Vascular System & Hematology

Question 1

Vascular system:

Answer 1

network of arteries, veins, and capillaries

Question 2

Hematologic system:

Answer 2

living blood cells
and plasma within the blood vessels.

Question 3

Lymphatic system:

Answer 3

assists the vascular
system by draining unabsorbed plasma
from tissue spaces and returning this fluid
(lymph) to the heart via the thoracic duct ,
which empties into the left jugular vein

Question 4

Functions of Blood

Answer 4

Oxygen & carbon dioxide transport
Nutrient & metabolite transport
Hormone transport
Transport of waste products to kidneys & liver
Transport cells & substances involved in immune reactions
Clotting at breaks in blood vessels
Maintenance of fluid balance
Body temperature regulation
Maintenance of acid
base balance

Question 5

Vascular Examination

Answer 5

History
Inspection
Palpation
Auscultation
Vascular Tests
Diagnostic Studies

Question 6

Vascular Examination (History)

Answer 6

• Relevant medical history (DM, HTN, hyperlipidemia, syncope or
vertigo, & nonhealing ulcers).
• Relevant social history (exercise, dietary habits, & use of tobacco or
alcohol).
• Pain in arms & legs (visceral pain & arthritis pain may radiate to the
extremities).
• Presence of intermittent claudication . If so, the speed , distance ,
and the site of the pain, should be noted.
• Presence of nocturnal pain (can develop as the vascular occlusion
worsens). Caused by leg elevation & reduced cardiac output.
• History of acute or chronic peripheral edema .
• Precautions (weight bearing or BP parameters after vascular surgery).

Question 7

Vascular Examination (Inspection)

Answer 7

• Skin color: (discoloration of the distal extremities/nail bed).
• Hair distribution: patchy hair loss on the lower leg may indicate arterial insufficiency
• Venous pattern: dilated veins, particularly in the calf.
• Edema or atrophy:
– Peripheral edema from right sided CHF : bilaterally in dependent
– Edema from trauma, lymphatic obstruction, or chronic venous insufficiency: generally unilateral.
• Presence of cellulitis.
• Presence of petechiae: small, purplish, hemorrhagic spots on the skin.
• Skin lesions: ulcers, blisters, or scars.
• Digital clubbing: poor arterial oxygenation or circulation.

Question 8

Vascular Examination (Palpation)

Answer 8

• Pain & tenderness
• Strength & rate of peripheral pulses
• BP
• Skin temperature
• Limb girth (if edematous)

Question 9

Vascular Examination

(Vascular Tests)

Answer 9

Capillary refill time
Elevation pallor
Manual compression test
Allen’s test
Homans’ sign
Ankle
brachial index (ABI)

Question 10

Capillary refill time

Answer 10

is defined as the time taken for a distal capillary bed to regain its color after pressure has been applied to cause blanching

Question 11

Manual compression test

Answer 11

if varicose v are seen then occlude the proximal and palpate the distal. If a pulse is felt, then it is a positive test.

Question 12

Homans’ sign

Answer 12

for people you expect has DVT. Bring pt foot into DF and squeeze at the calf make sure knee is flexed to take away potential of tight hamstrings. Pos if pt feels pain and discomfort.

Question 13

Allen’s test

Answer 13

used to assess collateral blood flow to the hands, generally in preparation for a procedure that has the potential to disrupt blood flow in either the radial or the ulnar artery.

Question 14

Modified wells Criteria:

Answer 14

Criteria for predicting the probability of a DVT

If you have more than 2 than you are at risk for DVT

Question 15

Vascular Examination (Diagnostic Studies)

Noninvasive Lab studies

Answer 15

• Doppler ultrasound
• Plethysmography
• Exercise testing
• CT
• MRI
• Magnetic resonance angiography
(MRA)

Question 16

Vascular Examination (Diagnostic Studies)
Invasive Vascular Studies

Answer 16

Arteriography (Most common)

• Postangiogram care:
– Bed rest for 4 to 8 hours.
– Pressure dressings to the injection site with assessment for hematoma formation.
– Intravenous fluid administration to help with dye excretion.
– Frequent vital sign monitoring with pulse assessments.

