ASSESSMENT OF peripheral Vascular System
1. Identify the anatomy and physiology of the peripheral vascular and lymphatic systems.
2. Develop questions that guide the focused interview.
3. Explain client preparation for assessment of the peripheral vascular system.
4. Describe techniques required for assessment of the peripheral vascular system.
5. Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.
6. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system.
7. Discuss the focus areas of Healthy People 2010 as they relate to issues of the peripheral vascular system.
8. Apply critical thinking in selected simulations related to physical assessment of the peripheral vascular system.
- The peripheral vascular system is made up of the blood vessels of the body.
- The heart, peripheral vascular, and lymphatic vessels are part of the circulatory system.
- The vascular system plays a key role in the development of heart disease.
- The nurse’s role is to promote health and prevent problems with the circulatory system.
Anatomy and physiology review
- The arteries receive oxygenated blood from the heart and carry it to organs and tissues.
- The pumping of the heart creates the pulse.
- Arterial pulses are palpable where an artery lies over a bone.
- Arterial pulses include carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis.
- The veins deliver deoxygenated blood from the periphery to the heart.
- Venous return is assisted by skeletal muscle contraction and one-way intraluminal valves, which prevent backflow.
- Exchange of gases and nutrients between arterial and venous systems occurs in the capillaries.
- Lymphatic vessels form their own circulatory system and provide a network of defense against invading microorganisms.
- Lymph is excess fluid from tissue spaces—that is, the fluid that cannot be absorbed by venules.
- Lymph nodes are clumps of tissue along the lymphatic vessels. They filter lymph fluid and remove pathogens before fluid is returned to circulation.
- Assessing blood pressure in children less than 1 year of age is generally unnecessary unless the child is lethargic, becomes cyanotic when crying, or easily tires while feeding.
- Blood pressure increases with age.
- Fever can cause an increase in pulse rate.
- Blood pressure should be monitored throughout pregnancy to treat for pregnancy-induced hypertension.
- Pressure from the uterus obstructs venous return and can cause edema, varicosities, and hemorrhoids.
- The elasticity of the blood vessels decreases in aging. The increased peripheral resistance results in increased blood pressure.
- Enlargement of calf vessels increases the risk for thrombosis in older adults.
- Stress can contribute to hypertension.
- Hypertension is more prevalent in African Americans than in other groups.
- Standing or sitting for long periods increases the risk for varicosities.
Gathering the data
- The focused interview elicits subjective information and guides physical assessment of the peripheral vascular and lymphatic systems.
- Questions in the focused interview include those related to illness, symptoms, aging, and the environment.
- Equipment for physical assessment of the peripheral vascular and lymphatic systems includes an examination gown, stethoscope, sphygmomanometer, and Doppler.
- The assessment of the peripheral vascular system follows an organized pattern of blood pressure measurement, assessment of carotid arteries, and assessment of the upper and lower extremities.
- The normal adult blood pressure is systolic less than 130 and diastolic below 85.
- The palpable blood pressure is measured first to avoid inaccuracy due to auscultatory gap when auscultating blood pressure.
- Blood pressure is assessed with the client in the sitting and supine positions. Standards for blood pressure measures are for the sitting position.
- The carotid pulses are assessed one at a time to prevent occlusion of blood flow to the brain.
- The color, size, and temperature of the hands and arms should be symmetrical and are indicators of circulatory status.
- Capillary refill is normally less than 1 to 2 seconds.
- Characteristics of arterial pulses include rate, rhythm, symmetry, and amplitude.
- The brachial, radial, and ulnar pulses are assessed in the arms. Allen’s test is used to determine patency of the radial and ulnar arteries.
- The epitrochlear node is nonpalpable and drains the forearm and the third, fourth, and fifth fingers.
- The legs and feet are assessed for color, temperature, hair distribution, superficial vessels, size, shape, symmetry, and pulses.
- The manual compression test is used to determine the length of varicose veins and the competency of valves in varicose veins.
- Homans’ sign is used to assess blood clots in the deep veins of the leg.
- Lymph nodes in the inguinal areas are palpated.
- Palpated pulses in the lower extremities include the femoral, popliteal, dorsalis pedis, and posterior tibial.
