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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.

Peripheral Circulatory System and Vascular System

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Page 1: Peripheral Circulatory System and Vascular System

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

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- 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.

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- 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.

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- 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

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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

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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.

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• 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

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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:

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• 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

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- 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

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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

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• 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

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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

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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

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• 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

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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

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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

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- 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

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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

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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

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• 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

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• 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

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• 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

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• 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

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• 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

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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

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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

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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

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• - 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

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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

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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

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• 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

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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

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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.