PERIPHERAL

VASCULAR
DISEASE
OVERVIEW OF
ANATOMY AND
PHYSIOLOGY
STRUCTURE &
FUNCTION OF BLOOD
VESSELS

BLOOD
VESSELSchannels
 blood
distributed to body
tissues
WALLS OF AN ARTERY OR
VEIN 3 LAYERS
1- tunica intima
2-tunica media
3-tunica adventitia

the pressure a
vessel must endure
determine
– thickness of the walls
– amount of connective
tissue
– smooth muscle
DIVIDED INTO THE ARTERIAL &
VENOUS SYSTEM
ARTERIAL
SYSTEM
high pressure
vessels,
– Aorta- largest
branch into
arterioles

less than 0.5 mm

in diameter

functions
• to deliver blood to
various tissues for
nourishment

• contribute to tissue
temperature
regulation
 VENOUS
SYSTEM

• large diameter

• thin walled
vessels

• less pressure
• Leg veins
– contain valves
• regulate one-way
flow
1.MUSCULAR
PUMP
– Milking action of
skeletal muscle
contraction
2.RESPIRATORY
PUMP
– Changes in
abdominal and
thoracic pressures
occur with
breathing
Functions
• to return blood
from the
capillaries to the
right atrium

– for circulation

– acts as a
reservoir for
blood volume
CAPILLARIES • Connects arterioles and
venules

• Permeable to gases and

molecules exchanged
between blood and tissue
cells

• Found between in
interwoven networks

• Filter and shunt blood

from terminal arterioles to
postcapillary venules
B. CIRCULATION AND DYNAMICS OF BLOOD
FLOW
BLOOD FLOW
• amount of fluid
moved

• per unit of time

• through a vessel,
organ or
throughout the
entire circulatory
system
• Systemic circulation
–supplies nourishment
to all of the tissue
located throughout
your body,
• with the exception of
the heart and lungs
because they have
their own systems.

• Systemic circulation
–major part of the
overall circulatory
system.
• The blood vessels
(arteries, veins, and
capillaries)
– delivery of oxygen and
nutrients to the tissue.
• Oxygen-rich blood
– enters the blood vessels
– through the heart's main
artery -- the aorta.
– The forceful contraction of
left ventricle
• forces the blood into the aorta
which
• then branches into many
smaller arteries
• which run throughout the
body.
• inside layer of artery
– very smooth,
• allowing quick blood flow
• outside layer of an artery
– very strong,
• allowing forceful blood flow.
• The oxygen-rich blood
– enters the capillaries where
• oxygen & nutrients are released.
• The waste products are
collected
• waste-rich blood
– flows into the veins
• to circulate back to the heart
• Where pulmonary circulation
– will allow the exchange of gases in
the lungs.
• During systemic circulation,
– blood passes through the
kidneys
• renal circulation
– During this phase
• the kidneys filter much of the
waste from the blood.
– Blood also passes through
the small intestine during
systemic circulation.
• portal circulation.
– During this phase
• the blood from the small
intestine collects in the portal
vein
• passes through the liver.
• The liver filters sugars from the
blood, storing them for later.
BLOOD FLOW THROUGH THE HEART

• 1. deoxygenated blood
– returning from the body enters the heart
– through the superior vena cava and
inferior vena cava.

• 2. blood passes into

– the right atrium and right ventricle
BLOOD FLOW THROUGH THE HEART

• 3. right ventricle
– pushes the blood
– through the pulmonary arteries

• 4. blood passes
– through the lungs
• where it loses carbon dioxide
• picks up oxygen
BLOOD FLOW THROUGH THE HEART

• 5. this oxygenated blood

– returns to the heart
– via the pulmonary veins

• 6. blood enters
– the left atrium and left ventricle
BLOOD FLOW THROUGH THE HEART

• 7. the left ventricle

– pushes the blood out
• through the main artery,
– the aorta

• 8. blood travels to all parts of the body

– where it delivers oxygen
– picks up carbon dioxide
FACTORS AFFECTING
ARTERIAL
CIRCULATION • 1. BLOOD VOLUME

– Volume of blood
transported in vessel, organ
or throughout entire
circulation in a given period
of time
FACTORS • 2. PERIPHERAL VASCULAR
AFFECTING RESISTANCE [PVR]
ARTERIAL – Opposing forces or impedance to
CIRCULATION 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 • 3. BLOOD PRESSURE
AFFECTING – Force exerted against the walls of
arteries by blood
ARTERIAL
CIRCULATION – 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 • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION
– 1. SYMPATHETIC AND
PARASYMPATHETIC NS

• SYMPATHETIC stimulation

– Vasoconstriction of arterioles
– Increasing BP
FACTORS • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION – 1. SYMPATHETIC AND
PARASYMPATHETIC NS

• PARASYMPATHETIC
stimulation

– Vasodilation of arterioles
– Lowering BP
FACTORS • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION – 1. SYMPATHETIC AND
PARASYMPATHETIC NS

