target area, and the results are configured in three dimensions so that the image closely remsembles a regular angiogram.
- CTA of thoracic or abdominal vasculature may be peformed using 1- 1.5 mm slices.
VI. Magnetic resonance angiography- Is used to generate images of the
arteries in order to evaluate them for stenosis (abnormal narrowing), occlusion or aneurysms (vessel wall dilatations, at risk of rupture).
- Used to isolate the blood vessels- This study is useful in patients with
poor renal function or allergy to contrast agent.
VII. Angiography- To confirm diagnosis of occlusive
arterial disease when considering surgery or other interventions.
- It involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessel.
- Allergic reaction to iodine; manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities.
- It may include the administration of epinephrine, antihistamines, or corticosteroids.
VIII. Air plethysmograph- isused to quantifyvenous reflux
and calf muscle pumpejection.- provides information about
venousfilling time, functionalvenous volume, ejected volume, and residual volume
- Useful in evaluating patients with suspected valvular incompetence or chronic venous insufficiency but not used for deep vein thrombosis
IX. Contrast Phlebography - Also known as venography - involves injecting a radiopaque
contrast agent into the venous system.
X. Lyphangiography- Way of detecting lymph node
involvement resulting from
metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.
XI. Lymphoscintigraphy- is a reliable alternative to
lymphangiography.- a radioactively labeled colloid is
injected subcutaneously in the second interdigital space.
LABORATORY EXAMS Complete blood count (CBC) Bone marrow aspiration
- is used to document infection or tumor within the marrow
Hemoglobin electrophoresis Coombs test
- also referred to as the direct antiglobulin test (DAT)
ARTERIAL PROBLEMSI. Arteriosclerosis
- the common disease of the arteries; the term means “hardening of the arteries”
- It is a diffuse process whereby the muscle fibers and the endothelial
lining of the walls of small arterioles become thickened.
Atherosclerosis - affects the intima of the large and
medium-sized arteries.- Intermittent claudication (pain,
weakness, numbness, or cramping in muscles due to decreased blood flow)
Atherosclerotic lesions:1. Fatty streaks2. Fibrous plaques
Surgical ManagementVascular Surgical procedures:
• Inflow Procedures – which improve blood supply from the aorta into the femoral artery
• Outflow Procedures – which provide blood supply to vessels below the femoral artery.
Radiologic Interventions• Angioplasty – also called
percutaneous transluminal angioplasty (PTA).
- A balloon-tipped catheter is maneuvered across the area of stenosis.- It widens the arterial lumen by “cracking” and flattening
the plaque against the vessel wall.
• Dissection – separation of the vessel, and bleeding
- Stents may be inserted to support the walls of blood vessels and prevent collapse immediately after the balloon inflation.
II. Peripheral Arterial Occlusive disease
- Peripheral vascular disease (PVD), commonly referred to as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD), refers to the obstruction of large arteries not within the coronary, aortic arch vasculature, or brain.
- Arterial insufficiency of the extremities occurs most often in men and is a common cause of disability.
- Obstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below
the renal arteries to the popliteal artery.
Signs and symptoms: Intermittent claudication coldness or numbness of
extremities decreased ability to walk ischemic rest pain.
Nursing Management: Maintaning circulation Avoid leg cross and prolong
extremity dependencyMedical Management:
Pentoxifylline (Trental) Cilostazol (pletal) Vascular grafting or
endarterectomy - is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an artery constricted by the buildup of soft/hardening deposits.
Bypass graft – to reroute the blood flow around the stenosis or occlusion.
Distal anastomosis Thromboangitisobliterans
(Buerger’s disease)
is a recurring progressive inflammation and thrombosis (clotting) of small and
medium arteries and veins of the hands and feet. It is strongly
associated with use of tobacco products, primarily from smoking, but
also from smokeless tobacco.
III.UPPER EXTREMITY ARTERIAL OCCLUSIVE DISEASE- arterial occlusions occur less frequently in the upper extremities than in the legs and cause less severe symptoms because the collateral circulation is significantly better than in the arms.- stenosis and occlusions in the upper extremity result from atherosclerosis or trauma.
Signs and symptoms: coolness and pallor of the
affected extremity Decreased capillary refill Difference in arm blood
pressures of more than 20mmHgNursing Management:• Arm kept at heart level or
elevated, with the fingers at the highest level.
• BP assessment every hour for 8 hours.
• Doppler assessment of the arterial flow every hour for 8 hours.
Medical Management:PTA – if a focal lesion is identified
IV. Buerger’s Disease (THROMBOANGIITIS OBLITERANS)- is characterized by recurring
inflammation of the intermediate and small arteries and veins of the lower and upper extremities.
- The cause is unknown, but it is believed to be an autoimmune vasculitis
- occurs in men between 20 and 35 years of age.- Superficial thrombophlebitis may be present.
