PERIPHERAL VASCULAR DISEASE

OVERVIEW OF ANATOMY AND PHYSIOLOGY

STRUCTURE & FUNCTION OF BLOOD VESSELS BLOOD VESSELSchannels blood distributed to body tissues

WALLS OF AN ARTERY OR VEIN 3 LAYERS

1- tunica intima 2-tunica media 3-tunica adventitia

the pressure a vessel must endure determine

thickness of the walls amount of connective tissue smooth muscle

DIVIDED INTO THE ARTERIAL & VENOUS SYSTEM

ARTERIAL SYSTEM high pressure vessels,
Aorta- largest

branch into arterioles less than 0.5 mm in diameter functions to deliver blood to various tissues for nourishment contribute to tissue temperature regulation

VENOUS SYSTEM large diameter thin walled vessels less pressure

 Leg veins
contain valves
regulate one-way flow

1.MUSCULAR PUMP
Milking action of skeletal muscle contraction

2.RESPIRATORY PUMP
Changes in abdominal and thoracic pressures occur with breathing

Functions to return blood from the capillaries to the right atrium

for circulation acts as a reservoir for blood volume

CAPILLARIES

Connects arterioles and venules

Permeable to gases and molecules exchanged between blood and tissue cells Found between in interwoven networks Filter and shunt blood from terminal arterioles to postcapillary venules

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

 Systemic circulation
supplies nourishment to all of the tissue located throughout your body,
with the exception of the heart and lungs because they have their own systems.

Systemic circulation
major part of the overall circulatory system.

 The blood vessels (arteries, veins, and capillaries)

delivery of oxygen and nutrients to the tissue.

Oxygen-rich blood
enters the blood vessels through the heart's main artery -- 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.

 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 are collected waste-rich blood

flows into the veins
to circulate back to the heart Where pulmonary circulation
will allow the exchange of gases in the lungs.

 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 during systemic circulation.
portal circulation.

During this phase

the blood from the small intestine collects in the portal vein passes through the liver. The liver filters sugars from the blood, storing them for later.

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

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

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

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

FACTORS AFFECTING ARTERIAL 1. BLOOD VOLUME CIRCULATION

Volume of blood transported in vessel, organ or throughout entire circulation in a given period of time

FACTORS AFFECTING ARTERIAL CIRCULATION

2. PERIPHERAL VASCULAR RESISTANCE [PVR]

Opposing forces or impedance to blood flow as arterial channels are more 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 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 AFFECTING ARTERIAL CIRCULATION

3. BLOOD PRESSURE OTHER FACTORS REGULATING BP

1. SYMPATHETIC AND PARASYMPATHETIC NS
SYMPATHETIC stimulation
Vasoconstriction of arterioles Increasing BP

FACTORS AFFECTING ARTERIAL CIRCULATION

3. BLOOD PRESSURE OTHER FACTORS REGULATING BP

1. SYMPATHETIC AND PARASYMPATHETIC NS
PARASYMPATHETIC stimulation
Vasodilation of arterioles Lowering BP

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 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 decrease in 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 AFFECTING ARTERIAL CIRCULATION

3. BLOOD PRESSURE OTHER FACTORS REGULATING 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 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

DIANOSTIC TEST AND ASSESSMENT

 DOPPLER ULTRASOUND
measures the velocity of the blood flow through a vessel emits an audible signal when arterial palpation is difficult or impossible because of occlusive disease useful in determining blood flow

DIAGNOSTIC TESTS AND ASSESSMENT

palpable pulse & Doppler pulse are not equivalent & should not be used interchangeably

biologic changes in volume in a portion of the body

associated with cardiac contractions or in response to pneumatic venous occlusion

PLETHYSMOGRAPHY

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 on the 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 technology visualization of blood vessels

occurs after IV injection of contrast material

DIGITAL INTRAVENOUS ANGIOGRAPHY

allows for small peripheral venous injections of contrast medium, compared with large doses that must be injected via arterial cannulation

DIGITAL INTRAVENOUS ANGIOGRAPHY

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

most commonly used parameter for

overall evaluation of extremity status

ANKLE-BRACHIAL INDEX

ankle pressure normally is the same or slightly higher than brachial systolic pressure

expected ABI is 0.8 to 1.0

ANKLE-BRACHIAL INDEX

gives the ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery of the arm

COMPUTED TOMOGRAPHY

allows for visualization

of the arterial wall and its structures

used in the diagnosis of abdominal aortic aneurysm [AAA] and postoperative vascular complications
graft occlusion hemorrhage

MAGNETIC RESONANCE IMAGING [MRI]

uses magnetic fields rather than radiation used with angiography to detect abnormalities
especially in people who are unable to have dye injected

