Physical Assessment: Assessing Peripheral Vascular System - Exam #3

what is the function of arteries?

transport blood rich with oxygen away from the heart & to the other parts of the body

what is the function of pulmonary arteries?

transport deoxygenated blood from the hearts right ventricle to the lungs

true or false: arteries have valves and cannot rely solely on pressure to move blood

false (no valves, rely on pressure)

characteristics of of artieries

- thicker muscular walls to withstand high pressure

- found deeper in body BUT provide a detectable pulse

what are the 3 types of arteries?

elastic, muscular, arterioles

what is the function of veins?

transport blood that has been depleted of O2 back to the heart

what is the function of pulmonary veins?

transport oxygenated blood from the lungs to the heart's left atrium

characteristics of veins

- valves to ensure blood flow in the right direction

- thin walls

- close to surface

- do not give off a pulse

true or false: veins can often be injured leading to varicose veins or vein disease

true

what are the 4 types of veins?

deep, superficial, pulmonary & systemic veins

true or false: veins & arteries are palpated for pulse

false (only arteries)

assessment techniques for this system

interview, inspection, palpation

how do you collect subjective data for this system?

collect questions pertaining to reason for visit, history of present illness, past medical history, family history, lifestyle & health practices

reason for visit questions...

what brought you in today?

history of present illness questions...

- changes in skin color or temperature

- pain in lower extremities

- edema

- paresthesia

- leg veins

- sores

- coldness, canosis

- varicosities, tingling

past medical history questions...

heart/blood disease & surgery

lifestyle & heath practices questions...

- tobacco use

- meds

- well-fitting shoes

- garments

- hosiery

- sitting or standing for long periods of time

- exercise

- IF MALE: changes in sexual activity

what is the nurse inspecting for in this system?

upper & lower extremeties

what is the nurse inspecting for in the upper extremities?

- edema & venous pattern

- skin tone

what is the nurse inspecting for in the lower extremities?

- skin tone

- hair distribution

- edema

- lesions

what are expected findings of the upper extremities - edema & venous pattern?

symmetric & no edema

what are unexpected findings for the upper extremities - edema & venous pattern?

- unilateral non pitting edema suggests lymphedema

- prominent venous pattern may indicate venous obstruction

what are the expected findings for the upper extremities - skin tone?

expected for ethnicity & uniform bilaterally

what are the unexpected findings for the upper extremities - skin tone?

- pallor

- erythema

- cyanosis

- rapid change of color suggests raynauds

what are expected findings for the lower extremities - skin tone?

- expected for ethnicity

- uniform bilaterally

- no changes in pigmentation

what are unexpected findings for the lower extremities - skin tone?

- pallor when elevated

- rubor when dependent

- dark colored toes

- blisters

- rubor around ankles

what does pallor when elevated & rubor when dependent, dark colored toes & blisters indicate?

arterial insufficiency

what is rubor? what does it indicate when around the ankles?

- rusty, ruddy, brownish pigmentation

- venous insufficiency

what are expected findings for lower extremities - hair distribution?

presence of hair

what are unexpected findings for lower extremities - hair distribution?

loss of hair indicating arterial insufficiency

what are expected findings in the lower extremities - edema?

identical size & shape bilaterally

what are unexpected findings in the lower extremities - edema?

bilateral edema may be detected by the absence of visible veins, tendons, bony prominences

what does bilateral edema usually suggest?

- systematic problem

- HF or venous insufficiency

what are expected findings of the lower extremities - lesions?

no lesions or ulcerations

what are unexpected findings of the lower extremities - lesions?

- arterial ulcers at the end of toes

- irregular wound border

- ulcer wound pale

- foot cool, hair loss

- pain reported at rest

- pedal pulses absent

- edema, discoloration

what is the nurse palpating for in the upper extremities?

- temperature

- radial pulse

- capillary refill

what is the nurse palpating for in the lower extremeties?

- temperature

- sensation

- edema found on inspection

- dorsalis pedis pulse

what are expected findings in upper extremities - temperature?

warm bilaterally

what are the unexpected findings in the upper extremities - temperature?

cool suggesting arterial insufficiency

what are the expected findings for the radial pulse?

- 60 to 100 bpm

- regular

- 2+ resilient quality (bounce)

what are expected findings for the upper extremities - capillary refill?

refill returns in 3 seconds or less

what are the unexpected findings in the upper extremities - capillary refill?

refill time is over 3 seconds

what does a refill time greater than 3 seconds suggest?

- vasoconstriction

- decreased cardiac output

- shock

- arterial occlusion

- hypothermia

what are expected findings of the lower extremities - temperature?

warm bilateral

what are unexpected findings of the lower extremities - temperature?

- unilateral coolness

- increased warmth (thrombosis)

what does unilateral coolness suggest?

arterial insufficiency

what does bilateral coolness suggest?

vasoconstriction due to cigarette, anemia, anxiety, or cold room

what are expected findings of the lower extremities - sensation?

equal sensation bilaterally

what are the unexpected findings of the lower extremities - sensation?

diminished sensation unilaterally or bilaterally

what are expected findings of the lower extremities - edema?

no edema

what are uexpected findings of the lower extremities - edema?

- non pitting edema

- pitting

what is the scale of pitting edema?