Pathophysiology: Cause is UNKNOWN Probably an Autoimmune
disease Inflammation of the arteriesà
thrombus formationà occlusion of the vessels
Signs and symptoms: Rubor (reddish-blue
discoloration)
Absence of pedal pulse Paresthesias
Nursing Management: Advise to stop using tobacco
Medical Management: Same treatment of Buerger’s
disease Regional sympathetic block or
ganglionectomy – to produce vasodilation and increase blood flow.
Amputation
V. Raynaud’s Disease is a vasospastic disorder causing
discoloration of the fingers, toes, and occasionally other areas. Also known as "Primary Raynaud's phenomenon"
Causes of Reynaud’s Disease Scleroderma Carpal Tunnel Syndrome Injury Nerve Problems Artery Diseases Arteriosclerosis Stress Cold temperature
Signs and Symptoms Cyanosis
Numbness Pain Reduce sensation in the fingers
and toes Finger Tingling Rubor Gangrene
Treatment: vasodilators prevent cold keep warm analgesics clean wound surgery (symphatectomy)
VI. Aortitis- is the inflammation of the aorta.
Two Types:1. Takayasu’s disease (occlusive
thromboaortopathy)- a chronic inflammatory disease of the aortic arch and its branches, primarily affects young or middle-aged women and is more common in those of Asian descent.- nonatherosclerotic
2. Syphilitic aortitis- A pathological state of the aorta associated with
the tertiary stage of syphilis infection
TreatmentManagement appears to include the following treatment priorities; stop the inflammation, treat complications, prevent and monitor for re-occurrence. VII. AORTOILIAC DISEASE
-also known as Leriche's syndrome and Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries.
- Classically, it is described in male patients as a triad of symptoms consisting of:• claudication of the buttocks and thighs• atrophy of the musculature of the legs• impotence (due to paralysis of the L1 nerve)
Nursing Management:• Assessment of the different sites
of pulses• Monitor for signs of thrombosis• Monitoring of urine output
Medical Management:
• Sametreatmentwithatheroscleroticperipheralarterial occlusive disease.
• Aortoiliacbypassgraft• Axillofemoraland femoral-
femoral bypass (sometimes abbreviated "ax-fem fem-fem")
VIII. AORTIC ANEURYSM- general term for any swelling
(dilation or aneurysm) of the aortaTypes of Aortic Aneurysm
Abdominal Aortic Aneurysm - localized dilatation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50 percent.
Thoracic Aortic Aneurysm - a widening (bulging) of part of the wall of the aorta, the body's largest artery.
Causes:• Age 55 years or older • Male sex• High blood pressure• Smoking• DM• High Serum Cholesterol• Genetic
• AtherosclerosisInherited diseases that cause weakening of the blood vessels, with emphasis on Marfan's syndromeSigns and symptoms:• A pulsating bulge or a strong
pulse in the abdomen• Feeling of fullness after minimal
food intake• Nausea• Pain in the chest• Shortness of breath• Hoarseness• Difficulty or pain while
swallowing• Signs of shock• Extreme drop in blood pressure• Vomiting
IX. AORTIC DISSECTION- Tear in the wall of the aorta that
causes blood to flow between the layers of the wall of the aorta and force the layers apart.
- Aortic dissection is a medical emergency and can quickly lead to death.
Causes of Aortic Dissection- Hypertension- Vasculitis
- 50 to 70 years old- Pregnancy- Chest Trauma
Signs and Symptoms of Aortic Dissection - Severe Pain- Hypertension- Syncope- CHF / MI- Ischemia- Aortic insufficiency- Pleural effusion
Classification of Aortic Dissection - DeBakey- Type I - Originates in ascending
aorta, propagates at least to the aortic arch and often beyond it distally.
- Type II – Originates in and is confined to the ascending aorta.
- Type III – Originates in descending aorta, rarely extends proximally but will extend distally.
- Stanford- A = Type I and IIDeBakey- B = Type IIIDeBakey
Diagnosis:• Chest X-ray• ECG
• Biochemical markers• Transesophageal
echocardiography• Aortogram• Computed tomography
angiography• MRI
Treatment:• Open abdominal or open chest
surgery• Endovascular surgery
• X. Diseases
X.ARTERIAL THROMBOSIS- a blood clot (thrombus) adheres to
the wall of a vessel (artery) and blocks the flow of blood.
Causes:• Arterial thrombosis usually
affects individuals who already haveatherosclerosis, or narrowing of the arteries. Atherosclerosis causes the walls of the arteries to 'fur up' with deposits of atheroma, a porridge-like substance.
