chapter 22- Assessing Peripheral vascular

Palpate the client's fingers, hands, and arms, and note the temperature.

A cool extremity may be a sign of arterial insufficiency. Cold fingers and hands, for example, are common findings with Raynaud's. Capillary refill time exceeding 2 seconds may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.

palpate the posterior tibialis pulses

A weak or absent pulse indicates partial or complete arterial occlusion Edema in the ankles may make it difficult or impossible to palpate a posterior tibial pulse. In this case, Doppler ultrasound may be used to assess the pulse.

palpate the dorsalis pedis pulses

A weak or absent pulse may indicate impaired arterial circulation. Further circulatory assessments (temperature and color) are warranted to determine the significance of an absent pulse It may be difficult or impossible to palpate a pulse in an edematous foot. A Doppler ultrasound device may be useful in this situation.

palpate the popliteal pulses

Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. Cyanosis may be present yet more subtle in darker-skinned clients

Peripheral venous disease symptoms

Although peripheral venous disease (PVD) is not as common as PAD, it often occurs with PAD but can occur in isolation. Symptoms of PVD include: heaviness of legs, aching sensation in legs aggravated by standing or sitting for long periods of time, leg edema, or varicosities.

necrotic great toe with blisters on toe and foot

Arterial ulcer. Great toe is necrotic with blisters on the toes and foot seen in arterial insufficiency.

Inspect for edema. Inspect the legs for unilateral or bilateral edema. Note veins, tendons, and bony prominences. If the legs appear asymmetric, use a centimeter tape to measure in four different areas: circumference at mid-thigh, largest circumference at the calf, smallest circumference above the ankle, and across the forefoot

Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as heart failure, or a local problem, such as lymphedema, but lymphedema is always unilateral unless elephantiasis is diagnosed or prolonged standing or sitting (orthostatic edema). Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema (see Abnormal Findings 22-2). A difference in measurement between legs may also be due to muscular atrophy. Muscular atrophy usually results from disuse due to stroke or from being in a cast for a prolonged time.

Auscultate the femoral pulses.

Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremities.

edema associated with lymphedema

Caused by abnormal or blocked lymph vessels Nonpitting Usually bilateral; may be unilateral No skin ulceration or pigmentation

edema associated with chronic venous insufficiency

Caused by obstruction or insufficiency of deep veins Pitting, documented as: 1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit; gross edema in extremity Usually unilateral; may be bilateral Skin ulceration and pigmentation may be present

(male) change in sexual activity

Central arterial or venous disease may be manifested early as erectile dysfunction (ED). ED may occur with decreased blood flow or an occlusion of the blood vessels in one type of PAD known as aortoiliac occlusion (Leriche syndrome) (Frederick et al., 2010). Men may be reluctant to report or discuss difficulties achieving or maintaining an erection.

Have you noticed any color, temperature, or texture changes in your skin?

Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. Warm skin, edema and brown pigmentation around the ankles are associated with venous insufficiency.

formula for calculating ABI

Divide the higher ankle pressure for each foot by the higher brachial pressure. For example, you may have measured the highest brachial pulse as 160, the highest pulse in the right ankle as 80, and the highest pulse in the left ankle as 94. Dividing each of these ankle pressures by 160 (the highest brachial pressure; 80/160 and 94/160) will result in a right ABI of 0.5 and a left ABI of 0.59. 0.00-0.40: Severe peripheral arterial disease (PAD) sufficient to cause resting pain or gangrene 0.41-0.90: PAD sufficient to cause claudication 0.91-1.30: Normal vessels >1.30: Noncompressible, severely calcified vessel

Raynaud's phenomenon

Dramatic blanching of fingers on both hands in Raynaud phenomenon

index (ABI), also known as ankle-brachial pressure index (ABPI). . If the client has symptoms of arterial occlusion, the ABPI should be used to compare upper- and lower-limb systolic blood pressure. The ABI is the ratio of the ankle systolic blood pressure to the arm (brachial) systolic blood pressure

