NUR 114 EXAM 3 –Questions With Precise Solutions
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Terms in this set (335)
includes disorders that change the natural flow of blood
through the arteries and veins of the peripheral
Peripheral vascular disease
circulation. Generally, a diagnosis of PVD implies arterial
(PAD)
disease, rather than venous involvement.
effects 60 - 70 year old
PAD affects the legs much than the arms
more frequently
result of systemic atherosclerosis
chronic condition in which partial or total arterial
occlusion deprives the lower extremities of oxygen and
Pathophysiology of PAD
nutrients
The tissues below the blockage (obstruction) cannot
live without adequate oxygen and nutrient supply
involve the distal end of the aorta and the common,
Inflow obstructions internal, and external iliac arteries.
located above the inguinal ligament
involve the femoral, popliteal, and tibial arteries and are
Outflow obstructions
below the superficial femoral artery.
Risk factors for atherosclerosis and also:
• Hypertension
• Hyperlipidemia
• Diabetes
PAD Common risk factors
• Cigarette smoking
• Obesity
• Familial predisposition
• Advancing age
developing chronic angina, MI, or stroke and are much
Patients with PAD have an
more likely to die within 10 years compared with those
increased risk for
who do not have the disease.
, classic leg pain known as intermittent claudication.
Usually they can walk only a certain distance before a
cramping, burning muscle discomfort or pain forces
them to stop. The pain stops after rest. The pain is
consistently produced with the same degree of activity
PAD Assessment: Physical (reproducible). Eventually progresses to rest pain, a
numbness or burning sensation, often described as
feeling like a toothache that is severe enough to awaken
patients at night. Patients can sometimes get pain relief
by keeping the limb in a dependent position (below the
heart).
discomfort in back, buttocks, or thighs
- Mild discomfort after 2 blocks
- Moderate discomfort after 1 or 2 blocks
PAD Inflow assessment
- Severe discomfort after less than 1 block
These patients usually have rest pain and there is less
tissue damage.
discomfort in the calves, ankles, feet, and toes.
- mild discomfort after walking about 5 blocks
- moderate after about 2 blocks,
PAD Outflow Assessment - severe less than ½ block.
These patients usually experience more frequent rest
pain and have more tissue damage
Observe for loss of hair on the lower calf, ankle, and
foot; dry, scaly, dusky, pale, or mottled skin; and
PAD physical assessment
thickened toenails. Extremity will be cold and gray-blue
part 2
(cyanotic) or darkened. Pallor may occur when the
extremity is elevated
may occur when the extremity is lowered. Palpate all
Dependent rubor (redness)
pulses in both legs.
The most sensitive and specific indicator of arterial
function
posterior tibial pulse
The strength of each pulse should be compared
bilaterally.
painful and develop on the toes, between the toes, or
Arterial ulcers
on the upper aspect of the foot.
, contrast medium is injected into the arterial system and
Diagnostic Assessment: vessels are visualized using fluoroscopy and xrays. This
Arteriography procedure has serious risks including hemorrhage,
thrombosis, embolus, and death.
like ABI test with the addition of 2 or 3 additional blood
pressure cuffs (thigh, calf, and ankle). The cuffs are then
Diagnostic Assessment:
inflated above the patient's normal systolic BP and BPs
Segmental systolic blood
are taken with the Doppler. A significant drop in
pressure measurements
pressure between the cuffs indicates narrowing or
blockage in that portion of the leg.
used to evaluate outflow disease. The ankle pressure is
compared with the brachial pressure, which provides
Diagnostic
the ABI ratio. An ABI of less than 0.9 in either leg is
Assessment:Ankle-brachial
diagnostic of PAD. Patients with diabetes are known to
index (ABI):
have a falsely elevated ABI. Less than 0.8 is moderate
and less than 0.5 is severe.
may give valuable information about claudication
without rest pain. The technician obtains resting pulse
volume recordings and asks the patient to walk until the
symptoms are reproduced. At the time of onset the
technician obtains another pulse volume recording. In
Diagnostic Assessment:
patients with arterial disease, the waveforms are
Exercise tolerance testing
decreased and there is a decrease in the ankle pressure
of 40 to 60 mm Hg for 20 to 30 seconds in the affected
limb. If the return to normal pressure is delayed (longer
than 10 minutes), the results abnormal arterial flow in the
affected limbs.
