2. CARDIOVASCULAR - 2ND SCERNARIO

NCM112 LECTURE
MEDICAL-SURGICAL NURSING
CARDIOVASCULAR DISORDERS
TOPIC OUTLINE
I. VASCULAR DISORDERS AND PROBLEMS
IN PERIPHERAL CIRCULATION
I. Vascular Disorders and Problems in
Peripheral circulation
A. ASSESSMENT OF THE VASCULAR SYSTEM
A. Assessment of the Vascular System
1. Health History HEALTH HISTORY
2. Physical Assessment
3. Diagnostic Evaluation  The nurse obtains an in-depth description from the
a. Doppler Ultrasound Flow Studies patient with peripheral vascular disorders of any pain
b. Duplex Ultrasonography
and its precipitating factors. A muscular, cramp type
B. Arterial Disorders pain, discomfort, or fatigue in the extremities
1. Arteriosclerosis and Atherosclerosis consistently reproduced with the same degree of
2. Peripheral Arterial Occlusive Disease activity or exercise and relieved by rest is
3. Aneurysms experienced by patients with peripheral arterial
a. Thoracic Aortic Aneurysm insufficiency.
b. Abdominal Aortic Aneurysm  Referred to as intermittent claudication, this pain,
4. Arterial Embolism and Arterial Thrombosis
5. Raynaud Phenomenon discomfort, or fatigue is caused by the inability of the
arterial system to provide adequate blood flow to the
C. Venous disorders tissues in the face of increased demands for
a. Venous Thromboembolism nutrients and oxygen during exercise.
b. Chronic Venous Insufficiency/Post thrombotic  As the tissues are forced to complete the energy
Syndrome cycle without adequate nutrients and oxygen, muscle
c. Varicose veins
metabolites and lactic acid are produced.
D. Hypertension  Pain is experienced as the metabolites aggravate the
nerve endings of the surrounding tissue. Typically,
II. Hematologic Function and Treatment about 50% of the arterial lumen or 75% of the cross-
modalities sectional area must be obstructed before intermittent
A. Assessment & Health History claudication is experienced.
B. Physical Assessment
 The progression of the arterial disease can be
C. Diagnostic Evaluation
1. Hematologic Studies monitored by documenting the amount of exercise or
2. Bone Marrow Aspiration and Biopsy the distance the patient can walk before the onset of
3. Blood Component Therapy pain. Distance is measured in blocks, feet, or meters.
4. Procuring Blood and Blood Products Persistent pain in the anterior portion of the foot
 Blood Donation (forefoot) when the patient is resting indicates a
 Complications of Blood Donation severe degree of arterial insufficiency and a critical
 Blood Processing state of ischemia.
5. Transfusion
 Setting  Known as rest pain, this discomfort is often worse at
 Pretransfusion Assessment night and may interfere with sleep. This pain
 Patient Education frequently requires that the extremity be lowered to a
 Complications dependent position to improve perfusion to the distal
 Nursing Management for Transfusion tissues.
 Reactions Pharmacologic Alternatives to Blood PHYSICAL ASSESSMENT
Transfusions
D. Hematologic Disorders  A thorough assessment of the patient’s skin color
a. ANEMIA and temperature and the character or quality of the
b. Bleeding disorders peripheral pulses is important in the diagnosis of
arterial disorders.
c. Platelet defects
d. Hemophilia INSPECTION
e. Disseminated Intravascular Disorders
 Skin color to assess perfusion. Inspect the face,
lips, and fingertips for cyanosis or pallor.
BSN3A | PBL GROUP 1 1

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Note: Cyanosis is a bluish discoloration of the skin, size, color, temperature, and for
lips, and nail beds and indicates decreased perfusion presence of pain in the calves.
and oxygenation. Pallor is the loss of color, or Unilateral warmth, redness,
paleness of the skin or mucous membranes, as a tenderness, swelling in the calf, or
result of reduced blood flow, oxygenation, or sudden onset of intense, sharp
decreased number of red blood cells. Patients with muscle pain that increases with
light skin tones should be pink in color. For those with dorsiflexion of the foot is an
darker skin tones, assess for pallor on the palms,
indication of a deep vein
conjunctiva, or inner aspect of the lower lip.
thrombosis (DVT). for an image of
a DVT in the patient’s right leg,
 Jugular Vein Distension (JVD). Inspect the neck for
indicated by unilateral redness
JVD that occurs when the increased pressure of the
and edema.
superior vena cava causes the jugular vein to bulge,
making it most visible on the right side of a person’s
neck. JVD should not be present in the upright
AUSCULTATION
position or when the head of bed is at 30-45 degrees.
 Precordium for abnormalities. Inspect the chest HEART SOUNDS
area over the heart (also called precordium) for
deformities, scars, or any abnormal pulsations the  Auscultation is routinely performed over five specific
areas of the heart to listen for corresponding valvular
underlying cardiac chambers and great vessels may
sounds. These auscultation sites are often referred
produce.
to by the mnemonic “APE To Man,” referring to
 Extremities: Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral
○ Upper Extremities: Inspect the fingers, areas.
arms, and hands bilaterally noting Color,  Note: The aortic area is the second intercostal space
Warmth, Movement, Sensation (CWMS). to the right of the sternum. The pulmonary area is the
Alterations or bilateral inconsistency in second intercostal space to the left of the sternum.
CWMS may indicate underlying conditions Erb’s point is directly below the aortic area and
or injury. Assess capillary refill by located at the third intercostal space to the left of the
compressing the nail bed until it blanches sternum. The tricuspid (or parasternal) area is at the
and record the time taken for the color to fourth intercostal space to the left of the sternum. The
mitral (also called apical or left ventricular area) is the
return to the nail bed. Normal capillary refill
fifth intercostal space at the midclavicular line.
is less than 3 seconds.
○ Lower Extremities: Inspect the toes, feet, CONSIDERATIONS
and legs bilaterally, noting CWMS, capillary
refill, and the presence of peripheral  To effectively auscultate heart sounds, patient
edema, superficial distended veins, and repositioning may be required. Ask the patient to lean
hair distribution. Document the location and forward if able, or position them to lie on their left
size of any skin ulcers. side.
 Edema: Note any presence of  It is common to hear lung sounds when auscultating
edema. Peripheral edema is the heart sounds. It may be helpful to ask the patient
swelling that can be caused by to briefly hold their breath if lung sounds impede
infection, thrombosis, or venous adequate heart auscultation. Limit the holding of
insufficiency due to an breath to 10 seconds or as tolerated by the patient.
accumulation of fluid in the tissues.  Environmental noise can cause difficulty in
 Deep Vein Thrombosis (DVT): auscultating heart sounds. Removing environmental
Note: A deep vein thrombosis noise by turning down the television volume or
(DVT) is a blood clot that forms in shutting the door may be required for an accurate
a vein deep in the body. DVT assessment.
requires emergency notification of  Patients may try to talk to you as you are assessing
the health care provider and their heart sounds. It is often helpful to explain the
immediate follow-up because of procedure such as, “I am going to take a few minutes
the risk of developing a life- to listen carefully to the sounds of blood flow going
threatening pulmonary through your heart. Please try not to speak while I am
embolism.Inspect the lower listening, so I can hear the sounds better.”
extremities bilaterally. Assess for

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CAROTID SOUNDS DIAGNOSTIC EVALUATION
 The carotid artery may be auscultated for bruits.  The nurse should educate the patient on the purpose
 Note: Bruits are a swishing sound due to turbulence of the diagnostic studies, what to expect, and any
in the blood vessel and may be heard due to possible side effects related to these examinations.
atherosclerotic changes. Trends in results are noted because they provide
information about disease progression as well as the
PALPATION patient’s response to therapy. Various tests may be
performed to identify and diagnose abnormalities
 Palpation is used to evaluate peripheral pulses, that can affect the vascular structures (arteries,
capillary refill, and for the presence of edema. veins, and lymphatics).
 Note: When palpating these areas, also pay attention DOPPLER ULTRASOUND FLOW STUDIES
to the temperature and moisture of the skin.
PULSES  When pulses cannot be reliably palpated, a handheld

continuous wave (CW) Doppler ultrasound device
 Compare the rate, rhythm, and quality of arterial may be used to detect the blood flow. This handheld
pulses bilaterally, including the carotid, radial, device emits a continuous signal through the
brachial, posterior tibialis, and dorsalis pedis pulses. patient’s tissues. The signals are reflected by the
moving blood cells and received by the device. The
Note: Carotid pulses should be palpated on one side at a filtered output Doppler signal is then transmitted to a
time to avoid decreasing perfusion of the brain. loudspeaker or headphones, where it can be heard
for interpretation as arterial or venous signals.
 The posterior tibial artery is located just behind the
medial malleolus. It can be palpated by scooping the ASSESSING PERIPHERAL PULSES
patient’s heel in your hand and wrapping your fingers
around so that the tips come to rest on the  Popliteal pulse.
appropriate area just below the medial malleolus.  Dorsalis pedis pulse
 The dorsalis pedis artery is located just lateral to the  Posterior tibial pulse
extensor tendon of the big toe and can be identified
by asking the patient to flex their toe while you
EVALUATE LOWER EXTRIMITIES
provide resistance to this movement. Gently place
the tips of your second, third, and fourth fingers
 Patient is placed in the supine position with the head
adjacent to the tendon, and try to feel the pulse. of the bed elevated 20 to 30 degrees.
CAPILLARY REFILL  The legs are externally rotated, if possible, to permit
adequate access to the medial malleolus.
 The capillary refill test is performed on the nail beds
to monitor perfusion, the amount of blood flow to  Acoustic water-soluble gel is applied to the patient’s
skin to permit uniform transmission of the ultrasound
tissue. Pressure is applied to a fingernail or toenail
wave.
until it pales, indicating that the blood has been
 The tip of the Doppler
forced from the tissue under the nail. This paleness
is called blanching. Once the tissue has blanched,
 Transducer is positioned at a 45- to 60-degree angle
over the expected location of the artery and angled
pressure is removed. Capillary refill time is defined
slowly to identify arterial blood flow.
as the time it takes for the color to return after
pressure is removed. If there is sufficient blood flow NOTE: Excessive pressure is avoided because
to the area, a pink color should return within 2 to 3 severely diseased arteries can collapse with
seconds after the pressure is removed. even minimal pressure.
EDEMA  The transducer can detect blood flow in advanced

arterial disease states, especially if collateral
 Edema occurs when one can visualize visible
circulation has developed; identifying a signal
swelling caused by a buildup of fluid within the indicates only the presence of blood flow. The
tissues. If edema is present on inspection, palpate patient’s provider must be notified of the absence of
the area to determine if the edema is pitting or a signal if one had been detected previously.
nonpitting. Press on the skin to assess for  CW Doppler is more useful as a clinical tool when
indentation, ideally over a bony structure, such as the combined with ankle blood pressures, which are
tibia. If no indentation occurs, it is referred to as used to determine the ankle-brachial index (ABI)
nonpitting edema. If indentation occurs, it is referred o The ABI is the ratio of the systolic
to as pitting edema. blood pressure in the ankle to the
systolic blood pressure in the arm.

NCM112 LECTURE
NURSES IMPLICATION aorta, such as an increasing aortic diameter
indicating aneurysmal formation.
 Nurses should perform a baseline ABI on any patient  CT of a lymphedematous arm or leg, for example,
with decreased pulses or any patient 65 years or demonstrates a characteristic honeycomb pattern in
older, especially patients with a history of diabetes or the subcutaneous tissue.
nicotine use
 Patients who undergo an arterial intervention or
surgery should have ABIs performed per their
institution’s protocols.
 If there is a change in the clinical status of a patient,
such as a sudden cold or painful limb, an ABI should
be performed.
DUPLEX ULTRASONOGRAPHY
 involves B-mode grayscale imaging of the tissue,

organs, and blood vessels (arterial and venous) and
permits estimation of velocity changes by use of a
pulsed Doppler.
 Color flow techniques, which can identify vessels, NURSING IMPLICATIONS
may be used to shorten the examination time.
 Duplex ultrasound may be used to determine the  Patients with impaired renal function scheduled for
level and extent of venous disease as well as MDCT may require preprocedural treatment to
chronicity of the disease. prevent contrast-induced nephropathy. This may
 Duplex ultrasound findings help in planning include oral or IV hydration 6 to 12 hours
treatment and monitoring its outcomes. The test is preprocedure or administration of sodium
noninvasive and usually requires no patient bicarbonate, which alkalinizes urine and protects
preparation. against free radical damage.
 Patients who undergo abdominal vascular duplex  The nurse should encourage fluids and monitor the
ultrasound, however, should be advised to not eat or patient’s urinary output post procedure, which should
drink (i.e., NPO status) for at least 6 hours prior to be at least 0.5 mL/kg/h.
the examination to decrease production of bowel gas  Contrast-induced acute kidney injury may occur
that can interfere with the examination. within 48 to 96 hours post procedure; therefore, the
 The equipment is portable, making it useful nurse should follow up with the patient’s primary
anywhere for initial diagnosis, screening, or follow-up provider if this occurs.
evaluations.  Patients who have known iodine or shellfish allergies
may need premedication with steroids and histamine
blockers.
ANGIOGRAPHY
 An arteriogram produced by angiography may be

used to confirm the diagnosis of occlusive arterial
disease when surgery or other interventions are
considered.
 It involves injecting a radiopaque contrast agent
directly into the arterial system to visualize the
vessels.
 The location of a vascular obstruction or an
aneurysm (abnormal dilation of a blood vessel) and
the collateral circulation can be demonstrated.
 Manifestations include dyspnea, nausea and
vomiting, sweating, tachycardia, and numbness of
COMPUTED TOMOGRAPHY SCANNING the extremities.
 Additional procedural risks include vessel injury,
 provides cross-sectional images of soft tissue and acute arterial occlusion, bleeding, or contrast
visualizes the area of volume changes to an nephropathy.
extremity and the compartment where changes take
place.
 CT scans of the abdomen are useful in assessing
characteristics and monitoring changes within the

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CONTRAST PHLEBOGRAPHY
 Also known as venography, contrast phlebography

involves injecting a radiopaque contrast agent into
the venous system.
 If a thrombus (a blood clot within an artery or vein)
exists, the x-ray image reveals an unfilled segment
of vein in an otherwise completely filled vein.
 The nurse should instruct the patient that they will
receive contrast dye through a peripheral vein and
will be monitored for 2 hours post venogram for
access site oozing or hematoma.
MAGNETIC RESONANCE ANGIOGRAPHY LYMPHOSCINTIGRAPHY
 is performed with a standard magnetic resonance  involves injection of a radioactively labeled colloid
imaging (MRI) scanner and special software subcutaneously in the second interdigital space.
programmed to isolate the blood vessels.  The extremity is then exercised to facilitate the
 The resulting images can be rotated and viewed from uptake of the colloid by the lymphatic system, and
multiple angles serial images are obtained at preset intervals.
NURSING IMPLICATIONS NURSING IMPLICATIONS
 Prior to the MRA, the nurse should assess for the  The nurse should educate the patient about what to
presence of any incompatible devices, such as expect.
aneurysm clips, old tattoos, which may contain trace  For instance, the blue dye typically used for this
elements (newer materials used in tattoos such as procedure may stain the injection site.
nitinol and titanium are MRI compatible), some  If the patient has a lymphatic leak, as can occur with
medication patches, or a cardiac implantable groin incisions, there may be blue drainage from the
electronic device. incision until the dye clears from the system, which
 Patients with any type of cardiac implantable may take several days.
electronic device need to be screened to determine
if they can safely undergo MRI.
 The nurse should educate the patient regarding what B. ARTERIAL DISORDERS
to expect during and after the procedure. The patient  arterial disorders cause ischemia and tissue
should be prepared to lie on a cold, hard table that necrosis. These disorders may occur because of
slides into an enclosed small tube. chronic progressive pathologic changes to the
 The nurse should inform the patient that they will arterial vasculature (e.g., atherosclerotic changes) or
hear noises, including periodic banging and popping an acute loss of blood flow to the tissues (e.g.,
sounds. aneurysm rupture).
 Patients with claustrophobia may be prescribed a
ARTERIOSCLEROSIS
sedative prior to the procedure.
 Patients should be instructed to close their eyes  also known as hardening of the arteries
before entering the tube, and to keep them closed,  is the most common disease of the arteries. It is a
as this may decrease claustrophobic symptoms. diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened.
ATHEROSCLEROSIS
 involves a different process, affecting the intima of

large and medium-sized arteries. These changes
consist of the accumulation of lipids, calcium, blood
components, carbohydrates, and fibrous tissue on
the intimal layer of the artery. These accumulations
are referred to as atheromas or plaques.
 Although the pathologic processes of arteriosclerosis
and atherosclerosis differ, rarely does one occur
without the other, and the terms are often used

