VASCULAR STRESSORS

ANATOMY & PHYSIOLOGY

ARTERIES – WALLS ARE THICKER

DUE TO GREATER SMOOTH
MUSCLE, HENCE STRONGER &
CAN WITHSTAND HIGH
PRESSURE
 ANATOMY & PHYSIOLOGY

PHYSICAL PRINCIPLES THAT

DETERMINE BLOOD FLOW

1. PRESSURE CREATED BY
PUMPING OF HEART
2. RESISTANCE OF BLOOD
PUMPED (PVR) PERIPHERAL
VASCULAR RESISTANCE
(CHANGE IN VESSEL RADIUS)
 ARTERIAL DISORDERS

SUSTAINED HIGH ARTERIAL PRESSURE

INCREASES THE EFFECTS OF INJURY AND
DISEASE

EFFECTS OF ARTERIAL DISEASE CAUSES

TISSUE ISCHEMIA  DEATH OF TISSUE

SEVERITY OF SYMPTOMS IS DEPENDENT

UPON METABOLIC RATE & TISSUE NEEDS

SURGERY MAY RE-ESTABLISH CIRCULATION

ARTERIAL ASSESSMENT

PURPOSE: TO DETERMINE
ADEQUATE TISSUE PERFUSION
GUIDE LINES
1. COMPARE UPPER & LOWER
2. COMPARE BILATERALLY
3. COMPARE DISTAL & PROXIMAL
4. SUPINE (VS) DEPENDENT
CHANGES
 ARTERIAL ASSESSMENT

 MAJOR AREAS OF ASSESSMENT

1. CIRCULATION – PULSE MEANS
PERFUSION
2. MOTION – MUSCLES NEED
OXYGEN
3. SENSATION – PAIN, BURNING,
PROPRIOCEPTION, NUMBNESS
 ARTERIAL ASSESSMENT

 CIRCULATION
CHECK PULSE POINTS
CAROTID
RADIAL
FEMORAL
DORSALIS PEDIS
POSTERIOR TIBIAL
CAPILLARY REFILL
 ARTERIAL ASSESSMENT

 PULSES ARE BASED ON A SCALE

0 to 4+
 0 = NO PULSE
 1+ = THREADY PULSE
 2+ = NORMAL PULSE
 3+ = BOUNDING PULSE
 4+ = ANEURYSM
 ARTERIAL ASSESSMENT
 ARTERIAL INSUFFICIENCY
1. SKIN COOL, SHINY THIN, ONION
LIKE
2. PAIN /W COLD
3. PALE /W ELEVATION
4. DISTAL PULSES  OR ABSENT
5. DECREASED OR ABSENT HAIR
6. ISCHEMIC ULCERS
7. THICK NAILS
 COMMON DIAGNOSTIC
VASCULAR TESTS
 NON-INVASIVE TECHNIQUES
 DUPLEX ULTRASOUND
HELPS Dx NARROWING OR
OCCULUSION OF INTERNAL
CAROTIDS or DVT
FALSE (+) DUE TO
NO PATIENT PREP CALCIFICATION
PAINLESS & SAFE OF VESSELS

SUPINE POSITION
 COMMON DIAGNOSTIC
VASCULAR TESTS
 NON-INVASIVE TECHNIQUES
 SEGMENTED ARTERIAL PRESSURE
MONITORING
MEASURES PRESSURE DIFFERENCE
BETWEEN EXTREMITIES AT DIFFERENT
LEVELS
USES B/P MONITOR & DOPPLER
 ANKLE/BRACHIAL INDEX
EXAMPLE:
BRACHIAL PRESSURE =120mmHg
ANKLE PRESSURE = 96mmHg
ABI = 96 / 120 = 0.8

NORMAL 0.9 - 1.2 RISK IS LOW

VASCULAR 0.6 – 0.9 MODERATE
DISEASE RISK EXISTS
SEVERE < 0.5 VERY HIGH
DISEASE RISK EXISTS
 ARTERIAL ASSESSMENT

 CLAUDICATION
INTERMITTANT CRAMPING OF
SKELETAL MUSCLES WITH EXERCISE
• STANDARD – ABLE TO WALK ONE
CITY BLOCK W/O PAIN
• (+) = PAIN WITH AMBULATION, PAIN
WITH ELEVATION, RELIEF WITH
DEPENDENT POSITION
• Tx: pentoxyphylline (Trental)
• cilostazol (Pletal)
 ACUTE ARTERIAL
INSUFFICIENCY
THE 5 P’s
WHEN PRESENT = SURGICAL EMERGENCY!
1. PAIN
2. PALLOR
3. PULSELESSNESS
4. PARALYSIS
5. PARESTHESIA
 COMMON DIAGNOSTIC
VASCULAR TESTS
 ANGIOGRAPHY (ANGIOGRAM)
INVASIVE TECHNIQUE – USED WHEN
SURGICAL INTERVENTION IS BEING
CONSIDERED

