Assessment peripheral blood vessel
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Transcript of Assessment peripheral blood vessel
Peripheral Vascular
Assessment
Maria Carmela L. Domocmat, MSN, RN
Associate Professor, College of Nursing
Manila Adventist College
a. Dorsalis pedis
b. Facial
c. Carotid
d. Brachial
e. Radial
f. Femoral
g. Popliteal
h. Posterior tibial
i. Temporal
j.
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Answer
a. Dorsalis pedis
b. Facial
c. Carotid
d. Radial
e. Brachial
f. Femoral
g. Popliteal
h. Posterior tibial
i. Temporal
j.
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1. i.
2. b.
3. c.
4. e.
5. d.
6. f.
7. g.
8. h.
9. a.
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Equipments
centimeter tape
stethoscope
Doppler ultrasound devices
conductivity gel
tourniquet
gauze or tissue
waterproof pen
BP cuff
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Arms
Observe arm size and venous pattern; also look for edema
Observe for coloration of the hands and arms
Palpate the client’s fingers, hands, arms, and note the temperature
Palpate to assess for capillary refill time
Palpate for radial pulse
Palpate the ulnar pulse
You can also palpate the brachial pulses if you suspect arterial insufficiency
Palpate the epitrochlear lymph nodes
Perform the Allen Test
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Legs
Observe skin color while inspecting both legs
from the toes to the groin
Inspect distribution of hair
Inspect for lesions or ulcers
Inspect for edema
Palpate edema
Palpate bilaterally from temperature of feet and
legs
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Legs
Palpate the superficial inguinal lymph nodes
Palpate the femoral pulses
Auscultate the femoral pulses
Palpate the popliteal pulses
Palpate the dorsalis pedis pulses
Palpate the posterior tibial pulses
Inspect for varicosities and thrombophlebitis
Check for Homan’s sign
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Special Tests for Arterial or Venous
Insufficiency
Position change test for arterial insufficiency
Ankle-Brachial pressure index (ABPI)
Manual compression test
Trendelenburg test
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Assessing the Arms
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1. Observe arm size and venous
pattern; also look for edema
o normal findings:
arms- bilaterally symmetric; minimal variation in size
and shape
no edema or prominent venous patterning
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o abnormal findings:
lymphedema – blocked lymphatic circulation; from
breast surgery
usually affect 1 extremity; causing induration and
nonpitting edema
prominent venous patterning with edema – venous
obstruction
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2. Observe for coloration of the
hands and arms
o normal findings:
color varies – depend on client’s skin tone
should be same bilaterally
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o abnormal findings:
rapid changes of color (pallor, cyanosis, and
redness), swelling, pain, numbness, tingling, burning,
throbbing, and coldness – Raynaud’s disease:
vascular disorders caused by vasoconstriction or
vasospasm of dingers or toes
commonly occurs bilaterally
symptoms last minutest to hours
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3. Palpate the client’s fingers, hands,
arms, and note the temperature
o normal findings:
skin form fingertips to upper arms – warm to touch
bilaterally
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o abnormal findings:
cool extremity – sign arterial insufficiency
cold fingers and hands – Raynaud’s dse
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4. Palpate to assess for capillary refill
time
o Note: inaccurate findings – may result if
room is cool
client has edema
client has anemia
client recently smoked a cigarette
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o normal findings:
capillary beds refill in 1 to 2 seconds or less
o abnormal findings:
capillary refill time exceeding 2 seconds –
vasoconstriction, decreased CO, shock, arterial
occlusion, or hypothermia
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5. Palpate for radial pulse
Note: for difficult-to-palate pulse – use Doppler
ultrasound device
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o normal findings:
radial pulse – equal strength bilaterally (2+)
artery walls have a resilient quality (bounce)
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o abnormal findings:
increased radial pulse volume – hyperkinetic state
diminished or absent pulse – partial or complete
arterial occlusion
decreased pulse – Buerger’s dse, scleroderma
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6. Palpate the ulnar pulse if you
suspect arterial insufficiency
o not routinely assessed – located deeper than
radial pulse
o normal findings:
may not be detectable
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o abnormal findings:
lack of resilience or inelasticity of artery wall –
arteriosclerosis
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7. Palpate the brachial pulses if suspect
arterial insufficiency
o normal findings:
equal strength bilaterally
o abnormal findings:
increased, diminished, or absent