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interchangeably. Atherosclerosis is a generalized
disease of the arteries, and when it is present in the
extremities, it is usually present elsewhere in the
body.
PATHOPHYSIOLOGY
 The most common direct results of atherosclerosis in

arteries include stenosis (narrowing) of the lumen,
obstruction by thrombosis, aneurysm, ulceration,
and rupture. Its indirect results are malnutrition and
the subsequent fibrosis of the organs that the
sclerotic arteries supply with blood. All actively
functioning tissue cells require an abundant supply of  Schematic concept of the progression of
nutrients and oxygen and are sensitive to any atherosclerosis. Fatty streaks are an early
reduction in the supply of these nutrients. If such manifestation of atherosclerosis. Fatty streaks either
reductions are severe and permanent, the cells regress or progress to fibrous plaques and eventually
undergo ischemic necrosis (death of cells due to to atheroma. Atheromatous plaque may be
deficient blood flow) and are replaced by fibrous complicated by hemorrhage, ulceration, calcification,
tissues, which require much less blood flow. or thrombosis leading to myocardial infarction,
 Atherosclerosis can develop in any part of the stroke, claudication, rest pain, or gangrene.
vascular system, but certain sites are more
vulnerable, such as regions where arteries bifurcate
or branch into smaller vessels, with males having
more below-the-knee pathology than females
(Jelani, Petrov, Martinez, et al., 2018). In the
proximal lower extremity, these include the distal
abdominal aorta, the common iliac arteries, the
orifice of the superficial femoral and profunda femoris
arteries, and the superficial femoral artery in the
adductor canal, which is particularly narrow. Distal to
the knee, atherosclerosis can occur anywhere along
the course of the artery.
 Although many theories exist about the development
of atherosclerosis, no single theory explains the
pathogenesis completely; however, tenets of several
theories are incorporated into the reaction-to-injury
 Development of channels for collateral blood flow in
theory. According to this theory, vascular endothelial
response to occlusion of the right common iliac artery
cell injury results from prolonged hemodynamic
and the terminal aortic bifurcation.
forces, such as shearing stresses and turbulent flow,
irradiation, chemical exposure, or chronic RISK FACTORS
hyperlipidemia.
 Gradual narrowing of the arterial lumen stimulates Modifiable Risk Factors
the development of collateral circulation. Collateral
circulation arises from preexisting vessels that  Nicotine use
enlarge to reroute blood flow around a  Diabetes
hemodynamically significant stenosis or occlusion.  Hypertension
Collateral flow allows continued perfusion to the  Diet
 Stress
tissues, but it is often inadequate to meet increased
 Sedentary lifestyle
metabolic demands, and ischemia results.
 Hyperlipidemia
 Elevated C-reactive protein
 Hyperhomocysteinemia
Non-modifiable Risk Factors
 Increasing age
 Genetics
PREVENTION
 Intermittent claudication is a symptom of generalized

atherosclerosis and may be a marker of

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atherosclerosis in other arterial territories, such as the patient use a reclining chair or sit with the feet
the coronary and carotid arteries. resting on the floor.
 The suspicion that a high-fat diet contributes to  The nurse can assist the patient with walking or other
atherosclerosis means that it is reasonable to moderate or graded isometric exercises that promote
measure serum cholesterol and to begin disease blood flow and encourage the development of
prevention efforts that include diet modification. collateral circulation.
 Certain medications that supplement dietary  The amount of exercise a patient can tolerate before
modification and exercise are used to reduce blood the onset of pain is determined to provide a baseline
lipid levels. for evaluation.
 Hypertension, which may accelerate the rate at  The nurse instructs the patient to walk to the point of
which atherosclerotic lesions form in high-pressure pain, rest until the pain subsides, and then resume
vessels, can lead to a stroke, ischemic renal disease, walking so that endurance can be increased as
severe PAD, or coronary artery disease. collateral circulation develops.
 Pain can serve as a guide in determining the
appropriate amount of exercise.
CLINICAL MANIFESTATIONS
 The onset of pain indicates that the tissues are not
 Coronary artherosclerosis (heart disease) receiving adequate oxygen, signaling the patient to
rest.
 Angina
 A supervised exercise therapy (SET) program should
 Acute myocardial infarction be prescribed for patients with claudication.
 Transient ischemic attack  SET can result in increased walking distance before
 Stroke the onset of claudication.
 Aneurysm  Before recommending any exercise program or SET,
 Renal artery stenosis the patient’s primary provider should be consulted.
 End-stage kidney disease  Conditions that worsen with exercise include leg
ulcers, cellulitis, gangrene, or acute thrombotic
occlusions.
MEDICAL MANAGEMENT
 The management of atherosclerosis involves

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE
modification of risk factors, a controlled exercise
program to improve circulation and functional  Arterial insufficiency of the extremities occurs most
capacity, medication therapy, and interventional or often in men and is a common cause of disability.
surgical procedures.  The legs are most frequently affected; however, the
SURGICAL MANAGEMENT upper extremities may be involved.
 In PAD, obstructive lesions are predominantly
 Vascular surgical procedures are divided into two confined to segments of the arterial system
groups: inflow procedures, which improve blood extending from the aorta below the renal arteries to
supply from the aorta into the femoral artery, and the popliteal artery.
outflow procedures, which provide blood supply to  Distal occlusive disease is frequently seen in patients
vessels below the femoral artery. Inflow surgical with diabetes and in older patients
procedures are described with diseases of the aorta
and outflow procedures with peripheral artery
disease.
 Angioplasty
 Atherectomy
 Embolus (blood clot, fatty deposit, or air that travels
through theblood, lodges in an artery or vein, and
blocks flow)
 Dissection (separation of the intima) of the vessel
NURSING MANAGEMENT
 Arterial blood supply to a body part can be enhanced

by positioning the body part below the level of the
heart. CLINICAL MANIFESTATIONS
 For the lower extremities, this is accomplished by
 Intermittent claudication
elevating the head of the patient’s bed or by having

NCM112 LECTURE
 Decreased ability to walk observations are recorded initially every 15 minutes
 Increased pain with ambulation and then at progressively longer intervals if the
patient’s status remains stable.
 Continuous monitoring of urine output, central
ASSESSMENT AND DIAGNOSTIC FINDINGS venous pressure, mental status, and pulse rate and
volume permits early recognition and treatment of
 A sensation of coldness or numbness in the
fluid imbalances.
extremities may accompany intermittent claudication
and is a result of reduced arterial flow.  Leg crossing and prolonged extremity dependency
are avoided to prevent thrombosis.
 Skin and nail changes, ulceration, gangrene, and
muscle atrophy may be evident.  Edema is a normal postoperative finding due to
increased arterial flow; however, elevating the
 Bruits may be auscultated with a stethoscope.
extremities and encouraging the patient to exercise
 Peripheral pulses may be diminished or absent.
the extremities while in bed reduces edema.
 The color and temperature of the extremity are noted
 The nurse determines whether the patient has a
and the pulses palpated.
network of family and friends to assist with ADLs.
 The diagnosis of PAD may be made using CW
 The patient is encouraged to make the lifestyle
Doppler and ABIs, treadmill testing for claudication,
changes necessitated by the onset of disease,
duplex ultrasonography, or other imaging studies
including pain management and modifications in diet,
described earlier in this chapter.
activity, and hygiene (skin care).
MEDICAL MANAGEMENT
UPPER EXTREMITY ARTERIAL DISEASE
 Generally, patients feel better and have fewer
symptoms of claudication after they participate in a  Arterial stenosis and occlusions occur less frequently
SET program. SET programs are covered by in the upper extremities (arms) than in the legs, and
insurance for a specific number of sessions. cause less severe symptoms because the collateral
Reimbursement requires that SET is administered circulation is significantly better in the arms.
under direct provider supervision.  The arms also have less muscle mass and are not
 The person providing the program supervision must subjected to the workload of the legs.
be trained in the optimal delivery of SET and in both
basic life support and advanced cardiac life support
techniques.  Stenosis
 Patients should not be promised that their symptoms  Forearm claudication
will be relieved if they stop nicotine use, however,  Subclavian steal
because claudication may persist, and they may lose  Vertebrobasilar symptoms (vertigo, ataxia, syncope,
their motivation to stop using nicotine. and bilateral visual changes).
 In addition to these interventions, arm-ergometer
exercise training effectively improves physical
fitness, central cardiorespiratory function, and ASSESSMENT AND DIAGNOSTIC FINDINGS
walking capacity in patients with claudication.
 Coolness and pallor of the affected extremity,
decreased capillary refill, and a difference in arm
PHARMACOLOGIC THERAPY blood pressures of more than 15 to 20 mmHg.
 Evaluate upper extremity arterial occlusions include
 Cilostazol upper and forearm blood pressure determinations
 Antiplatelet agents (aspirin & clopidogrel) and duplex ultrasonography to identify the anatomic
 Statins location of the lesion and to evaluate the
hemodynamics of blood flow.
 Transcranial Doppler evaluation is performed to
SURGICAL MANAGEMENT
evaluate the intracranial circulation and to detect any
 Endarterectomy siphoning of blood flow from the posterior circulation
 Bypass grafts to provide blood flow to the affected arm.
 Vein graft  If an endovascular or surgical procedure is planned,
a diagnostic arteriogram may be necessary.
NURSING MANAGEMENT MEDICAL MANAGEMENT
 Pulses, Doppler assessment, color and  If a short focal lesion is identified in an upper
temperature, capillary refill, and sensory and motor extremity artery, a PTA with possible stent or stent
function of the affected extremity are checked and graft placement may be performed.
compared with those of the other extremity; these

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 If the lesion involves the subclavian artery with complications such as aortic dissection,
documented siphoning of blood flow from the hemorrhage, and organ failure.
intracranial circulation and an endovascular
procedure is not possible, a surgical bypass may be RISK FACTORS
performed.
 Age: The risk of developing Thoracic Aortic
Aneurysm increases with age, especially in those
NURSING MANAGEMENT over 65 years of age.
 High Blood Pressure: Hypertension is one of the
 Nursing assessment involves bilateral comparison of leading causes of TAA. High blood pressure can
upper arm blood pressures (obtained by stethoscope cause the walls of the aorta to weaken, leading to an
and Doppler), radial, ulnar, and brachial pulses, aneurysm.
motor and sensory function, temperature, color  Genetic factors: A family history of aortic aneurysm
changes, and capillary refill every 2 hours. increases the risk of developing TAA.
 Disappearance of a pulse or Doppler flow that had  Connective Tissue Disorders: Certain connective
been present may indicate an acute occlusion of the tissue disorders such as Marfan Syndrome, Ehlers-
vessel, and the primary provider is notified Danlos Syndrome, and Loeys-Dietz Syndrome can
immediately. lead to the development of TAA.
 After surgery or an endovascular procedure, the arm  Bicuspid Aortic Valve: A bicuspid aortic valve is a
is kept at heart level or elevated, with the fingers at congenital heart condition in which the aortic valve
the highest level. Pulses are monitored with Doppler has only two cusps instead of the usual three. This
assessment of the arterial flow every hour for 2 hours condition can increase the risk of developing TAA.
and then every shift.  Smoking: Cigarette smoking is a significant risk
 Blood pressure (obtained by stethoscope and factor for TAA. Smoking can damage the blood
Doppler) is also assessed every hour for 4 hours and vessels and lead to the weakening of the aortic walls.
then every shift.  Trauma: Traumatic injuries to the chest, such as a
 Motor and sensory function, warmth, color, and car accident, can cause TAA.
capillary refill are monitored with each arterial flow  Gender: Men are more likely to develop TAA than
(pulse) assessment. women.
 Inflammation: Inflammation in the aorta can lead to
the formation of an aneurysm
ANEURYSMS
 Chest or back pain: Aneurysms can cause chest or

THORACIC AORTIC ANEURYSM back pain, which can be sudden, sharp, or throbbing
in nature. The pain can also radiate to the neck,
 A thoracic aortic aneurysm is a weakened area in the shoulders, or arms.
body's main artery (aorta) in the chest. When the  Shortness of breath: As the aneurysm enlarges and
aortic wall is weak, the artery may widen. When the compresses the surrounding structures, it can lead to
vessel is significantly widened, it's called an shortness of breath, especially during physical
aneurysm. activity.
 A thoracic aortic aneurysm is also called a thoracic  Hoarseness or difficulty swallowing: An aneurysm
aneurysm. in the upper part of the aorta can compress the
recurrent laryngeal nerve or the esophagus, leading
PATHOPHYSIOLOGY to hoarseness or difficulty swallowing.
 A thoracic aortic aneurysm (TAA) is a localized  Coughing or wheezing: Aneurysms in the aortic
dilation of the thoracic aorta that results from a arch can cause coughing or wheezing due to
weakening of the aortic wall. The pathophysiology of compression of the trachea or bronchi.
TAA involves a complex interplay of genetic,  Palpitations: An enlarged aneurysm can cause
environmental, and mechanical factors that palpitations, which are sensations of a racing,
contribute to the development and progression of the fluttering, or pounding heart.
disease. Inherited genetic mutations and conditions  High blood pressure: TAA can lead to high blood
such as Marfan syndrome, Ehlers-Danlos syndrome, pressure, especially if it compresses the renal
and Loeys-Dietz syndrome can predispose arteries, which supply blood to the kidneys.
individuals to TAA. Additionally, chronic  Pulsatile mass: A large aneurysm can cause a
hypertension, atherosclerosis, and other pulsatile mass in the chest, which can be felt by the
inflammatory conditions can lead to the degradation patient or the physician during a physical exam.
of the aortic wall and the formation of aneurysms.
Over time, the weakened aortic wall can further dilate
and eventually rupture, leading to life-threatening