Early recognition of cardiovascular disease even in asymptomatic people can be determined using ABI measurements (Taylor-Piliae et al., 2011). People who smoke, are physically inactive, have a body mass index >30 or are hypertensive are more likely to have an abnormal ABI, suggesting PAD (Taylor-Piliae et al., 2011). Suspect medial calcification sclerosis any time you calculate an ABPI of 1.3 or greater or measure ankle pressure at more than 300 mm Hg. This condition is associated with diabetes mellitus, chronic renal failure, and hyperparathyroidism. Medial calcific sclerosis produces falsely elevated ankle pressure by making the vessels noncompressible. In addition to abnormal ABI findings, reduced or absent pedal pulses, a cool leg unilaterally, lack of hair, and shiny skin on the leg suggests peripheral arterial occlusive disease. Inaccurate readings may also occur in people with diabetes because of artery calcification (WoundRounds, 2013). Abnormal ABI findings, indicating PVD, are associated significantly with poorer walking endurance

Palpate the epitrochlear lymph nodes. Take the client's left hand in your right hand as if you were shaking hands. Flex the client's elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles (Fig. 22-12). If nodes are detected, evaluate for size, tenderness, and consistency. Repeat palpation on the opposite arm.

Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm, or they may occur with generalized lymphadenopathy. Enlarged lymph nodes may also occur because of a lesion in the area.

swollen lymph nodes

Enlarged lymph nodes may indicate a local or systemic infection. With aging, lymphatic tissue is lost, resulting in smaller and fewer lymph nodes.

trendelenburg test

Filling from above with the tourniquet in place and the client standing suggests incompetent valves in the saphenous vein. Rapid filling of the superficial varicose veins from above after the tourniquet has been removed also indicates retrograde filling past incompetent valves in the veins. Arterial blood flow is not occluded if there are arterial pulses distal to the tourniquet.

Palpate bilaterally for temperature of the feet and legs. Use the backs of your fingers

Generalized coolness in one leg or change in temperature from warm to cool as you move down the leg suggests arterial insufficiency. Increased warmth in the leg may be caused by superficial thrombophlebitis (see Abnormal Findings 22-4), resulting from a secondary inflammation in the tissue around the vein. Bilateral coolness of the feet and legs suggests one of the following: the room is too cool, the client may have recently smoked a cigarette, the client is anemic, or the client is anxious. All of these factors cause vasoconstriction, resulting in cool skin.

Manual compression test

If the client has varicose veins, perform manual compression to assess the competence of the vein's valves. Ask the client to stand. Firmly compress the lower portion of the varicose vein with one hand. Place your other hand 6-8 in above your first hand (Fig. 22-25). Feel for a pulsation to your fingers in the upper hand. Repeat this test in the other leg if varicosities are present. You will feel a pulsation with your upper fingers if the valves in the veins are incompetent.

Palpate the radial pulse.

Increased radial pulse volume indicates a hyperkinetic state (3+ or bounding pulse). Diminished (1+) or absent (0) pulse suggests partial or complete arterial occlusion (which is more common in the legs than the arms). The pulse could also be decreased from Buerger disease or scleroderma

inspect distribution of hair on legs

Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well.

PAD symptoms and intermittent claudication

Peripheral arterial disease (PAD) can develop over a lifetime, and often symptoms do not appear until there is a 60% blockage (Cleveland Clinic, 2016). Although many people have no symptoms with PAD, intermittent claudication is usually the first symptom and is characterized by weakness, cramping, aching, fatigue, or frank pain with activity; located in the calves, thighs, or buttocks but rarely in the feet. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate PAD (Criqui & Aboyans, 2015). Additional symptoms to intermittent claudication include: A burning or aching pain in the feet and toes while resting, especially at night while lying flat Cool skin in the feet Redness or other color changes of the skin Increased occurrence of infection Toe and foot sores that do not heal Jain et al. (2012) found that a lower tolerance for stair climbing predicted a higher mortality rate in people with PAD. Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. However, the lack of pain sensation may signal neuropathy in such disorders as diabetes. Reduced sensation or an absence of pain can result in a failure to recognize a problem or fully understand the problem's significance. Older clients with arterial disease may not have the classic symptoms of intermittent claudication, but may experience coldness, color change, numbness, and abnormal sensations.

peripheral edema

Peripheral edema (swelling) results from an obstruction of the lymphatic flow or from venous insufficiency from such conditions as incompetent valves or decreased osmotic pressure in the capillaries. It may also occur with deep vein thrombosis (DVT). Risk factors for DVT include reduced mobility, dehydration, increased viscosity of the blood, and venous stasis (Sommers, 2012). With leg or foot ulcers, edema can reduce tissue perfusion and wound oxygenation

Palpate edema. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting (see Abnormal Findings 22-2). Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.

