Peripheral Vascular Flashcards
Pulse characteristics
Contour - quick rising or falling Amplitude - strength of pulse Rate Rhythm Symmetry -lack of symmetry may be impaired circulation
Assessment of pulses
Auscultation for bruits Inspect for distentions at 45 degrees Inspect extremities for color,skin and nail changes Presence of hair Muscular atrophy Edema Varicose
Palpate extremities for
Warmth
Pulse quality
Tenderness
Putting edema
Arteries
Tough, tensile and less distensibleb
Veins
Less sturdy and more passive
Valves
Can expand if increased BF
Arterial pulse
From systole
0.2 seconds to reach dorsalis pesos
2 seconds for RBCs to travel there
Characteristics of Pulses
Volume of blood ejected (SV)
Distensibility of aorta and large arteries
Viscosity
Arteriole resistance
A wave (JVP)
Most prominent
Brief backflow into vena cava
C wave
Backward push created by TV closure during systole
V wave
Increased volume and pressure of RA
X slope
Passive RA filling
Y slope
Open TV and filling of RV
HPI: leg pain
Onset Character Continuous pain in toes, thigh , butt Skin changes - cold, pallor, redness Limping Walking at night with pain Swelling
HPI SWOLLEN ANKLES
Onset and duration Related circumstances- elevation, air travel Associated symptoms - nocturia, SOB Treatment - rest, massage, heat, elevate Meds - heparin, warfarin
Varicose Veins
Women 4x more likely Genetics Tobacco, sedentary, high BMI Age decreases elasticity Hx of lower extremity trauma, DVT
Palpatable pulses
Carotid Brachial Radial Femoral Poiteal Dorsalis pedis Posterior tibial
Amplitude pulse scale
4: bounding, aneurysmal
3: full, increased
2: expected
1: diminished, barely palpable
0: absent
Irregular HR
Increased HR on inspiration and decreases on expiration
Compare on auscultation
Strength? Lack of symmetry?
Compare upper, lower, left and right extremities
Femoral pulse
Usually as strong as radial
Absent femoral may be coarctation of aorta, atherosclerosis, PAD, vasculitis
Which arteries are asucultated for bruits
Temporary Carotid Subclavian Abdominal aorta Renal Iliac Femoral *hold breath to suspend breath sounds
Types of Bruits
Radiation of murmurs
Obstructive arterial disease
Diminished circulation will lead to signs and symptoms that are related to the following
Site
Degree of stenosis
Ability of collateral channels to compensate
Rapidity at which problem develops
Claudication
Dull ache Muscle fatigue and cramps Usually appears during exercise Few minutes rest provides relief Recurs with more activity Continued activity makes pain worse
Theee P’s of occlusion
Pain
Pallor
Pulselessness
After determining pain characteristics, note the following
Pulses Bruits Loss of warmth Pallor or cyanosis Collapsed veins Atrophied skin or hair loss
Arterial insufficiency
Pain Pulses Color Temp Edema Skin changes Ulceration Gangrene
Pain in calf
Obstruction of superficial femoral artery
Pain in thigh
Obstruction of femoral artery/external Iliad
Pain in buttock
Iliac artery or distal aorta obstruction
JVP
Can be visualized not palpate
Lay or flat to reveal distentions then raise head up for evident pulsation
Value should be less than 9cm
Conditions that make JVP examination difficult
Severe R CHF, TV insufficiency, constructive pericarditis, tamponade
Severe volume depletion
Obesity
Assessment for venous obstruction and insufficiency
Thrombosis - red,thick,tender
Homan sign - flex knee and foot to test calf pain which could mean thrombosis
Edema grade 1-4 to assess R CHF
varicose veins incompetent wall or valve or obstruction
Assessing Edema
1 slight,no visible deformities, disappears rapidly
2 - 10-15s no dostoritons
3- >1min, full/swollen extremity
4 - 2-5mins, grossly distorted
Venous insufficiency
Pain Pulses Color Temp Edema Skin changes Ulceration Gangrene
Arterial aneurysm
Localized dilation
1.5x diameter of normal artery
PAD
Stenosis of BF to extremities caused by plaque
Atrterial Embolic Disease
A fib can lead to clot in heart which can become embolism
Venous thrombosis
Sudden or gradual
Immboilization or trauma
Infants
Brachial, radial, femoral easily palpable
Evaluate capillary refill
Children
Venous hum common
HTN in 1-3%
Caused by renal disease, coarctation or pheochromocytoma
Stenosis of descending aortic arch is common near origin of left subclavian
Rule out COA by checking lower extremity for equal pulses
Preganant
BP falls 16-20 weeks
Greater than 140/90 indicates preganancy induced HTN
Preeclampsia-eclampsia
HTN that occurs after 20th week of pregnancy and presence of proteinuria
Eclampsia is PE with seizures
Older adults
Foot pulses difficult to palpate
Loss of elasticity increases BP
HTN in older is >140/90
Venous ulcers
Chronic venous insufficiency leads to lower extremity venous HTN
Sinus arrythmia
Increased HR on inspiration and decreased on expiration
Unpredictable rate may be heart disease or a-fib
Noting an irregular rate
Compare bilateral
Auscultate heart
Note strength of pulse
After determining leg pain, note the following
Pulses - strong, weak or absent Possible systolic bruits Loss of expected body warmth over area Localized pallor or cyanosis Collapsed superficial veins with delay in filling Thin, atrophied skin, muscle atrophy
Judge degree of narrowing and potential severity of arterial insufficiency
Have patient lie supine
Elevate extremity
Note degree of blanching
Have pt sit on edge of bed or table
Note time it takes for maximal color return
Slight pallor and return to full is expected
A delay of many seconds or minutes is abnormal
Constant pain in venous insufficiency occurs along with the following
swelling and tenderness of muscles
engorgement of superficial veins
erythema or cyanosis
Thrombosis
Redness, thickening and tenderness along a superficial vein
Unilateral vs Bilateral edema
Unilateral - occlusion of major vein
Bilateral - CHF
Edema w/o pitting - aterial insufficiency or lymphedema
Edema with thickening of ulceration of skin indicates
deep venous obstruction
venous valvular incompetence
Caused by mechanical pressure of increased blood volume in area
Varicose veins
dilated, swollen, with diminished rate of BF and increased intravenous pressure
Have pt stand ten times on toes in succession
Competent veins will disappear in a few seconds
Distention that is sustained is venous insufficiency
