wk 2- vascular assessment Flashcards
populations for CVD. who is at a higher risk?
-CVD is leading cause of illness and death in women in australia
-indigenous peoples are twice as likely to have CVD compared to non indigenous
What are the behavioural risk factors for CVD 4
smoking
poor diet
sedentary
alchohol consumption
what are the biomedical risk factors for CVD 4
high blood pressure
abnormal blood lipids
diabetes
overweight and obesity
what are the vessels of the vascular system 5
Arteries
Arterioles
Capillaries
Venules
Veins
arteries are
large and medium sized vessels that transport oxygenated blood to the tissues and organs
the 3 layers of arteries
Tunica Intima- inner layer, direct contact with blood
tunica media- thickest layer- controls vasodilation/constriction
tunica externa- outer layer
how are veins different to arteries (4)
thinner than arteries
carry deoxygenated blood back to the heart
lower pressure system
contain valves to prevent backflow of blood
how does the venous system get pumed back to the pulmonary system
through valves opening and closing and contracted skeletal muscle pushing the deoxygenated blood back up
when are instances that pressure within the capillaries changes? (2)
-lying, sitting and standing
-temperature changes
what system controls the vascular response
autonomic system
what is the lymphatic system
Where circulatory system meets the immune
system
* Not a closed system
* No pump so movement is slow
* A network of lymphatic vessels that move
lymph toward heart
* Lymph is derived from
interstitial fluid also contains
immune cells
-helps return plasma
FINAL EXAM - arteries of the lower limb!
aorta down to the peripheral arteries. anterior and posterior aspect. and what compartments/muscles they supply
cutaneous blood flow is important for what
identifying location of pain can indicate the true anatomical regions by cutaneous blood supply
FINAL EXAM- veins of the lower limb
overview of the veins draining the lower limb
Final Exam- lymphatics of the lower limb
!
anatomical variation in the foot for arteries and its %
- Absent or very thin posterior tibial artery – 6.35%
- Absent or very thin anterior tibial artery – 5.27%
- Absent or very thin peroneal artery – 2.8-3.8%
- Absent dorsalis pedis – 12%
two components to vascular assessment
-general assessment (subjective)
-peripheral assessment (objective)
general assessment includes (5) and give examples/ risk factors for these categories
-past history: surgery, myocardial infarctions (and age when- secondary question), cerebrovascular accidents, transient ischemic attacks
-current medication: antihypertensive, hyperlipidemia meds, anticoagulants
-symptoms: angina, breathlessness, lassitude, pallor
-observation: BMI, oedema, spoon shaped nails, smoking stains, fatty deposits in the skin, lack of circulation
-clinical tests: bp, hr, ecg, x rays, blood test
peripheral vascular disease can be what? 3
-arterial disease
-venous incompetence
-oedema (primary or secondary)
peripheral assessment includes what structures 3
-arterial
-venous
-lymphatic
principles of the peripheral assessment
anatomy
medical history
symptoms
observations
clinical tests
risk factors for peripheral vascular disease with patient history
family history
age
hypertension
dyslipidaemia
smoker
obesity
diabetes
medications- NSAIDS (heart attack risk), oral contaceptive (blood clots), CVD medications
signs and symtpoms- pain, cramping, oedema, numbness, etc
risk factors for peripheral vascular disease for social history (behavioural)
smoking
alcohol
psychosocial
socioeconomic
diet
weight
exercise
3 major signs of patient history (symptoms) to indicate peripheral arterial disease
- intermittent claudication: pain on exertion (particular distance or time)
-rest pain: usually in calves at rest and eased by standing
-non-healing lesions
patient examination for peripheral assessment (2) and examples underneath these categories
- Visual Inspection
Skin appearance
Hair growth
Nail quality
Colour
oedema
muscle bulk - Physical examination
Temperature gradient - perfusion
Pulse palpation
Doppler assessments (rate, amplitude, phasic, shape, pressures)
4 areas/ things to exam for the venous system
- varicose veins: locations and severeity
- oedema
- haemosiderin deposits
- telangiectasia
history and examination for venous issues
- Varicose pain
- Busting pain
- Aching
- Oedema
- Alleviated by elevation
- Night cramps relieved by getting up
- Unilateral* Peripheral cause
- Symmetrical §Systemic cause
what causes nighttime cramps
syptom of venous disease
blood in veins is high in waste products which can leak out to surrounding tissues causing painful muscle cramping and contractions
CEAP - seven clinical classes of chronic venous disorders. physical examination for veins
chronic venous disorders can be divided into seven clinical classes C0 to
C6 with specific signs:
C0: No visible or palpable signs of venous disease
C1: Telangiectasis (spider veins) or reticular veins
C2: Varicose veins
C3: Edema
C4: Skin changes (pigmentation, eczema, induration)
C5: Healed venous ulcer
C6: Active venous ulcer
clinical assessment of oedema (4)
- Press firmly with your thumb or index finger for at least 2 seconds on each extremity
1.Over the dorsum of the foot
2.Behind the medial malleolus
3.Lower calf above the medial malleolus
4.Record indention recovery time in seconds
scoring system is based off the mm of indention
risk factors for impaired venous return (8)
Age
* Family history
* Female gender
* History of DVT in legs
* Obesity
* Pregnancy
* Sitting or standing long
periods
* Tall height
symptoms of impaired venous return (6)
- Dull aching, heaviness,
cramping, pain, warmth - Itching and Swelling
- Redness of ankles & legs
- Haemosiderin desposits
- Varicose veins
- Ulcers and impaired healing
at the ankles or legs
venous insufficiency and compression therapy key things to remember
Compression therapy can be very helpful for those with venous
insufficiency – you MUST check the ABPI BEFORE making this
recommendation!
