Assessment Peripheral Vascular System

arterial disease (PAD or arterial insufficiency)

can vasodilate + vasoconstrict
usually due to injury / inflammation of intima which allows liquid to go into the lining and cause plaques (arterosclerosis) and cause narrowing, decreased blood flow plaques can occlude or rupture and cause bleeding
stenosis or occlusion
decreased blood flow to tissues - ischemia

venous disease

venous insufficiency: dilated veins and incompetent valves which results from venous hypertension which is caused by incompetent valves, venous pooling (positive feedback loop, it keeps getting worse)
gravity will keep blood distally and decrease blood flow to heart if valves are damaged
venous thromboembolism - blood clots in veins
caused by venous HTN, age, trauma, blood clot

capillaries

fluids diffuse across the capillary membrane (down pressure gradient) - maintains equilibrium between the vascular and interstitial space
increase venous pressure causes a pressure disturbance at the capillary, fluid remains in the interstitial space because the capillary pressure is too high

symptoms related to peripheral vascular system

pain in limbs (arterial or venous)
intermittent claudication - exercise induced pain or cramping that resolves with rest after 10 minutes (arterial)
coldness, numbness, pallor (arterial)
hair loss (arterial)
poorly healing or nonhealing wounds in LEs (arterial or venous disease)
color changes (arterial or venous disease)
swelling in extremity (venous)

acute limb ischemia / acute arterial occlusion

complete blockage of artery, no oxygenated blood is able to reach that tissue
sudden onset of cold LE with pain and absent pulses
six P’s: pain, pallor, pulselessness, paresthesias, paralysis, poikilothermia (cold)
untreated will leads to gangrene and loss of limb

chronic peripheral arterial disease (arterial insufficiency)

starts before acute ischemia
partial blockage
pain: intermittent claudication (pain with activity) progressing to pain with rest, pain worse with elevation (more resistance because working against gravity)
coolness of extremity
numbness / tingling
tissue ischemia
no edema

chronic peripheral arterial disease physical exam findings

skin: cool to touch, pallor / cyanosis, shiny atrophic, loss of hair, dependent rubor (dusty redness that develops especially when limb is down)
thickened nails
diminish pulses
ulcerations: toes or areas of trauma, gangrene, painful

chronic venous insufficiency physical exam findings

minimal pain (diffuse / aching), but in advanced will have pain
pain worse in dependent position because gravity helps with venous
edema
skin: thickened dull appearance, stasis dermatitis, increased pigmentation
edema
varicose veins
normal temperature and pulses
ulcerations in medial malleolus and painful, but no gangrene
due to venous status / hypertension

superficial thrombosis / superficial phlebitis (process, location, timing, worse / better, associated manifestations)

pain, redness along site of superficial vein
phlebitis: inflammation
thrombosis: clotting
commonly seen at IV
PE: erythema, induration, tenderness, ± swelling of involved limb, palpable subcutaneous cord
timing: days or longer
worsens: immobility, venous stasis and chronic venous disease, venous procedure (IV cannula placement), obesity
better: supportive care, walking

deep vein thrombosis

pain in calf or popliteal, femoral, and iliac veins, but can also be painless
erythema + swelling
low grade fever
homan’s sign
calf measurement
assess for DVT risk factors - hypercoagulability, vessel wall injury, lower extremity trauma
worsens: immobilization or recent surgery, lower extremity trauma, pregnancy, postpartum state, hypercoagulable state
better: antithrombotic and thrombolytic therapy

lymphedema

can look similar to peripheral vascular disease
edema in extremity due to lymphatic dysfunction
early: soft, pitting
later: indurated, hard, non pitting, skin is thickened
skin: thickened and rare ulcerations
no evidence of venous / arterial disease (no changes in pigment / pulses)
may be caused by obstruction / surgical manipulation of lymph nodes

examination of carotid arteries

inspection: obvious pulsations / masses
palpation: pads of index / middle fingers, assess individually, pulsations (rate, rhythm, amplitude, contour, variability from beat to beat), thrills (turbulence in vessels, humming / vibration, palpable bruit)
auscultate: take a deep breath and hold it so you don’t hear breathing sounds, bruits hear with bell

assessment of jugular venous pressure (JVP)

raise head of bed to 30 degrees
turn patient’s head away from side you’re inspecting
using tangential lighting observe the pulsation of the internal jugular vein
identify highest point of pulsation of IJV
measure height of pulsation above sternal angle
height of >4 cm above the sternal angle is considered to be elevated

low venous pressure for JVP

lower head of bed
low cardiac output
dehydration
blood loss

high venous pressure for JVP

raise height of bed
right heart failure
left heart failure
pulmonary hypertension
pericardial compression / tamponade

hepatojugular reflex

same positioning as JVP
breath normally
firm pressure in RUQ for 30-60 secs
sustained > 4 cm increase in JVP as positive finding
unchanged or temporary elevation is normal
assesses for fluid overload

brachial pulse

index and middle finger pads
medial to biceps tendon in antecubital fossa (bend of elbow)
patient’s palm is supinated

radial pulse

index and middle finger pads
lateral to flexor tendon
partially flex wrist

ulnar pulse

index and middle finger pads
medial flexor wrist
partially flex wrist

grading pulse amplitude

4+ bounding - aortic regurgitation / hyperthyroid
3+ increased
2+ brisk (normal)
1+ diminished (PAD)
0+ absent / nonpalable (acute ischemia)

epitrochlear lymph nodes

flex elbow
support forearm and palpate groove between biceps and triceps above medial epicondyle
non palpable normally

axillary lymph nodes

warn about discomfort
support patient’s arm with your nondominant hand
use dominant hand to press into apex of axilla towards midclavicle
slide fingers down chest wall
palpable small nontender lymph nodes are normal

