Heart & Peripheral Vascular Assessment pt 2 (study alongside notes)

During assessment of the peripheral vascular system, the nurse should ask the client if they experience leg __________, __________, or __________.

pain; heaviness; aching

When inspecting the legs, assess the veins for __________, which may appear ropelike, distended, tortuous, or painful.

varicosities

The nurse should also inspect for leg __________ or open __________.

sores; wounds

Swelling in the __________ or __________ may indicate impaired venous return.

legs; feet

Signs of thrombophlebitis include __________, __________, __________, and __________ in the affected area.

pain; redness; inflammation; tenderness

During a cardiovascular assessment, the nurse inspects the __________ and __________ extremities.

upper; lower

An expected finding is that the extremities are __________ in size.

symmetrical

The skin should be __________ and color should be __________ throughout.

intact; consistent

Normal nails appear __________ and __________ in color.

curved; normal

Evenly distributed __________ on the extremities is considered an expected variation.

hair

Asymmetry between extremities is considered an __________ finding.

abnormal

Variations in skin __________ may indicate circulatory or perfusion issues.

tone

Absence of __________ on the lower legs can suggest poor arterial circulation.

hair

__________ and __________ veins are an unexpected finding and may indicate venous insufficiency.

dilated; twisted

Nail __________ or __________ may indicate poor oxygenation.

pitting, clubbing (cyanosis; swelling)

__________ of the nails is a chronic sign of inadequate oxygenation.

Clubbing

When palpating the extremities, the nurse assesses skin __________, capillary __________, pulse quality, and skin __________.

temperature; refill; turgor

An expected finding is a __________ skin temperature throughout.

consistent

Normal capillary refill time is less than __________ seconds.

2

Peripheral pulses should be __________, __________, and have a strength of __________.

regular; equal; +2

Normal skin turgor shows __________ __________ when the skin is pinched.

rapid recoil

An abnormally __________ or __________ skin temperature may indicate poor circulation.

cold; hot

__________ skin turgor, where the skin stays elevated after being pinched, indicates dehydration.

Tenting

A __________ capillary refill time indicates decreased peripheral perfusion.

delayed

Excessive sweating of the skin is referred to as __________.

diaphoresis

Absent, weak, bounding, or __________ pulses are considered unexpected findings.

unequal

The presence of __________ indicates fluid accumulation in the tissues.

edema

Pulse volume refers to the amount of __________ produced by blood pushing through the __________.

force; arteries

A pulse that cannot be felt is graded as __________.

0

A weak or thready pulse is graded as __________.

1+

A normal, brisk pulse is graded as __________.

2+

A pulse that is increased or strong is graded as __________.

3+

A bounding or forceful pulse is graded as __________.

4+