MRI

COMMON NURSING A. BLOOD PRESSURE TECHNIQUES AND is primarily a PROCEDURES: BLOOD function of cardiac PRESURE MEASUREMENT output and systemic vascular resistance B. ARTERIAL BLOOD PRESSURE= CARDIAC OUTPUT X SYSTEMIC VASCULAR RESISTANCE

1. Client seated
with arm bared, supported and at heart level

C. PROPER TECHNIQUE

2. Client should not have smoked or ingested caffeine

30 minutes prior

3. BP
taken in both arms initially

4. Appropriate sized cuff must be used

rubber bladder should encircle the arm by 80%

5. After palpating the brachial or radial pulse,

inflate the cuff 30 mmHg above the level at which the pulse disappears

6. Record systolic and diastolic sounds---Korotkoff sounds

the disappearance of sound is the diastolic reading

7. Two or more readings 2 minutes apart - average 8. If the clients arms are inaccessible,
thigh or calf, auscultating the popliteal or posterior tibial arteries,

cuff size must be adjusted for larger extremity

PATIENTS WITH PERIPHERAL VASCULAR DISEASE

PERIPHERAL VASCULAR DISEASE

Disease of blood vessels In the periphery
Especially those supplying to meet the needs to the tissues

IMPAIRED CIRCULATION: PATHOLOGIC CHANGES

Coldness Pallor
Decrease in color Reduced oxyhemoglobin Decrease blood flow
Buccal mucosa

Cyanosis
Blueness Seen in areas least pigmentation
Lips Nailbeds Palpebral conjunctiva Palms

Rubor
Redness Reddish blue color Superficial vessels injured Anoxia Coldness dilated

Pain
Intermittent claudication

Tropic changes
Dryness Scaling of skin Brittle toenails

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

GENERAL NURSING CARE

Prescribe exercise
Short walks Buerger-Allen routine
Feet up from 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

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

GENERAL NURSING CARE

Patient Education
Avoid standing in any positionlong 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

GENERAL NURSING CARE

Promote Vasodilation
Warmth
Home thermostat 70-72F Not to exceed 37.8C Apply hot water bottle to abdomen Cause reflex dilatation of arteries in extremities Peripheral nerve degeneration---lessen sensitivity to heat---resulting to burns Use of hot water bottles, heating pads and hot foot soaks CONTRAINDICATED Applying heat to extremities dangerous

GENERAL NURSING CARE

Promote Vasodilation
Prevent vasoconstriction
Nicotine Cause vasospasm High emotion Stimulates sympathetic nervous system Chilling

Vasodilators
Cilostazol (Pletaal) MOA: inhibits pletelet aggregation & allows vasodilation Nsg Resp: minimal side effects, take with meals

GENERAL NURSING CARE

Vasodilators

Promote Vasodilation
Pentoxifylline (Trental) MOA: decreases viscosity----increased bld flow to microcirculation Nsg Resp: take with meals, minimal side effects Alcohol 30-60 ml 3-4 x a day

Sympathectomy
Surgical procedure Sympathetic nerve fibers Severed Causing relaxation of the arterioles Better blood flow

GENERAL NURSING CARE

Prevent and Treat Vascular Obstruction

Low cholesterol diet Exercise Control obesity Avoid tobacco Calm & rational attitude

Venous thrombosiscaused by venous stasis, hypercoagulability of blood, injury to venous wall

Preventive measures Avoid prolonged bed rest Fluids---to prevent dehydration & hypercoagulability Proper positioning Use anticoagulants & fibrinolytics

GENERAL NURSING CARE

ANTICOAGULANTS Action: prolong clotting time of blood
Wont dissolve clots already formed Prevent extension of clot Inhibit formation of new clots Parenterally
Destroyed by gastric secretions NOT absorbed from GIT

Effect immediate
Ceases after 3-4 hours

Heparin
ACTION: prevents activation of thrombin
Inhibits thromboplastin formation

Hypersensitivity:
Mild fever, urticaria, rhinitis, burning sensation in the feet

50 mg ave. dose (5000 ) IV q 3-4 hrs through heparin lock Monitor PTT (partial thromboplastin time) value
1.5-2.5 x the control Therapeutic value

GENERAL NURSING CARE

ANTICOAGULANTS 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 to 2 times (18-30 seconds) the normal activity time [N 11-13 seconds-controls]

Warfarin sodium (Coumadin)

Used widely ACTION: depresses liver synthesis of prothrombin & factor VII, IX, & X Monitor INR value N 0.75-1.25 Therapeutic level2.0-3.0

GENERAL NURSING CARE

ANTICOAGULANTS Ethyl Biscoumacetate (Tromexan)
ACTION: similar to Dicumarol Acts more quickly Effects lasts for a shorter time

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

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.

