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Dr. Yousef Aljeesh Dr. Motasem Salah

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1 Dr. Yousef Aljeesh Dr. Motasem Salah
By Dr. Yousef Aljeesh Dr. Motasem Salah Associate Professor PhD Nursing Administration Chapter 31 Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation Medical Surgical- Part B

2 Dr.Yoused Aljeesh Dr. Motasem Salah
Objectives: On completion of this chapter, the learner will be able to: 1. Identify anatomic and physiologic factors that affect peripheral blood flow and tissue oxygenation. 2. Use the nursing process as a framework of care for patients with circulatory insufficiency of the extremities. 3. Compare the various diseases of the arteries, their causes, pathologic and physiologic changes, clinical manifestations, management, and prevention. 4. Describe the prevention and management of venous thrombosis. 5. Compare the preventive management of venous insufficiency, leg ulcers, and varicose veins. 6. Describe the relationship between lymphangitis and lymphedema. 7. Define ELEPHANTIASIS Dr.Yoused Aljeesh Dr. Motasem Salah

3 Assessment and Management of patient with vascular disorder
Vascular system: consist of two interdependent system 1- Right heart pump: blood to the lung through the pulmonary circulation. 2- Left heart pumps: blood to all body tissue through systemic circulation. Adequate blood flow → adequate perfusion → adequate O2 and nutrient to body tissue. Characterize: each one depend on another(pulmonary circulation depend on systemic ) Dr.Yoused Aljeesh Dr. Motasem Salah

4 Dr.Yoused Aljeesh Dr. Motasem Salah
Arteries: distribute oxygenated blood from the left side of the heart to the tissues [ blood distribution] Veins: carry deoxygenated blood from the tissues to the right side of the heart. [blood collection] Arterioles: small arteries Venules: small veins Capillaries: microscopic vessels that carry blood from small arteries to small veins [ from arterioles to venules] Dr.Yoused Aljeesh Dr. Motasem Salah

5 Systemic and Pulmonary Circulation
Dr.Yoused Aljeesh Dr. Motasem Salah

6 Dr.Yoused Aljeesh Dr. Motasem Salah
Blood flow Left heart to aorta → arteries→ arterioles → capillaries → venules → veins → vena cavae → finally to the right heart. This unidirectional flow is caused by pressure difference between the arterial and venous systems. Arterial pressure a proximal 100 mm Hg is greater than venous pressure a proximal 4 mm Hg. Fluid flows from an area of high pressure to an area of low pressure. Dr.Yoused Aljeesh Dr. Motasem Salah

7 Pathophysiology of the vascular system
Decrease blood flow to extremities Decrease tissue perfusion ↓ o2 and nutrients Inability to maintain normal function of tissue Damage of the tissue Dr.Yoused Aljeesh Dr. Motasem Salah

8 Assessment of circulation insufficiency
The most important point for the diagnosis of arterial disorders are: Pain Skin color & temperature Pulse (peripheral pulses)

9 Dr.Yoused Aljeesh Dr. Motasem Salah
1. Pain Intermittent claudication: The hallmark clinical manifestation of peripheral arterial occlusive disease is intermittent claudication. This pain may be described as sever sharp pain induced by the same degree of exercise or activity as a result of inadequate blood flow to the tissue and is relieved with rest. During rest, pain is decreased or relieved as result of ↓ metabolic need of the muscles. Pain in the extremities, during rest indicate sever degree of arterial insufficiency. Dr.Yoused Aljeesh Dr. Motasem Salah

10 2. Skin appearance and temperature Dr.Yoused Aljeesh Dr. Motasem Salah
Adequate blood flow → warms the extremities and give rosy coloring. Inadequate blood flow results → cool and pale extremities. Cyanosis: bluish coloring of the skin because the amount of O2 contained in the blood is reduced Dr.Yoused Aljeesh Dr. Motasem Salah

11 Dr.Yoused Aljeesh Dr. Motasem Salah
3. Pulses Absence of a pulse may indicate that the site of stenosis (narrowing or constriction) is proximal to that location. Occlusive arterial disease impairs blood flow and can reduce palpable pulsations in the extremities. Dr.Yoused Aljeesh Dr. Motasem Salah