- Assessment includes checking for edema. Edema is graded on a scale of 1 to 4.
- Toenails are assessed for color and thickness.
- Findings include normal and abnormal pulses.
- Common alterations of the peripheral vascular and lymphatic systems include arterial and venous insufficiency, aneurysm, varicosities, edema, Raynaud’s disease, and deep vein thrombosis.
- A normal pulse is regular and even in intensity.
- A weak pulse may be difficult to palpate, may wax and wane, and has an amplitude of 11.
- A bounding pulse has amplitude of 14, may be observed, is easily palpated, and is difficult to obliterate.
- Unequal pulses refer to differences in intensity or amplitude between right and left pulses.
Health promotion and client education
- Lymph nodes enlarge during infections.
- Provide prenatal education and care to reduce the risk for hypertension and valvular changes.
- Provide education regarding healthy eating and exercise to reduce obesity and the associated vascular problems.
Click on the glossary term to listen to the audio.
Allen test Test used to determine patency of the radial and ulnar arteries.
arterial aneurysm A bulging or dilation caused by a weakness in the wall of an artery.
arterial insufficiency Inadequate circulation in the arterial system, usually due to the buildup of fatty plaque or calcification of the arterial wall resulting in diminished pulses; cool, shiny skin; absence of hair on toes; pallor on elevation, red color when dependent; and deep muscle pain, usually in the calf or lower leg aggravated by activity and elevation of the limb.
arteries Part of the peripheral vascular system that receive oxygen-rich blood from the heart and carry it to the organs and tissues of the body.
bruit An obstruction causing turbulence, indicated by a swishing sound.
capillaries The smallest vessels of the circulatory system that exchange gases and nutrients between the arterial and venous systems.
clubbing Flattening of the angle of the nail and enlargement of the tips of the fingers is a sign of oxygen deprivation in the extremities.
edema Increased accumulation of fluid which could indicate an obstruction of the lymphatic system.
epitrochlear node Node located on the medial surface of the arm above the elbow that drains the ulnar surface of the forearm and the third, fourth, and fifth digits.
Homan's sign Diagnostic maneuver in which pain may increase with sharp dorsiflexion of the foot.
lymph nodes Clumps of tissue located along the lymphatic vessels either deep or superficially in the body.
lymph Excess fluid from the tissue spaces.
lymphatic vessels Vessels that extend from the capillaries of their system to the two main lympathic trunks and form their own circulatory system in which their collected fluid flows to the heart.
manual compression test Test used to determine the length of varicose veins.
peripheral vascular system Blood vessels of the body that together with the heart and the lymphatic vessels make up the body’s circulatory system.
pulse A high-pressure wave that causes the arteries to expand and contract.
Raynaud's Disease A condition in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis and then rubor (red color).
varicosities Distended veins that are dilated but have a diminished blood flow and an increased intravenous pressure.
veins Parts of systemic circulation that deliver deoxygenated blood from the body periphery back to the heart.
venous insufficiency Inadequate circulation in the venous system usually due to incompetent valves in deep veins or a blood clot in the veins.
The vascular system serves several purposes:
Ø To provide conduits for blood to travel from
the heart to
nourish the various tissues of the body
Ø To carry cellular wastes to the excretory organs
Ø To allow lymphatic flow to drain tissue fluid back into the circulation
Ø To return blood to the heart for recirculation
This system of conduits depends on an efficient heart and patent blood vessels to regulate and maintain systemic and regional blood flow and temperature.
The vascular system consists of the vessels of the body.
Vessels are tubes for transporting fluid, such as the blood or lymph.
Function - transporting the blood or lymph :
v Delivery of oxygen to the tissues
v Delivery of nutrients to the tissues
v Elimination of carbon dioxide from cells
v Elimination of waste products from cellular metabolism
The vascular system is divided into the arterial system and the venous system. In the arterial system, blood moves from the larger conduits to a network of smaller blood vessels. In the venous system, blood travels from the capillaries to the venules and to the larger system of veins, eventually returning in the venae cavae to the heart for recirculation.
The high-pressure blood vessels of the arterial vascular system may be classified according to their size and wall structure. The large arteries, such as the aorta and femoral arteries, follow relatively straight routes and have few branches.