NURSING RESPONSIBILITIES
ANTIDOTE
IM NOT DONE---large painful hematomas
2.1Fibrinolytics
Used to dissolve fibrinous materials & purulent accumulation 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

GENERAL NURSING CARE

Relieve ischemic pain
By increasing circulation to the extremities

Prevent tissue damage & infection & promote healing of existing lesions
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

DISEASES OF THE ARTERIES AND VEINS

1.ARTERIOSCLEROSIS
Thickening and hardening of the arteries intimal layer Lead to hypertension

1.ARTERIOSCLEROSIS
Raises systolic pressure
By decreasing arterial distensibility By decreasing lumen diameter
Narrowing Decreased elasticity Elevated Diastolic blood pressure

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

1.ARTERIOSCLEROSIS
ARTERIOSCLEROSIS
Plaque
Can rupture
Clot formation Instability Vasoconstriction Obstruction of the lumen Inadequate oxygen delivery to tissues

HYPERTENSION

HYPERTENSION
Elevation of systemic arterial blood pressure

increases in cardiac output or total peripheral resistance or both

HYPERTENSION
PRIMARY
Without a known cause

SECONDARY
Caused by a primary disease

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

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

HYPERTENSION
PRIMARY HYPERTENSION
Unknown etiology
Overactivity of sympathetic nervous system Overactivity of reninangiotensin-aldosterone system Sodium and water retention by the kidneys Hormonal inhibition of sodiumpotassium transport across the cell walls Complex interactions involving insulin resistance and endothelial function

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 data a. past history 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 target organ damage

2.OBJECTIVE DATA a. BP consistently >140 mmHg systolic and >90 mmHg diastolic prehypertension category of at risk population is systolic BP > 130 or diastolic > 85 b. peripheral edema, retinal vessel changes, diminished/ absent peripheral pulses, bruits, murmurs and S3 and S4 heart sounds

ORTHOSTATIC HYPOTENSION
Drop in blood pressure Occurs on standing Compensatory vasoconstriction Response to standing is replaced by marked vasodilation

ORTHOSTATIC HYPOTENSION

ACUTE
Caused by delay in the normal regulatory mechanisms

CHRONIC
Secondary to a specific disease idiopathic

ORTHOSTATIC HYPOTENSION

CLINICAL MANIFESTATIONS
Fainting Cardiovascular symptoms Impotence Bowel and bladder dysfunction

HYPERTENSION
PRIMARY HYPERTENSION
MANAGEMENT
Pharmacologic Nonpharmacologic

1. blood pressure readings E. PLANNING AND 2. asymptomatic, and symptoms will not reliably IMPLEMENTATION indicate BP levels 3. Explain that long-term follow up and therapy will be necessary 4. Accurately record intake and output and daily weights of hospitalized clients

MEDICATION THERAPY
1. no one primary drug is used a combination of drugs are used until desired blood pressure is achieved with the fewest side effects 2. medications used include diuretics, beta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors [ACE] inhibitors. Angiotensin II receptor blockers [ARBs] and vasodilators

3. lifestyle changes and medications

PERIPHERAL ARTERIAL DISEASE

PERIPHERAL ARTERIAL interrupt or DISEASE impede arterial

peripheral blood flow due to
vessel compression, Vasospasm structural defects in the vessel wall

1. primarily caused by atherosclerosis local accumulation of lipid and fibrous tissue

intimal layer of an artery trauma, embolism, thrombosis, vasospasm, inflammation autoimmunity vessel is about 75 % narrowed

ETIOLOGY AND PATHOPHYSIOLOGY

may also be caused by

2. symptoms appear

3. the femoral-popliteal area

nondiabetics

arteries below the knees

diabetic

4. Chronic inadequate oxygenation of the tissues

intermittent claudication

ischemic muscle pain

precipitated by a predictable amount of exercise relieved by rest

1. Subjective a. client reports

C. ASSESSMENT

aching, cramping, fatigue or weakness in the legs that is relieved by rest [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. Objective a. extremities - cool & pale - cyanotic color on elevation b. bruits may be auscultated c. peripheral pulses may be diminished or absent d. nails may be thickened and opaque [trophic change] e. skin on the legs may be shiny with sparse hair growth [trophic change] f. ulcers-- LE reduced circulation -deep pale base, demarcated edges, painful treated with wet to moist saline dressings or surgical revascularization