12 Assessing Peripheral Pulses
We assess peripheral pulse through Dorsalis pedis Popliteal artery Posterior tibial art. Dr.Yoused Aljeesh Dr. Motasem Salah

13 Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites
Dr.Yoused Aljeesh Dr. Motasem Salah

14 Dr.Yoused Aljeesh Dr. Motasem Salah
Continuous-wave Doppler ultrasound detects blood flow, this diagnostic technique helps characterize the nature of peripheral vascular disease. Dr.Yoused Aljeesh Dr. Motasem Salah

15 Risk factors for peripheral vascular disease
Controllable risk factors Tobacco use ↑ B.P [hypertension] Obesity Sedentary lifestyle Stress D.M. Noncontrollable risk factors: Age Gender Dr.Yoused Aljeesh Dr. Motasem Salah

16 Dr.Yoused Aljeesh Dr. Motasem Salah
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: Diagnosis Ineffective peripheral tissue perfusion related to compromised circulation Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen Risk for impaired skin integrity related to compromised circulation Deficient knowledge regarding self-care activities Dr.Yoused Aljeesh Dr. Motasem Salah

17 Dr.Yoused Aljeesh Dr. Motasem Salah
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: Planning Major goals include increased arterial blood supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program. Dr.Yoused Aljeesh Dr. Motasem Salah

18 1. Improving Peripheral Arterial Circulation
Exercises and activities: walking, graded isometric exercises. Positioning strategies Elevating the head of the bed “sitting position” [in cause of arterial insufficiency]. Temperature; effects of heat and cold: Smoking cessation Stress reduction Dr.Yoused Aljeesh Dr. Motasem Salah

19 Buerger – Allen exercises
Placing the extremities in 3 position : Position 1: the patient lies flat in bed with both legs elevated above the heart for 2-3 min. Position 2: sitting on the edge of the bed with the legs relaxed and dependent, the patient exercise the feet and toes [upward + downward , inward + outward] for about 3 min Position 3: the pt lies flat with legs at the same level as the heart for about 5 minutes. [The exercise series is performed 6 times, 4 times day] Dr.Yoused Aljeesh Dr. Motasem Salah

20 Dr.Yoused Aljeesh Dr. Motasem Salah
Note: persons with venous insufficiency should elevated their leg above the level of the heart and should avoiding standing & sitting position because problem worse Exercise will be contraindication in case of: leg ulcer, cellulities, gangrene, acute thrombotic occlusions. All of these cases required the pt to be in bed rest. Dr.Yoused Aljeesh Dr. Motasem Salah

21 2- Promoting vasodilation & preventing vascular compression.
Warmth promotes arterial flow Adequate clothing & warm temperatures protect the patient from chilling. Dr.Yoused Aljeesh Dr. Motasem Salah

22 2- Promoting vasodilation & preventing vascular compression.
Applying a heating pad to the abdomen can cause reflex vasodilation in the extremities and is safer than direct application of heat to affected extremities. Instruct the pt stop smoking. Instruct the pt to avoid emotional upset & stress. Avoid crossing the legs because it leads to further vascular compression & also avoid constricting clothing. Dr.Yoused Aljeesh Dr. Motasem Salah

23 Dr.Yoused Aljeesh Dr. Motasem Salah
3- Relieving Pain Analgesic may be helpful in reducing pain. Vasodilator medications are helpful in reducing pain. Dr.Yoused Aljeesh Dr. Motasem Salah

24 Dr.Yoused Aljeesh Dr. Motasem Salah
4- Pt education Cleanliness [wash feet daily & use mild soap] Warmth [wear extra socks in cold weather] Safety [inspect feet daily with mirror] Comfort measures [use powder daily between the toes to promote drying] Prevent construction of blood vessels [do not cross legs & quit smoking] Exercise [participate in regular walking exercise] Dr.Yoused Aljeesh Dr. Motasem Salah

25 Characteristics of Arterial and Venous Insufficiency
Cramping , aching [minimal pain] Intermittent claudication to sharp [very painful] Pain present Diminished or absent Pulse Reddish, blue in color Dry, shiny skin Skin Superficial Deep Ulcer Moderate to sever Minimal Edema Dr.Yoused Aljeesh Dr. Motasem Salah