• BARORECEPTORS &
CHEMORECEPTORS (in aortic arch,
carotid sinus and other large vessels

– Sensitive to pressure and chemical

changes causing

» REFLEX SYMPATHETIC
STIMULATION

vasoconstriction
increased HR & BP
FACTORS • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION – 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 • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION – 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 • 3. BLOOD PRESSURE
AFFECTING • OTHER FACTORS
ARTERIAL REGULATING BP
CIRCULATION – 5. DIETARY FACTORS
• Salt
• Saturated fat
• Cholesterol
– 6. OTHER FACTORS
• Race
• Gender
• Age
• Weight
• Time of day
• Position
• Exercise
• Emotional state
DIANOSTIC TEST AND
ASSESSMENT
• DOPPLER DIAGNOSTIC TESTS
ULTRASOUND
– measures the velocity of
AND ASSESSMENT
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
biologic changes in volume in a portion PLETHYSMOGRAPHY
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
utilizing computer DIGITAL INTRAVENOUS
technology ANGIOGRAPHY

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
VENOGRAPHY
injection of radiopaque dye
into veins
– serial x-rays are taken to
detect deep vein thrombosis
and incompetent valves

ANGIOGRAPHY
injection of radiopaque dye
into arteries
– to detect plaques,
occlusions, injury, etc…
 ANKLE-BRACHIAL INDEX
most 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 A. BLOOD PRESSURE
PROCEDURES: BLOOD is primarily a
PRESURE MEASUREMENT function of cardiac
output and systemic
vascular resistance

B. ARTERIAL BLOOD
PRESSURE=
CARDIAC OUTPUT
X SYSTEMIC
VASCULAR
RESISTANCE
1. Client seated
C. PROPER TECHNIQUE
– 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%
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 • Cyanosis
• Pallor – Blueness
– Decrease in color – Seen in areas –least
– Reduced pigmentation
oxyhemoglobin • Lips
• Nailbeds
– Decrease blood
flow • Palpebral conjunctiva
• Buccal mucosa • Palms
• Rubor • Pain
– Redness – Intermittent
claudication
– Reddish blue color
– Superficial vessels • Tropic changes
injured – Dryness
– Anoxia – Scaling of skin
– Coldness – Brittle toenails
– dilated
 GENERAL
NURSING CARE
• Increased arterial blood
flow and venous return
– Proper positioning
– ARTERIAL
• Blood flow towards their legs
and feet
• Because they suffer from a
deficit of oxygenated blood to
their extremities
– VENOUS
• Elevate legs above the level of
the heart
• Suffer from a pooling of
deoxygenated blood in the
extremities and poor venous
return to the heart
• Elevate 6 inches block
GENERAL NURSING CARE
– Prescribe exercise
• Short walks
• Buerger-Allen routine
– Feet up from 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 CARE
ANTICOAGULANTS – Parenterally
• Action: prolong clotting time of • Destroyed by gastric
secretions
blood
• NOT absorbed from GIT
– Won’t dissolve clots already formed
– Effect immediate
– Prevent extension of clot • Ceases after 3-4 hours
– Inhibit formation of new clots – 50 mg –ave. dose (5000
• Heparin “μ”)
– ACTION: prevents activation of – IV q 3-4 hrs through
thrombin heparin lock
• Inhibits thromboplastin formation – Monitor PTT (partial
– Hypersensitivity: thromboplastin time)
• Mild fever, urticaria, rhinitis, burning value
sensation in the feet • 1.5-2.5 x the control
• Therapeutic value
 GENERAL NURSING CARE
ANTICOAGULANTS
• Bishydroxycoumarin
(Dicumarol)
– ACTION: suppresses the act.
Of liver in formation of
prothrombin
– 12-24 hrs to take effect
– Persist for 24-72 hrs
– 25-100 mg/day p.o. –
maintenance dose
– 10-30% normal or 1 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 CARE
ANTICOAGULANTS
• Ethyl Biscoumacetate
(Tromexan)
– ACTION: similar to Dicumarol
– Acts more quickly
– Effects lasts for a shorter time
NURSING RESPONSIBILITIES
• Careful regulation
– Amount & continuity of dose
• Drugs that potentiate anticoagulants
– Indocin, salicylates, dilantin, noctec,
antibiotics, quinidine,
adrenocorticosteroids
• Inhibit anticoagulant effect
– Oral contraceptives, barbiturates, lasix
NURSING RESPONSIBILITIES
• ANTIDOTE
– 1.Protamine Sulfate to heparin
• Acts immediately
• Effect persist for 2 hours
• 1 % IV
– 2.Vitamin K (Synkavit or aquamephyton)
to Dicumarol IV or p.o.
NURSING RESPONSIBILITIES
• ANTIDOTE
– IM NOT DONE---large painful
hematomas
• 2.1Fibrinolytics
– Used to dissolve fibrinous materials & purulent
accumulation by direct enzyme action
– Eg. Streptokinase---& Fibrinuclease (Elase)
• 2.2Dextran
– Plasma expander- IV
– Hasten resolution
– Prevent propagation of thrombus
– Administered as 500 ml of a 6% solution of NaCl
GENERAL NURSING CARE
– Relieve ischemic pain
• By increasing circulation to the
extremities
– Prevent tissue damage & infection
& promote healing of existing
lesions
• Avoid injury
– Check bath water with bath
thermometer –instead of toes
– Wear shoes to avoid injury to feet
– Vigorous rubbing is always avoided
• Leather shoes
– Give good support to feet
• Rubber shoes
– Not advised
– Retard evaporation
– Contribute to development of fungal
infection
DISEASES OF THE
ARTERIES AND
VEINS
1.ARTERIOSCLEROSIS
• Thickening and
hardening of the
arteries
• 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
 • RISK FACTORS
HYPERTENSION – Family history [+]
– Male
– Advancing age
– Black race
– Obesity
– High sodium intake
– Low magnesium,
potassium or calcium
intake
– DM
– Labile BP
– Cigarette smoking
– Heavy alcohol
consumption
HYPERTENSION
• PATHOPHYSIOLOGY
– Damage and inflammation of
the vessel walls
• Thick
• Hard
• Narrow
– Vasoconstriction
– Increased permeability of
vessel wall
» Influx of sodium, calcium,
water, plasma proteins
increases
smooth muscle
contraction
HYPERTENSION
• PRIMARY
HYPERTENSION
– Unknown etiology
• Overactivity of sympathetic
nervous system
• Overactivity of 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 data
a. past history
– of cardiovascular,
– cerebrovascular,
– renal or thyroid diseases,
– diabetes,
– smoking
– or alcohol use