NCM112 LECTURE
ASSESSMENT AND DIAGNOSTIC FINDINGS site of the aneurysm, where it is expanded to
reinforce the weakened aortic wall.
 Medical history: A detailed medical history is  Lifestyle changes: Individuals with thoracic aortic
essential in identifying potential risk factors for TAA aneurysms can help manage their condition by
such as hypertension, smoking, connective tissue making lifestyle changes such as quitting smoking,
disorders, family history of aneurysm or genetic maintaining a healthy weight, and getting regular
disorders like Marfan syndrome. exercise. They should also avoid strenuous activities
 Physical examination: Physical examination may that could put too much strain on the aorta, such as
reveal asymmetrical or pulsatile swelling in the chest heavy lifting or competitive sports.
or abdomen, a bruit (abnormal sound) over the aorta,
and signs of associated cardiovascular disease such NURSING INTERVENTIONS
as murmurs, elevated blood pressure or decreased
peripheral pulses.  Monitor vital signs: It is important to regularly monitor
 Imaging studies: Various imaging studies can help the patient's blood pressure and heart rate, as
to diagnose and assess the size, shape and location changes in these vital signs may indicate worsening
of TAA. These include: of the aneurysm or a potential rupture.
 Chest X-ray: Chest X-rays may show the enlarged  Administer medications: Medications may be given
aorta, a widened mediastinum, or any associated to manage blood pressure and heart rate, to reduce
pleural effusion. the risk of rupture or dissection.
 Computed tomography (CT) scan: CT scan is the  Assess for pain: Pain in the chest, back, or abdomen
most common imaging test for TAA. It can provide may be a sign of a TAA. Assess the patient's pain
detailed information about the size and shape of the level and administer appropriate pain relief
aneurysm, and identify any associated complications measures.
like dissection or rupture.  Provide emotional support: A diagnosis of TAA can
 Magnetic resonance imaging (MRI): MRI can be be overwhelming for patients and their families. Offer
used in patients who cannot tolerate CT contrast emotional support, provide information, and answer
agents, or for assessing the risk of rupture based on any questions they may have.
the morphology of the aneurysm wall.  Encourage a healthy lifestyle: Encourage the patient
 Laboratory tests: Laboratory tests are used to to maintain a healthy weight, quit smoking, and
evaluate the patient's overall health and any potential engage in regular physical activity to help prevent the
risk factors for TAA. These may include blood tests progression of the aneurysm.
to evaluate electrolyte imbalances, lipid profile, and  Prepare for surgery: In some cases, surgical
liver and kidney function, as well as genetic testing intervention may be necessary to repair the
for connective tissue disorders or familial aneurysm. Educate the patient about the procedure
predisposition. and provide emotional support before and after the
surgery.
MANAGEMENT AND TREATMENT
 Provide education: Educate the patient on signs and
 Regular monitoring: For small aneurysms, symptoms of TAA rupture, and instruct them to seek
monitoring the condition may be the only course of medical attention immediately if they experience any
action. Aneurysms smaller than 5 centimeters in of these symptoms.
diameter may be monitored with regular imaging
ABDOMINAL AORTIC ANEURYSM
tests such as CT scans, MRI scans, or ultrasounds
to track their size and growth over time.
 An abdominal aortic aneurysm (AAA) is a localized,
 Medications: Medications such as beta-blockers or abnormal dilation or bulging of the abdominal aorta,
calcium channel blockers may be prescribed to help which is the main artery that carries oxygenated
lower blood pressure and reduce the risk of the blood from the heart to the lower body. The diameter
aneurysm rupturing or growing larger. of the abdominal aorta typically measures less than
 Surgery: Surgery is often recommended for 3 cm in healthy individuals, but in an AAA, the
aneurysms larger than 5.5 centimeters in diameter or diameter exceeds 3 cm, and it can continue to grow
those that are growing quickly. The type of surgery over time. AAA is a potentially life-threatening
will depend on the location and extent of the condition, as the aneurysm can rupture and cause
aneurysm, as well as the individual's overall health. severe internal bleeding, which can be fatal.
Some common surgical options include:
 Open surgical repair: This involves making a large PATHOPHYSIOLOGY
incision in the chest or abdomen to access the
aneurysm and replace the damaged portion of the  Abdominal aortic aneurysm (AAA) is a pathological
aorta with a synthetic graft. dilatation of the aortic wall in the abdominal region,
resulting in the weakened vessel wall bulging out and
 Endovascular repair: This minimally invasive
becoming prone to rupture. The pathophysiology of
procedure involves inserting a stent graft through a
AAA involves a complex interplay between genetic
small incision in the groin and threading it up to the

NCM112 LECTURE
and environmental factors, which ultimately leads to  Leg Pain: AAA can also cause leg pain if it
the degradation of extracellular matrix proteins, such compresses or obstructs blood flow to the legs.
as elastin and collagen, in the medial layer of the  Rupture: A ruptured AAA is a medical emergency
aorta. This process is mediated by a variety of and can lead to severe symptoms such as sudden
proteolytic enzymes, including matrix and intense abdominal and back pain, rapid
metalloproteinases, cathepsins, and elastases, heartbeat, dizziness, and shock.
which are produced by inflammatory cells infiltrating
the aortic wall. As the aortic wall weakens, the ASSESSMENT AND DIAGNOSTIC FINDINGS
pressure of blood flowing through the aorta can
 Physical examination: During a physical
cause it to expand, leading to the formation of an
examination, the healthcare provider may feel a
aneurysm. If the aneurysm ruptures, it can result in
pulsating mass in the abdomen, which is often
life-threatening internal bleeding. Risk factors for
indicative of an aneurysm.
developing AAA include age, male gender, smoking,
hypertension, atherosclerosis, and genetic  Imaging studies: Imaging studies such as
predisposition. ultrasound, CT scan, or MRI are used to diagnose
and monitor the progression of AAA. These tests can
RISK FACTORS also determine the size, location, and shape of the
aneurysm.
 Age: The risk of developing an AAA increases with  Blood tests: Blood tests may be performed to check
age, particularly in people over the age of 60. for signs of infection or inflammation, which could
 Gender: Men are at a higher risk of developing an indicate a rupture of the aneurysm.
AAA than women.  Electrocardiogram (ECG): An ECG may be done to
 Smoking: Smoking is a major risk factor for check for any irregular heart rhythms, which can be
developing AAA. It weakens the walls of the aorta a sign of complications related to AAA.
and increases the risk of developing an aneurysm.  Angiography: Angiography may be performed to
 High blood pressure: People with high blood provide more detailed images of the aneurysm and
pressure are at an increased risk of developing AAA. surrounding blood vessels.
 High cholesterol: People with high cholesterol  Computed Tomography Angiography (CTA): CTA
levels are at a higher risk of developing AAA. is a specialized CT scan that produces detailed
 Family history: If someone in your family has had images of the blood vessels in the abdomen and
AAA, you may be at an increased risk of developing pelvis. This test can provide a more detailed picture
the condition. of the aneurysm and surrounding blood vessels.
 Atherosclerosis: This is a condition in which the  Magnetic Resonance Imaging (MRI): MRI is a
arteries become narrowed and hardened due to the noninvasive diagnostic tool that uses a magnetic field
buildup of plaque. Atherosclerosis can increase the and radio waves to create detailed images of the
risk of developing an AAA. inside of the body. This test can also provide a more
 Marfan syndrome and other connective tissue detailed picture of the aneurysm and surrounding
disorders: These genetic disorders can weaken the blood vessels.
walls of the aorta, increasing the risk of an AAA.
MANAGEMENT AND TREATMENT
 Obesity: People who are obese are at a higher risk
of developing AAA.  Observation: If the aneurysm is small (less than 5
 Gender: Men are more likely to develop AAA than cm in diameter), doctors may choose to monitor the
women. aneurysm with regular ultrasound or CT scans to
CLINICAL MANIFESTATIONS detect any growth or changes.
 Lifestyle changes: If the patient has risk factors for
 Abdominal Pain: Abdominal pain is a common aneurysm development, such as smoking or high
symptom of an AAA. Pain may be dull, deep, and blood pressure, lifestyle changes may be
constant or sudden and severe. recommended, such as quitting smoking, exercising
 Back Pain: Back pain may also be present and may regularly, and eating a healthy diet.
indicate the aneurysm is pressing on the spine or  Medications: Medications may be prescribed to
surrounding nerves. control high blood pressure, which can help slow the
 Pulsating Mass: In many cases, a pulsating mass or growth of an aneurysm.
a feeling of a heartbeat in the abdomen can be felt  Endovascular Aneurysm Repair (EVAR): EVAR is
by the patient or physician during a physical a minimally invasive procedure that involves placing
examination. a stent-graft in the aneurysm to prevent it from
 Gastrointestinal Symptoms: As the aneurysm rupturing. This procedure is typically recommended
grows, it may start to compress adjacent organs and for aneurysms that are larger than 5 cm or are
cause gastrointestinal symptoms like bloating, growing rapidly.
nausea, vomiting, and constipation.  Open surgical repair: In this procedure, the
aneurysm is removed, and a synthetic graft is used

NCM112 LECTURE
to replace the damaged section of the aorta. This is  Arterial emboli arise most commonly from thrombi that
typically recommended for larger aneurysms that are develop in the chambers of the heart as a result of atrial
at risk of rupturing. fibrillation, myocardial infarction, infective endocarditis, or
chronic heart failure.
NURSING INTERVENTIONS  These thrombi become detached and are carried from the
 Monitor vital signs: Regular monitoring of the left side of the heart into the arterial system, where they
patient's vital signs, including blood pressure, heart lodge in and obstruct an artery that is smaller than the
rate, and respiratory rate, is essential to detect any embolus.
changes or abnormalities.  Emboli may also develop in advanced aortic
 Assess pain: Assess the patient's pain level and atherosclerosis because the atheromatous plaques
ulcerate or become rough. Acute thrombosis frequently
location frequently, and administer pain medication
occurs in patients with preexisting ischemic symptoms.
as ordered by the healthcare provider.
 Administer medications: Administer medications CLINICAL MANIFESTATIONS
as ordered by the healthcare provider, such as Symptoms of arterial emboli depend primarily on the size of
antihypertensives to control blood pressure, beta- the embolus, organ involvement, and the state of collateral
blockers to reduce the risk of rupture, and antibiotics vessels.
to prevent infection.
 Positioning: Encourage the patient to maintain a  The immediate effect is cessation of distal blood flow.
semi-fowler's position to reduce pressure on the  The blockage can progress distal and proximal to the
aneurysm. site of the obstruction.
 Teach relaxation techniques: Teach the patient  Secondary vasospasm can contribute to the
relaxation techniques such as deep breathing and ischemia.
visualization to help them manage stress and  The embolus can fragment or break apart, resulting
anxiety. in occlusion of distal vessels.
 Promote mobility: Encourage the patient to engage  Emboli tend to lodge at arterial bifurcations and
in regular physical activity as directed by the areas narrowed by atherosclerosis.
healthcare provider, such as walking and light  Cerebral, mesenteric, renal, and coronary arteries
exercise, to promote circulation and reduce the risk are often involved in addition to the large arteries of
of blood clots. the extremities
 Monitor for complications: Monitor the patient for  The symptoms of acute arterial embolism in
signs of complications such as rupture, bleeding, or extremities with poor collateral flow are acute, severe
infection, and report any changes to the healthcare pain, and a gradual loss of sensory and motor
provider immediately. function.
 Provide education: Provide education to the patient
Note: The six Ps associated with acute arterial embolism are
and family members about the importance of
pain, pallor, pulselessness, paresthesia, poikilothermia
maintaining a healthy lifestyle, including quitting
(coldness), and paralysis. Eventually, superficial veins may
smoking, eating a healthy diet, and managing
collapse because of decreased blood flow to the extremity.
chronic conditions such as hypertension and
diabetes.
 Because of ischemia, the part of the extremity distal to the
occlusion is markedly colder and paler than the part
ARTERIAL EMBOLISM AND ARTERIAL THROMBOSIS proximal to the occlusion.
 Acute vascular occlusion may be caused by an embolus ARTERIAL THROMBOSIS

or acute thrombosis.
 Acute arterial occlusions may result from iatrogenic injury,  Can also acutely occlude an artery. A thrombosis is a
which can occur during insertion of invasive catheters slowly developing clot that usually occurs where the
such as those used for arteriography, PTA or stent arterial wall has become damaged, generally as a result
placement, or an intra-aortic balloon pump, or it may of atherosclerosis. Thrombi may also develop in an
occur as a result of illicit IV drug use. arterial aneurysm.
 Other causes include trauma from a fracture or  The manifestations of an acute thrombotic arterial
dislocation, crush injury, compartment syndrome, and occlusion are similar to those described for an embolic
penetrating wounds that disrupt the arterial intima. occlusion.
 treatment is more difficult with a thrombus because the
RISK FACTORS arterial occlusion has occurred in a degenerated vessel
 History of atrial fibrillation and requires more extensive reconstructive surgery to
 Myocardial infarction restore flow than is required with an embolic event
 Infective endocarditis or chronic heart failure
PATHOPHYSIOLOGY

NCM112 LECTURE
ASSESSMENT AND DIAGNOSTIC FINDINGS  In select cases, the radial or brachial artery can be
An arterial embolus is usually diagnosed on the basis of the accessed, allowing patients to be ambulatory post
sudden onset of symptoms and an apparent source for the procedure.
embolus.  To qualify for this approach, the height of the patient
is considered to ensure that the length of the catheter
 Two-dimensional transthoracic echocardiography or can reach the thrombus.
transthoracic echocardiogram (TTE),  Patients who are 5 feet 6 inches or shorter are
 chest x-ray potential candidates.
 electrocardiography (ECG) may reveal underlying  Some endovascular devices require that a small
cardiac disease incision (cut-down) be made into the patient’s artery.
 Noninvasive duplex and Doppler ultrasonography can  These devices may use a jet of fluid to disrupt the
determine the presence thrombus and then aspirate the particles; a rotating,
sinusoidal-shaped wire that mixes a thrombolytic
 and extent of underlying atherosclerosis, and
agent that simultaneously dissolves the clot; or high
arteriography may be performed.
frequency, low-energy ultrasound to dissolve an
MEDICAL MANAGEMENT occlusive thrombus.
 Complications arising from the use of any
 Management of arterial thrombosis depends on its endovascular device may include arterial dissection
cause. or distal artery embolization
 Management of acute embolic occlusion usually PHARMACOLOGIC THERAPY
requires surgery because there is only a 4- to 6-hour
window to restore blood flow before irreversible  IV anticoagulation with heparin, which can prevent
death of tissue. the thrombus from extending and reduce muscle
 The event is acute with no collateral circulation necrosis.
developed, and the patient quickly moves through  Intra-arterial thrombolytic medications are used to
the list of six Ps to paralysis, the most advanced dissolve the embolus. Thrombolytic medications
stage. (e.g., tissue plasminogen activator [t-PA] and single-
 Heparin therapy is initiated immediately to prevent chain urokinase-type plasminogen activator) interact
further development of emboli and to prevent the with plasminogen to generate plasmin which then
extension of existing thrombi. breaks down fibrin clots. If t-PA is used for the
 Typically, an initial IV bolus of 60 to 80 U/kg body treatment, heparin is usually given to prevent another
weight is given, followed by a continuous infusion of thrombus from forming at the site of the lesion.
12 to 18 U/kg/h until the patient undergoes an  The t-PA activates plasminogen on the thrombus, but
endovascular intervention or surgery it does not decrease the clotting factors as much as
other thrombolytic therapies; therefore, patients
ENDOVASCULAR MANAGEMENT
receiving t-PA can make new thrombi more readily
 Emergency embolectomy is the procedure of choice
than if they receive other thrombolytics.
if the involved extremity is viable
 Other thrombolytic medications are reteplase and
 Arterial emboli are usually treated by insertion of an
tenecteplase. Although these agents differ in their
embolectomy catheter. The catheter is passed
pharmacokinetics, they are given in a similar
through an incision into the affected artery and
manner: A catheter is advanced under
extended through the embolus that is causing the
 x-ray visualization to the clot, and the thrombolytic
arterial occlusion.
agent is infused
 Thrombolytic therapy should not be used when there
are known contraindications to therapy or when the
 The embolectomy catheter balloon is inflated with
extremity cannot tolerate the several additional hours
sterile saline solution, and the thrombus is extracted
of ischemia that it takes for the agent to lyse
as the catheter is withdrawn.
(disintegrate) the clot.
 This procedure involves incising the vessel and
 Contraindications to peripheral thrombolytic therapy
removing the clot.
include active internal bleeding, cerebrovascular
 Percutaneous mechanical thrombectomy devices
hemorrhage, recent major surgery, uncontrolled
may also be used for the treatment of an acute
hypertension, and pregnancy.
thrombosis.
 All endovascular devices necessitate obtaining NURSING INTERVENTIONS
access to the patient’s arterial system and inserting  Before an intervention or surgery, the patient remains on
a catheter into the patient’s artery to obtain access to bed rest with the affected extremity level or slightly
the thrombus. dependent (15 degrees).
 The approach is similar to that used for angiograms,  The affected extremity is kept at room temperature and
in that it is typically made through the groin to the protected from trauma.
femoral artery.