26 Arteriosclerosis & Atherosclerosis
Arteriosclerosis is the most common disease of the arteries; the term means hardening of the arteries. It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened. Atherosclerosis. A disease of the arteries in which fatty plaques develop in their inner walls, with eventual obstruction of blood flow. It is mainly affect large and medium arteries. Dr.Yoused Aljeesh Dr. Motasem Salah

27 Progression of Atherosclerosis
Fatty streaks constitute one of the earliest lesions of atherosclerosis. Many fatty streaks regress, whereas others progress to fibrous plaques and eventually to atheroma, which may be complicated by hemorrhage, ulceration, calcification, or thrombosis and may produce myocardial infarction, stroke, or gangrene. Dr.Yoused Aljeesh Dr. Motasem Salah

28 Common Sites of Atherosclerotic Obstruction
These plaques are found predominantly in the abdominal aorta and the coronary, popliteal, and internal carotid arteries. Dr.Yoused Aljeesh Dr. Motasem Salah

29 Risk Factors for Atherosclerosis Modifiable Nonmodifiable
Nicotine Diet (↓ fat diet) Hypertension (↓ B.P by diet + medication) Diabetes (diet + medication) Obesity Stress Sedentary lifestyle Age Gender Familial predisposition/genetics Dr.Yoused Aljeesh Dr. Motasem Salah

30 Dr.Yoused Aljeesh Dr. Motasem Salah
Management Prevention (Modification of risk factors) Exercise program (Improve circulation and increase the functioning capacity of the circulation) Medications (Reduce blood lipid levels) Use of antiplatelet agents Note: We can determined the obstruction through angiogram [X-ray examination of blood vessels, a dye is injected into the artery & X-ray films is taken. Dr.Yoused Aljeesh Dr. Motasem Salah

31 Peripheral arterial occlusive disease
Arterial insufficiency of the extremities is usually found in individual over 50 years old. Legs are mostly affected. The severity are influenced by the number of atherosclerotic risk factors [ D.M , ↑ B.P, smoking , life style] Clinical manifestation Intermittent claudication: sever sharp pain in the calf & legs muscles, induced by exercise & relieved by rest Coldness or numbness Ulcerations & gangrene Muscle atrophy Peripheral pulses may be diminished or absent Dr.Yoused Aljeesh Dr. Motasem Salah

32 Diagnostic evaluation and management:
1- Doppler ultrasonic flow studies :- its an electronic stethoscope that can reflect the sound of blood flow even when pulses are not palpable. 2- Angiography :- x-ray examination of blood vessels, a dye is injected into the artery and rapid x- ray films is taken. Complication of the angiography: a- local irritation at the injection site B- allergic reactions [such as dyspnea , nausea + vomiting, sweating and tachycardia] Rx : antihistamine and steroids Dr.Yoused Aljeesh Dr. Motasem Salah

33 Dr.Yoused Aljeesh Dr. Motasem Salah
Care of the feet & legs for the person with peripheral vascular problem 1- Cleanliness [wash feet daily, mild soap, dry feet] 2- Warmth [wear clean socks + extra socks in case of cold weather]. 3- Safety [inspect feet daily with mirror for redness wear soft shoes , & Trim Nails straight after showering] 4- Comfort measures [use cream if feet dry but never put between the toes], but you can use powder. Dr.Yoused Aljeesh Dr. Motasem Salah

34 Dr.Yoused Aljeesh Dr. Motasem Salah
Care of the feet & legs for the person with peripheral vascular problem 5- Prevent constriction of blood vessels [do not cr0ss legs, quit smoking, avoid compression around knees] 6- Exercise [participate in regular walking exercise program to stimulate circulation] 7- Seeking medical attention [contact health care provider at the onset of skin breakdown ]. Dr.Yoused Aljeesh Dr. Motasem Salah

35 Buerger’s Disease: Thromboangiitis Obliterans
Recurring inflammatory process of the small and intermediate vessels of (usually) the lower extremities; probably an autoimmune disorder Most often occurs in men ages 20-35 Risk or aggravating factor: tobacco Progressive occlusion of vessels results in pain, ischemic changes, ulcerations, and gangrene. Etiology: The cause of Buergers disease is unknown but it believed to be due to autoimmune disease {autoimmune vasculitis} Dr.Yoused Aljeesh Dr. Motasem Salah

