Medical Surgical Peripheral Vascular Disease #3

Question

A nurse caring for a client with peripheral arterial insufficiency determined the nursing diagnosis of altered peripheral arterial insufficiency. Which intervention will be most appropriate for the client?

Answers

  1. Elevate his legs and arms above his heart when resting.
    • Rationale:

      This answer is not correct because elevation of the legs and arms above the head when resting decreases circulation because the blood has to go “up hill” when elevated. Having the legs down for short times will have gravity assist in promotion of blood flow to the feet. Extended periods of sitting and standing is not recommended because oftentimes, where there is artery insufficiency, venous can occur so movement is very important for overall circulation.

  2. Encourage the client to engage in a moderate amount of exercise.
    • Rationale:

      This answer is correct because the goal of nursing interventions is to promote or increase circulation. Pain and cramping from decreased circulation (intermittent claudication) can be reduced by gradually increasing activity. The nurse should encourage the client to engage in a moderate amount of exercise to help improve those symptoms by promoting circulation.

  3. Encourage extended periods of sitting or standing.
    • Rationale:

      This answer is not correct because extended periods of sitting or standing will further decrease circulation in the client’s lower extremities and worsen peripheral arterial insufficiency. The nurse should encourage the client to engage in a moderate amount of exercise to help improve those symptoms by promoting circulation.

  4. Discourage walking in order to limit pain.
    • Rationale:

      This answer is not correct because claudication symptoms can be reduced by gradually increasing activity. The nurse should encourage the client to engage in a moderate amount of exercise to help improve those symptoms by promoting circulation.

Overview

The nursing diagnosis of alteration in peripheral arterial insufficiency should have an intervention to increase circulation. Encouraging the client to engage in a moderate amount of exercise will promote circulation and perfusion.

Explanation

Learning Outcomes

Peripheral arterial insufficiency is a circulation problem where the lower extremity arteries are narrowed and blood flow is decreased. Symptoms include pain and cramping that occurs from the hips, thighs, or calf muscles when the client performs certain physical activities, like climbing steps or walking (intermittent claudication). Other symptoms include leg weakness, numbness, coolness of the affected lower extremity, unhealing sores to the foot or leg. The goal of nursing interventions is to promote or increase circulation. Claudication symptoms can be reduced by gradually increasing activity so the nurse should encourage the client to engage in a moderate amount of exercise.

Test Taking Tip

An understanding of artery and venous circulation anatomy and physiology can help the nursing student grasp and understand circulation issues and symptoms associated with the conditions.

Video Rationale