Medical Surgical Nursing:Periphero Vascular Disorder.

Debre Brehan University
School of Health Science

Program of Nursing
Medical-Surgical Nursing I
Peripheral Vascular disorder

Prepared by Tesfa D.
(B.Sc. In Nursing)
2
Lecture Note for Second

Year Regular Nursing
Student, November
2003/2010.
Hypertension
3

Student, November
2003/2010.
Learning objectives
On completion of this chapter, the learner will be able to:
1. Define blood pressure and identify risk factors for
hypertension.
2. Explain the difference between normal blood pressure and
hypertension and discuss the significance of hypertension.
3. Describe the treatment approach for hypertension,
including lifestyle changes and medication therapy.
4. Use the nursing process as a framework for care of the
patient with hypertension.
5. Describe the necessity for immediate treatment of
hypertensive crisis.
4

Student, November
2003/2010.
Definition of terms
Dyslipidemia: abnormally high or low blood lipid levels.
Hypertensive emergency: a situation in which blood pressure
must be lowered immediately to prevent damage to target
organs
Hypertensive urgency: a situation in which blood pressure
must be lowered within a few hours to prevent damage to
target organs.
JNC VI: Sixth Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood Pressure;
committee established to study and make recommendations
about hypertension in the United States. Findings and
recommendations of JNC VI are contained in an extensive
report published in 1997.
5

Student, November
2003/2010.
Cont…d
Monotherapy: medication therapy with a single
medication.
Primary hypertension: also called essential hypertension;
denotes high blood pressure from an unidentified cause.
Rebound hypertension: pressure that is controlled with
therapy and that becomes uncontrolled (abnormally high)
with the discontinuation of therapy
Secondary hypertension: high blood pressure from an
identified cause, such as renal disease.
6

Student, November
2003/2010.
Introduction
Blood pressure is the product of cardiac
output multiplied by peripheral resistance.
(BP=CO x PR)
Cardiac output is the product of the
heart rate multiplied by the stroke volume.
(CO=HR x SV)
In normal circulation, pressure is exerted by
the flow of blood through the heart and blood
vessels.
7

Student, November
2003/2010.
Cont…d
High blood pressure, known as hypertension, can
result from a change in;
 Cardiac output,
Peripheral resistance, or
Both.
The medications used for treating
hypertension decrease peripheral
resistance, blood volume, or the strength
and rate of myocardial contraction.
8

Student, November
2003/2010.
Hypertension
Hypertension is a systolic blood pressure
greater than 140 mm Hg and a diastolic pressure
greater than 90 mm Hg over a sustained period,
based on the average of two or more blood pressure
measurements taken in two or more contacts with
the health care provider after an initial screening.
9

Student, November
2003/2010.
Classification of Hypertension
1. Based on the responsible cause.
A.Primary Hypertension meaning that the reason for
the elevation in blood pressure cannot be identified.
B.Secondary hypertension is the term used to signify
high blood pressure from an identified cause (such
narrowing of the renal arteries, renal
parenchymal disease, hyperaldosteronism
(mineralocorticoid hypertension), certain
medications, pregnancy, and coarctation of the
aorta).
10

Student, November
2003/2010.
Based on the Measured BP

2. Based on the measured blood pressure.
11

Student, November
2003/2010.
Cont…d
To say normal the measurement is done while the individual
not taking antihypertensive drugs and not acutely ill.
When systolic and diastolic blood pressures fall into different
categories, the higher category should be selected to classify
the individual’s blood pressure status. For example, 160/92
mm Hg should be classified as stage 2 hypertension, and
174/120 mm Hg should be classified as stage 3 hypertension.
In addition to classifying stages of hypertension on the basis
of average blood pressure levels, clinicians should specify
presence or absence of target organ disease and additional
risk factors. This specificity is important for risk
classification and treatment.
12

Student, November
2003/2010.
Cont…d
 The classification shows the direct relation between
the risk of morbidity and mortality from
hypertension and the level of systolic and diastolic
blood pressures.
 The higher the systolic or diastolic pressure, the
greater the risk.
 The JNC VI also developed recommendations for
follow-up monitoring according to initial blood
pressure readings at the time of diagnosis.
13

Student, November
2003/2010.
Recommendations for Follow-up Based on Initial

Blood Pressure Measurements for Adults
14

Student, November
2003/2010.
Cont…d
*If systolic and diastolic categories are different,
follow recommendations for shorter follow-up time
(eg, 160/86 mm Hg, evaluate or refer to source of
care within 1 month).
†Modify the scheduling of follow-up according to
reliable information about past blood pressure
measurements, other cardiovascular risk factors, or
target organ disease.
‡Provide advice about lifestyle modifications.
15

Student, November
2003/2010.
Cont…d
Hypertension is sometimes called “the silent killer”
because people who have it are often symptom free.
In a national survey (1991 to 1994), 32% of people who had
pressures exceeding 140/90 mm Hg were unaware of their
elevated blood pressure (Burt et al., 1995a).
Once identified, elevated blood pressure should be monitored
at regular intervals because hypertension is a lifelong
condition.
Hypertension often accompanies risk factors for
atherosclerotic heart disease, such as dyslipidemia and
diabetes mellitus.
16

Student, November
2003/2010.
Cont…d
High blood pressure can be viewed in three ways:
As a sign:- nurses and other health care
professionals use blood pressure to monitor a patient’s
clinical status.
A risk factor:- hypertension contributes to the
rate at which atherosclerotic plaque accumulates within
arterial walls.
A disease:-hypertension is a major contributor to
death from cardiac, renal, and peripheral vascular
disease.
17

Student, November
2003/2010.
Cont…d
 Prolonged blood pressure elevation eventually damages blood
vessels throughout the body, particularly in target organs
such as the heart, kidneys, brain, and eyes.
 The usual consequences of prolonged, uncontrolled
hypertension are;
 myocardial infarction,
 heart failure,
 renal failure,
 strokes,
 impaired vision, and
 left ventricular hypertrophy (echocardiogram).
18

Student, November
2003/2010.
Risk factor
Smoking.
Dyslipidemia (elevated LDL cholesterol and /or
low HDL cholesterol).
DM.
Impaired renal function (GFR <60ml/min and/or
microalbuminuria).
19

Student, November
2003/2010.
Cont…d
Obesity.
Physical inactivity.
Age (older than 55years for men, 65 years for
women).
Family Hx of CVD (in female relative younger
than 65 years or male relative younger than 55
years).
20

Student, November
2003/2010.
Cause and Pathophysiology

Several hypotheses about the pathophysiologic bases
of elevated blood pressure are associated with the
concept of hypertension as a multifactorial condition.
Hypertension may be caused by one or more of the
following:
Increased sympathetic nervous system
activity.
 Increased renal reabsorption of sodium,
chloride, and water.
21

Student, November
2003/2010.
Cont…d
Increased activity of the renin-
angiotensin-aldosterone system.
 Decreased vasodilation of the arterioles.
Resistance to insulin action.
Hypertriglyceridemia.
Obesity.
Glucose intolerance.
22