USED TO DIAGNOSE
EMBOLI, THROMBOSIS, TRAUMA,
ANEURYSM, BUERGER’S DISEASE,
ARTERIOSCLEROSIS
 ARTERIAL DISORDERS

ARTERIAL SYSTEM PROBLEMS

CAN BE CONTROLLED BY
MODIFYING RISK FACTORS:
SMOKING
DIET
GLUCOSE CONTROL
ACTIVITY LEVEL
HYPERLIPIDEMIA
BP (DOUBLES RISK)
WHEN ARTERIES BECOME
OCCLUDED
HEALTHY ARTERIES ARE BLOOD
VESSELS WHICH ARE FLEXIBLE,
STRONG & ELASTIC
THEIR INSIDE LINING IS
SMOOTH SO BLOOD CAN FLOW
WITHOUT RESTRICTION
Risk Factors cause arteries to become
occluded.
Progression of Occlusion
PLAQUE DEPOSIT
ORIGINAL DIAMETER
 ARTERIAL DISORDERS

PERIPHERAL ARTERIAL
INSUFFICIENCY / OCCLUSION

ASSESSMENT:

WEAK/ ABSENT PULSES

PAIN /W LEG ELEVATION
SKIN COOL TO TOUCH
PALE SKIN COLOR
THICKENED TOENAILS
 ARTERIAL DISORDERS

GOALS:
1. IMPROVE PERIPHERAL ARTERIAL
CIRCULATION WITH EXERCISE

REGULAR EXERCISE SUCH AS

WALKING INCREASES
CIRCULATION
 ARTERIAL DISORDERS

GOALS:
2. PREVENT VASCULAR COMPRESSION

AVOID RESTRICTIVE CLOTHING,

CROSSING LEGS, SITTING FOR
PROLONGED PERIODS
 ARTERIAL DISORDERS

GOALS:
3. RELIEVE PAIN

CONSIDER ANALGESICS SO
PATIENT CAN PARTICIPATE IN
ACTIVITIES
 ARTERIAL DISORDERS

GOALS:
4. MAINTAIN TISSUE INTEGRITY

• AVOID TRAUMA, WEAR CORRECT

SHOE GEAR (NO BARE FEET!)
• TEST WATER TEMP WITH HAND
NOT FOOT!
• REGULAR PODIATRY CARE
• GOOD NUTRITION
 ANGIOPLASTY

 BALLOON
ANGIOPLASTY
CATHETER
 INSERTED
THROUGH AN
ARTERY
 BALLOON IS
INFLATED AND
USED FOR
COMPRESSES INSERTION OF
LESION STENTS
ANGIOPLASTY
 MEDICAL MANAGEMENT

THROMBOLYTIC THERAPY
USED TO DISSOLVE CLOTS:
Retavase, streptokinase, tPa

SURGICAL MANAGEMENT
1. GRAFTING – BYPASS SURGERY
2. ENDARTERECTOMY – REMOVAL OF
ATHEROSCLEROTIC PLAQUE
3. AORTO/FEMORAL/TIBIAL BYPASS
 NURSING DX/ ARTERIAL
DISORDERS & GOALS
1. ALTERED PERIPHERAL TISSUE
PERFUSION
( ARTERIAL BLOOD FLOW)
GOAL: MAXIMIZE TISSUE PERFUSION
2. ACTIVITY INTOLERANCE – VASCULAR
SUPPLY CAN NOT KEEP UP WITH
TISSUE DEMANDS
GOAL: MANAGE ACTIVITY WITHIN
LIMITATIONS
 NURSING DX/ ARTERIAL
DISORDERS & GOALS

3. ANTICIPATORY GRIEVING RELATED TO

POTENTIAL LOSS OF LIMB
GOAL: EXPRESS CONCERNS

4. BODY IMAGE DISTURBANCE AS

RELATED TO LOSS OF BODY PART
GOAL: DISCUSS IMAGE & OPTIONS
 NURSING DX/ ARTERIAL
DISORDERS & GOALS

5. IMPAIRED TISSUE INTEGRITY AS

RELATED TO  CIRCULATION
GOAL: MAINTAIN TISSUE
INTEGRITY
6. KNOWLEDGE DEFICIT OF SELF
CARE ACTIVITIES

GOAL: EDUCATE PATIENT

 NURSING DX/ ARTERIAL
DISORDERS & GOALS

7. PAIN DUE TO ISCHEMIA

GOAL: RELIEVE PAIN
8. POTENTIAL FOR INJURY DUE TO 
SENSATION
GOAL: EDUCATE PATIENT TO INSPECT FOR
INJURY, WATCH FOR TRAUMA

