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7/31/2019 Peripheral Vascular Diseases k
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PERIPHERAL
VASCULAR
DISEASE
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OVERVIEW OFANATOMY AND
PHYSIOLOGY
STRUCTURE &
FUNCTION OF BLOODVESSELS
BLOODVESSELSchannels
blood
distributed to bodytissues
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WALLS OF AN ARTERY OR
VEIN 3 LAYERS
1- tunica intima
2-tunica media
3-tunica adventitia
the pressure avessel must enduredetermine
– thickness of the walls
– amount of connectivetissue
– smooth muscle
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DIVIDED INTO THE ARTERIAL &
VENOUS SYSTEM ARTERIAL
SYSTEM
high pressure
vessels, – Aorta- largest
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branch into
arterioles
less than 0.5 mmin diameter
functions• to deliver blood to
various tissues for
nourishment
• contribute to tissue
temperature
regulation
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VENOUS
SYSTEM
• large diameter
• thin walled
vessels
• less pressure
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• Leg veins
– contain valves
• regulate one-way
flow
1.MUSCULAR
PUMP
– Milking action of
skeletal musclecontraction
2.RESPIRATORY
PUMP
– Changes inabdominal and
thoracic pressures
occur with
breathing
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Functions
• to return blood
from the
capillaries to the
right atrium
– for circulation
– acts as a
reservoir for blood volume
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CAPILLARIES • Connects arterioles andvenules
• Permeable to gases andmolecules exchangedbetween blood and tissue
cells
• Found between ininterwoven networks
• Filter and shunt bloodfrom terminal arterioles topostcapillary venules
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B. CIRCULATION AND DYNAMICS OF BLOOD
FLOW
BLOOD FLOW• amount of fluid
moved
• per unit of time
• through a vessel,
organ or
throughout the
entire circulatory
system
S i i l i
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• Systemic circulation –supplies nourishment
to all of the tissuelocated throughoutyour body,• with the exception of
the heart and lungsbecause they havetheir own systems.
• Systemic circulation –major part of the
overall circulatory
system.
Th bl d l
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• The blood vessels(arteries, veins, andcapillaries)
– delivery of oxygen andnutrients to the tissue.
• Oxygen-rich blood – enters the blood vessels
– through the heart's mainartery -- the aorta. – The forceful contraction of
left ventricle• forces the blood into the aorta
which• then branches into many
smaller arteries• which run throughout the
body.
i id l f t
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• inside layer of artery – very smooth,
• allowing quick blood flow
• outside layer of an artery – very strong,• allowing forceful blood flow.
• The oxygen-rich blood
– enters the capillaries where• oxygen & nutrients are released.
• The waste products arecollected
• waste-rich blood – flows into the veins
• to circulate back to the heart• Where pulmonary circulation
– will allow the exchange of gases inthe lun s.
D i t i i l ti
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• During systemic circulation, – blood passes through the
kidneys• renal circulation
– During this phase• the kidneys filter much of the
waste from the blood.
– Blood also passes through
the small intestine duringsystemic circulation.
• portal circulation.
– During this phase
• the blood from the smallintestine collects in the portalvein
• passes through the liver.• The liver filters sugars from the
blood, storing them for later.
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BLOOD FLOW THROUGH THE HEART
• 1. deoxygenated blood
– returning from the body enters the heart – through the superior vena cava and
inferior vena cava.
• 2. blood passes into
– the right atrium and right ventricle
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BLOOD FLOW THROUGH THE HEART
• 3. right ventricle – pushes the blood
– through the pulmonary arteries
• 4. blood passes
– through the lungs
• where it loses carbon dioxide
• picks up oxygen
BLOOD FLOW THROUGH THE HEART
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BLOOD FLOW THROUGH THE HEART
• 5. this oxygenated blood – returns to the heart
– via the pulmonary veins
• 6. blood enters
– the left atrium and left ventricle
BLOOD FLOW THROUGH THE HEART
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BLOOD FLOW THROUGH THE HEART
• 7. the left ventricle – pushes the blood out
• through the main artery,
– the aorta
• 8. blood travels to all parts of the body
– where it delivers oxygen
– picks up carbon dioxide
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FACTORS AFFECTING
ARTERIAL
CIRCULATION • 1. BLOOD VOLUME
– Volume of blood
transported in vessel, organ
or throughout entire
circulation in a given periodof time
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 2. PERIPHERAL VASCULAR
RESISTANCE [PVR]
– Opposing forces or impedance to
blood flow as arterial channels aremore distant from heart
– Determined by 3 factors
• Blood viscosity-thickness of blood
– Greater viscosity the greater resistance to moving & flowing
• Length of vessel
– Longer the vessel the greater the
resistance to blood flow
• Diameter of vessel – Smaller the diameter of vessel, the
greater the friction against the walls
of the vessel and greater impedance
to blood flow
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
– Force exerted against the walls of
arteries by blood
– Mean arterial pressure –MAP
• Highest pressure
– Peak of venticular contraction or systole
– SYSTOLIC BLOOD PRESSURE
• Lowest pressure
– Exerted during ventricular relaxation
– DIASTOLIC BLOOD PRESSURE
– MEAN ARTERIAL PRESSURE
[MAP]:MAP= CO [cardiac output] X PVR
– Estimated clinical calculation of MAP
• DBP + 1/3 OF PULSE PRESSURE
(DIFFERENCE BETWEEN SYSTOLIC
AND DIASTOLIC BLOOD PRESSURE)
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORS
REGULATING BP
– 1. SYMPATHETIC AND
PARASYMPATHETIC NS
• SYMPATHETIC stimulation
– Vasoconstriction of arterioles
– Increasing BP
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORS
REGULATING BP
– 1. SYMPATHETIC AND
PARASYMPATHETIC NS
• PARASYMPATHETIC
stimulation
– Vasodilation of arterioles
– Lowering BP
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORS
REGULATING BP
– 1. SYMPATHETIC AND
PARASYMPATHETIC NS
• BARORECEPTORS &
CHEMORECEPTORS (in aortic arch,carotid sinus and other large vessels
– Sensitive to pressure and chemical
changes causing
» REFLEX SYMPATHETIC
STIMULATION
vasoconstriction
increased HR & BP
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORS
REGULATING BP
– 2. ACTION OF KIDNEYS TO
EXCRETE OR CONSERVE
SODIUM AND WATER
• Kidneys initiate renin-angiotensin
mechanism in response to decreasein BP
– Release of aldosterone from adrenal
cortex
– Sodium ion reabsorption & water
retention• Kidneys reabsorb water in response
to pituitary release of antidiuretic
hormone
• Increase in blood volume
– Increase CO & BP
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORSREGULATING BP
– 3. TEMPERATURE• Cold
– Vasoconstriction
• Warmth
– Vasodilation
– 4. CHEMICALS, HORMONES,DRUGS
• Vasoconstriction
– Epinephrine
– Endothelin [chemical fr.bld vsl inn
lining] – Nicotine
• Vasodilation
– Prostaglandin
– Alcohol & histamine
FACTORS
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FACTORS
AFFECTING
ARTERIAL
CIRCULATION
• 3. BLOOD PRESSURE
• OTHER FACTORS
REGULATING BP
– 5. DIETARY FACTORS
• Salt
• Saturated fat
• Cholesterol
– 6. OTHER FACTORS
• Race
• Gender
• Age
• Weight• Time of day
• Position
• Exercise
• Emotional state
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DIANOSTIC TEST AND ASSESSMENT
DIAGNOSTIC TESTS• DOPPLER
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DIAGNOSTIC TESTS
AND ASSESSMENT
• DOPPLERULTRASOUND – measures the velocity of
the blood flow
– through a vessel
– emits an audible signal
– when arterial palpation isdifficult or impossiblebecause of occlusivedisease
– useful in determining
blood flow• palpable pulse &
Doppler pulse are notequivalent & should not
be used interchangeably
PLETHYSMOGRAPHYbiologic changes in volume in a portion
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PLETHYSMOGRAPHYbiologic changes in volume in a portion
of the body
– associated with cardiac contractions or in
response to pneumatic venous occlusion
can detect & quantify vascular disease – changes in pulse contour, blood pressure. or
arterial /venous blood flow
A plethysmography test is
• performed by placing blood pressure cuffs onthe extremities
• to measure the systolic pressure
• The cuffs are then attached to a pulse
volume recorder (plethysmograph)
– that displays each pulse wave.
