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Course: Medical Surgical Nursing

Topic: Diagnostic Evaluation for Peripheral Circulation

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Discuss Doppler Ultrasound Flow Studies and the nursing management.
Discuss Exercise Testing, Duplex Ultrasonography, Computer Tomography Scanning (CT) and the nursing management.
Discuss Angiography and Magnetic Resonance Angiography (MRA) and the nursing management.
Discuss Contrast Phlebography (Venography) and Lymphoscintigraphy and the nursing management.

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Doppler Ultrasound Flow Studies

Evaluates blood flow through various vessels in the body.
Utilizes the Doppler effect, allowing for detection and analysis of blood flow patterns and velocities.
Sonographer uses handheld device(transducer), which emits and receives ultrasound waves.
The transducer is placed on the skin over the area being examined, and a gel is applied to improve sound wave transmission.

Sheps, 2019

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Exercise Testing (Exercise Tolerance Testing)

Assesses how well the cardiovascular system functions during physical exertion.
Evaluates the heart's response to exercise
Diagnoses/evaluates coronary artery disease
Assesses exercise capacity
Determines appropriate exercise prescriptions.

Hill & Timmis, 2002

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Exercise Testing (Continued)

Patient performs physical activities such as walking or running
Patient's heart rate, blood pressure, electrocardiogram (ECG), symptoms, and perceived exertion are monitored throughout the test.
Monitoring and Measurements
Exercise endpoints
Interpretation of results

Hill & Timmis, 2002

Contact info: info@nursesinternational.org

Procedure: During an exercise test, the patient is typically asked to perform physical activities, such as walking or running on a treadmill or pedaling a stationary bicycle. The exercise intensity gradually increases in predetermined stages or based on the patient's tolerance. The patient's heart rate, blood pressure, electrocardiogram (ECG), symptoms, and perceived exertion are monitored throughout the test.
Monitoring and Measurements: The patient's vital signs, including heart rate, blood pressure, and oxygen saturation, are monitored continuously or at regular intervals throughout the exercise test. The ECG records the electrical activity of the heart during exercise, helping identify any abnormal changes or signs of myocardial ischemia (insufficient blood flow to the heart muscle). In some cases, additional monitoring devices, such as a pulse oximeter or gas analyzer, may be used to measure oxygen consumption.
Exercise Endpoints: Exercise testing is typically performed until the patient achieves a target heart rate, reaches symptom limitation, or exhibits certain ECG changes (such as ST segment depression or arrhythmias). The test may also be terminated if the patient experiences severe fatigue, shortness of breath, chest pain, or significant changes in blood pressure.
Interpretation of Results: The collected data, including ECG tracings, heart rate response, blood pressure changes, and symptoms, are analyzed by a healthcare professional. Abnormalities during exercise, such as ST segment depression or symptoms suggestive of myocardial ischemia, may indicate coronary artery disease. The overall exercise capacity and heart rate response can provide insights into cardiovascular fitness and exercise tolerance.

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Exercise Testing (Continued)

Indications:

Evaluating symptoms
Assessing cardiovascular fitness
Diagnosing coronary artery disease
Assessing treatment effectiveness
Risk stratification

Hill & Timmis, 2002

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Evaluating symptoms: Exercise testing helps determine the cause of chest pain (angina), shortness of breath, or unexplained fatigue during physical activity.
Assessing cardiovascular fitness: It measures exercise capacity and aerobic fitness, which can be useful for exercise prescription and assessing the effectiveness of cardiac rehabilitation.
Diagnosing coronary artery disease: Exercise testing can help detect abnormalities in blood flow to the heart and diagnose or evaluate the severity of coronary artery disease.
Assessing treatment effectiveness: It can determine the effectiveness of medications, interventions (e.g., stents), or lifestyle modifications in managing heart conditions.
Risk stratification: Exercise testing may be used to assess the risk of adverse cardiovascular events in patients with known heart disease or those at high risk.

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Duplex Ultrasonography (Imaging Technique)

Non-invasive

Combines two types of ultrasound:

Grayscale imaging
Doppler ultrasound

Uses an ultrasound machine equipped with a transducer to convert sound waves into images.

Medline Plus, 2022

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Duplex Ultrasonography (Continued)

Evaluation of blood vessel diseases.
Evaluation of abdominal organs (e.g., liver, kidneys, pancreas) and their blood supply.
Assessment of venous insufficiency and varicose veins.
Assessment of cardiac structures, such as the heart valves and chambers.
Diagnosis and monitoring of carotid artery disease and stroke risk assessment.

Cheung, Singh & Firstenberg, 2022

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Computer Tomography (CT) Scanning

Imaging technique combines

X-ray technology and computer processing to produce detailed cross-sectional images of the body.