b. family history
– of hypertension
– or cardiovascular disease

c. possible absence of symptoms

d. reports
– of fatigue,
– nocturia,
– dyspnea on exertion,
– palpitations,
– angina,
– headaches,
– weight gain,
– edema,
– muscle cramps
– or blurred vision
symptoms caused by target
organ damage
2.OBJECTIVE DATA
a. BP consistently >140
mmHg systolic and >90
mmHg diastolic
prehypertension
category of at risk
population is systolic BP
> 130 or diastolic > 85

b. peripheral edema,
retinal vessel changes,
diminished/ absent
peripheral pulses,
bruits, murmurs and S3
and S4 heart sounds
ORTHOSTATIC
HYPOTENSION
• Drop in blood
pressure
• Occurs on standing
• Compensatory
vasoconstriction
• Response to
standing is
replaced by
marked
vasodilation
ORTHOSTATIC
HYPOTENSION
• ACUTE
– Caused by delay in
the normal
regulatory
mechanisms

• CHRONIC
– Secondary to a
specific disease
– idiopathic
ORTHOSTATIC
HYPOTENSION • CLINICAL
MANIFESTATIONS
– Fainting
– Cardiovascular
symptoms
– Impotence
– Bowel and bladder
dysfunction
HYPERTENSION
• PRIMARY
HYPERTENSION
– MANAGEMENT
• Pharmacologic
• Nonpharmacologic
1. Tell client the numeric
blood pressure readings E. PLANNING AND
so he or she can keep an IMPLEMENTATION
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 treatment
this
protocol begins
with lifestyle
changes and
adds
medications
based on
response to
previous therapy
PERIPHERAL
ARTERIAL
DISEASE
 PERIPHERAL ARTERIAL
interrupt or DISEASE
impede arterial
peripheral
blood flow

• due to
– vessel
compression,
– Vasospasm
– structural
defects in the
vessel wall
1. primarily caused by ETIOLOGY AND
atherosclerosis PATHOPHYSIOLOGY
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
 1. Subjective
a. client reports
C. ASSESSMENT – aching,
– cramping,
– fatigue or
– weakness in the legs that is relieved by
rest [claudication]
• this is an early indication of disease
b. client reports
rest pain
– while resting
– awaken the client at night
– toes, arch, forefoot, heel
– relieved when foot is placed in the
dependent position
• this indicates more advanced disease
c. client compliants of
– coldness
– numbness in the LE
2. Objective
a. extremities - cool & pale - cyanotic
color on elevation
b. bruits may be auscultated
c. peripheral pulses may be diminished
or absent
d. nails may be thickened and opaque
[trophic change]
e. skin on the legs may be shiny with
sparse hair growth [trophic
change]
f. ulcers-- LE
reduced circulation -deep pale
base, demarcated edges, painful
treated with wet to moist saline
dressings or surgical revascularization
3. Diagnostic testing

a. digital subtraction
angiography [DSA]

b. angiography

c. doppler ultrasound

d. plethysmography
 PRIORITY NURSING DIAGNOSES

Ineffective tissue perfusion

Impaired skin integrity

Pain
E. PLANNING AND IMPLEMENTATION
1. Goal: ADEQUATE TISSUE PERFUSION
a. assess and record strength of pulses
b. encourage client to stop smoking as nicotine causes
vasoconstriction & hypercoagulability of blood
c. teach client to change position at least hourly and avoid
crossing the legs
d. 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 circulation
e. teach client to avoid restrictive clothing, including girdles,
garters and socks
2. Goal: RELIEF OF PAIN
a. 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 position