Symptoms:• Heart disease • Heart attack
ARTERIAL EMBOLISM- occlusion of blood flow by a
foreign particle (embolus) other than a blood clot within the vesselSymptoms:• Cold arm or leg• Decreased or no pulse in an arm
or leg• Fingers or hands feel cool• Lack of movement in the arm or
leg• Muscle pain in the affected area• Muscle spasm in the affected
area• Numbness and tingling in the
arm or leg• Pale color of the arm or leg
(pallor)• Weakness of an arm or leg• Diseases
Later symptoms:• Blisters of the skin fed by the
affected artery• Shedding (sloughing) of skin• Skin erosion (ulcer)• Tissue death (necrosis; skin is
dark and damaged)Symptoms of a clot in an organ vary with the organ involved but may include:
• Pain in the part of the body that is involved
• Temporarily decreased organ function
• Exams or test:• Angiography of the affected
extremity or organ• Doppler ultrasound exam of an
extremity• Duplex Doppler ultrasound exam
of extremity• Echocardiogram• MRI• Myocardial contrast
echocardiography (MCE)• Plethysmography• Transcranial Doppler exam of
arteries to the brain• Transesophageal
echocardiography (TEE)• Diseases
This disease may also affect the results of the following tests:• Euglobulinlysis time (ELT)• Factor VIII assay• Isotope study of the affected
organ• Plasminogen activator inhibitor-1
(PAI-1) activity• Platelet aggregation test
• Tissue-type plasminogen activator (t-PA) levels
• Diseases Treatment:• Medications include:• Anticoagulants (such as warfarin
or heparin) can prevent new clots from forming
• Antiplatelet medications (such as aspirin, ticlopidine, and clopidogrel) can prevent new clots from forming
• Painkillers given through a vein (by IV)
• Thrombolytics (such as streptokinase) can dissolve clots
• Some people need surgery. Procedures include:
• Bypass of the artery (arterial bypass) to create a second source of blood supply
• Clot aspiration (thromboaspiration)
• Clot removal through a balloon catheter placed into the affected artery or through open surgery on the artery (embolectomy)
• Opening of the artery with a balloon catheter (angioplasty)
with or without a stent implanted
VENOUS PROBLEMI. THROMBOSIS
obstructing the flow of blood through the circulatory system.
Classification of Thrombosis Venous thrombosis - formation
of a thrombus (blood clot) within a vein
Deep vein thrombosis - Deep vein thrombosis (DVT) is the formation of a blood clot within a deep vein. It most commonly affects leg veins, such as the femoral vein
Causes Hyper coagulability Endothelial cell injury Disturbed blood flow
Signs and Symptoms Swelling of the leg or along a
vein in the leg Pain or tenderness in the leg,
which you may feel only when standing or walking
Increased warmth in the area of the leg that's swollen or in pain
Red or discolored skin on the leg
THROMBOPHLEBITIS is phlebitis (vein inflammation)
related to a thrombus (blood clot)
Causes of Thrombophlebitis thrombus in the vein prolonged sitting deep venous thrombosis
Signs and Symptoms of Thrombophlebitis
pain in the part of the body affected
skin redness or inflammation (not always present)
swelling (edema) of the extremities (ankle and foot)
PHLEBOTHROMBOSIS thrombosis of a vein without
inflammation of the vein (phlebitis).
Deep venous thrombosis can occur without the presence of phlebitis. However most of the veins that develop thrombosis also have phlebitis.
Causes of Phlebothrombosis intimal damage to the vein
stasis from prolonged immobilization
idiopathic thrombocytopenia purpura
blood dyscrasiasSigns and Symptoms
Calf pain Tenderness positive Homans’ sign (calf pain
on foot dorsiflexion) Edema increased size of involved
extremity redness and warmth over vein
site
CHRONIC VENOUS INSUFFIECIENCY a medical condition where the
veins cannot pump enough oxygen-poor blood back to the heart.
sometimes referred to as an impaired Musculovenous pump''
Causes of CVI Deep vein thrombosis Family history Obesity Pregnancy Prolonged standing Smoking
Thrombophlebitis Varicose veins
Symptoms of CVI Dull aching, heaviness, or
cramping in legs Itching and tingling Pain gets worse when standing Pain gets better when legs are
raised Swelling of the legs
VT, DVT, THROMBOPHLEB, PHLEBOTHROMDiagnostics
• intravenous venography• X-rays• Blood tests (D-dimer)
Management• Elevate the affected area to
reduce swelling. • Keep pressure off of the area to
reduce pain and decrease the risk of further damage.
• Apply moist heat to reduce inflammation and pain.
• Support stockings and wraps to reduce discomfort
Treatment • analgesics
• anticoagulants e.g. warfarin or heparin to prevent new clot formation• thrombolytics to dissolve an existing clot such as intravenous streptokinase.• nonsteroidal anti-inflammatory medications (NSAIDS) such as ibuprofen to reduce pain and inflammation• antibiotics• Surgical removal, stripping, or bypass of the vein is rarely needed but may be recommended in some situations.