3. Diagnostic testing a. digital subtraction angiography [DSA] b. angiography

c. doppler ultrasound
d. plethysmography

PRIORITY NURSING DIAGNOSES

Ineffective tissue perfusion

Impaired skin integrity

Pain

E. PLANNING AND IMPLEMENTATION 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

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, HEALTHY SKIN ON EXTREMITIES

a. skin care and daily inspection of feet b. 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 tissue at 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 appropriate 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 x 4, 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 neurovascular assessment

4] instruct the client to notify the nurse and apply 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 sand bag [or other occlusive device] at site

b. bypass grafting
1] provide standard postoperative care
2] assess for occlusion of graft by assessing for severe ischemic pain, loss of pulses, decreasing anklebrachial 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 2. Pentoxifylline [Trental] decreases blood 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. CLIENT EDUCATION

1. Promote vasodilation -provide warmth [never by direct heat to the limb] -prevent long periods of exposure to cold -avoid use of restrictive clothing 2. Proper positioning -keep feet dependent to increase blood flow to legs -may elevate feet at rest but not above level of the heart -never crosslegs or ankles -following bypass surgery, may keep legs level with rest of the body

3. Stop smoking 4. Meticulous foot care as would be performed by clients with diabetes mellitus 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 platelet aggregate inhibitors before undergoing any invasive procedures

CLIENT & FAMILY EDUCATION FOR PERIPHERAL ARTERIAL DISEASE

stop smoking lose weight and eat a low fat diet do 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 shoes avoid 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

ARTERIAL EMBOLISM

DESCRIPTION arterial emboli usually arise from thrombi that developed in the heart as a result of atrial fibrillation, myocardial infarction, prosthetic valves or congestive heart failure

ARTERIAL EMBOLISM

thrombi become detached B. ETIOLOGY AND and are carried from the left PATHOPHYSIOLOGY side of the heart into the arterial system where they may lodge and cause obstruction the symptoms may be abrupt and will depend on the size and location of the embolus

ischemia will progress to necrosis and gangrene within hours

1- pain 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]

C. ASSESSMENT: the six Ps

D. PRIORITY NURSING DIAGNOSES

Ineffective peripheral tissue perfusion

Impaired protection

E. PLANNING AND IMPLEMENTATION

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 AND IMPLEMENTATION

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 THERAPY

---if no necrosis present thrombolytic therapy with streptokinase heparin

warfarin therapy at home

G. CLIENT EDUCATION

1- PRE AND POSTOPERATIVE TEACHING IF EMBOLECTOMY IS PERFORMED

2- MEASURES TO PROMOTE PERIPHERAL CIRCULATION AND MAINTAIN TISSUE INTEGRITY

BUERGERS DISEASE [THROMBOANGIITIS OBLITERANS]

A. DESCRIPTION an inflammatory disease of the small and medium sized veins and arteries accompanied by thrombi and sometimes vasospasm of arterial segments may occur in upper or lower extremities but is most common in the leg

ETIOLOGY & PATHOPHYSIOLOGY 1- the cause of Buergers disease is unknown but since it occurs mostly in young men who smoke it is currently thought to be a reaction to something in cigarettes nd/ or to have a genetic or autoimmune

ETIOLOGY & PATHOPHYSIOLOG Y 2- inflammation occurs mirothrombi form these can lead to vasospasm this process ultimately obstructs blood flow

ASSESSMENT 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

4- blood vessels become blocked intermittent claudication

C. ASSESSMENT

other symptoms similar to those of chronic obstructive arteril disease aften appear
5- ischemic ulcers and gangrene common complications of progressive Buergers disease

D. PRIORITY NURSING DIAGNOSES

INEFFECTIVE TISSUE PERFUSION PAIN

E. PLANNING AND IMPLEMENTATION

1- arrest progress of disease by smoking cessation 2- take measures to promote vasodilation [similar to other arteril disorders]

3-provide for pain relief

4-provide emotional support

F. MEDICATION THERAPY

analgesic pain medications calcium channel blockers to ease vasospasm pentoxifylline [Trental] to reduce blood viscosity

G. CLIENT EDUCATION 1- stop smoking 2- take measures to promote peripheral circulation maintain tissue integrity

RAYNAUDS DISEASE

- LOCALIZED A. DESCRIPTION - INTERMITTENT EPISODES OF VASOCONSTRICTION OF SMALL ARTERIES OF THE HANDS - LESS COMMONLY THE FEET - CAUSING COLOR AND TEMPERATURE CHANGES