Question 17

Hematologic Examination (History)

Answer 17

• What are the presenting symptoms?
• Was the onset of symptoms gradual , rapid , or associated with trauma or other
disease?
• Is the pt unable to complete daily activities secondary to fatigue
• Hx of anemia or other blood disorders, cancer, hemorrhage, or systemic
infection?
• Hx of blood transfusion
• Hx of chemotherapy , radiation therapy, or other drug
• Night sweats, chills, or fever?
• Easily bruised ? Is wound healing delayed?

Question 18

Hematologic Examination (Inspection)

Answer 18

• General appearance ( lethargy , malaise , or apathy
• Degree of pallor or flushing of the skin, mucous
membranes, nail beds, and palmar creases.
• Presence of petechiae ecchymosis (bruising).
• RR.

Question 19

Laboratory Studies

(CBC)

Answer 19

• Decreased Hgb levels can reduce oxygen transport capacity -> reduce O2 supply -> ↓endurance level.
• Be aware of S&S of hypoxia to major organs : brain, heart, & kidneys

• Hct may be falsely high w/ dehydration & falsely low w/ fluid overload
• Low Hct -> weakness, dyspnea, chills, ↓activity tolerance, or exacerbate
angina.

Question 20

Pancytopenia

Answer 20

Significant ↓in RBCs, all types of WBCs, & platelets

Question 21

Neutropenia

Answer 21

An abnormal decrease in WBCs, particularly neutrophils.

Question 22

Leukocytosis

Answer 22

High level of WBC

Question 23

Thrombocytopenia

Answer 23

A significant decrease in platelets.

Question 24

Thrombocytosis

Answer 24

An abnormal increase in platelets.

Question 25

Laboratory Studies (ESR)

Answer 25

• A measurement of how fast RBCs fall in a sample of blood. • Normal values: – Males: up to 15 mm/hour – Females: up to 20 mm/hour • ESR may be elevated in systemic infection , collagen vascular disease, and HIV. – Disease worsens -\> ↑ESR – Disease improves -\> ↓ESR

Question 26

Laboratory Studies (Coagulation Profile)

Answer 26

• Coagulation tests assess the blood's ability to clot. – Prothrombin time (PT) (11 12.5 seconds) – International normalized ratio (INR) (0.8 1.1) – Partial thromboplastin time (PTT) (60 70 seconds) • Activated PTT ( aPTT ) (30 40 seconds) • Used in clinical conditions in which an increased risk of thrombosis is present ( DVT)

Question 27

Laboratory Studies (D-Dimer)

Answer 27

• Provides measurement of the amount of fibrin degradation fragment. • Accurately identifies pts w/ DVT (high negative predictive value): – Negative -\> patient has a very low likelihood of having DVT. – Positive -\> less helpful (multiple conditions).

Question 28

Arterial Disorders

Answer 28

Atherosclerosis, Aneurysm, Aortic Dissection, Hypertension, Raynaud's Disease, Chronic Regional Pain Syndrome, Compartment Syndrome.

Question 29

Venous Disorders

Answer 29

• Varicose Veins, Venous Thrombosis, Pulmonary Embolism, Chronic Venous Insufficiency.

Question 30

Combined Arterial & Venous Disorders

Answer 30

Arteriovenous Malformations

Question 31

Hematologic Disorders

Answer 31

• Anemia, Polycythemia, Thrombocytic Disorders.

Question 32

Lymphatic Disorders

Answer 32

Lymphedema

Question 33

Atherosclerosis

Answer 33

* Deposition of plaques of fatty material on their inner walls  ↓blood perfusion past the area. * A 50% to 60% reduction in blood flow is necessary for pts to present w/ symptoms (e.g., pain). * The underlying cause of ~ 90% of all MI and a large proportion of strokes.

Question 34

Atherosclerosis Risk Factors

Answer 34

– Reversible: HTN, DM, HLD, cigarette smoking, obesity. – Irreversible: male gender, family history, genetic.