– The test compares the systolic blood
pressure of the lower extremity to the upper
extremity,
• to help rule out disease that blocks the
arteries in the extremities
utilizing computer
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DIGITAL INTRAVENOUS
ANGIOGRAPHY
utilizing computer
technology
visualization of bloodvessels
– occurs after IV injection of
contrast material
allows for small peripheral
venous injections of
contrast medium, comparedwith large doses that must
be injected via arterial
cannulation
G O S G OG
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DIGITAL INTRAVENOUS ANGIOGRAPHY
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VENOGRAPHY
injection of radiopaque dye
into veins – serial x-rays are taken to
detect deep vein thrombosis
and incompetent valves
ANGIOGRAPHY
injection of radiopaque dye
into arteries – to detect plaques,
occlusions, injury, etc…
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ANKLE-BRACHIAL INDEXmost commonly used
parameter for
– overall evaluation of extremity status
ankle pressure normally
is the same or slightlyhigher than brachial
systolic pressure
expected ABI is 0.8 to 1.0
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ANKLE-BRACHIAL INDEX
gives the ratio of the
systolic blood pressure
in the ankle to the
systolic blood pressurein the brachial artery of
the arm
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COMPUTED TOMOGRAPHY
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COMPUTED TOMOGRAPHY
allows for visualization
– of the arterial wall and itsstructures
used in the diagnosis of
abdominal aorticaneurysm [AAA]
and postoperativevascular complications
– graft occlusion
– hemorrhage
MAGNETIC RESONANCE
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MAGNETIC RESONANCEIMAGING [MRI]
uses magnetic fields rather than radiation
used with angiography to
detect abnormalities
– especially in people who
are unable to have dye
injected
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MRI
COMMON NURSINGA BLOOD PRESSURE
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COMMON NURSINGTECHNIQUES AND
PROCEDURES: BLOOD
PRESURE MEASUREMENT
A. BLOOD PRESSURE
is primarily a
function of cardiac
output and systemicvascular resistance
B. ARTERIAL BLOODPRESSURE=
CARDIAC OUTPUT
X SYSTEMIC
VASCULAR
RESISTANCE
1. Client seated
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1. Client seated – with arm bared,
– supported and at heart level
2. Client should not havesmoked or ingestedcaffeine
– 30 minutes prior
3. BP – taken in both arms initially
4. Appropriate sized cuff mustbe used
– rubber bladder should
encircle the arm by 80%
C. PROPER TECHNIQUE
5. After palpating the brachial or
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p p gradial pulse, – inflate the cuff 30 mmHg above the
level at which the pulse disappears
6. Record systolic and diastolicsounds---Korotkoff sounds – the disappearance of sound is the
diastolic reading
7. Two or more readings – 2 minutesapart - average
8. If the client’s arms areinaccessible, – thigh or calf, – auscultating the popliteal or posterior
tibial arteries,
cuff size must be adjusted for larger
extremity
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PATIENTS WITHPERIPHERAL VASCULAR
DISEASE
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PERIPHERAL VASCULAR DISEASE
• Disease of blood
vessels
• In the periphery – Especially those
supplying to meet
the needs to the
tissues
IMPAIRED CIRCULATION
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IMPAIRED CIRCULATION:
PATHOLOGIC CHANGES
• Coldness• Pallor
– Decrease in color
– Reducedoxyhemoglobin
– Decrease bloodflow
• Buccal mucosa
• Rubor – Redness
– Reddish blue color – Superficial vesselsinjured
– Anoxia
– Coldness
– dilated
• Cyanosis – Blueness
– Seen in areas –leastpigmentation
• Lips
• Nailbeds• Palpebral conjunctiva
• Palms
• Pain – Intermittent
claudication
• Tropic changes – Dryness
– Scaling of skin
– Brittle toenails
GENERAL
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GENERAL
NURSING CARE• Increased arterial blood
flow and venous return
– Proper positioning
– ARTERIAL
• Blood flow towards their legs
and feet• Because they suffer from a
deficit of oxygenated blood to
their extremities
– VENOUS
• Elevate legs above the level of
the heart
• Suffer from a pooling of
deoxygenated blood in the
extremities and poor venous
return to the heart
• Elevate 6 inches block
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GENERAL NURSING CARE – Prescribe exercise
• Short walks
• Buerger-Allen routine
– Feet up from ½ to 3
minutes
– Sit on edge of bed
– Do foot exercise for 3
minutes
– Lie down for 5 minutes
• Oscillating bed
– If cannot do Buerger-Allen• Circoelectric bed
– To change position
– Improve circulation
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GENERAL NURSING CARE – Patient Education
• Avoid obesity – Extra pounds exhaust the
heart
– Decreases circulation &
increases congestion
– DIET: high in protein &
decrease in saturated fat
» Prevents breakdown of
tissues
» Promote healing of
vascular ulcer
– DIET: high vitamin B comp.
» Maintain N health of bld
vsl
– DIET: vitamin C
» Healing
» Prevent bleeding
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GENERAL NURSING CARE – Patient Education
• Avoid standing in anyposition—long period
– Promotes venous stasis
• Never wear constricting
clothes
– Garters – Girdles
– Tight belts
– Tight shoe laces
– Never cross legs at the
knee» Constricts the popliteal
vessels
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GENERAL NURSING CARE – Promote Vasodilation
• Warmth – Home thermostat 70-72°F
» Not to exceed 37.8°C
– Apply hot water bottle to abdomen
» Cause reflex dilatation of arteries in extremities
» Peripheral nerve degeneration---lessen sensitivity toheat---resulting to burns
– Use of hot water bottles, heating pads and hot foot soaks
» CONTRAINDICATED
– Applying heat to extremities
» dangerous
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GENERAL NURSING CARE – Promote Vasodilation
• Prevent vasoconstriction – Nicotine
» Cause vasospasm
– High emotion
» Stimulates sympathetic
nervous system – Chilling
• Vasodilators
– Cilostazol (Pletaal)
» MOA: inhibits pletelet
aggregation & allowsvasodilation
» Nsg Resp: minimal side
effects, take with meals
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GENERAL NURSING CARE – Promote Vasodilation
• Vasodilators
– Pentoxifylline (Trental)
» MOA: decreasesviscosity----increasedbld flow tomicrocirculation
» Nsg Resp: take withmeals, minimal sideeffects
– Alcohol
» 30-60 ml 3-4 x a day
• Sympathectomy
– Surgical procedure – Sympathetic nerve fibers
– Severed
– Causing relaxation of thearterioles
– Better blood flow
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GENERAL NURSING CARE – Prevent and Treat Vascular
Obstruction – Low cholesterol diet
– Exercise
– Control obesity
– Avoid tobacco
– Calm & rational attitude
• Venous thrombosis—caused byvenous stasis, hypercoagulabilityof blood, injury to venous wall
– Preventive measures
» Avoid prolonged bed rest
» Fluids---to preventdehydration &hypercoagulability
» Proper positioning
» Use anticoagulants &fibrinolytics
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GENERAL NURSING CARE ANTICOAGULANTS
• Action: prolong clotting time of blood
– Won’t dissolve clots already formed
– Prevent extension of clot
– Inhibit formation of new clots
• Heparin
– ACTION: prevents activation of
thrombin
• Inhibits thromboplastin formation
– Hypersensitivity:• Mild fever, urticaria, rhinitis, burning
sensation in the feet
– Parenterally
• Destroyed by gastricsecretions
• NOT absorbed from GIT
– Effect immediate
• Ceases after 3-4 hours
– 50 mg –ave. dose (5000―μ”)
– IV q 3-4 hrs through
heparin lock
– Monitor PTT (partial
thromboplastin time)value
• 1.5-2.5 x the control
• Therapeutic value
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GENERAL NURSING CAREANTICOAGULANTS
• Bishydroxycoumarin(Dicumarol) – ACTION: suppresses the act.