9. SLEEP PATTERN DISTURBANCE DUE TO REST

PAIN

GOAL: MAXIMIZE SLEEP

 NURSING INTERVENTIONS

1. RISK FACTOR MODIFICATION

SMOKING (Most significant RISK FACTOR)
 NICOTINE CAUSES VASOSPASMS
WEIGHT LOSS
 REDUCES WORKLOAD IN
EXTREMITIES
LOW FAT DIET WILL RETARD
PROGRESSION OF ATHEROSCLEROSIS
CONTROL HTN
 NURSING INTERVENTIONS

2. PAIN MANAGEMENT
INTENSITY IS VARIABLE
MANAGEMENT- RTC
PAIN MEDICATION
(MAY NOT BE EFFECTIVE)
 DEPENDENT POSITION MAY 
COMFORT
 NURSING INTERVENTIONS

3. MAINTAIN FLUID VOLUME

IN SEVERE STENOSIS PATIENT MUST
MAINTAIN SUFFICIENT BLOOD PRESSURE
TO AVOID COMPLETE OCCLUSION
 NURSING INTERVENTIONS

4. ACTIVITY
 MONITOR CLAUDICATION
 TEACH PATIENT – PAIN IS NOT
HARMFUL, BUT A BODY SIGNAL
FOR NEED TO REST
 EMPHASIZE: EXERCISE INCREASES
COLLATERAL CIRCULATION
 CHECK WITH DOCTOR ABOUT ANY
EXERCISE
PROGRESSION SHOULD BE GRADUAL
 NURSING INTERVENTIONS

5. MAINTAINING TISSUE INTEGRITY

 CHANGE POSITION FREQUENTLY
 AVOID CROSSING LEGS
& CONSTRICTIVE CLOTHING
 METICULOUS FOOT CARE (PODIATRIST)
 PROTECT FROM INJURY
 KEEP EXTREMITIES WARM
(NO HEATING BLANKET OR HOT WATER
BOTTLES!)
 SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY- Postop
 NEUROVASCULAR ASSESSMENT
 COMPLICATIONS
• GRAFT OCCLUSION:THROMBOSIS
• COMPARTMENT SYNDROME
• GRAFT INFECTIONS
• FISTULA/ULCER FORMATION
 EDUCATE PATIENT TO
• REPORT PAIN UNRELIEVED BY MEDS
• STOP SMOKING
• ID NORMAL HEALING PROCESS
 SURGICAL NURSING
MANAGEMENT
S/P BYPASS SURGERY
 POSITIONING
• KEEP LOWER EXTREMITY LEVEL
AND AVOID CONSTRICTION
• AVOID DEPENDENT POSITION
WHICH ’s EDEMA , PAIN &
HEALING
• MOBILITY IS PROGRESSIVE
 ARTERIAL DISEASES

BUERGER’S DISEASE [TAO]

(aka: Thromboangiitis Obliterans)
1. DISEASE IS LINKED DIRECTLY TO
SMOKING (REQUIRED HX FOR DX)
2. POSSIBLE IMMUNOPATHOGENESIS
3. INFLAMMATION PRODUCES CRITICAL
LIMB ISCHEMIA
4. DISEASE CAN PROGRESS PROXIMALLY
 Raynaud’s Disease

VASOSPASTIC DISORDERS:
1. BLOOD VESSELS (FINGERS & TOES) GO
INTO SPASM
2. EXTREME SENSITIVITY TO TEMP
CHANGES (ESPECIALLY COLD)
3. MORE COMMON FEMALE > MALE
4. Color changes are Red/White/Blue
 RAYNAUD’S

CLASSIFIED:
1. RAYNAUD’S DISEASE = WHEN
SYMPTOMS ARE THE ONLY PRESENTING
FACTOR
2. RAYNAUD’S PHENOMENON = WHEN
SYMPTOMS ARE SECONDARY TO
ANOTHER CONDITION
EX: RA, SCLERODERMA, LUPUS, CARPAL
TUNNEL SYDROME, THORACIC OUTLET
SYNDROME
 RAYNAUD’S

DX:
1. BILATERAL
2. OCCURS X 2 YEARS
3. NO OTHER CAUSE

Prevention:
1. PROTECT FROM COLD EXPOSURE
2. AVOID EXCESSIVE EMOTIONAL STRESS
3. DO NOT USE VIBRATING TOOLS
 ANEURYSM

ANEURYSM = AN
LOCALIZED
ABNORMAL
DILATION OF A
BLOOD VESSEL

HIGH RISK
IN
MARFAN’S
SYNDROME
 Abdominal Aortic
Aneurysm:Pathophysiology
Aneurysm-permanent localized dilation
of an artery
-enlarges to 2x normal
diameter
-middle layer of artery is
weakened
-HTN produces more tension
and enlargement within the artery
 AORTIC ANEURYSMS

