peripheral vascular diseases edited
TRANSCRIPT
PERIPHERAL VASCULAR DISEASE
OVERVIEW OF ANATOMY AND PHYSIOLOGY
STRUCTURE & FUNCTION OF BLOOD VESSELS
BLOODVESSELSchannels
blood distributed to body tissues
WALLS OF AN ARTERY OR VEIN 3 LAYERS
1- tunica intima2-tunica media3-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 SYSTEMhigh 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 CIRCULATION • 1. BLOOD VOLUME
– 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
vasoconstrictionincreased 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
DIAGNOSTIC TESTS 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
palpable pulse & Doppler pulse are not equivalent & should not be used interchangeably
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 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
DIGITAL INTRAVENOUS ANGIOGRAPHY
utilizing computer technology
visualization of blood vessels – occurs after IV injection of
contrast material
allows for small peripheral venous injections of contrast medium, compared with large doses that must be injected via arterial cannulation
DIGITAL INTRAVENOUS ANGIOGRAPHY
VENOGRAPHYinjection of radiopaque dye
into veins serial x-rays are taken to
detect deep vein thrombosis and incompetent valves
ANGIOGRAPHYinjection of radiopaque dye
into arteries to detect plaques,
occlusions, injury, etc…
ANKLE-BRACHIAL INDEXmost commonly used parameter for – overall evaluation of
extremity status
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 TECHNIQUES AND PROCEDURES: BLOOD PRESURE MEASUREMENT
A. BLOOD PRESSUREis primarily a function of cardiac 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
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%
C. PROPER TECHNIQUE
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 client’s 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
• Rubor– Redness– Reddish blue color– Superficial vessels
injured– Anoxia– Coldness – dilated
• Cyanosis– Blueness– Seen in areas –least
pigmentation• Lips• Nailbeds• Palpebral conjunctiva• Palms
• Pain– Intermittent
claudication• Tropic changes
– Dryness– Scaling of skin– Brittle toenails
GENERAL NURSING CARE
• Increased arterial blood Increased arterial blood flow and venous returnflow 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 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
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 position—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
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 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– Promote Vasodilation
• Vasodilators– 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 thrombosis—caused 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 CAREANTICOAGULANTS• 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 gastric
secretions • 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
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 ½
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 level-
2.0-3.0
GENERAL NURSING CAREANTICOAGULANTS• 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
• Involving the intimal layer
• Leading 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
– Is a form of arteriosclerosis– Leading contributor of
coronary artery disease [CAD] & cerebrovascular disease [CVD]
– An inflammatory disease– Begins with 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
• Resulting from 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 proteinsincreases smooth muscle contraction
HYPERTENSION• PRIMARY
HYPERTENSION– Unknown etiology
• Overactivity of sympathetic nervous system
• Overactivity of renin-angiotensin-aldosterone system
• Sodium and water retention by the kidneys
• Hormonal inhibition of sodium-potassium 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 dataa. 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 DATAa. 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/ 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
E. PLANNING AND IMPLEMENTATION
1. Tell client the numeric blood pressure readings so he or she can keep an on-going record
2. Inform client that hypertension is usually asymptomatic, and symptoms will not reliably indicate BP levels
3. Explain that long-term followup 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. the stepped care approach is often used to guide treatmentthis protocol begins with lifestyle changes and adds medications based on response to previous therapy
PERIPHERAL ARTERIAL DISEASE
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 by atherosclerosis
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– 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