II. CHRONIC VENOUS INSUFFICIENCY/ POSTTHROMBOTIC SYNDROME-Venous insufficiency results from obstruction of the venous valves in the legs or aa reflux of blood through the valves. Superficial and deep legs veins can be involved. Resultant venous hypertension can occur whenever there has been a prolonged increase in venous pressure, such as occurs with DVT.S&S:
• Edema• Altered pigmentation
• Pain• Stasis dermatitis
The patient may notice the symptoms less in the morning and more in the evening
Management:• Directed at reducing venous stasis
and preventing ulceration.• Elevating the leg
DAY:at least 15-30 minutes every 2 hours NIGHT:Sleep with the foot of the bed elevated about 15cm (6 inches)
• Compression of superficial veins with graduated compression stockings
• Walking• When sitting, avoid placing
pressure on popliteal spacesTreatment:
• Compressionusing bandages, stockings, and pneumatic devices
• Wound Careshould be done initially and with each dressing change; ordinary soap and water (not hot) is usually best. Cleaning often involves irrigation with saline
solution at pressures sufficient to remove bacteria without traumatizing tissue
• Surgery:venous ligation, stripping, valve reconstruction
Diagnostics:• Duplex ultrasongraphy
III. LEG ULCER Tissue breakdown on the leg or
foot due to any cause. They occur in association with a
range of disease processes, most commonly with venous and/or arterial disease.
Causes of Leg Ulcer Poor blood circulation in the legs. Injuries - traumatic ulcers Diabetes - because of poor blood
circulation or loss of sensation (nerve damage) resulting in pressure ulcers
InfectionSymptoms of Leg Ulcer
Hyper pigmentation Leg pain A 'heavy' feeling in the affected
leg Aching
Itching Swelling Venous eczema Diseases
Management:• Pharmacologic Therapy
Antibiotic therapy is prescribed when the ulcer is infected.
• Compression TherapyAdequate compression therapy involves the application of external or counter pressure to the lower extremity to facilitate venous return to the heart.
• DebridementFlush the area with normal saline solution or clean it with aanoncytotoxic wound-cleansing agent.
• Topical Therapy• Wound Dressing• Stimulated healing• Hyperbaric Oxygenation• Negative Pressure Wound
TherapyTreatment:
• weight loss if you are overweight• regular exercise to promote good
circulation.
• Body detox can also help to purify the blood and cleanse the system.
Diagnostics:• Doppler• Duplex ultrasound studies• Arteriography• Venography
IV. VARICOSE VEINS-Veins that have become enlarged
and tortuous.- The term commonly refers to the
veins on the leg- Varicose veins are most common
in the superficial veins of the legsCauses of Varicose Veins
Pregnancy Obesity Menopause Aging Prolonged Standing
Signs & Symptoms of Varicose Veins Aching, heavy legs Appearance of spider veins
(telangiectasia) Ankle swelling A brownish-blue shiny skin
discoloration near the affected veins
Whitened, irregular scar-like patches can appear at the ankles
AVOID:- activities that cause venous stasis, such as wearing socks that are too tight at the top or that leaves marks on the skin.- crossing the legs at the thighs- sitting and standing for long periods
• Changing position frequently• Elevating legs• Walk 1 or 2 miles each day if there are no contraindication• Graduated compression stockings
Treatment:• Ligation and stripping
Requires that the deep veins be patent and functional
• Thermal ablationNon surgical approach using thermal energy
• SclerotherapyInjection of an irritating chemical into a vein to produce localized phlebitis and fibrosis, thereby obliterating the lumen of the vein.
Diagnostics:
• Duplex ultrasound studies• Air Plethysmography• Venography
LYMPH PROBLEMSI. CELLULITIS
-a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin
Causes of Cellulitis Group A Streptococcus Staphylococcus Insect bites Tattoos Athlete's foot
Signs and Symptoms of Cellulitis Pain and tenderness Edema (swelling caused by fluid
in the tissues) Redness of the skin Skin that is warm to the touch Fever Chills
II. LYMPHANGITIS- an inflammation of the lymphatic
channels that occurs as a result of infection at a site distal to the channel
- Lymphangitis is also sometimes called "blood poisoning".
Causes of Lymphangitis Streptococcus pyogenes (Group A
strep) Stap. Aureus Pseudomonas
Signs and Symptoms of Lymphangitis Deep reddening of the skin Warmth Lymphadenitis Moderate pain Swelling
III. LYMPHADENITISCauses of Lymphadenitis
Bacteria Virus Fungi Cancer Cells Inflammation
Symptoms of Lymphadenitis Swelling Painful Lump Fever Axillary Pain Lymphadenitis
IV. LYMPH EDEMA
- is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system.
- also known as lymphatic obstruction
Causes of Lymph edema Inherited (primary) Injury to the lymphatic vessels
(secondary) Parasitic infection Burns Trauma Radiation
Signs and Symptoms of Lymph Edema Severe fatigue Heavy swollen limb discoloration of the skin
overlying the lymph edema
V. ELEPHANTIASIS- is a disease that is characterized
by the thickening of the skin and underlying tissues, especially in the legs, male genitals.