NCM112 LECTURE
 Heating and cooling pads are contraindicated because rheumatoid arthritis, or scleroderma; trauma; or
ischemic extremities are easily traumatized by alterations obstructive arterial lesions.
in temperature.
 If possible, tape and ECG electrodes should not be used CLINICAL MANIFESTATIONS
on the extremity to protect from trauma.
 Pallor (brought on by sudden vasoconstriction)
 Pressure injury prevention through offloading the heel
 Skin becomes cyanotic (because of pooling of
with a heel device and lifting the bedsheets using a bed deoxygenated blood during vasospasm)
cradle are important to protect the affected leg.
 Rubor (because of hyperemia (exaggerated reflow) due to
 If the patient is treated with thrombolytic therapy, the dose vasodilation)
is based on the patient’s weight.
 Characteristic sequence of color change of Raynaud’s
 The patient is admitted to a critical care unit for phenomenon is described as white, blue, and red.
continuous monitoring.
 Numbness, tingling, and burning pain occur as the color
 Vital signs are taken initially every 15 minutes and then at changes.
progressively longer intervals if the patient’s status
remains stable. MEDICAL MANAGEMENT
 The patient is closely monitored for bleeding.
 The nurse minimizes the number of punctures for  Calcium channel blockers [Nifedipine, Amlodipine] -
inserting IV lines and obtaining blood samples, avoids may be effective in relieving symptoms.
intramuscular injections, prevents any possible tissue  Sympathectomy - interrupting the sympathetic nerves
trauma, and applies pressure at least twice as long as by removing the sympathetic ganglia, or blocking or
usual after any puncture is performed. dividing their branches.
 During the recovery phase, the nurse collaborates with  NOTE: Avoidance of exposure to cold and trauma and
the primary provider about the patient’s appropriate implementing measures to improve local circulation
activity level based on the patient’s condition. are the primary focus of treatment for acrocyanosis.
 Encourage the patient to move the extremity to stimulate
NURSING MANAGEMENT
circulation and prevent stasis.
 Anticoagulant therapy may be continued  The nurse instructs the patient with Raynaud or
postendovascular intervention to prevent thrombosis of acrocyanosis to avoid situations that may be stressful or
the affected artery and to diminish the development of unsafe.
subsequent thrombi at the initiating site.  Exposure to cold must be minimized, and in areas where
 Assesses for evidence of local and systemic hemorrhage, the fall and winter months are cold, the patient should wear
including mental status changes, which can occur when layers of clothing when outdoors. Hats and gloves or
anticoagulants are given. mittens should be worn at all times when outside. Fabrics
 Pulses, Doppler signals, ABI, and motor and sensory specially designed for cold climates (e.g., Thinsulate™)
function are assessed every hour for the first 24 hours, are recommended.
because significant changes may indicate reocclusion.  During summer, a sweater should be available when
 Metabolic abnormalities, acute kidney injury, and entering air-conditioned rooms.
compartment syndrome may be complications after an  Patients should avoid all forms of nicotine, which may
acute arterial occlusion. induce attacks; this includes nicotine gum or patches used
to aid smoking cessation.
RAYNAUDS PHENOMENON
 Patients should be cautioned to handle sharp objects
 is a form of intermittent arteriolar vasoconstriction that carefully to avoid injuring their fingers.
results in coldness, pain, and pallor of the fingertips or  Patients should be informed about the orthostatic
toes. hypotension that may result from medications, such as
 symptoms may result from a defect in basal heat calcium channel blockers.
production that eventually decreases the ability of
cutaneous vessels to dilate.
 episodes may be triggered by emotional factors, stress, C. VENOUS DISORDERS
or by unusual sensitivity to cold.  cause a reduction in venous blood flow, which results
 five times more common in women with the typical onset in stasis of blood. This may then cause a host of
before age 30. pathologic changes, including coagulation defects,
 edema, tissue breakdown, and an increased
susceptibility to infections.
2 TYPES OF RAYNAUD’S PHENOMENON
 Primary or Idiopathic Raynaud’s - occurs in the absence VENOUS THROMBOEMBOLISM

of an underlying disease.
 Secondary Raynaud - occurs in association with an  Deep vein thrombosis (DVT) and pulmonary
underlying disease, usually a connective tissue embolism (PE) collectively make up venous
disorder, such as systemic lupus erythematosus, thromboembolism.

NCM112 LECTURE
 is frequently not diagnosed because DVT and PE are SURGICAL MANAGEMENT
often clinically silent or asymptomatic.
 In surgical patients, most symptomatic  Embolectomy to remove a pulmonary embolism in
thromboembolic complications occur after hospital your lung.
discharge due to shorter lengths of stay (Stubbs,  Thrombectomy to remove a blood clot in your leg,
Assareh, Curnow, et al., 2018). pelvis or arm.
 Placement of an inferior vena cava (IVC) filter inside
PATHOPHYSIOLOGY the large vein (inferior vena cava) that carries blood
from your lower body to your heart. The filter
Superficial veins, which include the greater saphenous, short captures a clot from your legs before it can reach
saphenous (also known as lesser saphenous), cephalic, your lungs.
basilic, and external jugular veins, are muscular structures
with strong walls that lie just beneath the skin. Deep veins, on
the other hand, have thin walls and less muscle in the media.
Deep veins are veins that run parallel to arteries and have the CHRONIC VENOUS INSUFFICIENCY/POST
same names as arteries. The valves in deep and superficial THROMBOTIC SYNDROME
veins allow unidirectional flow back to the heart. The valves
 Venous insufficiency results from obstruction of the
are located at the base of a venous segment that has been
venous valves in the legs or a reflux of blood through the
enlarged into a sinus. This configuration allows the valves to
valves.
open without meeting the vein wall, allowing for quick closure
 Superficial and deep leg veins can be involved.
when the blood begins to flow backward. Perforating veins are
 Resultant venous hypertension can occur whenever
another form of vein. These veins contain valves that allow
there has been a prolonged increase in venous pressure,
one-way blood flow from the superficial to the deep venous
such as occurs with DVT.
systems.
Although the specific origin of VTE is unknown, three variables
known as the Virchow triad are thought to be important in its  Chronic venous stasis, resulting in edema
development: endothelial injury, venous stasis, and altered  Altered pigmentation
coagulation. Damage to the blood vessel's intimal lining
 Pain
creates a location for clot development. Direct trauma to the
 Stasis dermatitis
veins can occur as a result of fractures or dislocations, as well
 Superficial veins may be dilated
as disorders of the veins. The veins, as well as chemical
 Stasis ulcers develop as a result of the rupture of small
irritation of the veins caused by IV drugs or solutions.
skin veins and subsequent ulcerations
When blood flow is decreased, as in heart failure or shock,
COMPLICATIONS
venous stasis ensues. When veins dilate as a result of some
drug regimens; and when skeletal muscle contraction is  Venous ulceration is the most serious complication of
decreased, as in immobility, extremity paralysis, or chronic venous insufficiency and can be associated
anesthesia. Altered coagulation is most common in people with other conditions affecting the circulation of the
who have had their anticoagulant medicines abruptly lower extremities. Cellulitis or dermatitis may
discontinued. complicate the care of chronic venous insufficiency
and venous ulcerations.
Oral contraceptive use, increased CRP levels, and a variety
of blood dyscrasias (abnormalities) can all cause
hypercoagulability, with the prevalence varying according to
the patient's ethnicity. MANAGEMENT
CLINICAL MANIFESTATIONS  Providing Compression Therapy

 Stockings (Graduated compression stockings
 Swollen and tender legs that are painful to the touch (if you usually are prescribed for patients with venous
have blood clots that block blood flow to your leg veins) disease as soon as possible after diagnosis.
 Shortness of breath and pain when breathing (if you have a Graduated compression stockings are designed
blood clot that travels to the lungs) to apply 100% of the prescribed pressure
MEDICAL MANAGEMENT gradient at the ankle and then decrease along
the 2347 length of the stocking, reducing the
 Anticoagulants (these medications keep a clot from caliber of the superficial veins in the leg and
getting bigger while your body reabsorbs it. They increasing flow in the deep veins. Each stocking
also prevent the formation of new clots.) should fit so that pressure is greater at the foot
 Thrombolytic therapy (this IV infusion breaks apart and ankle and then gradually declines to a
and dissolves a large blood clot. Your provider may lesser pressure at the knee or groin.)
call this medication a “clot buster.”)

NCM112 LECTURE
 External Compression Devices and Bandages o Worsened pain after sitting or standing for
(to reduce the likelihood of PTS and reduce a long time
symptoms. o Itching around one or more of the veins
 Intermittent Pneumatic Compression Devices o Changes in skin color around a varicose
vein
(used to help prevent blood clots in the deep
 Spider veins are similar to varicose veins, but
veins of the legs. The devices use cuffs around they're smaller. Spider veins are found closer to the
the legs that fill with air and squeeze your legs. skin's surface and are often red or blue.
This increases blood flow through the veins of  Spider veins occur on the legs but can also be
your legs and helps prevent blood clots.) found on the face. They vary in size and often look
like a spider's web.
VARICOSE VEINS
 Varicose veins (varicosities) are abnormally dilated, RISK FACTORS

tortuous, superficial veins caused by incompetent  Age
venous valves. o Aging causes wear and tear on the valves
 Most commonly, this condition occurs in the lower in the veins that help control blood flow.
extremities, the saphenous veins, or the lower trunk; Eventually, that wear causes the valves to
however, it can occur elsewhere in the body, such as allow some blood to flow back into the
esophageal varices. veins, where it collects.
 The condition is most common in women and in  Sex
people whose occupations require prolonged o Women are more likely to develop the
standing, such as salespeople, hair stylists, condition. Hormonal changes before a
teachers, nurses, ancillary medical personnel, and menstrual period or during pregnancy or
construction workers. menopause might be a factor because
female hormones tend to relax vein walls.
Hormone treatments, such as birth control
pills, might increase the risk of varicose
veins.
 Pregnancy
o During pregnancy, the blood volume in the
body increases. This change supports the
growing baby but can also enlarge the
veins in the legs.
 Family history
o If other family members had varicose
veins, there's a greater chance you will
too.
 Obesity
CAUSES o Being overweight puts added pressure on
 Weak or damaged valves can lead to varicose veins.
veins. Arteries carry blood from the heart to the rest  Standing or sitting for long periods of time.
of the body. Veins return blood from the rest of the o Movement helps blood flow.
body to the heart. To return blood to the heart, the
veins in the legs must work against gravity.
 Muscle contractions in the lower legs act as pumps, COMPLICATIONS
and elastic vein walls help blood return to the heart.  Ulcers
Tiny valves in the veins open as blood flows toward o Painful ulcers can form on the skin near
the heart, then close to stop blood from flowing varicose veins, particularly near the
backward. If these valves are weak or damaged, ankles. A discolored spot on the skin
blood can flow backward and pool in the veins, usually begins before an ulcer forms. See
causing the veins to stretch or twist. your health care provider immediately if
you think you've developed a leg ulcer.
 Blood clots.
CLINICAL MANIFESTATIONS o Occasionally, veins deep within the legs
 Varicose veins might not cause pain. Signs of become enlarged and might cause leg
varicose veins include: pain and swelling. Seek medical attention
o Veins that are dark purple or blue for persistent leg pain or swelling because
o Veins that appear twisted and bulging, it can be a sign of a blood clot.
often appearing like cords on the legs  Bleeding
 When painful signs and symptoms of varicose veins o Occasionally, veins close to the skin burst.
occur, they might include: Although this usually causes only minor
o An achy or heavy feeling in the legs bleeding, it requires medical attention.
o Burning, throbbing, muscle cramping and
swelling in the lower legs

NCM112 LECTURE
PREVENTION  may lead to cardiovascular disease (CVD), stroke,
The patient should avoid activities that cause venous stasis, and chronic kidney disease (CKD) when not
such as: appropriately treated
 wearing tight socks SYSTOLIC & BLOOD PRESSURE CATEGORY

 a constricting panty girdle DIASTOLIC
 crossing the legs at the thighs BP (mmHg)
 sitting or standing for long periods <120 / <80 Normal
 changing position frequently, elevating the legs 120-129 / <80 Elevated
when they are tired 130-139 / 80- High Blood Pressure (Hypertension)
 getting up to walk for several minutes of every hour 89 Stage 1
promote circulation ≥ 140 / ≥ 90 High Blood Pressure (Hypertension)
 The patient should be encouraged to walk 1 or 2 Stage 2
miles each day if there are no contraindications. ≥ 180 / ≥ 120 Hypertensive Crisis (consult your doctor
 Walking up the stairs rather than using the elevator immediately
or escalator is helpful in promoting circulation.
 Swimming is also good exercise for the legs.
RISK FACTORS
 Elastic compression stockings, especially knee-high
stockings, are useful. Patients are more likely to use
 Advancing adult age
knee-high stockings than thigh-high stockings.
 African American
 The overweight patient should be encouraged to
begin a weight-reduction plan.  Chronic kidney disease
 Diabetes
 Drinking too much alcohol (i.e., more than two
ASSESSMENT AND DIAGNOSIS drinks per day
Diagnostic tests for varicose veins include the:  for men and more than one drink per day for
women)
 Duplex Scan which documents the anatomic site of
reflux and provides a quantitative measure of the  Family history
severity of valvular reflux.  Gender-related:
 Air Plethysmography measures the changes in o Men have greater risk until 64 y of age
venous blood volume. o Women have greater risk at 65 y of age
 Venography is not routinely performed to evaluate and later
for valvular reflux. When it is used, however, it  Hypercholesterolemia
involves injecting an x-ray contrast agent into the  Overweight/obesity
leg veins so that the vein anatomy can be visualized  Poor diet habits, particularly if it includes too much
by x-ray studies during various leg movements. salt, as well
 as limited intake of vegetables, fiber, fish fats, and
MEDICAL MANAGEMENT potassium
 Surgery for varicose veins requires that the deep  Sedentary lifestyle
veins be patent and functional. The saphenous vein  Use of tobacco and nicotine products (e.g.,
is ligated and divided. cigarettes, e-cigarettes) and exposure to
 The vein is ligated high in the groin, where the secondhand smoke
saphenous vein meets the femoral vein.  Stress
Additionally, the vein may be removed (stripped).  Sleep apnea
 After the vein is ligated, an incision is made in the
ankle, and a metal or plastic wire is passed the full CAUSES OF HYPERTENSION
length of the vein to the point of ligation. The wire is
then withdrawn, pulling (removing, “stripping”) the PRIMARY HYPERTENSION (essential hypertension)
vein as it is removed. Pressure and elevation keep
bleeding at a minimum during surgery.  diagnosed when there is no identifiable cause
 90% to 95% of adults with hypertension have
D. HYPERTENSION primary hypertension
 hypertension has developed on its own and does
HYPERTENSION
not have a secondary cause.
 High blood pressure SECONDARY HYPERTENSION

 Silent killer: typically has no warning signs or
 high blood pressure from an identifiable underlying
symptoms
cause
 May remain asymptomatic for years
 5% and 10% of all adults with hypertension have
 most common chronic disease among adults secondary hypertension
 leading risk factor for premature death, disability,
and overall disease burden worldwide

NCM112 LECTURE
 SECONDARY CAUSES OF HYPERTENSION:
(ROPE)
o R- Renal disease (most common cause)
o O- Obesity
o P- Pregnancy induced hypertension/
pre-eclampsia
o E- Endocrine (hyperaldosteronism or
Conns syndrome – tested thru renin
aldosterone ratio)
 ADDITIONAL COMMON CAUSES OF
SECONDARY HYPERTENSION:
o Chronic kidney disease
o Coarctation of the aorta
o Cushing’s syndrome
o Hyperaldosteronism (primary or
secondary)
o Hyperparathyroidism
o Hypo- or hyperthyroidism
o Medication abuse (nonsteroidal anti-
inflammatory drugs [NSAIDs]) or
substance
o abuse disorder (alcohol, cocaine,
amphetamines)
o Obstructive sleep apnea
o Pheochromocytoma
o Preeclampsia PHYSIOLOGIC PRECEDENTS THAT CAN LEAD TO
o Polycystic kidney disease HYPERTENSION
o Prostatism
o Renal artery stenosis  Increased sympathetic nervous system activity
related to dysfunction of the autonomic nervous
PATHOPHYSIOLOGY system
 Increased renal reabsorption of sodium, chloride,
 Blood pressure: product of cardiac output x and water related to a genetic variation in the
peripheral resistance
pathways by which the kidneys handle sodium
 Cardiac output: product of the heart rate x stroke
 Increased activity of the renin–angiotensin–
volume aldosterone system, resulting in expansion of
 Each time the heart contracts, pressure is extracellular fluid volume and increased systemic
transferred from the contraction of the myocardium vascular resistance
to the blood and then pressure is exerted by the  Decreased vasodilation of the arterioles related to
blood as it flows through the blood vessels dysfunction of the vascular endothelium
 Hypertension can result from increases in cardiac  Resistance to insulin action, which may be a
output, increases in peripheral resistance common factor linking hypertension, type 2
(constriction of the blood vessels), or both. diabetes, hypertriglyceridemia, obesity, and glucose
 Increases in cardiac output are often related to an intolerance
expansion in vascular volume  Activation of the innate and adaptive components of
the immune response that contribute to vascular
inflammation and dysfunction
GERONTOLOGIC CONSIDERATIONS
 Structural and functional changes in the heart,

blood vessels, and kidneys contribute to
increases in blood pressure that occur with
aging.
o These changes include:
 Accumulation of atherosclerotic plaque
 Fragmentation of arterial elastins
 Increased collagen deposits
 Impaired vasodilation
 Renal dysfunction
 DBP decreases, SBP increases