36 Clinical manifestation
The pt will complain of sever sharp cramp pain in the feet or legs. often exercise [intermittent claudication] which relieved by rest. The early S & S of Burgers disease is “numbness and coldness” sensation to cool & burning sensation. Pulse may be diminished or absent. Ulceration & gangrene and tissue damage eventually occurs. Circulatory insufficiency Decrease circulation extremities. Burning sensation Dr.Yoused Aljeesh Dr. Motasem Salah

37 Management & Nursing interventions:
Improve circulation. Protect extremities from trauma and infection. Instruct the patient to stop smoking. Vasodilators are rarely prescribed because these medication cause dilation of only healthy vessels. Instruct the patient avoid emotional stresses Instruct the patient avoid exposure to cold. Instruct the pt avoiding high risk. Should the pt to avoid trauma. Dr.Yoused Aljeesh Dr. Motasem Salah

38 Dr.Yoused Aljeesh Dr. Motasem Salah
Prognosis bad prognosis Gangrene below knee → below knee amputation. Gangrene above knee → above knee amputation. Dr.Yoused Aljeesh Dr. Motasem Salah

39 Dr.Yoused Aljeesh Dr. Motasem Salah
Aortic aneurysms Classification 2 types: 1] Thoracic aortic aneurism. 2] Abdominal aortic aneurism Definition of aneurysms: Is a localized sac or swelling in the wall of an artery due to weak point in the vessel wall. An aneurysm is a weak point in a blood vessel wall, most commonly in an artery. We have many forms of aneurysms but the most common forms of aneurysms are saccular or fusiform aneurysm. Dr.Yoused Aljeesh Dr. Motasem Salah

40 Characteristics of Arterial Aneurysms
Normal artery. False aneurysm—actually a pulsating hematoma. The clot and connective tissue are outside the arterial wall. (C) True aneurysm. One, two, or all three layers of the artery may be involved. (D)Fusiform aneurysm—symmetric, spindle-shaped expansion of entire circumference of involved vessel. (E) Saccular aneurysm—a bulbous protrusion of one side of the arterial wall. (F) Dissecting aneurysm—this usually is a hematoma that splits the layers of the arterial wall. Dr.Yoused Aljeesh Dr. Motasem Salah

41 Dr.Yoused Aljeesh Dr. Motasem Salah
Causes: 1- Atherosclerosis: the most common cause of aneurysms. 2- Trauma to the wall of the artery. 3- Infection. Aneurysms are serious because they can rupture lead to bleeding & death. Dr.Yoused Aljeesh Dr. Motasem Salah

42 1] Thoracic Aortic Aneurysm:
Definition: sac present in the chest cavity. Approximately 85% of all cases of thoracic aortic aneurysm are caused by atherosclerosis. They occur most frequently in men between the ages 40 and 70 years. About one third of patients with thoracic aneurysms die of rupture of the aneurysm Dr.Yoused Aljeesh Dr. Motasem Salah

43 Signs & Symptoms (Thoracic Aortic Aneurysm)
Some patients are asymptomatic. In most cases, pain is the most prominent symptom. The pain in the chest is usually constant and boring. Dysphagia, dyspnea and horsiness of voice (the result of pressure of the sac against the trachea, esophagus, main bronchus, or the lung itself) Aphonia [ result from pressure on laryngeal nerve]. Dr.Yoused Aljeesh Dr. Motasem Salah

44 Dr.Yoused Aljeesh Dr. Motasem Salah
Diagnosis (Thoracic aortic aneurysm): Chest x-rays. C.T scan. [computerized tomography] provide an image of the soft structures of the body particular brain. Management: Surgical repair Control blood pressure: by antihypertensive drugs & controlling risk factors. Open heart surgery to remove aneurism Physical examination (6 month) Dr.Yoused Aljeesh Dr. Motasem Salah

45 Repair of an Ascending Aortic Aneurysm
Dr.Yoused Aljeesh Dr. Motasem Salah

46 2) Abdominal Aortic Aneurism
Definition: aortic aneurism (sac) in the abdominal cavity The most common cause of abdominal aortic aneurysm is atherosclerosis. (other causes: trauma & infection) The condition is more common among Caucasian affects men four times more than women, most prevalent after age of 60. Most of these aneurysms occur below the renal arteries. Untreated, the eventual outcome may be rupture and death Dr.Yoused Aljeesh Dr. Motasem Salah

