Arterial versus venous in one comparison
The exam loves this distinction because it can be assessed entirely from the description in the stem. Peripheral arterial disease means inadequate blood delivery. The limb is cool, pale or dusky, hair is absent, nails are thick, pulses are diminished or absent, capillary refill is delayed, and ulcers appear at the toes or lateral malleolus with a punched-out, dry appearance. Pain occurs with exertion and is relieved by rest or by dangling the leg, which uses gravity to improve perfusion.
Chronic venous insufficiency means inadequate blood return. The limb is warm, oedematous, and stained brown from haemosiderin deposits. Ulcers appear at the medial malleolus with irregular borders and heavy drainage. Pain is a dull ache that worsens with prolonged standing and is relieved by elevation, which assists venous return.
The management follows directly from the mechanism and this is where students slip. Elevation helps venous disease and harms arterial disease. Compression stockings help venous disease and are dangerous in significant arterial disease because they further reduce already limited inflow. Warmth is helpful for arterial disease but a heating pad is never applied directly because neuropathy risks burns.
For arterial disease teach smoking cessation as the highest-yield intervention, a supervised walking programme to the point of pain then rest, meticulous foot care with daily inspection, well-fitting shoes, never going barefoot, and avoiding crossing the legs or wearing constrictive clothing.
| Feature | Arterial | Venous |
|---|---|---|
| Skin | Pale, cool, shiny, hairless | Warm, brown discolouration, oedematous |
| Pulses | Weak or absent | Usually present |
| Pain | With exertion, relieved by dangling | Dull ache, relieved by elevation |
| Ulcer location | Toes, lateral malleolus | Medial malleolus |
| Ulcer appearance | Punched out, dry, pale base | Irregular, moist, heavy exudate |
| Position | Keep legs dependent | Elevate above heart level |
Deep vein thrombosis: prevention, recognition and don'ts
Virchow's triad explains every risk factor an item can list: venous stasis from immobility, surgery or long travel; endothelial injury from trauma, surgery or central lines; and hypercoagulability from malignancy, pregnancy, oestrogen therapy, dehydration or inherited disorders. If a stem stacks two or more of these, the question is heading towards thrombosis.
Classic findings are unilateral calf or thigh swelling, warmth, redness, tenderness and a measurable difference in leg circumference. Bilateral symmetrical swelling is far more likely to be heart failure or venous insufficiency. Measure both calves at a marked level rather than estimating by eye.
The most tested action is a prohibition: do not massage or vigorously exercise the affected extremity, because dislodging the clot can cause pulmonary embolism. Also avoid using sequential compression devices on a limb with an established DVT unless specifically ordered. Anticoagulation, elevation of the limb, and monitoring for embolism are the correct interventions.
Prevention is the more common exam angle: early and frequent ambulation, ankle pumps and leg exercises for immobile clients, adequate hydration, sequential compression devices or graduated stockings used prophylactically, and prophylactic low-molecular-weight heparin such as enoxaparin. Avoid pillows placed directly under the knees and prolonged sitting with crossed legs.
- •Virchow's triad: stasis, endothelial injury, hypercoagulability
- •Unilateral swelling, warmth and tenderness suggest DVT
- •Never massage the affected limb
- •Ambulate early; use ankle pumps when confined to bed
- •Prophylactic enoxaparin plus compression devices for at-risk clients
Pulmonary embolism and anticoagulation teaching
Pulmonary embolism is the complication the exam is testing for whenever a DVT appears in a stem. Sudden onset dyspnoea, pleuritic chest pain, tachycardia, tachypnoea, apprehension or a sense of impending doom, haemoptysis and hypoxaemia are the presentation. The immediate nursing actions are to raise the head of the bed, apply high-flow oxygen, stay with the client and activate the rapid response system, then anticipate anticoagulation and diagnostic CT angiography.
Anticoagulation teaching recurs constantly. Warfarin is monitored with INR, target 2 to 3 for most indications, and reversed with vitamin K. Clients keep vitamin K intake consistent rather than eliminating green vegetables. Heparin is monitored with aPTT, target 1.5 to 2.5 times control, and reversed with protamine sulfate. Low-molecular-weight heparin does not need routine monitoring and is injected into the abdomen without expelling the air bubble and without aspirating or massaging the site.
Bleeding precautions apply across the board: soft toothbrush, electric razor, avoid contact sports, report black tarry stools, blood in the urine, unusual bruising, or a headache that could indicate intracranial bleeding. Heparin-induced thrombocytopenia should be suspected if the platelet count falls significantly after heparin exposure, and heparin must be stopped.
For deeper practice see the anticoagulant questions guide, the shock and sepsis article, and the adult health question sets with NGN case studies on postoperative thrombosis.
- •PE: sudden dyspnoea, pleuritic pain, anxiety, hypoxaemia
- •First actions: high Fowler's, oxygen, stay with client, call rapid response
- •Warfarin — INR, vitamin K reversal, consistent leafy greens
- •Heparin — aPTT, protamine reversal, watch platelet count
- •Enoxaparin — abdominal injection, do not expel the air bubble