Causes of Elephantiasis Wuchereriabancrofti Brugiamalayi Brugiatimori Repeated streptococcal infection
Hereditary Surgical removal of lymph nodes
(usually to prevent the spread of cancer)
Signs and Symptoms of Elephantiasis Gross enlargement of a limb or
areas of the trunk or head Abnormal accumulation of
watery fluid in the tissues Skin usually develops a
thickened, pebbly appearance and may become ulcerated and darkened
General feeling of ill health (malaise) may be present
HEMATOLOGIC DISORDERS
ANEMIA• A condition in which the
hemoglobin concentration is lower than normal, reflects the present of fewer than normal erythrocytes within the circulation.
Signs and symptoms:• Shortness of breath
• Dizziness• Headache• Coldness in the hands and feet• Pale skin• Chest pain
Management:Increase fluid intakeIncreased in dietary supplements
IronSpinach and other dark green leafy vegetablesPeanuts, peanut butter, and almondsEggsPeas; lentils; and white, red, and baked beansDried fruits, such as raisins, apricots, and peachesPrune juice
Vitamin CMedicines• Antibiotics to treat infections.
Procedures• Blood Transfusion
A blood transfusion is a safe, common procedure in which blood is given to you through an intravenous (IV) line in one of your blood vessels. Transfusions require careful
matching of donated blood with the recipient’s blood.
• Blood and Marrow Stem Cell Transplant
• A blood and marrow stem cell transplant replaces your abnormal or faulty stem cells with healthy ones from another person (a donor). Stem cells are found in the bone marrow. They develop into red and white blood cells and platelets.
• Surgery• If you have serious or life-
threatening bleeding that’s causing anemia, you may need surgery. For example, you may need surgery to control ongoing bleeding due to a stomach ulcer or colon cancer.
• If your body is destroying red blood cells at a high rate, you may need to have your spleen removed. The spleen is an organ that removes worn-out red blood cells from the body. An enlarged or diseased spleen may remove more red blood cells than normal, causing anemia.
Diagnostic findings :
• MCV (mean corpuscular volume)• RDW ( red cell distribution width)
Classification• Hypoproliferative anemia• Hemolytic anemia• Bleeding
HYPOPROLIFERATIVEI. IDA (iron deficiency anemia) • Is the most common type of
anemia in all age groups, and it is the most common anemia in the world.
• Typically result when the intake of dietary iron is inadequate for hemoglobin synthesis.
Signs and Symptoms:if the deficiency is severe or
prolonged they may also have a smooth, sore tongue; brittle and ridged nails; and angular cheilosis ( an ulceration of the corner of the mouth).
Nursing management• Food sources high in iron• Taking iron-rich foods with a
source of Vit.C• Nutritional counseling• Iron therapy
Medical management
• Iron supplements• Vitamin C
Diagnosis• Bone marrow aspiration• MCV
II. APLASTIC ANEMIA- Aplastic anemia is a rare disease
caused by a decrease in or damage to marrow stem cells, damage to the microenvironment within the marrow, and replacement of the marrow with fat.
Signs and symptoms: Pallor Fatigue Dyspnea purpura (bruising )- may
developed later Nursing management
Assessed carefully for signs of infection and bleeding
Medical management Bone marrow transplant (BMT) Peripheral blood stem cell
transplant Immunosuppressive therapy
III. MEGALOBLASTIC ANEMIA- In the anemias caused by
deficiencies of vitamin B9 or folic acid, identical bone marrow and peripheral blood changes occur because both vitamins are essential for normal DNA synthesis. In the either anemia, the erythrocytes that are produced are abnormally large and are called megaloblastic red cells.
*Folic acid deficiency• eat uncooked vegetables • Alcoholism• Increased in patients with
chronic hemolytic anemias• Women who are pregnant
*Vitamin B9• Inadequate dietary intake • Vegetarians• Faulty absorption from the GI
tract• Diseases
Nursing management• Inspection of the skin and
mucous membranes• Physical and occupational
therapy
• Eat small amounts of bland, soft food frequently
Medical management• Increased amount of Folic acid• Vitamin B12 replacement• Oral supplements with vitamins
or fortified soy milkDiagnosis• Schilling test
IV. MYELODYSPLASTIC SYNDROME- Is a group of disorders of the
myeloid stem cell that causes dysplasia in one or more types of cell lines
Nursing management• Instruction about infection risk• Chelation therapy
Medical management• BMT• Chemotherapy
HEMOLYTIC ANEMIAis anemia due to hemolysis the abnormal breakdown of redblood cells(RBCs) either in the blood vessels (intravascular hemolysis) or elsewhere in the body (extravascular). It has numerous possible causes, ranging
from relatively harmless to life-threatening. The general classification of hemolytic anemia is either inherited or acquired. Treatment depends on the cause and nature of the breakdown. Types
– Sickle cell– Thalassemia– G6PD
I. SICKLE CELL ANEMIA• Is a severe hemolytic anemia
that results from inheritance of the sickle hemoglobin gene. This gene causes the hemoglobin molecule to be defective
• The sickle hemoglobin acquires a crystal lie formation when exposed to low oxygen tension.
Sickle cell Crisis• 3 types of sickle cell crisis• Sickle crisis – results from tissue
hypoxia and necrosis due to inadequate blood flow to a specific region of tissue or organ
• Aplastic crisis – results from infection with the human parvovirus
• Sequestration crisis - results when other organs pool the sickled cells.
