Peripheral Vascular Examination Flashcards
Diaphoresis
Excess sweating can be associated with decreased cardiac output
Arterial Pulses
Decreased or absent pulses associated with peripheral artery disease; examine bilaterally starting with most distal pulses
Lower extremity pulses
- Position patient in supine, check femoral, popliteal, dorsalis pedis, posterior tuba pulses
Upper extremity pulses
- check radial, brachial, carotid pulses
Cyaniosis
bluish color related to decreased cardiac output or cold; especially lips, fingertips, nail beds
Pallor
absence of rosy color in light skinned inidividuals, associated with decreased peripheral blood flow, PAD
Rubor
dependent redness with PAD
Clubbing
curvature of the fingernails with soft tissue enlargement at base of nail; associated with chronic oxygen deficiency, chronic pulmonary. disease or heart failure
Trophic changes
pale, shiny, dry skin, with loss of hair is associated with PAD
Fibrosis
- tissues are thick, firm, and unyielding
Stemmers Sign
Dorsal skin floss of the toes or fingers are resistant to lifting
- vindictive of fibrotic changes and lymphedema
What else is associated with PAD
abnormal pigmentation, ulceration, dermatitis, gangrene
temperature
decrease in superficial temperature is associated with poor arterial perfusion
Intermittent claudication
- pain, cramping, and lower extremity fatigue occurring during exercise and relieved by rest, associated with PAD
- may be in calf, thigh, hip, or butt
Why might a patient experience pain at rest?
severe decrease arterial blood supply, typically in forefoot, worse at night
peripheral causes of edema
chronic venous insufficiency and lymphedema
Should you examine venous or arterial system first?
venous insufficiency can invalidate some arterial tests
what does percussion test do
determines competence of greater saphenous vein
How to perform percussion test?
- in standing, palpate one segment of vein while percussing vein approximately 20 cm higher
- if pulse wave if felt by lower hand, the intervening vales are incompetent
What does trendelenburg test do? (retrograde filling test)
Determines competence of communicating veins and saphenous system
How to perform Trendelenburg/ Retrograde filling test
- Patient is positioned in supine with legs elevated to 60 degrees
- Tourniquet is placed on proximal thigh (occludes venous flow in superficial veins)
- patient stands
- examiner notes whether veins fill in normal pattern (should take 30 secs)
What does venous filling time test look at
Examines time necessary to refill veins after emptying
How to do venous filling time test
- with patient supine passively elevate lower extremity to 45 degrees for 1 min then place in dependent position
- Delayed filling (>15 secs) is indicative of venous insufficiency
Doppler ultrasound
- Examination of ultrasonic oscillator
- Determines blood flow within a vessel; useful in venous and arterial disease
How to utilize doppler ultrasound
- Doppler probe placed over large vessel; US signal given transcutaneously; movement of blood causes audible shift in signal frequency
- useful in located non palpable pulses and measuring systolic BP in extremities
Air Plethysmography (APG)
- pneumatic device calibrated to measure patency of venous system/volume
- cuff of device inflated around calf; attached to a 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 onto toes
What is ABI
Ratio ofLE pressure divided by UE pressure
How to perform ABI
- Pt is positioned in supine and at rest for 5 mins
- BP cuff inflated then deflated; listens for return of flow
- Performed at brachial artery and post tib/dorsalis pedis arteries
ABI scale
> 1.4: indicates non-compliant arteries
- 1.00-1.4: normal
- 0.91-0.99: borderline
< 0.9: abnormal
- < 0.5: severe arterial disease, risk for critical limb ischemia, may have pain at rest
What does ABI assist in?
- stratification for cardiovascular disease
- <.90 is associated with 2 and 4 fold increased risk for CV events and death
- ABI <0.5: increased risk of progression to severe or critical limb ischemia in one year
clinically significant change in ABI
> 0.15 or >0.10 in pts with symptoms
What does rubor of dependency look at?
- color changes in skin during elevation of foot followed by dependency (seated, hanging position)
Rubor of dependency insufficiency
- Pallor develops in elevated position, reactive hyperemia develops in dependent position
- changes that take longer than 30 seconds are also indicative of arterial insufficiency
Treadmill test of intermittent claudication
- have pt walk on level grade, 1 mph and note level of claudication pain and time of test pain was experienced
- examine for coldness, numbness, or pallor in legs or feet; loss of hair over ant tib
- higher levels of claudication may be acceptable during this test
What can also cause leg cramps
diuretics –> hypokalemia
Rating of pain with intermittent claudication
- Grade I: minimal discomfort or pain
- Grade II: Moderate discomfort or pain; patients attention can be diverted
- Grade III: Intense pain; patient’s attention cannot be diverted
- Grade IV: excruciating and unbearable pain
Which superficial lymph nodes should you palpate for examination
- cervical
- axillary
- epitrochlear
- superficial inguinal
Examining skin when inspecting the lymphatic system
- look for presence of papules, leakage, and wounds
Lymphangiography and Lymphoscintigraphy
- X ray of lymph vessels
- provides information about lymph flow, lymph nodes uptake and back flow
