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Assessment of Peripheral Vascular System

Maysa Al-Momani, RN, PhD

NUR 206 – Fall 2015

Chapter 12

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arteries

• Heart pump oxygenated blood through arteries• Contain muscle fibers = control amount of boold

delivered to tissue ( contract or dilate to control rate of blood flow )

• Pulse : pressure waves from heart beat that expand & recoil

• Arterial pulses are palpable in arteries lying close to the body surface

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Arteries and Veins

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Charach. of vessels

arteries veins Lymph

Strong, tough, tense to withstand Bp

Thin & large diameter , capacity up to two-thirds of circulating bld. flow

Elastic fiber stretch &recoil

highly distended

Expand & hold more bld

No valves valves valves

High BP system Low BP system

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.• Efficient venous return depends in

1- contraction skeletal muscles

2- competent valves in veins

3- patent lumen

*** any problem in any of these factors lead to venous stasis

Lymphatic System

• Extensive vascular network that drains lymph from body tissues and returns it to venous circulation

• Lymph nodes– Round, oval, or bean-shaped structures

– Vary in size according to location

• Important role in body’s immune system– Cells in lymph nodes engulf cellular debris/bacteria and

produce antibodies

• Only superficial lymph nodes accessible to physical examination

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Assessment of Peripheral Vascular System Subjective Data

I. Common or concerning symptoms•Leg/arms pain or cramp: Indicate PVD

•Intermittent claudication•Skin changes

– Such as Coolness, numbness, pallor in the legs, hair loss, leg ulcer, varicose vein.

•Swelling– Bilateral or unilateral edema in calves, legs, or feet

•Color change in fingertips or toes in cold weather•Lymph node enlargement

– Occurs in infectious, immunological, or malignant diseases.

– Swelling with redness or tenderness

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Health History: Subjective data (cont.)Leg pain or cramp •Any leg pain ? Where •Type of pain : burning, aching ,stabbing•Did pain comes gradually or suddenly •Aggravated by activity ,walking ?•How many block (stairs) does it take to produce pain

•Peripheral arterial disease (PAD)– Intermittent Claudication distance:

• Ask patients, “Have you ever had any pain or cramping in the legs when walking or with exercise?” “Does the pain get better with rest?”

• Pain worsen by elevation , with cool temperature

•Arterial spasm: fingers and toes– Ask patients, “Do your fingertips or toes ever change color in

cold weather or when you handle cold objects?”•Venous peripheral vascular disease

– Swelling of feet and legs• Ask about ulcers on lower legs, often near ankles

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Subjective data

•Edema is bilateral when caused by systemic problem such as heart failure

•and unilateral when to the result of local obstruction or inflammation

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Subjective data

• Lymph nodes enlargement• Any swollen gland (lumps), where in body, how long

have you had? • Any recent changes ?• How do they feel to you ,soft or hard• Are the swollen gland associated with pain or local

infection ?• *enlarged Lymph nodes occur with

infections ,malignancies,& immune disease

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• Inspecting the ARMS: from fingertips to the shoulders– Color of skin & nail beds– Texture of skin – Size, symmetry, & any swelling– Venous pattern

• Palpation the ARMS:– Radial, brachial pulses– To, texture, turgor of skin– Capillary refill (< 2 sec)– Palpating pulses: note their

• Rate, rhythm, elasticity of wall, and force (amplitude)• Grade the force on a 3-point scale as follow:

– 3+: bounding (may occur with hyperthyroidism, exercise, fever, anxiety)– 2+: Brisk, expected (Normal)– 1+: Diminished, weak/thready (may occur with shock, peripheral arterial Ds.)– 0 : Absent, unable to palpate

Assessment of Peripheral Vascular SystemObjective Data

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.- Palpate with the pads of your fingers:• Radial pulse: lateral flexor surface at wrist