NCM112 LECTURE
 Isolated systolic hypertension: predominant o associated w/ stroke
form of hypertension in older people  urinalysis, blood chemistry (i.e., analysis of sodium,
potassium, creatinine, fasting glucose, cholesterol
levels), and a 12-lead electrocardiogram
CLINICAL MANIFESTATIONS  creatinine clearance, renin level, urine tests, and
24-hour urine protein
 Retinal changes: hemorrhages, exudates (fluid
accumulation), arterial narrowing, & cotton-wool MEASURING BLOOD PRESSURE
spots (small infarctions) For patient at home:
 Severe hypertension: papilledema  Automatic or semiautomatic upper-arm electronic
 Consequence of HTN: coronary artery disease w/ device with digital display of readings
angina & myocardial infarction For the practitioner:
 Pathologic changes in the kidneys  Preferably, a validated electronic oscillometric
o Increased BUN device; if not available, a recently calibrated
o Increased serum creatinine levels aneroid sphygmomanometer
(nocturia)  Appropriately sized arm cuff
 Cerebrovascular involvement: transient ischemic Instructions for the Patient
attack (TIA) or stroke
o Manifested by alterations in vision or  Avoid eating, smoking, drinking caffeinated
speech, dizziness, weakness, a sudden beverages, and physical activity for 30 min
fall, or transient or permanent hemiplegia before blood pressure (BP) is measured.
(paralysis on one side)  Empty bladder.
 Sit quietly for 5 min before the measurement.
ASSESSMENT AND DIAGNOSTIC FINDINGS  Sit comfortably, with back supported, with the
forearm supported at heart level on a firm
 Blood pressure measurement surface, with both feet on the ground; avoid
o at least two blood pressure readings on at talking while the measurement is being taken
least two occasions to confirm the
diagnosis
 Patients with a clinic blood pressure between MEDICAL MANAGEMENT
140/90 mmHg and 180/120 mmHg should have 24
 GOAL: to prevent complications & death by
hour ambulatory blood pressure or home
maintaining a blood pressure lower than 130/80
readings to confirm the diagnosis.
mmHg
 Masked hypertension: elevated blood pressure
 Lifestyle advice includes a healthy diet, stopping
outside the hospital or clinic (normal in health care
smoking, reducing alcohol, caffeine and salt intake
settings) and taking regular exercise.
 White coat hypertension: elevated blood pressure  Medications used in management are:
in health care settings (normal in other settings)
 thorough health history and physical examination o A – ACE inhibitor (e.g., ramipril)
o palpation of all peripheral pulses o B – Beta blocker (e.g., bisoprolol)
o absent, weak, or delayed femoral pulses = o C – Calcium channel blocker
coarctation of the aorta or severe (e.g., amlodipine)
peripheral vascular disease o D – Thiazide-like diuretic
o neck should be examined for carotid bruits, (e.g., indapamide)
distended veins, or enlarged thyroid gland  used as an alternative if the
o upper abdomen should be auscultated for patient does not tolerate calcium
presence of renal artery bruit = renal artery channel blockers (commonly
stenosis due to ankle oedema).
o ARB – Angiotensin II receptor blocker
 patient’s health history (e.g., candesartan)
 cardiac examination to determine Left Ventricular
Hypertrophy (LVH)
o s/s:
 displacement of apex LIFESTYLE MODIFICATION TO PREVENT AND
 sustained & enlarged apical MANAGE HYPERTENSION
impulse MODIFICATION RECOMMENDATION
 presence of S4 cardiac sound Weight Reduction  Maintain normal
 assessed by echocardiography body weight (body
mass index 18.5–
 fundoscopic eye examination
24.9 kg/m2).
o hypertensive retinopathy (e.g., retinal
 Ideal body weight
hemorrhages, microaneurysms, cotton- is best goal; but
wool spots, papilledema) aim for at least 1

NCM112 LECTURE
kg (2.2 lb) weight
loss.
 Expect ∼ 1 mm Note: RESISTANT HYPERTENSION -- when a patient takes
Hg SBP decrease at least three antihypertensive medications from different
per 1 kg reduction classes (including a diuretic) and the blood pressure is still
in weight. not controlled (i.e., not less than 130/80 mm Hg)
Adopt DASH eating plan  Consume a diet
rich in fruits, HYPERTENSIVE EMERGENCY
vegetables, and
low-fat dairy  ACCELERATED HYPERTENSION
products with a o malignant hypertension
reduced content of o extremely high blood pressure, above
saturated and total 180/120
fat o patients with a blood pressure above
Dietary sodium reduction  Sodium <2g/day is 180/120 require a fundoscopy
optimal goal but examination
aim for atleast o Additional complications also warrant
1000mg/day same-day assessment, such as confusion,
reduction. Check heart failure, suspected acute coronary
sodium amount on syndrome or acute kidney injury.
food labels o Intravenous options in a hypertensive
Dietary potassium  Preferred emergency (guided by an experienced
increase potassium intake specialist) include:
is 3500– 5000
mg/day. Choose  Sodium nitroprusside
high potassium  Labetalol
foods; check  Glyceryl trinitrate
potassium amount  Nicardipine
on food labels
Physical activity Engage in: III. HEMATOLOGIC FUNCTION AND
 Regular aerobic TREATMENT MODALITIES
physical activity
such as brisk HEMATOLOGIC FUNCTION AND TREATMENT
walking 90–150 MODALITIES
min weekly
 Regular dynamic ASSESSMENT
resistance training
90–150 min HEALTH HISTORY
weekly
 Regular isometric  assessments of ethnicity and family history
resistance training  obtaining a nutritional history
at least three  assessing the use of prescription and over-the-
times weekly counter medications as well as herbal supplements
Moderation of alcohol  Limit consumption  Careful attention to the onset of a symptom or
consumption to ≤2 drinks (e.g., finding (e.g., rapid vs. gradual; persistent vs.
24-oz beer, 10-oz intermittent), its severity, and any contributing
wine, or 3-oz 80- factors can further differentiate potential causes.
proof whiskey) per
day in most men FAMILY HISTORY ASSESSMENT SPECIFIC TO
and to ≤1 drink HEMATOLOGIC DISORDERS
per day in women.
 Collect family history information on maternal and
DASH (Dietary Approaches to Stop Hypertension) Diet paternal relatives from three generations of the
Food Group # of servings daily family.
Grains and grain 7 or 8  Assess family history for other family members with
products histories of blood disorders or episodes of abnormal
Vegetables 4 or 5 bleeding.
Fruits 4 or 5  If a family history or personal risk is suspected, the
Low-fat or fat-free dairy 2 or 3 person should be carefully screened for bleeding
foods disorders prior to surgical procedures.
Lean meat, fish, and ≤2
poultry
Nuts, seeds and dry 4 or 5 servings weekly
beans

NCM112 LECTURE
PATIENT ASSESSMENT SPECIFIC TO HEMATOLOGIC  Distended neck veins, edema, chest pain on
DISORDERS exertion, murmurs, gallops [severe edema]
 Assess for specific symptoms of hematologic  Hypotension
diseases:  Hypertension
o Extreme fatigue (the most common
symptom of hematologic disorders) GENITOURINARY
o Delayed clotting of blood
o Easy or deep bruising  Hematuria [hemolysis, thrombocytopenia]
o Abnormal bleeding (e.g., frequent
 Proteinuria [myeloma]
nosebleeds)
o Abdominal pain (hemochromatosis) or joint
pain (sickle cell disease) MUSCULOSKELETAL
 Review blood cell counts for abnormalities.
 Rib/sternal tenderness to palpation [leukemia,
 Assess for presence of illness despite low risk for
the illness (e.g., a young adult with a blood clot) myeloma]
 Back pain; loss of height, kyphosis [myeloma]
 Pain/swelling in knees, wrists, hands [hemophilia,
PHYSICAL ASSESSMENT sickle cell disease]
 This should be comprehensive and include careful CENTRAL NERVOUS SYSTEM

attention to the skin, oral cavity, lymph nodes, and
spleen.  Cranial nerve dysfunction [Vitamin B12 deficiency]
 Peripheral nerve dysfunction (especially sensory)
SKIN [Vitamin B12 deficiency, amyloidosis, myeloma]
 Visual changes, headache, alteration in mental
 Gray-tan or bronze skin color [Hemochromatosis
status [Severe thrombocytopenia]
(primary or secondary)]
 Ruddy complexion [Polycythemia] GYNECOLOGIC
 Ecchymoses [ Thrombocytopenia, coagulopathy]
 Petechiae [Severe thrombocytopenia ]  Menorrhagia [Thrombocytopenia, coagulopathy]
 Rash [polycythemia, other non–hematologic-related
disorders] CONSTITUTION
 Bleeding [Thrombocytopenia, coagulopathy]
 Conjunctival hemorrhage [Severe  Fever, chills, sweats, asthenia [leukemia, lymphoma;
thrombocytopenia, coagulopathy] infection]
 Pallor, especially in mucous membranes (including
conjunctiva), nail beds [Anemia]
DIAGNOSTIC EVALUATION
 Jaundice in mucous membranes (including
conjunctiva), nail beds, palate [Hemolysis]
ORAL CAVITY HEMATOLOGIC STUDIES
 Petechiae in the buccal mucosa, gingiva, hard palate HEMATOLOGY

[Severe thrombocytopenia]
 the study of blood disorders
 Ulceration of oral mucosa [Infection, leukemia]
 a branch of internal medicine that deals with the
 Tongue: Smooth Pernicious [anemia]
physiology, etiology, diagnosis, treatment,
 Beefy red [Vitamin B12 /folate deficiency] prognosis, and prevention of blood-related disorders.
 Enlarged [Amyloidosis]
 Angular cheilosis [Anemia] COMPLETE BLOOD COUNT (CBC)
 Enlarged gums: hyperplasia [Leukemia]
 Components: RBC, hemoglobin, hematocrit, WBC,
LYMPH NODES MCV (mean corpuscular volume), MCH (mean
corpuscular hemoglobin), MCHC (mean corpuscular
 Enlarged size, firm and fixed vs mobile and tender hemoglobin concentration), RDW (rbc distribution
[leukemia, lymphoma] width), platelet count, differential count (neutrophil,
basophil, lymphocytes, monocytes, and eosinophil)
RESPIRATORY SYSTEM
 Increased rate and depth of respirations;

adventitious breath sounds [anemia, infection]
CARDIOVASCULAR

NCM112 LECTURE
REASONS
 These procedures are used to diagnose and monitor

various blood and bone marrow disorders such as
leukemia, lymphoma, anemia, and myeloma.
 These can also be uses to evaluate the effectiveness
of treatment and monitor disease progression.
PREPARATION
 Patient will undergo blood tests to check their blood

clotting ability to ensure they are healthy enough for
the procedure.
 Patients may receive a local anesthetic to numb the
PERIPHERAL BLOOD SMEAR area where the needle will be inserted.
A test done by spreading a drop of blood onto a glass plate PROCEDURE

and turning the drop into a thin film. Healthcare providers treat
the blood with chemicals that highlight blood cells' specific
characteristics. Then, they examine the sample under a
 During the bone marrow aspiration, the px will lie
microscope.
on their side or stomach while it is inserted into the
hipbone or breastbone.
 The entire procedure typically takes less than 30
minutes and px may experience some discomfort or
pressure during the procedure.
 After the procedure, px may need to rest for a short
period of time before resuming normal activities.
 During the bone marrow biopsy, a larger needle is
used to remove a small piece of bone and bone
marrow from the hipbone or breatsbone.
 The procedure typically takes less than 1 hour and
px may experience some discomfort or pressure
during the procedure.
 After the procedure, px may need to rest for a short
period of time before resuming normal activities.
Normal results:  Px may also experience some soreness or bruising
at the biopsy site, can be managed with an OTC
 RBC are the same size and color and are a lighter
medication.
color in the center
 Normal appearance of cells BLOOD COMPONENT THERAPY
 Normal WBC differential
 A single unit of whole blood contains 450 mL of
Abnormal results: blood and 50 mL of an anticoagulant, which can
 RBC's size, shape, color, or coating is not normal. be processed and dispensed for administration.
However, it is more appropriate, economical, and
 +1 means one quarter of cells are affected
practical to separate that unit of whole blood into its
 +2 means half of cells are affected
primary components:
 +3 means three quarters are affected
 +4 all of the cells are affected ERYTHROCYTES
BONE MARROW ASPIRATION AND BIOPSY  the plasma is removed, a unit of packed red blood
cells (PRBCs) is very concentrated (hematocrit
BONE MARROW ASPIRATION
approximately 70%).
 involves collecting a small amount of liquid in bone  PRBCs are stored at 4°C (39.2°F). With special
marrow using a needle. preservatives, they can be stored safely for up to 42
days before they must be discarded.
BONE MARROW BIOPSY
PLATELETS
 involves removing a small piece of bone and bone
marrow using a larger needle.  platelets must be stored at room temperature
because they cannot withstand cold temperatures.

NCM112 LECTURE
 they last for only 5 days before they must be BLOOD DONATION
discarded. To prevent clumping, platelets are gently
agitated while stored.  To protect both the donor and the recipients, all
prospective donors are examined and interviewed
PLASMA (LEUKOCYTES ARE RARELY USED) before they are allowed to donate their blood.
 The intent of the interview is to assess the general
 Plasma is immediately frozen to maintain the activity health status of the donor and to identify risk factors
of the clotting factors within; it lasts for 1 year if it that might harm a recipient of the donor’s blood.
remains frozen.  There is no upper age limit to donation.
 Alternatively, plasma can be further pooled and  The American Red Cross (2020c) requires that
processed into blood derivatives, such as albumin, donors be in good health and meet specific eligibility
immune globulin, factor VIII, and factor IX. criteria related to medications and vaccinations,
NOTE: Each component must be processed and stored medical conditions and treatments, travel outside the
differently to maximize the longevity of the viable cells United States, lifestyle and life events, and so on.
and factors within it; thus, each individual blood Examples of the minimal requirements include (American
component has a different storage life. Red Cross, 2020a, 2020d):
SPECIAL CONSIDERATIONS  Body weight should be at least 50 kg (110 lb) for a
standard 450-mL donation.
⎯ Factor VIII concentrate (antihemophilic factor) is
 Donors must wait at least 8 weeks between whole
a lyophilized, freeze-dried concentrate of pooled
blood (standard) donations.
fractionated human plasma used in treating
hemophilia A.  People younger than 17 years require parental
⎯ Factor IX concentrate (prothrombin complex) is consent in some states.
similarly prepared and contains factors II, VII, IX, and  The oral temperature should not exceed 37.5°C
X. It is used primarily for the treatment of factor IX (99.6°F).
deficiency (hemophilia B).  The systolic arterial blood pressure should be 80 to
⎯ Factor IX concentrate is also useful in treating 180 mm Hg, and the
congenital factor VII and factor X deficiencies.  diastolic pressure should be 50 to 100 mm Hg.
Recombinant forms of factor VIII, such as Humate-  The hemoglobin level should be at least 12.5 g/dL.
P or Alphanate, are also useful. Because they  The destinations of people who traveled outside the
contain von Willebrand factor, these agents are used United States
in von Willebrand disease as well as in hemophilia A,  Prospective donors who received a blood
particularly when patients develop factor VIII transfusion must wait 12 months before a donation
inhibitors. is accepted.
 Men who have sexual relations with men must wait

3 months from their last sexual encounter before a
⎯ Plasma albumin is a large protein molecule that donation is accepted.
usually stays within vessels and is a major
contributor to plasma oncotic pressure. This protein DIRECTED DONATION
is used to expand the blood volume of patients in
hypovolemic shock and, rarely, to increase the  At times, friends and family of a patient wish to
concentration of circulating albumin in patients with donate blood for that person. These blood donations
hypoalbuminemia. are referred to as directed donations.
⎯ Immune globulin is a concentrated solution of the  These donations are not any safer than those
antibody immunoglobulin G (IgG), prepared from provided by random donors, because directed
large pools of plasma. It contains very little donors may not be as willing to identify themselves
immunoglobulin A (IgA) or IgM. Intravenous as having a history of any of the risk factors that
immunoglobulin (IVIG) is used in various clinical disqualify a person from donating blood. Therefore,
situations to replace inadequate amounts of IgG in many blood centers no longer accept directed
patients who are at risk for recurrent bacterial donations.
infection (e.g., those with chronic lymphocytic STANDARD DONATION
leukemia, those receiving HSCT).
 Donors are placed in a semirecumbent position.
The skin over the antecubital fossa is carefully
PROCURING BLOOD AND BLOOD PRODUCTS cleansed with an antiseptic preparation, a tourniquet
is applied, and venipuncture is performed.
 The process of procuring blood and blood products
Withdrawal of 450 mL of blood usually takes less
includes donation and processing.
than 15 minutes.

