36 Vascular Disorders
http://evolve.elsevier.com/Linton/medsurg
Objectives
1. Indicate data to collect for assessment of a patient with
selected vascular disorders
2. Describe the pathophysiology, signs and symptoms,
complications, and medical or surgical treatments of
selected vascular disorders.
3. Assist in developing a plan of nursing care for patients with
selected vascular disorders.
Key Terms
aneurysm (ĂN-yŭr-ĭzm)
embolism (ĔM-bō-lĭzm)
ischemia (ĭs-KĒ-mē-ă)
phlebitis (flĕ-BĪ-tĭs)
thrombosis (thrŏm-BŌ-sĭs)
vasoconstriction (vā-zō-kŏn-STRĬK-shŭn)
The delivery of oxygen (O2) and nutrients to the tissues depends on adequate perfusion (blood flow to an
organ or tissue), which requires a functionally intact
cardiovascular system. When the cardiovascular system is compromised by vascular disease, the homeostasis of the body is affected. Risk factors for vascular
disease include advanced age, heredity, smoking, obesity, physical inactivity, hypertension, hyperlipidemia
(elevated cholesterol), and diabetes mellitus. Vascular
diseases can affect the arterial and venous components
of the circulation, resulting in pain, impaired function,
and even death.
Atherosclerosis is discussed in Chapter 36. Other
peripheral vascular disorders, as well as aortic aneurysm and aortic dissection, are presented here.
occlusion. Peripheral nerves and muscles are more susceptible to harm from hypoxia than the skin and subcutaneous tissues. Severe O2 deprivation may lead to
ischemia and then to necrosis (tissue death).
Because PAD develops gradually, compensatory
mechanisms attempt to maintain circulation. These
compensatory mechanisms include the development
of collateral blood vessels, vasodilation, and anaerobic metabolism. Collateral blood vessels are small new
vessels that branch out to supply blood to poorly perfused tissues. The extent of collateral circulation determines the severity of symptoms.!
PERIPHERAL ARTERIAL DISEASE OF LOWER
EXTREMITIES
PATHOPHYSIOLOGY
Lower extremity peripheral artery disease (PAD) affects 12% to 20% of Americans aged over 60 years and
nearly 50% in those 85 years and older. The most significant risk factors are hyperlipidemia (high cholesterol), hypertension, diabetes, chronic kidney disease,
and smoking (Firnhaber, 2019).
PAD is characterized by pathologic changes in the
arteries, typically plaque formations that arise where
the arteries branch, veer, arch, or narrow (Fig. 36.1).
The most common sites for arterial occlusion are the
distal superficial femoral and the popliteal arteries.
Occlusions prevent the delivery of O2 and nutrients
to the tissues. Hypoxia affects all tissues distal to the
702
CLINICAL MANIFESTATIONS
The clinical manifestations of PAD develop gradually. A classic sign of PAD is intermittent claudication.
Symptoms such as aching, cramping, tiredness, and
weakness in the legs commonly occur with walking and are relieved by rest; however, persistent and
aching pain that occurs during rest may be present.
Complaints of tingling or numbness (or both) in the
toes are common. The affected extremity is cold and
numb because of the reduction in the flow of blood to
the area. Muscle atrophy may be evident. The skin of
the affected area is pale because of reduced blood flow.
When the extremity is in a dependent position, the color becomes red. Reduced blood supply to toenails can
cause the nails to thicken. Other signs of arterial occlusion are shiny, scaly skin; subcutaneous tissue loss;
hairlessness on the affected extremity; and ulcers with
a pale gray or yellowish hue, especially at the ankles.
If one extremity is affected more than the other, size
differences between the extremities may be apparent.!
Vascular Disorders CHAPTER 36
703
Normal artery
Artery with
fat build up
Artery blocked
with fat
A
Fig. 36.1 Development of atherosclerosis. (From Ignatavicius DD,
Workman ML: Medical-surgical nursing: patient-centered collaborative
care, ed 7, St. Louis, 2013, Saunders.)
MEDICAL DIAGNOSIS
The ankle-brachial index (ABI) is an inexpensive and
reproducible method for assessing lower extremity hemodynamics. The ABI index test compares the blood
pressure at the ankle with the blood pressure measurement at your arm. The ABI test can easily be done in
the office setting by experienced staff. If results are less
than 0.9, the risk of major cardiovascular events and
overall mortality nearly doubles. Additional diagnostic tests used to confirm a diagnosis of PAD are duplex
imaging, and, if surgery is contemplated, angiography
(see Chapter 33, Table 33.3).!
MEDICAL AND SURGICAL TREATMENT
The first step in managing PAD is to encourage the
patient to make lifestyle changes, including smoking
cessation, exercise, and weight management. Smoking
cessation is a high priority. The use of e-cigarettes (also
known as vaping) is not recommended as a tool to stop
smoking tobacco. e-cigarettes introduce nicotine into the
body plus noxious substances into the lungs. Success
may be enhanced with varenicline (Chantix), nicotine
replacement therapy, or bupropion (Zyban). Exercise
programs found to be most successful with PAD include
at least three sessions of 30 to 60 minutes of exercise each
week. Training programs typically use a treadmill that
allows gradual increases in speed and grade (incline).
The benefits are sustained only as long as the patient
continues regular exercise. Treatment should be initiated for hypertension, hyperlipidemia, and diabetes, if
present. Angiotensin receptor blockers and angiotensinconverting enzyme (ACE) inhibitors ramipril (Altace)
and telmisartan (Micardis) improve outcome.
Bypass graft
using
autogenous
(native) vein
Bypass graft using
synthetic graft
Superficial
femoral
artery
Popliteal
artery
Superficial
femoral
artery
Popliteal
artery
Anterior
tibial artery
Anterior
tibial artery
Peroneal
artery
Posterior
tibial artery
Peroneal
artery
Posterior
tibial artery
B
Fig. 36.2 (A) Femoral-popliteal bypass graft around an occluded
superficial femoral artery. (B) Femoral-posterior tibial bypass graft
around occluded superficial femoral, popliteal, and proximal tibial
arteries. (From Lewis LL, et al.: Medical-surgical nursing, ed 10, 2017,
Elsevier.)
Among the drugs used to treat claudication are cilostazol (Pletal) and pentoxifylline (Trental), which dilate
blood vessels and prevent platelets from clumping.
Aspirin or clopidogrel (Plavix) is used for antiplatelet
activity. Several new types of drugs under study include recombinant growth factor, immune modulators,
and carnitine. Scientists hope that gene therapy will
stimulate growth of new blood vessels. See Chapter 33,
Table 33.9 for a complete list of medications prescribed
for cardiovascular conditions.
Surgical interventions include stenting (to keep the
vessel lumen open), endarterectomy, grafting, and
catheter-based interventional radiology procedures.
Endarterectomy is the surgical removal of the obstruction. Grafting is the surgical replacement of a diseased
segment of an artery with a graft of some type, either
synthetic or from another blood vessel (Fig. 36.2).
Interventional radiology is done in the catheterization laboratory, is highly successful, and requires a
recovery period of only 24 to 48 hours. Percutaneous
angioplasty (PTA) is one interventional radiology procedure. By inserting a catheter containing a balloon at
the tip into the femoral artery, PTA enlarges the interior
diameter of the blood vessel. A stent is placed immediately within the artery to keep it open. Possible complications of PTA are hematoma formation, embolus,
arterial dissection, and allergic reaction. Nursing care
for the procedure is the same as for a diagnostic angiography (see Table 33.3).
Asymptomatic patients with PAD generally are
not candidates for revascularization. However, patients with claudication who have not responded to
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UNIT IX Cardiovascular System
treatment and supervised exercise therapy should be
referred to a vascular surgeon.!
NURSING CARE OF THE PATIENT WITH
PERIPHERAL ARTERIAL DISEASE
Focused Assessment
Assessment of the patient with PAD is summarized in
Chapter 33, Box 33.2. When the patient has had surgical
intervention, it is especially important to monitor the
pulses distal to the surgical site and compare them with
the same pulses in the unaffected extremity. Cessation
of a pulse suggests possible arterial occlusion, and the
surgeon must be notified immediately. Other important aspects of the postoperative assessment are vital
signs, color and temperature of the affected extremity,
fluid intake and output, central venous pressure, and
mental status. If the patient has pain, document the location, severity, and nature of the pain.
Patient Problems, Goals, and Outcome Criteria:
Peripheral Arterial Disease
Patient Problems
Decreased activity
tolerance related to
decreased blood flow to
extremities
Chronic pain related to
ischemia
Disrupted tissue integrity
related to inadequate
circulation
Altered body image related
to muscle atrophy,
stasis ulcers, and skin
discoloration
Inadequate peripheral
tissue perfusion related
to vascular occlusion
Goals and Outcome
Criteria
Improved activity
tolerance: patient states
is increasingly able
to perform activities
without pain
Reduced pain: patient
states pain is reduced,
relaxed manner
Healthy skin: skin intact
with normal color and
warmth
Positive body image:
positive patient
statements about self,
patient makes effort to
maintain good physical
appearance
Adequate peripheral tissue
perfusion: palpable
peripheral pulses,
extremity warm with
normal skin color
Patient carries out proper
self-care measures:
patient describes and
demonstrates self-care
Potential for infection
related to surgical
incision, graft placement
Patient Problems
Decreased cardiac output
related to hemorrhage,
diuresis, fluid shifts
Inadequate peripheral
circulation related to
graft thrombosis
Acute pain related to
surgical incision
Decreased mobility related
to weakness, fear,
surgical procedure
Goals and Outcome
Criteria
Normal cardiac output:
pulse and blood
pressure consistent with
patient norms
Patent graft: operative
extremity warm, with
improved color and
palpable pulses
Pain relief: patient relaxed,
states that pain is relieved
Increased physical
mobility: increasing
activity without pain
!