It must be above 0.8 for safe recommendation of compression
what is deep vein thrombosis
Blood clot in the deep veins
Most commonly in thigh or calf
Medical emergency
risk factors for deep vein thrombosis (7)
Risk factors:
* Prolonged bed rest
* Inactivity (travel)
* Major surgery
* Injury (fracture)
* Illness
* Oral contraceptive pill
* Pregnancy or recently
post-partum
symptoms and complications for deep vein thrombosis (DVT)
Symptoms
* None
* Dull aching, heaviness, cramping,
pain, warmth
* Swelling
* Shortness of breath
* dizziness
Complications
* Pulmonary embolism (clot
breaks off, lodges in the lung)
* Valve damage
* Vessel damage
* Long term oedema
why is DVT more common on the left side?
iliac artery sits around and puts pressure on the left
examples of DVT differential diagnosis (6)
*Phlebitis
*Cellulitis
*Acute ischaemia
*Baker’s cyst rupture
*Muscle tears
*Tendon, tears, partial rupture
transport through the lymphatic system is done by?
Lymphatic system has no central pump
* Lymph transportation influenced by
–Pressure of tissue fluids
–Valves of lymphatic vessels
–Contraction of smooth muscle in lymphatic
vessel walls
–Pressure on vessels from surrounding
skeletal muscles
–Pulsations of adjacent arteries
–Auxiliary respiratory pump
what are the main lymph nodes and ducts for podaitrists
- Popliteal nodes – drain
lower leg and knee - Inguinal nodes – drain legs,
external genitalia, lower
abdominal wall
what is venous hypertension
superficial or deep will increase the intra-luminal hydrostatic pressure at the venous end so it resists the colloid osmotic pressure and reduces the ability of pulling fluid back into the capillaries
this causes oedema
what is the stemmers sign?
lymphoedema, inability to pinch the skin of the proximal phalanx of the second or third toe
what is lymphoedema
Interstitial oedema of the extremities
due to a failure of the Lymphatic
System
Protein rich fluid – this attracts more
fluid
Fibroblast proliferation, thickening of
tissues
begins off as soft swelling, develops into firmer condition. induced risk of bacterial infection due to increased levels of protein
treatment of lymphoedema
Compression (minimum 30mmHg)
*Elevation
*Exercise
*Lose weight
*Pneumatic night pumps
*Surgery
what is PAD
poor blood(arterial) circulation to the lower leg and foot
* Generally due to atherosclerosis
what should you look for in patient history (medical history and symptoms) to raise suspicion of PAD (7)
Medical history
* MI
* CVA’s (Stroke)
* TIA’s
* Coronary or Femoral-Popliteal Bypass
* Medications
Symptoms
* Pain- site, duration, cramps, rest pain, etc
-disease in the aortoiliac vessels causes butt/thigh symptoms
-disease in femoral/popliteal regions will give calf pain
-Ischaemic pain may be lacking due to diabetic neuropathy
differential diagnosis for PAD 7
- Arthropathy
- Spinal stenosis (pseudoclaudication) * Diabetic neuropathy
- Deep vein thrombosis
- Venous claudication
- Buerger’s disease
- Compartment syndrome
the 4 categories of PAD
asymptomatic
claudication
critical limb ischemia
acute limb ischemia
when should adults without known history of CVD have an assessment?