Smaller arteries, such as the internal iliac and mesenteric arteries, divide from larger ones and have multiple branches.
Arteries may branch into arterioles or anastomose with other arteries. The arterioles branch into terminal arterioles, which join with capillaries and ultimately with venules to form the capillary network. The exchange of nutrients across the capillary membrane occurs primarily by three processes: osmosis, filtration, and diffusion.
The arterial system delivers blood to various tissues for nourishment. At the tissue level, nutrients, chemicals, and body defense substances are distributed and exchanged for cellular waste products, depending on the needs of the particular tissue. The arteries transport the cellular wastes to the excretory organs (e.g., kidneys and lungs) to be reprocessed or removed. The arteries also contribute to temperature regulation in the tissues. Blood can be either directed toward the skin to promote heat loss or diverted away from the skin to conserve heat.
■ Blood Pressure
Blood pressure is the force of blood exerted against
the vessel walls. Pressure in the larger arterial blood vessels is greater
(about 80 to
■ INDIRECT MEASUREMENT OF BLOOD PRESSURE
The blood pressure in the arterial system is determined primarily by the quantity of blood flow or cardiac output (CO), as well as by the resistance in the arterioles:
Blood pressure = Cardiac output x Peripheral vascular resistance
Any factor that increases CO or total peripheral vascular resistance increases blood pressure. In general, blood pressure is maintained at a relatively constant level; therefore an increase or decrease in total peripheral vascular resistance is associated with a decrease or an increase in CO, respectively.
Three mechanisms mediate and regulate blood pressure:
Ø The autonomic nervous system, which excites or inhibits sympathetic nervous system activity in response to impulses from chemoreceptors and baroreceptors
Ø The kidneys, which sense a change in blood flow and activate the renin-angiotensin-aldosterone mechanism
Ø The endocrine system, which releases various hormones (e.g., catecholamine, kinins, serotonin, and histamine) to stimulate the sympathetic nervous system at the tissue level
Systolic blood pressure represents
the amount of pressure/force generated by the left ventricle to distribute
blood into the aorta with each contraction of the heart; diastolic blood
pressure represents the amount of pressure/force sustained by the arteries
during the relaxation phase of the heart. In the adult, systolic pressure is
normally 90 to
Systolic pressure is affected by a number of factors, including CO. When CO decreases, systolic pressure also decreases. Diastolic pressure is primarily determined by the amount of vasoconstriction in the periphery. An increase in peripheral vascular resistance increases diastolic pressure and cardiac workload.
REGULATION OF BLOOD PRESSURE
The autonomic nervous system (ANS) and the renal system are primarily responsible for regulating blood pressure. External factors can also affect blood pressure.
Autonomic nervous system. Blood pressure is regulated by balancing the sympathetic and parasympathetic nervous systems of the autonomic nervous system. Changes in sympathetic and parasympathetic activity are responses to messages sent by the sensory receptors in the various tissues of the body. These receptors, including the baroreceptors, chemoreceptors, and stretch receptors, respond differently to the biochemical and physiologic changes of the body.
Baroreceptors in the arch of the aorta and at the origin of the internal carotid arteries are stimulated when the arterial walls are stretched by an increased blood pressure. Impulses from these baroreceptors inhibit the vasomotor center, which is located in the pons and the medulla. Inhibition of this center results in a drop in blood pressure.
Several 1- to 2-mm collections of tissue have been identified in the bifurcations of the carotid arteries and along the aortic arch. These carotid and aortic bodies contain specialized chemoreceptors that are sensitive primarily to hypoxemia (a decrease in the partial pressure of arterial oxygen [Pao2]). When stimulated, the carotid chemoreceptors send impulses along Hering's nerves, and the aortic chemoreceptors send impulses along the vagus nerves to activate a vasoconstrictor response.
The chemoreceptors are also stimulated by hypercapnia (an increase in partial pressure of arterial carbon dioxide [Paco2]) and acidosis. However, the direct effect of carbon dioxide on the central nervous system is 10 times stronger than the effect it produces by stimulating the chemoreceptors.
Stretch receptors found in the venae cavae and the right atrium are sensitive to pressure or volume changes. When a client is hypovolemic, the stretch receptors in the blood vessels sense a reduced volume or pressure and send fewer impulses to the central nervous system. This reaction stimulates the sympathetic nervous system to increase heart rate and constrict the peripheral blood vessels.