Medical management• Medication with antisickling
properties• Antiadhesion treatment• HydroxyureaArginine
Treatment • Pharmacologic therapy• Hydroxyurea (Hydrea) – a
chemotherapy agent increasing hemoglobin F in patient with sickle cell anemia.
• Transfusion therapyChronic RBC transfusion
II. THALASSEMIAS• Associated with defective
synthesis of the hemoglobin chain
• The production of one or more globulin chains within the hemoglobin molecule is reduced
Two major group• Alpha-thalassemia – milder than
beta thalassemia and often occur without symptoms
• Beta-thalassemia – varies depending on the extenet to
which the hemoglobin chains are affected
III. Glucose 6 Phosphate Dehydrogenase deficiency• Is the source of the abnormality
in this disorder; this gene produces an enzyme within the erythrocyte that essential for membrane stability
Nursing management• The patient is educated about
the disease and given a list of medications to avoid
Medical management• Stop offending medication• Transfusion
Diagnosis• Screening test
IV. POLYCYTHEMIA-“too may cells in the blood”
*Polycythemia Vera
-Proliferative disorder in which the myeloid stem cells seem to have escaped normal contolr mechanismsNursing management• Instruct the patient to avoid Iron
supplementsMedical management
• Phlebotomy• Anagrelide• Allopurinol
Secondary Polycythemia • Caused by excessive production
of erythropoietin• Reduced amount of oxygen• It can results from certain
hemoglobinopathies
LEUKOPENIAI. NEUTROPENIA
- Results from decreased production of neutrophils or increased destruction of neutrophils. Production of Neutrophils• Aplastic Anemia (due to
medications or toxins)• Metastatic cancer, lymphoma.
leukemia• Myelodysplastic syndromes• Chemotherapy• Radiation therapy
Destruction of Neutrophils• Hypersplenism• Medication Induced• Immunologic disorders• Viral Disease
• Bacterial Infections• Diseases
Nursing Management• Patient teaching
Medical Management• Antibiotics/Antifungal• Corticosteroids
Diagnostics• CBC• Culture of blood, urine and
sputum• CXR
LEUKEMIAIs a neoplastic proliferation of one particular cell type. Classification • According to the stem cell line:• Lymphoid• Myeloid
Based on the time it takes for symptoms to evolve:• Acute• Chronic
Common symptoms of chronic or acute leukemia may include:• Swollen lymph nodes• Fevers
• Frequent infections• Weakness• Bleeding• Swelling• Weight loss• Pain in the bones or joints
Nursing Management– Physical exam
Medical Management• Chemotherapy• Radiation therapy• Interferon therapy• Stem cell transplantation(SCT)• Surgery
Diagnostics• Blood tests• Biopsy• CXR
I. ACUTE MYELOID LEUKEMIA- Results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells.
Signs & Symptoms:– Neutropenia– Weakness– Fatigue– Bleeding
– Pain– hyperplasia
Nursing Management– Low microbial diets– Nutritional supplements– Daily body weight– OFI– Activity & rest– Maintaining F&E balance
Medical Management• Chemotherapy• Antineoplastic tx• ATRA• Administering blood products• PBSCT
Diagnostics• CBC
II. CHRONIC MYELOID LEUKEMIA– Arises from a mutation in
the myeloid stem cell.Signs & Symptoms
– Enlarged spleen– Malaise– Low-grade fever– Gout– Infection– Anemia– Thrombocytopenia– Splenomegaly
Nursing Management• Preventing infection• Bed rest• Personal hygiene• Patient teaching
Medical Management• Chemotherapy• Allopurinol
Diagnostics• CBC• Biopsy
III. ACUTE LYMPHOCYTIC LEUKEMIA- Results from an uncontrolled
proliferation of immature cells derived from lymphoid stem cells.
Signs & Symptoms: Weakness/fatigue Anemia Fever & infections Weight loss & loss of
appetite Bruising Bone pain Breathlessness Enlarged liver, lymph
nodes, and spleen Pitting edema
PetechiaeNursing Management
– All interventions for Acute Myeloid Leukemia
Medical Management• Chemotherapy• Bone marrow transplant
Diagnostics• Physical Examination• CBC• Biopsy• Ultrasound/CT scanning
IV. CHRONIC LYMPHOCYTIC LEUKEMIA
Is a blood and bone marrow disease.
Common in adults, often occurs during or after middle age; it rarely occur in children.
Signs & Symptoms: Enlarged, but painless,
lymph nodes Fatigue Fever Night sweats Weight loss Frequent infections
Medical Management• Chemotherapy• Biopsy
Diagnostics• Physical examination• Biopsy
V. LYMPHOMA– Is a type of cancer involving
cells of the immune system, called lymphocytes.