all adults aged 45+
aboriginal and torres strait islander people ages 35+
the 6 P’s to the acute limb ischaemia pathway
- Pulseless
- Pain (constant, exacerbated by movement)
- Pallor – cyanotic blotches (non-blanching – caplillary bed thrombosis)
- Parathesia – 1-3 hours after onset (sensory nerve ischaemia – loss of light touch)
- Paralysis – motor nerve damage (6 hours) – without collateral flow – loss of toe and ankle
- Perishing cold (Poikiothermia) – ambient room temperature
- “waterhammer” pulse – above the stenosis
interpretting different colours
white, blue, blue with central cyanosis, hazy blue. red, brown , black
white- White. Pale (pallor)
Cold (to conserve heat), anaemia, chillblains, raynaud’s phenomenon, cardiac failure, insufficient arterial supply, occlusion (precursor to gangrene)
Blue (peripheral)
(deoxygenation) Cold, chillblains, raynauds phenomenon, venous status
Blue with central cyanosis
Cardiac, respiratory failure
Hazy blue
Infection, necrosis, bruising
Red
Heat, exercise, extreme cold (cold-induced vasodilation), inflammation, infection (cellulitis), chillblains, raynaud’s phenomenon. Dusky red (severe vascular deficiency)
Brown
Haemosiderin deposits, necrosis, melanoma, gangrene
black
bruising, nercosis, melanoma, gangrene
clinical assessments include what for vascular system (7)
- Pulses (macrovascular)
- Capillary refill time / Sub-capillary venous plexus filling time (SVPFT)
- Elevation dependency test (Buerger’s test)
- Perfusion (temperature)
- Doppler waveform
- Systolic pressures
- Segmental pressures
ØAnkle brachial index (ABI)
ØToe pressure index (TPI)
minimal vascular assessment includes 7 things
- history of modifiable and non modifiable risk factors
- palpation of foot pulses
- skin, temp
4 intermittent claudication and ischaemic rest pain indentified - differential diagnosis of common leg symptoms
- identification of arterial ulceration/severity
- identify venous disease, oedema, lympheodema
where can u pulse palpate?
Dorsalis pedis (Absent in approximately 12% of
population)
Anterior tibial
Posterior tibial (Absent in approximately 2%)
Popliteal
Femoral
how do you report results from pulses
Pulses
Grading (0-4) (Merriman et.al.) 0 = no pulse
1 = feeble pulse
2 = normal pulse
3 = bounding pulse
4 = aneurysmal (rare below popliteal artery)
Rhythm Regular
Irregular
Rate (beats per minute)
< 1 year old (100-120 bpm) Adult (65-80 bpm)
Athlete (<50 bpm)
capillary refill time Sub-capillary venous plexus filling time (SVPFT) clinical assessment
- Raise digit to heart level
- Milk venous blood
- Press hard for several seconds
- Release and record time for colour to return
- <3-5 seconds (adequate)
- > 5 seconds (delayed)
- > 10 seconds (significant disease)
perfusion clinical assessment
The temperature gradient of the skin is checked using the back of the hands and gently moving them from the pre-tibial region of the leg distally over the dorsum of the foot to the toes while keeping in contact with the person’s skin. An asymmetric gradient may indicate either unilateral ischaemia on the colder side or unilateral inflammatory response such as Charcot osteoarthropathy or infection on the warmer side.
what is Raynaud’s phenomenon
a hyperactivation of the sympathetic nervous system causing extreme vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia. it is common in a range of auto immune diseases.
the elevation dependency test (buergers test)
- Elevate the leg to 60 degrees and hold for 1 minute
- Record the time to pallor of the sole of the foot
- Grading
Ø 0 = no/mild pallor in 60 seconds Ø 1 = definite pallor in 60 seconds Ø 2 = pallor <60 seconds
Ø 3 = pallor <30 seconds
Ø 4 = pallor at rest - Dependency
Ø Record time for foot to return to normal colour after lowering the limb
§ 10-15 seconds = adequate
§ 15-25 seconds = inadequate supply § 40+ seconds = severe ischemia
doppler ultrasound clinical assessment
Pulse examination
Audible pulse waveform which reflects the character and velocity of
the pulse
In normal vasoconstricted state, normal arterial pulses forms 3 clear sounds
Triphasic response
First sound is the loudest and of a higher pitch – ventricular bolus from
the heart
The second and third sounds are the diastolic sounds due to the reversal of flow caused by the elastic distension in the arteries and final forward flow as the arteries rebound
Loss of reverse flow or dampening of waveform can indicate disease u Frequency and amplitude