Renal system. The renal system also helps to regulate cardiovascular activity. When renal blood flow or pressure decreases, the kidneys retain sodium and water. Blood pressure tends to rise because of fluid retention and because of activation of the renin-angiotensin-aldosterone mechanism. Vascular volume is also regulated by the release of antidi-uretic hormone (vasopressin) from the posterior pituitary gland.
External factors. Other factors can influence the activity of the cardiovascular system. Emotional behaviors (e.g., excitement, pain, anger) stimulate the sympathetic nervous system to increase blood pressure and heart rate. Increased physical activity such as exercise increases blood pressure and pulse rate. Body temperature can affect the metabolic needs of the tissues, thereby influencing the delivery of blood. In hypothermia, tissues require fewer nutrients and blood pressure sure falls. In hyperthermia, the metabolic requirement of the tissues is greater, and blood pressure and pulse rate rise.
The venous system is composed of a series of veins that are located adjacent to the arterial system. A second superficial venous circulation runs parallel to the subcutaneous tissue of the extremity. These two venous systems are connected by communicating veins that provide a means for blood to travel from the superficial veins to the deep veins. Blood flow is directed toward the deep venous circulation.
The venules collect blood from the capillaries and the terminal arterioles. White blood cells also enter and exit the body tissues at the venules.
Venules branch into veins, which are low-pressure blood vessels. Veins have the ability to accommodate large shifts in volume with minimal changes in venous pressure. This flexibility allows the venous system to accommodate the administration of intravenous (IV) fluids and blood transfusions, blood loss, and dehydration. All veins in the superficial and deep venous systems in the legs (except the smallest and the largest veins) have valves that direct blood flow back to the heart; this prevents retrograde flow (backflow).
The primary function of the venous system is to complete the circulation of blood by returning blood from the capillaries to the right side of the heart. The venous system also acts as a reservoir for a large portion of the blood volume. In contrast to the arterial system, which consists of a high-pressure, continuous flow system through relatively rigid conduits, the venous system consists of a low-pressure, intermittent flow system through collapsible tubes that work against the effects of gravity.
Gravity exerts an increase in hydrostatic pressure (capillary blood pressure) when the client is in an upright position, which delays venous return. Hydrostatic pressure is lessened when the client is lying down, and thus there is less hindrance of venous return to the heart.
Cardiovascular Changes Associated with Aging
A number of physiologic changes in the cardiovascular system occur with advancing age. Many of these changes result in a loss of cardiac reserve. Thus these changes are usually not evident when the older adult is resting. They become apparent only when the person is physically or emotionally stressed and the heart cannot meet the increased metabolic demands of the body.
n A completely separate vascular system.
n It retrieves excess fluid from the tissue spaces and returns it to the blood stream.
Lymphatic ducts and drainage patterns
Functions of the lymphatic system:
à To converse fluid and plasma proteins that leak out of the capillaries.
à To form the major part of the immune system that defends body against infection.
à To absorb lipids from the intestinal tract.
§ Filter the fluid before it comes back to the bloodstream
§ Filter out microorganisms
§ Pharyngeal (adenoid)
Peyer’s patches (Lymphoid tissue in intestines)
Taking client’s complaints and history
n Ask: “Any leg pain (cramps)? Where?”
n Detail: pain type, onset (gradual/sudden), aggravating/ relieving factors (activity, walking, dangling, rubbing), associated signs (skin changes, sexual malfunction), relation to time of day, claudication distance.
The nurse obtains a thorough history, which includes demographic data, personal and family history, diet, socioeconomic status, and a functional assessment. The focus of the history is on obtaining information relative to client's risk factors and symptoms of cardiovascular disease.
■ DEMOGRAPHIC DATA
Demographic data include the client's age, sex, and ethnic origin. The incidence of conditions such as coronary artery disease (CAD) and valvular disease increases with age (AHA, 1998). The incidence of CAD also varies with the client's sex. Women who are premenopausal have a lower incidence of CAD than do men.
