PT Exam and Interventions of the Vascular System Flashcards
what is peripheral arterial disease (PAD)?
plaque buildup in arteries (atherosclerosis)
systemic-affects all arteries
if someone has PAD, it is likely they also have what?
coronary artery disease (CAD)
t/f: ischemic stroke can be caused by plaque buildup from atherosclerosis
true
what are the VTEs?
DVT and PE
what are the types of peripheral vascular disease?
peripheral arterial disease (PAD)
venous insufficiency
what is a clot that has not dislodged?
a thrombus
what is a clot that has dislodged?
an emboli
what is a VTE?
the formation of a blood clot in a vein
what are the risk factors for VTE formation?
Virchow’s triad
what is Virchow’s triad?
1) vascular stasis
2) endothelial injury
3) hyper-coagulability
cause a coagulation cascade
what may cause venous stasis?
immobility
what can cause endothelial injury?
surgery
what is the main concern of a DVT?
it turning into a PE
what is PTS (post thrombotic syndrome)?
permanent damage to valves in veins; blood reflux
what are the complications of DVT
PE
post thrombotic syndrome (PTS)
chronic symptoms: aching, pain, edema, limb heaviness, leg ulcers
long term outcomes: impaired fxnal mobility, poor QOL, increased healthcare cost
what are the chronic symptoms of DVT?
aching, pain, edema, limb heaviness, leg ulcers
what are the long term outcomes of DVT?
impaired fxnal mobility, poor QOL, increased healthcare cost
what are the complications of PE?
death
chronic thromboembolic pulmonary HTN (CTPH)
what are the PT responsibilites for VTEs?
prevent VTE
assess for VTE
discuss safe initiation of mobility w/VTE
educate pts
prevent long term consequences
to prevent VTEs, PTs should advocate for what in all practice settings?
a culture of mobility and physical activity
why is it so difficult to practice advocate for a culture of mobility?
bc we don’t know who’s responsibility it is since we don’t get paid for it
t/f: when a pt is high risk for VTE, we should provide preventative measures, including education on the s/s of VTE, activity, exercise, hydration, mechanical compression, and referral for medical treatment
true
what should PTs promote for pts at risk for VTE?
LE exercises, ambulation, hydration, mechanical compression, medical referral
how do we assess risk for DVT?
during the initial interview and physical exam, assess risk of DVT in pts with reduced mobility
Padva prediction score
according to the Padva prediction score, what are the most items with the highest risk for DVT?
active CA (CA within the last 6 months)
prior VTE
reduced mobility
thrombophilia condition
what conditions increase risk for DVT?
CA
inherited protein diseases
COVID-19
what predicts the presence of DVT?
when a pts presents with pain , tenderness, swelling, warmth, and/or discoloration in the LE, establish the likelihood of a LE DVT
use the Wells criteria for presence of DVT
what is the lab blood test used for ruling out a DVT?
D-Dimer
t/f: if a D-Dimer is positive, the pt has a DVT
false, it doesn’t have good specificity to rule it in
if the PT observes s/s of DVT or suspects DVT, what should they do?
perform Well’s test to determine likelihood and communicate results to medical team for further action
if a PT observes s/s of DVT or suspects DVT, they perform Well’s test to determine likelihood and communicate results to medical team for further action and it is <2 (DVT unlikely), what do we do?
D-Dimer
if a PT observes s/s of DVT or suspects DVT, they perform Well’s test to determine likelihood and communicate results to medical team for further action and it is >2 (DVT likely), what do we do?
further medical dx testing
if we do a D-Dimer, and it is negative, what do we do?
encourage mobility and physical activity in addition to any additional preventative measures
if we do a D-Dimer and it is positive what do we do?
further medical dx testing
bc there are lots of false positives
if we do a D-Dimer and it’s positive, so we do a further testing and it is negative for DVT, what do we do?
encourage mobility and physical activity in addition to any additional preventative measures
if we do a D-Dimer and it is negative, what do we do?
encourage mobility and physical activity in addition to any additional preventative measures
if we do a D-Dimer and it is positive, so we do further medical dx testing and it is positive for DVT, what do we do?
consider medical interventions based on the location and person’s current medical status
what is the gold standard test for diagnosing DVT?
US Dopler
t/f: when a pt presents w/dyspnea, chest pain, presyncope/syncope, and/or hemoptysis, evaluate the likelihood of PE and take appropriate action based on results
true
what is the test for PE?
revised Geneva clinical predication rule for PE
t/f: when a pt w/a recently diagnosed LE DVT reaches the therapeutic threshold of anticoagulant med, physical therapist should mobilize the pt
true
why is being immobile post VTE dangerous?
bc it puts them at risk for more DVTs from not moving
what are the types of medication that affect mobilization?