Location: Thoracic
Abdominal aortic aneurysms
Etiology:
Atherosclerosis (+HTN & smoking)
Syphillis
Marfan Syndrome
Ehlers-Danlos syndrome
 AAA Assessment

 Upper abdomen pulsation, left of

midline
 + bruit over mass
 Abdominal, flank or back pain- if
leaking or ruptured
 Abd Xray- “Eggshell Calcification”
 Cat scan
 Aortic angiography
 Ultrasonography
 Interventions

 Nonsurgical
 Surgical- AAA Resection
- Endovascular stent graft

Post-op care of the AAA patient:

 VENOUS
ANATOMY & PHYSIOLOGY
VEINS – HAVE THIN WALLS
(LESS SMOOTH MUSCLE)
ALLOW VESSELS TO DISTEND
MORE THAN ARTERIES
 Venous System
ANATOMY & PHYSIOLOGY
BLOOD FLOWS AGAINST
GRAVITY BECAUSE:
VALVES – ONE WAY VALVES
PREVENT BACKFLOW. (VALVE
COMPETENCY DEPENDS UPON
INTEGRITY OF VEIN WALL)
MUSCLE CONTRACTION MILKS
BLOOD THROUGH VESSELS
 VENOUS ASSESSMENT
 VENOUS INSUFFICIENCY
1. DRY, FLAKY
(BROWN & BLOTCHY)
2. PURPLE – DEPENDENT
3. ELEVATION ’s DEPENDENT EDEMA
4. EDEMA MAY OBLITERATE PULSES
5. VENOUS STASIS ULCERS
6. PARESTHESIAS
 Disorders of Venous
Circulation
 PHLEBITIS-Vein  PHLEBOTHROMBOSIS
inflammation
CLOT DEVELOPS DUE
TO VENOUS STASIS OR
“THICK BLOOD”
 THROMBOPHLEBITIS
HYPERCOAGUABILITY
INFLAMMATION OF & INFLAMMATION
WALLS OF VEINS WITH
CLOT FORMATION DVT- Deep Vein
Thrombosis
 VENOUS DISORDERS
VIRCHOW’S TRIAD
PREDISPOSING FACTORS
a) VENOUS STASIS – Bedrest, BP,
HYPOVOLEMIA,
b) HYPERCOAGULABILITY – CANCER,SMOKING,
POLYCYTHEMIA, SURGERY, SEPSIS, OC
c) ENDOTHELIAL DAMAGE – STIMULATES
PLATELET AGGREGATION, VENOUS
INFLAMMATION
 VENOUS DISORDERS
Other Risk Factors
d) IMMOBILIZATION – PARALYSIS, PROLONGED
BEDREST, LONG PLANE OR CAR RIDES
e) DISEASE PROCESSES – SEPSIS,
SLE,HEMATOLOGICAL DISORDERS, MS,MALIGNANCY,
CHF, MI, ULCERATIVE COLITIS
f) PRESSURE – OBESITY, PREGNANCY, TUMOR
g) TRAUMA – FRACTURES, VENIPUNCTURE
h) CLOTTING DYSFUNCTION
i) SURGICAL PROCEDURES – HIP, GYN & UROLOGICAL
& in age >40
j) OC use- especially in women who smoke
k) OTHER – DEHYDRATION, ADVANCED AGE
 VENOUS DISORDERS

DEEP VENOUS THROMBOSIS (DVT)

1. PATHOPHYSIOLOGY – DEEP VEIN CLOT
MOST COMMON IN LOWER LEG (CALF)
UNDIAGNOSED DVT OCCURS IN 50% OF
PATIENTS WITH PULMONARY EMBOLI
 Assessment of DVT
S&S
-Calf or groin tenderness
-Pain that can be dull or aching, especially when walking
-Sudden onset of unilateral swelling of the leg
-Cyanosis of the affected extremity
-Slightly elevated temp
-General malaise
 Assessment of DVT

Homan’s Sign-pain on dorsiflexion of foot

NO LONGER ADVISED-can increase the risk of
detaching the thrombus as the calf muscle
contract
Coag studies
D Dimer-increased values with venous thrombosis,
PE, DIC and Malignancy
Duplex Scan
 INTERVENTIONS