Pitting edema is associated with systemic problems, such as heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema). A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe

Observe coloration of the hands and arms

Raynaud disorder is sometimes referred to as a disease, syndrome, or phenomenon. It is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours. Raynaud affects about 5% of the population and can often be controlled with minor lifestyle changes

PAD risk factors

Smoking Diabetes Obesity (a body mass index over 30) High blood pressure High cholesterol Increasing age, especially after reaching 50 years of age A family history of PAD, heart disease, or stroke High levels of homocysteine, a protein component that helps build and maintain tissue African American (more than twice as likely to have as non-Hispanic whites)

smoking

Smoking significantly increases the risk for chronic arterial insufficiency. Furthermore, Fritschi et al. (2013) found smokers with PAD had a lower self-reported quality of life and shorter claudication pain onset when walking than nonsmokers with PAD. The risk increases according to the length of time a person smokes and the amount of tobacco smoked. If willing to quit smoking, provide resources to assist in quitting. If unwilling to quit, provide information and help identify barriers to quitting. Smoking cessation has the following benefits: reduced workload on the heart, improved respiratory function, and reduced risk for lung cancer.

superficial thrombophlebitis

Superficial thrombophlebitis resulting from thrombus formation in the superficial veins. Often seen with unilateral localized pain, achiness, edema, redness, and warmth to touch.

inspect for lesions or ulcers

Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle result from venous insufficiency

varicose veins

Varicose veins are hereditary but may also develop from increased venous pressure and venous pooling (e.g., as happens during pregnancy). Standing in one place for long periods of time also increases the risk for varicosities.

Inspect for varicosities and thrombophlebitis. Ask the client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. As the client is standing, inspect for superficial vein thrombophlebitis. To fully assess for a suspected phlebitis, lightly palpate for tenderness. If superficial vein thrombophlebitis is present, note redness or discoloration on the skin surface over the vein.

Varicose veins may appear as distended, nodular, bulging, and tortuous, depending on severity. Varicosities are common in the anterior lateral thigh and lower leg, the posterior lateral calf, or anus (known as hemorrhoids). Varicose veins result from incompetent valves in the veins, weak vein walls, or an obstruction above the varicosity. Despite venous dilation, blood flow is decreased and venous pressure is increased. Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted

palpate the femoral pulses

Weak or absent femoral pulses indicate partial or complete arterial occlusion.

Perform position change test for arterial insufficiency. If pulses in the legs are weak, further assessment for arterial insufficiency is warranted. The client should be in a supine position. Place one forearm under both of the client's ankles and the other forearm underneath the knees. Raise the legs about 12 in above the level of the heart. As you support the client's legs, ask the client to pump the feet up and down for about a minute to drain the legs of venous blood, leaving only arterial blood to color the legs. At this point, ask the client to sit up and dangle legs off the side of the examination table. Note the color of both feet and the time it takes for color to return

When the client sits up and dangles the legs, a pinkish color returns to the tips of the toes in 10 seconds or less. The superficial veins on top of the feet fill in 15 seconds or less. Marked pallor with legs elevated is an indication of arterial insufficiency (Fig. 22-23C). Return of pink color that takes longer than 10 seconds and superficial veins that take longer than 15 seconds to fill suggest arterial insufficiency. Persistent rubor (dusky redness) of toes and feet with legs dependent also suggests arterial insufficiency This assessment maneuver will not be accurate if the client has PVD of the veins with incompetent valves.

You can also palpate the brachial pulses if you suspect arterial insufficiency.

abnormal: Brachial pulses are increased, diminished, or absent.

