Week 6 - Peripheral Perfusion

Question 1

How does the nurse perform an assessment of the PVS? (2)

Answer 1

• inspecting and palpating the patient’s arms and legs
• informs the nurse about the person’s peripheral perfusion, or the body’s ability to circulate blood to and from the extremities

Question 2

Arteries of the arm diagram

Answer 2

Question 3

Arteries in the leg diagram

Answer 3

Question 4

Veins in the legs diagram

Answer 4

Question 5

What is subjective data to assess in the PVS? (5)

Answer 5

1. Leg pain or cramps
2. Skin changes on arms or legs related to PVD
3. Swelling in arms or legs relating to PVD
4. Lymph node enlargement - swollen glands
5. Medications

Question 6

How should you assess leg pain/cramps related to PVS? (3)

Answer 6

• OPQRSTUV to assess leg pain r/t Peripheral vascular disease
• is it aggravated by activity, walking?
• is it burning, aching, cramping, stabbing?

Question 7

How should you assess skin changes on arms or legs related to PVS? (4)

Answer 7

• colour change to an extremity
• enlarged veins
• ulcers
• change in temp

Question 8

How should you assess swelling in arms/legs related to PVS? (3)

Answer 8

• feel that swell after patient has been sitting all day
• ask what triggers it
• what relieves the swelling? (elevation? TED stockings?)

Question 9

What other objective data can you assess in the PVS? (4)

Answer 9

1. Palpate/compare the colour, warmth, sensation, movement of arms and legs (CWSM)
2. Assess capillary refill of fingers and toes
3. Palpate pulses
4. Colour changes

Question 10

How should you assess CWSM of arms and legs? (4)

Answer 10

Colour - widespread colour changes or colour changes to extremities
Warmth - warm to touch? (use back of hand)
Sensation - Can they feel you touching their body?
Movement - Is the patient able to move their arms and legs on both sides?

Question 11

How do you assess cap refill of fingers and toes? (4)

Answer 11

• depress the nail edge to cause blanching, and then release
• note the return of colour: Brisk vs sluggish
  Brisk: <3-5 sec
  Sluggish: >3-5 sec

Question 12

How do you palpate pulses (review)? (3)

Answer 12

• tip of 1-2 fingers (not thumb)
• feel for rate (bpm) + strength
• bilaterally equal

Question 13

Pulse landmarks + assessment notes diagram

Answer 13

Question 14

How should you assess colour changes in PVS? (4)

Answer 14

suspected arterial deficit:
1. lift the patient’s leg above the table and ask the patient to move their feet
2. hold for 30 sec to drain venous blood
3. have patient sit up with legs over bed
4. assess how long for colour to return (normal is <10 sec)