Interventions
Decreased activity tolerance. To monitor the patient’s
activity tolerance, assess the patient before, during,
and after planned activities; then monitor progress as
treatment progresses. When planning an exercise regimen, use the following guidelines:
1. Work with the patient to plan the activity schedule
and goals.
2. Gradually increase the exercise time as tolerance
increases.
3. Discontinue activity if the patient has chest pain,
bradycardia, dyspnea, or intermittent claudication.
After rest relieves the pain of intermittent claudication, the patient may resume activity.
4. Reduce the intensity of the activity if the pulse takes
longer than 3 to 4 minutes to return to the baseline
rate or if the patient has severe dyspnea.
5. For patients confined to bed, start exercises with
range-of-motion exercises performed twice daily.
6. Patients should not exercise when they have leg ulcers,
cellulitis, deep vein thrombosis (DVT), or gangrene.!
Chronic pain. The chronic pain associated with ischemia
Goals and Outcome
Criteria
is exhausting and greatly reduces the patient’s quality
of life. Therefore, pain management must be a priority.
The most direct interventions are those that increase
circulation or decrease metabolic demands of ischemic
tissues. Resting the extremities in a dependent position
may help to relieve the pain of arterial occlusive disease.
Administer analgesics as prescribed, along with other
comfort measures. Nonpharmacologic pain relief measures include relaxation techniques, warm baths, breathing exercises, and back rubs (see the Complementary
and Alternative Therapies box). See Chapter 8 for a detailed discussion of pain management.
Absence of infection: normal
body temperature,
decreasing wound
redness and drainage
Relaxation, warm baths, breathing exercises, and back rubs
can help the patient with chronic pain.
Ineffective self-care
management related
to lack of knowledge
of disease process,
treatment, and self-care
If surgical intervention is performed, additional
diagnoses and goals may include the following.
Patient Problems
Patient Problems, Goals, and Outcome Criteria:
Peripheral Arterial Disease—cont’d
Complementary and Alternative Therapies
!
Vascular Disorders CHAPTER 36
Disrupted tissue integrity. The nursing interventions
for maintaining skin integrity focus on improving
circulation and avoiding tissue trauma. If the patient
has an ulcerated area, keep it clean and free of pressure. Various wound care products may be prescribed
to protect the wound and prevent infection. However,
unless circulation is improved, healing is unlikely. The
physician will prescribe any activity limitations.
The feet are especially susceptible to injury and require special care. Advise the patient not to go barefoot,
to wear only shoes that fit properly, to inspect the feet
daily for signs of pressure or lesions, and to keep the
toenails neatly trimmed. Because of the risk of ingrown
nails, nails should not be trimmed too short. Toenails
should always be cut straight across rather than in a
curved shape. The patient should see a peripheral vascular specialist promptly if any foot problems develop.!
Altered body image. Encourage the patient to express
any feelings that result from problems associated with
PAD, such as activity intolerance, stasis ulcers, discoloration of the extremities, and, for some, amputations.
It is important to be supportive and help the patient to
identify coping strategies to deal with the feelings.!
Inadequate peripheral circulation. Administer vaso-
dilators and other drugs that improve blood flow as
ordered. Encourage exercise according to the individualized exercise plan. Maintain adequate warmth and
discourage smoking. Elevation of the extremities is not
usually recommended with arterial disease.
Additional interventions are indicated for the postoperative patient.!
Inability to manage self-care. To cope with PAD, the
patient must understand the disease process and treatment. Include the family in patient teaching because
their fears and concerns can have an enormous effect
on the patient’s perception of the situation. The patient
teaching plan is the same as for the patient with arterial
embolism. Adaptation to lifestyle changes is essential
to good management of PAD. Additional interventions
are indicated for the postoperative patient.!
Potential for infection. After surgery, patients are at risk
for infection of the surgical incision and the grafts (especially synthetic grafts) that are used to replace the diseased blood vessel. An infected synthetic graft is very
serious because it necessitates removal of the graft and
often amputation. Monitor the patient’s temperature
and report fever to the surgeon. It is vital to inspect the
incision for increasing redness, edema, and drainage that
suggest infection. Antimicrobials are usually ordered
before surgery and may be continued after surgery.!
Decreased cardiac output. Monitor for signs and symp-
toms of deficient fluid volume: tachycardia, restlessness, decreased urine output, pallor, and hypotension.
705
Provide intravenous and oral fluids as ordered and
maintain records of fluid intake and output. Monitor
daily weights and inspect the surgical dressing for
bleeding, which must be reported immediately to the
surgeon.!
Inadequate peripheral circulation. Thrombus forma-
tion can occur in the graft, causing occlusion and impaired blood flow. Monitor the pulses, warmth, and
color of the operative extremity and promptly inform
the surgeon of diminishing pulses, coolness, and pallor
or cyanosis. Some patients are given anticoagulants or
thrombolytics to decrease the risk of graft occlusion.
Edema for 4 to 8 weeks is common after bypass surgery. The leg is usually wrapped in a light dressing or
vascular boot and kept flat initially. Elastic stockings
are not used immediately after a vein graft.!
Acute pain. Postoperative pain is treated with anal-
gesics, positioning, and relaxation techniques as described in Chapters 17 and 33.!
Decreased physical mobility. After surgery, the pa-
tient’s activities are increased gradually. A specific program of exercises may be prescribed. Assist the patient
and assess muscle strength and tolerance of activity.!
ARTERIAL EMBOLISM
PATHOPHYSIOLOGY
The development of an arterial embolism is a potentially life-threatening event. An arterial embolus usually
forms from a thrombus in the heart. Heart conditions
that may cause a thrombus include infective endocarditis, mitral valve disease, atrial fibrillation, cardiomyopathy, and prosthetic heart valves. In any artery,
roughened atheromatous plaque as well as traumatic
injury can lead to thrombus formation. If a thrombus
breaks loose, it becomes an embolus traveling through
the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion. Thrombi from
the right side of the heart lodge in the lungs, causing
a pulmonary embolism (addressed later), whereas
thrombi from the left side usually affect a leg. The effects of arterial occlusion depend on the size of the
embolus formed, the organs involved, and the extent
to which collateral circulation can maintain sufficient
blood supply to affected tissues.!
PREVENTION
Increased risks for clots are:
• Smoking
• Minimal exercise
• High blood pressure
• Elevated cholesterol levels
• Diabetes
• Overweight
• Stress!
706
UNIT IX Cardiovascular System
CLINICAL MANIFESTATIONS
Whereas some patients with arterial obstruction have
no pain, others experience severe pain and other symptoms of tissue ischemia. When the collateral circulation
cannot compensate for the compromised blood flow,
the patient has distinct symptoms of reduced blood
flow to the tissues. Signs and symptoms of inadequate
blood supply in the lower extremities include:
• Severe, acute pain
• Weakness and gradual loss of sensory and motor
function in the affected areas
• Pain aggravated by movement or pressure
• Absent distal pulses
• Muscle pain or spasm in the affected area
• Pallor (pale color) and mottling (irregular discoloration)
• A sharp line of color and temperature demarcation
(tissue beyond the obstruction is pale and cool)!
DIAGNOSIS
An arterial embolism may result in a decreased or absent
pulse, absent blood pressure and possible signs of tissue
death (darkened skin) in the extremities distal to the obstruction. Specific tests include angiography, Doppler ultrasound, and MRI of the affected extremity. If embolism
is suspected in the lung, plethysmography can measure
the air volume or if embolism of the brain is suspected,
transcranial Doppler examines the arteries of the brain.!
MEDICAL AND SURGICAL TREATMENT
Arterial embolism requires prompt treatment at a hospital. The goals of treatment are to control symptoms
and to improve the interrupted blood flow to the affected area of the body. Arterial embolism is managed
with intravenous anticoagulants and thrombolytics.
Anticoagulants (such as warfarin and heparin) and
antiplatelet medicines such as aspirin and clopidogrel (oral blood thinner) can prevent new clots from
forming. Thrombolytics (called “clot busters”) such
as streptokinase can dissolve clots. These medications
cannot be used with active internal bleeding, cardiovascular accident, recent major surgery, uncontrolled
hypertension, and pregnancy. See Chapter 33, Table
33.9 for a complete list of medications and nursing
implications for cardiovascular disease. Patients who
cannot be treated with medications may be prepared
for thrombectomy (surgical removal of the embolus).
Failure to restore perfusion results in tissue death and
requires amputation of the affected part. Patients at
risk for future arterial emboli are often treated long
term with oral anticoagulants.!
NURSING CARE OF THE PATIENT WITH
ARTERIAL EMBOLISM
Focused Assessment
The assessment of the patient with peripheral vascular disease (PVD) is outlined in Chapter 33, Box 33.2,
Assessment of Patients With Cardiovascular Disorders.
Patient Problems, Goals, and Outcome Criteria:
Arterial Embolism
Patient Problems
Inadequate peripheral
tissue perfusion related
to compromised
circulation
!
Goals and Outcome
Criteria
Improved tissue perfusion:
normal skin color,
palpable pulses,
capillary refill time
less than 3 seconds in
affected extremity
Reduced stress: patient
is calm, states fear is
reduced or relieved
Improved mobility:
patient increases activity
without discomfort
Healthy skin in affected
areas: skin intact
Stress related to fear of
treatments, environment,
and risk of limb loss
Immobility related to the
surgical procedure and
compromised circulation
Disrupted tissue integrity
related to ischemic
changes from the
impairment of peripheral
circulation
Inability to manage selfPatient knows and
care related to lack of
practices prescribed selfknowledge of self-care,
care measures: patient
including drug therapy
correctly describes and
demonstrates self-care
measures and selfmedication
Interventions
Nursing interventions are designed to improve circulation and prevent further damage to the affected tissue.
