Perfusion-Peripheral Vascular

PERFUSION: PERIPHERAL VASCULAR

Definition of Perfusion

Arteries

• Structure: Smaller, more muscular; carry 30% of blood.

• Function: Transport oxygenated blood from the heart to various tissues and organs.

• Normal Findings: Include pulse, which should correlate with heart rate and rhythm.

• Bruit: Indicates turbulence; a sign of potential vascular issues.

• Changes Due to Atherosclerosis: Arteries can become more rigid and less springy, leading to complications like reduced blood flow and increased myocardial demand.

Veins

• Structure: Closer to the body surface; carry 70% of blood.

• Function: Return non-oxygenated blood to the heart and lungs for reoxygenation, and remove metabolic waste products.

• Normal Finding: Veins do not pulse but can demonstrate refill capacity.

• Age-related Changes: As individuals age, veins may engorge due to decreased elasticity or valve issues leading to chronic venous insufficiency.

Peripheral Vascular Disease (PVD)

Peripheral Arterial Disease (PAD)

• Characteristics: Characterized by occluded or narrowed arteries due to atherosclerosis or thrombus formation.

• Symptoms: Pain during exercise (intermittent claudication) due to decreased oxygen supply, usually in the calf, thigh, or buttock.

• Physical Findings: Extremities may feel cold or cool to touch, requiring assessment of temperature gradients. Skin appears shiny, hairless, and thin, indicating poor perfusion.

• Ulcers on Toes or Feet: Typically circular, dry, dark, and painful due to ischemia.

Peripheral Venous Disease

• Blood flows to the extremity but faces challenges returning to the heart.

• Causes: Include venous obstruction or valve incompetence.

• Symptoms: Pooling blood leads to increased pressure and fluid leakage, resulting in edema (swelling). Skin may appear tough and darkened, exhibiting a warty texture, and may feel warm or hot due to inflammation.

• Wounds: Often irregularly shaped and less painful than arterial ulcers due to the presence of adequate blood flow.

Venous Thromboembolism

• Definition: Clot formation in peripheral veins (e.g., Deep Vein Thrombosis - DVT).

• Symptoms: Red, hot, painful, with visible veins or a palpable cord.

• Important Note: Do not palpate affected areas to avoid dislodging the clot.

Insufficiencies

• Arterial Insufficiency: Decreased blood flow to the limb; check for pallor or coolness.

• Venous Insufficiency: Decreased blood return from the limb; assess for significant edema and skin changes (brown discoloration).

• Assessment: Check for both arterial and venous stasis ulcers, documenting size, depth, and any signs of infection.

Arterial System Assessment

Lesion Characteristics, Location, and Appearance

• Arterial Lesions:

  • Locations: End of toes, top of feet, lateral ankle (malleolus).

  • Appearance: Minimal drainage; pale/light pink tissue granulation; "punched out" deep round lesions with clear margins.

• Venous Lesions:

  • Locations: Medial aspect of the legs, particularly the medial ankle region.

  • Appearance: Swollen with drainage; deep pink/red granulation; irregular edges, with shallow depth typically representative of chronic venous ulcers.

Physical Assessment Process

General Inspection

• Look for signs of poor perfusion (cyanosis, pallor, rubor).

• Assess for skin temperature variations (cool/clammy vs. warm/hot).

• Document characteristics of any edema present.

• Examine types of wounds: circular/dry or irregular/beefy, often compared to normal skin integrity.

• Conduct pain assessment: note location, timing, and relief measures.

Heart Failure Assessment

• Left-Sided Heart Failure:

  • Symptoms: Paroxysmal nocturnal dyspnea due to pulmonary congestion.

  • Elevated pulmonary capillary wedge pressure; congestion leads to cough, crackles, wheezes, and tachypnea.

  • Possible blood-tinged sputum indicating lung congestion.

  • Other signs include restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, and cyanosis.

• Right-Sided Heart Failure (Cor Pulmonale):

  • Symptoms: General fatigue and weakness.

  • Increased peripheral venous pressure leads to swelling (ascites), enlarged liver/spleen.

  • Characteristics include distended jugular veins, anorexia, GI distress, weight gain, and dependent edema seen in the lower extremities.

Physical Assessment Methods

• Techniques:

  • Inspection: of upper and lower extremities, observing for edema and color changes.

  • Palpation: Includes pulse palpation, testing for edema, and assessing capillary refill.

  • Incorporate Allen's Test to assess hand perfusion.

  • Auscultation: May utilize Doppler instruments if pulses are absent to determine blood flow.

Palpating Pulses

Sites to Assess

• Upper Body: Temporal, Carotid, Brachial, Radial (& Ulnar).

• Lower Body: Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis.

Nail and Skin Assessment

• Nail Changes: Clubbing of nail beds: angle exceeds 180°, and absence of a diamond window indicates chronic oxygen depletion.

• Constriction Disorders: Conditions such as Raynaud's disease impact blood flow, typically causing finger and toe discoloration upon exposure to cold or stress.

Capillary Refill Testing Procedure

• Method: Press over nail bed and quickly release.

• Normal Outcome: Blanching with return to pink color in < 2 seconds.

• Abnormal Outcomes: Failure to blanch or return to pink within designated time frame indicates poor perfusion, warranting further investigation.

Trunk and Peripheral Assessment

Inspection

• Assess color, skin integrity, and symmetry between limbs.

• Look for: Skin changes related to vascular conditions (venous/arterial).

• Check for wounds, ulcers, and mottling, documenting any relevant findings.

Palpation

• Document rate and strength of pulses in all relevant regions, and assess for edema accurately.

Documenting Skin Condition

• Note conditions related to: Peripheral arterial disease, venous insufficiency, DVT, lymphedema, capillary refill status, and nail clubbing alternatives.

Limb Changes Assessment

Observing Skin/Tissue Changes

• Assess for color changes: rubor, pallor, cyanosis, and note variability between limbs.

• Distinguish between venous and arterial insufficiency signs to formulate an accurate clinical impression.

Pitting Edema Assessment Grading Scale

• 0+: No pitting edema.

• 1+: Mild pitting (2 mm, disappears rapidly).

• 2+: Moderate pitting (4 mm, disappears in 10-15 seconds).

• 3+: Moderately severe pitting (6 mm, lasts over 1 min).

• 4+: Severe pitting (8 mm, lasts over 2 min).

Lymph-Edema

• Understand signs and implications of lymphedema, its management, and how it affects the limb's function and appearance.

Varicosities Assessment

• Check for filling time and assess for causes: decrease in elastin and pressure issues leading to varicose veins.

• Treatment Options: May include elevation, compression garments, and potential surgical interventions but do not restore elasticity to the veins.

Limb Circumference Assessment

• Importance and Method: Document limb circumference for edema assessment, noting size comparisons. Measure from the same site on both limbs; changes of 1 cm or less are considered normal adaptations.

• Example: Document findings for medical records and follow-up evaluations.

Leg Elevation Test (PAD) Procedure

• Method: Elevate legs and observe color changes in elevated vs. dependent positions, assessing the degree of arterial supply.

• Assessment: Document pain history relative to activity levels, noting potential claudication symptoms. If Pain relieves w/ rest,  resumes w/ activity

Allen Test for Hand Perfusion Procedure

• Method: Assess hand perfusion by occluding radial and ulnar arteries while observing recovery of color in the palmar area.

• How to: Hold hand Supine on table. Pump hand for a few times

• Questions for Assessment: •What are we testing for?, Why does this test work?, Indications to do the test?

• Normal Recovery Time: Under 10 seconds, indicating appropriate collateral circulation.