do not elevate feet if pain is present
3. Goal: INTACT, HEALTHY
SKIN ON EXTREMITIES
a. skin care and daily inspection of
feet
b. always wear shoes / slippers and
avoid trauma to the feet
bath water should be checked with the
hands,not with the feet,to prevent burns to tissue
at high risk for injury that may also have
decreased sensation
c. toenail care performed by a
professional only
d. if an ulcer develops,
healing will be slow unless arterial blood
flow to the affected limb is improved
through a surgical revascularization
procedure
4. If surgery is indicated, provide appropriate
postoperative care
a. angioplasty
1] monitor neurovascular status
color, motion, sensitivity, temperature
and presence of distal peripheral pulses
to the affectd extremity every 15 minutes x
4, every 30 min x 4, then q 1-4 hrs after
sheath removal
2] notify physician if client experiences weak
or thready pulses, coolness, numbness or
tingling in the extremity
 3] monitor the sheath site for signs of external and
subcutaneous bleeding at the same frequency s
neurovascular assessment
4] instruct the client to notify the nurse and
apply manual pressure to the site should a
sensation of warmth or wetness be felt at the site
5] maintain immobilization of affected
extremity for at least 6 hours by reminding client to
keep extremity still or lightly immobilize ankle with sheet tucked
under both sides of mattress
6] maintain a pressure dressing and sand
bag [or other occlusive device] at site
b. bypass grafting
1] provide standard postoperative care
2] assess for occlusion of graft by
assessing for severe ischemic pain,
loss of pulses, decreasing ankle-
brachial index, numbness /
tingling in extremity, coolness of the
extremity

c. Endarterectomy
opening the artery and removing
obstructing plaque
or amputation in severe cases
use same principles of care
F. MEDICATION THERAPY
1. Aspirin inhibits platelet aggregation

2. Pentoxifylline [Trental] decreases

blood viscosity to increase blood
flow to the microcirculation and
tissues of the extremities

3. Cilostazol [Pletal] inhibits platelet

aggregation and enhances
vasodilation

4. Clopidogrel [Plavix] inhibits platelet

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

4. Meticulous foot care as would be

performed by clients with diabetes
mellitus

5. Trental and Plavix should be

taken with food and any effects
may take 6 to 8 weeks to notice

6. Notify caregiver of any platelet

aggregate inhibitors before
undergoing any invasive
procedures
CLIENT & FAMILY EDUCATION FOR PERIPHERAL
ARTERIAL DISEASE
stop smoking
lose weight and eat a low fat diet
do not cross legs while sitting
elevate feet at rest, but not above heart level
do not stand or sit for long periods of time
do not wear restrictive clothing
keep affected extremity warm but never apply direct heat
inspect feet daily and keep them clean & dry
avoid walking barefoot; wear proper fitting shoes
avoid mechanical or thermal injury to the legs and feet
begin and maintain an exercise & walking program
notify healthcare provider of any changes in color, sensation,
temperature or pulses in extremities
ARTERIAL EMBOLISM
DESCRIPTION
arterial emboli usually
ARTERIAL
arise from thrombi that EMBOLISM
developed in the heart
as a result of

atrial fibrillation,
myocardial infarction,
prosthetic valves or
congestive heart
failure
thrombi become detached B. ETIOLOGY AND
and are carried from the left PATHOPHYSIOLOGY
side of the heart into the
arterial system where they
may lodge and cause
obstruction

the symptoms may be abrupt

and will depend on the size
and location of the embolus

ischemia will progress to

necrosis and gangrene
within hours
1- pain C. ASSESSMENT: the
six P’s
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
IMPLEMENTATION
1- assess peripheral pulses and neurovascular status
every 2 to 4 hours

2- place affected extremity in a neutral position with no

restrictive bedding / clothing
---keep extremity warm

3- assess level of pain using a 1 to 10 scale

4- change position every 2 hours to increase or

improve collateral circulation
E. PLANNING AND
IMPLEMENTATION
5- assess for and report unusual bleeding from
anticoagulant therapy

6- monitor lab vaues, including APTT, PT and INR

levels

7- if necrosis is present, surgical treatment is required;

---an emergency embolectomy needs to be
performed within 4 to 5 hours of embolism to prevent
necrosis and permanent damage to the extremity
F. MEDICATION
THERAPY

---if no necrosis present

thrombolytic therapy with streptokinase

heparin

warfarin therapy at home

 G. CLIENT EDUCATION

1- PRE AND POSTOPERATIVE TEACHING IF

EMBOLECTOMY IS PERFORMED

2- MEASURES TO PROMOTE PERIPHERAL

CIRCULATION AND MAINTAIN TISSUE
INTEGRITY
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
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
 ETIOLOGY &
PATHOPHYSIOLOG
Y
2- inflammation occurs

mirothrombi form

these can lead to

vasospasm

this process
ultimately obstructs
blood flow
 ASSESSMENT
1- bluish cast to a toe or finger
and a feeling ofcoldness in
the affected limb

