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Nurs 203 > Peripheral Vascular System & Lymphatic Assessment > Flashcards

Peripheral Vascular System & Lymphatic Assessment Flashcards

1
Q

Subjective Data
Health History Questions:

Leg pain or cramps
-how do you ask about it
-what is Claudication
Skin Changes on arms or legs
-what are varicose veins
Swelling in arms or legs
-What kind of swelling can happen and its types
Lymph node enlargement
Medications
-What drugs affect the system
A

Leg pain or cramps

  • PQRSTU
  • Claudication- pain produced by decreased blood flow during exercise (relieved by rest)
  • Claudication distance= the number of blocks walked OR stairs climbed that produces pain

Skin changes on arms or legs
-Varicose veins: dilated veins

Swelling in arms or legs

  • Edema:
  • *Bilateral from systemic problem
  • *Unilateral from local problem

Lymph node enlargement

Medications
-Oral contraceptives, hormone replacement, ASA

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2
Q

Objective Data

Inspect & palpate the Arms 6

Inspect & palpate the Legs 10

A

Inspect & palpate the Arms

  • Skin
  • Profile Sign
  • Capillary Refill
  • Symmetry
  • Pulses: Radial, Ulnar, Brachial
  • Epitrochlear Node

Inspect & palpate the Legs

  • Skin & hair
  • Varicosities
  • Symmetry
  • Temperature
  • Calf muscle
  • Inguinal lymph nodes
  • Pulses: femoral, popliteal, posterior tibial, dorsalis pedis
  • Edema
  • Colour changes
  • Strength, sensation, capillary refill
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3
Q

Objective Data: ARMS
What data should be looked for

  • Skin7
  • Profile Sign 1
  • Capillary Refill 1
  • Symmetry 2
  • Asymmetrical Arms means
  • Pulses: Radial, Ulnar, Brachial 5
  • Epitrochlear Node 3
A

Skin
-Colour, temperature, texture, turgor, Lesions, scars, edema

Profile Sign
-Normal: Nail bed angle of 160°

Capillary Refill
-Normal: colour return in 1-2 seconds

Symmetry
Arms symmetrical in size
-Asymmetrical Arms- Lymphedema

Pulses

  • Rate= 60-100 bpm
  • Rhythm= Regular? Irregular?
  • Force= 0-3+
  • Equality= equal?
  • Elasticity= stiff?

Epitrochlear Node

  • “Shake hands”
  • Normally NOT palpable
  • Enlarged:
  • *Infection of the hand or forearm
  • **General lymph infections
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4
Q

Objective Data: Lymph Nodes

How lymph nodes feel with:
-Acute infections
Chronic infection-
Cancer-

A

Acute infections- enlarged, warm, tender, firm but freely movable

Chronic infection- Clumped

Cancer- hard, unilateral, non-tender, & fixed

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5
Q

Objective Data: LEGS
What should be inspected for and what are the normals

Skin & Hair 7
Varicosities
Symmetry 3
Temperature 2
Calf muscle 2 
Inguinal lymph nodes 4
Pulses
-4 pulses and where they can be found
A

Skin & Hair
-Colour, hair distribution, venous pattern, size, Lesions, ulcers

Varicosities
-Inspect for with pt standing

Symmetry

  • Equal, no swelling or atrophy
  • If asymmetric: measure calf circumference (suspect DVT)
  • Normal: <1 cm difference

Temperature

  • Use dorsum of hands
  • Warm and equal bilateral

Calf muscle

  • Flex pt’s knee, gently compress gastrocnemius muscle against tibia
  • Homan’s Sign- Pain in calf when foot is sharply dorsiflexed (poor sensitivity)

Inguinal lymph nodes
-Normal: May find small (<1cm), movable, nontender, palpable nodes

Pulses (rated 0-3) [2 is normal]
-Femoral Pulse (by genitals)
-Popliteal Pulse
(try second manoeuvre and it might be impossible to find)
-Posterior Tibial Pulse
(Behind MEDIAL malleolus, Can try dorsiflexion)
-Dorsalis Pedis Pulse
(Lateral to extensor tendon of big toe)
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6
Q

Objective Data: LEGS
What should be inspected for and what are the normals
PART 2

Edema 2
-Describe Edema grading scale
Colour Change (Suspect ARTERIAL problem)
-2 tests and describe them, and their insufficiency's 
Strength, sensation, capillary refill
-normals
-CSWM

Doppler Ultrasonic Stethoscope

  • magnifies what
  • detects what Doppler Ultrasonic Stethoscope
  • magnifies what
  • detects what
A

Edema
-Press down for 5 seconds on medial malleolus or tibia then release
-Edema Grading Scale
1+: Mild pitting- slight indentation, no noticeable leg swelling
2+: Moderate pitting- indentation subsides rapidly
3+: Deep pitting- indentation remains for a short time, leg looks swollen
4+: Very deep pitting- indentation lasts a long time, leg is very swollen