Question 35

Atherosclerosis S & S

Answer 35

Reduced to absent peripheral pulses Coolness & pallor skin, more w/ elevation Ulcerations, atrophic nails, & hair loss Increased BP Burning pain in LE, more w/ elevation Pain at rest? Severe (80% 90%) occlusion Calf cramp ↑by walking & ↓by rest

Question 36

Artherosclerosis Ambulation

Answer 36

• The distance a person can walk before the onset of pain indicates the degree of circulatory inadequacy: * ≥2 blocks: mild * 1 block: moderate * ≤½ block: severe

Question 37

Aneurysm

Answer 37

• Localized dilatation or outpouching of the vessel. • Common places: – Abdominal aorta or iliac arteries, popliteal, femoral, & carotid. • ~ 80% of the aneurysms are identified incidentally.

Question 38

Aortic Dissection

Answer 38

• Caused by an intimal tear, which allows creation of a false lumen between the media and adventitia. • Twice as frequently in men than in women.

Question 39

Aortic Dissection S&S

Answer 39

– Sudden pain in upper back migrates to the neck, abdomen, or groin. – Cardiogenic or hypovolemic shock. – Syncope. – Hypertension. – Reduced or absent pulses. – Pleural effusions – Neurological manifestations (CVA).

Question 40

Aortic Dissection Clinical Tip

Answer 40

– pain can mimic that of myocardial ischemia

Question 41

Hypertension

Answer 41

* Elevated arterial blood pressure, both systolic & diastolic, that is abnormally sustained at rest. * Frequently asymptomatic. * Causes: genetic predisposition, smoking, type A personality, obesity, DM, atherosclerosis. * Hypertensive crisis is a medical emergency.

Question 42

Hypertention (Brain)

Answer 42

• Cerebrovascular accident

Question 43

Hypertension (Eyes)

Answer 43

• Blurred or impaired vision

Question 44

Hypertension (Heart)

Answer 44

* Myocardial infarction * Congestive heart failure * Myocardial hypertrophy * Dysrhythmias

Question 45

Hypertension (Kidneys)

Answer 45

* Renal insufficiency * Renal failure

Question 46

Hypertension | (PT Considerations)

Answer 46

* HTN is a risk factor for heart attack, stroke, & kidney failure * Women typically have lower BP than men until after menopause * Physical exertion increases BP acutely & decreases resting BP over time * Knowledge of medication schedule may facilitate activity tolerance * Review & clarify strict BP parameters by physician * BP is high? check cuff size, take in the opposite side, then notify the team * If contraindicated in the UEs, take it in the LE

Question 47

Raynaud's Disease

Answer 47

Symptoms that occur to exposure to cold and or emotional stress Fingertip color change (white -\> Blue-\> Red) due vasoconstriction or occlusion Raynaud’s Phenomenon: comes from other systemic disease like lupus. May not be able to be changed or reverse. Which can lead to atrophy, gangrene.

Question 48

Complex Regional Pain Syndrome

Answer 48

* A disorder of the extremities characterized by autonomic & vasomotor instability. * Constant, extreme pain after the healing phase of minor or major trauma, fractures, surgery.

Question 49

Complex Regional Pain Syndrome Stages

Answer 49

Stage 1 (hrs to days): Pain, tenderness, edema, & temperature Stage 2 (3 to 6 mo): Pain beyond the area, loss of hair & dystrophic nails, muscle wasting, osteoporosis, & ↓ROM. Stage 3 (6 mo): Atrophy, functional impairment, & irreversible damage.

Question 50

Compartment Syndrome

Answer 50

The circulation within a closed compartment is compromised by an increase in pressure within the compartment. Causes necrosis of muscles & nerves and eventually of the skin.

Question 51

Compartment Syndrome if left untreated can lead to ...

Answer 51

--\> Volkmann ischemic (necrotic muscle & nerve replaced w/ fibrous tissue).

Question 52

Compartment Syndrome Cases/ Causes

Answer 52

– Fractures, crush injuries, hematomas, penetrating injuries, circumferential burn injury, & electrical injuries. – External factors: casts & circular dressings that are too constrictive.