Of liver in formation of
prothrombin – 12-24 hrs to take effect
– Persist for 24-72 hrs
– 25-100 mg/day p.o. –maintenance dose
– 10-30% normal or 1 ½ to 2 ½times (18-30 seconds) thenormal activity time
– [N 11-13 seconds-controls]
• Warfarin sodium
(Coumadin) – Used widely
– ACTION: depressesliver synthesis of
prothrombin & factor VII, IX, & X
– Monitor INR value
– N 0.75-1.25
– Therapeutic level-2.0-3.0
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GENERAL NURSING CAREANTICOAGULANTS
• Ethyl Biscoumacetate(Tromexan)
– ACTION: similar to Dicumarol
– Acts more quickly
– Effects lasts for a shorter time
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NURSING RESPONSIBILITIES
• Careful regulation
– Amount & continuity of dose
• Drugs that potentiate anticoagulants
– Indocin, salicylates, dilantin, noctec,
antibiotics, quinidine,
adrenocorticosteroids
• Inhibit anticoagulant effect – Oral contraceptives, barbiturates, lasix
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NURSING RESPONSIBILITIES
• ANTIDOTE
– 1.Protamine Sulfate to heparin
• Acts immediately
• Effect persist for 2 hours• 1 % IV
– 2.Vitamin K (Synkavit or aquamephyton)
to Dicumarol IV or p.o.
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NURSING RESPONSIBILITIES
• ANTIDOTE – IM NOT DONE---large painful
hematomas
• 2.1Fibrinolytics – Used to dissolve fibrinous materials & purulentaccumulation by direct enzyme action
– Eg. Streptokinase---& Fibrinuclease (Elase)
• 2.2Dextran
– Plasma expander- IV – Hasten resolution
– Prevent propagation of thrombus
– Administered as 500 ml of a 6% solution of NaCl
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GENERAL NURSING CARE – Relieve ischemic pain
• By increasing circulation to theextremities
– Prevent tissue damage & infection& promote healing of existinglesions
• Avoid injury – Check bath water with bath
thermometer –instead of toes
– Wear shoes to avoid injury to feet
– Vigorous rubbing is always avoided
• Leather shoes
– Give good support to feet
• Rubber shoes
– Not advised
– Retard evaporation
– Contribute to development of fungal
infection
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DISEASES OF THEARTERIES AND
VEINS
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1.ARTERIOSCLEROSIS
• Thickening and
hardening of the
arteries
• intimal layer
• Lead to
hypertension
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1.ARTERIOSCLEROSIS
• Raises systolicpressure
– By decreasing arterial
distensibility – By decreasing lumen
diameter • Narrowing
• Decreased elasticity• Elevated Diastolic blood
pressure
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1.ARTERIOSCLEROSIS• ATHEROSCLEROSIS
– Iform of arteriosclerosis
– Lead to coronary artery
disease [CAD] &
cerebrovascular disease
[CVD]
– An inflammatory disease
– Begins --endothelial injury
• Smoking, hypertension,
diabetes [insulin resistance]
– Progresses through several
stages
• Become fibrotic palque
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1.ARTERIOSCLEROSIS
• ARTERIOSCLEROSIS – Plaque
• Can rupture
– Clot formation
– Instability – Vasoconstriction
» Obstruction of the
lumen
» Inadequate oxygen
delivery to tissues
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HYPERTENSION
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HYPERTENSION
• Elevation of systemic arterial
blood pressure
• increases in
cardiac output or
total peripheral
resistance or
both
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HYPERTENSION
• PRIMARY
– Without a
known cause
• SECONDARY
– Caused by a
primarydisease
• RISK FACTORS
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HYPERTENSION• RISK FACTORS
– Family history [+]
– Male
– Advancing age
– Black race
– Obesity
– High sodium intake – Low magnesium,
potassium or calcium
intake
– DM – Labile BP
– Cigarette smoking
– Heavy alcohol
consumption
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HYPERTENSION• PATHOPHYSIOLOGY
– Damage and inflammation of
the vessel walls
• Thick
• Hard
• Narrow
– Vasoconstriction
– Increased permeability of
vessel wall
» Influx of sodium, calcium,
water, plasma proteins
increases
smooth muscle
contraction
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HYPERTENSION• PRIMARY
HYPERTENSION – Unknown etiology
• Overactivity of sympatheticnervous system
• Overactivity of renin-angiotensin-aldosteronesystem
• Sodium and water retention bythe kidneys
• Hormonal inhibition of sodium-
potassium transport across thecell walls
• Complex interactions involvinginsulin resistance andendothelial function
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HYPERTENSION• PRIMARY
HYPERTENSION
– CLINICAL
MANIFESTATIONS – Damage of organs and
tissues outside the vascular system
• Heart disease
• Renal disease
• Central nervous system
• Musculoskeletal dysfunction
1. Subjective dataa. past history
of cardiovascular
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– of cardiovascular, – cerebrovascular, – renal or thyroid diseases, – diabetes, – smoking – or alcohol use
b. family history – of hypertension – or cardiovascular disease
c. possible absence of symptoms
d. reports – of fatigue, – nocturia, – dyspnea on exertion, – palpitations,
– angina, – headaches, – weight gain, – edema, – muscle cramps – or blurred vision
symptoms caused by targetorgan damage
2.OBJECTIVE DATA
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2.OBJECTIVE DATA
a. BP consistently >140
mmHg systolic and >90
mmHg diastolicprehypertension
category of at risk
population is systolic BP
> 130 or diastolic > 85
b. peripheral edema,
retinal vessel changes,
diminished/ absentperipheral pulses,
bruits, murmurs and S3
and S4 heart sounds
ORTHOSTATIC
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ORTHOSTATIC
HYPOTENSION
• Drop in bloodpressure
• Occurs on standing
• Compensatoryvasoconstriction
• Response tostanding is
replaced bymarkedvasodilation
ORTHOSTATIC
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ORTHOSTATIC
HYPOTENSION
• ACUTE – Caused by delay in
the normal
regulatory
mechanisms
• CHRONIC
– Secondary to a
specific disease – idiopathic
ORTHOSTATIC
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ORTHOSTATIC
HYPOTENSION• CLINICAL
MANIFESTATIONS – Fainting
– Cardiovascular
symptoms
– Impotence
– Bowel and bladder
dysfunction
HYPERTENSION
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HYPERTENSION• PRIMARY
HYPERTENSION
– MANAGEMENT
• Pharmacologic
• Nonpharmacologic
E PLANNING AND1. blood pressure readings2 asymptomatic and
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E. PLANNING AND
IMPLEMENTATION2. asymptomatic, and
symptoms will not reliablyindicate BP levels
3. Explain that long-termfollow up and therapy willbe necessary
4. Accurately record intakeand output and dailyweights of hospitalizedclients
MEDICATION THERAPY
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MEDICATION THERAPY
1. no one primary drug isused
a combination of drugsare used until desired
blood pressure is
achieved with the fewest sideeffects
2. medications used includediuretics, beta blockers,
calcium channel blockers,angiotensin convertingenzyme inhibitors [ACE]inhibitors. Angiotensin IIreceptor blockers [ARBs] andvasodilators
3 lifest le
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3. lifestyle
changes and
medications
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PERIPHERALARTERIAL
DISEASE
PERIPHERAL ARTERIAL
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PERIPHERAL ARTERIAL
DISEASEinterrupt or
