chapter 26

🧠 0. EXAM-CRITICAL VOCAB (must-know only)

🧠 1. SYSTEMS MAP (big picture causal web)

A) Normal vascular physiology → what it’s supposed to do

1. Heart pump + vessels + volume = perfusion.

   • Pump must generate pressure.

   • Arteries deliver.

   • Capillaries exchange.

   • Veins return + store.

   • Lymph drains excess fluid/protein.

2. Flow follows hemodynamics:

   • Flow = ΔP / R

   • ΔP mostly set by heart/BP.

   • R mostly controlled by arterioles (resistance vessels).

3. Microcirculation + Starling forces:

   • Arterial capillary end: hydrostatic > oncotic → filtration out.

   • Venous end: oncotic > hydrostatic → reabsorption in.

   • Extra fluid/protein → lymphatics pick it up.

4. Laminar vs turbulent:

   • Normal vessels → laminar, silent.

   • Narrowing/dilation/hi-flow → turbulent → bruit.

Logic checks (answer quick):

1. If arteriole radius ↓, what happens to resistance and flow?

2. Why do veins hold most of the blood volume?

3. What two pressures decide whether fluid leaves or reenters a capillary?

B) Assessment & diagnostics arise directly from that physiology

1. Arterial assessment targets perfusion failure:

   • Pain pattern (claudication → rest pain).

   • Pulses ↓/absent.

   • Temp cool/cold, pallor, rubor.

   • Trophic changes (shiny skin, hair loss).

   • Distal ulcers/gangrene.

2. Venous assessment targets return failure:

   • Dull ache/heaviness.

   • Edema.

   • Warm skin, pulses present.

   • Brown hemosiderin staining.

   • Weepy malleolar ulcers.

3. Lymphatic assessment targets drainage failure:

   • Non-pitting, protein-rich edema.

   • Heavy limb, thickened skin.

   • Recurrent cellulitis risk.

4. Diagnostics follow the map:

   • ABI + Doppler = arterial flow adequacy.

   • Duplex US = stenosis vs occlusion + venous reflux/DVT.

   • CT/MRA/angiography = structure + surgical planning.

   • Lymphoscintigraphy = lymph obstruction.

Logic checks:

1. Why does PAD pain show up only with walking at first?

2. Why can venous pulses still be “present” even with severe CVI?

3. Why is ABI required before compression?

C) Disorders are just failures of specific parts of the system

1. Arterial disorders = delivery failure (high R / blockage).

   • Acute occlusion → no time for collaterals → 6 P’s/necrosis.

   • Chronic narrowing → collaterals + claudication.

2. Aneurysm/dissection = wall structural failure.

   • HTN/atherosclerosis weaken media → dilation or tearing.

3. Acute arterial emergencies

   • Embolus/thrombus → sudden ischemia → compartment syndrome risk after reperfusion.

4. Venous disorders = return failure (valves/pump/stasis).

   • CVI/varicose veins → venous HTN → edema → ulcers.

   • DVT/PE from Virchow triad.

5. Lymphatic disorders

   • Obstruction → protein edema → fibrosis/elephantiasis + infection.

Logic checks:

1. Why does chronic arterial disease allow some adaptation but acute doesn’t?

2. How does venous HTN directly create edema?

3. Why is lymphedema harder to mobilize than venous edema?

D) Complications are predictable endpoints of the cascade

• Delivery failure → ischemia → ulcer → gangrene → amputation.

• Wall failure → rupture/dissection → internal hemorrhage/death.

• Return failure → stasis → DVT → PE.

• Drainage failure → trapped proteins → fibrosis + cellulitis.

Logic checks:

1. What complication do you fear most with an expanding AAA?

2. What’s the lethal complication of a DVT?

3. Why does chronic edema wreck skin integrity?

E) Management is cause-based

• Arterial = improve inflow (revascularize, antiplatelet, risk-factor control, protect limb).

• Venous = improve outflow (compression if ABI ok, elevate, treat reflux/DVT).

• Lymphatic = improve drainage (compression + manual drainage + infection control).

• Ulcers = moist bed + correct circulation + debride only when safe.

• Emergencies = restore flow fast.

  • BUT watch reperfusion → compartment syndrome.

⚡ 2. HIGH-YIELD PATTERN RECOGNITION (with NCLEX focus tags)

1. ANY arterial problem = “6 P’s” directionally

   • Pain (sharp), Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (cold).

   • NCLEX Focus Point: they want early ischemia recognition + rapid escalation.

2. Chronic arterial insufficiency pattern

   • Claudication → rest pain → ulcers/gangrene.

   • Cool, shiny, hairless limb, weak pulses.