LMWH
Fondaparinux
UFH
DOACs
if a pt is on a preventative dose of LMWH, what should we do?
wait for a higher dose to be given
if a pt is on a new dose LMWH, what should we do?
wait for initial dose to be given
if a higher dose LMWH was given 2 hours ago, should we mobilize the pt?
no
if a higher dose of LWMH is given 4 hours ago, should we mobilize the pt?
check with the medical team first
if a higher dose LMWH was given 6 hours ago, should we mobilize the pt?
yes
if LMWH was given <3 hours ago, what should we do?
wait to mobilize
if LMWH was given 3-5 hours ago, what should we do?
check with the medical team
if LMWH was given >5 hours ago, what should we do?
mobilize them
if Fondaparinux was given <2 hours ago, what should we do?
don’t mobilize the pt
if Fondaparinux was given 2-3 hours ago, what should we do?
check with the medical team
if Fondaparinux was given >3 hours ago, what should we do?
mobilize the pt
if UFH was given <24 hours ago, what should we do?
don’t mobilize them
if UFH was given >24 hours ago, what should we do?
check with the medical team and/or check the aPTT is bw 1.5-2.5x the control value
if a DOAC was given <2 hours ago, what should we do?
don’t mobilize the pt
if a DOAC was given 2-3 hours ago, what should we do?
check w/medical team
if a DOAC was given >3 hours ago, what should we do?
mobilize
what kind of drug is Lovenox (enoxaparin)?
LMWH (low molecular weight heparin)
how is LMWH given?
subQ injection
when is the peak levels of LMWH?
3-5 hours
t/f: LMWH is often given prophylactically to prevent DVT
true
what kind of drug is Arixtra?
Fondaparinux
how is Fondaparinux given?
subQ injection
what are the peak levels of Fondaparinux?
2-3 hours
how is prophylactic UFH given?
subQ injection
how is treatment UFH given?
IV infusion
when are the peak levels of UFH?
> 24 hours
what do we need to monitor with UFH?
aPTT levels
what levels should aPTT be?
1.5-2.5x the control value
if UFH is overdosed and supratherapeutic what is the risk?
spontaneous bleeding
what kind of drugs is Xarelto (rivaroxaban) and Eliquis (apixaban)?
direct acting oral anticoagulants (DOACs)
when is the peak levels of DOAC?
2-3 hours
what is the international normalized ratio (INR)?
measures of prothrombin test time (PT)
monitors Coumadin (warfarin) levels
what is the reference range for INR?
.8-1.1
what is the critical value for INR?
> 5.5
what is the risk of INR >5.5?
spontaneous bleeding
what is the therapeutic range for INR for DVT prophylaxis?
1.5-2.0
what is the therapeutic range for INR for hx of TIA or CVA?
2.5-3.5
what is the therapeutic range for INR for PE?
2.5-3.5
what is the therapeutic range for DVT, a-fib, mechanical heart valve, orthopedic surgery?
2-3 hours
when a pt is on Coumadin, why are they usually given a heparin drip too?
bc it takes a few days to work
do we typically look at Coumadin and INR when mobilizing pts?
nope
when a pt w/a non-massive, low risk PE reaches therapeutic threshold of anticoagulant medication, should we mobilize the pts?
yup!
UE DVT is associated with what?
cancer and use of indwelling central venous catheters
what are the s/s of UE DVT?
swelling, pain, edema, cyanosis, dilation of superficial veins (similar to LE DVT)
t/f: there is risk for PE with UE DVTs
true
if a pt presents with s/s of an UE DVT, what should we do?
use clinical tools to assess likelihood of DVT
if UE DVT is confirmed, when can we begin UE activities?
when therapeutic anticoagulation is achieved (use the same decision tree as LE DVT)
what does a PICC line put someone at risk for?
UE DVT
what population is a common group to see UE DVTs in?
cancer pts bc of PICC line use for treatments
what is an IVC filter?
an inferior vena cava filter placed in the inferior vena cava to catch clots b4 they can reach the lungs and cause a PE
who are IVC filters used for?
those who can’t be anticoagulated
when can we mobilize a pt after they have an IVC filter placed?
once hemodynamically stable and no bleeding at the puncture site
what should we do for a pt w/DVT below the knee who aren’t anticoagulated and don’t have an IVC filter?
discuss the risk vs benefit of mobility w/the pt and medical team
what population will often not be anticoagulated or have an IVC filter placed when there is a DVT?
oncology pts
when we have a pt w/DVT below the knee who aren’t anticoagulated and don’t have an IVC filter, what is usually the ultimate decision made?
to still mobilize them
when is compression recommended?
when a person is high-risk of VTE to prevent a DVT
when symptoms of PTS, esp pain and swelling, are present
t/f: compression helps prevent PTS
false, we don’t really know if it does or not
t/f: there is good evidence that mechanical compression can prevent DVTs
true
what characteristics of arterial insufficiency can we gain from the pt interview?
intermittent claudication
pain with elevation
relief of pain with dependency
what is the intermittent claudication pain seen in arterial insufficiency?
