Peripheral Vascular and Lymphatic Assessment

1. Peripheral Vascular and Lymphatic Assessment Dr. Zyad Saleh

2. COLLECTING SUBJECTIVE DATA: • THE NURSING HEALTH HISTORY: • the history questions may overlap those asked when assessing the heart and the skin because of the close relationship between systems.

3. 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.

4. History of Present Health Concern Warm skin and brown pigmentation around the ankles  venous insufficiency.

5. 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

6. absence of a prior palpable pulse; thick and opaque nails

7. 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

8. leg veins that are rope-like, bulging, or contorted Varicose veins are hereditary and may develop from increased venous pressure and venous pooling

9. 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.

10. swelling (edema) in the legs or feet Peripheral edema (swelling)  an obstruction of the lymphatic flow, venous insufficiency, incompetent valves, decreased osmotic pressure, DVT

11. swollen glands or lymph nodes Enlarged lymph nodes  a local or systemic infection.

12. PHYSICAL EXAMINATION

13. 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.

14. Lymphedema  blocked lymphatic circulation  nonpitting edema (indentation does not persist) edema  venous obstruction

15. 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)

16. 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.

17. 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.

18. 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).

19. 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.

20. Palpate the epitrochlear lymph nodes. epitrochlear lymph nodes are not palpable. Enlarged epitrochlear lymph nodes  an infection in the hand or forearm  generalized lymphadenopathy.

21. 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.

22. 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

23. 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.

24. 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

25. 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.

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

27. 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

28. 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.

29. Palpate the femoral pulses. Femoral pulses strong and equal bilaterally. Weak or absent femoral pulses  partial or complete arterial occlusion.

30. Auscultate the femoral pulses. No sounds auscultated over the femoral arteries. Bruits over one or both femoral arteries  partial obstruction

31. Palpate the popliteal pulses. difficult or impossible to detect Palpate the dorsalis pedis and posterior tibial pulses Bilaterally strong.

32. 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,

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

34. 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.

35. 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.

36. Determine ankle-brachial index (ABI) the ankle pressure in a healthy person is the same or slightly higher than the brachial pressure

37. 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.

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

39. Trendelenburg test • 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.

40. 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