Cardiovascular- The Exam: Peripheral Vascular System Flashcards
Examine Extremities: why check for diaphoresis
excess sweating can be associated with decreased cardiac output
Examine Extremities: why check arterial pulses
decreased or absent pulses associated with peripheral artery disease (PAD)
Examine Extremities: how to check arterial pulses
Must check bilaterally and start distal
For LE: check in supine- dorsalis pedic, posterior tibial, popliteal, femoral
For UE: radial, brachial, carotid
Examine Extremities: check skin- what is cyanosis
blueish color
decreased cardiac output or cold
very visible at lips, fingers, nail beds
Examine Extremities: check skin- what is pallor
absence of rosy color in light skin
associated with decrease blood flow
common in PAD
Examine Extremities: check skin- when does rubor occur
dependent redness with PAD
Examine Extremities: check skin- besides color what should you check
temperature changes
decrease in superficial skin associated with poor arterial perfusion
Examine Extremities: check skin- clubbing
curvature of finger nails with soft tissue enlargement at base of nail
associated with chronic O2 deficiency, chronic pulmonary disease, or heart failure
Examine Extremities: check skin- trophic changes
pale, shiny, dry skin
hair loss associated w/ PAD
Examine Extremities: check skin- fibrosis
tissues that are thick, firm, and unyielding
Examine Extremities: check skin- Stemmer’s sign
dorsal skin folds of the toe or fingers are resistant to lifting
indicative of fibrotic changes and lymphedema
Examine Extremities: check skin- abnormal qualities of skin
abnormal pigmentation
ulceraton
dermatitis
gangrene
Examine Extremities: Intermittent claudication (IC)
- IC is pain, cramping, and LE fatigue occurring during exercise and relieved by rest
- Associated w/ PAD
- pain is typical in calf, but may be in thigh or butt
- pain at rest will occur with severe decreased in arterial blood supply, typically in forefoot, and worse at night
Examine Extremities: check edema- measuring edema
- girth measurements using tape measure at regular intervals
- volumetric measurements using a volumeter (useful for irregular body parts such as hand or foot
- pitting edema grades 1+ through 4+ (depression made when pressuing firmly into skin)
Examine Extremities: check edema- 1+
mild, barely perceptible indentation
<1/4 inch pitting
Examine Extremities: check edema- 2+
moderate
easily identified depression
returns to normal w/in 15 sec
1/4-1/2 inch pitting
Examine Extremities: check edema- 3+
Severe depression
takes 15-30 sec to rebound
1/2-1 inch pitting
Examine Extremities: check edema- 4+
very severe
depression lasts for > 30 seconds or more
> 1 inch pitting
Examine Extremities: check edema- causes of peripheral edema
- include chronic venous insufficiency and lymphedema
- BIL edema associated with CHF
Peripheral venous circulation: what to do first
examine venous system before arterial; venous insufficiency can invalidate some arterial test.
Peripheral venous circulation: what is the percussion test
- determines competence of greater saphenous vein
- in standing, palpate one segment of vein while percussing vein app. 20 cm. higher
- if pulse wave is felt in lower hand, the intervening valves are incompetent
Peripheral venous circulation:what is the trendelenburg test (retrograde filling test)
- determines competence of communicating veins and saphenous system
- pt. is supine, LE elevated 60 degrees (empties venous blood)
- tourniquet put on upper thigh (occludes venous flow in superficial veins
- ask pt. to stand
- note if veins fill in normal pattern. should take app. 30 sec.
**I’m never doing this to a patient
Peripheral venous circulation: venous filling time
- examines time needed for veins to refill
- put pt. supine and passively elevate LE to 45 degrees for 1 min; place in dependent position; note how long to refill
- delayed filling (>15 sec) is indicative of venous insufficiency
Peripheral venous circulation: doppler ultrasound
- examine using an ultrasonic oscillator connected to ear phones
- determines blood flow in a vessel; good for venous and arterial
- probe goes over large vessel, US signal given transcutaneously
- movement of blood causes audible shift in frequency
- good for locating nonpalpable pulses and measuring systolic BP in extremities
Peripheral venous circulation: air plethysmography (APG)
pneumatic device calibrated to measure patency of venous system; volume
- cuff inflated around calf, attached to pressure transducer and microprocessor
- occludes venous return, permits arterial inflow, recorder registers increasing volume with cuff, time to return to baseline with cuff deflation
- comparison tests performed in sitting, standing, and up on toes
Peripheral arterial circulation: Ankle Brachial index (ABI)
- the ratio in LE pressure divided by UE pressure
- pt. rests in supine for 5 min
- BP cuff inflated to occlude arterial blood flow
- Performed at in UE at brachial artery and LE at post tib artery and dorsalis pedis
- assiss with risk stratification of CV disease
Peripheral arterial circulation: ABI index and meaning of values
<0.9 = associated with 2-4x increased risk for CV events or death
< 0.5 = increased risk of progression tosevere or critical limb ischemia in one year
1 = normal
> 1.4 non-compliant arteries
Peripheral arterial circulation: changes in color with LE positional changes
- with insifficiency, pallor develops in elevation; reactive hyperemia (rubor) develops in dependent position
- changes taking more than 30 sec are also indicative of arterial insufficiency
Peripheral arterial circulation: intermittent claudication (IC)
- exercise induced pain or cramping in LE, most typically in calf, that goes away with rest
- have pt. walk on level grade, 1 mile/hour
- test is stopped with claudicatory pain
- note time fo test and usesubjective ratings of pain scale to classify degree of claudification
- examine LE for cold, numbness, pallor, and loss of hair over ant. tib. area
- leg cramps may also result from diuretic use with hypokalemia
Peripheral arterial circulation: Subjective ratings of pain with IC scale
Grade 1- min discomfort or pain
Grade 2- mod discomfort or pain; pt.’s attention can be diverted
Grade 3- intense pain; pt.’s attention cannot be diverted
Grade 4- excruciating and unbearable pain