47 Dr.Yoused Aljeesh Dr. Motasem Salah
Signs & symptoms: Some patients can feel their heart beating in their abdomen [pulsated mass] when lying down. Most common signs & symptoms the pt will have abdominal mass. Mainly this disease Caucasian people more than others Mainly the disease more male than female. Dr.Yoused Aljeesh Dr. Motasem Salah

48 Dr.Yoused Aljeesh Dr. Motasem Salah
Diagnosis: Abdominal X-ray confirm the existence of an aneurysm C-T scan is useful for determining the size of aneurysm. Pulsated mass in the middle and upper abdomen. Management: Surgery is the treatment of choice for abdomen aneurysm larger than 5 cm in diameter. Dr.Yoused Aljeesh Dr. Motasem Salah

49 Indication of rupturing abdominal aortic aneurysm
Sever constant back pain Rigid abdomen Decreasing hematocrit Hematomas in the scrotum, perineum area, flank or penis. S & S of hypovolemic shock (Hypotension) Note : The surgical mortality rate with ruptured aneurysm is 50 to 75%. Dr.Yoused Aljeesh Dr. Motasem Salah

50 Arterial Embolism & Arterial Thrombosis
Embolus: material such as blood clot, fat, air, or foreign body. Embolism: the condition in which an embolus becomes lodged in an artery & obstructs its blood flow. Rx: embolectomy, anticoagulant therapy & streptokinase. Thrombus: blood clot Thrombosis: the condition in which the blood changes from liquid to solid state and produces blood clot. Thrombosis in an artery obstructs the blood flow to the tissue it supplies. Rx: thrombectomy Dr.Yoused Aljeesh Dr. Motasem Salah

51 Clinical manifestation:
Sever pain, gradual loss of sensory & motor function. Four P associated with acute arterial embolism are Pain, Pallor, Pulselessness, Paresthesia. Dr.Yoused Aljeesh Dr. Motasem Salah

52 Dr.Yoused Aljeesh Dr. Motasem Salah
Raynaud's Disease Raynauds Disease: is refer to localized, intermittent arterial vasoocclusion of small arteries of the feet and hands (fingertips or toes) that cause color and temperature changes. Cause : unknown Occurs most frequently in young women Manifestations: sudden vasoconstriction results in color changes, numbness, and burning pain Dr.Yoused Aljeesh Dr. Motasem Salah

53 Management of Raynaud's Disease
Avoiding upsetting situation (cold, stress) Avoid smoking. Emotional support. Avoid injury by sharp object. Vasodilator drugs Protect from cold/other triggers. Avoid injury to hands/fingers. Dr.Yoused Aljeesh Dr. Motasem Salah

54 Dr.Yoused Aljeesh Dr. Motasem Salah
Venous thrombosis Factors play significant role in venous thrombosis: 1- Stasis of blood: occur when blood flow is retarded occur with heart failure, shock, and bed rest. 2- Damage of the blood vessels: creates site for clot formation. 3- Altered blood coagulation: suddenly stopped the anticoagulant medication Dr.Yoused Aljeesh Dr. Motasem Salah

55 THROMBOPHLEBITIS & PHLEBOTHROMBOSIS
Thrombophlebitis: inflammation of the walls of the vein and is frequently accompanied by the formation of clot. Phlebothrombosis: condition of developing clot in the veins. When a thrombus develops initially in the veins as a result of stasis or hypercoagulability but without inflammation, the process is referred to as phlebothrombosis Dr.Yoused Aljeesh Dr. Motasem Salah

56 DVT [Deep Venous Thrombosis]
DVT: is a blood clot that forms in a vein deep in the body. Most occur in the leg or hip veins. However, a deep vein thrombosis also can occur in other parts of the body. Risk factors: 1- Bed rest, obesity. 2- Spinal cord injury [because of immobilization]. 3- Low blood flow in a deep vein due to injury, surgery, or immobilization. 4- Pregnancy. 5- Malignancy. Dr.Yoused Aljeesh Dr. Motasem Salah