Patient slides into a doughnut-shaped machine called a CT scanner and rotates around the patient, emitting a series of X-ray beams.

Computer processes information to create cross-sectional images, viewed in different planes or reconstructed into 3D images.

NIH, 2022

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Computer Tomography (CT) Scanning

Indications:

Assessment

head and brain injuries, strokes, tumors, bone fractures, joint abnormalities, and spinal conditions.

Evaluation of the chest,

including lungs, heart, and mediastinum.

Diagnosis and staging of cancers in various parts of the body.
Examination of the abdomen and pelvis

including the liver, kidneys, and gastrointestinal tract.

Assessment of Imaging of blood vessels and identification of vascular diseases.

Cleveland Clinic, 2023

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Angiography

Use of contrast dye and X-ray technology to visualize blood vessels.
Detailed visualization of the vessels and any abnormalities (blockages/aneurysms)
Commonly used to evaluate:

coronary artery disease,
peripheral arterial disease
cerebrovascular disease.

It can also be used for interventional procedures, such as angioplasty or stent placement, to treat narrowed or blocked vessels.

NHS, 2023

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Magnetic Resonance Angiography (MRA)

Non-invasive imaging technique that uses magnetic fields and radio waves to create detailed images of blood vessels.
The patient lies on a table that slides into a large cylindrical machine called an MRI scanner.
Indications: evaluate blood vessels in various parts of the body

brain,
neck
heart
extremities
Diagnose aneurysms, arterial stenosis and vascular malformations.

RadiologyInfo.org, 2021

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Contrast Phlebography (Venography)

Imaging technique visualizes the veins of the body.
Evaluation of blood flow and the detection of any abnormalities or blockages in the veins.
Indications/diagnosis:

deep vein thrombosis (DVT)
venous insufficiency and varicose veins.
it can also be used to guide interventions such as vein ablation or venous stenting.

RadiologyInfo.org, 2023

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Lymphoscintigraphy

Procedure: diagnostic imaging technique to assess the lymphatic system.
Evaluates lymphatic flow

identifies lymphatic blockages or abnormalities
detects the presence of lymphedema.

Indications:

evaluation of lymphedema
sentinel lymph node mapping for cancer staging,
assessment of lymphatic malformations.

RadiologyInfo.org, 2022

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Nursing Management

Preparing and educating the patient
Positioning
Patient comfort and privacy
Equipment and supplies
Allergies to gel, dye, or contrast
Patient safety

RegisteredNursing.org, 2023

Contact info: info@nursesinternational.org

Here are some important nursing considerations:

Preparing the patient: Inform the patient about the procedure, including its purpose, benefits, and any necessary preparations (such as fasting or specific positioning). Assess and document relevant patient information, such as medical history, allergies, and current medications. Address any concerns or questions the patient may have.

Ensure the patient is appropriately dressed and remove any metallic objects or jewelry that may interfere with the imaging.

Positioning: Assist the patient in assuming the appropriate position for the specific study being performed. This may involve lying down or assuming specific positions to optimize access to the area being examined (e.g., supine, left lateral decubitus for cardiac studies).
Patient comfort and privacy: Ensure the patient's comfort and privacy throughout the procedure. Provide appropriate draping and coverings to maintain modesty. Offer support and reassurance to alleviate anxiety or discomfort associated with the procedure.
Equipment and supplies: Verify that the equipment is in working order and properly calibrated. Ensure that the necessary transducers, gel, and other supplies are readily available.
Verify the patient's identification and assess for any contraindications or allergies to contrast agents.
Patient safety: Adhere to infection control protocols by ensuring proper hand hygiene, using sterile gel or disposable transducer covers, and maintaining a clean environment. Verify patient identification before initiating the procedure to ensure accurate documentation and prevent errors.

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Nursing Management

Collaboration and communication
Patient education
Emotional support
Monitoring and documentation
Follow-up and post-test/procedure care
Signs of complications

RegisteredNursing.org, 2023

Contact info: info@nursesinternational.org

Collaboration and communication: Collaborate with other healthcare team members, such as radiologists, sonographers, or physicians, to ensure coordinated care. Communicate relevant patient information and any special considerations or precautions to the team.
Patient education: Explain the procedure to the patient, including what to expect during the study. Provide instructions on any specific actions the patient needs to take (e.g., holding their breath, changing position). Address any potential risks, such as the supplies or equipment or the temporary discomfort.
Emotional support: Assess and address any patient anxiety or concerns related to the procedure. Offer emotional support, answer questions, and provide reassurance throughout the process.
Documentation: Accurately document the patient's baseline vital signs, relevant patient information, procedural details, and any observed reactions or complications during or after the study. Ensure timely and accurate documentation of findings and nursing interventions.
Follow-up care: Monitor the patient post-procedure for any adverse reactions or complications. Provide any necessary post-procedure care instructions, including information on any limitations or restrictions. Coordinate follow-up appointments or further testing as directed by the healthcare provider.