*Bedrest and leg elevation

*Warm moist soaks may be ordered
*Evaluate for PE
*Anti-inflammatory drugs for superficial
thrombophlebitis – ASA or NSAIDS
*Heparin therapy
*Warfarin (Coumadin)
 Heparin Therapy
1.Prior to initiation of therapy:
Hx of bleeding disorders
CBC w/ platelet count
UA
Stool for occult blood
Creatinine level
PTT,PT, INR baseline

2. Heparin bolus is given IVP (100u/kg) followed by

continuous infusion and protocol
3. Goal is to attain aPTT level 1.5-2.5x normal
 Heparin therapy
4. Assess for signs and symptoms of bleeding
5. Monitor platelet counts- can lead to heparin induced
thrombocytopenia.
6. Antidote available- protamine sulfate

Other Options:
LMWH-Longer half-life and more predictable
Lovenox- 1mg/kg Adjust for renal pts
Fragmin
Coumadin- started while pt is on heparin
-takes 3-4 days to be therapeutic
-monitor INR/PT
-antidote-Vitamin K
 VENOUS DISORDERS
TREATMENT
a) PREVENTIVE
i. EARLY AMBULATION
ii. EXTERNAL COMPRESSION (VCB)
iii. PROPHYLACTIC ANTICOAGULANTS
LOW DOSE HEPARIN
LOW MOLECULAR WT. HEPARIN (FRAGMIN©)
b) WHEN DVT EXISTS
i. BR TO CHANCE OF EMBOLI
ii. ELEVATION TO  VENOUS RETURN &  EDEMA
iii. ANTICOAGULANTS PREVENT CLOTS FROM
INCREASING (THEY DO NOT DISSOLVE THEM!)
 VENOUS DISORDERS

AMBULATION – PERMITTED WHEN EDEMA .

BELOW KNEE TEDS USED IF NO ARTERIAL
DISEASE
(TEDS MAY INTERFERE WITH ARTERIAL FLOW)
THROMBECTOMY – SURGICAL TREATMENT OF
CHOICE WHEN ARTERIAL FLOW IS AFFECTED
BY DVT
(GREENFIELD FILTER PREVENTS “SHOWER” OF
PULMONARY EMBOLI) INSERTED IN INFERIOR
VENA CAVA
 GREENFIELD FILTER

 Inserted into
Inferior Vena
Cava
 Filters out clots
as blood returns
to the right side
of the heart
 GREENFIELD FILTER

 READILY
IDENTIFIED ON
X-RAY
 VENOUS DISORDERS
Health Teaching
Safety and comfort measures
Balance rest and activity
Need for follow up
Importance of taking drugs and not missing doses
Medi-alert bracelet
Avoid OTC meds
Avoid hi fat and hi Vitamin K foods- cabbage,
cauliflower,broccoli, asparagus, spinach, kale, fish and
liver
Patient teaching re: LMWH injections
 CHRONIC VENOUS
INSUFFICIENCY
1. PATHOPHYSIOLOGY & EPIDEMIOLOGY
• OCCURS IN 10% OF POPULATION /W DVT
• Stasis of blood in lower extremity-due to
prolonged standing, sitting in one position,
pregnancy, and obesity
• INCOMPETENT VALVES IN DEEP VEINS
•  VENOUS PRESSURE IMPEDES CAPILLARY
PERFUSION
• PROTEINS LEAK INTO INTERSTITIAL TISSUES
• EDEMA IS CHRONIC  ULCERS & SCARRING
 CHRONIC VENOUS INSUFFICIENCY
Venous Stasis Ulcers

2. SIGNS & SYMPTOMS – INDURATION 

HYPERPIGMENTATION, STASIS DERMATITIS &
ULCERATIONS, EDEMA
3. GOALS: Decrease edema and Promote venous return
4. INTERVENTIONS:
a) COMPRESSION – STOCKINGS OR DRESSINGS
b) ULCERS TREATED WITH TOPICAL AGENTS-Unna,Accuzyme
c) AVOID TRAUMA
d) AVOID SITTING FOR LONG PERIODS
e) EXERCISE TO  MUSCLE ACTIVITY
f) Platelet derivative growth factor ointments-Regranex
g) Apligraf-type of skin graft
 Varicose Veins

 Protruding veins that are

darkened/tortuous are caused by weak
vein walls, increased venous pressure &
incompetent valves
 Common in patients that stand for long
periods
 Pregnancy
 Obesity
 Family hx of varicose veins
 Systemic problems-heart disease
 Assessment- S & O Data

 Severe, aching pain in leg

 Leg fatigue and heaviness
 Itching over the affected leg (statis
dermatitis)
 Feelings of heat in the leg
 Visibly dilated veins
 Thin, discolored skin above the ankles
 Increased incidence of PE and
thrombophlebitis
 Diagnostic Tests