B. ETIOLOGY AND 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

1- symptoms may appear in the hands after exposure to cold and / or stress bilateral and symmetrical 2- classic triphasic color changes in the hands with accompanying reduction in skin temperature pallor cyanosis rubor 3- the intensity of pain increases as disease progresses 4- the skin of the fingertips may thicken and nails may become brittle

C. ASSESSMENT

D. PRIORITY NURSING DIGNOSES

INEFFECTIVE TISSUE PERFUSION CHRONIC PAIN

1- keep hands warm and free from injury 2- avoid stressful situations 3- in severe cases, a sympathectomy
surgical dissection of the nerve fibers that allows vasoconstriction to occur -may be performed to relieve symptoms associated with vasospasm

E. PLANNING AND IMPLEMENTATION

F. MEDICATION THERAPY

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
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

AORTIC ANEURYSM

A. DESCRIPTION

-localized dilation -outpouching of a weakened area in the aorta is classified by region as thoracic or abdominal, or s dissecting

B. ETIOLOGY AND PATHOPHYSIOLOGY

1- aorta is susceptible to aneurysm formation because of constant 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 within 1 year
6- the major risk factor is atherosclerosis

C. ASSESSMENT

1- THORACIC ANEURYSMS asymptomatic with the first sign being rupture a- symptoms pain in the back, neck and substernal area that may only occur when lying supine b-client may experience dysphagia dyspnea stridor or cough when pressing on the esophagus or laryngeal nerve

C. ASSESSMENT

2- ABDOMINAL ANEURYSMS may also be asymptomatic 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. ASSESSMENT

2- ABDOMINAL ANEURYSMS d- the client may experience claudication

e- cool or cyanotic extremities may be noted

f- systolic bruit my be heard

3- DISSECTING ANEURYSMS present with sudden, severe and persistent pain described as tearing or ripping in the anterior chest or the back a- pain may extend to the shoulder, epigastric area or abdomen b- pallor, sweating and tachycardia will be evidenced c- initially the client may have an elevated BP that may be different in one arm from the other

D. PRIORITY NURSING DIAGNOSES

INEFFECTIVE TISSUE PERFUSION PAIN

ANXIETY

E. PLANNING AND IMPLEMENTATION

1. Diagnostic test that may be ordered a- chest x-ray b- transesophageal echocardiography c- aortography d- ultrasound e- 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

3. Surgical care

a- surgical management may be performed on an emergency or elective basis surgery not usually performed on aneurysms less than 4 to 5 cm in size b- emergency surgery is the only intervention for clients with a ruptured aneurysm c- hematomas into the scrotum, perineum, flank or penis indicate retroperitoneal rupture d- once the aorta ruptures anteriorly into the peritoneal cavity, death is almost certain

3. Surgical care

e- surgical technique involves excision of the aneurysm with replacement of the excised segment with a synthetic graft f- preoperatively the nurse marks and assesses 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

F. MEDICATION THERAPY

1- the goal of nonsurgical management is to maintain blood pressure at a normal level to decrese the pressure on the arterial system and reduce the risk of rupture 2- antihypertensive therapy and diuretics may be prescribed 3- pulsatile flow may be reduced by medications that reduce cardiac contractility 4-postoperatively clients will be placed on anticoagulant therapy heparin while the client is in the hospital and warfarin [Coumadin] when discharged to home

G. CLIENT EDUCATION

1- clients who do not undergo operative repair must be urged to receive routine physical exminations to monitor the status of the aneurysm 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

G. CLIENT EDUCATION

5- for postoperative clients, teach routine postoperative care a- do limited lifting for 4 to 6 weeks after 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 synthetic graft may require prophylactic antibiotics before invasive procedures

H. EXPECTED OUTCOMES / EVALUATION

1- client has normal tissue perfusion

2- the aneurysm does not rupture 3- for surgical clients, absence of postoperative complications and maintenance of normal tissue perfusion postsurgical grafting

THROMBOPHLEBITIS

A. DESCRIPTION

The formation of a thrombus [CLOT] in association with inflammation of the vein Classified as superficial or deep

1- ETIOLOGY VIRCHOWS TRIAD [at least 2 or 3 present for thrombosis to occur]

a-stasis of venous flow b-damage to the inner lining of the vein [endothelial layer] c-hypercoagulability of the blood

ETIOLOGY & PATHOPHYSIOLOGY

2-PATHOPHYSIOLOGY
a-RBCs, WBCs and platelets adhere to form a thrombus [usually in valve cusps of veins] b- as thrombus enlarges it eventually occludes the lumen of the vein
c- if only partial occlusion of the vein occurs, blood flow continues and the thrombotic process stops
if detechment does not occur, it will become firmly organized and attached within 24 to 48 hours