Inadequate tissue perfusion. To promote circulation,
maintain the affected extremities at or slightly below
the horizontal position. Administer prescribed medications and perform range-of-motion exercises as
ordered.!
Stress. To decrease fear, orient the patient to the envi-
ronment and the expected therapies using simple statements to explain the disease process and procedures.
Encourage the patient to express feelings of helplessness and anxiety and to identify coping mechanisms
that have worked in other situations.!
Immobility. Until the thrombus is removed, the affected
limb may be immobilized. The physician will order the
appropriate level of activity. Improved physical mobility requires instruction in range-of-motion exercises
and the development of a progressive exercise plan.
This exercise plan usually is limited to 15 minutes, 3
times a day, in the initial days after surgery or treatment. The progression of exercise is determined by the
individual patient’s response.!
Disrupted tissue integrity. With arterial embolism, the
affected tissue is highly susceptible to injury. Protect
Vascular Disorders CHAPTER 36
the limb from pressure, trauma, and extreme heat or
cold. Edematous tissue is equally susceptible to injury
and must be protected.!
Inability to manage self-care. Patient teaching enables
the patient to participate in the plan of care during and
after hospitalization. For information on teaching interventions for patients, see the Patient Teaching box.
Patient Teaching
Arterial Embolism
• Protect affected limbs from pressure, trauma, and
temperature extremes.
• Exercise to improve blood flow; gradually increase
activity as you are able to tolerate it.
• Report pain, numbness, coolness, and pale or bluish
skin color to your health care provider.
!
CHRONIC VENOUS INSUFFICIENCY
PATHOPHYSIOLOGY
Venous insufficiency is a condition in which the veins
have difficulty sending blood from the extremities back
to the heart. For example, valves in leg veins normally
keep blood moving forward toward the heart. With
chronic venous insufficiency, the walls and valves inside the veins are weakened. This causes the veins to
stay filled with blood, especially when standing.
Elevated venous pressure causes edema, primarily
around the ankles. Red blood cells (RBCs) seep into the
tissues and combine with metabolic wastes to impart a
brownish color, called stasis dermatitis, around the ankles. Ulcers may form because of the pressure exerted
by edema or as a result of trauma. The ulcers develop
most often on the medial malleolus (the prominent
bone on the inner aspect of the ankle). Because of the
poor circulation, the ulcers are very resistant to healing
and susceptible to infection. Some ulcers eventually
necessitate amputation (Fig. 36.3).!
RISK FACTORS
Risk factors for venous insufficiency include age, family history, female gender, history of deep vein DVT in
Fig. 36.3 Venous leg ulcer. (From Kamal A, Brockelhurst JC: Colour
atlas of geriatric medicine, ed 2, Europe, 2017, Mosby-Year Book.)
707
the legs, obesity, pregnancy, sitting or standing for long
periods, and tall height.!
CLINICAL MANIFESTATIONS
Signs and symptoms of chronic venous insufficiency
include edema around the lower legs, pain, leg cramps,
brownish skin discoloration (stasis dermatitis), and
stasis ulcerations. Patients often describe pain as heaviness or dull ache in the calf or thigh. Discomfort becomes worse when standing and is relieved when the
legs are raised. The skin temperature is cool, and nails
are normal. Peripheral pulses are present but may be
difficult to palpate because of the edema. The feet and
ankles often are cyanotic when in a dependent position.!
MEDICAL DIAGNOSIS
The physical examination provides evidence of chronic venous insufficiency. The diagnosis usually is made
based on the appearance of the leg and leg veins when
standing. Noninvasive screening called duplex ultrasound may be done to check how the blood flows in
the veins and to confirm the diagnosis of chronic venous insufficiency or to assess its severity. A culture
may be ordered to determine the infectious agent if a
stasis ulcer has formed and is draining.!
MEDICAL AND SURGICAL TREATMENT
Self-care steps to help manage venous insufficiency
include avoiding standing or sitting for long periods,
losing weight if overweight, and exercising regularly.
The medical management of stasis ulcerations is
constantly changing; however, compression, which
promotes venous return, remains the key to healing
existing ulcers and preventing new ones. Among the
many options are elastic or compression stockings and
pneumatic compression devices. However, high-pressure compression is contraindicated if the patient’s arterial blood flow is poor.
Endovenous laser ablation and radiofrequency ablation are both minimally invasive procedures that can
be done in an office or clinic. A tube (catheter) puts
heat directly into an affected vein. This closes the vein
so less blood pools in the leg. Overall blood flow is
improved.
If the patient has an ulcer, treatment typically includes special dressings along with compression.
Topical debriding agents may be used to prepare a
clean wound bed. Dressings that maintain a moist
environment are believed to be superior to dry dressings. However, evidence supporting one type of
dressing over another is limited. A wound, ostomy,
continence nurse (WOC nurse) can advise on the most
current effective treatment for a specific situation.
Infected ulcers are treated with systemic antibiotics,
which are more effective than topical ointments. Skin
grafting or surgical closure of the ulcer along with removal of the associated varicose veins is sometimes
done. Hyperbaric O2 therapy may be prescribed to
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UNIT IX Cardiovascular System
promote healing of the ulcer by reducing capillary
pressure and hyperoxygenating the blood. The overall goal for medical management of ulcerations is to
preserve the extremity by stimulating granulation tissue in the ulcer.!
every 4 to 6 months. The patient should avoid standing
still, crossing the legs, and wearing restrictive clothing, especially socks or hose with tight, narrow bands.
When sitting, encourage the patient to exercise the feet,
ankles, and knees to promote venous return.!
NURSING CARE OF THE PATIENT WITH CHRONIC
VENOUS INSUFFICIENCY
Altered self-concept. Encourage the patient to share
Focused Assessment
The general assessment of peripheral vascular status is summarized in Chapter 33, Box 33.2. When
the patient has chronic venous insufficiency, inspect
the lower extremities for rubor and stasis dermatitis,
palpate skin temperature, evaluate edema, and determine the presence of pain in the affected extremity
(see Nursing Care Plan: Patient With a Venous Stasis
Ulcer).
Potential for infection. Carefully monitor for signs of
Patient Problems, Goals, and Outcome Criteria:
Chronic Venous Insufficiency
Patient Problems
Goals and Outcome
Criteria
Inadequate peripheral
tissue perfusion related
to reduced vascular
circulation
Improved peripheral
circulation and venous
return: absence of
edema and lesions,
improved skin color
Altered self-concept related Patient adapts to changes
to chronic, open stasis
in appearance: patient
ulcerations
expresses concerns
about changes, makes
effort to maintain or
improve appearance
Potential for infection
Decreased risk for
related to compromised
infection: healed ulcer,
circulation and impaired
intact skin.
skin integrity
Absence of infection:
normal body
temperature, absence
of local redness or
drainage
Disrupted skin tissue
Restored skin integrity:
integrity related to
skin intact in affected
stasis dermatitis and
areas
ulcerations
!Interventions
Inadequate peripheral tissue perfusion. To improve circulation in areas of compromised vascular function, the
patient should elevate the legs when sitting and wear
compression stockings. Stocking size is determined by
patient leg measurements. The patient should put on
the stockings before rising. The toe opening should be
under the toes and the heel section in place. The thigh
gusset should be on the inner thigh. The stocking must
be smooth and not allowed to roll down at the top. The
stocking should be removed for 10 to 20 minutes for
bathing and skin care. Stockings should be replaced
feelings about body image changes and be accepting
and supportive. Encourage the patient to pay attention
to grooming; they may prefer clothing that conceals
stockings or dressings.!
infection such as elevated temperature; chills; general malaise; and localized redness, pain, and purulent
drainage. Teach the patient thorough hand washing,
good hygiene, and appropriate wound care. The fragile edematous tissue must also be protected from trauma to avoid creating portals for pathogens.!
Disrupted skin tissue integrity. Inspect for dermatitis
and ulcerations, especially in the ankle area. Apply a
moisturizer to dry, intact skin. Patient education is critical because these ulcerations are frequently treated on
an outpatient basis. Instruct the patient and family in
the management of the ulcerations while in the home
setting. A referral for home health care and wound care
may be appropriate.!
Prognosis. Chronic venous insufficiency tends to get
worse over time. It can be managed if treatment is
started in the early stages. By taking self-care steps, the
condition can be stabilized and most likely prevented
from getting worse. If there is an increase in swelling,
fever, redness or leg sores, a vascular surgeon should
be consulted.!
VENOUS THROMBOSIS
PATHOPHYSIOLOGY
A variety of terms are used to describe inflammation
and thrombus formation in the veins. Phlebitis is inflammation of a superficial vein. When a thrombus
forms in the presence of phlebitis, the condition is
called venous thrombosis. Depending on the depth
of the affected veins, venous thrombosis is labeled
superficial vein thrombosis (SVT) or DVT. The superficial vein that is most often the site of thrombus formation is the saphenous vein. The deep veins commonly involved are the femoral, popliteal, and small
calf veins. Venous thromboembolism (VTE) is a clot that
moves. VTE includes both SVT and DVT. Research
has identified three factors (called Virchow’s triad) that
contribute to venous thrombus formation: (1) stasis
of the blood, (2) damage to the vessel walls, and (3)
hypercoagulability (increased tendency of blood to
clot). A grave complication of DVT is a pulmonary
embolism.!
