peripheral vascular assessment Flashcards
1
Q
components for assessment
A
- arteries
- veins
- lymphatics
2
Q
arteries
A
- arms: brachial and radial
3
Q
legs – arteries
A
- femoral
- popliteal – behind knee
- dorsal pedis – on top of foot
- posterior tibial
4
Q
veins
A
- arms: superficial and deep
- legs: deep (femoral and popliteal)
- superficial: great saphenous and small saphenous
5
Q
venous flow
A
- Drains deoxygenated blood & its waste products and returns to the heart
- A low-pressure system
- System to propel blood
- Contracting skeletal muscles that milk the blood proximally
- Pressure gradient caused by breathing
- Intraluminal valves that ensure unidirectional flow
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
7
Q
lymphatics(conserve)
A
- conserve fluid and plasma proteins
- forms a major part of the immune system
- absorb lipids from the intestinal track
8
Q
lymph nodes
A
- cervical
- axillary
- epitrochlear – above elbow and not normally palpable
- inguinal – will feel like little round balls
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
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
11
Q
objective data equipment and supplies
A
- Paper centimeter tape
- Stethoscope
- Doppler ultrasound device
- Conductivity gel
- Tourniquet/ Blood pressure
cuff
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
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
- Located in depression above & behind medial
- Modified Allen test – compress radial and ulnar. checking if it is supporting blood flow to fingers
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
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
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
- 132 ankle systolic/124 arm systolic = 1.06
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
