N209 - Vascular Periphery

claudification

= pain when walking

Modified Allen test

= assessment of adequacy of collateral circulation that is done before cannulating the radial artery

1. occlude both the radial and ulnar artery, have the pt make a fist multiple times until the hand blanches

2. open the hand and release only the ulnar artery

Hand should return to normal color in <7 seconds

What are the steps of a Modified Allen Test? What should normally happen?

Normal findings in the upper extremeties

• pink & warm bilaterally

• 2+ radial pulses

• elastic turgor

• feels soft, blunt, sharp sensations

• free of edema, lesions or pain

Abnormal findings in the upper extremities

• cold, cool or hot

• 0, 1+ or 3+ radial pulse

• poor turgor

• paresthesia (pins & needles) or absent sensation

• paralysis/weakness

• edema, lesions, pain

Raynaud Phenomenon

= episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress

1. White (pallor) at the fingertips

2. Blue (cyanosis) in the lower figure

3. Red (rubor) in the heel of the hand

chronic lymphedema

= chronic progressive accumulation of protein rich fluid in the interstitial spaces

• From a blockage in the lymphatic system

Femoral artery

Which lower extremity pulse is located just below inguinal ligament halfway between pubis and anterior superior iliac spines?

Dorsalis Pedis

Which lower extremity pulse is lateral to and parallel with the extensor tendon of the big toe?

Popliteal

Which lower extremity pulse is located by anchoring your thumb on the knee and curling your fingers around into the popliteal fossa?

posterior tibial

Which lower extremity pulse is located by curving your fingers around the medial malleolus?

60-100 bpm

What is the normal rate of a pulse?

Asystole

= absent pulse (no palpable pulse or waveform)

Causes:

• Arterial line disconnected

• cardiac arrest

Weak/thready

= 1+ intensity; may wax and wane; difficult to find

Causes:

• shock

• decreased cardiac output

• peripheral arterial disease

• aortic valve stenosis

Bounding

= 3+ intensity easy to observe near skin surface; very easy to palpate & difficult to obliterate with fingertips

Causes:

• hyperkinetic states (exercise, anxiety, fever)

• anemia

• hyperthyroidism

• increased CO

Pulsus Bisferiens

= each pulse has 2 strong systolic peaks with a dip in between

causes:

• aortic regurgitation

• aortic stenosis

• cardiomyopathy

Pulsus Alternans

= alternating strong and weak pulses; rhythm regular

causes:

• aortic regurgitation

• left ventricular heart failure

• systemic hypertension

Pulsus Bigeminus

= rhythm is coupled; every other beat comes in early or a normal beat is followed by a premature beat.

causes:

• conduction disturbances

  • PVCs (premature ventricular contractions)

  • PACs (premature atrial contractions)

Pulsus Paradoxus (paradoxical pulse)

= reduced intensity of pulse during inspiration and stronger with expiration

causes:

• cardiac tamponade

• pericarditis

• chronic lung disease

• acute pulmonary embolus

• hypovolemic shock

• pregnancy

Waterhammer or Corrigan’s pulse

= 3+ intensity; rapid systolic upstroke and then suddenly collapses

causes:

• aortic regurgitation

• patent ductus arteriosus

Unequal Pulses

= different intensity b/t right and left pulses

causes:

• dissecting aneurysm (location determines where felt)

Normal findings in the lower extremities

• pink & warm bilaterally

• elastic turgor

• venous pattern is flat & barely visible

• intact sensation

• symmetrical size

• free of lesions, pain, edema

abnormal findings in the lower extremeties

• cold, cool or hot

• tents for >3 sec

• severe/multiple varicosities/broken veins

• paresthesia/pain

  • intermittent claudication

• paralysis/hemiparesis

• lesions, ulcers, color changes

no edema is indicated by the fingers leaving no indentation

What is a normal finding for checking for edema?

Brawny Edema

= result of lymphatic obstruction & hemosiderin deposition

• nonpitting and hard

Mild Pitting (1+)

• slight indentation (2mm)

• no perceptible swelling of the leg

• returns to normal quickly

Moderate Pitting (2+)

• indentation ~4mm (1/4 in)

• contour appears normal

• returns to normal in 13-15 seconds

Deep Pitting (3+)

• indents 6mm (1/4-1/2 in)

• returns to normal in 1-2 minutes

• looks edematous

Very Deep Pitting (4+)

• indentation 8mm (1/2-1 in)

• returns to normal in 2-5 minutes

• grossly edematous

• raise the legs about 30 cm (12 in) and have the pt. wag there feet to drain off venous blood

  • skin now reflects only arterial blood (should still be pink)

• have the pt. sit w legs dangling

  • should take 10 sec or less for color to return to feet

  • should take 15 sec for superficial veins around the feet to fill

How would you assess the legs if you suspect arterial deficit?

• pallor

• rubor

• cyanosis

• mottled

What are abnormal colors you might see in the lower legs?

Varicose Veins

= legs have dilated bc of chronic increased veinous pressure & reflux of blood back towards the legs (instead of heart) from incompetent valves

severe PAD

What does an ABI of <0.40 indicate?

moderate PAD

What does an ABI of 0.41-0.70 indicate?

Mild PAD

What does an ABI of 0.71-0.90 indicate?

borderline risk

What does an ABI of 0.91-0.99 indicate?

normal

What does an ABI of 1.0-1.4 indicate?

counterclockwise (right arm, right PT, right DP, left DP, left PT, left arm)

What order would you perform and ankle-brachial index (ABI)?

Phlebitis

= inflammation of a vein

• note redness, enlargement of extremity, heat, pain, & tenderness

Thrombophlebitis

= inflammation with clot formation

Deep Vein Thrombophlebitis (DVT)

= a deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, edema

• requires emergency referral bc of risk for pulmonary embolism

Arterial abnormalities

• dec/absent pulses

• pale w elevation and rubor

• cold temp

• no edema

• shiny/thick nails

• ulcers on toes

• pain w exercise & cold

• decreased sensations

Venous abnormalities

• palpable pulses

• pink to cyanotic color

• warm temp

• pitting edema

• ulcers/thick dark skin

• pain w standing & relief when lying

Pediatric Variations

• Transient acrocyanosis & mottling at birth can occur

• Pulse force should be normal and symmetric in both UE & LE

• Palpable lymph nodes occur often in healthy infants & children

  • Small, firm (shotty), mobile, and nontender

• Vaccinations can produce local lymphadenopathy

OA Variations

• Arteriosclerosis (hardening) and Atherosclerosis (plaques)

• DP and PT pulses may become more difficult to find

• Trophic changes associated with arterial insufficiency may be seen:

  • Thin, shiny skin

  • Thick, ridged nails

  • Loss of hair on lower legs

What are trophic changes associated with arterial insufficiency?

• Thin, shiny skin

• Thick, ridged nails

• Loss of hair on lower legs