   • Pallor w/ elevation + dependent rubor.

   • NCLEX Focus Point: stages + positioning (don’t elevate severe PAD).

3. Acute arterial occlusion pattern

   • Sudden, severe ischemic pain not relieved by opioids.

   • Rapid loss of pulses + neuro deficits.

   • NCLEX Focus Point: limb emergency = call now.

4. ANY venous problem = stasis → edema → skin breakdown

   • Dull ache/heaviness, warm limb, pulses present.

   • Brown gaiter staining + dermatitis.

   • Ulcers “wet, wide, weeping” near malleolus.

   • NCLEX Focus Point: they test compression + elevation + ulcer ID.

5. Venous HTN → Starling shift

   • ↑ venous pressure → ↑ cap hydrostatic → filtration > reabsorption → edema.

   • NCLEX Focus Point: mechanism behind edema/ulcers.

6. ANY lymph obstruction = protein-rich, hard edema

   • Non-pitting, thick heavy limb, skin fibrotic.

   • NCLEX Focus Point: compression + infection prevention.

7. Laminar vs turbulent

   • Turbulent = bruit = stenosis/aneurysm.

   • NCLEX Focus Point: bruit ≠ benign; it’s a pathology clue.

8. Resistance rule

   • Arterioles control SVR. Small radius change → huge flow change.

   • Chronic ↑SVR → LVH → HF.

   • NCLEX Focus Point: links vascular to cardiac failure.

9. ABI rule

   • Normal ≈ 1.0.

   • ≤0.90 PAD.

   • <0.50 rest pain.

   • ≤0.40 tissue loss risk.

   • ABI >1.2 in DM/CKD may be false high.

   • NCLEX Focus Point: decides compression safety + severity.

10. Ulcer ID pattern

• Arterial: punched-out, distal/toes, dry, painful.

• Venous: shallow/irregular, ankle, exudative, aching.

• Neuropathic: plantar/metatarsal, painless.

• NCLEX Focus Point: treatment depends on ID.

11. Dry gangrene rule

• Dry, stable, black toe in severe PAD → NO debridement, keep dry, protect.

• NCLEX Focus Point: safety trap — debriding = amputation spiral.

12. Reperfusion → compartment syndrome risk

• After embolectomy/thrombolysis: pain out of proportion, tense limb, neuro loss.

• NCLEX Focus Point: watch limb after restoring flow.

🔗 3. CROSS-CHAPTER CONNECTIONS (Chapter 26 ↔ All Cardiac Chapters)

These are the EXAM-WINNING links your instructors expect you to make.

A) Chapter 26 ↔ Chapter 27 (Hypertension)

HTN is the #1 cause of every major vascular catastrophe:

• AAA formation

• AAA expansion

• Aortic dissection

• PAD progression

• Arterial emboli lodging more easily

• Endothelial injury → DVT risk ↑

Mechanism:
HTN = ↑ shear stress → intimal tearing → media degeneration → aneurysm/dissection.

NCLEX link:
Thoracic/abdominal aneurysm + HIGH BP → rupture risk (call provider before giving fluids!).

B) Chapter 26 ↔ Chapter 23 (ACS/CAD)

Atherosclerosis in arteries = a BODY-WIDE disease.
If it’s in the:

• Coronary arteries → MI

• Carotids → stroke

• Peripheral arteries → PAD

• Aorta → aneurysm/dissection

• Renal arteries → secondary HTN

NCLEX link:
Patient with CAD + leg pain → assume PAD until proven otherwise.

C) Chapter 26 ↔ Chapter 22 (Arrhythmias)

Vascular problems cause dysrhythmias by:

• Ischemia → irritates myocardium → PVCs, VT

• Hypoxia from PE → sinus tach → A-fib → RVR

• Shock states from rupture → brady/asystole

NCLEX link:
PE → sudden P-wave loss + tachy
Aortic dissection → hypertension → brady → loss of pulses (tamponade risk)

D) Chapter 26 ↔ Chapter 25 (Heart Failure)

HF worsens vascular disorders, vascular disorders worsen HF.

• HF → ↓ CO → ↓ peripheral perfusion → ↑ PAD progression

• Venous congestion → ↑ venous pressure → ↑ edema → ↑ CVI

• PAD → ↑ afterload → worsens HFpEF/HFrEF

• Renal underperfusion → RAAS → more HTN → more vascular strain

NCLEX link:
Worsening leg ulcers + worsening HF symptoms = venous congestion, not arterial.

