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What is the purpose of arteries?
- carries oxygenated blood to peripheral tissues
Partial arterial occlusion can lead to...
decreased O2 delivery to distal tissues and tissue ischemia
untreated total occlusion may result in
tissue death and loss of limb
What are veins and what do they do?
- Veins consist of superficial and deep veins.
- They return venous blood to the heart.
Venous return depends on:
- 1. skeletal muscle contraction (moves blood proximally) ---BR decreases return
- 2. functional valves prevent backflow (valves open towards heart)
- 3. a patent lumen (to keep maximum forward flow)
- 4. respirations (help flow by decreasing thoracic pressure and increasing abdominal pressure)
What are the veins in the legs that are most responsible for venous return?
- 1. Deep veins (femoral and popliteal veins)
- 2. Superficial veins (great saphenous vein (medial surface)--site for CABG
- - removal does not significantly compromise venous return since the deep
- 3. Perforators (connect the veins)
What are the types of subjective data questions that you would ask?
- - past history of vascular problems, inflammatory conditions, heart disease
- - enlarged lymph nodes (painful, chronic, acute)
What is arterial insufficiency? How is it caused?
- decreased arterial blood supply to the tissues.
- - intermittent claudication: muscle ischemia- usually affects gastrocnemius muscle
- - classic symptoms (calf pain with exercise; relieved by rest)
- - high occlusive disease may manifest as pain in thigh or buttock
- - smoking (vascoconstriction)
What is venous insufficiency and how is it caused?
- decreased venous return.
- It is caused by swelling by:
- 1) unilateral vs bilateral
- - unilateral (e.g. venous occlusion)
- - bilateral (e.g. heart failure)
- 2) precipitating factors (prolonged standing/sitting, travel (airplanes)
- 3) associated symptoms (SOB, nocturia)- may be HF
- 4) nutritional status (hypoalbuminemia may lead to edema)
- 5) varicose veins
- 6) blood clots
- 7) hormonal contraceptives- increase risk of venous thrombosis
An objective arterial assessment would include these factors?
- 1. assess all palpable pulses
- 2. grade pulses
- 3. use doppler as needed (detects weak pulses)
- 4. auscultatory sites
- 5. assess capillary refill (normal=CRT < 2sec)
- 6. typical changes of arterial insufficiency
What palpable pulses would you assess?
- 1) head and neck (temporal, carotid)
- 2) Arms (brachial, radial, ulnar)
- 3) Legs (femoral, popliteal, posterior tibial, dorsalis pedis)
What is the scale for grading pulses?
- 4+ bounding
- 3+ full/increased; may be normal
- 2+ normal
- 1+ weak, barely palpable
- 0 absent
How do you detect weak pulses?
Where do you auscultate to assess for bruits?
- carotid aortic
How do you assess for capillary refill and what are the abnormal factors?
- apply pressure to fingernail or toenail for a few seconds and assess blanch response of nailbed
- color should return in less than 2 seconds
- - color return greater than 2 sec indicates;
- - arterial occlusion
- - hypothermia shock
What are typical changes of arterial insufficiency?
- 1. decreased or absent pulses
- 2. pallor of extremity
- 3. cool skin
- 4. thin, shiny atrophic skin
- 5. thick ridged nails
- 6. loss of hair (check dorsum of toes)
- 7. ulcers and gangrene
What are three special tests of Arterial Patency?
- 1. Leg elevation
- 2. Ankle-Brachial Index
- 3. Allen test
What does the Leg elevation test entail?
- - with pt supine, raise the leg until it blanches
- - then have pt sit and dangle legs (note the time of color return)
- - arterial occlusion = delay in color return of many seconds or minutes
- - severe disease= delay in color return of more than 2 minutes
What is the ankle-brachial index?
- - the ratio of B/P in lower legs compared to arms.
- - A lower B/P in the leg is a sign of arterial occlusion
How does the Allen test work?
- - it assesses the patency of the radial and ulnar arteries
- 1. hold hand up and clench fist
- 2. occlude radial and ulnar arteries
- 3. release pressure on radial artery (should pink up immediately)
- * repeat procedure to test ulnar artery.
The venous assessment for edema includes:
- 1. grade 1+ to 4+ (finger pressure against skin)
- 2. Pedal (foot)
- 3. Pretibial (anterior leg along tibia)- press directly over the bone
- 4. Dependent (feet, sacrum, etc.)
- 5. Anasarca (entire body)
- 6. pitting versus non pitting
What is the pitting scale?
- 1+ 2mm pit: disappears rapidly
- 2+ 4 mm pit: disappears in 10-15 sec
- 3 + 6mm pit: may last more than 1 minute
- 4+ 8 mm pit: lasts 2-5 minutes
What are the skin changes associated with edema?
redness (rubor) or brown discoloration, leg ulcers
What is superficial thrombophlebitis?
redness, thickening, tenerness along a superficial vein
What is deep vein thrombosis?
- may be life threatening, predisposes to a pulmonary embolis
- - pain, warmth, tenderness and swelling over a vein
- - asymmetric calf size
- - homan's sign is unreliable: it is better to assess with a venous doppler
What are the risks for deep vein thrombosis?
- 1. bedrest or immobility (casted leg)- increased risk b/c of decreased skeletal muscle activity
- 2. trauma
- 3. hypercoagulable state (increased clotting)
- 4. varicosities (genetic, obesity, pregnancy)-creates incompetent valves
- 5. hormonal contraceptives (increased risk with smoking) -especially after 35
what are varicose veins and how are they caused?
dilated and sollen vessels d/t incompetent venous valves or proximal vein obstruction
Compare arterial and venous disease.
- Chronic arterial insufficiency Chronic Venous Insuffiency
- exercise pain with exercise; relieved by rest discomfort after exercise
- pulses diminished or absent not affected
- color pale if elevated; bluish if dependent brown hyperpigmentation
- skin smooth, thin, shiny, decreased hair may have varicose veins
- thick toenails
- ulcers lateral malleolus medial malleolus
- temp cool normal
How would you do an lymph node assessment?
- -palpate the epitrochlear nodes
- - palpate inguinal lymph nodes