ETIOLOGY & PATHOPHYSIOLOGY

d- it detachment occurs, emboli from which generally flow through the venous system, back to the heart, and into the pulmonary circulation

1-SUBJECTIVE: history of thrombophlebitis pelvic/ abdominal surgery obesity neoplasm [hepatic & pancreatic] congestive heart failure atril fibrillation prolonged immobility myocardial infarction pregnancy & / or postpartum period IV therapy hypercoagulable states [polycythemia, dehydration / malnutrition]

ASSESSMENT

2- OBJECTIVE-signs vary according to thrombus size, location and adequacy of collateral circulation

a. Superficial
-palpable, firm, subcutaneous, cordlike vein -surrounding area warm, red, teder to the touch -edema may or may not be present -most common cause in the arms is IV therapy
in the legs it is often related to varicose veins

B- deep -unilteral edema -pain -warm skin and elevated temperature -if the inferior vena cava is involved, both legs will be edematous -if the superior vena cava is involved, both upper extremities, neck, back, and face may become edematous or cyanotic
-if the calf is involved, Homans sign may be present [pain on dorsiflexion of the foot, especially when the leg is raised]

DIAGNOSTIC STUDIES
a-venous duplex scanning b-Doppler ultrasonic flowmeter c-D-dimer, a poduct of fibrin degradation, indicates fibrinolysis [that occurs as a reaction to thrombosis] d-venography & plethysmography, former gold standards for diagnosis are rarely used today e-MRI F-Lung scan

PRIORITY NURSING DIAGNOSES

PAIN INEFFECTIVE TISSUE PERFUSION

RISK FOR IMPAIRED SKIN INTEGRITY

C. PLANNING & IMPLEMENTATION

1-educate client about diagnostic tests that may be performed 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 drainage c-provide analgesics as ordered 3-decreased edema a-apply warm,moist compresses, intermittent or continuous, to affected extremity b-measure and monitor leg/arm circumference when edema is present c-monitor status of peripheral pulses

4-prevent skin ulceration a-keep bed covers from touching affected limb by using an overbed cradle b- do not allow use of restrictive clothing 5-prevent pulmonary emboli a-maintain strict bedrest, usually enforced until anticoagulant therapy is therapeutic b-never massage affected extremity c- instruct client to report any pink-tinged sputum and monitor for tachypnea, tachycardia, shortness of breath, chest pain and apprehension, which may indicate a pulmonary embolism d-prepare client for vena cava filter [greenfield filter] placement

MEDICATION THERAPY
1-anticoagulant therapy 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 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
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

VENOUS INSUFFICIENCY

DESCRIPTIO N
INADEQUATE VENOUS RETURN OVER A LONG PERIOD OF TIME THAT CAUSES PATHOLOGIC CHANGES AS A RESULT OF ISCHEMIA I THE VASCULATURE, SKIN, AND SUPPORTING TISSUES

1- occurs after prolonged venous hypertension, which stretches the veins and damages the valves, preventing blood return

ETIOLOGY & PATHOPHYSIOLOGY

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 edema of the lower limbs, discoloration to the skin of the legs & feet, venous stasis ulceration

1-subjective a-past history of thrombophlebitis, hypertension and varicosities b-past history oflong periods of sitting and / or standing 2-objective a-edema of the lower legs,may extend to the knee b-thick, coarse, brownish skin around the ankles [gaiter area] and the feet c-stasis ulcers, usually in the malleolar area [ruddy base, uneven edges]

ASSESSMENT

PRIORITY NURSING DIAGNOSIS

IMPAIRED SKIN INTEGRITY RISK FOR INFECTION RELATED TO SKIN ULCERATIONS DISTURBED BODY IMAGE INEFFECTIVE TISSUE PERFUSION

PLANNING & IMPLEMENTATION

1- increase venous blood return, decrease venous pressure -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 at night c-never push stockings down around the legthey will further impair circulation d-handwash stockings daily and air dry; machine washing or drying will damage elastic fibers

2-treat venous stasis ulcer/s a-open lesions are treated with a hydrocolloid dressing 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
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 short period of time

CLIENT EDUCATION
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 standing 4- do not cross legs when sitting 5-do not wear tight, restrictive pants, socks or boots avoid girdles and garters that restrict circulation in the upper leg 6- wear suppoert stockings as instructed

VARICOSE VEINS

DESCRIPTION
A VEIN OR VEINS IN WHICH BLOOD HAS POOLED, PRODUCING DISTENDED, TORTUOUS AND PALPABLE VESSELS

ETIOLOGY & PATHOPHYSIOLOGY

1-one in 5 people worldwide will develop varicosities 2-they are more commonin women over 35. those who are 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 legs 4-as the vein swells, increased hydrostatic pressure will push plasma through the stretched vessel walls and edema of surrounding tissue may occur

