Peripheral Vascular System

Question 1

Inspection, Upper Extremity

(7 components)

Answer 1

1. Size
2. Symmetry
3. Swelling
4. Venous pattern
5. Color
6. Texture
7. Nail beds

Question 2

Inspection, Lower Extremity

(12 components)

Answer 2

1. Size
2. Symmetry
3. Swelling
4. Rashes
5. Ulcerations
6. Texture
7. Venous enlargement
8. Unusual pigmentation
9. Hair distribution
10. Scars
11. Color
12. Nail beds

Question 3

Palpable Pulses

(8)

Answer 3

1. Carotid
2. Brachial
3. Radial
4. Ulnar
5. Femoral
6. Popliteal
7. Dorsalis pedis
8. Posterior tibialis

Question 4

Peripheral Vascular Competencies

(8)

Answer 4

1. Upper extrem inspection
2. Lower extrem inspection
3. Palpate pulses
4. Use technique to assess for edema
5. Detect and describe varicosities
6. Perform Allen test
7. Assess BP
8. Assess cap refill

Question 5

Upper Extrem Pulse Obtainability

Answer 5

• Arterial pulses are palpable when artery lies close to body surface
• In upper extremity the ulnar pulse may be obscured by overlying tissues

Question 6

Veins

(two relative locations, descriptions)

Answer 6

1. Deep veins - carry 99% of venous return from lower body, well supported by surrounding tissues
2. Superficial veins - subcutaneous and poorly supported by surrounding tissues

Question 7

Blood Movement in Veins

Answer 7

• All veins (deep, communicating, superficial) have one way valves
• Blood flows from superficial → deep toward the heart
• Muscle pumps sqeeze blood against gravity
• Competent valves prevent backflow

Question 8

Lymph Node Shapes

(3)

Answer 8

Vary in size

1. Round
2. Oval
3. Bean-shaped

Question 9

Superficial Lymph Nodes Accessable on Exam

(4 groups)

Answer 9

1. Cervical
2. Axillary
3. Epitrochlear - medial arm, ~3 cm superior to elbow
4. Inguinal - normally between 1 and 2 cm
   
   • ​​Horizontal group - below inguinal ligament
   • Vertical group - near upper part of saphenous vn

Question 10

Pulse Technique

(4 aspects)

Answer 10

1. Use fingertips, not thumbs
2. Firm even pressure
3. Ensure you are perceiving the pt’s pulses, not your own
4. Never palpate both carotids at once

Question 11

Pulse Descriptions

(5)

Answer 11

*Remember to compare these bilaterally and note assymetry *

• 0: absent unable to palpate
• +1: diminished, weaker than expected
• +2: brisk, expcted (avg)
• +3: increased
• +4: bounding

Question 12

Widened Pulse

(definition, implicaiton)

Answer 12

Definition: larger diameter where pulse is palpable

Implication: aneurysm

Question 13

Arterial Occlusion

(definition, clinical presentation, pt pop)

Answer 13

Definition - fatty plaques impede bloodflow; most common cause of arteriosclerosis

Presentation - decreased/absent pulses distal to occlusion (usually in thigh)

Pt Pop: diabetics

Question 14

Symptoms of Ischemia (c arterial occlusion)

(6)

Answer 14

6 P’s

1. Polar (cold) - typically first notable symptom
2. Pain - 80% of cases; absent in remaining 20% due to prompt onset of anesthesia or paralysis
3. Pallor - replaced by mottled cyanosis in a few hours
4. Paresthesia - loss of light touch followed by other sensory modalities
5. Paralysis/Power - indicative of severity
6. Pulselessness

Question 15

Carotid Pulse Procedure

(3 steps)

Answer 15

1. Inspect neck for pulsations just medial to SCM
2. Place 2nd and 3rd fingers on lower 1/3 of neck
3. Press posteriously and feel for pulse

Question 16

Brachial Pulse Procedure

(4 steps)

Answer 16

1. Patient’s arm should rest c elbow etended palm up
2. Use 2nd and 3rd digits of opposite hand
3. Cup hand under pt’s elbows
4. Feel for pulse just medial to biceps tendon

Question 17

Radial Pulse Procedure

(2 steps)

Answer 17

1. Use pads of fingers on the flexor surface of the lateral wrist
2. Partially flexing pt’s wrist may help

Question 18

Ulnar Pulse Procedure

Answer 18

Using the pads of your fingers, feel for the pulse deeply on the flexor surface of teh wrist medially

Question 19

Femoral Pulse Procedure

Answer 19

Press deeply below the inguinal ligament and about midway between teh anterior superior iliac spine and the symphysis pubis

Question 20

Popliteal Pulse Procedure

(4 steps)

Answer 20

1. Patient should be prone
2. Flex the knee to 90 degrees
3. Let the leg rest against you
4. Use your thumbs to press deeply into the popliteal fossa

Question 21

Dorsalis Pedis Pulse Procedure

(2 steps)

Answer 21

1. Feel the dorsum of the food just lateral to the extensor tendon of the great toe
2. If no luck, try more laterally

Question 22

Posterior Tibial Pulse

Answer 22

Curve your fingers behind and slightly below the medial malleolus of the ankle

Question 23

Examination Technique for Edema

Answer 23

1. Press firmly but gently for 5 seconds over
   
   • ​Dorsum of each foot
   • Behind medial malleolus of each ankle
   • Over each shin
2. Observe for pitting (depression caused by finger pressure)
   
   • ​Bilateral edema is usually pitting
   • Unilateral may not be
3. Grade edema on 5 point scale (trace to +4)
4. In the event of present edema, measure and compare circumference bilaterally in the following places. Difference of > 1 cm above ankle or 2 cm above calf is unusual and can suggest edema.
   
   • ​Forefoot
   • Above ankle
   • Largest circumference of calf
   • Mid-thigh (measured distance above the patella c knee extended)

Question 24

Edema Scoring

Answer 24

• Trace = minimal edema of foot
• +1 = edema of foot
• +2 = edema to ankle
• +3 = edema halfway up shin
• +4 = edema to knees

Question 25

Edema Causes | (4)

Answer 25

1. Recent DVT 2. Chronic venous insufficiency 3. Incompetent venous valves 4. Lymphedema

Question 26

Varicosity Examination | (3 steps)

Answer 26

*You can map the course of varicosities by transmitting pressure waves in filled veins* 1. Stand pt 2. Place fingers gently on vein 3. Compress sharply

Question 27

Lower Extremity Fluid Pathology | (3)

Answer 27

* Superficial thrombophlebitis - local swelling, reddness, warmth, and palpable cord * Venous insufficiency - brownish color or ulcers just above the ankle * Lymphedema - thickened skin

Question 28

Allen Test | (purpose, indication, procedure)

Answer 28

_Purpose_: Evaluate arterial blood supply to the hand _Indication_: Assess ulnar artery patency before puncturing radial artery for blood draws or line placement _Procedure_: 1. Position pt's hands c palms up 2. Occlude radial and ulnar arteries 3. Instruct pt to tighten fist 4. Instruct pt to release fist 5. Observe palor of hand 6. Open one artery 7. Circulation is intact if hand turns pink

Question 29

Capillary Refill | (Function, Normal, Procedure)

Answer 29

_Function_: assess ability of capillaries to refill c blood when emptied _Normal_: \< 3 sec _Procedure_: 1. Ensure clean nails - no polish, blood, or fungus 2. Press on end of nail until nail bed becomes pale 3. Release and assess time to turn pink