- 1+ (2mm)

- 2+ (4mm)

- 3+ (6mm)

- 4+ (8mm)

what are expected findings in the lower extremities - dorsalis pedis pulse?

2+ amplitude

what are unexpected findings in the lower extremities - dorsalis pedis pulse?

weak or absent arterial pulse

what does the nurse assess while palpating the pulse?

rate, rhythm, amplitude

how is rate measured?

BPM

how is rhythm measured?

regular or irregular

how is amplitude measured?

- 0 = absent

- 1+ = weak, diminished (easy to obliterate)

- 2+ = normal (obliterate with moderate pressure)

- 3+ = strong (obliterate with firm pressure)

- 4+ = bounding (unable to obliterate)

if the peripheral pulse is not palpable, what is the nurses next action?

- reposition

- let up pressure

- press harder

if the nurse repositioned when palpating the client's pulse, but it is still not palpable what is the next action?

- use doppler

- mark spot w/ an X

what is an allens test?

evaluate the patency of the radial or ulnar arteries when patency is questionable or before such procedures as a radial artery puncture

what is step one of the allen's test?

assess ulnar patency

what is the second step of the allen's test?

have the client rest the hand palm side up on the examination table and make a fist

what is the third step of the allen's test?

then use your thumbs to occlude the radial & ulnar arteries

what is the fourth step of the allen's test?

- continue pressure to keep both arteries occluded & have the client release the fist

- note that the palm remains pale

what is the fifth step of the allen's test?

release the pressure on the ulnar artery and watch for color return to the hand

how does the nurse assess radial patency?

repeat the procedure as before but as the last step, release pressure on the radial artery

how does the nurse assess pitting edema?

- palpate with thumb

- note depth & time it takes to rebound

what measurement is used for palpating edema?

mm

how is edema documented?

- 2mm = 1+

- 4mm = 2+

- 6mm = 3+

- 8mm = 4+

what is virchow's triad?

- venous stasis

- hypercoagulability

- trauma to a vessel

true or false: virchow's triad is the increased risk of developing venous thrombosis

true

arterial occlusion - disease process

reduced blood flow through major blood vessels by obstruction or narrowing

arterial occlusion - risk factors

- smoking tobacco

- hypolipidemia

- HTN, DM, sedentary lifestyle

- male, over 50 yr old, non-hispanic black

arterial occlusion - manifestations

- unilateral

- 6 Ps

- swelling/redness

- shiny skin, thick nails

- absence of hair

- ulcers on toes

- onset pain with exercise relieved by rest

what are the 6 Ps?

- Pain

- Pulselessness

- Pallor

- Polar (cold legs)

- Paresthesia

- Paralysis

true or false: absence of a normally palpable pulse is the most reliable sign of occlusive disease

true

what kind of pain is associated with arterial occlusion?

intermittent claudication-to sharp, under relenting

what are the nursing priorities for arterial occlusion?

- assess circulation & perfusion

- pain management

- promote circulation

how does the nurse assess circulation & perfusion for arterial occlusion?

- monitor for S&S of arterial occlusion (6Ps)

- check distal pulse to evaluate the extent of blood flow restriction

- assess capillary refill time

- monitor for changes in skin tone and cool temperature distal to the occlusion

how does the nurse help with pain management for arterial occlusion?

- administer pain meds

- positioning: keep limb neutral or slightly dependent to promote blood flow

true or false: you should elevate a limb suffering arterial occlusion

false

how does the nurse help promote circulation for clients with arterial occlusion?

- administer prescribed anticoagulants or thrombolytics

- assist with interventions: in some cases surgery or vascular procedures

- avoid applying cold compresses

what medications are prescribed to help reduce clots?

heparin or tissue plasminogen activator (tPA)

what is the disease process for venous thrombus?

clot/thrombophlebitis (inflammation of vein)

what are the risks for venous thrombus?

- virchow's triad

- cigarette smoking

- dehydration

- recovery from major surgery

- lower extremity fractures

- female, pregnant

- prolonged standing or immobility

- sedentary

- older age

- african american

- obesity

- lack of dietary fiber

- constricting clothes

what kind of pain is associated venous thrombus?

aching cramping pain

what are manifestations of venous thrombus?

- some cases asymptomatic

- swelling, pain, erythema over the areas of the thrombus

what are chronic manifestations of venous thrombus?

- brown pigment at ankles

- ulcers on ankles

- scaly lesion

what are nursing priorities for venous thrombus?

- assess circulation & perfusion

- prevent clot propagation & complications

- manage pain & discomfort

how does the nurse assess circulation & perfusion for venous thrombus?

monitor for S&S of venous occlusion

what are S&S of venous occlusion?

- swelling in affected leg

- pain/tenderness

- redness

- warmth

- visible surface veins

- pitting edema

how does the nurse prevent clot propagation & complications?

administer anticoagulants as prescribed

what are nursing considerations when administering anticoagulants?

- heparin or warfarin reduces the risk of pulmonary embolism

- monitor for signs of pulmonary embolism (PE): if a clot dislodges, it can travel to the lungs

- watch for sudden onset of chest pain, shortness of breath, tachycardia or hemoptysis (coughing up blood)

- avoid massaging the affected area: this could dislodge the clot and lead to embolism

how does the nurse manage pain & discomfort?

- administer analgesics as needed

- elevate affected limb

- compression stockings