2- nerves alsoinflamed
there may be severe pain
& constriction of smal blood
vessels controlled by them

rest pain is common

3- overactive sympathetic
nerves
4- blood vessels become C.
blocked ASSESSMENT
intermittent 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 blockers

to ease vasospasm

pentoxifylline [Trental]
to reduce blood viscosity
G. CLIENT EDUCATION

1- stop smoking

2- take measures to promote

peripheral circulation
maintain tissue integrity
RAYNAUD’S DISEASE
 - LOCALIZED

A. DESCRIPTION
- INTERMITTENT
EPISODES OF
VASOCONSTRICTION
OF SMALL ARTERIES
OF THE HANDS

- LESS COMMONLY
THE FEET

- CAUSING COLOR AND

TEMPERATURE
CHANGES
 B. ETIOLOGY AND
PATHOPHYSIOLOGY
1- a vasospastic disorder of unknown
origin that primarily affects young
women

2- vasospastic attacks tend to be

bilateral and manifestations
usually begin at the tips of the
digits causing pallor, numbness
and sensation of cold

3-attacks are triggered by exposure

to cold, emotional stress, caffeine
ingestion, and tobacco use
1- symptoms may appear in the
hands after exposure to cold and / C. ASSESSMENT
or stress
bilateral and symmetrical

2- classic triphasic color changes in

the hands with accompanying
reduction in skin temperature
pallor
cyanosis
rubor

3- the intensity of pain increases as

disease progresses

4- the skin of the fingertips may

thicken and nails may become
brittle
D. PRIORITY NURSING DIGNOSES

INEFFECTIVE TISSUE
PERFUSION

CHRONIC PAIN
1- keep hands warm and
free from injury E. PLANNING AND
IMPLEMENTATION
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 PATHOPHYSIOLOGY
1- aorta is susceptible to aneurysm formation because of constant
stress on the vessel wall

2- aneurysms occur in men more often than women and their

incidence increases with age

3- most aneurysms are found in the abdominal aorta below the

level of the renal arteries

4- the growth rate of n aneurysm is unpredictable

5-half of all aneurysms greater than 6 cm in size will rupture within

1 year

6- the major risk factor is atherosclerosis

 1- THORACIC ANEURYSMS
C. ASSESSMENT asymptomatic with the
first sign being rupture

a- symptoms
pain in the back, neck
and substernal area that
may only occur when lying
supine

b-client may experience

dysphagia
dyspnea
stridor or cough
when pressing on the
esophagus or laryngeal
nerve
 2- ABDOMINAL ANEURYSMS
C. may also be asymptomatic
ASSESSMENT until rupture

a- the client may report a

“heartbeat” in the abdomen
when lying down

b- a pulsating abdominal
mass may be present

c- moderate to severe
abdominal or lumbar back
pain may be present
C. 2- ABDOMINAL
ASSESSMENT ANEURYSMS
d- the client may
experience claudication

e- cool or cyanotic
extremities may be noted

f- systolic bruit my be
heard
3- DISSECTING ANEURYSMS
present with sudden, severe and
persistent pain described as
“tearing” or “ripping” in the
anterior chest or the back

a- pain may extend to the

shoulder, epigastric area or
abdomen

b- pallor, sweating and

tachycardia will be evidenced

c- initially the client may have an

elevated BP that may be different
in one arm from the other
D. PRIORITY NURSING DIAGNOSES

INEFFECTIVE TISSUE
PERFUSION

PAIN

ANXIETY
E. PLANNING AND IMPLEMENTATION
1. Diagnostic test that may be ordered
a- chest x-ray
b- transesophageal echocardiography
c- aortography
d- ultrasound
e- CT scan or MRI
2- The overall goals for a client with an aneurysm
a- normal tissue perfusion
b- intact motor and neurologic function
c- reduction in anxiety
d- no complications of surgical repair
 a- surgical management may be
performed on an emergency or
elective basis
surgery not usually performed on
aneurysms less than 4 to 5 cm in size
b- emergency surgery is the only
intervention for clients with a ruptured
aneurysm
c- hematomas into the scrotum,
perineum, flank or penis indicate
retroperitoneal rupture
3. Surgical d- once the aorta ruptures anteriorly into
care the peritoneal cavity, death is almost
certain
 e- surgical technique involves excision of
the aneurysm with replacement of the
excised segment with a synthetic
graft
f- preoperatively the nurse marks and
assesses all peripheral pulses for
comparison postoperatively
g- postoperatively the nurse assesses for
complications, which may include:
1- graft occlusion
2-hypovolemia / renal failure
3- respiratory distress
3. Surgical 4-cardiac dysrhythmias
care 5- paralytic ileus
6- paraplegia / paralysis
 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
F. on anticoagulant therapy
MEDICATION heparin while the client is in the
THERAPY hospital and warfarin [Coumadin]
when discharged to home
 1- clients who do not undergo
operative repair must be urged to
G. CLIENT receive routine physical exminations
EDUCATION 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
 5- for postoperative clients, teach
routine postoperative care
a- do limited lifting for 4 to 6 weeks
G. CLIENT after surgery [no heavy lifting at all]
EDUCATION
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 &
1- ETIOLOGY PATHOPHYSIOLOGY
VIRCHOW’S TRIAD
[at least 2 or 3 present for
thrombosis to occur]

