COMPETENCY APPRAISAL 2

PERIPHERAL VASCULAR and HEMATOLOGIC DISORDERS

● Types of aneurysm
o : localized outpouching of the artery wall
o : dilation of the entire arterial circumference
o : Blood separates layers of the artery wall; forming a cavity in between them
o False/ Pseudoaneurysm where clot and connective tissue are outside the arterial wall

● Manifestations
Abdominal Aortic Aneurysm
Prominent pulsating mass in abdomen at or above the umbilicus
Systolic bruit over the aorta
Tenderness on deep palpation
Abdominal or lower back pain
Ruptured Aneurysm
● Abdominal pain combined with intense back flank pain & possible scrotal pain
● A pulsating abdominal mass or a rigid abdomen from the hemorrhage
● Shock with systolic BP below 100 mmHg and apical PR greater than 100 bpm

Management
- If smaller than 4 to 5 cm
o UTZ every 6 months
o Antihypertensive
- If 4 to 5 cm and above
❖ Endovascular Procedure – newer method for non-emergency treatment
● Two small incisions are made in the groin, and a vascular graft is guided into the aorta.
❖ Aneurysm Resection – surgical resection or excision of the aneurysm
● The excised section is replaced with a graft that is sewn end to end
Nursing Interventions:
● Monitor vital signs.
● Note signs and symptoms, especially of rupture
● Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of
discoloration of the extremities or persistent elevation of blood pressure, chest pain, shortness of breath, difficulty
swallowing or hoarseness, these signs must be reported immediately
● Administer antihypertensives as ordered
● Postoperative
o Monitor peripheral pulses distal to the graft site.
o Monitor for : pulse changes, cool to cold extremities below the graft, white or blue
extremities or flanks, serve pain or abdominal distention.
o Limit elevation of the head of the bed to 45 degrees

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Venous Disorders
Superficial Thrombophlebitis DVT
Red, warm area radiating up the vein and Calf or groin tenderness or pain, with or w/o
extremity. Pain, swelling
Soreness Swelling Positive sign
Warm skin, Tender to Touch
1. Warm moist soaks 1. Provide bed rest as prescribed.
2. Assess for COMPLICATIONS: Tissue 2. Elevate the extremity the level of
necrosis, Infection the heart
3. Avoid using knee gatch or pillow under the knee
4. No massage.
5. Thigh high or knee high anti embolic stockings
6. Intermittent, or Continuous warm, moist compresses
as prescribed.
7. Palpate the site gently; monitor for
edema and warmth
8. Measure circumference of the thighs and calves.
9. Monitor for SOB and chest pain
10.Administer thrombolytic therapy within 5 days of
onset of symptoms.
11.Administer Heparin therapy
12.Monitor while on Heparin Therapy.
13.Administer Warfarin following Heparin therapy
when symptoms of DVT have been resolved.
14.Monitor when under Warfarin
Therapy.
15.Monitor for SE of anticoagulant therapy.
16.Administer analgesics for pain.

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 17.Administer diuretics for lower extremity edema.
*Administer medications, as prescribed.

Educate client regarding hazards of

anticoagulant therapy.
Avoid prolonged sitting, or standing,
constrictive clothing, or crossing of legs.
Elevate legs for 10 to 20 minutes every few hours each
day.
Plan a progressive walking program. Avoid
smoking.
Obtain and wear a Medic Alert Bracelet.

Venous Insufficiency
● Results from prolonged venous hypertension which stretches the veins and damages the

● Edema occurs + venous stasis = venous stasis ulcers, swelling and cellulitis
● Treatment focus: Decrease Edema and Promote venous return from affected extremity.
● Treatment focus for Venous stasis ulcers: Heal the ulcer, Prevent stasis and Ulcer Recurrence
● Assessment:
o - brown discoloration along ankles and calf
o Edema
o Uneven edges along Ulcers, Pink Ulcer Bed, presence of granulation tissue
● Interventions
1. Use of elastic or compression during day and evening as prescribed
2. Use of clean pair of stockings everyday.
3. Avoid prolonged sitting, standing, crossing of legs and use of constrictive clothing
4. Elevate legs heart level when in bed.
5. Use of intermittent sequential pneumatic compression device twice daily for 1 hour, in the morning and
evening.
6. Compression devices are worn over the dressing of the ulcer
7. Wound care
a. Wound is cleansed with normal saline and may be covered by an Unna Boot which is changed weekly.
b. Unna boot is covered with an elastic wrap that hardens
c. Monitor for signs of arterial occlusion from a tight Unna boot.
8. Apply topical agents to the wound to debride the ulcer, eliminate necrotic tissue and promote healing.
9. Apply oil based agent on healthy skin to prevent from debridement
10.Administer antibiotics as prescribed if infection and cellulitis occurs.

