Assessment of Peripheral Vascular
System
Maysa Al-Momani, RN, PhD
NUR 206 – Fall 2015
Chapter 12
1
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
2
Arteries and Veins
3
4
Charach. of vessels
arteries
veins
Lymph
Strong, tough, tense to Thin & large diameter
withstand Bp
, capacity up to twothirds of circulating
bld. flow
Elastic fiber stretch
&recoil
highly distended
Expand & hold more
bld
No valves
valves
High BP system
Low BP system
valves
5
.
• 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
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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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Assessment of Peripheral Vascular System
Objective Data
• 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
o
T , 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
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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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Brachial Pulse
Radial pulse
Epitrochlear Node
Flexed elbow 90 degree
Ulnar Pulse
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Objective Data
Allen Test
• Determine the patency of radial & Ulnar arteries
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Objective Data
Modified 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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Assessment of Peripheral Vascular System
Objective Data
• 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
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Palpating the LEGS
–Temperature: with the
.
back of your fingers
- Texture, turgor of skin
- Capillary refill
-Tenderness
Flex 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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Assessment of Peripheral Vascular System
Objective Data
• Palpating the LEGS for:
– Inguinal lymph nodes horizontal & vertical groups
Note: 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
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Dorsalis Pedis
Femoral
Posterior Tibial
Popliteal
20
.
– Look for edema: compare size& prominence of veins, tendons &
Peripheral Veins:
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 releasing21the
pressure
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Assessment of Peripheral Vascular System
Objective Data
Postural color changes of chronic arterial
insufficiency:
-if pain or diminished pulses
Inspect 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 System
Objective 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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Assessment of Peripheral Vascular System
Objective Data
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).
Feel for a
pressure
wave
15
20
cm
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Assessment of Peripheral Vascular System
Objective Data
• 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:
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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 System
Objective 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
• Sudden onset of
intense, sharp,
deep muscle pain,
may increase with
dorsiflexion
• Warm, swelling,
redness, tender,
• Aching, heaviness in
calf, night foot cramp
• Dilated tortuous veins
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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.
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