Peripheral Artery Circulation Examination Flashcards
Inspects for evidence of arterial insufficiency in the upper and lower limbs: skin, dry thin skin, pallor, ulcers, thickened nails, loss of hair, etc.
Ask patient to remove socks and expose upper and lower limbs.
“First, I will inspect for any signs of arterial insufficiency. Starting with the upper limbs, I do not see any signs of edema, or changes in skin color such as pale skin (pallor) due to reduced blood flow and O2. The skin doesn’t appear dry, thin, or shiny (explain findings), and there are no scars or rashes. Ulcers and abnormal hair loss are not present. The patient’s nails are not thickened.”
“Can I adjust your drape? (adjust drape appropriately, uncovering lower limbs; replace drape once finished with this portion of examination). I do not see any signs of edema, or changes in skin color such as pale skin (pallor) due to reduced blood flow and O2. The skin doesn’t appear dry, thin, or shiny (explain findings), and there are no scars or rashes. Ulcers and abnormal hair loss are not present (ask patient if they’ve noticed hair loss). The patient’s nails are not thickened.”
Palpates temperature, radial pulse and determines rate and rhythm. Palpates radial and brachial arteries bilaterally and comments on symmetry.
“I will now check your body temperature by placing the dorsum (back) of my fingers on your skin. I’m noting that the temperature of your skin is normal and not cool due to tissue ischemia (insufficient blood flow).”
“Now, I’ll check the radial pulse (bilaterally) which tells me how your heart is beating. (Time for 30 seconds then multiply). I’m noting that the rhythm of your pulses is present, regular, bilateral, synchronous, patent, full volume, brisk, 2+. Abnormal would be weak (+1) and bounding (3+).”
● Radial Pulse: Assess rate and rhythm (palpate for at least 5 cardiac cycles; assess for radio-radial delay- coarctation of the aorta)
“Next, I’ll be locating your brachial pulses (bilaterally – looking for symmetry in pulses), which are located medially to biceps muscles and the antecubital crease. I’m noting that the rhythm of your pulses is present, regular, bilateral, synchronous, full, brisk, and 2+.” Abnormal would be weak (+1) and bounding (+3).
Checks capillary refill
“I’ll also be checking for capillary refill. Can I please see your fingers? Upon checking for capillary refill, flow was restored in less than 2 seconds, which means that the body was oxygenated properly. A delay would be indicative of hypovolemia, shock, or PVD.”
● Temperature – if reduced may indicate poor peripheral perfusion
● Capillary refill time should be less than 2 seconds
Palpate the carotid arteries and comments on symmetry. Determines the character and volume. Auscultates for carotid bruits bilaterally
“Next, I will be moving on and checking your carotid pulse and checking for any possible carotid bruits. I’m going to locate the carotid artery starting from the midline, going lateral and medial to the SCM. I’ll place my index and middle finger on the carotid pulse, one side at a time, to avoid inducing syncope. After doing so, I can feel that the carotid pulse is present, bilateral, patent, monophasic, full volume, brisk, and 2+.”
“Now, I’ll use the bell of my stethoscope to check for any possible bruits (listen to both sides) in the carotid arteries, which is a whooshing sound that can be heard due to radiation of AS murmur (do this for 4-5 seconds on each side). I do not hear any bruits in the carotid arteries, which means the carotid arteries are patent.”
● Bruits may suggest stenosis at the carotid bifurcation.
Palpates the dorsalis pedis and posterior tibial artery bilaterally and comments on symmetry. Checks capillary refill. Comment on other arteries that could be examined in the lower limb.
“Now, I am moving on to your lower extremities. Can I adjust your drape? (adjust drape appropriately, uncovering lower limbs; replace drape once finished with this portion of examination). I’ll be palpating the dorsalis pedis pulses (bilaterally), which is present on the dorsum of the foot just lateral to the extensor tendon of the great toe. I’m noting that the rhythm of both were present, regular, bilateral, patent, brisk, filled, 2+.”
“Now I’ll palpate your posterior tibial artery pulses (posterior to the medial malleolus of the tibia), and I can feel that the rhythm of your pulses is present, regular, bilateral, synchronous, patent, full volume, brisk, and 2+.” “Upon palpation of the pulses, there were no signs of arterial or venous insufficiency in both upper and lower extremities.”
“I’ll also be checking for capillary refill. Upon for checking for capillary refill, the flow was restored in less than 2 seconds, which means that the body is oxygenated properly.”
“Other arterial pulses that can be examined in the lower limb includes femoral (best palpated at the mid-inguinal point located halfway between the anterior superior iliac spine and the pubic symphysis), and popliteal pulses ( palpated in the inferior region of the popliteal fossa; this pulse is often difficult to palpate).”
Demonstrates the Allen test and explain its significance.
This test involves the assessment of the arterial supply to the hand.
● “Could you please clench your fist? (Apply pressure over both the radial and ulnar artery to obstruct blood supply to the hand.) Now please open your hand.” Ask the patient to open their hand, which should now appear blanched (if not you have not completely occluded the arteries with your fingers). Remove pressure from the ulnar artery whilst maintaining pressure over the radial artery. If there is adequate blood supply from the ulnar artery, color should return to the entire hand within 3 - 5 seconds. (Release ulnar, then perform again and release radial)
Demonstrates the Buerger test and explain its significance.
This test is carried out to further demonstrate poor lower limb arterial perfusion.
● First ensure that the patient is positioned supine, and on the edge of bed. Standing at the bottom of the bed raise both of the patient’s feet to 45° for (1 minute is ok for OSCE; once you see pallor move on to the next part of the test) 2 mins (or until you see the paleness of the patients limb), then wiggle toes looking for pallor at sole and dorsum of feet and feet should be hanging from the edge of the table. (may change for OSCE purposes)
o Observe for pallor-emptying of the superficial veins. If a limb develops pallor, note at what angle this occurs e.g. 20° (known as Buerger’s angle). A healthy leg’s toes should remain pink, even at 90°. A Buerger’s angle of less than 20° indicates severe.
● Once the time limit has been reached, ask patient to place their legs over the side of the bed: Observe for a reactive hyperaemia- this is where the leg first returns to its normal pink color, then becomes red in color, then becomes red in color- this is due to arteriolar dilation (an attempt to remove built up metabolic waste