Student, November
2003/2010.
Gerontologic considerations
• Structural and functional changes in the heart and
blood vessels contribute to increases in blood
pressure that occur with age.
• The changes include;
 accumulation of atherosclerotic plaque,
 fragmentation of arterial elastins,
 increased collagen deposits, and
 impaired vasodilation.
23

Student, November
2003/2010.
Cont…d
 The result of these changes is a decrease in the elasticity
of the major blood vessels. Consequently, the aorta and
large arteries are less able to accommodate the volume of
blood pumped out by the heart (stroke volume), and the
energy that would have stretched the vessels instead
elevates the systolic blood pressure with out the
change of diastolic pressure called Isolated systolic
hypertension.
 Isolated systolic hypertension is more common in older
adults.
24

Student, November
2003/2010.
Clinical manifestations
People with hypertension can be asymptomatic and
remain so for many years. However, when specific
signs and symptoms appear, they usually indicate
vascular damage, with specific manifestations related
to the organs served by the involved vessels.
Physical examination may reveal no abnormalities
other than high blood pressure.
25

Student, November
2003/2010.
Cont…d
The manifestation is categorized based on the target
organs of HTN
Eye;
Retinal hemorrhages,
exudates (fluid accumulation),
arteriolar narrowing,
cottonwool spots (small infarctions), and
papilledema (swelling of the optic disc) may be seen.
26

Student, November
2003/2010.
Cont…d
Heart
Coronary artery disease (angina or myocardial
infarction)
Left ventricular hypertrophy
heart failure.
Kidney
increased blood urea nitrogen [BUN] and creatinine
levels) may manifest as nocturia.
27

Student, November
2003/2010.
Cont…d
Cerebrovascular
stroke or transient ischemic attack (TIA),
manifested by;
o alterations in vision or speech,
o dizziness,
o weakness,
o a sudden fall, or
o temporary paralysis on one side
(hemiplegia).
28

Student, November
2003/2010.
Assessment and diagnostic

evaluation
Health history.
A risk factor assessment.
Physical examination (Comprehensive).
Laboratory studies;
Urinalysis (BUN, creatinine, albumin, protein,
renin).
Blood chemistry (i.e., analysis of sodium, potassium,
creatinine, fasting glucose, and total and high-density
lipoprotein [HDL] cholesterol levels).
Electrocardiogram (ECG).
29

Student, November
2003/2010.
Medical management
• The goal of hypertension treatment is to;
 Prevent death and complications by achieving and
maintaining the arterial blood pressure at 140/90 mm
Hg or lower.
 The JNC VI specified a lower goal pressure of 130/85
mm Hg for people with diabetes mellitus or with
proteinuria greater than 1 g per 24 hours ( JNC VI,
1997).
30

Student, November
2003/2010.
Algorithm of hypertension treatment

31

Student, November
2003/2010.
Cont…d
32

Student, November
2003/2010.
Pharmacologic therapy
For patients with uncomplicated
hypertension and no specific
indications for another
medication, the recommended
initial medications include;
Diuretics,
Beta-blockers, or
Both.
33

Student, November
2003/2010.
Cont…d
Patients are first given low doses of medication. If blood
pressure does not fall to less than 140/90 mm Hg, the
dose is increased gradually, and additional medications
are included as necessary to achieve control.
When the blood pressure has been less than 140/90 mm
Hg for at least 1 year, gradual reduction of the types
and doses of medication is recommended.
To promote compliance, clinicians try to prescribe the
simplest treatment schedule possible, ideally one pill
once each day.
34

Student, November
2003/2010.
Preferred medication
1. Diuretics
A. Thiazide Diuretics (e.g. chlorothiazide (Diuril),
hydrochlorothiazide (Esidrix;HydroDIURIL).
B. Loop Diuretics (e.g. furosemide (Lasix)).
C. Potassium-Sparing Diuretics (e.g. spironolactone
(Aldactone)).
2. Adrenergic Agents
A. Peripheral Agents (e.g. reserpine (Serpasil)).
35

Student, November
2003/2010.
Cont…d
• B. Central Alpha Agonists (e.g. methyldopa (Aldomet)). Its
site of action appears to be in the brain rather than in the
periphery.
C. Beta-Blockers (e.g. propranolol (Inderal)).
D. Alpha Blocker (e.g. prazosin hydrochloride (Minipress)).
3. Vasodilators (e.g. hydralazine hydrochloride
(Apresoline), sodium nitroprusside (Nipride, Nitropress),
nitroglycerin diazoxide (Hyperstat, NitroBid IV, Tridil)).
4. Angiotensin-Converting Enzyme
Inhibitors (e.g. captopril (Capoten) enalapril (Vasotec),
lisinopril (Prinivil, Zestril), ramipril (Altace)).
36

Student, November
2003/2010.
Cont…d
5. Calcium Antagonists
A. Nondihydropyridines (e.g. verapamil)
B. Dihydropyridines (e.g.nifedipine (Procardia Adalat
CC), felodipine (Plendil), nicardipine (Cardene),
nisoldipine (Sular)).
37

Student, November
2003/2010.
Lifestyle modifications for hypertension

prevention and management
Lose weight if overweight.
Limit alcohol intake
Increase aerobic physical activity.
Reduce sodium intake.
Maintain adequate intake of dietary potassium.
 Maintain adequate intake of dietary calcium and
magnesium for general health.
 Stop smoking and reduce intake of dietary saturated
fat and cholesterol for overall cardiovascular health.
38

Student, November
2003/2010.
Cont…d
The DASH (Dietary Approaches to Stop
Hypertension) Diet (Based on 2000 calories per
day).
39

Student, November
2003/2010.
Hypertensive crises
 There are two hypertensive crises that require nursing
intervention: These are;
 Hypertensive emergency.
 Hypertensive urgency.
 Hypertensive emergencies and urgencies may occur in
patients whose hypertension has been poorly controlled
or in those who have abruptly discontinued their
medications.
 Once the hypertensive crisis has been managed, a complete
evaluation is performed to review the patient’s ongoing
treatment plan and strategies to minimize the occurrence of
subsequent hypertensive crises.
40

Student, November
2003/2010.
Hypertensive emergency
Hypertensive emergency is a situation in which blood
pressure must be lowered immediately (not necessarily
to less than 140/90 mm Hg) to halt or prevent damage to
the target organs.
Conditions associated with hypertensive emergency
include acute myocardial infarction, dissecting aortic
aneurysm, and intracranial hemorrhage.
 Hypertensive emergencies are acute, life threatening
blood pressure elevations that require prompt treatment in
an intensive care setting because of the serious target
organ damage that may occur.
41

Student, November
2003/2010.
Cont…d
 The medications of choice in hypertensive emergencies
are those that have an immediate effect.
 Intravenous vasodilators, including;
 Sodium nitroprusside (Nipride, Nitropress),
 Nicardipine hydrochloride (Cardene),
 Fenoldopam mesylate (Corlopam),
 Enalaprilat (Vasotec I.V.), and
 Nitroglycerin (Nitro-Bid IV, Tridil), have an immediate
action that is short lived (minutes to 4 hours), and they are
therefore used as the initial treatment.
42

Student, November
2003/2010.
Hypertensive urgency
• Hypertensive urgency is a situation in which blood
pressure must be lowered within a few hours.
• Severe perioperative hypertension is considered a
hypertensive urgency.
43