• Ineffective tissue perfusion: peripheral r/t decreased
arterial flow
• Impaired tissue integrity r/t decreased blood supply
• Pain r/t ischemia
PAD Nursing Diagnosis • Activity intolerance r/t imbalance between tissue
demand and blood supply
• Sleep pattern disturbance r/t rest pain
• Risk for infection r/t decreased tissue oxygenation
• Fear r/t possible limb loss
, • Patient will
o Have optimal tissue perfusion
o Manage activity within own limits
Peripheral arterial disease
o Express concerns to significant others
Planning
o Obtain adequate rest
o Have decreased pain
o Practice self-care to avoid tissue damage
o Promote wound healing
Peripheral arterial disease o Manage pain to allow for patient comfort and rest
Goals for nursing care o Promote tissue perfusion
o Optimize activity intolerance
Nonsurgical
may improve arterial blood flow to the affected leg
through buildup of the collateral circulation.
Patients with severe rest pain, venous ulcers, or
PAD Interventions: Exercise
gangrene should not participate. Instruct the patient to
walk until the point of claudication, stop and rest, and
then walk a little further. Eventually, he or she can walk
longer distances as collateral circulation develops.
provides blood to the affected area through smaller
Collateral circulation vessels that develop and compensate for the occluded
vessels
Nonsurgical
Because swelling prevents arterial flow, feet should be
elevated. Teach them to avoid raising their legs above
the heart level because extreme elevation slows arterial
PAD Interventions:
blood flow to the feet. In severe cases, patient with PAD
Positioning
and swelling may sleep with the affected leg hanging
from the bed or sit upright in a chair for comfort. The
patient will require frequent position changes (between
elevation and feet down).
4 stages
stage 1 - asymptomatic - no pain
Stages of Chronic PAD stage 2 - intermittent claudication - pain when walking
stage 3 - rest pain - pain even during rest
stage 4 - necrosis/gangrene - tissue starts to decay
Save
Terms in this set (335)
includes disorders that change the natural flow of blood
through the arteries and veins of the peripheral
Peripheral vascular disease
circulation. Generally, a diagnosis of PVD implies arterial
(PAD)
disease, rather than venous involvement.
effects 60 - 70 year old
PAD affects the legs much than the arms
more frequently
result of systemic atherosclerosis
chronic condition in which partial or total arterial
occlusion deprives the lower extremities of oxygen and
Pathophysiology of PAD
nutrients
The tissues below the blockage (obstruction) cannot
live without adequate oxygen and nutrient supply
involve the distal end of the aorta and the common,
Inflow obstructions internal, and external iliac arteries.
located above the inguinal ligament
involve the femoral, popliteal, and tibial arteries and are
Outflow obstructions
below the superficial femoral artery.
Risk factors for atherosclerosis and also:
• Hypertension
• Hyperlipidemia
• Diabetes
PAD Common risk factors
• Cigarette smoking
• Obesity
• Familial predisposition
• Advancing age
developing chronic angina, MI, or stroke and are much
Patients with PAD have an
more likely to die within 10 years compared with those
increased risk for
who do not have the disease.
, classic leg pain known as intermittent claudication.
Usually they can walk only a certain distance before a
cramping, burning muscle discomfort or pain forces
them to stop. The pain stops after rest. The pain is
consistently produced with the same degree of activity
PAD Assessment: Physical (reproducible). Eventually progresses to rest pain, a
numbness or burning sensation, often described as
feeling like a toothache that is severe enough to awaken
patients at night. Patients can sometimes get pain relief
by keeping the limb in a dependent position (below the
heart).
discomfort in back, buttocks, or thighs
- Mild discomfort after 2 blocks
- Moderate discomfort after 1 or 2 blocks
PAD Inflow assessment
- Severe discomfort after less than 1 block
These patients usually have rest pain and there is less
tissue damage.
discomfort in the calves, ankles, feet, and toes.
- mild discomfort after walking about 5 blocks
- moderate after about 2 blocks,
PAD Outflow Assessment - severe less than ½ block.
