Peripheral Vascular and Lymphatic Assessment Dr. Zyad Saleh

COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY:- Disorders of the peripheral vascular system

may develop gradually.- ask questions about symptoms that the client

may consider inconsequential.- the history questions may overlap those asked

when assessing the heart and the skin because of the close relationship between systems.

History of Present Health Concern any color, temperature, or texture changes

in the skin. Cold, pale, clammy skin on the extremities

and thin, shiny skin with loss of hair, especially over the lower legs arterial insufficiency.

History of Present Health Concern Warm skin and brown pigmentation

around the ankles venous insufficiency.

pain or cramping in the legs Intermittent claudication weakness,

cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks relieved by rest but reproducible with same degree of exercise peripheral arterial disease

Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest venous disease.

the lack of pain sensation neuropathy

leg veins that are rope-like, bulging, or contorted

Varicose veins are hereditary and may develop from increased venous pressure and venous pooling

sores or open wounds on the legs Ulcers associated with arterial disease

painful, located on the toes, foot, or lateral ankle.

Venous ulcers are usually painless and occur on the lower leg or medial ankle.

swelling (edema) in the legs or feet Peripheral edema (swelling) an

obstruction of the lymphatic flow, venous insufficiency, incompetent valves, decreased osmotic pressure, DVT

swollen glands or lymph nodes Enlarged lymph nodes a local or

systemic infection.

Personal Health History the past with the circulation in your arms and

legs (e.g., blood clots, ulcers, coldness, hair loss, numbness, swelling, or poor healing).

prior PVD risk for a recurrence. absence of a prior palpable pulse; cool pale

legs; thick and opaque nails; shiny, dry skin; leg ulcerations; and reduced hair growth peripheral arterial occlusive disease

heart or blood vessel surgeries or treatments such as coronary artery bypass grafting, repair of an aneurysm, or vein stripping

alter the appearance of the skin and underlying tissues surrounding the blood vessels.

Family History

history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated cholesterol or triglyceride levels

hereditary and cause damage to blood vessels.

treating PVD is to identify and then modify risk factors.

Lifestyle and Health Practices

smoke or use any other form of tobacco Exercise Contraceptives Stress problems with your circulation (i.e., peripheral

vascular system) affected your ability to function

Medications and any treatment

PHYSICAL EXAMINATION

Arms: INSPECTION Observe arm size and venous pattern; look for

edema. measure bilaterally the circumference of the

arms at the same locations with each re-measurement and record findings in centimeters.

Arms are bilaterally symmetric with minimal variation in size and shape.

No edema or prominent venous patterning.

Lymphedema blocked lymphatic circulation nonpitting edema (indentation does not persist)

edema venous obstruction

Observe coloration of the hands and arms Observe coloration of the hands and arms color should be the same bilaterally Raynaud’s disorder vascular disorder

vasoconstriction or vasospasm of the fingers or toes, characterized (pallor, cyanosis, and redness)

PALPATION

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

Skin is warm to the touch bilaterally from fingertips to upper arms.

A cool extremity arterial insufficiency.

Palpate to assess capillary refill time. Color returns in 2 seconds or less. time exceeding 2 seconds

vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.

Palpate the radial pulse Radial pulses are bilaterally strong (2+). Artery walls have a resilient quality (bounce). Increased radial pulse volume hyperkinetic

state (3+ or bounding pulse). Diminished (1+) or absent (0) pulse partial

or complete arterial occlusion (legs than the arms).

Palpate the ulnar pulses. The ulnar pulses may not be detectable.

palpate the brachial pulses if you suspect arterial insufficiency.

Brachial pulses have equal strength bilaterally.

Palpate the epitrochlear lymph nodes. epitrochlear lymph nodes are not palpable. Enlarged epitrochlear lymph nodes an

infection in the hand or forearm generalized lymphadenopathy.

Perform the Allen test. Pink coloration returns to the palms within

3–5 seconds if the ulnar artery and radial artery are patent.

Arterial Insufficiency pallor persists.

Legs: INSPECTION, PALPATION, AND AUSCULTATION Observe skin color while inspecting both legs

from the toes to the groin. Pink color Pallor elevated Rubor dependent, suggests arterial insufficiency. Cyanosis dependent venous insufficiency. A rusty or brownish pigmentation around the ankles

venous insufficiency

Inspect distribution of hair.

Inspect distribution of hair. Hair covers the skin on the legs and

appears on the dorsal surface of the toes. Loss of hair on the legs arterial

insufficiency.

Inspect for lesions or ulcers. Legs are free of lesions or ulcerations. Ulcers with smooth, even margins, occur at

pressure areas, such as the toes and lateral ankle arterial insufficiency.

Ulcers with irregular edges, bleeding, and possible bacterial infection, occur on the medial ankle venous insufficiency

Inspect for edema Identical size and shape bilaterally; no

swelling or atrophy. Bilateral edema the absence of visible

veins, tendons, or bony prominences. A difference in measurement between legs

muscular atrophy.

Palpate edema No edema (pitting or nonpitting) Pitting edema is associated with systemic

problems

Palpate bilaterally for temperature of the feet and legs

Toes, feet, and legs are equally warm bilaterally Generalized coolness or change in temperature

from warm to cool as you move down the leg arterial insufficiency.

Increased warmth superficial thrombophlebitis

Palpate the superficial inguinal lymph nodes. Nontender, movable lymph nodes up to 1 or

even 2 cm are commonly palpated. Lymph nodes larger than 2 cm with or without

tenderness (lymphadenopathy) local infection or generalized lymphadenopathy.

Fixed nodes malignancy.

Palpate the femoral pulses. Femoral pulses strong and equal

bilaterally. Weak or absent femoral pulses partial

or complete arterial occlusion.

Auscultate the femoral pulses. No sounds auscultated over the femoral

arteries. Bruits over one or both femoral arteries

partial obstruction

Palpate the popliteal pulses. difficult or impossible to detect

Palpate the dorsalis pedis and posterior tibial pulses

Bilaterally strong.

Inspect for varicosities and thrombophlebitis.

Veins are flat and barely seen under the surface of the skin.

Varicose veins may appear as distended, nodular, bulging, and tortuous,

Superficial vein thrombophlebitis redness, thickening, and tenderness along the vein Aching or cramping with walking Swelling and inflammation

Special Tests for Arterial or Venous Insufficiency Perform position change test for arterial

insufficiency. Feet pink to slightly pale in color a pinkish color returns to the tips of the

toes in 10 seconds or less. superficial veins on top of the feet fill in 15

seconds or less.

Marked pallor with legs elevated Return of pink color that takes longer than

10 seconds and superficial veins that take longer than 15 seconds to fill, Persistent rubor (dusky redness) with legs dependent arterial insufficiency.

Determine ankle-brachial index (ABI) the ankle pressure in a healthy person is

the same or slightly higher than the brachial pressure

Manual compression test assess the competence of the vein’s valves

No pulsation is palpated if the client has competent valves.

feel a pulsation with your upper fingers if the valves in the veins are incompetent.

Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins.

Saphenous vein fills from below in 30 seconds If valves are competent

there will be no rapid filling of the varicose veins from above (retrograde filling) after removal of tourniquet.

Filling from above with the tourniquet in place and the client standing incompetent valves in the saphenous vein.

Rapid filling of the superficial varicose veins from above after the tourniquet has been removed retrograde filling