Student, November
2003/2010.
Cont…d
Hypertensive urgencies are managed with oral doses of
fast-acting agents such as;
 loop diuretics (bumetanide [Bumex], furosemide
[Lasix]).
beta-blockers (propranolol (Inderal), metoprolol
(Lopressor), nadolol (Corgard)).
angiotensin-converting enzyme inhibitors
(benazepril [Lotensin], captopril [Capoten], enalapril
[Vasotec]), calcium antagonists (diltiazem [Cardizem],
verapamil [Isoptin SR, Calan SR, Covera HS]), or
alpha2-agonists (Clonidine (Catapres) and guanfacine
(Tenex)).
44

Student, November
2003/2010.
Disorderof
Arteries
45

Student, November
2003/2010.
Arteriosclerosis and Atherosclerosis

Arteriosclerosis is the most common disease of the
arteries, means hardening of the arteries.
It is a diffuse process where by 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 the large and medium sized arteries.
Atherosclerosis is usually present elsewhere in the body.
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.
46

Student, November
2003/2010.
Cont…d
Both occur together and used interchangeably.
Atherosclerosis can develop at any point in the body,
but certain sites are more vulnerable, typically
bifurcation or branch areas.
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.
Distal to the knee, atherosclerosis occurs anywhere along
the artery. There are no specific areas, such as arterial
bifurcations, that are more vulnerable for atherosclerosis.
47

Student, November
2003/2010.
Cont…d
Risk Factors
▫ Modifiable
 Nicotine use (i.e., tobacco smoking, chewing)
 Diet (contributing to hyperlipidemin)
 Hypertension
 Diabetes
 Stress
 Sedentary lifestyle
▫ Non-modifiable
 Age
 Gender
48

Student, November
2003/2010.
Cont…d
Clinical Manifestations
The clinical signs and symptoms resulting from
atherosclerosis depend on the organ or tissue affected.
Heart;
Coronary atherosclerosis (heart disease).
Angina.
Acute myocardial infarction.
Brain;
Cerebral ischemic attacks.
Stroke.
49

Student, November
2003/2010.
Cont…d
Aorta;
Aneurysm.
Extremities
Atherosclerotic lesions.
Kidney;
Renal artery stenosis.
End-stage renal disease.
Hypertension.
50

Student, November
2003/2010.
Cont…d
Medical Management
▫ Modification of risk factors.
▫ Controlled exercise program to improve circulation
and increase the functioning capacity of the
circulation.
▫ Medication.
▫ Interventional or surgical graft procedures.
51

Student, November
2003/2010.
Cont…d
Prevention
▫ Healthy diet (substituting unsaturated fats for saturated
fats, and decreasing cholesterol intake).
▫ Exercise.
▫ Several classes of medication are used to prevent
atherosclerosis: bile acid sequestrants (cholestyramine
[Questran, Prevalite] or colestipol [Colestid]), nicotinic
acid (niacin, B , Niacor; Niaspan), statins (atorvastatin
3
[Lipitor], lovastatin [Mevacor], pravastatin [Pravachol],

simvastatin [Zocor]), fibric acids (gemfibrozil [Lopid]),
and lipophilic substances (probucol).
▫ Elimination of all controllable risk factors, particularly
tobacco use, is strongly recommended.
52

Student, November
2003/2010.
Aneurysm
An aneurysm is a localized sac or dilation formed at
a weak point in the wall of the aorta.
It may be classified by its shape or form.
The most common forms of aneurysms are;
 Saccular: aneurysm projects from one side of the
vessel only.
Fusiform: entire arterial segment becomes dilated.
Very small aneurysms due to localized infection are
called mycotic aneurysms.
53

Student, November
2003/2010.
Cont…d
(A) Normal artery. (B) False aneurysm. (C) True aneurysm. (D) Fusiform aneurysm.
(E) Saccular aneurysm. (F) Dissecting aneurysm.
54

Student, November
2003/2010.
Cont…d
Causes
• Congenital:
▫ Primary connective tissue disorders (Marfan’s syndrome,
Ehlers-Danlos syndrome) and other diseases (tuberous
sclerosis, Turner’s syndrome, Menkes’ syndrome).
• Mechanical (hemodynamic):
▫ Poststenotic and arteriovenous fistula and amputation-
related.
• Traumatic (pseudoaneurysms):
▫ Penetrating arterial injuries.
▫ Blunt arterial injuries.
▫ Pseudoaneurysms.
55

Student, November
2003/2010.
Cont…d
• Inflammatory (noninfectious):
▫ Associated with arteritis (Takayasu’s disease, giant cell
arteritis, systemic lupus erythematosus, Behçet’s syndrome,
Kawasaki’s disease) and periarterial inflammation (i.e.,
pancreatitis)
• Infectious (mycotic):
▫ Bacterial.
▫ Fungal.
▫ Spirochetal infections.
• Pregnancy-related degenerative:
▫ Nonspecific, inflammatory variant.
• Anastomotic (postarteriotomy) and graft aneurysms:
▫ Infection.
▫ Arterial wall failure, suture failure, graft failure.
56

Student, November
2003/2010.
Thoracic aortic aneurysm

• 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.
• The thoracic area is the most common site for a
dissecting aneurysm.
• About one third of patients with thoracic aneurysms
die of rupture of the aneurysm.
57

Student, November
2003/2010.
Cont…d
▫ Pain (constant and boring occur in supine).
▫ Dyspnea.
▫ Cough(paroxysmal and with a brassy quality).
▫ Hoarseness.
▫ Stridor.
▫ Weakness or complete loss of the voice (aphonia).
▫ Dysphagia.
58

Student, November
2003/2010.
Cont…d
Assessment and Diagnostic Findings
▫ Hx.
▫ P/E.
 Superficial veins of the chest, neck, or arms become
dilated.
 Edematous areas on the chest wall and cyanosis.
 Unequal pupils.
▫ Chest x-ray.
▫ Transesophageal echocardiography.
▫ CT.
59

Student, November
2003/2010.
Cont…d
Medical Management
▫ Controlling blood pressure (Systolic pressure is
maintained at about 100 to 120 mm Hg) with
antihypertensive medications
▫ Correcting risk factors.
▫ Surgical repair.
60

Student, November
2003/2010.
Abdominal aortic aneurysm

The most common cause of abdominal aortic
aneurysm is atherosclerosis.
Most of these aneurysms occur below the renal
arteries (infrarenal aneurysms).
61

Student, November
2003/2010.
Cont…d
▫ Feeling their heart beating in their abdomen when
lying down.
▫ Feel an abdominal mass or abdominal throbbing.
▫ Blue toes.
62

Student, November
2003/2010.
Cont…d
▫ Hx.
▫ P/E.
 a pulsatile mass in the middle and upper abdomen.
 A systolic bruit may be heard over the mass.
▫ Ultrasonography or CT is used to determine the size,
length, and location of the aneurysm.
63