Question 53

Pressure that can cause Compartment Syndrome

Answer 53

Pressures of 32 to 37 mm Hg can cause compression of capillaries. *Normal pressure: 0-8 mmHg*

Question 54

Compartment Syndrome Permanent Damage time frame

Answer 54

– Muscles: after 4 to 12 hours. – Nerves: after 8 hours.

Question 55

Compartment Syndrome (PT Considerations)

Answer 55

* Edu on proper positioning * When compartment syndrome is present * Elevation most be discontinued * Circumferential bandages must be removed

Question 56

Venous Thrombosis

Answer 56

* Deep veins (femoral or iliac veins) or superficial (saphenous vein). * Result from: venous stasis ( immobility ), endothelial injury, and hypercoagulability (inflammation, malignancy). • Usually occurs in LE

Question 57

Venous Thrombosis S&S

Answer 57

– Pain & swelling distal to the site of thrombus – Redness & warmth in the area around the thrombus – Dilated veins – Low grade fever – Dull ache or tightness in the region of DVT

Question 58

How is Venous Thrombosis identified?

Answer 58

Ultrasonography

Question 59

Venous Thrombosis Clinical Tip

Answer 59

PT intervention for pts w/ suspected DVT should be withheld until cleared by the medical surgical team.

Question 60

Ways to prevent DVT

Answer 60

* Recommendations to prevent DVT: * Early mobilization: low risk individuals. * Anticoagulants: moderate to high risk. * Postoperatively: * Early ambulation, good hydration, calf muscles exercise * Routine use of elastic stockings.

Question 61

DVT Treatment

Answer 61

– Low molecular weight heparin (e.g., lovenox) – If cannot be anticoagulated --\> inferior vena cava (IVC) filter

Question 62

Pulmonary Embolism

Answer 62

Moving DVT A primary complication of venous thrombosis, emboli originating in the LE (75% to 90%).

Question 63

Pulmonary Embolism S&S

Answer 63

* dyspnea * CP * hemoptysis * tachypnea.

Question 64

Pulmonary Embolism Clinical Tip

Answer 64

PT intervention should be discontinued immediately if the S&S of an acute PE arise during session.

Question 65

Arteriovenous Malformations

Answer 65

Involve shunting (via arteriovenous fistula) of blood directly from the artery to the vein, bypassing the capillary bed.

Question 66

Where do Arteriovenous Malformations occur?

Answer 66

Majority of AVMs occur in the trunk & extremities, (may present in the cerebrovascular region).

Question 67

Arteriovenous Malformations Signs

Answer 67

– Skin color changes (erythema or cyanosis) – Edema – Limb deformity – Skin ulceration – Pulse deficit – Bleeding

Question 68

Anemia

Answer 68

* A significant reduction in the mass of circulating RBCs. * Resulting in diminishing O2 binding capacity of blood.

Question 69

Post hemorrhagic Anemia

Answer 69

• Rapid blood loss from traumatic artery severance.

Question 70

Post hemorrhagic Anemia Percentage Loss

Answer 70

_20% - 30% blood loss:_ Dizziness, hypotension, tachycardia w/ exertion. _30% - 40% blood loss:_ Thirst, dyspnea, diaphoresis, cold & clammy skin, hypotension, tachycardia, ↓urine output, clouding or LOC. _40% - 50% blood loss_: Severe state of shock & potential death.

Question 71

Post hemorrhagic Anemia Management

Answer 71

control of bleeding, IV & oral fluid, blood transfusion, & supplemental O2.

Question 72

Iron Deficiency Anemia

Answer 72

Iron loss exceeds iron intake --\> deplete body's iron stores --\> insufficient iron for normal Hgb production. The most common cause of anemia.

Question 73

Iron Deficiency Anemia S&S

Answer 73

– Easy fatigability , tachycardia, palpitations, & dyspnea on exertion. – Dizziness, headache & irritability, dysphagia. – Softening & spooning of nails, pale earlobes, & palms. – May develop pica (craving to eat unusual substances, ex,

Question 74

Iron Deficiency Anemia Causes

Answer 74

deficient diet, pregnancy, lactation, menstrual, blood donation.