 Tourniquet test
 Trendelenberg test
 Doppler ultrasound/ angiography
Medical and Surgical Interventions
for Varicose Veins
 Elevate extremity Vein stripping or
 Elastic Stockings ligation
 Sclerotherapy-for EndoVenous Laser
small/limited # of tx
veins RF (radio
frequency)
-vein is heated from
inside
 Nursing Interventions

 Monitor patient postop

 Assess circulation
 Elevate legs and perform active ROM
 Teach re: avoidance of venous stasis,
compression stockings, exercise, leg
elevation
 Lymphatic System
ANATOMY & PHYSIOLOGY

LYMPHATIC SYSTEM – WORKS WITH

CIRCULATORY SYSTEM
a) THORACIC DUCT b a
b) RIGHT LYMPHATIC DUCT

DRAINAGE:
THORACIC DRAINS ABDOMEN
(R) DRAINS HEAD, NECK & THORAX
 ANATOMY & PHYSIOLOGY

LYMPHATIC FLUID COLLECTS &

RETURNS TO VENOUS CIRCULATION BY
EMPTYING INTO SUBCLAVIAN VEINS
WHEN INTERSTITIAL FLUID PRESSURE
INCREASES LYMPHATIC FLOW
INCREASES

WHEN DRAINAGE IS IMPAIRED EDEMA

ENSUES (FLUID COLLECTS)
 ANATOMY & PHYSIOLOGY

 CAUSES OF LYMPHEDEMA INCLUDE:

LYMPHANGITIS
CELLULITIS
INSUFFICIENT NUMBER OF VESSELS
SECONDARY FACTORS
MALIGNANCY
TRAUMA
SURGICAL REMOVAL
 Assessment

 Pain at site of injury

 Redness of skin
 Fever and chills
 Red streak on skin extending toward the
lymph nodes
 Lymph nodes enlarged
 WBC, Blood & Wound cultures
 Lymphangiography-IV dye, Xrays
 Lymphoscintigraphy-simple,no SE
 INTERVENTIONS

 Moist heat
 Elevation and immobilization of the extremity
 Elastic stockings
 Na restriction
 Antibiotics/antifungals for infection
 Diuretics
 Analgesics
 CASE STUDY
MR. CHARLES HORSE WAS ADMITTED
TO THE HOSPITAL TODAY WHERE HE
PRESENTED HIS CHIEF COMPLAINTS
AND RECENT MEDICAL HISTORY.
THIS PATIENT IS A FIFTY-THREE YEAR
OLD WHITE MALE. MR. HORSE IS A
RUGGED INDIVIDUAL WITH AN
EXTENSIVE HISTORY.
HE SMOKES 1 PACK OF CIGARETTES PER
DAY FOR MORE THAN TWENTY
FIVE YEARS. AS A SINGLE LUMBERJACK HIS
DIET HAS RELIED HEAVILY ON FAST FOODS.
OVER THE PAST SEVERAL MONTHS MR.
HORSE REPORTED HE HAD GRADUALLY
BEEN EXPERIENCING PAIN IN THE LEFT LEG.
THESE PAINFUL SYMPTOMS INCREASED TO A
POINT WHERE HE CANNOT WALK MORE THAN
TWO CITY BLOCKS WITHOUT SEVERE
CRAMPING IN HIS LEFT LEG.
HE STATES HE MUST STOP, SIT AND
RUB HIS LEG UNTIL THE CRAMPING
STOPS. MR. HORSE HAS GRADUALLY
ADJUSTED HIS ACTIVITIES AROUND
THESE SYMPTOMS.

THIS MORNING, MR. HORSE AWOKE

FROM A DEEP SLEEP TO SUDDEN,
SEVERE PAIN IN THE LEFT LEG. THE
PAIN DIMINISHED SLIGHTLY WHEN HE
SAT UP AND HUNG HIS LEGS OVER
THE SIDE OF THE BED.
HE NOTICED CHANGES IN SKIN COLOR
AND TEMPERATURE. CONCERNED
ABOUT THE SUDDEN CHANGES, MR.
HORSE HEADED DIRECTLY TO THE
EMERGENCY ROOM.
WHEN YOU ASSESS THIS PATIENT
ATTENTION IS DIRECTED TOWARD HIS
LEFT LEG. THE SKIN IS COOL TO
TOUCH. ASSESSING PERIPHERAL
PULSES YOU NOTE THAT HIS
FEMORAL AND POPLITEAL PULSES
ARE STRONG AND PALPABLE
BILATERALLY.
HOWEVER, HIS POSTERIOR TIBIAL AND
DORSALIS PEDIS PULSES ON THE LEFT
LEG ARE NOT PALPABLE. A DOPPLER
READING INDICATES THERE IS SOME
DEGREE OF CIRCULATION PRESENT.
NAIL BEDS ARE CYANOTIC; CAPILLARY
FILLING IS SLOW (> 3 SECONDS) IN ALL
DIGITS ON THE LEFT FOOT.
ATTEMPTING TO IMPROVE MR.
HORSE’S COMFORT, THE NURSE
ELEVATES HIS FEET. MR. HORSE
REPORTS THE PAIN IS SIGNIFICANTLY
WORSE!
 LEFT LEG DISCUSSION
1. WHAT INFORMATION DOES
INSPECTION OF THE PATIENT’S LEG
PROVIDE?
a) COLOR OF SKIN PALE