Student, November
2003/2010.
Cont…d
Medical Management
Surgical graft.
64

Student, November
2003/2010.
Arterial embolism and arterial thrombosis

Acute vascular occlusion may be caused by an
embolus or acute thrombosis.
Cause
 Iatrogenic injury (during insertion of invasive
catheters such as those used for arteriography, or
an intra-aortic balloon pump).
 Fracture.
 Crush injury.
 Penetrating wounds.
65

Student, November
2003/2010.
Cont…d
Pathophysiology
o Arterial emboli arise most commonly from thrombi
that develop in the chambers of the heart (as a
result of atrial fibrillation, myocardial infarction,
infective endocarditis, or chronic heart failure).
o These thrombi become detached and are carried
from the left side of the heart into the arterial
system, where they lodge in and obstruct an artery
that is smaller than the embolus.
66

Student, November
2003/2010.
Cont…d
 The six P’s associated with acute arterial embolism are;
 Pain.
 Pallor.
 Pulselessness.
 Paresthesia.
 Poikilothermia (coldness).
 Paralysis.
67

Student, November
2003/2010.
Cont…d
▫ Hx.
▫ P/E.
▫ Echocardiography.
▫ Chest x-ray.
▫ Electrocardiography.
▫ Ultrasonography.
▫ Arteriography.
68

Student, November
2003/2010.
Cont…d
Medical Management
Management of arterial thrombosis depends on its
cause.
Management of acute embolic occlusion usually
requires surgery because time is of the essence.
Heparin therapy (an initial bolus of 5,000 to 10,000
units) is administered intravenously, followed by a
continuous infusion of 1,000 units per hour until
the patient is able to undergo surgery.
69

Student, November
2003/2010.
Cont…d
Surgical management
▫ Emergency embolectomy.
Nursing Management
 Preoperative care.
 Postoperative care.
70

Student, November
2003/2010.
Disorder of
Veins
71

Student, November
2003/2010.
Phlebitis
Is inflammation of a vein related to both a
chemical and mechanical irritation.
Common complication of intravenous
therapy.
The incidence depends on with;
Length of the therapy,
Cannula size,
Medication type.
72

Student, November
2003/2010.
Cont…d
Clinical Manifestation
▫ Redness.
▫ Warm area along the vein or
localized.
▫ Pain, tenderness at the site.
▫ Swelling.
73

Student, November
2003/2010.
Cont…d
Managements
▫ D/C (Discharge) IV fluid.
▫ Restart in another site.
▫ Applying a warm moist compress.
74

Student, November
2003/2010.
Cont…d
Prevention
▫ Use aseptic technique.
▫ Use appropriates size cannula.
▫ Consider the compositions of fluids
and medications when selecting a site.
▫ Observe the site for any
complications every hour.
75

Student, November
2003/2010.
Thrombophlebitis and Phlebothrombosis
Thrombophlebitis is inflammation of
the walls of the veins and frequently
accompanied by the formation of a clot.
Phlebothrombosis is when a clot
develops initially in the veins as a result of
stasis or hypercoagulablity, but with out
inflammation.
76

Student, November
2003/2010.
Cont…d
Venous thrombosis can occur in any vein but
occurs most frequently in the veins of the lower
extremities.
Both the superficial and deep veins of the legs
may be affected.
Of the superficial veins, the saphenous vein is
mostly frequently affected.
Of the deep leg veins, the iliofemoral,
popliteal, and small calf veins are most often
involved.
77

Student, November
2003/2010.
Cont…d
78

Student, November
2003/2010.
Cont…d
Exact cause of venous thrombosis remains unclear,
but three factors are believed to play a significant
role in its development:
1. Stasis of blood.
2. Vessel wall injury.
3. Altered blood coagulation.
The presence of at least two factors appears
to be necessary for thrombosis to occur.
79

Student, November
2003/2010.
Cont…d
1. Stasis of blood.
Venous stasis occurs;
 When blood flow is retarded (i.e. heart failure or shock).
 When veins are dilated, as a result of medication therapy.
 When skeletal muscle contraction is reduced, as with
immobility, extremity paralysis, or anesthesia.
 Bed rest has been shown to reduce blood flow in the legs
by at least 50%.
80

Student, November
2003/2010.
Cont…d
2. Vessel wall injury
 Damage to the intimal lining of blood vessels,
creates a site for clot formation.
 Direct trauma to the vessels, such as occurs
following a fracture or dislocation, diseases of the
veins, and chemical irritation of veins from
intravenous medication.
All surgical patients are at risk for deep vein
thrombosis (DVT).
81

Student, November
2003/2010.
Cont…d
As many as 50% of all patients with venous
thrombosis of the lower extremities have no
symptom.
In others symptoms are variable and not usually
specific for thrombophlebitis.
82

Student, November
2003/2010.
Cont…d
• Deep Veins;
▫ Tenderness .
▫ Heaviness’ on standing position.
▫ Cramping leg pain.
▫ Swelling.
▫ Pain on the calf (not specific to DVT).
▫ Sign of pulmonary embolus.
83

Student, November
2003/2010.
Cont…d
• Superficial veins (dissolve spontaneously
so risk of dislodge or fragmenting is low).
▫ Pain or tenderness.
▫ Redness and warmth in the involved
area.
▫ Local swelling: bumpy and knotty.
▫ Red tender, local indurations on
saphenous vein.
84

Student, November
2003/2010.
Cont…d
Diagnostic evaluation
▫ For superficial
 Venography.
 Venous scanning.
85

Student, November
2003/2010.
Cont…d
Management
▫ Bed rest.
▫ Elevation of leg.
▫ Analgesics.
▫ Anti-inflammatory medication.
86

Student, November
2003/2010.
Varicose veins
Varicose veins (varicosities) are abnormally
dilated, tortuous, superficial veins caused by
incompetent venous valves.
Most commonly, this condition occurs in the lower
extremities, the saphenous veins, or lower trunk.
However, it can occur elsewhere in the body (e.g.
esophageal varices).
87

Student, November
2003/2010.
Cont…d
Pathophysiology
 It can be;
▫ Primary varicose veins (which is not involving
the deep veins).
▫ Secondary varicose veins (resulting from
obstruction of deep veins).
88

Student, November
2003/2010.
Cont…d
C/F
▫ For superficial vein involvement no symptoms
 Dilated vein make trouble by the cosmetic appearance.
▫ If symptoms occurs
 Dull aching pain.
 Cramp.
 Increased muscle fatigue in the lower leg.
 Ankle edema.
 Felling heaviness of the legs.
89

Student, November
2003/2010.
Cont…d
▫ Deep vein involvement;
 Edema.
 Pain.
 Pigmentation.
 Ulceration.
 Susceptibility to injury and infection is increased.
90

Student, November
2003/2010.
Cont…d
Diagnostic evaluation
▫ Brodie- tendelenburg test.
▫ Perthe’s test.
▫ Additional diagnosis veins.
91

Student, November
2003/2010.
Cont…d
• Prevention
▫ Avoid venous stasis by wearing tight.
▫ Elevating the leg.
▫ Change position frequently.
▫ Elastic stoking (knee- high).
▫ Weight reduction.
▫ Walking up the stairs.
92

