NUR 326 Exam 4 - Answer Atherosclerosis 2. List some clinical ma...

NUR 326 Exam 4

• Hardening and plaque buildup of arteries and veins, *the leading cause of PAD.*

Answer Atherosclerosis

• List some clinical manifestations of PAD.

• Paresthesia (Numbness or tin- gling in the toes or feet)
• Thin, shiny taut skin.
• Loss of hair on legs.
• Diminished or absent pedal, popliteal or femoral pulses.
• *Intermittent claudication*
• Reactive hyperemia of foot with dependent position
• Chronic

Answer Rest pain

• Cold, pale extremities
• Longer capillary refill

• Pain with exercise that is relieved by rest. If there is not a lot of blood flow to extremities,

especially while exercising, there is pain from hypoxia and a buildup of lactic acid. Classic with arterial.

Answer Intermittent claudication

• Where are PAD ulcers commonly found? What do they look like? Is there drainage?

Answer Tips of toes, foot, or *lateral* malleolus.They are rounded, smooth, the hole usually looks "punched out". The edges are more demarcated. There is minimal drainage. There is black eschar or pale pink granulation. The ulcer may or may not be painful.

• Are you more likely to need an amputation with PAD or chronic venous insufficiency?

Answer PAD due to them not healing very well and gangrene occurring.

• / 3

• With peripheral arterial insufficiency, leg pain during rest can be reduced by

• Elevating the limb above heart level
• Lowering the limb so it is dependent
• Massaging the limb after application of cold compresses
• Placing the limb in a plane horizontal to the body

Answer B

• Mike, a 43-year old construction worker, has a history of hypertension. He smokes two

packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive dis- ease. The nursing diagnosis is probably

• Alteration in tissue perfusion related to compromised circulation
• Dysfunctional use of extremities related to muscle spasms
• Impaired mobility related to stress associated with pain
• Impairment in muscle use associated with pain on exertion

Answer A

• A nurse is assessing the neurovascular status of a client who returned to the surgical nursing

unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is

• Normal because of the increased blood flow through the leg
• Slightly deteriorating and should be monitored for another hour
• Moderately impaired, and the surgeon should be called.
• Adequate from the arterial approach, but venous complications are aris- ing.

Answer A (An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.) 2 / 3

• A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to

note that the ulcer

• Has a pale colored base
• Is deep, with even edges
• Has little granulation tissue
• Has brown pigmentation around it

Answer D (Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident.The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 are due to tissue malnutrition; and thus us an arterial problem))

• List three surgical/radiographic interventions for treating PAD.

Answer

• Debride- ment (The removal of damaged tissue or foreign objects from a wound.)
• Angioplasty (A procedure done to widen the artery occluded. It involves the doctor threading a

small tube into the artery that has a balloon attached to it, and the balloon is inflated open to widen the artery and increase blood flow.)

• Bypass (Surgery done to reroute the blood supply around a blocked artery in your leg.)

• Where are ulcers found with venous insufficiency? What does it look like? Is there

drainage?

Answer Medial malleolus. It will look irregularly shaped and there will be a moderate to large amount of drainage. There is a yellow slough or dark red, "ruddy" granulation.

• List some clinical manifestations associated with venous insufficiency.

Answer

• Edema
• Hemosiderin staining (Brown stains on their legs due to blood pooling in the legs and the

capillaries break as a result, when the RBCs break the iron is released, which causes brown/reddish discoloring of the skin.)

• Thick, hardened skin, leathery
• Easily breakable skin
• Capillary refill <3

• Brown stains on their legs due to blood pooling in the legs and the capillaries break as a
• / 3