1-subjective aching, heaviness, itching, swelling and unsightly appearance to the legs 2-objective a-dilated, tortuous superficial veins will be seen along the upper and lower leg b-superficial inflammation c-positive Trendelenburg test [ done to evaluate valve competence] -supine position, elevate legs -as client sits up, the veins would normally fill from the distal end -if [+] varicosities, veins fill from the proximal end

ASSESSMENT

PRIORITY NURSING DIAGNOSIS

PAIN
INEFFECTIVE TISSUE PERFUSION RISK FORIMPAIRED SKIN INTEGRITY RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION

E. PLANNIG & IMPLEMENTATION

1-asses and provide pain relief a-assess pain scale of 1 to 10 b-provide analgesics as needed 2-improve venous circulation a-assess pulses and neurovascular status of lower extremities b-teach/ apply support stockings c-avoid prolonged sitting and standing never cross legs. Walking is encouraged d-elevate feet above heart level when lying down e-avoid restrictive clothing / shoes

3-prevent skin breakdown; teach proper skin care and importance of avoiding trauma to legs 4-teach preoperative and postoperative care if surgery is chosen a-sclerotherapy-palliative not curative -elastic bandage- until 6 weeks b-vein ligation surgery---ligation of the entire vein usually the saphenous and dissection and removal of the incompetent tributaries -post op-perform hourly circulation checks -elevate extremity to a15 degree angle to prevent stasis and edema -apply compression gradient stockings from foot to groin

MEDICATION THERAPY

LOW DOSE ASPIRIN THERAPYto reduce platelet aggregation and subsequent clot development

CLIENT EDUCATION: PREVENTION

1-AVOID SITTING OR STANDING FOR LONG PERIODS 2-CHANGE POSITION OFTEN 3-AVOID CONSTRICTIVE CLOTHING 4-ELEVATE LEGS WHEN SITTING TO PROMOTE VENOUS RETURN 5-MAINTAIN IDEAL BODY WEIGHT

LYMPHATIC SYSTEM

LYMPHATIC SYSTEM
Composed of: lymphatic vessels lymphoid organs

Form network around arterial and venous channels

Interweave at capillary beds

 Lymph [tissue fluid] leaks from cardiovascular system and accumulates at end of capillary bed Fluid returned to heart through lymphatic veins and venules that drain into right lymphatic duct and left thoracic duct which empty 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 on rhythmic contraction of smooth muscle and muscular and respiratory pumps lymphatic system transports fluids throughout the body thin-walled lymphatic vessels, lymph nodes, and two collecting ducts

larger than capillaries

most are smaller than the smallest veins

Organs of the lymphatic system

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

Organs of the lymphatic system

SPLEEN
Filters blood by breaking down old red blood cells Stores or releases to liver byproducts such as iron Synthesizes lymphocytes Stores platelets for blood clotting Serves as reservoir for blood

Organs of the lymphatic system

THYMUS
Active in childhood

produces hormones facilitating the immune action of lymphocytes

Organs of the lymphatic system

TONSILS
Protect upper respiratory tract

PEYERS PATCHES OF SMALL INTESTINE

Protect digestive tract

 Lymphokinetic motion (flow of the lymph) due to:

1) Lymph flows down the pressure gradient.

2) Muscular and respiratory pumps push lymph forward due to function of the semilunar valves.

SEMILUNAR VALVES
either of two crescent-shaped valves in the heart that prevent blood from flowing back into the ventricles. The two valves are called the aortic valve and the pulmonary valve

 All lymph passes through strategically placed lymph nodes, which filter damaged cells, cancer cells, and foreign particles out of the lymph

Lymph nodes also produce specialized blood cells designed to engulf and destroy damaged cells, cancer cells, infectious organisms, and foreign particles.

FUNCTIONS OF THE LYMPHATIC SYSTEM

to remove damaged cells from the body
to provide protection against the spread of infection and cancer.

 Functions of the lymphatic system: to maintain the pressure and volume of the extracellular fluid by returning excess water and dissolved substances from the 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.