Student, November
2003/2010.
Cont…d
• Management
▫ Surgery.
▫ Sclerotherapy.
93

Student, November
2003/2010.
Varicose Ulcer
Varicose ulcers: A condition which is characterized
by an ulcer due varicose veins.
Cause
▫ Varicose veins.
▫ Phlebitis.
▫ Deep vein thromobosis.
▫ Leg trauma.
▫ Rheumatoid arthritis.
▫ Osteoarthritis Septic arthritis.
▫ Patellar tendonitis.
▫ Compartment syndrome.
94

Student, November
2003/2010.
Cont…d
C/M
 Localized destruction of tissue - usually on the
skin of lower legs.
 Localized swelling.
 Brownish discoloration.
95

Student, November
2003/2010.
Disorder of Lymphatic
System
96

Student, November
2003/2010.
The lymphatic system consists of a set of vessels that

spread throughout most of the body.
These vessels start as lymph capillaries that drain
unabsorbed plasma from the interstitial spaces
(spaces between the cells).
The lymphatic capillaries unite to form the lymph
vessels, which pass through the lymph nodes and then
empty into the large thoracic duct that joins the
jugular vein on the left side of the neck.
The fluid drained from the interstitial space by the
lymphatic system is called lymph.
The flow of lymph depends on the intrinsic
contractions of the lymph vessels, the contraction of
muscles, respiratory movements, and gravity.
97

Student, November
2003/2010.
Lymphangitis
 It is a spread of infection from a cellulitis
or abscess to the lymphatic system.
 Lymphangits is an acute inflammation of
the lymphatic channels.
 It arises most commonly from a focus of
infection in an extremity.
98

Student, November
2003/2010.
Cont…d
Cause
▫ Cellulitis.
▫ Hemolytic streptococcus.
C/F
▫ Red streaks that extend up the arm or the leg
from an infected wound outline the course of
the lymphatic vessels as they drain.
Rx
▫ Antibiotic.
99

Student, November
2003/2010.
lymphadenitis
The lymph nodes located along the course of the
lymphatic channels also become enlarged, red, and
tender (acute lymphadenitis).
They can also become necrotic and form an
abscess (suppurative lymphadenitis). The nodes
involved most often are those in the groin, axilla, or
cervical region.
100

Student, November
2003/2010.
Cont…d
Rx
An elastic compression stocking or sleeve
should be worn on the affected extremity
for several months to prevent long-term
edema.
Antibiotics.
101

Student, November
2003/2010.
Lymphedema
 Tissue swelling occurs in the extremities because of an
increased quantity of lymph that results from obstruction of
lymphatic vessels.
 It is especially marked when the extremity is in a dependent
position.
 Lymphedemas are classified as;
Primary (congenital malformations)
 The most common type is congenital lymphedema
(lymphedema praecox), which is caused by hypoplasia
of the lymphatic system of the lower extremity.
 This disorder is usually seen in women and first
appears between ages 15 and 25.
102

Student, November
2003/2010.
Cont…d
Secondary (acquired obstructions)
 The obstruction may be in the lymph nodes and the
lymphatic vessels.
 Sometimes, it is seen in the arm after an axillary node
dissection (eg, for breast cancer) and in the leg in
association with varicose veins or chronic
thrombophlebitis.
C/M
 Initially, the edema is soft, pitting, and relieved by treatment.
 As the condition progresses, the edema becomes firm,
nonpitting, and unresponsive to treatment.
103

Student, November
2003/2010.
Cont…d
Medical Management
• The goal of therapy is to reduce and control the edema and
prevent infection.
• It includes;
• Active and passive exercises.
• External compression (custom-fitted elastic
compression stockings or sleeves are worn; those
with the highest compression strength (exceeding 40
mm Hg).
• Strict bed rest with the leg elevated.
• Medication (diuretic furosemide (Lasix), antibiotic).
104

Student, November
2003/2010.
Cont…d
Surgical management
• Surgery is performed if the edema is severe and
uncontrolled by medical therapy, if mobility is
severely compromised, or if infection persists.
• One surgical approach involves the excision of the
affected subcutaneous tissue and fascia, with skin
grafting to cover the defect.
• Another procedure involves the surgical relocation of
superficial lymphatic vessels into the deep lymphatic
system by means of a buried dermal flap to provide a
conduit for lymphatic drainage.
105

Student, November
2003/2010.
Cont…d
Nursing Management
• Prophylactic antibiotics may be prescribed for 5 to 7
days.
• Constant elevation of the affected extremity and
observations for complications.
• The nurse instructs the patient or caregiver to inspect the
dressing daily.
• The patient is informed that there may be a loss of
sensation in the skin graft area.
• The patient is also instructed to avoid the application of
heating pads or exposure to sun to prevent burns or
trauma to the area.
106

Student, November
2003/2010.
Elephantiasis
Elephantiasis is lymphatic obstruction caused by a
parasite (filaria) is seen frequently in the tropics.
Pathophysiology
 When chronic swelling is present, there may be
frequent bouts of acute infection characterized by
high fever and chills and increased residual edema
after the inflammation has resolved.
107

Student, November
2003/2010.
Cont…d
 These lead to chronic fibrosis, thickening of the
subcutaneous tissues, and hypertrophy of the skin.
 This condition, in which chronic swelling of the
extremity recedes only slightly with elevation.
C/M
 Elephant like skin (rough).
Rx
 Minimize the risk of exposure to filaria.
108

Student, November
2003/2010.
Lymphoma
 The lymphomas are neoplasms of cells of lymphoid
origin.
 These tumors usually start in lymph nodes but can
involve lymphoid tissue in the spleen, the
gastrointestinal tract (eg, the wall of the stomach), the
liver, or the bone marrow.
 They are often classified according to the degree of cell
differentiation and the origin of the predominant
malignant cell.
 Lymphomas can be broadly classified into two
categories: Hodgkin’s disease (HL) and non-Hodgkin’s
lymphoma (NHL).
109

Student, November
2003/2010.
Hodgkin’s disease
• Hodgkin’s disease is a relatively rare malignancy that
has an impressive cure rate.
• It is somewhat more common in men than women
and has two peaks of incidence: one in the early 20s
and the other after 50 years of age.
• It is unicentric in origin in that it initiates in a single
node.
• The disease spreads by contiguous extension along
the lymphatic system.
110

Student, November
2003/2010.
Cont…d
• The malignant cell of Hodgkin’s disease is the Reed-
Sternberg cell, a gigantic tumor cell that is
morphologically unique and is thought to be of
immature lymphoid origin.
Cause
It is unknown, but a viral etiology (Epstein-Barr
virus) is suspected.
Heredity (first degree relatives).
111

Student, November
2003/2010.
Cont…d
• Lymphadenopathy (a painless, firm but not hard
enlargement of one or more lymph nodes on one
side of the neck).
• The most common sites for are the cervical,
supraclavicular, and mediastinal nodes.
• Pruritus.
• Severe pain after drinking alcohol.
112

Student, November
2003/2010.
Cont…d
 Health history.
 Physical examination.
 Lymph node biopsy and the finding of the Reed-Sternberg cell.
 A chest x-ray and a CT scan of the chest, abdomen, and pelvis
are crucial to identify the extent of lymphadenopathy within
these regions.
 Laboratory tests include CBC, platelet count, ESR, and liver
and renal function studies.
 A bone marrow biopsy is performed if there are signs of
marrow involvement.
 Bone scans may be performed to identify any involvement in
these areas.
 A staging laparotomy and lymphangiography.
113