a-stasis of venous flow

b-damage to the inner lining
of the vein [endothelial
layer]
c-hypercoagulability of the
blood
2-PATHOPHYSIOLOGY
ETIOLOGY &
a-RBCs, WBCs and platelets adhere PATHOPHYSIOLOGY
to form a thrombus [usually in valve
cusps of veins]

b- as thrombus enlarges it eventually

occludes the lumen of the vein

c- if only partial occlusion of the vein

occurs, blood flow continues and the
thrombotic process stops
if detechment does not occur, it will become firmly
organized and attached within 24 to 48 hours

d- it detachment occurs, emboli from

which generally flow through the
venous system, back to the heart, and
into the pulmonary circulation
 ASSESSMENT
1-SUBJECTIVE:
history of thrombophlebitis
pelvic/ abdominal surgery
obesity
neoplasm [hepatic & pancreatic]
congestive heart failure
atril fibrillation
prolonged immobility
myocardial infarction
pregnancy & / or postpartum period
IV therapy
hypercoagulable states [polycythemia, dehydration /
malnutrition]
 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 scanning

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

PAIN

INEFFECTIVE TISSUE PERFUSION

RISK FOR IMPAIRED SKIN INTEGRITY

C. PLANNING & IMPLEMENTATION
1-educate client about diagnostic tests that may be
performed
2-provide for relief of pain
a-assess pain on a scale of 1 to 10
b-elevate affected leg higher than the heart to
promote venous drainage
c-provide analgesics as ordered
3-decreased edema
a-apply warm,moist compresses, intermittent or
continuous, to affected extremity
b-measure and monitor leg/arm circumference
when edema is present
c-monitor status of peripheral pulses
4-prevent skin ulceration
a-keep bed covers from touching affected limb by
using an overbed cradle
b- do not allow use of restrictive clothing
5-prevent pulmonary emboli
a-maintain strict bedrest, usually enforced until
anticoagulant therapy is therapeutic
b-never massage affected extremity
c- instruct client to report any pink-tinged sputum and
monitor for tachypnea, tachycardia, shortness of
breath, chest pain and apprehension, which may
indicate a pulmonary embolism
d-prepare client for vena cava filter [greenfield filter]
placement
 MEDICATION THERAPY
1-anticoagulant therapy
a-inhibits clotting factors that would extend thrombus
formation

b-will not induce thrombolysis but prevents clot

extension

c-heparin: intravenously or subcutaneous while in the

hospital

d-warfarin: home therapy for 2 to 4 months

2-thrombolytics
a-dissolve blood clots by imitating natural enzymatic
processses

b-approved drugs include streptokinase [streptase]

and alteplase [activase]

c-is usually effective in less than 72 hours

d-higher risk for hemorrhage exists than when using

heparin therapy
 CLIENT EDUCATION
1-prevention
a-early ambulation postoperatively
b-use of compression stockings or sequential device
c-low dose anticoagulant therapy
d-avoid prolonged standing or sitting
avoid sitting with crossed legs
e-avoid restrictive clothing
f-stop smoking

2-provide education about anticoagulant therapy

 VENOUS
INSUFFICIENCY
 DESCRIPTIO
N
INADEQUATE VENOUS
RETURN OVER A
LONG PERIOD OF
TIME THAT CAUSES
PATHOLOGIC
CHANGES AS A
RESULT OF ISCHEMIA
I THE VASCULATURE,
SKIN, AND
SUPPORTING
TISSUES
1- occurs after prolonged venous
hypertension, which stretches the
ETIOLOGY &
veins and damages the valves,
PATHOPHYSIOLOGY
preventing blood return

2-occurs after thrombus formation

or when valves are not
functioning correctly,which may
result from
a-prolonged standing/ sitting
b-pregnancy and obesity

3-with time, stasis results in edema

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

RISK FOR INFECTION RELATED TO

SKIN ULCERATIONS

DISTURBED BODY IMAGE

INEFFECTIVE TISSUE PERFUSION

PLANNING & IMPLEMENTATION
1- increase venous blood return, decrease venous
pressure
-bedrest
-keep legs elevated
-avoid long periods of standing
-wear elastic support or compression stockings
a-apply stockings before getting out of the bed &
placing the leg in a dependent position
b-wear stockings during the day & evening, remove at
night
c-never push stockings down around the 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/s
a-open lesions are treated with a hydrocolloid
dressing and compression wraps; a topical
ointment, such as low-dose hydrocortisone, zinc
oxide, or an antifungal may also be indicated
b-ulcers may be treated with an Unna Boot or other
compression wrap that is changed every 1 to 2
weeks and is usually applied over a base dressing
c-severe ulcers may need surgical debridement
 MEDICATION THERAPY