NCM112 LECTURE
 After the needle is removed, donors are asked to erythrocytes and lower the hematocrit. However,
hold the involved arm straight up, and firm pressure patients who are at risk for myocardial injury should
is applied with sterile gauze for 2 to 3 minutes. A firm not be further stressed by hemodilution.
bandage is then applied.
 The donor is instructed to leave the dressing on and COMPLICATIONS OF BLOOD DONATION
to avoid heavy lifting for several hours, to avoid
 Excessive bleeding at the donor’s venipuncture site
smoking for 1 hour, to avoid drinking alcoholic
is sometimes caused by a bleeding disorder but
beverages for 3 hours, to increase fluid intake for 2
more often results from a technique error: laceration
days, and to eat healthy meals for at least 2 weeks.
of the vein, excessive tourniquet pressure, or failure
AUTOLOGOUS DONATION to apply enough pressure after the needle is
withdrawn.
 A patient’s own blood may be collected for future  Fainting may occur after blood donation and may be
transfusion; this method is useful for many elective related to emotional factors, a vasovagal reaction, or
surgeries where the potential need for transfusion is prolonged fasting before donation. Because of the
high (e.g., orthopedic surgery). loss of blood volume, hypotension and syncope may
 Preoperative donations are ideally collected 4 to 6 occur when the donor assumes an erect position.
weeks before surgery. Iron supplements are  A donor who appears pale or complains of faintness
prescribed during this period to prevent depletion of should immediately lie down or sit with the head
iron stores. lowered below the knees. The donor should be
 The primary advantage of autologous transfusions is observed for another 30 minutes.
the prevention of viral infections from another  Anginal chest pain may be precipitated in patients
person’s blood. Other advantages include safe with unsuspected coronary artery disease. Seizures
transfusion for patients with a history of transfusion can occur in donors with epilepsy, although the
reactions, prevention of alloimmunization, and incidence is very low.
avoidance of complications in patients with BLOOD PROCESSING
alloantibodies.
 Needless autologous donation (i.e., performed  Blood banking is the process that takes place in the
when the likelihood of transfusion is small) is lab to make sure that donated blood, or blood
discouraged because it is expensive, takes time, and products, are safe before they are used in blood
uses resources inappropriately. transfusions and other medical procedures. Blood
 Contraindications to donation of blood for autologous banking includes typing the blood for transfusion and
transfusion are acute infection, severely debilitating testing for infectious diseases.
chronic disease, hemoglobin level less than 11 g/dL,
unstable angina, and acute cardiovascular or
cerebrovascular disease. 1. Samples of the unit of blood are always taken
INTRAOPERATIVE BLOOD SALVAGE immediately after donation so that the blood can be
typed and tested.
 This transfusion method provides replacement for 2. Each donation is tested for antibodies to human
patients who cannot donate blood before surgery and for immunodeficiency virus (HIV) types 1 and 2,
those undergoing vascular, orthopedic, or thoracic hepatitis B core antibody (anti-HBc), hepatitis C
surgery. virus (HCV), human T-cell lymphotropic virus type
 During a surgical procedure, blood lost into a sterile cavity I (anti-HTLV-I/II), hepatitis B surface antigen
(e.g., hip joint) is suctioned into a cell-saver machine. The (HbsAG), and syphilis.
whole blood or PRBCs are washed, often with saline 3. Negative reactions are required for the blood to be
solution; filtered; and then returned to the patient as an IV used, and each unit of blood is labeled to certify the
infusion. Salvaged blood cannot be stored, because results.
bacteria cannot be completely removed from the blood 4. Nucleic acid amplification testing has increased
and thus cannot be used when it is contaminated with the ability to detect the presence of HCV, HIV, and
bacteria. West Nile virus infections because it directly tests
for genomic nucleic acids of the viruses rather than for
HEMODILUTION the presence of antibodies to the viruses. This testing
 This transfusion method may be initiated before or significantly shortens the “window” of inability to
after induction of anesthesia. About 1 to 2 units of detect HIV and HCV from a donated unit, further
blood are removed from the patient through a venous ensuring the safety of the blood; the risk of
or arterial line and simultaneously replaced with a transmission of HIV or HCV is now estimated at 1 in 2
colloid or crystalloid solution. million units and 1 in 200,000 units of blood donated,
 The advantage of this method is that the patient respectively (Zou, Dorsey, Notari, et al., 2010).
loses fewer erythrocytes during surgery, because the 5. Blood is also screened for cytomegalovirus (CMV);
added IV solutions dilute the concentration of if it tests positive for CMV, it can still be used, except

NCM112 LECTURE
in recipients who are negative for CMV and who are  Health History and Mini Physical are assessed
severely immunocompromised.  A whole blood donation, about 1 pint of blood is
6. Equally important is the accurate determination of the collected; several small test tubes of blood are also
blood type. More than 200 antigens have been collected for testing.
identified on the surface of RBC membranes. Of  Your donation, test tubes and your donor record are
these, the most important for safe transfusion are labeled with an identical bar code label.
the ABO and Rh systems. The ABO system  Your donation is kept on ice before being taken to a
identifies which sugars are present on the membrane Red Cross center for processing; the test tubes go to
of a person’s erythrocytes: A, B, both A and B, or the lab.
neither A nor B (type).
7. To prevent a significant reaction, the same type of STEP TWO: Processing
PRBCs should be transfused. Previously, it was
thought that in an emergency situation in which the  At the processing center, information about your
patient’s blood type was not known, type O blood donation is scanned into a computer database.
could be safely transfused. This practice is no longer  Most whole blood donations are spun in centrifuges to
recommended. separate it into transfusable components: red cells,
8. The Rh antigen (also referred to as D) is present on platelets, and plasma.
the surface of erythrocytes in 85% of the population  Plasma may be processed into components such as
(Rh positive). Those who lack the D antigen are cryoprecipitate, which helps control the risk of bleeding
referred to as being Rh negative. PRBCs are routinely by helping blood to clot.
tested for the D antigen as well as ABO. Patients  Red cells and platelets are leuko-reduced, which
should receive PRBCs with a compatible Rh type. means your white cells are removed in order to reduce
9. The majority of transfusion reactions are due to a the possibility of the recipient having a reaction to the
clerical error where the patient has transfused an transfusion.
incompatible unit of blood product. Reactions (other  Each component is packaged as a “unit,” a
than those due to procedural error) are most standardized amount that doctors will use when
frequently due to the presence of donor leukocytes transfusing a patient.
within the blood component unit (PRBCs or platelets);
STEP THREE: Testing
the recipient may form antibodies to the antigens
present on these leukocytes.  In parallel with Step 2, your test tubes arrive at a testing
10. PRBC components typically have 1 to 3 × 109 laboratory.
leukocytes remaining in each unit. Leukocytes from  A dozen tests are performed, to establish the blood
the blood product are frequently filtered to diminish type and test for infectious diseases
the likelihood of developing reactions and  Test results are transferred electronically to the
refractoriness to transfusions, particularly in patients processing center within 24 hours.
who have chronic transfusion needs. The process of  If a test result is positive, your donation will be
leukocyte filtration renders the blood component discarded and you will be notified (our test results are
“leukocyte poor” (i.e., leukopoor) confidential and are only shared with the donor, except
11. Filtration can occur at the time the unit is collected as may be required by law).
from the donor and processed, which achieves better
results but is more expensive, or at the time the blood STEP FOUR: Storage
component is transfused by attaching a leukocyte
filter to the blood administration tubing. Many centers  When test results are received, units suitable for
advocate routinely using leukopoor-filtered blood transfusion are labeled and stored.
components for people who have or are likely to  Red cells are stored in refrigerators at 6ºC for up to 42
develop chronic transfusion requirements. days.
12. When a patient is immunocompromised, as in the  Platelets are stored at room temperature in agitators
case following a stem cell transplant, any donor for up to five days.
lymphocytes must be removed from the blood  Plasma and cryo are frozen and stored in freezers for
components. In this situation, the blood component is up to one year.
exposed to low amounts of radiation (25 Gy) that kill
any lymphocytes within the blood component. STEP FIVE: Distribution
Irradiated blood products are highly effective in
 Blood is available to be shipped to hospitals 24 hours
preventing transfusion-associated graft-versus-host a day, 7 days a week.
disease, which is fatal in most cases. Irradiated blood
 Hospitals typically keep some blood units on their
products have a shorter shelf life. shelves, but may call for more at any time, such as in
BLOOD PROCESSING (ACC. TO AMERICAN RED CROSS) case of large scale emergencies.
STEP ONE: The Donation
 Arrive for your donation blood appointment

NCM112 LECTURE
STEP SIX: Transfusion
 An ill or injured patient arrives at a hospital or treatment

center.
 Physicians determine whether the patient requires a
transfusion and, if so, which type.
 Blood transfusions are given to patients in a wide range
of circumstances, including serious injuries (such as in
a car crash) surgeries, child birth, anemia, blood
disorders, cancer treatments, and many others. See
How Blood Donations Help.
 A patient suffering from an iron deficiency or anemia
may receive red blood cells to increase their
hemoglobin and iron levels, improving the amount of
oxygen in the body.
 Patients who are unable to make enough platelets, due
to illness or chemotherapy, may receive platelet
transfusions to stay healthy.
 Plasma transfusions are used for patients with liver
failure, severe infections, and serious burns.
TRANSFUSION
 Administration of blood and blood components requires

knowledge of correct administration techniques and
possible complications.
 It is a routine medical procedure in which donated blood
is provided to you through a narrow tube placed within a
vein in your arm.
 This potentially life-saving procedure can help replace
blood lost due to surgery or injury. A blood transfusion
also can help if an illness prevents your body from making
blood or some of your blood's components correctly.
People receive blood transfusions for many reasons — such

as surgery, injury, disease, and bleeding disorders. Blood has
several components, including:
 Red cells carry oxygen and help remove waste
products
 White cells help your body fight infections
 Plasma is the liquid part of your blood
 Platelets help your blood clot properly

NCM112 LECTURE
 The history should include the type of reaction, its
manifestations, the interventions required, and whether
any preventive interventions were used in subsequent
transfusions.
 Assess the number of pregnancies a woman has had,
because a high number can increase her risk of
reaction due to antibodies developed from exposure to
fetal circulation. Other concurrent health problems
should be noted, with careful attention to cardiac,
pulmonary, and vascular disease.
PHYSICAL ASSESSMENT
 The respiratory system should be assessed, including

careful auscultation of the lungs and the patient’s use
of accessory muscles.
 Cardiac system assessment should include careful
inspection for any edema as well as other signs of
cardiac failure (e.g., jugular venous distention).
 The skin should be observed for rashes, petechiae, and
ecchymoses.
 The sclera should be examined for icterus. In the event
of a transfusion reaction, a comparison of findings can
help differentiate between types of reactions.
PATIENT EDUCATION
 Review the signs and symptoms of a transfusion with

all patients, including those who have and have not
received a previous transfusion.
 Signs and symptoms of a reaction include fever,
chills, respiratory distress, low back pain, nausea,
pain at the IV site, or anything “unusual.”
 Nurses should also reassure the patient that the
blood is carefully tested against the patient’s own
SETTING blood (cross-matched) to diminish the likelihood of
any untoward reaction.
 Although most blood transfusions are performed in  Patient can be reassured about the very low
the acute care setting, patients with chronic possibility of contracting HIV from the transfusion;
transfusion requirements often can receive this fear persists among many people.
transfusions in other settings. Freestanding infusion
centers, ambulatory care clinics, physicians’ oɽces, COMPLICATIONS
and even patients’ homes may be appropriate
FEBRILE NONHEMOLYTIC REACTION
settings for transfusion. Typically, patients who need
chronic transfusions but are otherwise stable  Is caused by antibodies to donor leukocytes that
physically are appropriate candidates for outpatient remain in the unit of blood or blood component; it is
therapy. Veriɹcation and administration of the blood the most common type of transfusion reaction.
product are performed as in a hospital setting.  It occurs more frequently in patients who have had
Although most blood products can be Transfused in previous transfusions (exposure to multiple
the outpatient setting, the home is typically limited to antigens from previous blood products) and in Rh-
transfusions of PRBCs and factor components (e.g., negative women who have borne Rh-positive
factor VIII for patients with hemophilia). children (exposure to an Rh-positive fetus raises
antibody levels in the untreated mother).
PRETRANSFUSION ASSESSMENT ACUTE HEMOLYTIC REACTION
PATIENT HISTORY  The most dangerous, and potentially life-
threatening, type of transfusion reaction occurs
 Assess the history of previous transfusion as well as
when the donor blood is incompatible with that of the
previous transfusion reactions
recipient (i.e., type II hypersensitivity reaction).

NCM112 LECTURE
 The most common causes of acute hemolytic less than 90%; partial pressure of arterial
reaction are errors in blood component labeling, a oxygen[PaO2] to fraction of inspired oxygen [FIO2]
type of clerical error, and errors in patient ratio of less than 300), hypotension, fever, and
identification that result in the administration of an eventual pulmonary edema.
ABO-incompatible transfusion.  Diagnostic criteria include hypoxemia, bilateral
 Symptoms consist of fever, chills, low back pain, pulmonary infiltrates (seen on chest x-ray), no
nausea, chest tightness, dyspnea, and anxiety. evidence of cardiac cause for the pulmonary edema,
and no other plausible alternative cause within 6
ALLERGIC REACTION hours of completing transfusion.
 Some patients develop urticaria (hives) or DELAYED HEMOLYTIC REACTION
generalized itching during a transfusion; the cause is
thought to be a sensitivity reaction to a plasma  Delayed hemolytic reactions usually occur within 14
protein within the blood component being transfused. days after transfusion, when the level of antibody has
 Symptoms of an allergic reaction are urticaria, been increased to the extent that a reaction can
itching, and flushing. The reactions are usually mild occur.
and respond to antihistamines.  Signs and symptoms of a delayed hemolytic reaction
 If the symptoms resolve after administration of an are fever, anemia, increased bilirubin level,
antihistamine (e.g., diphenhydramine), the decreased or absent haptoglobin, and possibly
transfusion may be resumed. jaundice. Rarely, there is hemoglobinuria.
 Giving the patient antihistamines or corticosteroids
DISEASE ACQUISITION
before the transfusion may prevent future reactions.
TRANSFUSION-ASSOCIATED CIRCULATORY  Despite advances in donor screening and blood

OVERLOAD (TACO) testing, certain diseases can still be transmitted by
transfusion of blood components such as hepatitis,
 Too much blood is infused too quickly, hypervolemia AIDS (HIV and HTLV, cytomegalovirus (CMV), Graft-
can occur. This ), can be aggravated in patients who Versus-Host Disease (GVHD), and Creutzfeldt–
already have increased circulatory volume (e.g., Jakob Disease (CJD).
those with heart failure, renal dysfunction, advanced
age, acute myocardial infarction). LONG-TERM TRANSFUSION THERAPY
 Signs of circulatory overload include dyspnea,  Patients with long-term transfusion requirements
orthopnea, tachycardia, an increase in blood (e.g., those with myelodysplastic syndrome,
pressure, and sudden anxiety. Jugular vein thalassemia, aplastic anemia, sickle cell disease) are
distention, crackles at the base of the lungs, and at greater risk for infection transmission and for
hypoxemia will also develop. becoming more sensitized to donor antigens, simply
 TACO can develop as late as 6 hours after because they are exposed to more units of blood
transfusion. Therefore, patients need close and, consequently, more donors.
monitoring after the transfusion is completed.  Iron overload is a complication unique to people who
BACTERIAL CONTAMINATION have had long-term PRBC transfusions.
 Contamination can occur at any point during

procurement or processing but often results from NURSING MANAGEMENT FOR TRANSFUSION
organisms on the donor’s skin.
 The signs of bacterial contamination are fever, chills,  Stop the transfusion. Maintain the IV line with normal
and hypotension. These manifestations may not saline solution through new IV tubing, given at a slow
occur until the transfusion is complete, and rate.
occasionally not until several hours after the  Assess the patient carefully. Compare the vital signs
transfusion. with baseline, including oxygen saturation.
 Assess the patient’s respiratory status carefully. Note
TRANSFUSION-RELATED ACUTE LUNG INJURY (TRALI)
the presence of adventitious breath sounds; the use
 TRALI is a potentially fatal, idiosyncratic reaction that of accessory muscles; the extent of dyspnea; and
is defined as the development of acute lung injury changes in mental status, including anxiety and
occurring within 6 hours after the blood transfusion. confusion. Note any chills, diaphoresis, jugular vein
 All blood components have been implicated in distention, and reports of back pain or urticaria.
TRALI, including IVIG, cryoprecipitate, and stem  Notify the primary provider of the assessment
cells. TRALI is the most common cause of findings and implement any treatments prescribed.
transfusion-related death.  Continue to monitor the patient’s vital signs and
 Signs and symptoms include acute shortness of respiratory, cardiovascular, and renal status.
breath, hypoxia (arterial oxygen saturation [SaO2]  Notify the blood bank that a suspected transfusion
reaction has occurred.