Student, November
2003/2010.
Cont…d
Medical Management
• Early Hodgkin’s disease was treated by a staging
laparotomy followed by radiation therapy.
• A short course (2 to 4 months) of chemotherapy followed
by radiation therapy in certain subsets of early-stage
disease (IA and IIA).
• Combination chemotherapy, for example with
doxorubicin (Adriamycin), bleomycin (Blenoxane),
vinblastine (Velban), and dacarbazine (DTIC), referred to
as ABVD, is now the standard treatment for more
advanced disease (stages III and IV and all B stages).
114

Student, November
2003/2010.
Cont…d
Potential Long-Term Complications of Therapy for
Hodgkin’s Disease
 Immune dysfunction.
 Herpes infections (zoster and varicella)
 Pneumococcal sepsis.
 Acute myeloid leukemia (AML)
 Non-Hodgkin’s lymphoma
 Solid tumors
 Thyroid cancer
 Thymic hyperplasia
 Hypothyroidism
115

Student, November
2003/2010.
Cont…d
 Pericarditis (acute or chronic)
 Cardiomyopathy
 Pneumonitis (acute or chronic)
 Avascular necrosis
 Growth retardation
 Infertility
 Impotence
 Myelodysplastic syndromes (MDS)
 Dental caries
116

Student, November
2003/2010.
Non-hodgkin’s lymphomas (NHLs)

• The NHLs are a heterogeneous group of cancers that
originate from the neoplastic growth of lymphoid
tissue.
• Most NHLs involve malignant B lymphocytes; only
5% involve T lymphocytes.
• In contrast to Hodgkin’s disease, the lymphoid
tissues involved are largely infiltrated with malignant
cells.
117

Student, November
2003/2010.
Cont…d
• Lymph nodes from multiple sites may be infiltrated, as
may sites outside the lymphoid system (extranodal
tissue).
• The incidence increases with each decade of life; the
average age at diagnosis is 50 to 60 years.
• Although no common etiologic factor has been identified,
there is an increased incidence of NHL in people with;
 Immuno-deficiencies or autoimmune disorders.
 Viral infections (including Epstein-Barr virus and HIV).
 Exposure to pesticides, solvents, or dyes.
118

Student, November
2003/2010.
Cont…d
• The pt develop manifestation at these stages (III or
IV).
• Lymphadenopathy.
• Recurrent fever.
• Drenching night sweats.
• Unintentional weight loss of 10% or more.
119

Student, November
2003/2010.
Cont…d
• CT scans.
• Bone marrow biopsies.
• Occasionally cerebrospinal fluid analysis.
120

Student, November
2003/2010.
Cont…d
Medical Management
• Treatment is based on the actual classification of
disease, the stage of disease, prior treatment (if any),
and the patient’s ability to tolerate therapy.
• More intermediate forms are commonly treated with
combination chemotherapy and radiation therapy for
stage I and II disease.
121

Student, November
2003/2010.
Cont…d
Hematologic Disorder
122

Student, November
2003/2010.
1. Anemia
Anemia is a term that indicates a low red cell count
and a below –normal hemoglobin or hematocrit
level.
It is not a disease but rather reflects a disease state
or altered body function.
There are different kinds of anemia's;
▫ Due to inadequate production of red blood cells
secondary to chronic diseases (aplastic anemia).
▫ Premature or excessive destruction of red blood cells
(hemolytic anemia).
▫ Due to excessive blood loss (iron deficiency anemia).
▫ Deficits in nutrients ,such as vit B12, folic acid
(megaloblastic anemia).
123

Student, November
2003/2010.
Classification of Anemia
A. Aplasitc anemia
Aplastic anemia occurs when the bone marrow
produces too few of all types of blood cells: red cells,
white cells, and platelets. A reduced number of red
blood cells causes the hemoglobin (a type of protein
in the red blood cells that carries oxygen to the
tissues of the body) to drop.
A reduced number of white blood cells causes the
patient to be susceptible to infection.
A reduced number of platelets can cause the blood
not to clot as easily.
124

Student, November
2003/2010.
Cont…d
Risk factors
• Treatment with high-dose radiation or
chemotherapy for cancer
• Exposure to toxic chemicals
• Use of some prescription drugs — such as
chloramphenicol, which is used to treat bacterial
infections, and gold compounds used to treat
rheumatoid arthritis — that are known to rarely
induce aplastic anemia
• Certain blood diseases, autoimmune disorders and
serious infections
• Pregnancy, rarely.
125

Student, November
2003/2010.
Cont…d
Causes
High-dose radiation and chemotherapy
treatments.
Exposure to toxic chemicals (e.g. exposure to
benzene).
Use of certain drugs (medications used to treat
rheumatoid arthritis).
Autoimmune disorders (e.g. lupus).
A viral infection (e.g. hepatitis, Epstein-Barr,
cytomegalovirus, parvovirus B-19 and HIV).
Pregnancy.
Unknown factors/idiopathic.
126

Student, November
2003/2010.
Cont…d
C/F
• Fatigue
• Shortness of breath with exertion
• Rapid or irregular heart rate
• Pale skin
• Frequent or prolonged infections
• Unexplained or easy bruising
• Nosebleeds and bleeding gums
• Prolonged bleeding from cuts
• Skin rash
• Dizziness
• Headache
127

Student, November
2003/2010.
Cont…d
Dx
• Blood tests.
• Bone marrow biopsy.
128

Student, November
2003/2010.
Cont…d
Treatments
 Blood transfusions.
 Bone marrow transplantation.
 Immuno suppressants (such as cyclosporine and
anti-thymocyte globulin (Thymoglobulin).
 Corticosteroids (such as methylprednisolone).
 Bone marrow stimulants (such as sargramostim
(Leukine), filgrastim (Neupogen)).
 Antibiotics, anti-virals.
129

Student, November
2003/2010.
B. Iron–deficiency anemia
Iron deficiency anemia is a specific type of
anemia that is usually caused by blood loss or
decreased absorption of iron from foods.
Iron deficiency anemia can be mild or severe,
and can be temporary or chronic.
The condition is common in the United States,
affecting 1 to 2 percent of adults.
It is even more common in developing countries,
primarily due to differences in diet.
130

Student, November
2003/2010.
Cont…d
Causes
• Two common causes of iron deficiency anemia are blood loss (most
common) and decreased absorption of iron from food.
1. Blood loss :— The source of blood loss may be obvious, such as repeated
blood donations, trauma, surgery, heavy menstrual bleeding, bleeding in
digestive tract.
2. Decreased iron absorption:— If the GI tract is not functioning correctly, as
in people with certain conditions (eg, celiac disease, gastritis, ulcer, H.
pylori infection), an inadequate amount of iron may be absorbed.
3. Other causes — A common cause of iron deficiency anemia in developing
countries is a lack of foods that contain iron.
1. Vegetarians are at increased risk for developing iron deficiency anemia because
iron from plant sources is not absorbed as readily as iron from meat sources.
2. Pregnant women often develop iron deficiency anemia because of the increased
iron requirements of the growing fetus and placenta, and the increased volume
of blood circulating in the woman's body during pregnancy.
131