• Ulnar: medial flexor surface • Brachial pulses: medial to biceps tendon

-Palpate the epitrochlear lymph node: in the groove between biceps & triceps muscle, 3 cm above

medial epicondyle: difficult/impossible to identify)

note its: Size, consistency & tenderness

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Radial pulse

Ulnar PulseEpitrochlear NodeFlexed elbow 90 degree

Brachial Pulse

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Objective DataAllen Test

• Determine the patency of radial & Ulnar arteries

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Objective DataModified Allen Test

• Evaluate the adequacy of collateral circulation before cannulating the radial artery– Firmly occlude both the radial & Ulnar arteries of

ONE hand while the patient makes a fist,• Hand color will blanch (pale)

– Ask the patient to open the hand, then release pressure on the ulnar artery WHILE Maintaining pressure on radial artery,

– Adequate circulation , hand’s color will return to normal within 3-5 seconds

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• Palpating the LEGS: fro the groin & buttocks to the feet– Color & Texture of skin, – Color of nail beds– Hair distribution, on lower legs, feet, toes– Size, symmetry and swelling

• if DVT or lymphedema measure calf circumference

– Venous pattern (flat no varicose vein)/venous enlargement

– Any pigmentation, rashes, scars or ulcer– Any lesions, scars, edema, discoloration, gangrene

Assessment of Peripheral Vascular SystemObjective Data

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.Palpating the LEGS–Temperature: with the back of your fingers-Texture, turgor of skin -Capillary refill

-TendernessFlex the knee & relaxed, palpate the calf.-Normally NO tenderness present

-Abnormal: If pain present with this maneuver +ve homan’s sign , it is: A sign for DVT:

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• Palpating the LEGS for:– Inguinal lymph nodes horizontal & vertical groupsNote: size, consistency, discreteness, & tenderness.– Normally: Nontender, discrete nodes up to 1-2 cm are palpable

– Palpate the following pulses:• Femoral: below inguinal ligament

• Popliteal: behind knee

• Posterior tibial: dorsum of foot; lateral to extensor tendon of big toe

• Dorsalis pedis: behind medial malleolus of ankle

Assessment of Peripheral Vascular SystemObjective Data

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Femoral

Dorsalis Pedis

Popliteal

Posterior Tibial

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.Peripheral Veins:–Look for edema: compare size& prominence of veins, tendons & bones–Check for pitting edema: press firmly with your thumb for 5 seconds, over the dorsum, behind medial malleolus & over the shins of each foot .–Pitting edema

• Grade edema on this scale– 1+: Mild pitting, slight indentation, no perceptible swelling of

the leg– 2+: Moderate pitting, indentation subsides rapidly– 3+: Deep pitting, indentation remains for a short time, leg

looks swollen– 4+: Very deep pitting, indentation last a long time, leg is

very swollen• May be graded by measuring the depth of pitting in centimeters,

or by weight change, or the time pitting remains after releasing the pressure

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Assessment of Peripheral Vascular SystemObjective Data

Postural color changes of chronic arterial insufficiency:

-if pain or diminished pulsesInspect postural color changes-raise both legs 60 degree until pallor of the feet develops

for 1 min.-then ask pt. to sit up with dangling legs: normally the

pink color return within 10 sec. or less.-filling of veins of feet & ankles normally about 15 sec.

-Abnormal: rubor (dusky redness) take a min. or more

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Assessment of Peripheral Vascular SystemObjective Data

• Color Change:– If you suspect arterial deficiency

– Normally color return within 10 sec

– Veins refill within 15 sec

30 cm

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Mapping varicose veins : by transmitting pressure waves along the blood-filled veins.

• Pt. standing place palpating fingers on a vein & on with other hand below it compress the vein sharply.

• feel for a pressure wave transmitted to the fingers of your upper hand

• a palpable pressure wave indicates that the two parts of the vein are connected (incompetent valves).

Assessment of Peripheral Vascular SystemObjective Data

15-20 cm

Feel for a pressure wave

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• Evaluating the competency of venous valves: By

Retrograde filling (Trendelenburg) test: to test valve competency in communicating veins & the saphenous system.

