Chapter 22: Assessing Peripheral Vascular system

Which of the following wounds is most likely attributable to neuropathy?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.

A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?

Measure the diameter of the calves The nurse should complete the inspection process before going on to the other physical assessment techniques. After inspecting asymmetry of the legs, the nurse should measure the calves to determine the exact difference in diameter. Then the nurse can palpate for edema and temperature and notify the health care provider with the information once it is all gathered.

A client seeks medical attention for the condition shown. What finding does the nurse anticipate? (white fingers)

Raynaud's disease 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. Venous insufficiency, deep vein thrombosis, and arterial insufficiency all affect the blood vessels of the lower extremities.

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive?

Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill. The other options are distracters to the question.

When assessing temperature of the skin, which portion of the hand should the examiner use?

The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. The nurse may have difficulty detecting subtle differences without using the backs of the fingers.

During an assessment, the nurse first performs the action shown. (legs up) After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

The color change test is to check for arterial insufficiency. With the patient supine, the legs are elevated about 30 cm (12 in.) above the level of the heart. Then when have the patient sit up and dangle the legs. Color should return to the feet and toes within 10 seconds. The superficial veins of the feet fill within 15 seconds. Return of color taking longer than 10 seconds or persistent dependent rubor indicates arterial insufficiency. This is not a technique to assess lymphedema, the femoral pulse, or intermittent claudication.

nurse assessing pulse- posterior tibial

The posterior tibial pulse is located in the groove between the medial malleolus and Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament. The popliteal pulse is located behind the knee lateral to the medial tendon. The dorsalis pedis pulse is located halfway up the foot, immediately lateral to the extensor tendon of the great toe.

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction. The other options are distracters to the question.

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

What is a long-term complication of peripheral vascular disease?

amputation Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of patients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation.

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

arterial insufficiency Manifestations of arterial insufficiency include intermittent claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin in cool to cold in temperature and there is a loss of hair over the toes and dorsum of the foot.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

assist the client to walk as soon and as often as possible Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

The largest arteries of the upper extremities are the

brachial arteries

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

brachial pulse You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

capillary refill greater than 2 seconds The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool.

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

check feet daily for cuts and pressure areas Because of decreased blood flow, the client needs to check feet daily for cuts or pressure areas so that treatment to prevent arterial ulcers can begin immediately. Compression stockings should not be worn by clients with peripheral arterial disease. Disfigurement is not common in clients with peripheral arterial disease. There will be decreased hair and the skin will be shiny in clients with peripheral arterial disease.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

check the insertion site for redness Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Flushing the ports with saline can assist the nurse in checking patency of the lines.

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

cigarette smoking previous use of hormones high fat diet

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find?

cold fingers and hands Raynaud's is exhibited by cold fingers and hands. Cool extremities could be due to a cool room or arterial insufficiency. A capillary refill of less than 2 seconds is normal.

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

cool skin

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

cool temp and ulceration on clients great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphlococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

A patient has developed an infection of the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area?

epitrochlear Lymphatics from the ulnar surface of the forearm drain first into the epitrochlear nodes, which are located on the medial surface of the arm approximately 3 cm above the elbow. Lymphatics from the rest of the arm drain into the lateral and central axillary nodes and a few may drain directly into the infraclavicular nodes.

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?

extent of tobacco use and exposure

Walking contracts the calf muscles and forces blood away from the heart.

false

The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg?

femoral artery Since the nurse is unable to palpate the popliteal artery, the femoral artery should be palpated to determine if there is blood flow in the extremity. The dorsalis pedis and posterior tibial arteries are located in the foot. If the popliteal artery cannot be felt, it is likely that these two arteries will not be palpable either. Saphenous is a vein and is not routinely palpated to determine blood flow in an extremity.

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

firmly compress the lower portion of the varicose vein The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

Which nursing assessment findings support a medical diagnosis of acute lymphangitis? Select all that apply.

history of animal bite red streak noted on skin fever is present Acute lymphangitis presents with red streak(s) on the skin, with tenderness, enlarged, tender lymph nodes, and fever. Bacteria is often introduced by a animal bite. Compartment syndrome presents with pressure and numbness.

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?

impaired skin integrity This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

legs should be elevated for 15 seconds When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

If palpable, superficial inguinal nodes are expected to be:

nontender, mobile, 1 cm in diameter

A nurse assists the client to perform the position change test for arterial insufficiency. While dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test?

normal Return of a pink color to the legs after elevation should take less than 10 seconds. This test does not demonstrate arterial insufficiency. Delayed would be greater than 10 seconds for color to return.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

normal finding Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

notify the healthcare provider The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever.

A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?

pain in the calf muscles Clients undergoing vascular surgery are at increased risk for the development of deep vein thrombosis. The Homan's test has traditionally been used to detect the presence of a blood clot within a vessel. Homan's sign is positive if the client experiences tenderness or pain in the calf muscles on flexing the knee, and aching or cramping on dorsiflexion of the foot. Cramping pain in thighs may not be elicited by Homan's sign. Pallor of the leg on elevation is not elicited by Homan's test. Tenderness on plantar flexion of foot indicates negative Homan's sign.

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

palpate both radial arteries for symmetry Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record.

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?

peripheral artery disease Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

peripheral vascular problems The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?

popliteal 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.

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct.

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

thin shiny atrophic skin

The radial pulse is palpated over the lateral flexor surface.

true

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet?

use a doppler to evaluate presence of a pulse Edema in the feet or ankles may make it difficult or impossible to palpate for the posterior tibial pulse. In these cases, a Doppler should be used to assess for adequate circulation. Elevating the feet will not enhance the pulse. Assessing temperature is not an alternative for assessing circulation because this client demonstrates edema, which shows that circulation is compromised. About 15% of healthy clients may not have a posterior tibial pulse present.

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

venous insufficiency Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus.

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

venous thromboembolism Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.