1-topical agents to skin ulcers, such as hydrocortisone,

antifungals or zinc oxide, may be prescribed
2- oral or IV antibiotics may be prescribed when ulcers
become infected or cellulitis occurs
3-sclerosing agents [called sclerotherapy] may be used
to occlude blood flow in a vein, causing
disappearance of the varicosity, this may be followed
up with use of compression bandage for a short
period of time
 CLIENT EDUCATION

1-elevate legs for at least 20 minutes four times a day

2-keep legs above the level of the heart when in bed
3-avoid prolonged sitting or standing
4- do not cross legs when sitting
5-do not wear tight, restrictive pants, socks or boots
avoid girdles and garters that restrict circulation in the
upper leg
6- wear suppoert stockings as instructed
VARICOSE VEINS
 DESCRIPTION

A VEIN OR VEINS IN WHICH

BLOOD HAS POOLED,
PRODUCING DISTENDED,
TORTUOUS AND
PALPABLE VESSELS
ETIOLOGY & PATHOPHYSIOLOGY
1-one in 5 people worldwide will develop varicosities
2-they are more commonin women over 35. those who
are obese, those with a positive family history of
varicosities, and those who stand for long periods of
time
3-develop from trauma or damages to a vein or valve or
from gradual venous distension, which diminishes the
action of the muscle pump, and increases the pull of
gravity on blood within the legs
4-as the vein swells, increased hydrostatic pressure will
push plasma through the stretched vessel walls and
edema of surrounding tissue may occur
1-subjective
aching, heaviness, itching,
swelling and unsightly appearance ASSESSMENT
to the legs
2-objective
a-dilated, tortuous superficial veins
will be seen along the upper
and lower leg
b-superficial inflammation
c-positive Trendelenburg test [
done to evaluate valve
competence]
-supine position, elevate legs
-as client sits up, the veins
would normally fill from
the distal end
-if [+] varicosities, veins fill
from the proximal end
 PRIORITY NURSING
DIAGNOSIS
PAIN

INEFFECTIVE TISSUE
PERFUSION

RISK FORIMPAIRED
SKIN INTEGRITY

RISK FOR PERIPHERAL

NEUROVASCULAR
DYSFUNCTION
E. PLANNIG & IMPLEMENTATION
1-asses and provide pain relief
a-assess pain scale of 1 to 10
b-provide analgesics as needed
2-improve venous circulation
a-assess pulses and neurovascular status of lower
extremities
b-teach/ apply support stockings
c-avoid prolonged sitting and standing
never cross legs. Walking is encouraged
d-elevate feet above heart level when lying down
e-avoid restrictive clothing / shoes
3-prevent skin breakdown; teach proper skin
care and importance of avoiding trauma to
legs
4-teach preoperative and postoperative care if
surgery is chosen
a-sclerotherapy-palliative not curative
-elastic bandage- until 6 weeks
b-vein ligation surgery---ligation of the
entire vein usually the saphenous and
dissection and removal of the incompetent
tributaries
-post op-perform hourly circulation
checks
-elevate extremity to a15 degree
angle to prevent stasis and edema
-apply compression gradient
stockings from foot to groin
MEDICATION THERAPY

LOW DOSE ASPIRIN THERAPY—to

reduce platelet aggregation and
subsequent clot development
CLIENT EDUCATION:
PREVENTION
1-AVOID SITTING OR STANDING
FOR LONG PERIODS
2-CHANGE POSITION OFTEN
3-AVOID CONSTRICTIVE CLOTHING
4-ELEVATE LEGS WHEN SITTING TO
PROMOTE VENOUS RETURN
5-MAINTAIN IDEAL BODY WEIGHT
LYMPHATIC
SYSTEM
LYMPHATIC
SYSTEM
• Composed of:
lymphatic vessels
lymphoid organs

• Form network
around arterial and
venous channels

• Interweave at
capillary beds
• Lymph [tissue fluid] leaks from
cardiovascular system and
accumulates at end of capillary
bed

• Fluid returned to heart through

lymphatic veins and venules that
drain into right lymphatic duct
and left thoracic duct which
empty into subclavian vein
under the collarbones

• These veins join to form the

superior vena cava, the large
vein that drains blood from the
upper body into the heart.
• Low pressure system
depends on
rhythmic contraction of
smooth muscle and
muscular and respiratory
pumps

• lymphatic system
transports fluids
throughout the body

• thin-walled lymphatic
vessels, lymph nodes,
and two collecting ducts

• larger than capillaries

• most are smaller than the

smallest veins
Organs of the
lymphatic system
• LYMPH NODES

– Special cells of immune

system

– Remove foreign material,

infectious organism, tumor
cells from lymph

– Distributed along lymphatic

vessels forming clusters in
regions of neck, axilla, groin
Organs of the
lymphatic system
• SPLEEN
– Filters blood by breaking down
old red blood cells
– Stores or releases to liver 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
gradient.