Varicose Veins
● Distended, protruding veins that appear darkened and tortuous
● Vein walls weaken, dilate, and valves become incompetent.
● Pain in the legs with dull aching after standing
● Feeling of fullness in the leg
● Ankle edema
●
● Supine position with leg elevated.
● Client sits up, varicosities are present, veins fill from proximal end rather than distal end.
● Interventions
i. Emphasize need for anti-embolism stockings
ii. Elevate legs as much as possible
iii. Avoid constricting clothing and pressure on legs
iv.
● Solution is injected to the vein followed by pressure dressing
● Incision and drainage of trapped blood in 14 to 21 days after injection, followed by pressure
dressing application for 12 to 18 hours
v. Vein Stripping
● When veins are more than 4 mm and are in clusters.
● Evaluate pulses as baseline for comparison postoperatively.
● Maintain elastic bandage on client’s leg postoperatively.

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 ● Monitor groin and leg for bleeding through the elastic bandage.
● Monitor extremity for edema, warmth, color and pulses.
● Assess paresthesia indicating damage.
● Elevate leg above heart level postoperatively.
● Encourage range of motion exercises of the legs.
● Instruct to avoid dangling of legs or chair sitting.
● Wearing of elastic stockings after bandage removal.

2. Which of these is not a criteria for diagnosing Raynaud’s disease?

A. Bilateral or symmetrical involvement

B. Intermittent attacks of pallor or cyanosis of the digits after exposure from either cold or emotional stimuli.
C. Manifestation for at least 2 years.
D. Presence of occlusive disease

aka Thromboangiitis obliterans

Affected Artery/ies Artery/ies and Vein/s
Gender Female Male (20-45 y/o)
Cause EXPOSURE TO COLD HEAVY SMOKING
Pathology Vasospasm Obstruction
Common Areas FINGERS LOWER EXTREMITIES
(ears, cheeks, toes) (may also involve UE)
Manifestations Vasoconstriction (pallor, blanching, ARTERIAL AND VENOUS
cyanosis) Vasodilation hyperemia INSUFFICIENCY
(throbbing paresthesia redness)
TROPHIC CHANGES

Management ▪ Avoid cold exposure. ▪ Lifestyle modification

▪ Apply warmers. ▪ Rest if with intermittent
▪ DOC: Calcium Channel claudication.
Blockers ▪ PHARMA: adrenergic blokers and
vasodilators

3. A client who has been a smoker for the past decade has given reports of cramping pain while walking on both legs
which disappears at rest. The client’s condition is consistent with

A. Deep vein thrombosis

B. Raynaud’s disease
C. Peripheral arterial occlusive disease
D. Thrombophlebitis

MANIFESTATIONS
Intermittent claudication:
o Pain in the muscles resulting from inadequate bld supply
o - (when the person walks the same distance, same time, same speed and incline
will have the same manifestation)
- Rest pain
- Paresthesia
- Cold skin
- Weak or absent peripheral pulses
- Dependent Rubor
- Pallor with elevation
- Hypertrophied nails (thick and brittle)
- Hairless extremities
- Tissue atrophy
- Ulceration

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 - Gangrene
- Slow wound healing
- Paralysis
- Impotence

ETIOLOGY
- Atherosclerosis
Medical Management:
□ Promote Arterial Flow
o Pharmacologic management
▪ pentoxifylline (Trental)
▪ Cilostazol
▪ aspirin and clopidogrel
▪ L-arginine
□ Control Comorbid Diseases

Surgical Management:
1. Revascularization – reserved for clients with progressive, severe or disabling
manifestations, including ischemia at rest
o Endovascular Interventions
▪ Angioplasty
▪ Atherectomy
▪ Stent Placement
o Arterial Bypass

2. Amputation
i. Used to treat overwhelming limb gangrene and limb-threatening arterial dse or rest pain esp among
DM pts
ii. To prevent systemic rxn to the products of massive muscle destruction

TRUE or FALSE
Clients with below the knee amputations more successfully achieve independent function with prosthesis
than those with above the knee amputations.