LE pain w/exertion
reproducible (after a predictable distance or effort every time)
why is there pain with elevation in arterial insufficiency?
bc it makes it harder to push blood through the arteries to get to the end of the extremity
ischemic pain
what are the signs of arterial insufficiency?
cool skin
pale skin
shiny skin
dry skin
absent hair
brittle nails
what does capillary refill assess?
peripheral arterial flow
what is the technique for capillary refill?
compress the nail bed or finger pad
release when it turns white
time how long it takes to return to normal
what is a positive result from capillary refill test?
when it takes >2 seconds
what may a positive capillary refill test indicate?
PVD, shock, hypothermia, cool ambient temperature
older age
dehydration
what are the peripheral pulses?
brachial
radial
carotid
femoral
popliteal
posterior tibialis
dorsalis pedis
when we palpate peripheral pulses, what are we feeling for?
rate, rhythm (regular, regularly irregular, irregularly irregular), quality (absent, weak, normal, bounding)
B/L coolness and diminished pulses may indicate what?
a more global effect (cold environment, anxiety, etc)
where do we palpate the brachial artery?
medial antecubital fossa
UE supported w/elbow slightly flexed
where do we palpate the radial artery?
distal radius at the base of the thumb
where do we palpate the carotid artery?
bw the trachea and the medial border of the SCM
where do we palpate the femoral artery?
midpoint bw the ASIS and pubic symphysis in supine
where do we palpate the popliteal artery?
inferior popliteal fossa
deep
supine/prone with knee in relaxed flexed position
use 2 hands
where do we palpate the posterior tibialis artery?
posterior to the medial malleolus
where do we palpate the dorsalis pedis?
dorsal, medial aspect of the foot
lateral to the hallux extensor tendon
ankle slightly DFed
which pulse is congenitally absent in some individuals?
dorsalis pedis
what characteristics of venous insufficiency can be gained from the pt interview?
pain with dependency
pain relief with elevation
edema
venous insufficiency is typically caused by what?
failure of the valves in the veins
why is there pain with dependency in venous insufficiency?
bc it causes blood pooling and edema that leads to pain
what are the signs of venous insufficiency?
edema
scaling skin
hardened skin
skin discoloration (ruddy and hemosiderin staining)
visible superficial veins
what is the exercise intervention for arterial insufficiency?
supervised exercise programs that induce claudication pain
what do supervised exercise programs do for arterial insufficiency?
they increase QOL and fxnal status for people with intermittent claudication
what is the current main intervention for arterial insufficiency?
surgical intervention
what is the strongest recommendation for intervention for arterial insufficiency?
supervised exercise program
supervised exercise programs for arterial insufficiency are preferred in what settings?
hospital/outpatient settings but can be home based
why don’t people with arterial insufficiency like supervised exercise programs?
bc it involved inducing their pain
what is the frequency, intensity, timing, and type of exercise for supervised exercise programs for arterial insufficiency?
mod to max claudication pain 2-5x for 30-45 minutes at least 3x/week
walking, interval training
what is the gold standard for walking in the supervised exercise program for arterial insufficiency?
treadmill walking
what is a 0 claudication pain?
no claudication pain
what is a 1 claudication pain?
initial minimal pain
what is a 2 claudication pain?
moderate, bothersome pain
what is a 3 claudication pain?
intense pain
what is a 4 claudication pain?
max pain, can’t continue
what is the range for claudication pain we want to induce with supervised exercise programs for arterial insufficiency?
2-3 pain (moderate to intense)
what causes arterial insufficiency?
atherosclerosis
what are the considerations for post-op revascularization?
check for bed rest or WB precautions
check for BP goals (many with have hypertensive responses)
monitor BP
pain (make sure they have adequate pain control)
signs of SC ischemia if the aorta is involved
what are red flags for SC ischemia post-op revascularization?
decreased LE and saddle sensation
decreased mobility of the LEs
what are the interventions for venous insufficiency?
muscles activation to pump blood back to the heart
compression wraps
why is chart review and physical exam so important when it comes to using compression wraps?
bc they indicated for venous insufficiency but contraindicated for HF, both of which can present with edema