Student, November
2003/2010.
Cont…d
C/M
 Weakness
 Headache
 Irritability
 Fatigue
 Difficulty exercising (due to shortness of breath, rapid heart
beat)
• Less common symptoms;
 brittle nails,
 sore tongue,
 restless legs syndrome,
 Pica (it is an abnormal craving to eat non-food items, such as clay
or dirt, paper products, or starch (eg, cornstarch)).
 Pagophagia (It is an abnormal craving to eat ice).
132

Student, November
2003/2010.
Cont…d
Diagnosis
• Medical history.
• Physical examination.
• Blood tests.
▫ Complete blood count
 It includes a red blood cell count, Hgb, and Hct-low.
 It also includes the mean corpuscular volume (MCV,
referring to the cell size-microcytic), mean corpuscular
hemoglobin (MCH, referring to the cell color-
hypochromic), and others.
133

Student, November
2003/2010.
Cont…d
Further testing includes measure of;
 Serum iron.
 Total iron binding capacity (TIBC or
transferrin).
 Transferrin saturation.
 Ferritin.
134

Student, November
2003/2010.
Cont…d
Mgx
• Search for cause of iron deficiency.
• Ferrous sulfate, ferrous gluconate, ferrous fumarate
most effective less expensive.
• Blood transfusion (their hemoglobin or hematocrit level
is very low (eg, hemoglobin less than 7 g/dL or
hematocrit less than 20 percent)).
• Rx continued for years.
Nursing intervention
• Pt education food source high in iron include organ
meats (liver, cow, chicken leafy vegetables
• Vitamin C enhance absorption.
• Avoid antacid.
135

Student, November
2003/2010.
Megaloblastic anemia’s
• Megaloblastic anemia is the end-product of
deficiencies in the B vitamins folate or vitamin
B12 (also called cobalamin), or both. Such
deficiencies produce abnormally large red blood
cells (megaloblastic) that have a shortened
lifespan.
136

Student, November
2003/2010.
Cont…d
Causes (Vitamin B12 deficiency)
• Vitamin B12 deficiency from diet.
• Pernicious anemia.
• Complications of gastrointestinal surgery.
• Overgrowth of intestinal bacteria.
• Tropical sprue (an acquired malabsorption
disease occurring in tropical climates).
137

Student, November
2003/2010.
Cont…d
Causes (folate deficiency)
• Poor diet coupled with alcoholism.
• Any condition that disturbs the small intestine and
impairs its absorption ability (inflammatory bowel
disease).
• Parasitic diseases, such as giardiasis.
• Short bowel syndrome.
• High demand for folic acid caused by conditions
such as cancer, pregnancy, severe psoriasis, severe
hyperthyroidism, and hemolytic anemia.
• Some drugs, including phenytoin, methotrexate,
trimethoprim, and triamterene.
138

Student, November
2003/2010.
Cont…d
C/M
• Skin Color (pale all over the body).
• lack of appetite.
• weight loss.
• Mouth and Tongue soreness.
• Numbness in the hands and the feet.
• Nausea
• vomiting.
139

Student, November
2003/2010.
Cont…d
Dx
 Complete blood count (shows anemia with large red
blood cells).
 Bone marrow examination (can help show whether
your bone marrow is healthy and making enough
red blood cells).
 Serum B12 (can help show vitamin B12 blood level).
 Schilling test (detect vitamin B12 absorption).
 Serum folate (can help show whether you have
pernicious anemia or another type of anemia).
140

Student, November
2003/2010.
Cont…d
Rx
• Preventing or treating the anemia and its signs and symptoms.
• Controlling complications, such as heart and nerve damage.
• The treatment depends on the cause.
• Usually treatment may include vitamin B12 injections and folic acid
supplement.
• A well-balanced diet is essential to provide other elements for
healthy blood cell development, such as folic acid, iron, and vitamin
b12.
• Which foods are contain rich folic acid and vitamin B12:
eggs
meat
poultry
milk
shellfish
141

Student, November
2003/2010.
Hemolytic anemia
• Hemolytic anemia is a blood disorder in which the red blood cells are
destroyed prematurely.
• The cells are broken down at a faster rate than the bone marrow can
produce new cells.
• The term for destruction of red blood cells is hemolysis.
• Hemolysis may occur by two mechanisms:
▫ Extravascular (most common): red cells are removed from the circulation by
the mononuclear-phagocytic system either because they are intrinsically
defective or because of the presence of bound immunoglobulins to their
surfaces.
▫ Intravascular: due to complement fixation, trauma, or other extrinsic factors.
Examples are prosthetic cardiac valves, glucose-6-phosphate dehydrogenase
deficiency, thrombotic thrombocytopenic purpura, disseminated
intravascular coagulation and paroxysmal nocturnal hemoglobinuria.
• Hemolytic anemias, which result from the increased destruction of red
blood cells, are less common than anemias caused by excessive blood
loss or lack of red blood cell production, or high rates of red blood cell
destruction.
142

Student, November
2003/2010.
Cont…d
Types of Hemolytic anemia
1. Inherited Hemolytic Anemia
 One or more of the genes that control red blood cell production are
faulty.
 The defects may involve the hemoglobin, cell membrane, or enzymes
that maintain healthy red blood cells.
 The abnormal cells may be fragile and break down while moving through
the bloodstream. If this happens, an organ called the spleen may remove
the cell debris from the bloodstream.
 Inherited hemolytic anemias are often inherited, such as sickle cell
anemia, thalassemia and hereditary spherocytosis, in addition to include
G6PD Deficiency.
2. Acquired Hemolytic Anemia
 your red blood cells may be normal.
 However, some other disease or factor causes the body to destroy red
blood cells and remove them from the bloodstream.
 Acquired Hemolytic anemias, such as Autoimmune hemolytic anemia.
143

Student, November
2003/2010.
Cont…d
Causes
 The immediate cause is the early destruction of red blood cells.
 A number of diseases, conditions, and factors can cause the body to
destroy its red blood cells.
 Inherited hemolytic anemias are caused by;
 inborn defects in components of the red blood cells, the cell membrane,
the enzymes, or the hemoglobin.
 Acquired hemolytic anemias cuased by;
 Infections, such as hepatitis, cytomegalovirus, typhoid fever, escherichia
coli, or streptococcus.
 Medications, such as penicillin, antimalaria medications, sulfa
medications, acetaminophen.
 Autoimmune disease, such as systemic lupus erythematous (SLE, or
lupus), rheumatoid arthritis, Wiskott-Aldrich syndrome, or ulcerative
colitis.
 Lymphocytic leukemia or lymphoma.
144

Student, November
2003/2010.
Cont…d
C/M
• abnormal paleness or lack of color of the skin
• jaundice, or yellowing of the skin, eyes, and mouth
• dark color to urine
• fever
• weakness
• dizziness
• confusion
• intolerance to physical activity
• enlargement of the spleen and liver
• increased heart rate (tachycardia)
• heart murmur
145