Vascular Disorders CHAPTER 36
RISK FACTORS
Some of the factors that place a person at risk for the
development of thrombi are:
• Recent hospitalization and/or surgery
• Prescribed bed rest or extended travel
• Older age
• Leg trauma resulting in immobilization from casts
or traction
• Family history of VTE
• Previous venous insufficiency
• Obesity
• Use of oral contraceptives or hormone replacement
therapy
• Recent or recurring cancer
• During and just after pregnancy!
CLINICAL MANIFESTATIONS
The signs and symptoms of venous thrombosis vary
with the size and location of the thrombus, the amount
of obstruction, the collateral circulation, and the existence of other medical problems. SVT is characterized
by a vein that feels firm and cordlike when palpated.
The area around the vein may be warm, red, and tender. When obstruction occurs in a deep vein, the affected extremity may be edematous and painful with
warmth and tenderness at the area of compromise.
The patient may have a mild elevation in systemic
temperature.
Table 36.1 compares features of arterial and venous
disease.!
MEDICAL DIAGNOSIS
The primary diagnostic examinations used in the detection of venous thrombi are venography, Doppler
ultrasonography, duplex ultrasonography, and MRI. A
D-dimer blood test measures a substance in the blood
that is released when a clot breaks up. These tests are
instrumental in the confirmation of the disease process
and determination of the treatment plan. A ventilationperfusion lung scan, pulmonary angiogram, spiral CT
scan or MRI may be done if pulmonary embolism is
suspected. See Chapter 33, Table 33.3.!
MEDICAL AND SURGICAL TREATMENT
The goals of treatment are to prevent thrombus extension and pulmonary emboli, to reduce the risk of further thrombus formation, and to reduce discomfort.
Anticoagulant or thrombolytic therapy (or both) is
begun promptly after diagnosis. When anticoagulants
cannot be used, a filter can be inserted inside the vena
cava to trap the embolus before it reaches the lungs.
A treatment plan typically includes patient teaching about the disease; ongoing assessment for pulmonary emboli; bed rest; elevation of the extremity;
warm, moist soaks to the affected area; and compression stockings. Ambulation is initiated after the acute
phase. Surgery to remove the clot may be considered
when the patient cannot receive anticoagulants or
709
thrombolytic therapy or when the possibility of a pulmonary embolus is high.
NURSING CARE
Focused Assessment
Assessment of the patient with PVD is summarized in
Chapter 33, Box 33.2.
Patient Problems, Goals, and Outcome Criteria:
Venous Thrombosis
Patient Problems
Disrupted skin integrity
related to venous stasis
Pain related to impaired
circulation and tissue
ischemia
Anxiety related to
hospitalization and
uncertainty of disease
process
Activity intolerance related
to leg pain or swelling
Inadequate peripheral
tissue perfusion related
to impaired peripheral
circulation
Inadequate pulmonary
oxygenation related to
pulmonary embolus
Ineffective self-care
management related to
the developing disease
process, treatment, selfcare
Goals and Outcome
Criteria
Intact skin: absence of
redness, rash, pallor,
lesions
Pain relief: patient
verbalizes pain relief,
relaxed manner
Reduced anxiety: patient
states that anxiety is
reduced, calm manner
Improved ability to
tolerate activity:
increasing activity
without pain
Adequate tissue perfusion:
pulses present and
symmetric, normal skin
color and warmth
Normal oxygenation:
respiratory rate consistent
with patient norms, no
dyspnea or chest pain
Patient adheres to
prescribed plan of care:
correctly describes and
demonstrates selfmedication, exercises,
and precautions
Pain. The patient’s pain must be reduced before activ-
ity tolerance can improve. Administer analgesics as
prescribed and implement other prescribed comfort
measures such as warm, moist soaks, and elevation of
the extremity. Massage is contraindicated because it
may dislodge a thrombus resulting in an embolus that
can obstruct blood flow.!
Anxiety. Anxiety may be related to lack of knowledge
about the disease and its treatment as well as concerns about the effects of the condition on employment, activities of daily living (ADLs), and quality of
life. Patients worry about when and if another blood
clot could form and they feel a lack of control. Blood
clots are life-changing and traumatic. The patient may
even restrict activities out of fear. Many patients say
that time is the most critical factor in emotional healing. It is important to talk to people who understand.
UNIT IX Cardiovascular System
710
Table 36.1
Comparison of Arterial and Venous Disease in the Legs
CHARACTERISTIC
Peripheral pulses
PERIPHERAL ARTERY DISEASE
Decreased or absent
VENOUS DISEASE
Present; may be difficult to palpate with edema
Capillary refill
>3 seconds
<3 seconds
Edema
Absent unless leg constantly in dependent
position
Lower leg edema
Hair
Loss of hair on legs, feet, toes
Hair may be present or absent
Skin color
Dark reddish color when in dependent position;
pale when elevated
Bronze-brown pigmentation; varicose veins may
be visible
Skin texture
Thin, shiny, taut
Thick, hardened, indurated
Skin temperature
Cool, temperature gradient down the leg
Warm, no temperature gradient
Pain
Intermittent claudication or rest pain in foot;
ulcer may or may not be painful
Dull ache, heaviness in calf or thigh; ulcer often
painful
Ulcers
Location: tips of toes, foot, lateral malleolus
Margins: round, smooth
Drainage: minimal
Color: black or pale pink
Location: near medial malleolus
Margins: irregular
Drainage: moderate to large amount
Color: yellow or dark red
Dermatitis and pruritus
Rare
Frequent
Modified from Lewis SM, Bucher L, Heitkemper MM: Medical-surgical nursing: assessment and management of clinical problems, ed 10, St. Louis, 2017, Elsevier-Mosby.
There are private Facebook groups online. The relief
of anxiety can help the patient to move toward an acceptable level of activity and improved quality of life.
Understanding the symptoms that need attention immediately (such as shortness of breath, unable to lie
flat, and leg pain that inhibits walking) is important
to allay fears of unrelated symptoms. Journaling is a
helpful tool to clarify timing and severity of symptoms
at doctor visits.
Patient Teaching
Venous Thrombosis
•
•
•
•
Protect your legs from pressure and trauma.
Elevate your legs when sitting to improve circulation.
Do not massage or rub affected areas.
Gradually increase your activity; slow down or stop if you
have pain during activity.
• Avoid prolonged standing and crossing your legs.
• Notify your physician if you have any chest pain or
shortness of breath.
!
Inadequate peripheral tissue perfusion. Improved pe-
ripheral circulation aids in tissue perfusion, which decreases pain, improves skin integrity, reduces anxiety,
and increases physical activity. Administer prescribed
anticoagulants or platelet aggregation inhibitors to prevent new clots or administer thrombolytics to dissolve
existing clots and reestablish blood flow to the affected
area. Check blood test results before giving anticoagulants and take action according to agency policy. Apply
warm, moist packs to the affected area as ordered to
improve circulation and assist the patient in the placement of antiembolism hose, if prescribed, to prevent
stasis and improve circulation. Explain to the patient
how stress reduction and smoking cessation can improve tissue perfusion by reducing vasoconstriction.!
Inadequate pulmonary oxygenation. The possibility
of a pulmonary embolus developing during the treatment of venous thrombosis is ever present. When an
embolus lodges in the lung, the affected blood vessels
can no longer exchange gases. Pressure builds in vessels behind the embolus. Symptoms of pulmonary embolism depend on the amount of tissue affected. Small
emboli may produce no symptoms. Larger emboli can
cause dyspnea, chest pain, tachycardia, cough, fever,
anxiety, and a change in mental status. A massive embolus can cause heart failure and shock. Sixty percent
of people do not survive massive emboli.
To improve oxygenation when a patient has a pulmonary embolism, elevate the head of the bed to a
45-degree angle and administer O2 as ordered. It is
also vital to monitor and document any changes in the
patient’s respiratory pattern, address anxiety, teach
the patient deep-breathing and coughing techniques,
and assist with position changes every 2 hours.
Administer drugs as ordered to dissolve existing clots
and prevent future clots. Surgical removal of the clot,
called pulmonary embolectomy, is sometimes indicated. Additional discussion of pulmonary embolism is
found in Chapter 27.!
Inadequate self-care. To follow the long-term plan of
care, the patient must understand the condition and
how it can best be managed. Once the acute process
has resolved, discharge planning must include patient
teaching as outlined. In addition, for more on the care
of a patient with venous thrombosis, see the Patient
Teaching box.!
Vascular Disorders CHAPTER 36
MEDICAL AND SURGICAL TREATMENT
VARICOSE VEIN DISEASE
PATHOPHYSIOLOGY
Varicose veins are referred to as varicosities. Varicosities
are dilated, tortuous, superficial veins—often the saphenous veins in the lower extremities. The dilation
of the vessels results from incompetent valves in the
veins; that is, the valves cannot prevent backflow of
blood. Vein incompetence is a result of hereditary
weakness made worse by aging, pregnancy, obesity,
occupations requiring prolonged standing, or a combination of these. Restrictive clothing aggravates the
condition. Varicose veins are classified as primary (only
superficial veins are affected) and secondary (characterized by deep vein obstruction). In addition to peripheral veins, varicosities can occur in other areas such as
the esophageal and hemorrhoidal veins. Incompetent
valves cannot be repaired.!
CLINICAL MANIFESTATIONS
The onset of varicose vein disease is gradual, but
the condition is progressive. When only the superficial veins are involved, the signs and symptoms
are minimal except for the cosmetic changes that
occur. The dilated veins are seen as oversized, discolored (purplish), and tortuous. Symptoms typically include dull aching sensations when standing
or walking; a feeling of heaviness in the affected
legs; muscle cramps, especially at night; increased
muscular fatigue in the affected area; and ankle
edema. Over time, some people develop postphlebitic syndrome, which is evidenced by persistent
edema, brownish skin discoloration, and ulcers
most commonly on the inner aspect of the ankle
(Fig. 36.4).!