Question 75

Iron Deficiency Anemia Management

Answer 75

iron supplementation or nutritional counseling.

Question 76

Polycythemia

Answer 76

* A chronic disorder characterized by excessive production of RBCs. * Increase in blood volume, blood viscosity, and Hgb concentration --\> excessive workload for the heart and congestion of some organs.

Question 77

Polycythemia S&S

Answer 77

– Headache, dizziness, blurred vision, & vertigo. – Venous thrombosis. – Bleeding: nose, GI, & spontaneous bruising. – Fatigue. – Paresthesia in the hands and feet. – Splenomegaly.

Question 78

Polycythemia Management

Answer 78

phlebotomy (every 2 to 4 days, 250 - 500 ml)

Question 79

Thrombocyte Disorders

Question 80

Disseminated Intravascular Coagulation

Question 81

Hemophilia

Answer 81

spontaneous bleeding

Question 82

Thalassemia

Answer 82

Less than normal amount of hemoglobin. This can develop into clots

Question 83

Thrombocytopenia

Answer 83

reduced amount of platelets

Question 84

Heparin-Induced Thrombocytopenia

Answer 84

bleed easily

Question 85

**_\*\*Lymphedema_**

Answer 85

When venous is not able to work properly this will cause lymphatic system to be affected and causing fluid to stay stationary

Question 86

Types of Lymphedema

Answer 86

* Primary (idiopathic) lymphedema * Secondary (acquired) lymphedema.

Question 87

Lymphedema S&S

Answer 87

– Swelling (usually not relieved by elevation) – Pitting edema in early stages and nonpitting edema in later stages – Fatigue & heaviness, tightness, tingling, & numbness – Fibrotic changes in the skin – Increased circumferential limb girth & loss of ROM

Question 88

The International Society of Lymphology Scale (lymphedema grade)

Answer 88

* Stage 0: Lymph transport capacity is reduced; no clinical edema is present. Pts may begin to feel heaviness in limb. * Stage 1: * Accumulation of protein rich pitting edema * Reversible w/ elevation ; area affected may be normal in the * Increases with activity, heat, & humidity. * Stage 2: * Accumulation of protein rich nonpitting edema w/ connective & scar tissue. * Irreversible (does not resolve overnight; increasingly more difficult to pit) * Clinical fibrosis is present * Skin changes present in severe stage 2 * Stage 3: * Accumulation of protein rich edema w/ significant ↑in connective & scar tissue * Severe nonpitting fibrotic edema * Atrophic changes (hardening of dermal tissue, skin folds, skin papillomas

Question 89

Lymphedema Management

Answer 89

* _Manual Lymphatic drainage_: decreasing pressure as you go more proximal. Improves lymph transport capacity * _Lymphedema bandaging_: multiple layers for supportive structure. Used in b/w manual lymphatic drainage

Question 90

**_Anticoagulation Therapy_**

Answer 90

Heparin: prevent change in fibrin to fibrinogen. APPT- 30-40 sec. 60- 80 secs. Fast affect Coumadin or warfarin: vit k antagonist to prevent clotting factors. INR- 2-3

Question 91

Subtherapeutic

Answer 91

subtherapeutic: likely to clot / risk for thrombus

Question 92

\* Supertherapeutic

Answer 92

Likely to bleed/ hemorrhage. Pt needs to be given Vit k

Question 93

Blood Product Transfusion

Answer 93

Blood & blood products are transfused to replenish blood volume, maintain O2 delivery , or maintain proper coagulation.

Question 94

Blood Product Transfusion | (PT Considerations)

Answer 94

• You may defer out of bed or vigorous activities until the transfusion is complete. A blood unit takes 3 to 4 hours. • Defer PT intervention during the first 15 minutes. • During a blood transfusion, vital signs are usually taken every 15 to 30 minutes by the nurse. • After a blood transfusion, it takes 12 to 24 hours for the Hgb & Hct to increase.