E) Chapter 26 ↔ Chapter 47 (Kidney)

Kidneys = perfusion-dependent.
ANY ↓ perfusion (PAD, HF, aneurysm rupture) → ↓ GFR → ↑ BUN/Cr = pre-renal AKI, NOT “kidney damage.”

NCLEX trap:
High BUN/Cr from ↓ perfusion ≠ intrinsic renal failure.

F) Chapter 26 ↔ Chapter 21 (Cardiovascular Assessment)

Everything in Ch 21 (color, pulses, temp, cap refill) LEADS INTO:

• PAD dx

• CVI dx

• Acute occlusion recognition

• Aneurysm rupture detection

• Shock detection

NCLEX link:
Cool, pale limb + weak pulses → arterial issue
Warm, swollen limb + intact pulses → venous issue

G) Chapter 26 ↔ Chapter 24 (Valves)

Emboli from:

• A-fib

• Mitral stenosis

• Endocarditis vegetations
  → lodge in peripheral arteries → acute limb ischemia.

NCLEX link:
Sudden 6 P’s + known A-fib = call provider → prepare for heparin + embolectomy.

🚨 4. RED FLAG INTEGRATION LIST (ALL CHAPTER 26 EMERGENCIES)

This is the “if you miss these, you fail the exam” list.

A) Arterial Emergencies (LIFE OR LIMB)

Six P’s = surgical emergency

✔ Pain (severe, unrelenting)
✔ Pallor
✔ Pulselessness
✔ Paresthesia
✔ Paralysis
✔ Poikilothermia (cold)

Immediate nursing action:
→ Call provider STAT
→ Prepare for heparin, embolectomy, thrombolysis
→ Keep limb at level of heart (NO elevation)

B) AAA/TAA Red Flags

🔥 Rupture signs:

• Sudden severe abdominal/back pain

• Pulsatile mass

• Hypotension

• Syncope

• Grey-Turner sign (flank bruising)

🔥 Dissection signs:

• “Ripping/tearing chest pain”

• BP DIFFERENCE between arms

• Neurologic deficits

• Absent femoral pulses

• New diastolic murmur (aortic regurg)

Immediate danger:
→ Do NOT give fluids aggressively
→ Lower BP to reduce shearing
→ IV beta-blocker if ordered
→ Prepare for OR

C) Post-op Aortic Repair Red Flags

• Hypotension → graft thrombosis

• Hypertension → graft rupture

• Distended abdomen → retroperitoneal bleed

• ↓ pedal pulses → graft occlusion

• ↓ urine output → renal hypoperfusion

D) PE Red Flags

• Sudden dyspnea

• Pleuritic chest pain

• Tachycardia

• Anxiety, sense of doom

• Hemoptysis

• ↓ SpO₂ not improving on O₂

• New A-fib

Immediate danger:
→ O₂
→ Call rapid
→ Anticoagulate

E) DVT Red Flags

• Unilateral edema

• Warmth

• Tender calf

• Homan sign NOT tested (don’t do it)

• Sudden ↓ mobility after surgery

Immediate danger:
→ Do NOT massage
→ Heparin drip

F) Compartment Syndrome Red Flags

• Pain out of proportion

• Tense/firm compartments

• Pain with passive stretch

• Paresthesia → paralysis
  → Requires fasciotomy

Often occurs after reperfusion of an ischemic limb.

G) Cellulitis Red Flags

• Spreading redness

• High fever

• Lymphangitis streaking

• Sepsis signs (tachy, hypotension)

H) Lymphedema Crisis Signs

• Sudden swelling

• Erythema

• Pain
  → Think cellulitis → needs antibiotics urgently.

🩺 5. NURSING PRIORITIES + INTERVENTION MAP

A) ARTERIAL (PAD/acute occlusion):

✔ Keep limb dependent or neutral
✔ Warm environment (NO heating pads)
✔ NO compression stockings
✔ Pain control
✔ Inspect feet daily
✔ Promote walking (claudication therapy) unless acute
✔ Pre/post ABI
✔ Smoking cessation (biggest modifiable factor)

B) VENOUS (CVI/DVT):

✔ Elevate legs above heart
✔ Compression (ONLY if ABI > 0.8)
✔ Anticoagulation for DVT
✔ Early ambulation
✔ IPC devices
✔ Hydration
✔ Avoid long sitting/standing

C) LYMPHATIC:

✔ Manual drainage
✔ Compression wraps/stockings
✔ Meticulous skin care
✔ Avoid needle sticks & BP cuffs on affected limb
✔ Monitor for cellulitis

D) ANEURYSM/DISSECTION:

✔ Tight BP control
✔ Keep SBP around provider’s target (100–120)
✔ Avoid Valsalva/straining
✔ Frequent neuro + CV + renal checks
✔ Monitor for back pain or loss of pulses