• 2) Muscular and
respiratory pumps
push lymph forward
due to function of the
semilunar valves.
SEMILUNAR VALVES
• either of two crescent-shaped valves
in the heart that prevent blood from
flowing back into the ventricles.

• The two valves are called the aortic

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

• Lymph nodes also

produce specialized
blood cells designed to
engulf and destroy
damaged cells, cancer
cells, infectious organisms,
and foreign particles.
FUNCTIONS OF
THE LYMPHATIC
SYSTEM
• to remove
damaged cells
from the body

• to provide
protection against
the spread of
infection and
cancer.
• Functions of the lymphatic
system:

• to maintain the pressure and

volume of the extracellular
fluid by returning excess water
and dissolved substances from
the interstitial fluid to the
circulation.

• lymph nodes and other

lymphoid tissues are the site of
clonal production of
immunocompetent lymphocy
tes and macrophages in the
specific immune response.
 ASSESSMENT OF
LYMPHATIC SYSTEM
1. SUBJECTIVE DATA
• a. lymph node
enlargement

• b. infection or
impaired immunity
fever
fatigue
weight loss
2. PHYSICAL ASSESSMENT
• a. skin over
regional lymph
node

edema
erythema
red streaks
skin lesions
1. LYMPHANGITIS
• Inflammation of
lymph vessel

red streak with

hardness following
course of lymphatic
collecting duct
2. LYMPHEDEMA
• Swelling due to
lymphatic
obstruction

congenital anomaly
trauma to area as
with surgery
arm lymphedema
after radical
mastectomy
metastasis
LYMPH NODE ASSESSMENT
• 1.LYMPHADENOPATHY

– Enlargement over 1 cm with

or without tenderness
indicates inflammation,
infection or malignancy of
nodes or region drained by
nodes
LYMPH NODE ASSESSMENT
• 2.LYMPHADENITIS
[INFLAMMATION]

– Enlargement with tenderness

– Bacterial infection
– warm , localized swelling
LYMPH NODE ASSESSMENT
• 3. MALIGNANT OR
METASTATIC NODES

– Hard as lymphoma
– Rubbery as with 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
 • PRIMARY
ETIOLOGY 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
 • SECONDARY
ETIOLOGY LYMPHEDEMA
– Results from damage
or obstruction of the
lymph system by
disease or procedure
• Trauma
• Neoplasms
• Mosquito transmitted
filariasis
• Inflammation
• Surgical excision of
axillary, inguinal or iliac
lymph nodes
• High dose radiation
therapy
PATHOPHYSIOLOGY
• 1.Collection of lymph distal
to a blocked lymphatic
results in [backward flow]
– increased intralymphatic
pressures Causing
• lymphatic wall dilation
• Valve incompetency
– Increased intralymphatic
pressure leads to
• Protein accumulation in the
interstitial spaces
– Increased colloid osmotic
pressure in tissues
» Resulting in fluid retention &
edema
 • 1.Collection of lymph distal
PATHOPHYSIOLOGY to a blocked lymphatic
results in [backward flow]
– increased intralymphatic
pressures Causing
• lymphatic wall dilation
• Valve incompetency

– Increased intralymphatic
pressure leads to
• Protein accumulation in the
interstitial spaces
– Increased colloid osmotic
pressure in tissues resulting in
» fluid retention
» edema
 • 2. Chronic lymph
PATHOPHYSIOLOGY congestion leads to

– Fibrosis
– Formation of dense
connective tissue in
subcutaneous tissue
ASSESSMENT FINDINGS
• 1. CLINICAL
MANIFESTATIONS
– A. PRIMARY
LYMPHEDEMA
• Nonpitting edema
• Dull, heavy sensation
• Absence of pain
• Roughened skin without
ulceration of skin or cellulitis
• Marked limb enlargement
Grades of Lymphedema
The International Society of Lymphology has
graded lymphedma into categories:
• Grade 1
– skin is pressed the pressure will leave
a pit

– takes some time to fill back in

– referred to as pitting edema.

– swelling can be reduced by elevating

the limb for a few hours.

– little or no fibrosis (hardening)

– so it is usually reversible.
The International Society of Lymphology has
graded lymphedma into categories:
• Grade 2

– swollen area is pressed,

– it does not pit,

– swelling is not reduced very much

by elevation.

– If left untreated, the tissue in the

limb gradually hardens

– becomes fibrotic.
The International Society of Lymphology has
graded lymphedma into categories:
• Grade 3

– Elephantiasis

– almost exclusively in the legs

– after progressive, long term, and

untreated lymphedema

– gross changes to the skin

– protrude and bulge

– leakage of fluid through the tissue

in the affected area, especially if
there is a cut or sore

– rarely reversible.
ASSESSMENT • 1. CLINICAL
FINDINGS 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 