Colour Change
Leg Elevation
-Raise legs 30 cm off table & ask pt to wag feet for 30 seconds
-Colour reflects only arterial contribution (should be pink)
-Elevational pallor= arterial insufficiency
Legs Dangling
-Have pt sit with legs dangling
-Colour return to feet= 10 seconds or less
-Time for superficial veins to fill= 15 seconds
-Dependent rubor= arterial insufficiency

Strength, sensation, capillary refill

  • Strength: Should be equal bilaterally
  • Sensation: As per neuro exam
  • Capillary refill: 1-2 seconds
  • CSWM: Colour, Sensation, Warmth, Movement

Doppler Ultrasonic Stethoscope

  • Magnifies pulsatile sounds from blood vessels
  • Used to detect weak peripheral pulses
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7
Q

Objective Data: LEGS
Additional Techniques

Doppler Ultrasonic Stethoscope
-magnifies what
-detects what 
Modified Allen test 2
-assesses for what
Manual Compression test 2 for varicosities
-determines what
Ankle-brachial index (ABI)
-determines what
-How to calculate
A

Doppler Ultrasonic Stethoscope

  • Magnifies pulsatile sounds from blood vessels
  • Used to detect weak peripheral pulses

Modified Allen test

  • to assess the adequacy of collateral circulation
  • Compress both ulnar/radial arteries, normally blood returns via ulnar artery after letting go

Manual Compression test for varicosities

  • to determine competency of the valves in varicose veins
  • compress vein and then feel for wave further down
  • wave/no wave felt = in/competent valves,

Ankle-brachial index (ABI)
-to determine the extent of peripheral vascular disease
-Ankle systolic pressure
/Arm systolic pressure

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8
Q

Developmental Considerations

Infants and children 3
Older adults 3
Pregnant women 5

A

Infants and children

  • Lymph nodes palpable even when healthy
  • Small, firm (shotty), mobile, & nontender
  • Lymphatic system well developed at birth and highly active until puberty

Older adults

  • Arteriosclerosis increases with age (increased BP)
  • Pedal pulses difficult to palpate
  • Calf veins enlarge (increased risk of Deep vein thrombosis)

Pregnant women

  • Hormonal changes= vasodilation (decreased BP)
  • Growing uterus obstructs drainage from inferior vena cava
  • Diffuse bilateral pitting edema
  • Varicose veins
  • Hemorrhoids
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9
Q

Abnormal Findings: Peripheral Vascular Disease (PVD)- ARMS

Raynaud’s Phenomenon-

  • What is it
  • SS
  • Triggers
  • Causes

Lymphedema-

  • what is it
  • SS
  • Causes
Chronic Arterial Insufficiency*
Chronic Venous Insufficiency*
Diabetic Ulcer
-Caused by
Varicose Veins
-What are they and what do they cause
Deep Vein Thrombosis (DVT)
-What is it
A

Raynaud’s Phenomenon- episodic spasm of small arteries in the hand
S&S: pallor/cyanosis/redness in hand; pain, numbness
Triggers: cold, stress, vibration
Causes: Smoking, medications

Lymphedema- swelling due to blocked drainage of lymph
S&S: Unilateral swelling, non-pitting edema
Causes: Removal or damage of lymph nodes with breast cancer treatment

Chronic Arterial Insufficiency*

Chronic Venous Insufficiency*

Diabetic Ulcer- caused by local infection and poor sensation

Varicose Veins- incompetent valves cause backup of blood & veins become dilated

Deep Vein Thrombosis (DVT)- a deep vein is occluded by a thrombus (clot)

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10
Q

Abnormal Findings: PVD- LEGS

Chronic Arterial Insufficiency / Chronic Venous Insufficiency

Factors

  • Location
  • Aggravation
  • Relieving
  • Signs
  • Ulcer areas
  • Ulcer characteristics
  • Ulcer name
A

Deep muscle pain in calf or foot / Aching pain in calf or lower leg

Claudication, elevation / Prolonged sitting/standing

Rest, dangling / Elevation, walking

Coolness, pallor, dependent rubor, trophic skin / Firm brawny edema, thickened skin, brown pigment (hemosiderin)

Toes, heels, lateral ankle / Medial malleolus

Pale, blackened base, well-defined edges, no bleeding / Bleeding, uneven edges

Arterial (Ischemic) Ulcer /Venous (Stasis) Ulcer

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11
Q

Promoting Health: Foot Care

Good foot care is: 4

A

Checking your feet every day
-red spots, sensitive areas, pain, cuts, swelling, blisters, toenails

Keeping the blood flowing to your feet

  • circulation (activity, walking, elevation, massage, foot exercises)
  • do not smoke

Wearing shoes that fit well and are comfortable

Keeping skin soft and smooth
-lotions, mild soap, excess moisture

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12
Q

Blood return tools

A

Sequential Compression Stockings (with machine)

Antiembolic Stockings (just stockings)

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Nurs 203 (15 decks)

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