– Pt. in supine position elevate one leg 90 deg. To empty venous blood.

– by manual compression occlude the saphenous vein in the upper thigh

– then ask the pt. to stand, watch for venous filling in the leg while vein occluded:

Assessment of Peripheral Vascular SystemObjective Data

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Take off the tourniquet after 20 sec

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Evaluating the competency of venous valves

-Normally the saphenous vein fills from below in 35 sec.

-rapid filling indicates incompetent valves– after 20 sec, release the compression, look for:

• Sudden additional filling of superficial veins indicate Incompetent Valves in the saphenous vein

*if both steps are normal the response is termed negative-negative

• If both are abnormal, the test is positive-positive• Negative-positive & positive-negative may also occur

• Normally slow venous filling

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Assessment of Peripheral Vascular SystemObjective Data

• Doppler Ultrasonic Stethoscope– To detect weak thready pulse – Apply light pressure, place the device 45 degree angle,

use gel

• Ankle-Brachial Index (ABI): screening for PAD– Is a noninvasive way to determine the extent of

peripheral arterial disease.– Take ankle systolic BP and divide it by the brachial

systolic BP– Normal ABI is 0.90 to 1.30

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Ankle-Brachial Index (ABI):

– An ABI

• ABI 0.90-1.30: normal

• ABI 0.41-.90: mild to moderate disease

• ABI 0.00-0.40: severe disease with critical stenosis

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Chronic insufficiency of arteries & veins

Chronic arterial insuff. Chronic venous insuff.

Pain Inter. Claudication, progressing to pain at rest

Often painfull

Mechanism Tissue ischemia Venous hypertension

Pulses Decreased or absent Normal

Color Pale in elevation, dusky red on dependency

Normal or cyanotic on dependency.

Edema Absent or mild Present

Skin changes Trophic changes: thin, shiny, atrophic skin; loss of hair over foot & toes, thick nails

Brown pigmentation around the ankle, thickening of the skin, scar develops

Gangrene May develop Does not develop

Temp. cool normal

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Chronic Arterial Insufficiency with

Ulcers arterial insufficiency

Chronic Venous Insufficiency with Ulceration

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Peripheral vascular Disease

• As a result of arteriospasm– Pallor (white)– Cyanosis– Red (ruby)

• As a result of removal of lymph nodes with breast surgery, or damage due to radiation– Impede drainage of lymph– Lymph (rich in protein)

builds up in interstitial space.

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Peripheral vascular Disease

Arterial Insufficiency•Deep muscle pain in calf, claudication

•Coolness, pallor, elevation pallor, diminished pulses

Venous Insufficiency•Aching pain in calf or lower leg, worse at end of day, worse with prolonged standing or sitting

•Brown pigmentation, edema, thick skin, normal pulses

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Peripheral vascular Disease

• Aching, heaviness in calf, night foot cramp

• Dilated tortuous veins

• Sudden onset of intense, sharp, deep muscle pain, may increase with dorsiflexion

• Warm, swelling, redness, tender,

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The Doppler ultrasonic stethoscope

Used • To detect a weak peripheral pulse • To monitor BP in infants & children • To measure a low BP or BP in lower extremities• It is magnifies pulsatile sound from heart & bld vessels Steps 1- Pt in supine position with leg extremely rotated 2- place a drop of gel on transducer 3-Put transducer over pulse site ,swiveled at 45 degree angle 4-Apply very light pressure ,locate pulse by swishing

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• Doppler system

Doppler system

Doppler Ultrasound Stethoscope

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Diagnostic procedure

Arteriography: Is a technique by which dye (radiopaque contrast

material) is injected into vessels (arteries), permitting visualization of the vascular system. To locate and assess narrowing, occlusions, and other abnormalities of various arteries, especially the femoral arteries of the legs; the carotid arteries in the neck; and the arterial systems of the brain, heart, and kidneys

The information gained is used to formulate a treatment plan and assist in determining options. This is a test, administered by a physician, used to assess very accurately blockages and other abnormalities of the arteries.