A
711
B
Fig. 36.4 (A) Lateral aspect of varicose veins before treatment. (B)
Lateral aspect of varicose veins 2 years after initial treatment with
sclerotherapy. (From Goldman MP, Guex JJ, Weiss RA: Sclerotherapy
treatment of varicose and telangiectatic leg veins, ed 5, Philadelphia,
2011, Mosby.)
Conservative treatments of varicosities are used
whenever possible. Advise the patient to avoid
restrictive garments, prolonged standing or sitting, crossing the legs or knees, and injury to the
compromised areas. If the patient is obese, explain
that weight reduction usually reduces pressure on
the lower extremities. Support stockings are often
ordered, although research on the benefits of this
therapy has not consistently shown value. If the
physician recommends support stockings, help
the patient to learn how to put them on correctly.
Compression stockings squeeze the legs, helping veins and muscles move the blood toward the
heart more efficiently. (see the Complementary and
Alternative Therapies box).
Complementary and Alternative Therapies
Horse chestnut can improve the tone of the veins, making them less permeable and less fragile. Blood flow is increased, and edema is reduced. Feelings of pain, tiredness
and heaviness also may be alleviated.
Sclerotherapy (injection of a foam into the vein
causing closure of the vein), or laser therapy (sending strong bursts of light into the vein, causing the
vein to slowly disappear) may be effective in the
treatment of superficial varicosities. Surgery may
be recommended for cosmetic reasons or if stasis ulcers develop. The surgical procedure that removes
large, dilated veins is called ligation and stripping. It
requires several incisions along the course of the affected vein. For some patients, a simpler procedure
is possible in which the saphenous vein is ligated
(tied shut) at the groin, requiring only one incision.
Endovenous ablation uses a catheter that is threaded
into the vein. The catheter emits energy that causes
the vein to collapse. The vein is removed through a
small incision.!
NURSING CARE OF THE PATIENT WITH
VARICOSE VEIN DISEASE
Focused Assessment
When a patient has varicose veins, the health history determines the presence of pain, edema, cramps,
and muscle fatigue. Note a family history of varicose
veins and document the patient’s occupation and
usual activities. When taking a pain and discomfort history, determine what measures the patient
has used for pain control. The physical examination
focuses on inspection of the legs for color, edema,
turgor, and capillary refill. Palpate the legs for tenderness. Postoperative assessment is especially concerned with monitoring peripheral circulation and
tissue perfusion.
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UNIT IX Cardiovascular System
Patient Problems, Goals, and Outcome Criteria: Varicose Veins
Patient Problems
Chronic pain related to
engorgement of the veins
Activity intolerance related
to feelings of heaviness
and fatigue
Inability to manage
self-care related to
management of the
varicosities
THROMBOANGIITIS OBLITERANS
Goals and Outcome
Criteria
Reduced pain: patient
states that pain with
activity has decreased
Improved ability to
tolerate activity: patient
reports gradual increase
in activity with less
discomfort
Patient carries out
appropriate self-care:
patient correctly
verbalizes and
demonstrates self-care
!
Interventions
The primary nursing role in the care of the patient with varicose veins is teaching self-care.
Interventions to improve activity tolerance and to
manage pain are outlined in the Patient Teaching box.
In general, measures that improve venous return also
decrease pain.
For the surgical patient, patient teaching is also
of paramount importance because the procedure
is usually done as a same-day surgical procedure.
While the patient is still in the surgical suite, pressure bandages are placed on the extremities. The
surgeon orders specific aspects of postoperative
care, such as when the pressure bandages should
be removed, what types of stockings are recommended afterward, and how long they should be
worn. Activity restrictions and positioning of the
legs (usually 15–30 degrees for the first 24 hours)
are also ordered at this time. Serious complications
are rare; however, bleeding is most likely to occur
in the groin area, so the dressing in that area should
be monitored. After sclerotherapy or laser therapy,
both of which are outpatient procedures, the patient
is advised to wear compression stockings for as long
as 6 weeks.
Patient Teaching
Varicose Veins
• Exercise regularly to promote circulation.
• Avoid prolonged standing, sitting, and crossing your
legs.
• Avoid restrictive clothing.
• Elevate extremities whenever possible.
• Obesity contributes to the development of varicose
veins. People who are overweight usually see
improvement with weight loss.
• Nonprescription analgesics and frequent position
changes usually control pain.
• Wear support hose if recommended by your physician.
Thromboangiitis obliterans (TO), also called Buerger
disease, is an inflammatory thrombotic disorder rather
than an atherosclerotic process. The exact cause is unknown, but it occurs only in smokers (see the Cultural
Considerations box). Small blood vessels become inflamed and swollen. The blood vessels then narrow
and are blocked by blood clots (thrombosis). Blood
vessels of hands and feet are affected. Arteries are more
affected than veins. Average age when symptoms begin is around 35. Young men who smoke heavily or
chew tobacco are most often affected. Many people
who are afflicted by this condition have poor dental
health. Bacteria may be a contributing factor. Signs and
symptoms may include intermittent claudication, rest
pain, fingers and toes appear pale, red, or bluish and
feel cold to the touch, cold sensitivity, severe pain often
described as burning or tingling, abnormal sensation,
ulceration, and gangrene. Diagnosis is based on a history of young age at onset, physical findings, and arteriography. There are no blood tests that diagnose TO.
Cultural Considerations
What Does Culture Have to Do With Buerger Disease?
Buerger disease affects more people in the Middle East,
Asia, the Mediterranean, and Eastern Europe. It is relatively
uncommon in the United States. When assessing patients,
especially those of Indian, Korean, or Japanese heritage, be
alert for related signs and symptoms.
There is no cure for TO. The most important aspect
of treatment is smoking cessation. Palliative treatments
include sympathectomy (surgery to cut the nerves to
the area to control pain), spinal cord stimulation, analgesics for pain, vasodilators, and antibiotics if infected. The prostaglandin iloprost (Ventavist) has shown
some benefit in European studies. Gene therapy is
under study. Ulcers may respond to treatment with
vascular endothelial growth factor. If gangrene develops (most commonly below the knee), amputation is
the only treatment option. Forty percent of patients
who continue tobacco use eventually require amputations. Nursing care is similar to that of patients with
PAD. Emphasis is on smoking cessation measures (see
Chapter 28) and protection of the affected extremities.!
RAYNAUD DISEASE
!
PATHOPHYSIOLOGY
Primary and secondary Raynaud phenomena are
forms of an intermittent constriction of arterioles that
affects the hands primarily, although it can affect the
toes and tip of the nose. Increased or unusual sensations of coldness, pain, and pallor reflect temporary
constriction of the arterioles.
Vascular Disorders CHAPTER 36
The first step toward understanding Raynaud disease is determining whether it is primary or secondary.
Primary Raynaud phenomenon has no known cause,
but is more common in women, especially during winter months. The condition generally is not as severe as
secondary Raynaud phenomenon, but it can be very
frustrating.
Secondary Raynaud phenomenon occurs from an
underlying cause such as connective tissue disease that
affects blood flow to tissues and organs. The most common diseases causing secondary Raynaud phenomenon include lupus, Sjogren syndrome (dryness of the
eyes and mouth), scleroderma (hardening of skin and
tissues) and rheumatoid arthritis. Blood pressure, migraine, cancer medications and birth control pills can
also be the cause. Sometimes, people who work with
vibrating tools or are around certain chemicals are at
risk of acquiring this disorder. Additionally, smokers
have an increased risk of Raynaud disease. Gangrene is
not common but can develop in the skin on the tips of
the digits. The term primary Raynaud phenomenon is synonymous with Raynaud disease; secondary Raynaud
phenomenon is called simply Raynaud phenomenon.!
CLINICAL MANIFESTATIONS
The cardinal signs and symptoms of Raynaud disease are chronically cold hands, numbness, tingling,
and pallor. Finger involvement is not symmetric and
the thumb is not usually affected. During an arterial
spasm, the skin color changes from pallor to cyanosis
to redness. Pallor is the result of sudden vasoconstriction. Cyanosis reflects inadequate oxygenation. As the
spasm resolves, vasodilation allows blood flow to return, which produces a red color (Fig. 36.5).!
MEDICAL AND SURGICAL TREATMENT
The goals of the medical treatment plan for Raynaud
disease are to prevent pain and to promote vasodilation in the extremities (see the Complementary and
Alternative Therapies box). The most commonly used
drugs are calcium-channel blockers or alpha-adrenergic blockers. Other drugs that have been used include
transdermal nitroglycerin, an endothelin receptor antagonist (bosentan), phosphodiesterase inhibitors (e.g.,
sildenafil), and intravenous prostaglandins (e.g., iloprost, alprostadil). In severe cases, the physician may
resort to sympathectomy to interrupt the sympathetic
nerves. This surgical procedure aids some patients
but tends to have temporary effects and is not used
routinely.
Complementary and Alternative Therapies
Biofeedback is sometimes helpful in controlling vasospastic
episodes with Raynaud disease.
Patient Problems, Goals, and Outcome Criteria: Raynaud
Disease
Patient Problems
Chronic pain related to the
ischemia that develops
from vasoconstriction
Inadequate peripheral
tissue perfusion related
to vasoconstriction
!
Colour atlas of geriatric medicine, ed 2, Europe, 2017, Mosby-Year
Book.)
!