examination of lower extremity

inspection: size, symmetry, swelling, skin color, skin texture, distribution of hair, vascular pattern, vascular skin lesions, nails
palpation: temperature, edema (dorsum of foot, behind medial malleolus shins), femoral, popliteal, posterior tibialis, dorsalis pedis pulses (rate, rhythm, amplitude), superficial inguinal lymph nodes
auscultation: femoral arteries for bruits with bell

pitting edema

when you press your finger and remove it, there is a pit
soft, bilateral, palpable swelling from increased interstitial fluid volume and retention of salt and water

grading pitting edema

1+: 2 mm, barely detectable impression when finger is pressed into skin
2+: 4 mm, slight indentation 15 seconds to respond
3+: 6 mm: deeper indention 30 seconds to respond
4+: 8 mm: >30 seconds to rebound

femoral pulse

below inguinal ligament midway between anterior superior iliac spine and pubic symphysis

inguinal lymph nodes

horizontal group - runs parallel and inferior to inguinal ligament
vertical group - medal to femoral artery

popliteal pulse

flex knee
fingertips meet at midline of popliteal fossa
press deeply
alternating positioning - prone, flex knee to 90 degrees, thumb at midline, press deeply

posterior tibialis pulse

behind malleolus

dorsalis pedis pulse

lateral to extensor tendon of toe

allen test

evaluates patency of radial / ulnar arteries
instruct patient to clench fist
compress both radial and ulnar arteries with thumbs
have patient open fist observe pallor of palm of hands
release pressure on ulnar artery
observe return of normal color to palm within 3-5 seconds
repeat test, this time releasing pressure on radial artery instead
falsely negative: extending hand fully which can cause pallor

postural color change

evaluates for peripheral vascular disease
place patient in supine position and elevate legs 60 degrees until pallor develops
have patient sit up and dangle legs over exam table (observe for return of normal color (less than 10 seconds), filling of veins of feet and ankles (normal: 15 seconds), dependent rubor)

trendelenberg test

assesses competency of valves with saphenous vein
patient supine, elevate leg to 90 degrees to drain veins of blood
apply tourniquet to leg
have patient stand and observe for venous filling (over 30 seconds)
should be no further rapid filling after removal of tourniquet

abdominal aorta

celiac trunk: left gastric, common hepatic, splenic
superior mesenteric: small intestine
inferior mesenteric: large intestine

venous drainage

veins from arms, upper trunk, head, and neck drain into superior vena cava
veins from abdominal wall, liver, lower trunk, and legs drain into inferior vena cava
veins from abdominal viscera drain into portal vein which goes to liver

great saphenous vein

originates on dorsum of foot, passes just anteriorly to medial malleolus, continues up the medial aspect of leg and joins the femoral vein of deep venous system below inguinal ligament

small saphenous vein

begins on lateral side of foot, passes upward along posterior calf, and joins the deep venous system

arterial disorders (process, location, timing, better / worse, associated manifestations)

Raynaud phenomenon, primary: episodic reversible vasocontruction in the fingers and toes, usually cold
Raynaud’s phenomenon, secondary: symptoms / signs related to autoimmune diseases - scleroderma, systemic lupus erythematous, mixed connective tissue, cryoglobulinemia
location: distal portions or 1 or 2 more fingers, pain is usually not prominent unless fingered
timing: fast, but recurrent
worse: when cold / emotional upset
better: warm environment
associated manifestations primary: distinct digital color changes of pallor, cyanosis, and hyperemia, no necrosis
associated with manifestations, secondary: more severe with ischemia necrosis, and loss of digits, capillary loops are distorted

peripheral arterial disease (process, location, timing, worse / better, associated manifestations)

atherosclerotic disease leading to obstruction of peripheral arteries causing exertional claudication (muscle pain relieved by rest) and atypical leg pain; may progress to ischemic pain at rest
location: usually calf muscles, but also occurs in the buttock, hip, thigh, or foot, depending on the level of obstruction; rest pain may be distal in toes or barefoot
worse: exercise, if rest pain: leg elevation and bedrest
better: rest stops pain in 1-3 minutes, but if rest pain then may be relieved by walking (increases perfusion), sitting with legs dependent
associated manifestations: local fatigue, numbness, progressing to cool dry hairless skin, trophic nail changes, diminished to absent pulses, pallor with elevation, ulcerations, gangrene

chronic venous insufficency

edema is soft with pitting on pressure, occasionally bilateral
brawny changes and skin thickening, especially near ankle
ulceration, brownish pigment, edema in feet
arises from chronic obstruction and incompetent valves in deep venous system
diffuse aching of legs
worsens: prolonged standing, sitting with legs dependent
better: limb elevation, walking

iliofemoral thrombosis

painful, pale, swollen leg, together with tenderness in groin gove femoral vein

homan sign

discomfort behind the knee with forced dorsiflexion on foot

ankle brachial index (ABI)

ratio of blood pressure measurements in foot and arm
assess PAD
right ABI = highest pressure in right foot / highest pressure in both arms
normal: 0.90 to 1.40
>1.40: noncompressible calcified vessel
<0.90 diagnostic of PAD
<0.5: severe PAD

acute arterial occlusion (process, location, timing, associated manifestations)

embolism or thrombosis
location: distal pain, usually involving the foot and leg
timing: sudden onset; associated symptoms may occur without pain
manifestations: coldness, numbness, weakness, absent distal pulses

walls of arteries vs veins

arteries have thicker walls
veins have thinner walls

how does blood flow in veins

thin walls, skeletal muscle
have 1 way valves to prevent venous pooling