C. ASSESSMENT
1. Subjectivea. client reports
– 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. Objectivea. extremities - cool & pale - cyanotic
color on elevationb. bruits may be auscultatedc. peripheral pulses may be diminished
or absentd. 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 IMPLEMENTATION1. Goal: ADEQUATE TISSUE PERFUSION
a. assess and record strength of pulsesb. encourage client to stop smoking as nicotine causes vasoconstriction & hypercoagulability of bloodc. teach client to change position at least hourly and avoid crossing the legsd. encourage client to 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 circulatione. teach client to avoid restrictive clothing, including girdles, garters and socks
2. Goal: RELIEF OF PAINa. assess pain on a 1 to 10 scale and provide
analgesics as ordered
b. teach relaxation techniques because stress increases vasoconstriction
c. keep feet warm and in a dependent positiondo not elevate feet if pain is present
3. Goal: INTACT, HEALTHY SKIN ON EXTREMITIESa. skin care and daily inspection of feetb. always wear shoes / slippers and
avoid trauma to the feetbath 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 onlyd. 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 carea. angioplasty
1] monitor neurovascular statuscolor, motion, sensitivity, temperature
and presence of distal peripheral pulsesto 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 grafting1] provide standard postoperative
care2] 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. Endarterectomyopening the artery and removing
obstructing plaqueor amputation in severe casesuse same principles of care
F. MEDICATION THERAPY1. 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
7. Exercise program with weight reduction is helpful
CLIENT & FAMILY EDUCATION FOR PERIPHERAL ARTERIAL DISEASEstop smokinglose weight and eat a low fat dietdo not cross legs while sittingelevate feet at rest, but not above heart leveldo not stand or sit for long periods of timedo not wear restrictive clothingkeep affected extremity warm but never apply direct heatinspect feet daily and keep them clean & dryavoid walking barefoot; wear proper fitting shoesavoid mechanical or thermal injury to the legs and feetbegin and maintain an exercise & walking programnotify healthcare provider of any changes in color, sensation,
temperature or pulses in extremities
ARTERIAL EMBOLISM
ARTERIAL EMBOLISM
DESCRIPTIONarterial emboli usually arise from thrombi that developed in the heart as a result of
atrial fibrillation, myocardial infarction, prosthetic valves orcongestive heart failure
B. ETIOLOGY AND PATHOPHYSIOLOGY
thrombi become detached and are carried from the left 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
C. ASSESSMENT: the six P’s
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]
D. PRIORITY NURSING DIAGNOSES
Ineffective peripheral tissue perfusion
Impaired protection
E. PLANNING AND IMPLEMENTATION1- 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 IMPLEMENTATION5- 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
BUERGER’S 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 or foot
ETIOLOGY & PATHOPHYSIOLOGY
1- the cause of Buerger’s 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 component
ETIOLOGY & PATHOPHYSIOLOGY
2- inflammation occurs
mirothrombi form
these can lead to vasospasm
this process ultimately obstructs blood flow
ASSESSMENT1- bluish cast to a toe or finger and
a feeling ofcoldness in the affected limb
2- nerves alsoinflamedthere may be severe pain & constriction of smal blood vessels controlled by them
rest pain is common
3- overactive sympathetic nervesmay cause the feet to sweat excessively---even they feel cold
C. ASSESSMENT
4- blood vessels become blockedintermittent claudication
other symptoms similar to those of chronic obstructive arteril disease aften appear
5- ischemic ulcers and gangrene common complications of progressive Buerger’s 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 blockersto ease vasospasm
pentoxifylline [Trental]to reduce blood viscosity
G. CLIENT EDUCATION
1- stop smoking
2- take measures to promote peripheral circulation maintain tissue integrity
RAYNAUD’S DISEASE
A. DESCRIPTION
LOCALIZED
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
C. ASSESSMENT1- symptoms may appear in the
hands after exposure to cold and / or stressbilateral and symmetrical
2- classic triphasic color changes in the hands with accompanying reduction in skin temperaturepallorcyanosisrubor
3- the intensity of pain increases as disease progresses
4- the skin of the fingertips may thicken and nails may become brittle