Post-test care: After the exercise test, assist the patient in cooling down and recovering, providing a comfortable environment for resting if needed. Monitor the patient's vital signs and symptoms during the recovery period. Document any post-test findings, such as recovery time or any delayed symptoms.

Post-procedure care: Monitor the patient's vital signs, including blood pressure and heart rate. Assess the puncture site for signs of bleeding or infection. Monitor the patient for any allergic reactions or adverse effects related to the contrast dye. Provide post-procedure instructions regarding activity restrictions and wound care.

Monitor for signs and symptoms of complications such as allergic reactions or DVT.

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Outline what is involved in the education of a client who may be scheduled for a test related to the peripheral nervous system.

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Red Flags

Allergic reactions
Hemorrhage
Infection
Anaphylaxis

Study.com, 2023

Contact info: info@nursesinternational.org

Allergic reactions: Watch for signs of allergic reactions such as rash, itching, hives, swelling, difficulty breathing, or a drop in blood pressure. These can occur in response to contrast dyes, radioactive tracers, or medications used during the procedure.
Hemorrhage: Monitor for excessive bleeding or hematoma formation at the injection or puncture site. This can occur during procedures that involve the insertion of catheters or needles.
Infection: Look for signs of infection at the procedure site, such as redness, swelling, warmth, pain, or discharge. These can indicate local infection or, in rare cases, systemic infection.
Anaphylaxis: Anaphylaxis is a severe allergic reaction that can be life-threatening. It may present with symptoms such as difficulty breathing, wheezing, chest tightness, swelling of the face or throat, severe dizziness, or loss of consciousness. Prompt recognition and immediate intervention are crucial.

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Red Flags

Contrast-induced nephropathy
Radiation exposure
Neurological complications
Cardiac events

Study.com, 2023

Contact info: info@nursesinternational.org

Contrast-induced nephropathy: In procedures that involve the use of contrast agents, monitor for signs of contrast-induced nephropathy, which can cause kidney damage. Signs include a sudden decrease in urine output, swelling in the legs or feet, or signs of fluid overload.
Radiation exposure: Ensure that patients and healthcare providers are protected from excessive radiation exposure. Follow appropriate safety protocols and use lead shielding whenever necessary.
Neurological complications: In certain procedures, such as cerebral angiography or invasive neurological interventions, monitor for signs of neurological complications, including changes in consciousness, seizures, or focal neurological deficits.
Cardiac events: Some procedures may pose a risk of cardiac events, particularly in patients with pre-existing cardiovascular conditions. Watch for signs such as chest pain, shortness of breath, palpitations, or changes in heart rhythm.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be okay in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research and Quality (AHRQ). (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Cheung, M. E., Singh, V., & Firstenberg, M. S. (2022). Duplex Ultrasound. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459266/

Cleveland Clinic. (2023). CT (Computed Tomography) Scan. https://my.clevelandclinic.org/health/diagnostics/4808-ct-computed-tomography-scan

Hill, J., & Timmis, A. (2002). Exercise Tolerance Testing. BMJ, 324(7345), 1084-7. doi: 10.1136/bmj.324.7345.1084

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References

Medline Plus. (2022). Duplex Ultrasound. NIH. https://medlineplus.gov/ency/article/003433.htm

National Institute of Biomedical Imaging and Bioengineering (NIH). (2022). Computed Tomography (CT). https://www.nibib.nih.gov/science-education/science-topics/computed-tomography-ct

NHS. (2023). Angiography. https://www.nhs.uk/conditions/angiography/#:~:text=Angiography%20is%20a%20type%20of,during%20angiography%20are%20called%20angiograms

RadiologyInfo.org. (2021). MR Angiography (MRA). https://www.radiologyinfo.org/en/info/angiomr

RadiologyInfo.org. (2022). Lymphoscintigraphy. https://www.radiologyinfo.org/en/info/lympho

Contact info: info@nursesinternational.org

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References

RadiologyInfo.org. (2023). Venography. https://www.radiologyinfo.org/en/info/venography

RegisteredNursing.org. (2023). Potential for Complications of Diagnostic Tests, Treatments, and Procedures: NCLEX-RN. https://www.registerednursing.org/nclex/potential-complications-diagnostic-tests-treatments-procedures/

Sheps, S.G. (2019). Doppler Ultrasound: What is it Used For? Mayo Clinic. https://www.mayoclinic.org/doppler-ultrasound/expert-answers/faq-20058452

Study.com. (2023). Ch 34: Potential Complications from Diagnostics & Procedures. https://study.com/academy/topic/potential-complications-from-diagnostics-procedures.html

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