impede arterial
peripheral
blood flow
• due to – vessel
compression,
– Vasospasm
– structural
defects in the
vessel wall
ETIOLOGY AND
PATHOPHYSIOLOGY
1. primarily caused byatherosclerosis
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PATHOPHYSIOLOGYatherosclerosis
local accumulation of lipid
and fibrous tissue – intimal layer of an artery
• may also be caused by
– trauma,
– embolism,
– thrombosis,
– vasospasm,
– inflammation
– autoimmunity
2. symptoms appear
– vessel is about 75 % narrowed
3. the femoral-popliteal area
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– nondiabetics
• arteries below the knees
– diabetic
4. Chronic
• inadequate oxygenation of thetissues
– intermittent claudication
ischemic muscle pain• precipitated by a predictable amount
of exercise
• relieved by rest
1. Subjectivea. client reports
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C. ASSESSMENTp
– aching,
– cramping,
– fatigue or – weakness in the legs that is relieved byrest [claudication ]• this is an early indication of disease
b. client reports
rest pain – while resting
– awaken the client at night
– toes, arch, forefoot, heel
– relieved when foot is placed in the
dependent position• this indicates more advanced disease
c. client compliants of – coldness
– numbness in the LE
2. Objectivea. extremities - cool & pale - cyanotic
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p ycolor on elevation
b. bruits may be auscultated
c. peripheral pulses may be diminishedor absent
d. nails may be thickened and opaque[trophic change ]
e. skin on the legs may be shiny withsparse hair growth [trophic change ]
f. ulcers-- LE
reduced circulation -deep palebase, demarcated edges, painful
treated with wet to moist salinedressings or surgical revascularization
3. Diagnostic testing
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a. digital subtraction
angiography [DSA]
b. angiography
c. doppler ultrasound
d. plethysmography
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PRIORITY NURSING DIAGNOSES
Ineffective tissue perfusion
Impaired skin integrity
Pain
E. PLANNING AND IMPLEMENTATION
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1. Goal: ADEQUATE TISSUE PERFUSION
a. strength of pulses
b. stop smoking as nicotine causes• vasoconstriction & hypercoagulability of blood
c. change position at least hourly and avoid crossing the legs
d. exercise and walk to the point of pain as this decreases
claudication
explain to stop walking when pain occurs to decrease
oxygen needs to affected area and to resume when pain has
stopped in order to build tolerance to exercise and stimulate
growth of collateral circulation
e. avoid restrictive clothing, including girdles,garters and
socks
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2. Goal: RELIEF OF PAIN
a. pain on a 1 to 10 scale and provide
analgesics as ordered
b. relaxation techniques because stress
increases vasoconstriction
c. keep feet warm and in a dependent position
do not elevate feet if pain is present
3. Goal: INTACT, HEALTHYSKIN ON EXTREMITIES
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SKIN ON EXTREMITIES
a. skin care and daily inspection of
feetb. always wear shoes / slippers and
avoid trauma to the feet
bath water should be checked with the
hands,not with the feet,to prevent burns to tissueat high risk for injury that may also have
decreased sensation
c. toenail care performed by a
professional only
d. if an ulcer develops,
healing will be slow unless arterial blood
flow to the affected limb is improved
through a surgical revascularization
procedure
4. If surgery is indicated, provide appropriatepostoperative care
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postoperative care
a. angioplasty
1] monitor neurovascular status
color, motion, sensitivity, temperature
and presence of distal peripheral pulses
to the affectd extremity every 15 minutes x4, every 30 min x 4, then q 1-4 hrs after
sheath removal
2] notify physician if client experiences weak
or thready pulses, coolness, numbness or
tingling in the extremity
3] monitor the sheath site for signs of external and
subcutaneous bleeding at the same frequency s
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subcutaneous bleeding at the same frequency s
neurovascular assessment
4] instruct the client to notify the nurse andapply manual pressure to the site should a
sensation of warmth or wetness be felt at the site
5] maintain immobilization of affected
extremity for at least 6 hours by reminding client to
keep extremity still or lightly immobilize ankle with sheet tucked
under both sides of mattress
6] maintain a pressure dressing and sandbag [or other occlusive device] at site
b. bypass grafting
1] id d d i
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1] provide standard postoperative care
2] assess for occlusion of graft by
assessing for severe ischemic pain,loss of pulses, decreasing ankle-
brachial index, numbness /
tingling in extremity, coolness of the
extremity
c. Endarterectomy
opening the artery and removing
obstructing plaque
or amputation in severe cases
use same principles of care
F. MEDICATION THERAPY
1 Aspirin inhibits platelet aggregation
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1. Aspirin inhibits platelet aggregation
2. Pentoxifylline [Trental] decreasesblood viscosity to increase blood
flow to the microcirculation and
tissues of the extremities
3. Cilostazol [Pletal] inhibits platelet
aggregation and enhances
vasodilation
4. Clopidogrel [Plavix] inhibits platelet
aggregation
G. CLIENTEDUCATION
1. Promote vasodilation-provide warmth [never by direct
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EDUCATION p [ yheat to the limb]
-prevent long periods of exposure to cold
-avoid use of restrictive clothing
2. Proper positioning
-keep feet dependent toincrease blood flow to legs
-may elevate feet at rest but notabove level of the heart
-never crosslegs or ankles-following bypass surgery, maykeep legs level with rest of thebody
3. Stop smoking
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4. Meticulous foot care as would be
performed by clients with diabetesmellitus
5. Trental and Plavix should be
taken with food and any effects
may take 6 to 8 weeks to notice
6. Notify caregiver of any plateletaggregate inhibitors before
undergoing any invasive
procedures
CLIENT & FAMILY EDUCATION FOR PERIPHERALARTERIAL DISEASE
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ARTERIAL DISEASE
stop smoking
lose weight and eat a low fat dietdo not cross legs while sitting
elevate feet at rest, but not above heart level
do not stand or sit for long periods of time
do not wear restrictive clothing
keep affected extremity warm but never apply direct heat
inspect feet daily and keep them clean & dry
avoid walking barefoot; wear proper fitting shoesavoid mechanical or thermal injury to the legs and feet
begin and maintain an exercise & walking program
notify healthcare provider of any changes in color, sensation,
temperature or pulses in extremities
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ARTERIAL EMBOLISM
ARTERIALDESCRIPTION
arterial emboli usually
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EMBOLISMarterial emboli usually
arise from thrombi that
developed in the heartas a result of
atrial fibrillation,
myocardial infarction,
prosthetic valves or
congestive heart
failure
B. ETIOLOGY ANDPATHOPHYSIOLOGY
thrombi become detachedand are carried from the left