Signs & Symptoms: Painless swelling Enlargement of spleen Abdominal pain Discomfort Fevers Chills Weight loss Night sweats Lack of energy Itching
Medical Management• Chemotherapy• Radiation Therapy
Diagnostics• Blood test• Biopsy• Imaging Studies• Bone marrow Examination
VI. HODGKIN LYMPHOMA– Is a relatively rare
malignancy that has an impressive cure rate.
– Unknown cause.Signs & Symptoms:
– Painless swelling– Fevers– Night sweats– Weight loss– Itchy skin
Nursing Management– Patient teaching
Medical Management• Chemotherapy• Radiation Therapy• Stem cell transplant• Biological therapy
Diagnostics• Physical examination• Blood test• CXR• CT scan• Bone marrow aspiration• Biopsy• CBC
VII. NON-HODGKIN LYMPHOMAS• It is a heterogenous group of
cancers that originate from the neoplastic growth of lymphoid tissue.
Signs & Symptoms:• Abdominal bloating• Change in bowel habits• Fever• Sweating• Weight loss
Nursing Management– Patient teaching
Medical Management• Chemotherapt• BMT or PBSCT
Diagnostics• Physical examination• CT scan• Biopsy• CBC• CXR
VIII. MULTIPLE MYELOMA– Is a malignant disease of the
most mature form of B lymphocyte, the plasma cell.
Signs & Symptoms:– Bone pain
– Broken bones– Weakness– Fatigue– Weight loss– Repeated infections– Nausea & Vomiting– Constipation– Problem with urination
Nursing Management– Pain management– Activity restrictions– Infection prevention– Antiembolic stockings
Medical Management• NSAIDs• Opoiod analgesics• Raditaion Therapy• Chemotherapy
Diagnostics• Serum Protein electrophoresis• Urinr Protein electrophoresis• Serum free light chain analysis
BLEEDING DISORDERSI. THROMBOCYTOPENIA - medical term for a low blood platelet count; medical term for a low blood platelet count. Signs & Symptoms:• - Easy or excessive bruising
• - Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs
• - Prolonged bleeding from cuts• - Spontaneous bleeding from
your gums or nose• - Blood in urine or stools• - Unusually heavy menstrual
flows• - Profuse bleeding during surgery
or after dental work
II. HAEMOPHILIA - an inheritable disease, usually affecting only males but transmitted by women to their male children, characterized by loss or impairment of the normal clotting ability of blood so that a minor wound may result in fatal bleeding• Haemophilia A – clotting factor
VIII deficiency (most common); Classic Haemophilia
• Haemophilia B – clotting factor IX deficiency; Christmas Disease
Signs & Symptoms:• - Bleeding• - Bruising
III. VON WILLEBRAND’S DISEASE- most common
hereditary coagulation abnormality described in humans, although it can also be acquired as a result of other medical conditions.Type 1• In type 1 VWD, you have a low
level of von Willebrand factor, and you may have lower than normal levels of factor VIII. This is the mildest and most common form of VWD. About 3 out of 4 people who have VWD have type 1.
Type 2• In type 2 VWD, the von
Willebrand factor doesn't work the way it should. Type 2 is divided into subtypes: 2A, 2B, 2M, and 2N. Different gene mutations (changes) cause each type, and each is treated differently. So it's important to know the exact type of VWD that you have.
Type 3• In type 3 VWD, you usually have
no von Willebrand factor and low levels of factor VIII. Type 3 is the
most serious form of VWD, but it's very rare.
Signs & Symptoms : • Frequent, large bruises from
minor bumps or injuries• Frequent or hard-to-stop
nosebleeds• Extended bleeding from the
gums after a dental procedure• Heavy or extended menstrual
bleeding in women• Blood in your stools from
bleeding in your intestines or stomach
• Blood in your urine from bleeding in your kidneys or bladder
• Heavy bleeding after a cut or other accident
• Heavy bleeding after surgeryIV. ACQUIRED COAGULATION DISORDERSDISSEMINATED INTRAVASCULAR COAGULATION
- also known as consumptive coagulopathy, is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC
leads to the formation of small blood clots inside the blood vessels throughout the body.Signs & Symptoms:• Chest pain and shortness of
breath due to blood clots forming in the blood vessels in your lungs and heart.
• Pain, redness, warmth, and swelling in the lower leg due to blood clots forming in the deep veins of your leg.
• Headaches, speech changes, paralysis (an inability to move), dizziness, and trouble speaking and understanding due to blood clots forming in the blood vessels in your brain. These signs and symptoms may suggest a stroke.
• Heart attack and lung and kidney problems due to blood clots lodging in your heart, lungs, or kidneys. These organs may even begin to fail.
Internal Bleeding• Blood in your urine from
bleeding in your kidneys or bladder.
• Blood in your stools from bleeding in your intestines or
stomach. Blood in your stools can appear red or as a dark, tarry color. (Taking iron supplements also can cause dark, tarry stools.)
• Headaches, double vision, seizures, and other symptoms from bleeding in your brain.
External Bleeding• Prolonged bleeding, even from
minor cuts.• Bleeding or oozing from your
gums or nose, especially nosebleeds or bleeding from brushing your teeth.