Perform the Allen test. The Allen test evaluates patency of the radial or ulnar arteries. An Allen test is essential before arterial sampling (arterial blood gas) or arterial line insertion/placement. It is implemented when patency is questionable or before such procedures as a radial artery puncture. The test begins by assessing ulnar patency. Have the client rest the hand palm side up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries (Fig. 22-13A). Continue pressure to keep both arteries occluded and have the client release the fist (Fig. 22-13B). Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand. To assess radial patency, repeat the procedure as before, but at the last step, release pressure on the radial artery

coloration should return within 3-5 seconds. With arterial insufficiency or occlusion of the ulnar artery, pallor persists. With arterial insufficiency or occlusion of the radial artery, pallor persists Opening the hand into exaggerated extension may cause persistent pallor (false-positive Allen test).

lymphedema

massive localized lymphedema (abnormal venous finding)

stages of lymphedema

stage 1- Swelling is present. Affected area pits with pressure. Elevation relieves swelling. Skin texture is smooth. stage 2- Skin tissue is firmer. Skin may look tight, shiny, and tissue may have a spongy feel. Pitting may or may not be present as tissue fibrosis (hardening) begins to develop. Elevation does not completely alleviate the swelling. Hair loss or nail changes may be experienced in affected extremity. Assistance will be needed to reduce edema stage 3- LE has progressed to the lymphostatic elephantiasis stage, at which the limb is very large. Affected area is nonpitting, often with permanent eczema. Skin is firm and thick, with hard (fibrotic) underlying tissue having an unresponsive feel. Skin folds develop. At increased risk for recurrent cellulitis, infections (lymphangitis), or ulcerations. Affected limb may ooze fluid. Elevation will not alleviate symptoms.

doppler device

used to: Assess unpalpable pulses in the extremities Determine the patency of arterial bypass grafts Assess tissue perfusion in an extremity In partially occluded vessels, RBCs pass more slowly through the vessel, thus decreasing the sound. Fully occluded vessels produce no sound.

ulcers

PVD is often associated with delayed wound healing. Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle.

Venous Insufficiency

Pain: Aching, cramping Pulses: Present but may be difficult to palpate through edema Skin characteristics: Pigmentation in gaiter area (area of medial and lateral malleolus) Skin thickened and tough May be reddish-blue in color Frequently associated with dermatitis Ulcer characteristics: Location: Medial malleolus or anterior tibial area Pain: If superficial, minimal pain; but may be very painful Depth of ulcer: Superficial Shape: Irregular border Ulcer base: Granulation tissue—beefy red to yellow fibrinous in chronic long-term ulcer Leg edema: Moderate to severe

Arterial Insufficiency

Pain: Intermittent claudication to sharp, unrelenting, constant Pulses: Diminished or absent Skin characteristics: Dependent rubor Elevation pallor of foot Dry, shiny skin Cool-to-cold temperature Loss of hair over toes and dorsum of foot Nails thickened and ridged Ulcer characteristics: Location: Tips of toes, toe webs, heel or other pressure areas if confined to bed Pain: Very painful Depth of ulcer: Deep, often involving joint space Shape: Circular Ulcer base: Pale black to dry and gangrene Leg edema: Minimal unless extremity kept in dependent position constantly to relieve pain

Observe skin color while inspecting both legs from the toes to the groin.

Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency. Dark-colored toes and blisters are seen with arterial insufficiency and gangrene (see Abnormal Findings 22-3). Gangrene is evident with ulcerations that are slow to heal, dry and shriveled skin that changes color from blue to black and eventually sloughs off, cold and numb skin; pain may or may not be present. Cyanosis when dependent suggests venous insufficiency. A rusty, ruddy, or brownish pigmentation (rubor) around the ankles indicates venous insufficiency

female oral contraceptives

Oral contraceptive pills (OCPs) are contraindicated after the age of 35 if smoking. Oral or transdermal contraceptives increase the risk for thrombophlebitis, Raynaud disease, hypertension, and edema.

Palpate the superficial inguinal lymph nodes.

Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy

Observe arm size and venous pattern; also look for edema . If there is an observable difference, measure bilaterally the circumference of the arms

Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Prominent venous patterning with edema may indicate venous obstruction A patient with lymphedema usually presents with nonpitting edema of only one extremity, which causes induration (thickening) , not ulceration, of the skin and shows no pigment changes.

palpate the ulnar pulse

Obliteration of the pulse may result from compression by external sources, as in compartment syndrome. Lack of resilience or inelasticity of the artery wall may indicate arteriosclerosis.