b) COLOR OF NAIL BEDS CYANOTIC

2. WHAT CAN PALPATION TELL YOU
ABOUT THIS PATIENT’S CONDITION?

a) TEMPERATURE
COOL TO TOUCH INDICATES  BLOOD
FLOW,  SENSITIVITY

b) PULSES
 BLOOD FLOW, WEAK PULSES
(+) FEMORAL, (+) POPLITEAL PULSES
CHECK FLOW WITH DOPPLER
3. WHAT POSITION WOULD BE THE MOST
COMFORTABLE FOR MR. HORSE?

SUPINE OR DANGLE

4. WHAT PROBLEM DO YOU THINK MR.

HORSE HAS WITH HIS LEFT LEG?
ARTERIAL INSUFFICIENCY
5. WHAT WOULD PREDISPOSE MR. HORSE TO
DEVELOPING THIS TYPE OF PROBLEM?

SMOKING,  LIPIDS, PROBABLY CAD,

POSSIBLE DAMAGE TO INTIMAL LAYER
OF BLOOD VESSELS

6. WHAT IS THE CLINICAL TERM FOR A

CONDITION CAUSING PERIODIC CRAMPING
BROUGH ON BY WALKING?

INTERMITTANT CLAUDICATION
7. WHAT ARE THE 5 P’s YOU SHOULD
LOOK FOR?

PAIN
PALLOR THIS IS A
SURGICAL
PULSELESSNESS EMERGENCY!
PARALYSIS
PARESTHESIA
FOLLOWING A SUCCESSFUL
REVASCULARIZATION PROCEDURE,
MR. HORSE WAS D/C’d TO HOME IN
GOOD CONDITION. HIS LEFT LEG
WAS WARM, PINK IN COLOR AND ALL
TOES WERE MOBILE. MR. HORSE
WAS PLACED ON MEDICATIONS TO
MANAGE HIS CHF, WHICH WAS
DISCOVERED DURING IHIS MEDICAL
HISTORY AND PHYSICAL EXAM. TWO
WEEKS LATER THIS PATIENT
RETURNED TO THE HOSPITAL…
PRESENTING WITH DYSPNEA,
ORTHOPNEA AND BILATERAL +3
PITTING EDEMA. MR. HORSE WAS
READMITTED TO THE HOSPITAL WITH
A DX OF CHF. DIGOXIN (A
CARDIOTONIC) WAS STARTED AND
LASIX (A DIURETIC) ALSO WAS ADDED
TO HIS MEDICATION PROFILE. ONCE
AGAIN MR. HORSE WAS D/C’d TO
HOME AND PROVIDED WITH A HOME
HEALTH AIDE TO ASSIST HIM WITH HIS
ADL’s. HE WAS INSTRUCTED TO
REMAIN ON BED REST
FOR ONE WEEK. HE IS SEEN BY THE
VISITNING NURSE IN HIS HOME ON F/U
TO ASSESS HIS STATUS. THE NURSE
TAKES NOTICE OF MR. HORSE’S +2
PITTING EDEMA IN HIS RIGHT LEG,
EXTENDING FROM THE FOOT TO THE
LOWER THIGH. SKIN COLOR IS
NOTED TO HAVE A REDDISH/ PURPLE
HUE AND THE SURFACE TEMP IS
INCREASED LOCALLY. THE LIMB IS
TENDER TO TOUCH AND PAIN
INCREASES WITH DORSIFLEXION.
THE NURSE ALSO NOTES THAT
PERIPHERAL PULSES ARE
MODERATELY DIMINISHED ON THE
RIGHT SIDE ONLY. MR. HORSE
COMPLAINS THAT HIS RIGHT LEG
FEELS HEAVY AND THROBS.
 RIGHT LEG DISCUSSION
1. WHAT DOES INSPECTION OF HIS
RIGHT LEG REVEAL?
a) SKIN COLOR
DUSKY RED

