PERIPHERAL VASCULAR AND LYMPHATIC SYSTEMS

Chapter 20

Objectives

Understand the components of a peripheral vascular assessment. What do abnormal findings indicate?

Understand arterial and venous flow. What signs and symptoms would occur with abnormalities in either arterial or venous flow?

Understand the lymphatic system. What do abnormal findings indicate?

Apply nursing diagnoses to peripheral vascular abnormalities.

Peripheral Vascular Assessment Color – Remember from skin? Temperature – Remember from skin? Capillary Refill Pulses

Palpate and Doppler Peripheral Arterial Disease: Ankle-

brachial index Edema

Calf circumference Homan’s sign

Arterial Pulses

Temporal Carotid

Brachial Radial Ulnar

Rate, Rhythm and Force (0-3+)

Arterial Pulses

Femoral (bruit) Popliteal Posterior tibial Dorsalis pedis

Arterial Deficit What does it look

like? Motor Sensation

Rate, Rhythm and Force (0-4+)

Capillary Refill

Squeeze the nail bed until it blanches, release and observe the time for the color to return

Normal refill is less than 1-2 seconds, about the time it takes to say “capillary refill”

Ankle-brachial index (ABI)

http://www.youtube.com/watch?v=5Wclloi-qjU

Measurement of blood flow in your leg arteries.

Compares systolic blood pressure in arm with ankle.

A low ABI (<0.90) can indicate narrowing or blockage of the arteries in your legs (PAD)

Normal=1.0 to 1.2.

Lower extremity systolic pressure

Brachial artery systolic pressure

ABI =

Edema

Deep Vein Thrombophlebitis (DVT) Evaluation

Homan’s Sign

To Test:

Dorsiflex the foot toward the tibia.

Calf Circumference

Measure at the widest point of the calf and compare to other calf.

Chronic limb ischemia Looks like this. Caused by blockage of arteries with

symptoms >2 weeks

Signs and Symptoms of CLI

Claudication

Rest Pain

Lymphedema

1. The nurse is assessing a patient’s risk for developing a deep vein thrombosis (DVT). The patient considered at the highest risk is a 60-year-old patient who:

A. has been on bed rest for 3 days.

B. has been receiving physical therapy for left knee replacement.

C. has calf and thigh measurements that have less than an inch of variation on both legs.

D. was admitted to the hospital with asthma exacerbation.

Slide 2

2. The nurse is assessing the ankle-brachial index (ABI) of a patient with peripheral arterial disease (PAD). The nurse would be suspect of an ABI of:

A. 1.1.

B. 1.0.

C. –1.1.

D. 0.5.

Slide 3

For each case study:• What do you think is going on? Why?• What do you need to ask and/or

assess?• Write a nursing diagnosis for the

patient.• Look at the outcomes/interventions

that relate to this diagnosis.

Case Studies

E. A. has come to the health care provider with complaints of a sudden onset of throbbing pain in the hands. Radial pulses are absent, and the extremities are cold and pale.

E. H., age 77 years, comes to the clinic because she has been experiencing leg pain at night that “wakes me up out of a dead sleep.” She never notices any problems during the day.

D. S. is a 51-year-old nurse who has been having problems with her lower legs. She says that after a long shift she feels an aching heaviness in her calves and she can hardly bear to stand up toward the end of her shifts. The nurse notes a dilated, tortuous vein in the upper calf areas on both legs.

M. H. is recovering from a very prolonged surgery. During the morning assessment, he complains of pain when the left knee is flexed and the left foot is dorsi flexed. The calf circumference is 37 cm on the right and 40 cm on the left. The left calf is tender to palpation.

A. M. has come to the health practitioner with complaints of leg wounds that have persisted for 4 weeks. He works on a production line and is on his feet all day. On examination, the wounds are irregular, with a bright red wound base, and are not especially painful. There is moderate to heavy exudate and peripheral edema.

B. D. has been referred to the home health agency for a painful wound on the dorsal aspect of the right foot. The wound is round, measuring 3 cm in diameter. The wound base is pale with well-defined edges, and exudate is minimal.

O. S. is a 45-year-old woman who has been diagnosed with type II diabetes mellitus. She is extremely obese, and during a teaching session, the nurse notes that O. S. cannot reach the bottom of her feet to inspect them.