Health Assessment 2 Peripheral Vascular System

What's the purpose of arteries

giving tissues blood with oxygen and has a pulse

What are all the pulse locations in the body

temporal, popliteal, brachial, femoral, carotid, dorsalis pedis, posterior tibial

What's the reason that only certain areas you feel pulse

because those are the most superficial arteries

What's the purpose of veins

absorbs the CO2 and all waste products from periphery and carry them back to the heart, has valves that prevent any the backflow

Intermittent claudication

is the cramping that occurs in calf muscle on and off

Claudication distance

is the distance that it takes to produce pain

Arterial insufficiency

thickening and loss of elasticity of the arterial walls, blood pressure lower, someone that is smoking before 16 doubles the risk of peripheral arterial disease

[Arterial insufficiency] Color

pale, cyanotic, mottled

[Arterial insufficiency] Temperature

cool to cold

[Arterial insufficiency] Skin characteristics

thin, shiny skin, dependent rubor, elevation pallor on foot

[Arterial insufficiency] Nail characteristics

thickened and ridged

[Arterial insufficiency] Distribution of hair

there's no hair on toes or dorsum of foot lack of blood flow

[Arterial insufficiency] Edema

is none or small amount

[Arterial insufficiency] Pulses

decreased or absent

[Arterial insufficiency] Pain

intermittent claudication and is relieved by rest

[Arterial insufficiency] Ulcers

between toes or tips of toes, heels, lateral malleolus, well-defined edges, deep, circular ulcer base-black or gangrene, non-bleeding

Venous insufficiency

chronic incompetent valves in deep veins or clot, risk of infection because it's not getting all waste out

[Venous insufficiency] Color

reddish-blue or also a brown color (venous stasis)

Why the color of brown on skin with venous stasis

all the waste that is in the area stays there

[Venous insufficiency] Temperature

warm

[Venous insufficiency] Skin characteristics

firm, brawny, brown pigmentation in area between medial and lateral malleolus, skin thickened, skin thickened and tough, cyanosis when dependent

[Venous insufficiency] Nail distribution

thickend

[Venous insufficiency] Distribution of hair

present

[Venous insufficiency] Edema

moderate to severe, pitting, ankle, foot, lower leg

[Venous insufficiency] Pulses

present but might be kind of difficult palpate with edema

[Venous insufficiency] Pain

aching, cramping, feeling of fullness, relieved by elevation helping the return

[Venous insufficiency] Ulcers

medial malleolus, and lower leg, uneven edges, superficial, ulcer base-granulation tissue beefy-red to yellow, bleeding, may or may not be painful

Why when person is having arterial issues they have ulcers in toes?

because the heart is pumping heart throughout body toes tips the toes are very far away from heart

What's the body part where venous ulcers are common?

medial mallelous

Why is it important to know how much the patient smokes as a nurse when taking about the peripheral vascular system?

hardens the artery which increases coagulability injurying endothelium and causes some inflammation

What's the reason there is swelling?

veins aren't collecting as much as they should unilateral: blockage of vein and a cause of that would be DVT bilateral: systemic issue in the heart

[T/F] Sitting is cause of edema

true, with accumulation of some fluid in an area because sitting

What's the reason that medications cause peripheral vascular problems?

because they might be a cause of hypercoagulable state

What to do with preparing for physical exam?

arms with all the vital signs with person sitting, examine legs when patient is sitting, stand up evaluate the veins in legs, room temperature is about 22 °C and free drafts preventing vasodilation (hot) or vasoconstriction (cold)

What the inspection and palpation of skin should look like?

skin has pink undertones, and capillary refill <1-2 seconds

What's the sign that you look at with clubbing?

see the fingernails and note if nails are bulging and look at the side of the fingernails (profile sign)

normal nail bed: 160 degrees

Capillary refill >2 seconds what are some possible abnormalities?

vasoconstriction, hypovolemia, early congestive heart failure

[Upper extremity pulses] Brachial

between the tricep and bicep burrow, major artery supplying blood to the arm, branches to radial and ulnar

[Upper extremity pulses] Radial pulse

on the wrist on side thumb

[Upper extremity pulses] Ulnar pulse

on the wrist on side pinky

When the nurse not able feel pulse what do you do?

ask another nurse palpate the pulse and if not palpable use the doppler

What's the purpose of the modified allen test?

evaluate the collateral circulation in radial and ulnar arteries before puncture of the radial artery

How to perform the modified allen test?

put the thumbs on the ulnar and radial arteries at 11 pounds of pressure with thumbs have the patient squeeze hands let go of the ulnar artery

Where to look when patient has no hair on legs?

Look the hair that's on big toe

What's the procedure with measuring edema in legs unilateral

measure the calf the largest point >1 cm is concerning >2 cm is when the patient needs immediate care DVT

What's a venous pattern that's normal?

is flat and barely visible

How to document when there's gangrene

measure the size and exact location

What are all the pulses lower extremities?

posterior tibial, dorsalis pedis, femoral, popliteal

When not able to palpate popliteal pulse what do you palpate?

posterior tibial and dorsalis pedis

How to check the pretibial edema

palpate very firmly on skin over tibia or medial malleolus 5 seconds let go and see if theres an indention

Should a patient with peripheral arterial disease wear compression socks?

no

Edema pitting 1+

mild pitting, slight indention, no perceptible swelling of leg

Edema pitting 2+

moderate pitting, indentation subsides rapidly

Edema pitting 3+

deep pitting, indentation remains for a short time, legs look swollen

Edema pitting 4+

very deep pitting, indentation last a long time, legs very swollen

When the nurse then asks the patient to stand, what should they note?

note any visible, dilated tortuous veins, if present varicose veins cause pain, swelling, fatigue, and cramping

What are all the 5 cardiac auscultation points?

aortic area, pulmonic area, erb's point, tricuspid area, mitral area

What is s1 with heart sounds?

is the closing of AV valves beginning of systole

What is s2 with heart sounds?

is the closing of semilunar valves end of systole

Tachycardia

heart rate higher than 100 beats per minute

Bradycardia

heart rate less than 60 beats per minute

Where's the apex of heart?

is the area of heart at point of left ventricle

PMI

point of maximal impulse and is near apex heart

How long do you count an apical pulse?

1 minute

What long do you count a normal pulse?

30 seconds

The aortic and pulmonary valves are collectively known as what?

semilunar valves

What's the valves that are AV valves?

tricuspid valve and mitral valve

Vessels that provide a pressure wave, pumping O2 rich blood to all body tissues?

arteries

It is important to document subjective history of swelling because

because the edema that is unilateral is DVT and bilateral is systemic with heart

Investigate further...

Pt admitted for pneumonia, temp 103, HR 102, 3+ bounding, cap refill <2 sec

Pt admitted for pneumonia, anxious, pulse is 99 with 1+ force, temp 99.2

Pt admitted for pneumonia, temp 98.7, HR 88, 2+, Cap refill 5 seconds

Pt admitted for pneumonia, temp 98.7, HR 88, 2+, Cap refill 5 seconds

There are how many lower extremity pulse sites on one side

4

Venous insufficiency/arterial insufficiency increases risk of infection

venous

What's the artery that is major supply blood arm?

brachial

Ankle brachial index

is the measurement that shows the amount of someone's peripheral arterial disease

>1.4 incompressible arteries

0.91-0.94 boarderline CV risk

0.90-0.71 mild pad

0.70-0.41 moderate pad

>0.40 severe pad

When the skin is pallor what does that mean

means improper flow of blood example: vasoconstriction

When the patient has pitting edema where do you palpate

veins on neck