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PATHOPHYSIOLOGYside of the heart into the
arterial system where they
may lodge and cause
obstruction
the symptoms may be abruptand will depend on the size
and location of the embolus
ischemia will progress to
necrosis and gangrene
within hours
C. ASSESSMENT: thesix P’s
1- pain
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six P s 2- pallor [pale color]
3- pulselessness [diminished
or absent pulses]
4- paresthesia [altered local
sensation]
5- paralysis [weakness or
inability to move extremity]
6- POIKILOTHERMIA [body
temperature that varies with
environment]
D PRIORITY NURSING DIAGNOSES
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D. PRIORITY NURSING DIAGNOSES
Ineffective peripheral tissue perfusion
Impaired protection
E. PLANNING ANDIMPLEMENTATION
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1- assess peripheral pulses and neurovascular status
every 2 to 4 hours
2- place affected extremity in a neutral position with no
restrictive bedding / clothing
---keep extremity warm
3- assess level of pain using a 1 to 10 scale
4- change position every 2 hours to increase or
improve collateral circulation
E. PLANNING ANDIMPLEMENTATION
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5- assess for and report unusual bleeding from
anticoagulant therapy
6- monitor lab vaues, including APTT, PT and INR
levels
7- if necrosis is present, surgical treatment is required;
---an emergency embolectomy needs to be
performed within 4 to 5 hours of embolism to prevent
necrosis and permanent damage to the extremity
F MEDICATION
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F. MEDICATION
THERAPY
---if no necrosis present
thrombolytic therapy with streptokinase
heparin
warfarin therapy at home
G CLIENT EDUCATION
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G. CLIENT EDUCATION
1- PRE AND POSTOPERATIVE TEACHING IF
EMBOLECTOMY IS PERFORMED
2- MEASURES TO PROMOTE PERIPHERAL
CIRCULATION AND MAINTAIN TISSUEINTEGRITY
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BUERGER’S DISEASE
[THROMBOANGIITIS
OBLITERANS]
A. DESCRIPTION
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an inflammatory disease
of the small and mediumsized veins and arteries
accompanied by thrombiand sometimes
vasospasm of arterial
segments
may occur in upper or
lower extremities but is
most common in the leg
ETIOLOGY &
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
1- the cause of Buerger’sdisease is unknown
but since it occurs
mostly in young men whosmoke
it is currently thought tobe a reaction to
something in cigarettes
nd/ or to have a genetic
or autoimmune
ETIOLOGY &PATHOPHYSIOLOG
Y
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Y
2- inflammation occurs
mirothrombi form
these can lead tovasospasm
this processultimately obstructs
blood flow
ASSESSMENT
1- bluish cast to a toe or finger
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1 bluish cast to a toe or finger
and a feeling ofcoldness in
the affected limb
2- nerves alsoinflamed
there may be severe pain& constriction of smal blood
vessels controlled by them
rest pain is common
3- overactive sympathetic
nerves
C.
ASSESSMENT
4- blood vessels becomeblocked
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intermittent claudication
other symptoms similar
to those of chronic
obstructive arteril disease
aften appear
5- ischemic ulcers and
gangrene commoncomplications of
progressive Buerger’s
disease
D. PRIORITY NURSING DIAGNOSES
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O U S G G OS S
• INEFFECTIVE TISSUE PERFUSION
• PAIN
E PLANNING AND IMPLEMENTATION
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E. PLANNING AND IMPLEMENTATION
1- arrest progress of disease by smokingcessation
2- take measures to promote vasodilation[similar to other arteril disorders]
3-provide for pain relief
4-provide emotional support
F. MEDICATION THERAPY
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F. MEDICATION THERAPY
analgesic pain medications
calcium channel blockers
to ease vasospasm
pentoxifylline [Trental]
to reduce blood viscosity
G CLIENT EDUCATION
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G. CLIENT EDUCATION
1- stop smoking
2- take measures to promote
peripheral circulationmaintain tissue integrity
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RAYNAUD’S DISEASE
A DESCRIPTION
- LOCALIZED
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A. DESCRIPTION- INTERMITTENT
EPISODES OFVASOCONSTRICTION
OF SMALL ARTERIES
OF THE HANDS
- LESS COMMONLY
THE FEET
- CAUSING COLOR AND
TEMPERATURE
CHANGES
B. ETIOLOGY AND
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
1- a vasospastic disorder of unknown
origin that primarily affects young
women
2- vasospastic attacks tend to be
bilateral and manifestations
usually begin at the tips of the
digits causing pallor, numbness
and sensation of cold
3-attacks are triggered by exposure
to cold, emotional stress, caffeine
ingestion, and tobacco use
C. ASSESSMENT1- symptoms may appear in the
hands after exposure to cold and /or stress
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bilateral and symmetrical
2- classic triphasic color changes inthe hands with accompanyingreduction in skin temperature
pallor
cyanosisrubor
3- the intensity of pain increases as
disease progresses
4- the skin of the fingertips maythicken and nails may become
brittle
D. PRIORITY NURSING DIGNOSES
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INEFFECTIVE TISSUE
PERFUSION
CHRONIC PAIN
E. PLANNING ANDIMPLEMENTATION
1- keep hands warm andfree from injury
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2- avoid stressful
situations
3- in severe cases, asympathectomy
surgical dissectionof the nerve
fibers that allowsvasoconstriction to
occur
-may be performed torelieve symptoms
associated withvasospasm
F. MEDICATION THERAPY
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1- analgesics for pain
2- vasodilators may provide
some relief of symptoms, as
well as vascular smooth
muscle relaxants and
calcium channel blockers
G. CLIENT EDUCATION
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1- keep hands warm
-wear gloves when out of doors,in air-conditioned environments
or when handling cold food
2- avoid injury to hands
3- lifestyle changes
-stop smoking
-employ stress relief---eg.
biofeedback
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AORTIC ANEURYSM
A. DESCRIPTION
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-localized dilation
-outpouching of a
weakened area inthe aorta
is classified byregion as thoracic
or abdominal, or s
dissecting
B. ETIOLOGY AND PATHOPHYSIOLOGY
1- aorta is susceptible to aneurysm formation because of constanth l ll
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stress on the vessel wall
2- aneurysms occur in men more often than women and their incidence increases with age
3- most aneurysms are found in the abdominal aorta below the
level of the renal arteries
4- the growth rate of n aneurysm is unpredictable
5-half of all aneurysms greater than 6 cm in size will rupture within1 year
6- the major risk factor is atherosclerosis
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C.
ASSESSMENT
2- ABDOMINAL ANEURYSMSmay also be asymptomatic
til t
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ASSESSMENT until rupture
a- the client may report a
―heartbeat‖ in the abdomen
when lying down
b- a pulsating abdominal
mass may be present
c- moderate to severe
abdominal or lumbar back
pain may be present
C.
