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Health Assessment > peripheral vascular assessment > Flashcards

peripheral vascular assessment Flashcards

1
Q

components for assessment

A
  • arteries
  • veins
  • lymphatics
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2
Q

arteries

A
  • arms: brachial and radial
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3
Q

legs – arteries

A
  • femoral
  • popliteal – behind knee
  • dorsal pedis – on top of foot
  • posterior tibial
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4
Q

veins

A
  • arms: superficial and deep
  • legs: deep (femoral and popliteal)
    • superficial: great saphenous and small saphenous
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5
Q

venous flow

A
  • Drains deoxygenated blood & its waste products and returns to the heart
  • A low-pressure system
  • System to propel blood
    1. Contracting skeletal muscles that milk the blood proximally
    2. Pressure gradient caused by breathing
    3. Intraluminal valves that ensure unidirectional flow
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6
Q

lymphatics(form)

A
  • form a separate vessel system
  • retrieves excess fluid from the tissue spaces and returns it to the bloodstream
  • drains into 2 main trunks
    • right lymphatic duct and thoracic duct
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7
Q

lymphatics(conserve)

A
  • conserve fluid and plasma proteins
  • forms a major part of the immune system
  • absorb lipids from the intestinal track
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8
Q

lymph nodes

A
  • cervical
  • axillary
  • epitrochlear – above elbow and not normally palpable
  • inguinal – will feel like little round balls
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9
Q

subjective data

A
  • Ask about leg cramps, swelling, lymph node enlargement, skin changes on arms/legs, medications, smoking history
  • Nursing Health History
    • History of Current Symptoms
    • Past Health History
    • Family Health History
    • Life-Style and Health Practices
      • Evaluate risk factors for peripheral vascular disease
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10
Q

objective data

A
  • Client Preparation
    • Put on an examination gown
    • Sit upright on exam table
    • Make room comfortable & draft less
    • Explain position changes that may be needed
  • leave on underwear and room needs to be warm
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11
Q

objective data equipment and supplies

A
  • Paper centimeter tape
  • Stethoscope
  • Doppler ultrasound device
  • Conductivity gel
  • Tourniquet/ Blood pressure
    cuff
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12
Q

inspection of arms

A
  • Color of skin & nail beds
  • Temperature
  • Texture
  • Turgor
  • Presence of lesions, edema, clubbing
  • Capillary refill
  • Symmetry –> compare left side to right side
  • no percussion or auscultation
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13
Q

palpate of arms

A
  • Bilateral radial pulses
    • Grade accordingly
  • Bilateral ulnar pulse
    • Not always necessary
  • Bilateral brachial pulse
  • Epitrochlear lymph nodes
    • Located in depression above & behind medial
      condyle of the humerus
  • Modified Allen test – compress radial and ulnar. checking if it is supporting blood flow to fingers
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14
Q

inspection of legs

A
  • Skin color
  • Distribution of hair
  • Venous patterns – do we see veins
  • Symmetry
  • Lesions or ulcers
  • Size (swelling or atrophy)
  • Edema
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15
Q

palpation of legs

A
  • Temperature
  • Edema
  • Pain –> could indicate blood clot
    • Flex the knee and gently compress the gastrocnemius (calf) muscle anteriorly against the tibia
    • No tenderness should be present
  • Inguinal lymph nodes
    • Small (<1cm, movable, nontender)
  • Palpate peripheral arteries bilaterally
    • Femoral Pulses
    • Popliteal Pulses
    • Dorsalis Pedis Pulses
    • Posterior Tibial Pulses
  • don’t palpate if they are in pain
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16
Q

posterior tibial pulse

A
  • inside of ankle
  • behind and below the medial malleolus
17
Q

dorsalis pedis pulse

A
  • top of the foot
  • lateral to the extensor tendon
18
Q

PRETIBIAL EDEMA AND
PITTING EDEMA SCALE

A
  • Check for pretibial edema.
    • Firmly depress skin over tibia or medial malleolus for 5 seconds and release.
    • If pitting edema is present, grade it on following scale:
      • 1+ Mild pitting, slight indentation, no perceptible swelling
      • 2+ Moderate pitting, indentation subsides rapidly
      • 3+ Deep pitting, indentation remains, leg looks swollen
      • 4+ Very deep pitting, indentation lasts long time, leg grossly swollen and distorted
19
Q

color changes

A
  • If you suspect an arterial deficit
  • Raise legs 30cm (12 in) off the table
  • Ask patient to wag their feet for 30 seconds to drain off venous blood
    • Skin color now reflects only the contribution of arterial blood
  • Have person sit up with legs over the side of the exam table
  • Compare color of both feet
  • Note time it takes for color to return to feet
    • Normally = 10 sec or less
20
Q

doppler ultrasonic stethoscope

A
  • Detects
    • weak peripheral pulses
    • BP in infants and children
    • Measures low BP in adults
    • Measures BP in lower extremities
  • Magnifies
    • Pulsatile sounds from heart & blood vessels
  • Procedure
    • Position patient supine with legs externally rotated
    • Apply a small drop of coupling gel on transducer
    • Apply light pressure
    • Listen for the swishing, whooshing sound
21
Q

ankle brachial index (ABI)

A
  • Used to determine extent of Peripheral Artery Disease
  • Apply a regular arm BP cuff above the ankle and determine the systolic pressure in either the posterior tibial or dorsalis pedis pulse
  • Divide that number by the systolic pressure of the
    brachial artery
  • Normal = 1.0-1.2
    • 132 ankle systolic/124 arm systolic = 1.06
      • Equal 106% which means NO flow reduction
22
Q

the wells score for deep vein thrombosis

A
  • Many assessment findings for DVT are unreliable
  • Devised a simple scoring system that separate patients into groups of low, moderate, or high probability of DVT
23
Q

The nurse palpates a pulse just under the inguinal ligament. She should document this as the pulse of which artery?

A
  • femoral
24
Q

When examining a pale, white female with red hair and freckled skin, the nurse should focus health education on measures to manage which condition?

A
  • sun exposure
  • they burn easily
25
Q

The nurse notes the following data regarding an elderly client’s peripheral vascular status: cramping leg pain when walking, which is
relieved by rest; cool, pale feet; delayed capillary refill time in toenails; negative Homan’s sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Based on these data, the nurse suspects the etiology of these findings to be

A
  • arterial insufficiency

Health Assessment (9 decks)

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