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PERIPHERAL VASCULAR DISEASE 

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