b) GIRTH / TENSION

(+) SWELLING
2. WHAT DOES PALPATION TELL YOU
ABOUT THE STATUS OF HIS RIGHT
LEG?
a) TEMPERATURE

 TEMP INDICATES INFLAMMATION

b) EDEMA

(2+) PITTING EDEMA, VENOUS CONGESTION

3. WHAT DO YOU THINK THE PROBLEM
IS WITH MR. HORSE’S RIGHT LEG?
(+) DVT
4. WHAT DO YOU THINK CAUSED MR.
HORSE’S RECENT COMPLICATIONS?
PROLONGED BED REST DUE TO CHF,
INACTIVITY, DEHYDRATION FROM LASIX, 
BLOOD VISCOSITY
5. HOW COULD THESE PROBLEMS
HAVE BEEN AVOIDED?
LMWH, VCB, EXERCISE
 BONUS QUESTION
LIST EXAMPLES THAT PREDISPOSE A
PATIENT TO DVT
 FACTORS EXAMPLE
IMMOBILIZATION OPERATING ROOM > 2 HOURS
PARALYSIS

DISEASE PROCESS CARDIAC

DIABETES MELLITUS
LOWER EXTREMITY EDEMA
SEPTICEMIA
CANCER
PRESSURE CAST / BRACES
TRACTION
CLOTTING DYSFUNCTION POLYCYTHEMIA
SHORT CLOTTING TIME
 FACTORS EXAMPLE
SURGICAL PROCEDURES GYNECOLOGICAL
GENITOURINARY
ANY ABDOMINAL SURGERY
LOWER EXTREMITY FRACTURE

OTHER OBESITY
PREGNANCY

TRAUMA TRAUMA TO A VESSEL

 NCLEX TIME
Which of the following clients should the nurse assess first?
• A.The 76-year-old woman who has had laser-assisted
angioplasty of the right distal femoral artery 30 minutes
ago
• B.The 65-year-old man with a history of hypertensive
crisis who is on a labetalol drip and current blood
pressure is 149/80
• C.The 60-year-old woman with a history of peripheral
vascular disease who has a venous leg ulcer draining
purulent yellow fluid
• D.The 55-year-old man with a history of axillofemoral
bypass 5 years earlier who is currently admitted for a
diagnostic cardiac catheterization
 NCLEX TIME
Which of the following statements indicates the caregiver
does not understand proper care of the client with
peripheral arterial disease of the lower legs?
• A.“The client should drink fluids to decrease risk for
viscous blood.”
• B.“We must remind the client to refrain from wearing
restrictive clothing.”
• C.“The client should apply heat directly to the legs in
order to promote blood circulation.”
• D.“The client should be encouraged to stop smoking
because it increases the vasoconstriction of the arteries.”
 NCLEX TIME
You are caring for a 75-year-old man admitted to the
hospital for lower leg cellulitis. On admission, the nurse
notes that his blood pressure is 190/100 and notifies the
physician. Of the following orders, which would you have
the LPN implement?
A.Assess cardiac and respiratory status.
B.Administer Clonidine patch for hypertension.
C.Obtain an order from the doctor for dietary consult.
D.Develop plan for discharge and assess homecare needs.
 NCLEX TIME
A group of new graduate nurses is in orientation to work on
a cardiothoracic stepdown unit. Which statement, if
made by one of the nurses, demonstrates the need for
further teaching regarding the difference between
arteriosclerosis and atherosclerosis?
• A.“Arteriosclerosis is a thickening, or hardening, of the
arterial wall.”
• B.“Atherosclerosis is a type of arteriosclerosis that
involves the formation of plaque within the arterial wall
and is the leading contributor to coronary artery and
cerebrovascular disease.”
• C.“Atherosclerosis is caused by vascular damage.”
• D.“Arteriosclerosis happens when platelets aggregate
and then a group of blood lipids accumulate.”
 NCLEX TIME
Because Mr. Palan's condition has progressed to severe
rest pain that is now threatening loss of his limb, an
arterial revascularization has to be performed. Which
statement, if made by Mr. Palan, demonstrates that
further teaching is needed related to his postoperative
care?
A.“I should be concerned if my foot turns blue.”
B.“I should not get a fever or any drainage after the
surgery.”
C.“I may get a feeling of tenseness after the surgery.”
D.“Warmth, redness, and swelling are expected after
surgery.”
 NCLEX TIME
5.Clara is teaching a young woman ways to
prevent venous thromboembolism during
hospitalization. Which statement, if made by the
client, indicates the need for further teaching?
• A.“I need to stop taking my birth control pill.”
• B.“I should drink a lot of water so I don't get
dehydrated.”
• C.“I should exercise my legs when I have been
sitting or standing for a long time.”
• D.“If I wear pantyhose, I don't have to wear the
stockings that the hospital gives me.”