NUR 245: CH 20 Peripheral Vascular and Lymphatic Systems Terms in this set (26) Brachial Artery Peripheral arterial disease (PAD affects noncoronary vessels and refers to arteries affecting the limbs Frombosis blood clot Embolus blood clot that m

NUR 245: CH 20 Peripheral Vascular and Lymphatic Systems Terms in this set (26) Brachial Artery Peripheral arterial disease (PAD affects noncoronary vessels and refers to arteries affecting the limbs Frombosis blood clot Embolus blood clot that moves The nurse is assessing a patient's risk for developing a deep vein thrombosis (DVT). The patient considered at the highest risk is a 60-year-old patient who: has been on bed rest for 3 days. has been receiving physical therapy for left knee replacement. has calf and thigh measurements that have less than an inch of variation on both legs. was admitted to the hospital with asthma exacerbation. The correct answer is 1. Bed rest and inactivity increase a patient's risk of DVT. Answer 2 is incorrect because although this patient would be considered at risk, knee replacement patients are not the highest risk. Answer 3 is incorrect because this would be a normal assessment of calf and thigh for DVT. Answer 4 is incorrect because this patient would not be at high risk for DVT. The physician asks the nurse if the patient has any signs/symptoms related to a possible thrombophlebitis. What observations would the nurse provide that would provide the physician with the information requested? Signs and symptoms relative to a thrombophlebitis would include: S: Sudden onset of intense, sharp, deep muscle pain. O: Increased warmth; swelling; redness; dependent cyanosis is mild or may be absent; tender to palpation As the patient is not experiencing any of these symptoms, the nurse would respond with a negative assessment with regard to these criteria. three mechanisms keep blood moving toward the heart in the venous system 1) contraction of skeletal muscles 2) pressure gradient 3) intraluminal valves the lymphatic system has 3 major functions 1. conserves fluid and plasma proteins that leak out of capillaries 2. major part of the immune system that defends against disease 3. absorbs lipids from intestinal tract lymph node function filter fluid before it is returned to bloodstream; exposes blood to lymphocytes which eliminate pathogens 3 primary organs of lymphatic system 1) Spleen: left upper quadrant of the abdomen, destroys old red blood cells, produces antibodies, stores red blood cells, and filters organisms from the blood 2) The palatine, adenoid, and lingual tonsils: located at the entrance to the respiratory and gastrointestinal tracts, respond to local inflammation 3) Thymus: behind the sternum, develops T lymphocytes in the immune system in children but atrophies in adults ischemia an inadequate blood supply to an organ or part of the body, especially the heart muscles (partial blockage) arteriosclerosis hardening of the arteries (causing rise in systolic pressure) myocardial infarction heart attack; treatment now includes early mobilization and preemptive anticoagulants peripheral artery disease (PAD) atherosclerosis occurring in the lower extremities, such as in the feet, calves, or legs, or in the arms arterial pain vs venous pain arterial pain: leg cramps venous pain: aching pain, veracose veins or sudden cramping if its a clot Allen test determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery (typically release ulnar) Edema Scale • 1+ Mild pitting, slight indentation, no perceptible swelling of the leg • 2+ Moderate pitting, indentation, subsides rapidly • 3+ Deep pitting, indentation remains for a short time, leg looks swollen • 4+ Very deep pitting, indentation lasts a long time, leg is very swollen Ankel Brachial Index (ABI) compares ankel blood pressure to BP in arm (low number means arterial blockage in leg) Wells Score for Leg DVT combination of assessment findings categorized into Low risk (0) moderate risk (1-2) and high risk (3+) of DVT Abnormal findings in arms Raynaud Phenomenon: A condition in which some areas of the body feel numb and cool in certain circumstances. Lymphedema: Swelling in an arm or leg caused by a lymphatic system blockage. Abnormal findings in legs arterial ischemic ulcer: buildup of fatty plaques (atherosclerosis) (no bleeding, well defined edges) venous (stasis) ulcer: after acute DVT or chronic incompetent vlaves in deep beings, account for 80% of lower leg ulcers, bleeding and poorly defined edges) superficial varicose veins DVT lymphatic drainage right lymphatic duct (red) and thoracic duct (green) 28. During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position. ANS: B In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency. Raynaud disease The condition with episodes of abrupt, progressive tricolor changes of the fingers in response to cold, vibration, or stress is known as Raynaud disease 1. A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg ANS: A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems. A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day. ANS: A, B, E Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset with exertion and is relieved with rest or dangling. The skin appears cool and pale (see Table 20-3). The other responses reflect chronic venous problems.