D. PRIORITY NURSING DIGNOSES
INEFFECTIVE TISSUE PERFUSION
CHRONIC PAIN
E. PLANNING AND IMPLEMENTATION
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
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 PATHOPHYSIOLOGY1- 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. ASSESSMENT1- THORACIC ANEURYSMS
asymptomatic with the first sign being rupture
a- symptomspain in the back, neck and substernal area that may only occur when lying supine
b-client may experiencedysphagiadyspneastridor or coughwhen pressing on the esophagus or laryngeal nerve
C. ASSESSMENT
2- ABDOMINAL ANEURYSMSmay 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 presentsevere pain may be a sign of impending rupture
C. ASSESSMENT
2- ABDOMINAL ANEURYSMSd- the client may experience claudication
e- cool or cyanotic extremities may be noted
f- systolic bruit my be heard
3- DISSECTING ANEURYSMSpresent 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- possible syncope and paralysis of lower extremities may be present
D. PRIORITY NURSING DIAGNOSES
INEFFECTIVE TISSUE PERFUSION
PAIN
ANXIETY
E. PLANNING AND IMPLEMENTATION1. Diagnostic test that may be ordered
a- chest x-rayb- transesophageal echocardiographyc- aortographyd- ultrasounde- CT scan or MRI
2- The overall goals for a client with an aneurysma- normal tissue perfusionb- intact motor and neurologic functionc- reduction in anxietyd- no complications of surgical repair
3. Surgical care
a- surgical management may be performed on an emergency or elective basissurgery 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 occlusion2-hypovolemia / renal failure3- respiratory distress4-cardiac dysrhythmias5- paralytic ileus6- 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 therapyheparin 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 carea- 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
ETIOLOGY & PATHOPHYSIOLOGY1- ETIOLOGY
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 the blood
ETIOLOGY & PATHOPHYSIOLOGY
2-PATHOPHYSIOLOGYa-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 stopsif detechment does not occur, it will become firmly organized and attached within 24 to 48 hours
d- it detachment occurs, emboli from which generally flow through the venous system, back to the heart, and into the pulmonary circulation
ASSESSMENT1-SUBJECTIVE:
history of thrombophlebitispelvic/ abdominal surgeryobesityneoplasm [hepatic & pancreatic]congestive heart failureatril fibrillationprolonged immobilitymyocardial infarctionpregnancy & / or postpartum periodIV therapyhypercoagulable states [polycythemia, dehydration / malnutrition]
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, Homan’s sign may be present [pain on dorsiflexion of the foot, especially when the leg is raised]
DIAGNOSTIC STUDIES
a-venous duplex scanningb-Doppler ultrasonic flowmeterc-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-MRIF-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 paina-assess pain on a scale of 1 to 10b-elevate affected leg higher than the heart to promote venous drainagec-provide analgesics as ordered
3-decreased edemaa-apply warm,moist compresses, intermittent or
continuous, to affected extremityb-measure and monitor leg/arm circumference when edema is presentc-monitor status of peripheral pulses
4-prevent skin ulcerationa-keep bed covers from touching affected limb by using an overbed cradleb- do not allow use of restrictive clothing
5-prevent pulmonary embolia-maintain strict bedrest, usually enforced until anticoagulant therapy is therapeuticb-never massage affected extremityc- 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 embolismd-prepare client for vena cava filter [greenfield filter] placement
MEDICATION THERAPY1-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-thrombolyticsa-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-preventiona-early ambulation postoperativelyb-use of compression stockings or sequential devicec-low dose anticoagulant therapyd-avoid prolonged standing or sitting
avoid sitting with crossed legse-avoid restrictive clothingf-stop smoking
2-provide education about anticoagulant therapy
VENOUS INSUFFICIENCY
DESCRIPTION
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
ETIOLOGY & PATHOPHYSIOLOGY
1- occurs after prolonged venous hypertension, which stretches the veins and damages the valves, preventing blood return
2-occurs after thrombus formation or when valves are not functioning correctly,which may result froma-prolonged standing/ sittingb-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
ASSESSMENT1-subjectivea-past history of thrombophlebitis,