NURSING CARE OF THE PATIENT WITH
RAYNAUD DISEASE
Focused Assessment
Assessment of the patient with PVD is summarized in
Chapter 33, Box 33.1. With Raynaud disease, assessment of the hands is the priority.
MEDICAL DIAGNOSIS
The diagnosis of Raynaud disease is usually based on
the signs and symptoms and on the absence of evidence of occlusive vascular disease. There is no specific blood test to identify Raynaud disease, but a health
care provider may order other tests to rule out connective tissue diseases as mentioned above.!
Fig. 36.5 Raynaud phenomenon. (From Kamal A, Brockelhurst JC:
713
Stress related to fear of
potential loss of work,
difficulty performing
activities of daily living
(ADL)
Goals and Outcome
Criteria
Reduced pain: patient
states that pain has
decreased, appears
relaxed
Improved perfusion
of peripheral tissue:
improved warmth and
color of affected areas
Relief from stress: patient
states stress is reduced,
appears more relaxed
Interventions
Chronic pain and inadequate peripheral tissue perfusion. Nursing interventions to reduce pain and improve tissue perfusion focus on teaching the patient to
avoid the stimuli that cause the vasoconstriction: exposure to cold, smoking, and excessive stress. Encourage
the patient to take part in a smoking cessation program and to dress warmly when going outside in cold
weather. Wear thick socks and gloves or mittens (mittens are better than gloves for maintaining warmth).
Sometimes the patient can interrupt an acute attack by
714
UNIT IX Cardiovascular System
placing the affected parts in warm water or by using a
hair dryer or hand- and foot-warming devices. In addition to alcohol and caffeine, many over-the-counter
(OTC) cold remedies contain vasoconstrictors that
can aggravate Raynaud phenomenon. Patients should
wear medical alert identification and inform all new
health care providers of their diagnosis so that inappropriate medications will not be prescribed.
Pain can be managed by carefully warming the
area when vasoconstriction occurs. However, the affected areas must be protected from trauma. Hot water
should not be used to warm affected tissue, because
the lack of sensation during the period of vasoconstriction could result in serious burns.!
Stress. Stress can be addressed in much the same man-
ner as anxiety. Attempt to determine the actual cause
of fear, which might be loss of work, loss of limb, or
pain. Accept and explore the patient’s feelings, provide
factual information, encourage problem solving, and
help the patient to learn to live with the condition and
to manage the prescribed therapy.!
ANEURYSMS
PATHOPHYSIOLOGY
An aneurysm is a balloon-like bulge in an artery.
Aortic aneurysms occur in the aorta, the main artery carrying oxygen-rich blood to the body. There
are two types of aneurysms that affect the aorta: abdominal aortic aneurysm (AAA) and thoracic aortic
aneurysms (TAA). Aneurysms can be congenital or
acquired. Conditions associated with congenital aneurysms are Marfan syndrome and Ehlers-Danlos
syndrome. Those affected with Marfan Syndrome are
tall and thin with long arms, legs, fingers, and toes.
Serious complications involve the heart and aorta.
Ehlers-Danlos syndrome, another genetic condition,
affects the joints (overly flexible), the skin (stretchy),
and the capillaries. These genetic conditions cause
abdominal aneurysms and often run in families.
Thoracic aneurysms are less common because the
wall of the aorta in the thoracic (upper) wall is thicker, muscular, and stronger.
Acquired aneurysms can be caused by atherosclerosis, trauma, or infection. The most common cause is
atherosclerosis. Hypertension and high cholesterol are
contributing factors. Atherosclerosis weakens elastic
fibers in the media, which allows a segment of the vessel to balloon outward. Infections, including syphilis,
can also damage the media and result in the formation
of aneurysms. The abdominal aorta is the most common site of aneurysm formation.!
RISK FACTORS
Risk factors include age (most common in adults aged
over 65 years), family history, genes, lifestyle habits
(smoking, using cocaine, or weightlifting), medical
conditions (chronic obstructive pulmonary disease
and other heart related conditions), and male gender.!
CLINICAL MANIFESTATIONS
Generally, symptoms that occur before a rupture depend upon location of the aneurysm and whether it has
become large enough to affect other parts of the body.
People with TAA usually have no symptoms, although
some report deep, diffuse chest pain. If the aneurysm
puts pressure on the recurrent laryngeal nerve, the
patient may complain of hoarseness. Pressure on the
coronary arteries can cause angina and pressure on
the esophagus may cause dysphagia (difficulty swallowing). If the superior vena cava is compressed, the
patient may have edema of the head and arms. Signs
of airway obstruction may be present if the aneurysm
presses against pulmonary structures.
AAA is usually detected during routine physical
examinations or diagnostic procedures. The aneurysm may be palpated as a pulsating mass in the area
slightly to the left of the umbilicus. Although most
abdominal aneurysms are asymptomatic, pressure on
abdominal organs and nerves may cause back pain,
epigastric pain, or constipation.!
COMPLICATIONS
Complications of aneurysms include rupture, thrombus formation that obstructs blood flow, emboli, and
pressure on surrounding structures.!
MEDICAL DIAGNOSIS
Certain groups of people should be screened for aneurysm, especially those 65 to 75 years old with a history
of smoking and those who have a family member who
has had an aneurysm. An aneurysm can develop and
grow without any symptoms until it ruptures or dissects—both life-threatening events. If the aneurysm is
found early, treatment or surgery may slow its growth
and prevent rupture or dissection.
Diagnosis is made on the basis of physical findings and radiologic studies. Studies performed to
obtain better visualization of the aneurysm include
echocardiography, ultrasonography, computed tomography (CT), MRI, and aortography ( see Chapter
33, Table 33.3).!
MEDICAL AND SURGICAL TREATMENT
Repair of aneurysms may be done by replacing the dilated segment of the artery with a synthetic graft or, in
some cases, by suturing or patching the defective area.
For TAA, TEVAR (thoracic endovascular aneurysm
repair) has largely supplanted open repair because it
lowers morbidity and mortality. For the patient with
AAA, endovascular aneurysm repair (EVAR) may be
an option. EVAR places an aortic stent graft in the aneurysm through a femoral artery incision. This minimally
invasive procedure is less risky than open surgical repair. However, not all patients are candidates for EVAR.
Vascular Disorders CHAPTER 36
715
Patient Problems, Goals, and Outcome Criteria:
Aortic Aneurysm Repair
In addition to the routine problems of the postoperative
patient (see Chapter 17), patient problems for the patient
who has had an aortic aneurysm repair may include the
following.
Patient Problems
A
Impaired urinary
elimination related to
interrupted blood flow
B
C
Fig. 36.6 Surgical repair of an abdominal aortic aneurysm. (A) Incising
the aneurysmal sac. (B) Insertion of synthetic graft. (C) Suturing native
aortic wall over synthetic graft. (From Lewis LL, et al.: Medical-surgical
nursing, ed 10, 2017, Elsevier.)
Repair is usually done as soon as possible but may be
delayed until the patient is evaluated for other problems that increase surgical risk (Fig. 36.6).
Decisions to attempt repair of aneurysms are
based on the size of the defect and the patient’s general status. For example, an AAA smaller than 5 cm
is usually monitored with periodic ultrasound studies. If it begins to enlarge, surgical repair may be
recommended.
Complications of AAA surgery vary with the location of the defect. Complications of AAA surgery include myocardial infarction, sexual dysfunction, renal
failure, emboli, spinal cord ischemia with paralysis,
bowel and bladder incontinence, and impaired sensation. Although EVAR is generally safer, complications
can include graft leakage, stent migration, aneurysm
rupture, bleeding, and infection.
Because surgical repair of aneurysms is high risk
for the patient, research is taking place to better understand AAA pathogenesis and also to lead the development of medical therapies, such as drug-based and
cell-based strategies. Aneurysms are caused in part
by inflammation. Currently, no drug therapy is available for AAA. A clinical need exists to develop medical
therapies that limit or prevent the progressive expansion and rupturing of the aneurysm.!
PREOPERATIVE AND POSTOPERATIVE NURSING
CARE OF THE PATIENT WITH AN ANEURYSM
When surgical repair of an aneurysm is planned, the
patient should be prepared physically and emotionally
as described in Chapter 17. Preoperative and postoperative nursing care specifically for cardiovascular patients is described in Chapter 33.
Potential for injury related
to ileus
Inadequate pulmonary
oxygenation because of
poor breathing pattern
related to abdominal
incision or splinting
Decreased cardiac output
related to myocardial
infarction, occlusion
of blood vessels, graft
leakage
Inadequate peripheral
circulation related to
vascular occlusion
Goals and Outcome
Criteria
Normal urinary
function: urine output
approximately equal to
fluid intake
Absence of injury related
to ileus: wound margins
intact, no abdominal
distention, bowel
sounds present
Adequate breathing
pattern and
oxygenation: regular
respirations, 12 to 20
breaths per minute; clear
breath sounds
Adequate cardiac output:
pulse and blood
pressure consistent with
patient norms
Normal peripheral
circulation: warm
extremities with palpable
pulses
Interventions
Complications of both types of aortic aneurysm repair
can occur, and they may be life-threatening. Bleeding
and blood loss are the most urgent complications and
may need additional surgery or blood transfusions to
correct and/or stabilize.
Impaired urinary elimination. During repair of an ab-
dominal aneurysm, the aorta is clamped for a period
of time. This poses a risk of renal damage and subsequent renal failure. Thus fluid intake and urine output
are measured hourly at first, then less often if output is
satisfactory. Declining urine output must be reported
promptly to the physician. In addition to daily weights,
blood urea nitrogen (BUN), creatinine, and electrolyte
levels are usually measured daily to detect increases
associated with renal failure. Because fluid retention or
circulatory obstruction may cause edema, its presence
should be noted. Intravenous fluids should be administered as ordered.!