Postoperative care:
□ is controlled by elevating the stump for the 1st 24 hours after surgery and stump wrapping
techniques. Then the stump is placed to reduce hip fracture.
□ In , the knee is immobilized to eliminate joint flexion.
□ A trapeze is attached to bed to develop upper arm and shoulder strength.

Nursing Management:
- Ineffective Tissue Perfusion r/t interruption of blood flow secondary to arterial occlusion
o Place the affected side on dependent position.
o – this can be achieved by placing the head of the client’s
bed on 6-inch blocks (or heavy blocks such as encyclopedia)
o Instruct to avoid raising their feet above heart level (unless the doctor has specifically prescribed it as an
exercise)
o Explain the dangers of smoking.
o Do not advise client to use nicotine patches
o Encourage to avoid stressful situations
o Prevent client from becoming chilled. (encourage wearing protective clothing in layers during cold weather)

- Acute Pain r/t inadequate arterial blood supply to the legs

o Encourage client to rest.
o Assist client assume best position to promote circulation to the
o Instruct to avoid standing in one position and crossing legs for more than few minutes.
o Administer analgesics

- Risk for impaired skin integrity r/t decreased peripheral circulation

✔ Prevent injury to the extremities particularly the feet.
✔ Excellent foot care should be an integral part of daily routine.

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 o feet should be kept clean and protected against excessive drying, wear well-fitting and protective
shoes, elastic support hose should be avoided.
✔ Use fleece leg wraps or cotton stockings to keep feet warm and reduce friction injury.

- Risk for activity intolerance r/t leg pain after walking

o Assess for intermittent claudication to help determine the amount of activity to be undertaken.
o Supervised exercise for 30-45 minutes 3 times a week for 12 weeks on a treadmill or track
o Exercise should begin slowly with the client stopping at the onset of pain and progresses gradually until client
has substantially lengthened walking distances.
o Although exercise helps most clients with PVD, some clients must not exercise.

NURSING DIAGNOSES PRE-AMPUTATION

o Risk for delayed surgical recovery r/t preexisting health conditions
o Anxiety r/t impending loss of limb
o Acute pain r/t ischemia of the limb
NURSING DIAGNOSES POST-AMPUTATION
o Acute pain r/t phantom sensation in amputated limb
o Ineffective coping r/t response to change in body image

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 IRON DEFICIENCY PERNICIOUS FOLIC ACID
DEFICIENCY
Peripheral Smear Microcytic and Macrocytic and normochromic
hypochromic
CAUSE Decreased Fe intake Blood Decreased VitB12 Decreased folate intake
loss Impaired Fe intake Chronic alcoholism
absorpt’n Gastric Surgery Lack Malabsorption
of intrinsic fx
General S/Sx Fatigue, headache, dyspnea, palpitations, tachycardia, pallor, easy fatigability,
stomatitis, cheilitis, glossitis
Distinguishing Neurologic
feature manifestations BEEFY
RED
TONGUE
Treatment Fe supplementation Do not Parenteral B12 Green leafy
take with Tea, coffee, Green leafy vegetables
carbonated beverage, vegetables Organ Organ meats
EDTA, Magnesium meats

SICKLE CELL ANEMIA THALASSEMIA

TYPES None MAJOR and MINOR

Peripheral Smear Normocytic – normochromic Normocytic – normochromic

PATTERN Autosomal recessive

Pathology Sickling RBCs leading to occlusion Inflammation of the RBC containing abnormal
hemoglobin, thus, affecting the bone marrow

Manifestations Jaundice, bone marrow hyperplasia, Impairment in bone growth, bone brittleness
enlargement of the bones (face and skull), pain, (prone to pathologic fractures and
edema of the extremities, splenomegaly, hypercalcemia), increase Fe absorption,
hepatomegaly, ACUTE CHEST chipmunk facies
SYNDROME and
VASO-OCCLUSIVE CRISIS
Management PAIN: opioids, morphine SO4, NSAIDs, Chronic transfusion
acetaminophen. Fe chelation therapy Splenectomy
Hydroxyurea
Chronic blood transfusion

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 HEMOPHLIA A HEMOPHILIA B HEMOPHILIA C

A.K.A. Classic Hemophilia Christmas Hemophilia von Willebrand’s Dse.

Lacking

Dx PROLONGED COGULATION TIME ABNORMAL COAGULATION and

and NORMAL BLEEDING TIME BLEEDING TIME
S/Sx Uncontrolled bleeding

Hallmark HEMARTHROSIS

Mngt Control bleeding, avoidance of excessive activities, factor replacement

therapy

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