NCM112 LECTURE
 Send the blood container and tubing to the blood  It is particularly useful in preventing bacterial
bank for repeat typing and culture. The patient’s infections that would be likely to occur with
identity and blood component identifying tags and neutropenia.
numbers are verified.  G-CSF is given subcutaneously on a daily basis. The
primary side effect is bone pain; this probably reflects
If a hemolytic transfusion reaction or bacterial infection is the increase in hematopoiesis within the marrow.
suspected, the nurse does the following:
GRANULOCYTE-MACROPHAGE COLONY-STIMULATING
 Obtains appropriate blood specimens from the FACTOR (GM-CSF)
patient.
 Collects a urine sample as soon as possible to detect  GM-CSF (sargramostim) is a cytokine that is
hemoglobin in the urine. naturally produced by a variety of cells, including
 Documents the reaction according to the institution’s monocytes and endothelial cells.
policy.  It works either directly or synergistically with other
growth factors to stimulate myelopoiesis. GM-CSF is
not as specific to neutrophils as is G-CSF; thus, an
increase in erythroid (red blood cell) and
REACTIONS PHARMACOLOGIC ALTERNATIVES TO
megakaryocytic (platelet) production may also be
BLOOD TRANSFUSIONS
seen.
GROWTH FACTORS  Side effects include bone pain, fevers, and myalgias.
 Recombinant technology has provided a means to

produce hematopoietic growth factors necessary for THROMBOPOIETIN
the production of blood cells within the bone marrow.
 Thrombopoietin (TPO) is a cytokine that is necessary
 By increasing the body’s production of blood cells,
for the proliferation of megakaryocytes and
transfusions and complications resulting from
subsequent platelet formation.
diminished blood cells (e.g., infection from
 Nonimmunogenic second-generation thrombopoietic
neutropenia) may be avoided.
growth factors (romiplostim; eltrombopag) are used
for the treatment of idiopathic thrombocytopenic
purpura.
ERYTHROPOIETIN  Eltrombopag is also approved for use in certain
situations for patients with aplastic anemia and in
 Erythropoietin (epoetin alfa; darbopoietin) is an patients requiring hepatitis C treatment that can
effective alternative treatment for patients with cause significant thrombocytopenia.
chronic anemia secondary to diminished levels of
erythropoietin, as in chronic kidney disease. This
medication stimulates erythropoiesis.
 It also has been used for patients who are anemic HEMATOLOGIC DISORDERS
from chemotherapy or zidovudine (AZT) therapy and
for those who have diseases involving bone marrow
suppression, such as myelodysplastic syndrome ANEMIA
(MDS).
 The use of erythropoietin can also enable a patient  is a condition characterized by a lower-than-normal
to donate several units of blood for future use (e.g., hemoglobin concentration.
preoperative autologous donation). The medication  Fewer than the normal number of red blood cells (RBCs),
can be administered IV or subcutaneously, although also called erythrocytes, are present in the circulation.
plasma levels are better sustained with the  Subsequently, less oxygen reaches the tissues, causing
subcutaneous route. a variety of signs and symptoms.
 Rather than a disease state, anemia is a sign of an
GRANULOCYTE COLONY-STIMULATING FACTOR (G- underlying disorder. It is the most common of all
CSF) hematologic conditions and is prevalent throughout the
world
 G-CSF (filgrastim) is a cytokine that stimulates the
proliferation and differentiation of myeloid stem cells; TYPES OF ANEMIA
a rapid increase in neutrophils is seen within the
circulation. Nutritional anemias
 G-CSF is effective in improving transient but severe
neutropenia after chemotherapy or in some forms of  Pernicious anemia: Pernicious anemia, one of the
MDS. causes of vitamin B12 deficiency, is an autoimmune
condition that prevents your body from absorbing
vitamin B12.

NCM112 LECTURE
 Iron-deficiency anemia: As its name implies, iron-
deficiency anemia happens when your body doesn’t
have enough iron to make hemoglobin. Hemoglobin
is the substance in your red blood cells that enables
them to carry oxygen throughout your body.
 Megaloblastic anemia: Megaloblastic anemia is a
type of vitamin deficiency anemia that happens when
you don’t get enough vitamin B12 and/or vitamin B9
(folate).
Inherited Anemias
 Sickle cell anemia: Sickle cell anemia changes your

red blood cells’ shape, turning round flexible discs
into stiff and sticky sickle cells that block blood flow.
 Fanconi anemia: Fanconi anemia is a rare blood
disorder. Anemia is one sign of Fanconi anemia.
 Diamond-Blackfan anemia: This inherited disorder
keeps your bone marrow from making enough red
blood cells.
Anemias caused by abnormal red blood cells
 Hemolytic anemia: In this anemia, your red blood

cells break down or die faster than usual.
 Aplastic anemia: This anemia happens when stem
cells in your bone marrow don’t make enough red
blood cells.
 Autoimmune hemolytic anemia: In autoimmune
hemolytic anemia, your immune system attacks your
red blood cells.
 Sideroblastic anemia: In sideroblastic anemia, you
don’t have enough red blood cells and you have too PATHOPHYSIOLOGY
much iron in your system.  Anemia is classified in several ways. Most often it is
 Macrocytic anemia: This anemia happens when classified according to whether the decreased
your bone marrow makes unusually large red blood number of erythrocytes is associated with
cells. hypoproliferation (decreased production), hemolysis
 Microcytic anemia: This anemia happens when (increased destruction), or loss of cells through
your red blood cells don’t have enough hemoglobin bleeding. Hypoproliferative anemias occur when the
so they’re smaller than usual. bone marrow produces an inadequate number of
 Normocytic anemia: In this type of anemia, you erythrocytes.
have fewer red blood cells than usual, and those red  Decreased erythrocyte production results in a low or
blood cells don’t have the normal amount of inappropriately normal reticulocyte (i.e., immature
hemoglobin. RBC) count.
 Causes of hypoproliferative anemia may include
bone marrow damage from chemicals (e.g.,
benzene) or medication (e.g., chloramphenicol), lack
of important factors that promote erythrocyte
production such as erythropoietin, or lack of
nutrients, including iron, vitamin B12 and folic acid.
 In hemolytic anemias, premature destruction of
erythrocytes results in the liberation of hemoglobin
from the erythrocytes into the plasma; the released
hemoglobin is converted in large part to bilirubin and,
therefore, the bilirubin concentration rises.
 The increased erythrocyte destruction leads to tissue
hypoxia, which in turn stimulates erythropoietin
production. This increased production is reflected in
an increased reticulocyte count as the bone marrow
responds to the loss of erythrocytes.

NCM112 LECTURE
 Hemolysis (destruction of RBCs with release of
cellular components into the circulation) can result
from an abnormality within the erythrocyte itself (e.g.,
sickle cell disease [SCD], glucose-6-phosphate
dehydrogenase [G-6-PD] deficiency), within the
plasma Anemia is classified in several ways.
 Most often it is classified according to whether the
decreased number of erythrocytes is associated with
hypoproliferation (decreased production), hemolysis
(increased destruction), or loss of cells through
bleeding.
 Hypoproliferative anemias occur when the bone
marrow produces an inadequate number of
erythrocytes. Decreased erythrocyte production
results in a low or inappropriately normal reticulocyte
(i.e., immature RBC) count. Causes of
hypoproliferative anemia may include bone marrow
damage from chemicals (e.g., benzene) or
medication (e.g., chloramphenicol), lack of important
factors that promote erythrocyte production such as
erythropoietin, or lack of nutrients, including iron,
vitamin B12 and folic acid.
 In hemolytic anemias, premature destruction of
erythrocytes results in the liberation of hemoglobin
from the erythrocytes into the plasma; the released
hemoglobin is converted in large part to bilirubin and,
therefore, the bilirubin concentration rises. .
 The increased erythrocyte destruction leads to tissue CLINICAL MANIFESTATIONS
hypoxia, which in turn stimulates erythropoietin  The severity of the anemia, the rapidity with which the
production. This increased production is reflected in anemia developed, the duration (chronicity) of the
an increased reticulocyte count as the bone marrow anemia, metabolic requirements of the patient, the
responds to the loss of erythrocytes. presence of other conditions, such as cardiac or
 Hemolysis (destruction of RBCs with release of pulmonary disease, and complications or related features
cellular components into the circulation) can result of the condition that produced the anemia are some of
from an abnormality within the erythrocyte itself (e.g., these factors.
sickle cell disease [SCD], glucose-6-phosphate  In general, the more quickly the anemia develops, the
dehydrogenase [G-6-PD] deficiency), within the more severe the symptoms.
plasma (e.g., immune hemolytic anemias), or from  An otherwise healthy patient may be able to tolerate as
direct injury to the erythrocyte within the circulation much as a 50% reduction in hemoglobin over several
(e.g., hemolysis caused by a mechanical heart months without pronounced symptoms or significant
valve). incapacity; however, a rapid loss of 30% of the
 It is often possible to determine the cause of anemia hemoglobin over minutes may lead to profound vascular
in each patient based on the following factors: The collapse in the same person.
ability of the bone marrow to respond to the decrease  A patient who gradually becomes anemic, such as a
in erythrocytes by producing reticulocytes. The woman experiencing heavy menses over several months
degree to which immature erythrocytes proliferate in with hemoglobin levels between 9 and 11 g/dL, may have
the bone marrow and their ability to mature (as seen few or no symptoms except for slight tachycardia on
in a bone marrow biopsy) exertion or fatigue.
 People who are more active or who have significant life
demands are more likely to have symptoms than those
who are more sedentary.
 Patients with hypothyroidism with decreased oxygen
demands may be asymptomatic without tachycardia or
dyspnea with a hemoglobin of 10g/dL. Similarly, those
with co-existing cardiac, vascular, or pulmonary disease
may develop pronounced symptoms of anemia (e.g.,
dyspnea, chest pain, muscle pain, or cramping) with a
higher hemoglobin level than those without concurrent
health problems.

NCM112 LECTURE
 Some anemias, such as SCD, or autoimmune diseases  Percent saturation and ferritin.
are often complicated by other abnormalities that do not  Serum vitamin b12
result from the anemia but are inherent with the  Folate levels
associated disease.  Haptoglobin
 Pain and other symptoms may overshadow those caused  Erythropoietin level
by the anemia. Complications of severe anemia include  Bone marrow aspiration
heart failure, paresthesias, and delirium.  Colonoscopy or upper endoscopy
 Patients with underlying heart disease are more likely to
have angina and symptoms associated with heart failure MEDICAL MANAGEMENT
than those without heart disease.
 Management of anemia is directed toward correcting
 Weakness, fatigue, and general malaise are or controlling the cause of the anemia; if the anemia
common symptoms, and pallor of the skin and is severe, the erythrocytes that are lost or destroyed
mucous membranes (conjunctivae, oral mucosa) may be replaced with a transfusion of packed red
are common signs blood cells (PRBCs). Management of the various
types of anemia is covered in the discussions that
 Jaundice, angular cheilitis (inflammation and
follow.
fissures in the corners of the mouth), and brittle,
concave, ridged nails may be associated with GERONTOLOGIC CONSIDERATIONS
megaloblastic anemia (characterized by abnormally
large, nucleated RBCs) or hemolytic anemia. The  Anemia is the most common hematologic condition
tongue may be sore and beefy red in megaloblastic affecting older adults, particularly those admitted to
anemia, and smooth and red with iron deficiency hospitals and in long-term care facilities.
anemia.  The overall prevalence of anemia is 17% in older
adults, including approximately 10% of community-
ASSESSMENT AND DIAGNOSTIC FINDINGS
dwelling older adults, 45% of nursing homes
 Initial evaluation includes hemoglobin, hematocrit, residents, and 40% of those who are hospitalized.
reticulocyte count, and RBC indices, including mean
 Most have mild anemia with hemoglobin level of 11
corpuscular volume (MCV), and red cell distribution
g/dL or higher, but even mild anemia may be
width (RDW).
associated with decreased functional ability and
 Other studies may include iron studies (serum iron
increased morbidity and mortality.
level, total iron-binding capacity [TIBC], percent
 Mild anemia in older adults is associated with
saturation, and ferritin), serum vitamin B12, folate
decreased physical performance, decreased
levels, haptoglobin, and erythropoietin levels.
mobility, increased frailty, increased depression,
 The remaining complete blood count (CBC) values
increased risk of falls, and delirium
are also useful in determining if the anemia is an
 Studies have identified an association between
isolated condition or associated with another
anemia and cognitive decline.
hematologic condition such as leukemia (i.e.,
 Older adults with anemia are more likely to have
malignancy of the WBCs) or myelodysplastic
fatigue, dyspnea, and confusion because of reduced
syndrome (MDS).
cardiac reserve and inability to respond with an
 Bone marrow aspiration may be performed to asses
increase in heart rate and increased cardiac output.
for cellular abnormalities.
 Those with preexisting renal and cardiac disease and
 Additional studies such as colonoscopy or upper
those who have had recent surgery are at increased
endoscopy may be performed to determine if
risk for morbidity and mortality when anemic
underlying conditions causing the anemia are
present. NURSING MANAGEMENT
 Lesions in the gastrointestinal (GI) tract including
ulcers, polyps, or tumors may be sources of blood  History taking (Family,Health, medication)
loss.  Physical examination
 Assessment (Nutritional , Cardiac, GI)
Initial Assessment  Neurologic examination
 Hemoglobin
 Hematocrit BLEEDING DISORDERS
 Reticulocyte count
 RBC indices including mean corpuscular volume  The failure of normal hemostatic mechanisms can
(MCV) and red cell distribution width (RDW) result in bleeding which may be severe. Bleeding is
Other Studies usually caused by trauma, but can occur
 Iron studies such as: spontaneously. The causes of bleeding disorders
 Serum iron level can be classified based on platelet deficiency or
 Total iron-binding capacity (TIBC) defect, inherited or acquired coagulation factor
abnormality, and vasculature defects. When the