hypertension and varicositiesb-past history oflong periods of sitting and / or standing
2-objectivea-edema of the lower legs,may extend to the kneeb-thick, coarse, brownish skin around the ankles [gaiter area] and the feetc-stasis ulcers, usually in the malleolar area [ruddy base, uneven edges]
PRIORITY NURSING DIAGNOSISIMPAIRED SKIN INTEGRITY
RISK FOR INFECTION RELATED TO SKIN ULCERATIONS
DISTURBED BODY IMAGE
INEFFECTIVE TISSUE PERFUSION
PLANNING & IMPLEMENTATION1- increase venous blood return, decrease venous
pressure-bedrest-keep legs elevated-avoid long periods of standing-wear elastic support or compression stockingsa-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 leg—they will further impair circulation
d-handwash stockings daily and air dry; machine washing or drying will damage elastic fibers
2-treat venous stasis ulcer/sa-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 indicatedb-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 day2-keep legs above the level of the heart when in bed3-avoid prolonged sitting or standing4- do not cross legs when sitting5-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 & PATHOPHYSIOLOGY1-one in 5 people worldwide will develop varicosities2-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
ASSESSMENT1-subjective
aching, heaviness, itching, swelling and unsightly appearance to the legs
2-objectivea-dilated, tortuous superficial veins will be seen along the upper and lower legb-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
PRIORITY NURSING DIAGNOSIS
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 10b-provide analgesics as needed
2-improve venous circulationa-assess pulses and neurovascular status of lower extremitiesb-teach/ apply support stockingsc-avoid prolonged sitting and standing
never cross legs. Walking is encouragedd-elevate feet above heart level when lying downe-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 chosena-sclerotherapy-palliative not curative
-elastic bandage- until 6 weeksb-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 THERAPY—to reduce platelet aggregation and subsequent clot development
CLIENT EDUCATION: PREVENTION1-AVOID SITTING OR STANDING
FOR LONG PERIODS2-CHANGE POSITION OFTEN3-AVOID CONSTRICTIVE CLOTHING4-ELEVATE LEGS WHEN SITTING TO
PROMOTE VENOUS RETURN5-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 ductright lymphatic duct and left thoracic ductleft thoracic duct which empty into subclavian vein subclavian vein under the collarbones
• These veins join to form the form the superior vena cavasuperior vena cava, the large vein that drains blood from the upper body into the heart.
• Low pressure system 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 by- products 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
• PEYER’S PATCHES OF SMALL INTESTINE
– Protect digestive tract
• Lymphokinetic motion (flow of the lymph) due to:
• 1) Lymph flows down the pressure pressure gradientgradient.
• 2) Muscular and Muscular and respiratory pumpsrespiratory pumps push lymph forward due to function of the semilunar valvessemilunar 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 aortic valve and the pulmonary valvevalve and the pulmonary valve
• All lymph passes through strategically placed lymph lymph nodesnodes, which filter filter damaged cells, cancer damaged cells, cancer cells, and foreign particles cells, and foreign particles out of the lymphout of the lymph
• Lymph nodesLymph nodes also produce specialized blood cellsspecialized 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 maintain the pressure and volume of the extracellular fluidvolume 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 of clonal production of production of immunocompetent lymphocytes immunocompetent lymphocytes and macrophages in the specific and macrophages in the specific immune responseimmune response.
ASSESSMENT OF LYMPHATIC SYSTEM
1. SUBJECTIVE DATA
• a. lymph node enlargement
• b. infection or impaired immunityfeverfatigueweight loss
2. PHYSICAL ASSESSMENT
• a. skin over regional lymph node
edemaerythemared streaksskin 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 anomalytrauma to area as
with surgeryarm 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 Hodgkin’s
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
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
PATHOPHYSIOLOGY• 2. Chronic lymph
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 CLIENT’S
NEUROVASCULAR 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 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 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– 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