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8. Palpate the epitrochlear lymph
nodes
o normal findings:
not palpable
o abnormal findings:
enlarged – infection in hand or forearm, or
generalized lymphadenopathy; or lesion in area
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9. Perform the Allen Test
o normal findings:
pink coloration returns to palms within 3 to 5 secs if
ulnar is patent
o abnormal findings:
pallor persist – arterial insufficiency or occlusion of
ulnar artery
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ASSESSING THE LEGS
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1. Observe skin color while inspecting
both legs from the toes to the groin
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o normal findings:
color – same with body skin tone
o abnormal findings:
pallor – esp when elevated – arterial insufficiency
rubor, when dependent – arterial insufficiency
cyanosis when dependent– venous insufficiency
rusty or brownish pigmentation around ankles –venous
insufficiency
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2. Inspect distribution of hair
o normal findings:
hair covers skin on legs and appears on dorsal surface of
toes
elderly – may have hair loss on lower extremities
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o abnormal findings:
loss of hair in legs – arterial insufficiency
+ thin, shiny skin – arterial insufficiency
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Inspect for lesions or ulcers
o normal findings:
free of lesions or ulcerations
o abnormal findings:
ulcers with smooth, even margins that occur at pressure
areas (such as toes and lateral ankle)– arterial insufficiency
ulcers with irregular borders, bleeding and possible
bacterial infections that occur at medial ankle –venous
insufficiency
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Inspect for edema
omeasure bilateral using cm tape
o normal findings:
identical size and shape bilaterally
no swelling
no atrophy
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o abnormal findings:
absence of visible veins, tendons, bony prominences
- bilateral edema
bilateral edema – indicates systemic problem (CHF) or
local problem (lymphedema) or prolonged standing or
sitting (orthostatic edema)
lymphedema – abnormal or blocked lymph vessels
unilateral edema
1-cm difference in measurement of ankles; 2-cm
difference at calf; swollen extremity
indicates venous stasis due to insufficiency or obstruction
or lymphedema
difference in measurements of both legs – muscular
atrophy; from disuse due to stroke or from being in
cast for a long time
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Palpate edema
o determine if pitting or nonpitting
o normal findings:
no edema
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Palpate edema
o abnormal findings:
pitting edema
systemic problems (CHF, hepatic cirrhosis) or
local causes (venous stasis due to insufficiency or
obstruction or
prolonged standing or sitting (orthostatic edema)
nonpitting edema
Arterial disease, arterial occlusion
Unilateral – occlusion major vein
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Palpate edema
o abnormal findings:
1+ to 4+ scale – grading the severity of pitting
edema
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http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/rep
ository/ContentAssets/lesson10_pitting_edema_scal.gif
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Disappear 10-15 secs
Lasts for more than 1 min
Lasts for 2-5 min
Palpate bilaterally from temperature
of feet and legs
o normal findings:
toes, feet and legs – equally warm bilaterally
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o abnormal findings:
generalized coolness in one leg or change in
temperature from warm to cool as you move down
the leg – arterial insufficiency
increased warmth - superficial thrombophlebitis –
due to inflammation in tissue around vein
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Palpate the superficial inguinal
lymph nodes
normal findings:
nontender, movable lymph nodes, 1-2 cm
abnormal findings:
larger than 2 cm without tenderness –
lymphadenopathy
fixed node – malignancy
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Palpate the femoral pulses
normal findings:
strong and equal bilaterally
abnormal findings:
weak or absent - partial or complete arterial
occlusion
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Auscultate the femoral pulses
o if arterial occlusion is suspected
o normal findings:
no sounds auscultated
o abnormal findings:
bruits over 1 or both – partial obstruction of vessel
and diminished blood flow to lower extremities
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Palpate the popliteal pulses
o usually detected at medial tendon
o supine or prone positions
o normal findings: may be difficult or impossible to palpate
o abnormal findings: absent pulse – occluded artery
need further assessment – temperature changes, skin color
differences, edema, hair distribution variations, dependent
rubor (dusky redness)
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Representation of arterial coats: (A), tunica
intima; (B), internal elastic lamina; (C), tunica
media; (D), external elastic lamina; (E), tunica
externa.