57 Dr.Yoused Aljeesh Dr. Motasem Salah
Clinical manifestation DVT: 1- Deep calf pain when the foot is flexed backwards [Positive Homans signs]. 2- Heaviness on standing because of edema & swelling of the extremities. 3- Tenderness & affected leg may feel warmer than the unaffected leg. Because of inflammation. 4- Swelling of the leg 5- Red or discolored skin. Dr.Yoused Aljeesh Dr. Motasem Salah

58 Dr.Yoused Aljeesh Dr. Motasem Salah
Management DVT: When treating DVT, the goals are to stop the clot from getting bigger, keep the clot from traveling to the lungs, and reduce the chance of having another blood clot. Common treatments for this condition include medications, and graduated compression stockings. 1- Bed rest. 2- Foot of bed elevated to 15 cm to decrease edema 3- Thrombolytic and anticoagulant therapy 4- One leg is compared with the other at the same level to determined size differences. 5- Applying elastic compression stockings (For ambulatory patients, elastic compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning). Dr.Yoused Aljeesh Dr. Motasem Salah

59 Superficial vein thrombosis
Superficial vein thrombosis is a thrombus formation in a superficial vein. The skin over the vein becomes red, swollen, and painful. Superficial vein thrombosis most often affects the superficial veins in the legs but may also affect superficial in the arms. S & S: Pain, Redness , local swelling, warmth in the involved area. Dr.Yoused Aljeesh Dr. Motasem Salah

60 Dr.Yoused Aljeesh Dr. Motasem Salah
Note: superficial veins thrombosis [have negative Homans sign] Management: Most of superficial veins thrombosis dissolve spontaneously, and this condition can be treated at home. with bed rest elevation of the leg. Dr.Yoused Aljeesh Dr. Motasem Salah

61 Preventive Measure [Venous Thrombosis, DVT, Thrombophlebitis]
1- Elastic stocking: exert pressure over the entire surface of the calves, which reduce the caliber of the superficial vein in the leg lead to ↑ flow in the deeper vein . [Night→ Removal → Re applied →Morning] 2- Body position & exercise Lower legs should be elevated that allow the vein to empty rapidly. Passive & active leg exercises should be performed pre & post-operatively to ↑ venous flow. Early ambulation is most effective to prevent veous stasis. Dr.Yoused Aljeesh Dr. Motasem Salah

62 Dr.Yoused Aljeesh Dr. Motasem Salah
Preventive Measures Anticoagulant therapy: Subcutaneous heparin, warfarin (Coumadin) for extended therapy Positioning: periodic elevation of lower extremities Exercises: active and passive limb exercises, deep-breathing exercises Avoid sitting/standing for prolonged periods; walk 10 minutes every 1-2 hours. Dr.Yoused Aljeesh Dr. Motasem Salah

63 Anticoagulant therapy: Patient teaching
Carry identification, indicating anti-coagulant therapy being taken Contact or informed the physician a- dental extraction If any of the following sign appear report immediately. - Sever abdominal pain. - Red or brown color of urine. - Bleeding such as cut that do not stop. - Nasal bleeding - Red or black bowel movements. Avoid injury. The pregnant woman should notify their physician. Dr.Yoused Aljeesh Dr. Motasem Salah

64 Dr.Yoused Aljeesh Dr. Motasem Salah
Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve. Competent valves showing blood flow patterns when the valve is open (A) and closed (B), allowing blood to flow against gravity. (C) With faulty or incompetent valves, the blood is unable to move toward the heart. Dr.Yoused Aljeesh Dr. Motasem Salah

65 Dr.Yoused Aljeesh Dr. Motasem Salah
Leg Ulcers Leg ulcer is an excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off. Pathophysiology: Arterial/venous insufficiency → ↓ blood supply → ↓ O2 & nutrients in the tissue → damage of the tissue → ulcer. Clinical manifestation: According to cause. 1- Chronic arterial disease: pain caused by activity are relieved p- few minutes of rest. Pain [characterized by intermittent claudication]. 2- Chronic venous insufficiency : pain described as cramping or heaviness. Edema of the legs esp. foot and ankle. Dr.Yoused Aljeesh Dr. Motasem Salah

66 Dr.Yoused Aljeesh Dr. Motasem Salah
Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis Dr.Yoused Aljeesh Dr. Motasem Salah