Potential for injury. After abdominal surgery, peristalsis
ceases temporarily. A nasogastric tube may be inserted
and attached to suction to prevent gaseous distention
of the bowel, which is uncomfortable and places stress
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UNIT IX Cardiovascular System
on the abdominal incision. Ensure that the suction is
working properly and monitor for distention and the
return of bowel sounds.!
Inadequate pulmonary oxygenation. Whether the pa-
tient has an abdominal or a thoracic incision, a risk
of poor lung expansion exists. After thoracic surgery,
patients are at especially high risk for atelectasis and
pneumonia. Mechanical ventilation in the immediate
postoperative period maintains adequate ventilation
until the patient is able to breathe effectively. Thereafter
assist the patient to turn, deep breathe, and cough frequently. An incentive spirometer may be used to encourage lung expansion. It is important to support the
patient’s incision during the breathing exercises. Pain
control measures include patient-controlled analgesia
(PCA), an epidural catheter, as needed (PRN) parenteral analgesics, and other measures as appropriate. The
patient can breathe more effectively if good pain relief
is achieved. Monitor lung sounds frequently to assess
for abnormalities.!
Decreased cardiac output. Cardiac output may fall as a
result of myocardial infarction, cardiac dysrhythmias,
heart failure, or hemorrhage. Hemorrhage may occur
in the incision or by separation of the graft. Closely
monitor the patient’s vital signs and hemodynamics.
In addition, inspect wound dressing and drains for increasing bleeding. Early signs of circulatory failure are
restlessness and tachycardia. Later signs are hypotension, cyanosis, and decreased alertness. Immediately
notify the physician if evidence of decreasing cardiac
output is seen.!
Inadequate peripheral circulation. A risk of impaired
blood flow below the level of the repaired aneurysm
exists. Monitor peripheral pulses and the color and
warmth of the extremities. This assessment is especially important when a patient has had a femoral or
popliteal aneurysm repair. Signs and symptoms of occlusion include pain, pallor or cyanosis, and coldness
distal to the repair. If these manifestations occur, they
must be reported to the physician at once.!
AORTIC DISSECTION
Aortic dissection is different from an aneurysm. The
aorta wall is three layers thick. When the inner layer
(called the intima) tears, blood can move between the
middle and inner layer of the artery wall and dissect
(separate). Blood accumulates between the layers, possibly causing the media to split lengthwise. The split
may extend up and down the aorta, where it can occlude major arteries. Fig. 36.7 compares the various
types of aortic aneurysms with an aortic dissection.
People at highest risk of an aortic dissection are
males and individuals 60 to 70 years old. Precipitating
factors include aortic disease, atherosclerosis, trauma,
Artery
A
Fusiform area
Artery
Sacculated area
B
Ruptured area
Clot
Blood flow
C
Torn intima
D
Blood flow
Fig. 36.7 (A) True fusiform abdominal aortic aneurysm. (B) True
saccular aortic aneurysm. (C) False aneurysm or pseudoaneurysm.
(D) Aortic dissection. (From Lewis LL, et al.: Medical-surgical nursing,
ed 10, 2017, Elsevier.)
tobacco, cocaine or methamphetamine use, congenital
heart disease, connective tissue disorders, family history, history of heart surgery, pregnancy, and poorly
controlled hypertension.
Aortic dissections are classified in two ways:
• Type A: The most common and the most dangerous
dissection occurs as the aorta descends from the heart.
• Type B: This type of dissection occurs in the lower
part of the aorta toward the abdomen
Most patients with Type A aortic dissection experience an abrupt onset of excruciating anterior chest
pain, whereas patients with Type B usually experience pain in the back, abdomen or legs. The location
of the pain in both types may overlap, and the pain
is often characterized as “sharp,” “tearing,” “ripping,”
or “stabbing.” Older people are less likely to have an
abrupt onset of chest or back pain, and instead may
have hypotension and vague symptoms.
The risk of life-threatening complications (e.g., rupture, stroke) is much greater when the ascending aorta
is involved than when only the descending aorta is affected. If no complications occur, the patient may be
managed with antihypertensive agents and drugs that
decrease the strength of cardiac contraction. Surgery
is generally recommended for an acute Type A dissection, and it is considered a surgical emergency. The affected area containing the intimal tear is replaced with
a synthetic graft. The death rate and incidence of neurological complications are high. Preoperatively, the
patient should be kept in a semi-Fowler’s position in a
quiet environment to maintain their blood pressure and
Vascular Disorders CHAPTER 36
heart rate at the lowest safe level possible. Opioids and
sedatives should be given as ordered to minimize pain
and anxiety. Monitor vital signs frequently and look for
changes in peripheral pulses as well as signs of increasing pain, restlessness and anxiety. A key aspect of postoperative care is keeping the blood pressure at the lowest
possible level. In other respects, the care is similar to that
of a patient who has had an aortic aneurysm repair.!
LYMPHANGITIS
PATHOPHYSIOLOGY
Lymphangitis is acute inflammation of the lymphatic
channels. The inflammation is the result of an infectious process. Lymphangitis commonly develops after
microorganisms gain entry into the lymphatic vessels
through a skin wound.!
CLINICAL MANIFESTATIONS
The primary characteristic of lymphangitis is enlargement of the lymph nodes along the lymphatic channel. Each node can be palpated along the course of the
channel. The patient complains of node tenderness, a
wound that is not healing, and feeling sick or weak. A
red streak from the infected wound extends up the extremity along the path of the lymphatics, as each node
drains into the lymphatic system and the cardiovascular system. These nodes are located in the groin, the
axilla, and the cervical regions. The infectious material
can localize into an abscess with necrotic, purulent discharge from the area. Lymphangitis can spread to the
blood if left untreated. This life-threatening infection is
called sepsis, fever and inflammation throughout the
body causing a cascade of changes that damage multiple organ systems and sometimes result in death. With
prompt medical treatment, recovery is usually rapid,
and treatment is highly effective.!
MEDICAL DIAGNOSIS
The classic signs and symptoms, supported by wound
culture results, are usually adequate to confirm lymphangitis. Lymphangiography, which uses a contrast
medium for the radiologic visualization of the lymphatic
system, will also provide evidence of lymphangitis.!
MEDICAL AND SURGICAL TREATMENT
Antimicrobials (usually delivered intravenously) often
are used before culture results to treat lymphangitis.
When an abscess develops, the area is incised to drain
the purulent material. Other supportive measures that
may be ordered are rest and elevation of the limb;
warm, wet dressings; and elastic support hose.!
NURSING CARE OF THE PATIENT WITH
LYMPHANGITIS
Focused Assessment
Care of the patient with lymphangitis includes inspection of the skin for open wounds, signs of
717
inflammation (redness, warmth, edema), and presence
of red streaks along the paths of lymphatic channels
(see the Nutrition Considerations box). Palpate the
lymph nodes in the groin and underarm areas for any
enlargements. Report fever or chills.
Nutrition Considerations
1. Edema is frequently treated with a low-sodium diet;
sodium-restricted diets vary from 4 g (least restrictive) to
250 mg (severe sodium restriction) daily.
2. Foods high in sodium include salt, monosodium
glutamate, smoked or processed meats (ham, bacon,
frankfurters, cold cuts), salted foods (potato chips,
pretzels, salted nuts, popcorn), prepackaged frozen
foods, and canned foods.
3. Older adults who take diuretics are generally not
encouraged to restrict sodium intake because they are
at risk for the adverse effects of low sodium.
4. Salt substitutes are a source of potassium, which is
desirable in patients who are receiving potassiumwasting diuretics; however, a health care provider should
approve salt substitutes before they are used.
Patient Problems, Goals, and Outcome Criteria: Lymphangitis
Patient Problems
Pain related to the
inflammatory process in
the lymphatic system
Activity intolerance related
to pain with movement
Potential for injury related
to infection
Goals and Outcome
Criteria
Pain relief: patient
verbalizes less pain,
appears relaxed
Improved activity
tolerance: patient
increases activity
without increased pain
Decreased risk for injury:
protection of affected
tissue
Resolution of infection:
absence of fever, normal
white blood cell count,
decreasing swelling and
pain
!Interventions
Nursing care of the patient with lymphangitis is essentially the same as that for chronic venous insufficiency.
Interventions to relieve pain include administration of the prescribed analgesics and antimicrobials
and elevation of the extremity to reduce lymphedema.
Nonpharmacologic measures should be used in addition to analgesics. The application of warm, moist
soaks to the infected areas as prescribed improves the
circulation to the area. As the circulation is improved,
white blood cells (WBCs), nutrients, and O2 are delivered, which aids in the recovery of the healthy tissue.
Elastic support hose is used for several months after an
acute attack of lymphangitis to prevent the formation
of lymphedema.
718
UNIT IX Cardiovascular System
Nursing Care Plan
Patient With a Venous Stasis Ulcer
FOCUSED ASSESSMENT
Health History
A 75-year-old man is being seen in the community clinic for an ulcer on the medial malleolus of the right ankle. The ulcer
is shallow and measures 1.5 cm × 2.5 cm. He describes a “heavy” burning sensation in the lower legs. He worked for many
years as a tollbooth attendant and has had chronic venous insufficiency for 5 years. He reports having had hypertension in
the past but is taking no medication for it. Otherwise he has been in good health and remains active. He is the caregiver for
his wife, who has been disabled for 3 years because of a stroke. He has a daughter who helps with her care and who has been
dressing his leg ulcer.!