These patients usually experience more frequent rest
pain and have more tissue damage
Observe for loss of hair on the lower calf, ankle, and
foot; dry, scaly, dusky, pale, or mottled skin; and
PAD physical assessment
thickened toenails. Extremity will be cold and gray-blue
part 2
(cyanotic) or darkened. Pallor may occur when the
extremity is elevated
may occur when the extremity is lowered. Palpate all
Dependent rubor (redness)
pulses in both legs.
The most sensitive and specific indicator of arterial
function
posterior tibial pulse
The strength of each pulse should be compared
bilaterally.
painful and develop on the toes, between the toes, or
Arterial ulcers
on the upper aspect of the foot.
, contrast medium is injected into the arterial system and
Diagnostic Assessment: vessels are visualized using fluoroscopy and xrays. This
Arteriography procedure has serious risks including hemorrhage,
thrombosis, embolus, and death.
like ABI test with the addition of 2 or 3 additional blood
pressure cuffs (thigh, calf, and ankle). The cuffs are then
Diagnostic Assessment:
inflated above the patient's normal systolic BP and BPs
Segmental systolic blood
are taken with the Doppler. A significant drop in
pressure measurements
pressure between the cuffs indicates narrowing or
blockage in that portion of the leg.
used to evaluate outflow disease. The ankle pressure is
compared with the brachial pressure, which provides
Diagnostic
the ABI ratio. An ABI of less than 0.9 in either leg is
Assessment:Ankle-brachial
diagnostic of PAD. Patients with diabetes are known to
index (ABI):
have a falsely elevated ABI. Less than 0.8 is moderate
and less than 0.5 is severe.
may give valuable information about claudication
without rest pain. The technician obtains resting pulse
volume recordings and asks the patient to walk until the
symptoms are reproduced. At the time of onset the
technician obtains another pulse volume recording. In
Diagnostic Assessment:
patients with arterial disease, the waveforms are
Exercise tolerance testing
decreased and there is a decrease in the ankle pressure
of 40 to 60 mm Hg for 20 to 30 seconds in the affected
limb. If the return to normal pressure is delayed (longer
than 10 minutes), the results abnormal arterial flow in the
affected limbs.
• Ineffective tissue perfusion: peripheral r/t decreased
arterial flow
• Impaired tissue integrity r/t decreased blood supply
• Pain r/t ischemia
PAD Nursing Diagnosis • Activity intolerance r/t imbalance between tissue
demand and blood supply
• Sleep pattern disturbance r/t rest pain
• Risk for infection r/t decreased tissue oxygenation
• Fear r/t possible limb loss
, • Patient will
o Have optimal tissue perfusion
o Manage activity within own limits
Peripheral arterial disease
o Express concerns to significant others
Planning
o Obtain adequate rest
o Have decreased pain
o Practice self-care to avoid tissue damage
o Promote wound healing
Peripheral arterial disease o Manage pain to allow for patient comfort and rest
Goals for nursing care o Promote tissue perfusion
o Optimize activity intolerance
Nonsurgical
may improve arterial blood flow to the affected leg
through buildup of the collateral circulation.
Patients with severe rest pain, venous ulcers, or
PAD Interventions: Exercise
gangrene should not participate. Instruct the patient to
walk until the point of claudication, stop and rest, and
then walk a little further. Eventually, he or she can walk
longer distances as collateral circulation develops.
provides blood to the affected area through smaller
Collateral circulation vessels that develop and compensate for the occluded
vessels
Nonsurgical
Because swelling prevents arterial flow, feet should be
elevated. Teach them to avoid raising their legs above
the heart level because extreme elevation slows arterial
PAD Interventions:
blood flow to the feet. In severe cases, patient with PAD
Positioning
and swelling may sleep with the affected leg hanging
from the bed or sit upright in a chair for comfort. The
patient will require frequent position changes (between
elevation and feet down).
4 stages
stage 1 - asymptomatic - no pain
Stages of Chronic PAD stage 2 - intermittent claudication - pain when walking
stage 3 - rest pain - pain even during rest
stage 4 - necrosis/gangrene - tissue starts to decay
