NR 304 Exam 1 Concepts
How does once perform a capillary refill assessment? - answer- Depress and blanch
nail beds
- Hold for 5 seconds
- Release depression of nail bed
What is the capillary refill assessment an indicator of? - answer- peripheral perfusion
status
What should a nurse note during an capillary refill assessment? - answer- Time
capillaries took to refill
What is a normal refill rate of a capillary refill assessment? - answer- < 1-2 seconds
What are some subjective data when it comes to venous (stasis ulcers)? - answer-
Aching pain in lower leg / calf
- itching w/ stasis dermatitis
What makes the aching pain associated with venous ulcers worse? - answer- prolonged
standing
- prolonged sitting
What is some objective data you would note with venous disease / insufficiency (stasis
ulcers)? - answer- Lower extremity edema
- brawny edema
- coarse, thickened skin
- normal pulse
- brown pigment discoloration
- Petechiae
- Dermatitis
- shallow granulation
What does venous ulcers cause an increase in? - answer- venous pressure
What are some clinical manifestations of peripheral arterial disease (PAD)? - answer-
Leg pain
- Cramps
- Skin colorization change in arms/ legs
- swelling in arms / legs
- lymph node enlargement
- fatigue
- Claudication
,- Night pain
- Coolness to touch
- paralysis
What is poikilothermic? - answerCoolness to the touch
What does claudication mean? - answer- pain while walking
What clinical manifestation would be noted if PAD was severe? - answer- paralysis
What is the pulse associated with arterial insufficiency/ disease (PAD) - answer- Weak/
Thready pulses
- 1 + pulse
- Diminished pulses
What is the pule associated with Venous disease? - answer- Bounding force
-3+
What are some relieving factors for arterial insufficiency / disease (PAD)? - answer-
Rest
- Dangling feet
How long does resting take to relieve arterial disease (PAD)? - answer- 2 minutes
When should a nurse use the feet dangling method to cause relief for PAD? - answer-
when PAD is severe
What are some relieving factors associated with Venous insufficiency/ disease? -
answer- Elevation
- Lying
- Walking
- pain meds
What does intermittent claudication mean? - answer- pain impacting the calf muscle
What does claudication distance mean? - answer- Specific number of blocks / stairs that
can be met before pain is observed
What are some signs of worsening claudication? - answer- Cold feet
- Cramping
- Tingling
- Numbness
What are some subjective data examples of arterial ulcers? - answer- Deep pain in the
calf
- Claudication
, - Worsening pain with elevation
Where is the pain located in arterial ulcers normally? - answer- deep in the calf
What is claudication associated with? - answer- Peripheral vascular disease
- Arterial ulcers
What impacts does elevation cause on a patient with arterial ulcers? - answer-
increases pain of arterial ulcers
What impacts does elevation cause on a patient with venous ulcers? - answer-
decreases pain of venous ulcers
What are some objective data that is associated to arterial ulcers? - answer- coolness in
only one foot or leg
- pallor
- elevational pallor
- dependent rubor
- diminished pulses
- systolic bruits
- thin skin
- shiny skin
- thick-ridged nails
- muscle atrophy
- distal gangrene
What are some muscle changes associated with arterial ulcers? - answer- muscles
undergo atrophy
what are temperature changes that occur to a patient with arterial ulcers? - answer-
coolness can be felt in only one foot/ leg
What skin colorization changes occur in arterial ulcers? - answer- pallor
- dependent rubor
- gangrene
Where does the gangrene occur in arterial uclers? - answer- gangrene occurs on distal
end
What changes in skin can be noted w/ arterial ulcers? - answer- skin becomes thin
- skin becomes shiny
What are some nail changes that occur w/ arterial ulcers? - answer- Nails develop
thick / ridged
How does once perform a capillary refill assessment? - answer- Depress and blanch
nail beds
- Hold for 5 seconds
- Release depression of nail bed
What is the capillary refill assessment an indicator of? - answer- peripheral perfusion
status
What should a nurse note during an capillary refill assessment? - answer- Time
capillaries took to refill
What is a normal refill rate of a capillary refill assessment? - answer- < 1-2 seconds
What are some subjective data when it comes to venous (stasis ulcers)? - answer-
Aching pain in lower leg / calf
- itching w/ stasis dermatitis
What makes the aching pain associated with venous ulcers worse? - answer- prolonged
standing
- prolonged sitting
What is some objective data you would note with venous disease / insufficiency (stasis
ulcers)? - answer- Lower extremity edema
- brawny edema
- coarse, thickened skin
- normal pulse
- brown pigment discoloration
- Petechiae
- Dermatitis
- shallow granulation
What does venous ulcers cause an increase in? - answer- venous pressure
What are some clinical manifestations of peripheral arterial disease (PAD)? - answer-
Leg pain
- Cramps
- Skin colorization change in arms/ legs
- swelling in arms / legs
- lymph node enlargement
- fatigue
- Claudication
,- Night pain
- Coolness to touch
- paralysis
What is poikilothermic? - answerCoolness to the touch
What does claudication mean? - answer- pain while walking
What clinical manifestation would be noted if PAD was severe? - answer- paralysis
What is the pulse associated with arterial insufficiency/ disease (PAD) - answer- Weak/
Thready pulses
- 1 + pulse
- Diminished pulses
What is the pule associated with Venous disease? - answer- Bounding force
-3+
What are some relieving factors for arterial insufficiency / disease (PAD)? - answer-
Rest
- Dangling feet
How long does resting take to relieve arterial disease (PAD)? - answer- 2 minutes
When should a nurse use the feet dangling method to cause relief for PAD? - answer-
when PAD is severe
What are some relieving factors associated with Venous insufficiency/ disease? -
answer- Elevation
- Lying
- Walking
- pain meds
What does intermittent claudication mean? - answer- pain impacting the calf muscle
What does claudication distance mean? - answer- Specific number of blocks / stairs that
can be met before pain is observed
What are some signs of worsening claudication? - answer- Cold feet
- Cramping
- Tingling
- Numbness
What are some subjective data examples of arterial ulcers? - answer- Deep pain in the
calf
- Claudication
, - Worsening pain with elevation
Where is the pain located in arterial ulcers normally? - answer- deep in the calf
What is claudication associated with? - answer- Peripheral vascular disease
- Arterial ulcers
What impacts does elevation cause on a patient with arterial ulcers? - answer-
increases pain of arterial ulcers
What impacts does elevation cause on a patient with venous ulcers? - answer-
decreases pain of venous ulcers
What are some objective data that is associated to arterial ulcers? - answer- coolness in
only one foot or leg
- pallor
- elevational pallor
- dependent rubor
- diminished pulses
- systolic bruits
- thin skin
- shiny skin
- thick-ridged nails
- muscle atrophy
- distal gangrene
What are some muscle changes associated with arterial ulcers? - answer- muscles
undergo atrophy
what are temperature changes that occur to a patient with arterial ulcers? - answer-
coolness can be felt in only one foot/ leg
What skin colorization changes occur in arterial ulcers? - answer- pallor
- dependent rubor
- gangrene
Where does the gangrene occur in arterial uclers? - answer- gangrene occurs on distal
end
What changes in skin can be noted w/ arterial ulcers? - answer- skin becomes thin
- skin becomes shiny
What are some nail changes that occur w/ arterial ulcers? - answer- Nails develop
thick / ridged