ASSESSMENT OF LYMPHATIC SYSTEM

1. SUBJECTIVE DATA
a. lymph node enlargement b. infection or impaired immunity fever fatigue weight loss

2. PHYSICAL ASSESSMENT
a. skin over regional lymph node

edema erythema red streaks skin lesions

1. LYMPHANGITIS
Inflammation of lymph vessel red streak with hardness following course of lymphatic collecting duct

2. LYMPHEDEMA
Swelling due to lymphatic obstruction
congenital anomaly trauma to area as with surgery arm lymphedema after radical mastectomy metastasis

LYMPH NODE ASSESSMENT

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

2.LYMPHADENITIS [INFLAMMATION]
Enlargement with tenderness Bacterial infection warm , localized swelling

LYMPH NODE ASSESSMENT

3. MALIGNANT OR METASTATIC NODES
Hard as lymphoma Rubbery as with Hodgkins disease Fixed to adjacent structures Non-tender

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
PREAURICULAR AND CERVICAL NODES
Ear infection Scalp Face lesions

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
ANTERIOR CERVICAL NODES
Streptococcal pharyngitis or mononucleosis

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
OCCIPITAL NODES
Can occur with brain tumors

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
SUPRACLAVICULAR NODES-LEFT
Suggestive of metastatic disease

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
AXILLARY NODES
Associated with breast cancer

LYMPH NODE ASSESSMENT

4. SPECIFIC AREAS OF LYMPH NODE ENLARGEMENT
INGUINAL NODES
Lesions of genitals

LYMPH NODE ASSESSMENT

5.PERSISTENT GENERALIZED LYMPHADENOPATHY
Associated AIDS and AIDS related complex [ARC]

SPLEEN ASSESSMENT WITH ABNORMAL FINDINGS

Splenic enlargement
Associated with
Cancer Blood dyscrasias Viral infection
mononucleosis

LYMPHEDEMA
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

 PRIMARY LYMPHEDEMA
Congenital
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 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 lymph system by disease or procedure
Trauma Neoplasms Mosquito transmitted filariasis Inflammation Surgical excision of axillary, inguinal or iliac lymph nodes High dose radiation therapy

PATHOPHYSIOLOGY
1.Collection of lymph distal to a blocked lymphatic results in [backward flow]
increased intralymphatic pressures Causing
lymphatic wall dilation Valve incompetency

Increased intralymphatic pressure leads to

Protein accumulation in the interstitial spaces
Increased colloid osmotic pressure in tissues Resulting in fluid retention & edema

 1.Collection of lymph distal PATHOPHYSIOLOGY to a blocked lymphatic results in [backward flow]

increased intralymphatic pressures Causing
lymphatic wall dilation Valve incompetency

Increased intralymphatic pressure leads to

Protein accumulation in the interstitial spaces
Increased colloid osmotic pressure in tissues resulting in fluid retention edema

 2. Chronic lymph PATHOPHYSIOLOGY congestion leads to

Fibrosis Formation of dense connective tissue in subcutaneous tissue

ASSESSMENT FINDINGS
1. CLINICAL MANIFESTATIONS
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

The International Society of Lymphology has graded lymphedma into categories:

Grade 1
skin is pressed the pressure will leave a pit
takes some time to fill back in referred to as pitting edema. swelling can be reduced by elevating the 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:

Grade 2
swollen area is pressed, it does not pit,

swelling is not reduced very much by elevation.

If left untreated, the tissue in the limb gradually hardens

becomes fibrotic.

The International Society of Lymphology has graded lymphedma into categories:

Grade 3
Elephantiasis
almost exclusively in the legs after progressive, long term, and untreated lymphedema gross changes to the skin protrude and bulge

leakage of fluid through the tissue in the affected area, especially if there is a cut or sore
rarely reversible.

ASSESSMENT FINDINGS

1. CLINICAL MANIFESTATIONS
A. SECONDARY 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]

ASSESSMENT FINDINGS

1. CLINICAL MANIFESTATIONS
A. SECONDARY LYMPHEDEMA
Secondary lymphedema related to neoplasms
Nonpainful lymph node enlargement or edema

ASSESSMENT FINDINGS
2. LABORATORY AND DIAGNOSTIC STUDY FINDINGS
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
Injects a radiactive colloid subcutaneously Uptakes into the lymph system Serial images visualize abnormal lymph nodes

NURSING MANAGEMENT
1. ADMINISTER PRESCRIBED MEDICATIONS
Diuretics Anticoagulants

NURSING MANAGEMENT

2. ASSESS THE CLIENTS NEUROVASCULAR STATUS

By assessing for the 6 Ps 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 CLIENTS NEUROVASCULAR STATUS

By assessing for the 6 Ps 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 CLIENTS NEUROVASCULAR STATUS
By assessing for the 6 Ps 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
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
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
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
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

Assist the client with a diagnosis of neoplastic disease in coping with associated problems Encourage the client to express fears and concerns Listen actively
Altered body image

Assist the client

to select concealing clothing To take other measures to emphasize positive aspects of body image

THANK YOU