Physical Examination
Vital signs: blood pressure 194/102 mm Hg, pulse 64 beats per minute, respiration 16 breaths per minute, temperature 97°F
(36.1°C) measured orally. Height 5’9”, weight 170 lb. Alert and oriented. Walks with slight limp. 2+ edema, both ankles.
Varicosities noted in both legs. Stasis dermatitis in ankles and calves. Ulcer is 1.5 cm × 2.5 cm and shallow. Ulcer is slightly
moist, pink, with no drainage or odor. Ankles and feet are cooler than calves. Pedal pulses faint but palpable, slightly
stronger in left foot.
Patient Problem
Goals and Outcome Criteria
Interventions
Inadequate peripheral
tissue perfusion related to
compromised circulation
Perfusion of blood and oxygen will
improve, as evidenced by reduced
pain, redness, and edema; skin will
be warm to the touch.
Potential for infection related to
open wound
The patient will remain free of signs
and symptoms of infection: fever,
increasing redness, and purulent
drainage.
Pain related to circulatory
impairment
The patient will report pain relief.
Disrupted skin tissue integrity
related to circulatory
impairment
The patient’s wound will heal
completely.
Ineffective self-care management
related to lack of knowledge of
chronic venous insufficiency
and treatment of stasis ulcer
The patient will correctly explain
chronic venous insufficiency and
demonstrate correct care of the
ulcer.
Ineffective self-care management
related to lack of knowledge
of importance of treating
hypertension
The patient will verbalize
understanding of the need to have
his blood pressure evaluated and
will make an appointment for
evaluation.
Instruct the patient in measures to improve
circulation: exercise moderately each day,
elevate the legs above the level of the
heart when resting, avoid smoking, apply
dressings and compression stockings
as ordered, avoid prolonged periods of
walking or standing still. Teach wound
care as ordered. At each visit, assess the
condition of his ulcer, peripheral pulses,
skin color and warmth, pain, and edema.
Teach hygienic techniques of hand washing
and wound care. Encourage him to choose
a diet with adequate protein and vitamins.
Teach the signs and symptoms of infection
that should be reported to the physician.
Instruct him in antimicrobial therapy if
prescribed.
Encourage the patient to increase movement
and maintain warmth to improve
circulation. Teach pain relief measures
including relaxation, deep-breathing
techniques, cutaneous stimulation, and
behavior modification. Explain the use
of prescribed analgesics. Assess the
effectiveness of pain control measures.
Assess and document the condition of the
ulcer during each clinic visit. Advise the
patient to use gentle soap for bathing, to
avoid trauma, and not to rub the ulcer.
Encourage good nutrition and adequate
fluid intake. Discuss wound care with the
physician or wound, ostomy, continence
(WOC) nurse (specialist in wound care).
Assess the patient’s understanding of his
condition and self-care. Advise him to avoid
restrictive clothing, smoking, and weight
gain. Explore sources of stress and coping
strategies.
Explain the importance of detecting and
treating hypertension. Refer the patient to
the physician or blood pressure clinic for
evaluation.
!CRITICAL THINKING QUESTIONS
1. What data will contribute to the assessment of the effectiveness of pain and infection control techniques?
2. What role does nutrition play in the therapeutic treatment of venous stasis ulcers?
3. What data should you collect related to the condition of the ulcer?
Vascular Disorders CHAPTER 36
719
Get Ready for the NCLEX® Examination!
Key Points
Review Questions for the NCLEX® Examination
• The most dangerous complication of venous thrombosis is
pulmonary embolism.
• An arterial embolus, an unattached clot or other material in
an artery, can lodge in an artery and obstruct blood.
• Nursing care of the patient with an arterial embolus focuses
on inadequate peripheral circulation, stress, skin breakdown,
immobility, and inability to manage treatment program.
• PAD impairs blood flow and may be treated surgically.
• Nursing care of the patient with PAD focuses on inability
to tolerate activity, pain, skin breakdown, altered selfconcept, inadequate peripheral circulation, and inability to
manage treatment program.
• Thromboangiitis obliterans (Buerger disease) is an
inflammatory thrombotic disorder of arteries and veins in
upper and lower extremities of smokers; atherosclerosis is
not a factor.
• Primary and secondary Raynaud phenomena are
characterized by intermittent arteriolar vasoconstriction
that is usually treated with vasodilators.
• An aneurysm is a dilated segment of an artery, most often
the aorta, which can rupture, serve as a site for thrombus
formation, and compress surrounding tissues.
• Aortic dissection results from a tear in the intima that
allows blood to escape into the space between the intima
and the media, which causes the media to split lengthwise.
• Varicose veins are dilated, tortuous, superficial veins
that result from incompetent venous valves; they may
lead to chronic venous insufficiency and are treated with
conservative measures to improve venous return and
sometimes with surgical intervention or laser therapy.
• Phlebitis is inflammation of a vein wall.
• Thrombosis is clot formation and DVT indicates that the
clot is located in deep veins, a condition that poses a high
risk for pulmonary emboli.
• Risk factors for thrombus formation are bed rest, surgery
in people older than 40 years of age, leg trauma and
immobilization, previous venous insufficiency, obesity, oral
contraceptives, and malignancy.
• Nursing care of the patient with venous thrombosis
addresses skin breakdown, pain, anxiety, inability to
tolerate activity, inadequate peripheral circulation,
inadequate oxygenation, and inability to manage treatment
program.
• Chronic venous insufficiency causes edema and stasis
dermatitis around the ankles.
• Lymphangitis is an inflammation of the lymphatic channels
that is treated with antimicrobials, analgesics, heat therapy,
and rest.!
1. Mrs. P. has had an open abdominal aneurysm repair. Her nurse
knows that it is especially important to monitor:
Additional Learning Resources
6. Raynaud disease is characterized by which of the following
signs or symptoms?
SG Go to your Study Guide for additional learning activities
to help you master this chapter content.
Go to your Evolve website (http://evolve.elsevier.com/Linton/
medsurg) for the following learning resources and much more:
• Fluid and Electrolyte Tutorial
• Review Questions for the NCLEX® Examination
1. Reflexes in the lower extremities
2. Intake and output
3. Mental status
4. Electrocardiogram
NCLEX Client Need: Physiological Integrity: Physiological
Adaptation
2. Which of the following is the most serious complication of
venous thrombosis?
1. Pulmonary embolism
2. Stasis dermatitis
3. Ankle ulceration
4. Pitting edema
NCLEX Client Need: Physiological Integrity: Physiological
Adaptation
3. Signs and symptoms of an arterial embolism in the lower
extremities are (select all that apply):
1. Severe, acute pain
2. Hypotension
3. Excessive bleeding
4. Absent distal pulses
NCLEX Client Need: Physiological Integrity: Physiological
Adaptation
4. Because the patient with an acute aortic embolism is usually
immobilized, which actions should be taken by the nurse?
Select all that apply.
1. Perform range of motion exercises
2. Protect the affected limb from extreme heat or cold
3. Raise the affected limb above the level of the heart
4. Keep flat in bed
NCLEX Client Need: Physiological Integrity: Basic Care and
Comfort
5. For a patient with peripheral arterial disease, the nurse would
carry out which of the following actions to help to relieve
pain?
1. Elevate foot of bed
2. Administer opioids as prescribed
3. Use relaxation techniques
4. Keep immobilized
NCLEX Client Need: Physiological Integrity: Basic Care and
Comfort
1. Cold hands
2. Vasodilation
3. Swollen thumb
4. Symmetrical finger involvement
NCLEX Client Need: Physiological Integrity: Physiological
Adaptation
720
UNIT IX Cardiovascular System
7. Which is the most common cause of an acquired aneurysm?
1. Hypertension
2. Atherosclerosis
3. Trauma
4. Infection
11. SLO/Objective: Determine appropriate nursing actions for
patients experiencing postoperative complications.
NGN Item Type: Extended Drag and Drop
Cognitive Skill: Take Action
NCLEX Client Need: Physiological Integrity: Reduction of Risk
Potential
A 68-year-old man was admitted to the ICU from the PACU after
having a repair of an aortic aneurism. He has a history of hypertension and prostatitis and total knee replacement in his right knee.
8. A 60-year-old male has been diagnosed with a venous
thrombosis in his right lower leg. What signs and symptoms
would be expected distal to the obstruction? (Select all that
apply)
Indicate which nursing action listed in the far left column is appropriate for the potential postoperative complications. Note that
not all nursing actions will be used.
1. Absence of peripheral pulses
2. Ankle edema
3. Yellow or dark ulceration
4. Thick hardened skin
NCLEX Client Need: Physiological Integrity: Reduction of Risk
Potential
9. Which of the following is the primary nursing role in the care of
the patient with varicose veins?
1. Teaching self-care
2. Providing a warm environment
3. Encouraging fluids
4. Keeping patient immobilized
NCLEX Client Need: Physiological Integrity: Basic Care and
Comfort
10. Teaching a patient with a venous thrombosis should include:
(Select all that apply)
1 Protect legs from pressure and trauma
2. Elevate legs when sitting
3. Avoid prolonged standing and crossing your legs
4. Massage affected area to alleviate pain
NCLEX Client Need: Health Promotion and Maintenance
NURSING ACTION
POTENTIAL
POSTOPERATIVE
COMPLICATION
1. Assess
peripheral pulses
Renal failure
2. Encourage
the patient to
use an incentive
spirometer
Hemorrhage
3. Measure intake
and output
Pneumonia
4. Monitor
patient’s vital signs
Heart failure
5. Inspect wound
for bleeding
Vascular
occlusion
6. Elevate feet
above heart
7. Keep patient
immobilized
APPROPRIATE
NURSING
ACTION FOR
POSTOPERATIVE
COMPLICATION