Student, November
2003/2010.
Cont…d
Dx
Blood tests.
 Reticulocyte count.
Peripheral smear.
Haptoglobin.
Bilirubin test.
Hemoglobin electrophoresis.
Urine test.
Urobilinogen in the urine.
Bone marrow aspiration and biopsy.
146

Student, November
2003/2010.
Cont…d
Mgx
Treat the underlying course.
Blood transfusion.
147

Student, November
2003/2010.
Leukemias
• Leukemias is a malignant disorder of the hematopoietic
system involving the bone marrow and lymph nodes.
• It is characterized by;
▫ Uncontrolled proliferations of leukocytes, myelocytes and
their precursors.
▫ Enlargement of organ of hematopoiesis.
▫ Thrombocytopenia.
▫ Anemia due to immature WBCs.
 Decreased immunocompetence.
 Increased suseptabity to infection.
148

Student, November
2003/2010.
Cont…d
Classification
• The leukemias are classified as acute or chronic and
are further subdivided according to cell type or
maturity.
1. Acute leukemias
▫ Rapid on set.
▫ Short course ending in death if un treated.
2. Chronic leukemias
▫ Insidious onset
149

Student, November
2003/2010.
Cont…d
Acute lymphocytic leukemia
• It is a malignant disorder arising from lymphoid stem
cell.
• Cause is unknown.
• Affect age b/n 2 to 4 years and incidence decrease
after 10 years of age.
• It is a malignant disorder arising from a single
lymphoid stem cell with impaired maturation and
accumulation of malignant cell in the bone marrow.
150

Student, November
2003/2010.
Cont…d
Signs and symptoms
▫ Anemia
▫ Bleeding
▫ Lymphadenopathy
▫ Predisposition to infection
Diagnosis
▫ Blood smear may show immature lymphoblast.
▫ Platelet count and HCT level are reduced in most
patients.
151

Student, November
2003/2010.
Cont…d
Nursing intervention
Family education.
High protein fiber, and fluid diet.
Avoid infection (hand washing, avoid crowds).
Report injury, any sign of bleeding and infection.
Avoid spicy, hot food.
Acute myelogenous leukemia
• AML arises from a single myeloid stem cell and is
characterized by the development of immature
myeloblasts in the bone marrow.
152

Student, November
2003/2010.
Cont…d
Chronic lymphocytic leukemia
• CLL is characterized by a proliferation of small,
abnormal, mature lymphocytes after leading to
decreased synthesis of immunoglobulins and
depressed antibody response.
Chronic myelogenous leukemia
▫ Onset is 4th and 3rd decade.
153

Student, November
2003/2010.
Cont…d
• Uncontrolled proliferation of the granulocytosis
cell;
▫ Basophils
▫ Esnophils
▫ Neutrophils
▫ Circulating granulocytes increase.
▫ Polycythemia
▫ Hemocytoblast stem cell.
154

Student, November
2003/2010.
Cont…d
Hemorrhagic
disorder
155

Student, November
2003/2010.
Thrombcytosis
It is the presence of abnormally high number of
circulating platelets
Mild bleeding syndromes may be caused by
quantitatively normal but functionally defective
platelets.
156

Student, November
2003/2010.
Thrombocytopenia
• Thrombocytopenia is defined as a lower than normal
number of circulating platelets.
• Normal range  150,000 to 400,000/mm3.
Cause
• Decreased platelet production.
• Decreased platelet survival.
• Increased platelet destruction (common cause drug
induced).
• Sequestration of blood in the spleen (splenomegaly).
• Loss from hemorrhage.
157

Student, November
2003/2010.
Cont…d
C/F
▫ P/E
 Petechiae – skin spot, purple hemorrhagic spot.
 Only in platelet disorder.
 Ecchymosis – blue –black larger in diameter
irregular.
 Purpura.
▫ Hx
 Menorrhagia.
 Epistaxis.
 Gingival bleeding.
158

Student, November
2003/2010.
Cont…d
Dx
• Platelet count.
• Peripheral blood smear.
• Bleeding time.
• Bone marrow examination.
159

Student, November
2003/2010.
Cont…d
Treatment
▫ Corticosteroid (most common treatment ).
▫ Immununoglobulin.
▫ Splenectomy .
▫ Danazol and immunosuppressive drug.
▫ Platelet transfusion.
160

Student, November
2003/2010.
Cont…d
Nursing care
• Avoiding trauma
• Bleeding associated with trauma is likely with a platelet count less than
60,000/mm3 .
• Spontaneous hemorrhage may be a life –threatening possibility when the
platelet count is be low 20, 000/mm3 .
• Be alert for an increase in ecchymosis or petechiae, and bleeding from
other sites and change in mental status.
• Pt with platelet count below 20,000mm3 have bleeding precaution;
▫ Test all urine and stools for blood.
▫ Do not take temperature rectally.
▫ Do not administer intramuscular injections.
▫ Apply pressure to all venus puncture site for 5 minutes and 10 arterial puncture
site for 10min.
161

Student, November
2003/2010.
Hemophilia
• Hemophilia is a hereditary coagulation disorder.
• Factors:-deficiency, inherited as sex linked recessive
disorders and are exclusively limited to males.
C/F
• Hx of excessive bleeding after circumcision or dental
extractions.
• Lifelong bleeding.
• Bleeding can be spontaneous or after trauma.
Dx
• Specific assays for factors VIII, lX, Xl.
• Partial thromboplastin time (PTT).
162

Student, November
2003/2010.
Cont…d
Complication
▫ Joint deformity
▫ Retroperitoneal bleeding.
▫ Intracranial, paratracheal soft tissue hemorrhages.
Mgx
▫ Replacement of the deficient coagulation factor where
bleeding episodes do not respond to local treatment.
163

Student, November
2003/2010.
Vitamin K deficiency
• Vitamin K, a fat – soluble vitamin, is a cofactor in the
synthesis of clotting factors II, VII, lX, and X, obtained
from diet, and by intestinal bacteria.
Cause
• Decreased intake.
• Broad – spectrum antibiotics.
• Absorption problem i.e. ulcerative colitis.
• Drugs interfere with vitamin K function
 Salicylates
 Guanine
 Bribitureates
164

Student, November
2003/2010.
Cont…d
C/F
• Bleeding of mucous membranes and into the tissues.
• Post operative hemorrhage.
• In severe case measure GI bleeding.
Dx
• Prolonged PTT.
• Decreased in the level of vitamin K dependent clotting
factors.
Rx
• Vitamin K parenteral and oral preparation.
165

Student, November
2003/2010.
“Education is Enabling an
individual to win victory
over the five victory's; lust,
anger, greed, infatuation
and ego.” (Nanak, Gruru)

Medical Surgical Nursing:Periphero Vascular Disorder.

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Medical Surgical Nursing:Periphero Vascular Disorder.

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Debre Brehan University

School of Health Science

Peripheral Vascular disorder

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Based on the Measured BP

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Recommendations for Follow-up Based on Initial

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Cause and Pathophysiology

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Assessment and diagnostic

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Algorithm of hypertension treatment

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Lifestyle modifications for hypertension

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Arteriosclerosis and Atherosclerosis

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[Lipitor], lovastatin [Mevacor], pravastatin [Pravachol],

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