Question 95

Embolization Therapy

Answer 95

• Purposely occluding a vessel with Gelfoam , coils, balloons, or polyvinyl alcohol. • Indications: disorders characterized by inappropriate blood flow, such as AVMs.

Question 96

Embolization Therapy Complications

Answer 96

* Tissue necrosis * unintentional embolization of normal tissues * Passage of embolic materials through arteriovenous communications

Question 97

Transcatheter Thrombolysis

Answer 97

Dissolving clot w/ catheter with medicine

Question 98

**_Transcatheter Thrombectomy_**

Answer 98

**_Transcatheter Thrombectomy:_** fewer complications catheter that removes or lyses clot

Question 99

Peripheral Vascular Bypass Grafting

Answer 99

To reperfuse an area that has been ischemic from peripheral vascular disease. Pts require ~ 24 to 48 hours to become hemodynamically stable, usually monitored in the ICU.

Question 100

Peripheral Vascular Bypass Grafting Complications

Answer 100

* Hemorrhage * Thrombosis * Infections * Renal failure

Question 101

Aneurysm Repair & Reconstruction

Question 102

Aneurysm Repair & Reconstruction Complications

Answer 102

* Hemorrhage * Thrombosis * Infection * Renal Failure

Question 103

Aneurysm Repair (PT Considerations)

Answer 103

* Inspect incision * obtain weightbearing activity *

Question 104

Aortobifemoral Repair PT management goals

Answer 104

If fatigue is a problem make sure there is a wheel chair w/ you to make sure pt is safe.

Question 105

PT Management (Vascular disorders)

Answer 105

• If being evaluated for possible aortic dissection , modify or defer PT intervention until definite diagnosis is established. • A thorough review of the medical history is needed before any edema management

Question 106

PT management (Hematologic) PT should monitor CBC & coagulation profile daily to determine:

Answer 106

* potential risk for bruising and bleeding * thrombus formation * altered O2 carrying capacity

Question 107

PT management (Hematologic Disorders) To gain insight into the hemostatic condition, determine:

Answer 107

– Whether the abnormal blood lab values are expected or consistent w/ the pt's medical surgical status. – The relative severity (mild, moderate, or severe) of the abnormal laboratory values. – The pt's presentation & clinical symptoms.

Question 108

PT management Hemaologic Disorders

Answer 108

Monitoring of vital signs & O2 saturation at rest and with activity is crucial in pts with low H&H. Determine the need to modify or defer PT intervention according to the lab values (particularly Hct , platelet, & PT/INR).

Question 109

Thrombocytopenia Exercise Guidelines

Answer 109

* \<10,000 mm 3 * Spontaneous CNS, GI, and/or respiratory tract bleeding * \<20,000 mm 3 * ADLs, AROM, & ambulation with physician approval * 20,000 to 50,000 mm 3 * AROM & walking as tolerated, low intensity exercise (no resistance) * 50,000 to 150,000 * Progressive resistive exercise, ambulation, or stationary bicycling (w/ resistance)

Question 110

INR Scale

Answer 110

* INR \<4 * Regular exercise program if allowed by physician. * Advancing intensity should wait for the INR therapeutic range. * INR 4-5 * Resistive exercises should be held (light exercise only). * Unsteady gait addressed w/ appropriate AD. Precautions to avoid a fall. * INR \>5 * Mobilization depends on 1. pt's presentation (age, PLOF, functional status, & medical condition). 2. medical intervention for the high INR. 3. institutional guidelines & the risk/benefit of PT. * INR \>6 * Medical team may consider bed rest until the INR is corrected (usually corrected in 2 days).

Question 111

RBC Count Normal values

Answer 111

Female: 4.2 - 5.4 million/ul Male: 4.7 - 6.1 million/ul

Question 112

WBC Count Normal values

Answer 112

5,000 - 10,000 uL

Question 113

Hematocrit Count Normal values

Answer 113

Female: 37 - 47% Male: 42 - 52%

Question 114

Hemoglobin Count Normal values

Answer 114

Female: 12 - 16 g/100 ml Male: 14 - 18 g/100 ml

Question 115

Platelet Count Normal values

Answer 115

150,000 - 450,000 uL