ASSESSMENT2- ABDOMINAL
ANEURYSMS
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ASSESSMENT ANEURYSMS
d- the client mayexperience claudication
e- cool or cyanoticextremities may be noted
f- systolic bruit my beheard
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D. PRIORITY NURSING DIAGNOSES
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INEFFECTIVE TISSUE
PERFUSION
PAIN
ANXIETY
E PLANNING AND IMPLEMENTATION
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E. PLANNING AND IMPLEMENTATION
1. Diagnostic test that may be ordered
a- chest x-ray
b- transesophageal echocardiography
c- aortography
d- ultrasounde- CT scan or MRI
2- The overall goals for a client with an aneurysm
a- normal tissue perfusion
b- intact motor and neurologic function
c- reduction in anxiety
d- no complications of surgical repair
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e- surgical technique involves excision of the aneurysm with replacement of theexcised segment with a synthetic
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3. Surgical
care
g ygraft
f- preoperatively the nurse marks andassesses all peripheral pulses for comparison postoperatively
g- postoperatively the nurse assesses for
complications, which may include:1- graft occlusion
2-hypovolemia / renal failure
3- respiratory distress
4-cardiac dysrhythmias
5- paralytic ileus
6- paraplegia / paralysis
1- the goal of nonsurgicalmanagement is to maintain bloodpressure at a normal level to
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F.MEDICATION
THERAPY
pdecrese the pressure on the arterial
system and reduce the risk of rupture
2- antihypertensive therapy anddiuretics may be prescribed
3- pulsatile flow may be reduced bymedications that reduce cardiaccontractility
4-postoperatively clients will be placed
on anticoagulant therapyheparin while the client is in thehospital and warfarin [Coumadin]when discharged to home
1- clients who do not undergo
operative repair must be urged to
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G. CLIENT
EDUCATION
operative repair must be urged to
receive routine physical exminations
to monitor the status of theaneurysm
2- be aware of signs and symptoms of
impending rupture[see assessment of dissecting
aneurysms]
3-self monitor blood pressure and
report any increases immediately
4-how to self-manage anticoangulant
therapy
5- for postoperative clients, teachroutine postoperative care
a- do limited lifting for 4 to 6 weeks
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G. CLIENT
EDUCATION
a do limited lifting for 4 to 6 weeksafter surgery [no heavy lifting at all]
b- monitor the incision site for bleeding / infection
c- assess neurovascular status of the extremities and presence of pulses
d- clients who receive a syntheticgraft may require prophylacticantibiotics before invasive
procedures
H. EXPECTED OUTCOMES / EVALUATION
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H. EXPECTED OUTCOMES / EVALUATION
1- client has normal tissue perfusion
2- the aneurysm does not rupture
3- for surgical clients, absence of
postoperative complications andmaintenance of normal tissue perfusion
postsurgical grafting
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A. DESCRIPTION
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The formation of a
thrombus [CLOT] in
association with
inflammation of thevein
Classified as superficial
or deep
ETIOLOGY &
PATHOPHYSIOLOGY1- ETIOLOGY
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VIRCHOW’S TRIAD
[at least 2 or 3 present for thrombosis to occur]
a-stasis of venous flowb-damage to the inner lining
of the vein [endothelial
layer]
c-hypercoagulability of theblood
ETIOLOGY &
PATHOPHYSIOLOGY
2-PATHOPHYSIOLOGYa-RBCs, WBCs and platelets adhereto form a thrombus [usually in valve
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cusps of veins]
b- as thrombus enlarges it eventuallyoccludes the lumen of the vein
c- if only partial occlusion of the veinoccurs, blood flow continues and thethrombotic process stops
if detechment does not occur, it will become firmlyorganized and attached within 24 to 48 hours
d- it detachment occurs, emboli fromwhich generally flow through thevenous system, back to the heart, andinto the pulmonary circulation
ASSESSMENT1-SUBJECTIVE:
hi f h b hl bi i
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history of thrombophlebitis
pelvic/ abdominal surgeryobesity
neoplasm [hepatic & pancreatic]
congestive heart failure
atril fibrillation
prolonged immobility
myocardial infarction
pregnancy & / or postpartum periodIV therapy
hypercoagulable states [polycythemia, dehydration /malnutrition]
2- OBJECTIVE-signs vary according to thrombus size,
location and adequacy of collateral circulation
S fi i l
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a. Superficial
-palpable, firm, subcutaneous, cordlikevein
-surrounding area warm, red, teder tothe touch
-edema may or may not be present
-most common cause in the arms is IVtherapy
in the legs it is often related to varicoseveins
B- deep-unilteral edema
-pain
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-warm skin and elevated
temperature-if the inferior vena cava isinvolved, both legs willbe edematous
-if the superior vena cava is
involved, both upper extremities, neck, back,and face may becomeedematous or cyanotic
-if the calf is involved, Homan’s sign maybe present [pain on dorsiflexion of thefoot, especially when the leg israised]
DIAGNOSTIC STUDIES
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a-venous duplex scanningb-Doppler ultrasonic flowmeter
c-D-dimer, a poduct of fibrin degradation,
indicates fibrinolysis [that occurs as a reactionto thrombosis]
d-venography & plethysmography, former ―gold
standards‖ for diagnosis are rarely used today e-MRI
F-Lung scan
PRIORITY NURSING
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DIAGNOSES
PAIN
INEFFECTIVE TISSUE PERFUSION
RISK FOR IMPAIRED SKIN INTEGRITY
C. PLANNING & IMPLEMENTATION
1-educate client about diagnostic tests that may be
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g yperformed
2-provide for relief of pain
a-assess pain on a scale of 1 to 10
b-elevate affected leg higher than the heart to
promote venous drainagec-provide analgesics as ordered
3-decreased edema
a-apply warm,moist compresses, intermittent or
continuous, to affected extremityb-measure and monitor leg/arm circumferencewhen edema is present
c-monitor status of peripheral pulses
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MEDICATION THERAPY1-anticoagulant therapy
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a-inhibits clotting factors that would extend thrombus
formation
b-will not induce thrombolysis but prevents clot
extension
c-heparin: intravenously or subcutaneous while in the
hospital
d-warfarin: home therapy for 2 to 4 months
2-thrombolytics
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a-dissolve blood clots by imitating natural enzymatic
processses
b-approved drugs include streptokinase [streptase]
and alteplase [activase]
c-is usually effective in less than 72 hours
d-higher risk for hemorrhage exists than when using
heparin therapy
CLIENT EDUCATION
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1-prevention
a-early ambulation postoperatively
b-use of compression stockings or sequential device
c-low dose anticoagulant therapy
d-avoid prolonged standing or sitting
avoid sitting with crossed legs
e-avoid restrictive clothing
f-stop smoking
2-provide education about anticoagulant therapy
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VENOUS
INSUFFICIENCY
DESCRIPTION
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INADEQUATE VENOUSRETURN OVER A
LONG PERIOD OF
TIME THAT CAUSES
PATHOLOGICCHANGES AS A
RESULT OF ISCHEMIA
I THE VASCULATURE,
SKIN, AND
SUPPORTING
TISSUES
ETIOLOGY &
PATHOPHYSIOLOGY
1- occurs after prolonged venoushypertension, which stretches the
veins and damages the valves,
preventing blood return
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preventing blood return
2-occurs after thrombus formation
or when valves are not
functioning correctly,which may
result from
a-prolonged standing/ sitting
b-pregnancy and obesity
3-with time, stasis results in edemaof the lower limbs, discoloration
to the skin of the legs & feet,
venous stasis ulceration
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PRIORITY NURSING
DIAGNOSIS
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DIAGNOSIS
IMPAIRED SKIN INTEGRITY
RISK FOR INFECTION RELATED TO
SKIN ULCERATIONS
DISTURBED BODY IMAGE
INEFFECTIVE TISSUE PERFUSION
PLANNING & IMPLEMENTATION1- increase venous blood return, decrease venous
pressure
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p
-bedrest
-keep legs elevated
-avoid long periods of standing