NCM112 LECTURE
cause is platelet or coagulation factor cautiously because excessive inhibition of
abnormalities, bleeding can occur anywhere in the fibrinolysis can lead to thrombosis.
body. When the source is a vascular abnormality  A patient scheduled for an invasive procedure may
the site of bleeding is more localized. Some patients need to have transfusions of select blood products to
may have simultaneous defects in more than one reduce risk for excessive bleeding.
hemostatic mechanism.
 Sometimes an increase in platelets does not result NURSING MANAGEMENT
from increased platelet production, but from a loss of
 Patients with bleeding disorders should monitor
platelet pooling in the spleen. The spleen stores one
themselves for signs of bleeding.
third of circulating platelets. If the spleen is absent,
 They should avoid activities that increase risk of
leading to an abnormally high number of platelets
bleeding, such as contact sports.
entering the circulation. Eventually, platelet
production slows to restore normal levels.  Examine the skin for bleeding, including petechiae
and ecchymoses (bruises) and the nose, and gums
CLINICAL MANIFESTATIONS for bleeding.
 When bleeding disorders are severe, hospitalized
patients are monitored for bleeding by testing
drainage and excreta (feces, urine, emesis, and,
gastric drainage) for obvious and occult blood.
PLATELET DEFECTS
 Quantitative platelet defects (i.e., thrombocytopenia,

thrombocytosis) are common, but qualitative defects
can also occur. Despite normal platelet counts,
platelets do not function normally when quzlitative
defects are present.. A platelet function analyzer is
used to evaluate platelet function and valuable for
rapid screening. Examining platelet morphology with
peripheral blood smear can identify possible
 Signs and symptoms of bleeding disorders vary
qualitative defects.Platelet morphology is
depending on the type of defect. Abnormalities of the
hypogranular, pale, and larger than normal. (Coutre,
vascular system can lead to localized bleeding,
2018).
usually into the skin. Because platelets are primarily
 Aspirin even in small amounts can reduce platelet
responsible for stopping bleeding from small vessels,
aggregation and increase bleeding time for several
patients with decreased platelets develop petechiae,
days after ingestion. Patients with thrombocytopenia
often in clusters. These lesions can occur on the skin
and coagulation disorders such as hemophilia can
and mucous membranes and spread throughout the
experience significant bleeding after aspirin
body. Bleeding from platelet disorders can be
ingestion, especially after trauma and invasive
severe, but often, ressure can help control bleeding
procedures.
from platelet disorders.
 NSAIDs can impair platelet function, but not as long
 In contrast, Coagulation factor defects do not cause
as aspirin (4 days vs. 7 to 10 days). Other causes of
superficial bleeding due to intact hemostatic
platelet dysfunction include end-stage renal disease,
mechanisms. Instead, bleeding occurs deeper within
MDS, multiple myeloma, cardiopulmonary bypass,
the body (e.g., subcutaneous or intramuscular
herbal remedies, and other medications.
hematomas, hemorrhage into joint spaces). Local
pressure reduces external bleeding; CLINICAL MANIFESTATIONS
 Bleeding can range from mild to severe. Bleeding

it frequently recurs several hours after pressure is severity varies does not usually depend on platelet
removed. count and coagulation (prothrombin time [PT],
activated partial thromboplastin time [aPTT]).
MEDICAL MANAGEMENT  However, results from tests can help determine the
etiology of bleeding disorders. (Levi, Seligsohn, &
 Management varies depending on underlying
Kaushansky, 2016).
bleeding disorder. If bleeding is significant,
transfusion of blood products is indicated depending
on underlying defect and extent of bleeding.  Ecchymoses, particularly on the extremities, are
frequently evident.
 If fibrinolysis is excessive, Aminocaproic acid can be
used to inhibit fibrinolysis, but must be used

NCM112 LECTURE
 Patients with platelet dysfunction are at increased 2. Hemophilia B (Christmas Disease)
risk of bleeding after trauma or invasive  This type is caused by genetic defect that results by
procedures.(e.g., dental extraction, biopsy). a lack or decrease of clotting factor IX.
MEDICAL MANAGEMENT
 Both are clinically similar but are distinguishable by
 Platelet dysfunction that is associated with a
laboratory tests.
medication, medication should be stopped when
bleeding occurs.  Both hemophilia A and hemophilia B are inherited as
X-linked traits,making them more common in males
 If platelet dysfunction is present, Preventing bleeding
than females.
by transfusion of platelets before invasive
procedures.  Females can be carriers of the gene, but one third of
cases are due to spontaneous mutations rather than
 Antifibrinolytic agents (e.g., aminocaproic acid) and
familial transmission. (National Hemophilia
desmopressin can reduce bleeding and improve
Foundation, 2019).
hemostasis. (Levi et al., 2016).
 The tendency for bleeding is the basis for hemophilia
NURSING MANAGEMENT classification.
 Patients with platelet dysfunction should avoid

substances that can interfere with platelet function
(OTC medications, herbal preparations, nutritional
supplements, and alcohol).
 Patients should notify health care providers of their
underlying condition before any invasive procedure
to reduce risk of bleeding. Maintaining good oral
hygiene promotes good dental health and reduces
risk for gingival bleeding.
HEMOPHILIA  Hemophilia is often recognized in early childhood,

usually in the toddler period. However, Mild
hemophilia may not be diagnosed until severe
trauma or surgery..
 Hemophilia is a rare, inherited blood disorder that

causes your blood to clot less, which results in an
increased risk of bleeding or bruising.
 It happens because your body doesn’t make enough
protein (clotting factors) to help your blood form clots.
Clotting factors are proteins in your blood. They work
with your platelets to form blood clots that control
bleeding. Low clotting factor levels increase bleeding
risk.
Hemophilia is suggested by a history of hemorrhage
TWO FORMS OF HEMOPHILIA disproportionate to trauma or of spontaneous
hemorrhage, or a family history of bleeding problems.
1. Hemophilia A (Classic Hemophilia)
 This type is caused by a genetic defect that results  Bleeding into the joints- (Joints in knees, elbows,
by a lack or decrease of clotting factor VIII. ankles, shoulders, wrists, and hips)
 Hemophilia A is a common disease with 1 in every  Bleeding into the skin (which is bruising) or muscle
5000-7000 births and soft tissue causing a build-up of blood in the area
(called a hematoma).
 Five times more common than hemophilia B.
 Bleeding in gums or mouth (Dental procedures,
including extractions, are associated with bleeding)

NCM112 LECTURE
 Hematuria and GI bleeding. signs of bleeding to minimize bleeding and reduce
 Bleeding of mucous membranes (nasal passages, complications.
conjunctivae,soft tissue)  Stay alert for bleeding- Patients who have had recent
 Bleeding into the brain-(Intracranial and extracranial surgery need careful monitoring to assess for
hemorrhages). bleeding from surgical sites. Frequent monitoring of
 Excessive post-surgical bleeding vital signs, drains, and dressings is necessary to
identify postoperative bleeding.
 Precautions for patients undergoing invasive
procedures
 Relieve pain. Significant pain requiring analgesics is
MEDICAL MANAGEMENT often associated with hematomas and joint
hemorrhage. Warm baths can be helpful in relieving
 Factor VIII and FIX concentrates- used when
pain, promoting relaxation, and improving mobility.
patients are actively bleeding; treatment should be
initiated as soon as possible to reduce risk of
bleeding complications.
 Treatment of patients with inhibitors. Inhibitors can DISSEMINATED INTRAVASCULR DISORDER
lead to refractoriness to factor replacement, leading  or Disseminated Intravascular Coagulant (DIC)
to increased risk of bleeding. Antibody titers should  is a rare and serious condition that disrupts your
remain low to reduce the impact of inhibitors inducing blood flow.
immune tolerance is critical. Immunosuppressive  It is a blood clotting disorder that can turn into
therapy in the form of corticosteroids, IVIG or uncontrollable bleeding.
cyclophosphamide may be used to remove  DIC affects about 10% of all people who are very ill
with sepsis, diseases such as cancer or
inhibitors. Emicizumab is effective in preventing
pancreatitis, as well as people recovering from
bleeding in hemophilia A. Initially indicated as traumatic injuries such as burns or serious
effective therapy for patients with inhibitors, it is now complications from pregnancy and delivery.
also indicated for patients without inhibitors. Patients
with severe factor deficiency should be screened for
antibodies to reduce risk of bleeding complications. CAUSES
Other therapeutic options include recombinant factor  DIC creates many small blood clots that might keep
VIIa or activated prothrombin complex concentrates. your blood from traveling through your body. When
 Fibrin sealants, these can be applied directly to this happens, your blood might not be able to bring
wound sites to promote clotting and healing. Fibrin oxygen and nutrients to your head, heart and other
organs. Then, having used up the proteins and
sealants are especially useful for dental work.
platelets that make your blood clot, DIC might cause
 Aminocaproic acid, prevent the breakdown of blood uncontrollable internal or external bleeding.
clots and can be used to treat mucosal bleeding after  Disseminated intravascular coagulation has been linked
oral surgery. Desmopressin induces a significant but to certain medical treatments or conditions. Medical
short-lived increase in factor VIII levels; the treatments that can cause DIC include:
mechanism of this response is unclear. o Blood transfusion reactions.
Desmopressin can reduce the need for blood o Recent surgery or anesthesia.
products in mild forms of hemophilia A. o Complications from labor and delivery.
 Physical therapy-It can ease signs and symptoms if
internal bleeding has damaged your joints. Severe
 Medical conditions that can cause DIC include:
damage might require surgery.
o Cancer, especially certain types of leukemia.
 First aid for minor cuts. Using pressure and a o Pancreatitis.
bandage will generally take care of the bleeding. For o Blood infections.
small areas of bleeding beneath the skin, use an ice o Liver disease.
pack. Ice pops can be used to slow down minor o Severe tissue injury including burns and head
bleeding in the mouth. injuries.
o Unformed blood vessels called hemangioma.
NURSING MANAGEMENT
 Provide emotional support and provide patients with

extensive education to understand activity
restrictions and self-care strategies to reduce risk for RISK FACTORS
hemorrhage and complications associated with DIC can be caused by infection, injury and several medical
bleeding. Safety at home and at work should be conditions. That means almost anyone can be affected by
emphasized. DIC. This includes:
 Educate family caregivers need to learn how to o Sepsis, which is wide-spread inflammation or
administer factor concentrate at home at the earliest swelling in your body. Sepsis is the most common
cause of DIC.

NCM112 LECTURE
o Major damage to organs or tissues through  A controversial method to interrupt the thrombosis
illnesses such as pancreatitis, severe trauma, burns process is the
or major surgery.  use of heparin infusion. Heparin may inhibit the
o Medical conditions such as cancer, blood vessel formation of microthrombi and thus permit perfusion
abnormalities, pregnancy complications or severe of the organs (skin, kidneys, or brain) to resume.
immune system reactions to blood transfusions,  Heparin is typically reserved for the patient in whom
organ transplants or snake bites. thrombotic manifestations predominate or in whom
o Obstetric complications extensive blood component replacement fails to halt
o Acute hemolysis (eg, transfusion reaction) the hemorrhage or increase fibrinogen and other
o Shock clotting levels. When heparin is administered,
o Allergic reactions bleeding may actually worsen initially until the
thrombotic process is interrupted
 Consumed platelets and clotting factors need to be
replaced. The effectiveness of heparin can best be
 Patients with DIC may bleed from mucous
determined by observing for normalization of the
membranes, venipuncture sites, and the
plasma fibrinogen concentration and diminishing
gastrointestinal and urinary tracts. signs of bleeding.
 The bleeding can range from minimal occult internal o Plasma transfusions to reduce bleeding.
bleeding to profuse hemorrhage from all orifices. Plasma transfusion replace blood clotting
 Patients may also develop organ dysfunction, such factors affected by DIC.
as renal failure and pulmonary and multifocal o Transfusions of red blood cells and/or platelets.
central nervous system infarctions as a result of o Anti-coagulant medication (blood thinners) to
micro-thromboses, macro-thromboses, or prevent blood clotting.
hemorrhages.
 During the initial process of DIC, the patient may
have no new symptoms, the only manifestation
being a progressive decrease in the platelet count.
 One classic symptom is uncontrolled bleeding from
several areas of your body. Other symptoms are:
o Bruising.
o Blood clots.
o Confusion, memory loss or change of behavior.
o Difficulty breathing.
o Fever.
DIAGNOSTIC TEST
Providers use several tests to diagnose DIC. Those tests
are:
o Complete blood count (CBC).

o Partial thromboplastin time (PTT).
o Prothrombin time (PT) test. This test measures the
time it takes for your blood to clot.
o Fibrinogen blood test. Fibrinogen is a protein in your
blood that helps your blood to clot. This test
measures your fibrinogen levels.
o D-dimer. This is a blood test to check for blood
clots.
MEDICAL MANAGEMENT
 Until the cause is controlled, the mechanism for
 DIC will persist. A second goal is to correct the
secondary effects of tissue ischemia by improving
oxygenation, replacing fluids, correcting electrolyte
imbalances, and administering vasopressor
medications.
 If serious hemorrhage occurs, the depleted
coagulation factors and platelets may be replaced
to reestablish the potential for normal hemostasis
and thereby diminish bleeding.
 Cryoprecipitate is given to replace fibrinogen and
factors V and VII; fresh frozen plasma is
administered to replace other coagulation factors.

2. CARDIOVASCULAR - 2ND SCERNARIO

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2. CARDIOVASCULAR - 2ND SCERNARIO

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NCM112 LECTURE

BSN3A | PBL GROUP 1 1

BSN3A | PBL GROUP 1 2

PULSES  When pulses cannot be reliably palpated, a handheld

EDEMA  The transducer can detect blood flow in advanced

BSN3A | PBL GROUP 1 3

 involves B-mode grayscale imaging of the tissue,

 An arteriogram produced by angiography may be

BSN3A | PBL GROUP 1 4

 Also known as venography, contrast phlebography

MAGNETIC RESONANCE ANGIOGRAPHY LYMPHOSCINTIGRAPHY

NURSING IMPLICATIONS NURSING IMPLICATIONS

 involves a different process, affecting the intima of

BSN3A | PBL GROUP 1 5

 The most common direct results of atherosclerosis in

 Intermittent claudication is a symptom of generalized

BSN3A | PBL GROUP 1 6

 The management of atherosclerosis involves

 Arterial blood supply to a body part can be enhanced

BSN3A | PBL GROUP 1 7

NURSING MANAGEMENT MEDICAL MANAGEMENT

BSN3A | PBL GROUP 1 8

 Chest or back pain: Aneurysms can cause chest or

BSN3A | PBL GROUP 1 9

BSN3A | PBL GROUP 1 10

BSN3A | PBL GROUP 1 11

 Acute vascular occlusion may be caused by an embolus ARTERIAL THROMBOSIS

BSN3A | PBL GROUP 1 12

BSN3A | PBL GROUP 1 13

 Primary or Idiopathic Raynaud’s - occurs in the absence VENOUS THROMBOEMBOLISM

BSN3A | PBL GROUP 1 14

CLINICAL MANIFESTATIONS  Providing Compression Therapy

BSN3A | PBL GROUP 1 15

 Varicose veins (varicosities) are abnormally dilated, RISK FACTORS

BSN3A | PBL GROUP 1 16

 wearing tight socks SYSTOLIC & BLOOD PRESSURE CATEGORY

 High blood pressure SECONDARY HYPERTENSION

BSN3A | PBL GROUP 1 17

 Structural and functional changes in the heart,

BSN3A | PBL GROUP 1 18

BSN3A | PBL GROUP 1 19

BSN3A | PBL GROUP 1 20

 This should be comprehensive and include careful CENTRAL NERVOUS SYSTEM

ORAL CAVITY HEMATOLOGIC STUDIES

 Petechiae in the buccal mucosa, gingiva, hard palate HEMATOLOGY

 Increased rate and depth of respirations;

BSN3A | PBL GROUP 1 21

 These procedures are used to diagnose and monitor

 Patient will undergo blood tests to check their blood

A test done by spreading a drop of blood onto a glass plate PROCEDURE

BSN3A | PBL GROUP 1 22

 Men who have sexual relations with men must wait

BSN3A | PBL GROUP 1 23

BSN3A | PBL GROUP 1 24

STEP ONE: The Donation

 Arrive for your donation blood appointment

BSN3A | PBL GROUP 1 25

 An ill or injured patient arrives at a hospital or treatment

 Administration of blood and blood components requires

People receive blood transfusions for many reasons — such

BSN3A | PBL GROUP 1 26

 The respiratory system should be assessed, including

 Review the signs and symptoms of a transfusion with

BSN3A | PBL GROUP 1 27