E) ULCERS:

✔ Arterial → NO compression, keep dry gangrene dry
✔ Venous → compression + moist wound care
✔ Neuropathic → offloading
✔ Debridement if appropriate
✔ Nutrition: ↑ protein, ↑ zinc, ↑ vit C

F) IMAGING PREP & SAFETY:

✔ Check for kidney function pre-contrast
✔ Hydrate pre/post
✔ Watch for contrast allergy
✔ Check metal implants for MRA

💉 6. DRUG / PROCEDURE / DISEASE TIE-INS

A) Why Heparin is used for DVT/PE/Acute arterial embolism:

Stops clot propagation; doesn’t dissolve existing clot.

B) Why thrombolytics (tPA) are used in acute limb ischemia or massive PE:

Dissolves fibrin → restores flow.

C) Why compression works for venous disease:

Reduces venous HTN → moves blood back up → prevents edema.

D) Why compression is DANGEROUS in arterial disease:

Compression + low flow → NECROSIS.

E) Why beta-blockers for dissection:

↓ shear force → slows dissection progression.

F) Why ACE inhibitors/ARBs help PAD patients:

Atherosclerosis is systemic → BP control improves survival.

G) Why statins matter:

Stabilize plaque → decreases risk of emboli.

H) Why you NEVER debride dry gangrene:

No circulation → wound will not heal → leads to major amputation.

✨ ADD-ON 4 — WHAT BEGINNERS GET WRONG

✔ Thinking venous ulcers belong on toes (NO — those are arterial).
✔ Thinking warm skin = good perfusion (NO — venous congestion).
✔ Thinking ABI >1.2 is “great” (NO — it’s noncompressible, false).
✔ Thinking pain = DVT sign (NO — DVT is mostly silent).
✔ Thinking “normal SpO₂ on O₂” rules out PE (NO — they stay hypoxic).
✔ Thinking cellulitis = DVT (NO — cellulitis has fever + lymphangitis).
✔ Thinking edema = fluid overload (NO — venous HTN is biggest cause).
✔ Debriding dry gangrene (never).
✔ Massaging a swollen leg (never).
✔ Using heating pads for PAD (never).

✨ ADD-ON 5 — QUICK VISUAL PATTERNS / SHAPES

• Arterial ulcer: round, punched-out, pale

• Venous ulcer: irregular, wet, ankle-level

• Neuropathic: plantar, painless

• DVT leg: swollen, warm, one-sided

• PAD leg: pale, hairless, shiny

• Dissection: BP difference between arms

• AAA: pulsatile mass

• CVI: brown, thick skin around ankles

• Lymphedema: non-pitting, squared-off toes

• Cellulitis: red, warm, sharp borders or streaks

⚡ ULTRA-HIGH-YIELD EXAM SHEET (FINAL PAGE)

Numbers to memorize

• ABI ≤0.90 = PAD

• ABI <0.50 = rest pain

• ABI ≤0.40 = tissue loss

• Compression ONLY if ABI >0.8

• Veins hold 75% of blood volume

• Aorta diameter >5.5 cm = surgery

• BP differential >20 mmHg = dissection

• Pain + pallor + pulselessness = emergency

Fast patterns

• Arterial = cold, pale, painful

• Venous = warm, edematous, brown

• Lymphatic = massive, firm, protein-rich

• Acute occlusion = 6 P’s

• Cellulitis = fever + streaks

• DVT = unilateral swelling

• PE = sudden dyspnea + tachy

High-yield chains

• HTN → aneurysm → rupture

• Stasis → DVT → PE

• Ischemia → ulcer → gangrene

• Reperfusion → compartment syndrome

Priority actions

• Arterial: ↓ demand, ↑ flow

• Venous: ↑ return

• Lymph: ↑ drainage

• Aneurysm: tight BP control

• DVT/PE: anticoagulate

• Ulcers: correct circulation first

⚠ NCLEX TRAPS & COMMON ERROR LIST

❌ Using compression on arterial ulcers
❌ Debriding dry gangrene
❌ Relying on SpO₂ to detect PE
❌ Palpating pulses with thumb
❌ Massaging a DVT leg
❌ Thinking cool = venous (NO—cool = arterial)
❌ Confusing rest pain with neuropathy
❌ Missing the rupture signs (“tearing pain”)
❌ Treating ABI >1.2 as normal
❌ Elevating a limb with critical PAD
❌ Giving fluids for AAA rupture before BP assessment
❌ Forgetting kidney protection pre-contrast
❌ Not recognizing compartment syndrome after embolectomy