-wear elastic support or compression stockings
a-apply stockings before getting out of the bed &placing the leg in a dependent position
b-wear stockings during the day & evening, remove atnight
c-never push stockings down around the leg—they willfurther impair circulation
d-handwash stockings daily and air dry; machinewashing or drying will damage elastic fibers
2-treat venous stasis ulcer/s
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2 treat venous stasis ulcer/s
a-open lesions are treated with a hydrocolloiddressing and compression wraps; a topical
ointment, such as low-dose hydrocortisone, zinc
oxide, or an antifungal may also be indicated
b-ulcers may be treated with an Unna Boot or other compression wrap that is changed every 1 to 2
weeks and is usually applied over a base dressing
c-severe ulcers may need surgical debridement
MEDICATION THERAPY
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1-topical agents to skin ulcers, such as hydrocortisone,antifungals or zinc oxide, may be prescribed
2- oral or IV antibiotics may be prescribed when ulcers
become infected or cellulitis occurs
3-sclerosing agents [called sclerotherapy] may be used
to occlude blood flow in a vein, causing
disappearance of the varicosity, this may be followed
up with use of compression bandage for a shortperiod of time
CLIENT EDUCATION
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1-elevate legs for at least 20 minutes four times a day
2-keep legs above the level of the heart when in bed
3-avoid prolonged sitting or standing4- do not cross legs when sitting
5-do not wear tight, restrictive pants, socks or boots
avoid girdles and garters that restrict circulation in theupper leg
6- wear suppoert stockings as instructed
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VARICOSE VEINS
DESCRIPTION
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A VEIN OR VEINS IN WHICH
BLOOD HAS POOLED,
PRODUCING DISTENDED,
TORTUOUS ANDPALPABLE VESSELS
ETIOLOGY & PATHOPHYSIOLOGY
1-one in 5 people worldwide will develop varicosities
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1-one in 5 people worldwide will develop varicosities
2-they are more commonin women over 35. those whoare obese, those with a positive family history of
varicosities, and those who stand for long periods of
time
3-develop from trauma or damages to a vein or valve or
from gradual venous distension, which diminishes the
action of the muscle pump, and increases the pull of
gravity on blood within the legs4-as the vein swells, increased hydrostatic pressure will
push plasma through the stretched vessel walls and
edema of surrounding tissue may occur
ASSESSMENT1-subjective
aching, heaviness, itching,swelling and unsightly appearanceto the legs
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2-objective
a-dilated, tortuous superficial veinswill be seen along the upper and lower leg
b-superficial inflammation
c-positive Trendelenburg test [done to evaluate valvecompetence]
-supine position, elevate legs
-as client sits up, the veinswould normally fill fromthe distal end
-if [+] varicosities, veins fillfrom the proximal end
PRIORITY NURSINGDIAGNOSIS
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PAIN
INEFFECTIVE TISSUE
PERFUSION
RISK FORIMPAIRED
SKIN INTEGRITY
RISK FOR PERIPHERAL
NEUROVASCULAR
DYSFUNCTION
E. PLANNIG & IMPLEMENTATION1-asses and provide pain relief
a assess pain scale of 1 to 10
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a-assess pain scale of 1 to 10
b-provide analgesics as needed2-improve venous circulation
a-assess pulses and neurovascular status of lower
extremitiesb-teach/ apply support stockings
c-avoid prolonged sitting and standing
never cross legs. Walking is encouragedd-elevate feet above heart level when lying down
e-avoid restrictive clothing / shoes
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MEDICATION THERAPY
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LOW DOSE ASPIRIN THERAPY—to
reduce platelet aggregation and
subsequent clot development
CLIENT EDUCATION:PREVENTION
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1-AVOID SITTING OR STANDINGFOR LONG PERIODS
2-CHANGE POSITION OFTEN
3-AVOID CONSTRICTIVE CLOTHING4-ELEVATE LEGS WHEN SITTING TO
PROMOTE VENOUS RETURN
5-MAINTAIN IDEAL BODY WEIGHT
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LYMPHATIC
SYSTEM
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• Composed of:lymphatic vessels
lymphoid organs
• Form networkaround arterial and
venous channels
• Interweave at
capillary beds
• Lymph [tissue fluid] leaks from
cardiovascular system and
accumulates at end of capillary
bed
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bed
• Fluid returned to heart through
lymphatic veins and venules that
drain into right lymphatic duct
and left thoracic duct whichempty into subclavian vein under the collarbones
• These veins join to form the superior vena cava , the large
vein that drains blood from the
upper body into the heart.
• Low pressure system depends onrhythmic contraction of smooth muscle andmuscular and respiratory
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muscular and respiratorypumps
• lymphatic systemtransports fluidsthroughout the body
• thin-walled lymphaticvessels, lymph nodes,and two collecting ducts
• larger than capillaries
• most are smaller than thesmallest veins
Organs of thelymphatic system
LYMPH NODES
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• LYMPH NODES
– Special cells of immune
system
– Remove foreign material,
infectious organism, tumor
cells from lymph
– Distributed along lymphatic
vessels forming clusters in
regions of neck, axilla, groin
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Organs of the
lymphatic system
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• THYMUS
– Active in childhood
– produces hormonesfacilitating the immune
action of lymphocytes
Organs of the
lymphatic system
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• TONSILS
– Protect upper respiratory tract
• PEYER’S PATCHESOF SMALLINTESTINE
– Protect digestive tract
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SEMILUNAR VALVES
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• either of two crescent-shaped valvesin the heart that prevent blood from
flowing back into the ventricles.
• The two valves are called the aortic valve and the pulmonary valve
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FUNCTIONS OFTHE LYMPHATIC
SYSTEM
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• to remove
damaged cells
from the body
• to provide
protection against
the spread of
infection and
cancer.
• Functions of the lymphaticsystem:
• to maintain the pressure and
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to maintain the pressure and
volume of the extracellular fluid by returning excess water and dissolved substances fromthe interstitial fluid to the
circulation.
• lymph nodes and other lymphoid tissues are the site of
clonal production of immunocompetent lymphocy tes and macrophages in the specific immune response .
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ASSESSMENT OF
LYMPHATIC SYSTEM
1. SUBJECTIVE DATA
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• a. lymph nodeenlargement
• b. infection or
impaired immunity
fever
fatigue
weight loss
2. PHYSICAL ASSESSMENT
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• a. skin over regional lymph
node
edema
erythema
red streaks
skin lesions
1. LYMPHANGITIS
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• Inflammation of lymph vessel
red streak with
hardness following
course of lymphatic
collecting duct
2. LYMPHEDEMA• Swelling due to
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g
lymphaticobstruction
congenital anomaly
trauma to area as
with surgery
arm lymphedema
after radical
mastectomy
metastasis
LYMPH NODE ASSESSMENT
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• 1.LYMPHADENOPATHY
– Enlargement over 1 cm with
or without tenderness
indicates inflammation,infection or malignancy of
nodes or region drained by
nodes
LYMPH NODE ASSESSMENT
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• 2.LYMPHADENITIS[INFLAMMATION]
– Enlargement with tenderness
– Bacterial infection
– warm , localized swelling
LYMPH NODE ASSESSMENT
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• 3. MALIGNANT ORMETASTATIC NODES
– Hard as lymphoma
– Rubbery as with Hodgkin’s
disease
– Fixed to adjacent structures
– Non-tender
LYMPH NODE ASSESSMENT
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• 4. SPECIFIC AREAS OFLYMPH NODE
ENLARGEMENT
– PREAURICULAR ANDCERVICAL NODES
• Ear infection
• Scalp
• Face lesions
LYMPH NODE ASSESSMENT
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• 4. SPECIFIC AREAS OFLYMPH NODE
ENLARGEMENT
– ANTERIOR CERVICALNODES
• Streptococcal pharyngitis or