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http://img.tfd.com/dorland/thumbs/artery.jpg
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Palpating popliteal pulse
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Palpating popliteal pulse
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Manual Compression test
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Palpation of the dorsalis pedis artery
(sagittal view) (superior view)
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http://www.latrobe.edu.au/podiatry/vascular/vascpics/colourpics/PTpalpate.jpg
Palpation of the posterior tibial
artery An alternate method to
palpate this pulse is to
cup one hand (in this
case, the right hand)
around the posterior
aspect of the heel, letting
the fingers of the hand
rest close to the medial
malleolus. For the
average sized hands, this
often places the fingers in
a good position for
palpation automatically.
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http://en.academic.ru/pictures/enwiki/71/Great_saphenous_vein.png
Trendelenburg test:
Determines the competency of the valves in communicating veins between
the superficial and deep veins of the leg.
Used to evaluate the competence of the valves in the great saphenous vein
and in the communicating veins between the superficial and deep venous
systems.
Elevate the patient’s leg to 90 degrees to empty it of venous blood.
Place a tourniquet around the upper thigh tightly enough to occlude the great
saphenous
Ask the patient to stand
Normally this takes about 35s for the saphenous vein to fill from below
Release of the tourniquet at 60 s produces no sudden increment in venous
filling if the saphenous valves are competent.
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http://en.academic.ru/pictures/enwiki/71/Great_saphenous_vein.png
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MSN
93
Pulses of the lower limb
There are 4 arterial pulses which are routinely
felt in the lower limb.
The four pulses are:
1. femoral
2. popliteal
3. posterior tibial
4. dosalis pedis (dorsum of foot)
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http://www.gla.ac.uk/ibls/US/fab/tutorial/generic/sapulse.html
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MSN
95
Femoral pulse
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Popliteal pulse
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Posterior tibial pulse
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Dorsalis pedis pulse
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99
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http://www.gla.ac.uk/ibls/US/fab/tutorial/generic/sapulse.html
Arterial ulcers
most commonly occur distally on the foot (i.e.
toes and the sole of the foot).
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Venous ulcers
often occur in the region above the medial
malleolus.
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SPECIAL TESTS FOR ARTERIAL
OR VENOUS INSUFFICIENCY
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Position Change Test (Arterial Insufficiency )
indication: if pulses of legs weak
Note: inaccurate if client has peripheral vascular
dse of veins with incompetent valves
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Position Change Test
(Arterial Insufficiency )
supine position
place both your hand on ankle; raise both feet 12
inches above level of heart
ask client to pump feet up and down – to drain
venous blood, leaving only arterial blood to color the
legs
client sit and dangle legs off side of bed
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Position Change Test
(Arterial Insufficiency ) normal findings
(a) feet pink to slightly pale with elevation – for light-
skinned
inspect soles for dark-skinned – see subtle color changes
(b) pinkish color return to tips of toes in 10 sec or less
superficial veins on top of feet – fill in 15 sec or less
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Position Change Test
(Arterial Insufficiency ) abnormal findings
arterial insufficiency
marked pallor
longer 10 sec pink or 15 sec top of feet
persistent rubor (ducky redness) of toes or feet
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Peroneal artery
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