67 Dr.Yoused Aljeesh Dr. Motasem Salah
Diagnostic evaluation Leg Ulcer: The pulses of the lower extremities Doppler ultrasonic flow studies Angiography The history of the condition. Management: [All ulcer have the potential to become infected] Antibiotic therapy [C& S] Debridement: removal of dead tissue + to promote healing. Wound dressing [which provide barrier for protection because they adhere to the wound]. Dr.Yoused Aljeesh Dr. Motasem Salah

68 Nursing Process: The Care of the Patient with Leg Ulcers: Planning
Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications. Dr.Yoused Aljeesh Dr. Motasem Salah

69 Dr.Yoused Aljeesh Dr. Motasem Salah
Varicose Veins Abnormally dilated superficial vein. This condition occur in lower extremities. Most common in women & persons who require prolong standing. Increased pressure in the superficial venous system normally blood flows from superficial system to deep If the valves protecting the superficial veins become incompetent there is higher pressure in the superficial veins and they become varicose Dr.Yoused Aljeesh Dr. Motasem Salah

70 Dr.Yoused Aljeesh Dr. Motasem Salah
Causes Varicose veins may be considered primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins) Primary Congenital abnormality, most common cause Secondary Anything that raises intra-abdominal pressure or raises pressure in superficial/deep venous system Pregnancy Abdominal/pelvic mass Ascites Obesity Constipation Dr.Yoused Aljeesh Dr. Motasem Salah

71 Dr.Yoused Aljeesh Dr. Motasem Salah

72 Prevention & health promotion:
1- Avoid activities that cause venous stasis such as sitting or standing for along period of time. 2- The patient should encourage to walk. 3- Elevating legs when they are tired. 4- ↓ weight. 5- Elastic stockings. 6- Walking up the stairs rather than using the elevator. 7- Swimming Exercise Dr.Yoused Aljeesh Dr. Motasem Salah

73 Dr.Yoused Aljeesh Dr. Motasem Salah
Management Vein stripping :- an incision made in the ankle and metal or plastic wire is passed and vein stripping is done. Dr.Yoused Aljeesh Dr. Motasem Salah

74 Postoperative management:
1- Bed rest for 24 hrs. 2- Elastic compression of the leg is maintained for one week. 3- Elevation of the foot. 4- Analgesic to ↓ pain. Dr.Yoused Aljeesh Dr. Motasem Salah

75 Cellulitis and Lymphatic Disorders
Cellulitis: infection and swelling of skin tissues (deep dermis) Lymphangitis: inflammation/infection of the lymphatic channels “duct” (Cause: hemolytic streptococcus) Lymphadenitis: inflammation/infection of the lymph nodes The lymph nodes become enlarged, red and tender. [the node involved in the groin, axilla or cervical reg. Lymphedema: accumulation of lymph in the tissues, causing swelling, it could be due to congenital or obstruction Dr.Yoused Aljeesh Dr. Motasem Salah

76 Dr.Yoused Aljeesh Dr. Motasem Salah
Elephantiasis Elephantiasis: Enlargement of the arms, legs, or genitals to elephantoid size. Pathophysiology: Lymphatic system → obstruction of lymphatic vessels → chronic swelling → frequent infection & inflammation→ thickening of the subcutaneous tissues, and hypertrophy (enlargement) of the skin Signs + symptoms: 1- Swelling in the extremities are most common. 2- Swelling in scrotum, breast may involved. Dr.Yoused Aljeesh Dr. Motasem Salah

77 Dr.Yoused Aljeesh Dr. Motasem Salah
edema due to obstruction of lymphatic vessels. Edema will be soft, pitting and relieved by treatment, as the condition progresses the edema becomes firm, non-pitting and unresponsive to treatment. Dr.Yoused Aljeesh Dr. Motasem Salah

78 Cause It is caused by thread-like parasitic worms
Obstruction of the lymphatic vessels leads to swelling in the lower extremities and genital area

79 Dr.Yoused Aljeesh Dr. Motasem Salah
Management: The goal of therapy is to reduce edema by legs elevated. Active & passive exercise help in moving lymphatic fluid into the bloodstream . Lasix to prevent fluid overload. Antibiotic therapy in case of lymphangitis. Dithylcarbamazine Dr.Yoused Aljeesh Dr. Motasem Salah


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