mononucleosis
LYMPH NODE ASSESSMENT
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• 4. SPECIFIC AREAS OFLYMPH NODE
ENLARGEMENT
– OCCIPITAL NODES• Can occur with brain tumors
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LYMPH NODE ASSESSMENT
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• 4. SPECIFIC AREAS OFLYMPH NODE
ENLARGEMENT
– AXILLARY NODES• Associated with breast cancer
LYMPH NODE ASSESSMENT
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• 4. SPECIFIC AREAS OFLYMPH NODE
ENLARGEMENT
– INGUINAL NODES• Lesions of genitals
LYMPH NODE ASSESSMENT
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• 5.PERSISTENTGENERALIZED
LYMPHADENOPATHY
– Associated AIDS and AIDSrelated complex [ARC]
SPLEEN ASSESSMENT WITH ABNORMAL FINDINGS
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• Splenic enlargement
– Associated with
• Cancer
• Blood dyscrasias
• Viral infection
– mononucleosis
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LYMPHEDEMA
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• Tissue edema• Caused by obstructed lymph
flow in an extremity
• Lymphedema results when
the lymphatic system cannot
adequately drain lymph from
the tissues, causing swelling
• PRIMARYLYMPHEDEMA
– Congenital
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• Present at birth
– Praecox
• Developing early in life
• Most common type
• Second decade of life
• females
– Tardia
• Developing late in life
ETIOLOGY• PRIMARY
LYMPHEDEMA
– Also known as
lymphedema of
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lymphedema of
unknown origin or idiopathic
lymphedema
– May be associated
with• Aplasia-no lymph
vessels
• Hypoplasia-smaller or
fewer lymph vessels
than normal
• Hyperplasia-larger or
more numerous lymph
vessels
ETIOLOGY• SECONDARY
LYMPHEDEMA
– Results from damage
or obstruction of the
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or obstruction of the
lymph system bydisease or procedure
• Trauma
• Neoplasms
• Mosquito transmittedfilariasis
• Inflammation
• Surgical excision of
axillary, inguinal or iliac
lymph nodes• High dose radiation
therapy
PATHOPHYSIOLOGY• 1.Collection of lymph distal
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to a blocked lymphaticresults in [backward flow] – increased intralymphatic
pressures Causing• lymphatic wall dilation
• Valve incompetency
– Increased intralymphaticpressure leads to
• Protein accumulation in theinterstitial spaces
– Increased colloid osmoticpressure in tissues
» Resulting in fluid retention &edema
PATHOPHYSIOLOGY• 1.Collection of lymph distalto a blocked lymphatic
results in [backward flow]
– increased intralymphatic
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pressures Causing• lymphatic wall dilation
• Valve incompetency
– Increased intralymphaticpressure leads to
• Protein accumulation in the
interstitial spaces
– Increased colloid osmotic
pressure in tissues resulting in» fluid retention
» edema
PATHOPHYSIOLOGY• 2. Chronic lymph
congestion leads to
– Fibrosis
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Fibrosis
– Formation of dense
connective tissue in
subcutaneous tissue
ASSESSMENT FINDINGS
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• 1. CLINICALMANIFESTATIONS
– A. PRIMARY
LYMPHEDEMA
• Nonpitting edema• Dull, heavy sensation
• Absence of pain
• Roughened skin without
ulceration of skin or cellulitis
• Marked limb enlargement
Grades of Lymphedema
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The International Society of Lymphology has
graded lymphedma into categories:
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• Grade 1 – skin is pressed the pressure will leavea pit
– takes some time to fill back in
– referred to as pitting edema.
– swelling can be reduced by elevatingthe limb for a few hours.
– little or no fibrosis (hardening)
– so it is usually reversible.
The International Society of Lymphology has
graded lymphedma into categories:
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• Grade 2
– swollen area is pressed,
– it does not pit,
– swelling is not reduced very muchby elevation.
– If left untreated, the tissue in thelimb gradually hardens
– becomes fibrotic.
The International Society of Lymphology has
graded lymphedma into categories:• Grade 3
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– Elephantiasis
– almost exclusively in the legs
– after progressive, long term, anduntreated lymphedema
– gross changes to the skin
– protrude and bulge
– leakage of fluid through the tissuein the affected area, especially if there is a cut or sore
– rarely reversible.
ASSESSMENTFINDINGS
• 1. CLINICAL
MANIFESTATIONS
– A. SECONDARY
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LYMPHEDEMA• Secondary lymphedema
related to filariasis
– Intermittent high fever with
chills
– Malaise and fatigue – Tender regional
lymphadenopathy
– Severe muscle pain
– erythema with increased
edema and elephatiasis
[severe edema]
ASSESSMENTFINDINGS • 1. CLINICAL
MANIFESTATIONS
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– A. SECONDARYLYMPHEDEMA
• Secondary lymphedema
related to neoplasms
– Nonpainful lymph node
enlargement or edema
ASSESSMENT FINDINGS• 2. LABORATORY AND
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DIAGNOSTIC STUDYFINDINGS
– A. LYMPHANGIOGRAPHY
• Injects a contrast medium
• visualized on radiograph• Lymphomatous lymph nodes
retain the contrast agent for up to
1 year
ASSESSMENT FINDINGS• 2. LABORATORY AND DIAGNOSTIC STUDY
FINDINGS
– A LYMPHOSCINTIGRAPHY
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– A. LYMPHOSCINTIGRAPHY
• Injects a radiactive colloid subcutaneously
• Uptakes into the lymph system
• Serial images visualize abnormal lymph nodes
NURSING MANAGEMENT
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• 1. ADMINISTERPRESCRIBED
MEDICATIONS
– Diuretics
– Anticoagulants
NURSING MANAGEMENT• 2. ASSESS THE CLIENT’S
NEUROVASCULAR
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STATUS – By assessing for the 6 P’s on
both extremities• PAIN
– With exercise – With rest
– At all times
» Pain scale 1-10
» Type of pain
• PARESTHESIA
– Sharp or dull
» Use cotton tipped applicator
» All five toes, bottom of foot,up the leg
NURSING MANAGEMENT• 2. ASSESS THE CLIENT’S
NEUROVASCULAR
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STATUS – By assessing for the 6 P’s on
both extremities• POLOR
– Feel the feet» Warm or cold
• PARALYSIS
– Move his toes, ankles and knee
– Observe while ambulating
• PALLOR – Assess the color of feet
– Positions
» Neutral
» Dependent
» Elevated
NURSING MANAGEMENT• 2. ASSESS THE CLIENT’S
NEUROVASCULAR
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NEUROVASCULAR
STATUS
– By assessing for the 6 P’s on
both extremities
• PULSES
– Assess lower extremity pulses
» Dorsalis pedis
» Popliteal
» Posterior tibial
– Rating
0[absent]-4+[bounding]
– Mark with X if difficult to palpate
– If unable to assess pulses
» Use Doppler ultrasound
NURSING MANAGEMENT• 3. ASSESS FOR
LYMPHEDEMA
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LYMPHEDEMA
– Measure and compare
extremities for enlargement [at
risk]
– Assess for coexisting
symptoms of lymphedema
• Initially pitting
• Then brawny & nonpitting edema
• No pain
• Absence of infection
– TO RULE OUT VENOUS
DISORDER AS THE CAUSE
OF EDEMA
NURSING MANAGEMENT• 4. PROMOTE LYMPHATIC
DRAINAGE
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DRAINAGE
– Collaborate with physical
therapy
• Mechanical or manual squeezing
of tissue followed by specific
active and passive exercises – To press stagnant lymphatic
fluid into the blood stream
– Elevate the affected extremity
• Elevate the arm on a pillow with
the elbow higher than the
shoulder and the hand higher
than the elbow
NURSING MANAGEMENT• 4. PROMOTE LYMPHATIC
DRAINAGE
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DRAINAGE
– Apply an elastic sleeve or
stocking
– Measure the circumference of
the affected extremity
• To assess progress
– Prepare the client for
excisional removal of
edematous subcutaneous
tissue
NURSING MANAGEMENT• 5. PROVIDE CLIENT AND
FAMILY TEACHING
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FAMILY TEACHING
– Instruct the client and his
family to observe for and
report
• red streaks on the affected
extremity
• Fever and chills
• Penetrating wounds
• Enlarged & tender lymph nodes
NURSING MANAGEMENT• 5. PROVIDE EMOTIONAL
SUPPORT
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– Assist the client with adiagnosis of neoplasticdisease in coping withassociated problems
– Encourage the client toexpress fears and concerns
– Listen actively• Altered body image
– Assist the client• to select concealing clothing
• To take other measures toemphasize positive aspects of body image
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THANK YOU