• Heavy or extended menstrual bleeding in women.
LIVER DISEASE - (also called hepatic disease) is a broad term describing any single number of diseases affecting the liver. Many are accompanied byjaundice caused by increased levels of bilirubin in the system. The bilirubin results from the breakup of the hemoglobinof dead red blood cells; normally, the liver removes bilirubin from the blood and excretes it through bile.Diseases:• Hepatitis,
• Non-alcoholic fatty liver disease• Cirrhosis• Haemochromatosis• Cancer of the Wilson's disease,
a hereditary disease which causes the body to retain copper.
• Primary sclerosing cholangitis • Primary biliary cirrhosis• Budd-Chiari syndrome-
obstruction of the hepatic vein.• Gilbert's syndrome- a genetic
disorder of bilirubin metabolism• Glycogen storage disease type II -
the build-up of glycogen causes progressive muscle weakness throughout the body and affects various body tissues
Signs & Symptoms:• Jaundice• Drop of appetite & poor
digestion• Light coloration of stool• Polydypsia& polyuria • Headache• Problem of skin• Allergy• Feeling of Dizziness• Tinnitus• Ticks, Spasms and Tremors• Sudden Seizures
• Stroke• Redness and itchiness of eyes• Short temperedness and
constant irritation• Tension and pain in the back• Hypochondriac pain• Loss of flexibility of tendons and
ligaments• Depression• Mood Swings
VITAMIN K DEFICIENCY- is a form of avitaminosis resulting from insufficient vitamin KSigns & Symptoms : • - ecchymosis • - petechiae• - hematomas• - oozing of blood at surgical or
puncture sites• - stomach pains; risk of massive
uncontrolled bleeding• - cartilage calcification• - severe malformation of
developing bone or deposition of insoluble calcium salts in the walls of arteries
TreatmentsSPLENECTOMY• - is the total or partial surgical
removal of the spleen, an organ that is part of the lymphatic system.
Procedure:A. COMPLETE SPLENECTOMYREMOVAL OF ENLARGED SPLEEN.
A splenectomy is performed under general anesthesia. The most common technique is used to remove greatly enlarged spleens. After the surgeon makes a cut (incision) in the abdomen, the artery to the spleen is tied to prevent blood loss and reduce the size of the spleen. Tying the splenic artery also keeps the spleen from further sequestration of blood cells. The surgeon detaches the ligaments holding the spleen in place and removes the organ. In many cases, tissue samples will be sent to a laboratory for analysis.REMOVAL OF RUPTURED SPLEEN. When the spleen has been ruptured by trauma, the surgeon
approaches the organ from its underside and ties the splenic artery before removing the ruptured organ.B.PARTIAL SPLENECTOMY• In some cases, the surgeon
removes only part of the spleen. This procedure is considered by some to be a useful compromise that reduces pain caused by an enlarged spleen while leaving the patient less vulnerable to infection.
C. LAPAROSCOPIC SPLENECTOMY-Laparoscopic splenectomy, or
removal of the spleen through several small incisions, has been performed more frequently in recent years. Laparoscopic surgery, which is sometimes called keyhole surgery, is done with smaller surgical instruments inserted through very short incisions, with the assistance of a tiny camera and video monitor. Laparoscopic procedures reduce the length of hospital stay, the level of postoperative pain, and the risk of infection. They also leave smaller scars.
APHERESIS
- A procedure in which blood is drawn from a donor and separated into its components, some of which are retained, such as plasma or platelets, and the remainder returned by transfusion to the donor. Also called hemapheresis.Procedure:• Involve connecting the blood in
the patient/donor's veins through tubing to a machine that separates the blood components. The separation is done by either a centrifuge process or a filtration process on the blood in the machine. After the separation, the desired component of the blood is removed, while the remainders of the blood components are re-infused back into the patient. The entire procedure is painless and typically takes about two hours, or only slightly longer than a conventional blood donation.
PHLEBOTOMY- The act or practice of opening a
vein by incision or puncture to remove
blood as a therapeutic treatment. Also called venesection.Procedure:
– Select Site• Apply the tourniquet above the
elbow. Choose a vein that is prominent when the patient closes their fist. Never use an artery vein for venipuncture. – Prepare Yourself
• Wash hands and put on gloves. Clean the puncture site with an alcohol pad in a circular motion. – Perform the Venipuncture
• Pull the skin tight above the puncture site. Holding the needle in line with the vein, use a quick thrust to break the skin and enter the vein in one movement. Insert the tube to collect the blood sample. When the sample is collected, cover puncture with a gauze pad and remove needle.
BLOOD & BLOOD COMPONENT THERAPY
- transfusion of one or more of the components of whole blood.Procedure:
• Donated blood is nearly always separated into components. A person rarely receives a whole-blood transfusion. Usually, a blood component such as plasma or red blood cells is given. Patients also may receive a combination of components. The type of component patients receive depends on their medical condition.