Information about the client's ethnic or cultural background is important because some disease conditions may be more prevalent in specific ethnic groups. For example, African Americans and Mexican Americans have a higher incidence of hypertension than do Caucasians (AHA, 1998). The nurse should be aware that some clients may refer to their hypertension as "high blood."
Age, sex, ethnic background, and family history of cardiovascular disease are considered nonmodifiable or uncontrollable risk factors for cardiovascular disease. Modifiable risk factors (e.g., high blood pressure and excessive blood cholesterol), if controlled, can reduce the risk of heart disease.
PERSONAL AND FAMILY HISTORY
The nurse reviews the client's history, noting any major illnesses such as diabetes mellitus, renal disease, anemia, high blood pressure, stroke, bleeding disorders, connective tissue diseases, chronic pulmonary diseases, heart disease, and thrombophlebitis. These conditions can influence the client's cardiovascular status.
The nurse asks about previous treatment for cardiovascular disease, identifies previous diagnostic procedures (e.g., electrocardiography and cardiac catheterization), and requests information about any medical or invasive treatment of cardiovascular disease. It is important for the nurse to ask specifically about recurrent tonsillitis, streptococcal infections, and rheumatic fever, because these conditions may lead to valvular abnormalities of the heart. In addition, the nurse inquires about any known congenital heart defects. Many clients with congenital heart problems are living into adulthood because of improved treatment and surgical modalities.
Clients are asked in detail about their medication history, beginning with any current or recent use of prescription or over-the-counter (OTC) medications or herbal/natural products (e.g., ginseng). The nurse inquires about known sensitivities to any drug and the nature of the reaction (e.g., nausea, rash). Clients should be asked whether they have recently used cocaine or any IV "street" drugs, because they may be associated with chest pain or endocarditis.
The nurse also asks female clients whether they are taking oral contraceptives or an estrogen replacement. There is an increased incidence of myocardial infarction (MI) and stroke in women over the age of 35 who take oral contraceptives, but only if they smoke, have diabetes, or have hypertension
The nurse reviews the family history and obtains information about the age, health status, and cause of death of immediate family members. A family history of hypertension, obesity, diabetes, or sudden cardiac death is especially significant.
A diet history includes the client's recall of food and fluid intake during a 24-hour period, self-imposed or medically prescribed dietary restrictions or supplementations, and the amount and type of alcohol consumption.
The dietitian reviews the type of foods selected by the client for the amount of sodium, sugar, cholesterol, fiber, and fat. The nurse or dietitian also explores the client's attitude toward food, knowledge level of essential and nonessential dietary elements, and willingness to make changes in the diet. Cultural beliefs and economic status can influence the choice of food items and therefore must be reviewed. Family members or significant others who are responsible for shopping and cooking are included in this discussion.
The social history includes information about the client's domestic situation, such as marital status, number of children, household members, living environment, and occupation. The nurse also identifies support systems. It is especially important to explore the possibility that the client might have difficulty paying for medications or treatment.
The nurse asks about the client's occupation, including the type of work performed and the requirements of the specific job. For instance, does the job involve lifting of heavy objects? Is the job emotionally stressful? What does a day's work entail? Does the client's job require him or her to be outside in extreme weather conditions?
MODIFIABLE RISK FACTORS
Personal habits that are risk factors for heart disease include cigarette smoking, physical inactivity, obesity, and type A behavior. These factors are considered modifiable or controllable risk factors. The nurse inquires about each of the following modifiable risk factors.
Cigarette smoking is a major risk factor for cardiovascular disease, specifically CAD and peripheral vascular disease (PVD) (AHA, 1998). According to the U.S. Department of Health and Human Services (DHHS), cigarette smoking is directly responsible for 21% of all deaths from CAD. Three compounds in cigarette smoke have been implicated in the development of CAD: tar, nicotine, and carbon monoxide.
The risks to the cardiovascular system from cigarette smoking appear to be dose related, noncumulative, and transient. The smoking history should include the number of cigarettes smoked daily, the duration of the smoking habit, and the age of the client when smoking started. A person who smokes fewer than 4 cigarettes per day has twice the risk of cardiovascular disease of a person who does not smoke; a person who smokes more than 20 cigarettes per day has four times the risk. Typically, the nurse records the smoking history in pack-years, which is the number of packs per day multiplied by the number of years the client has smoked.
The nurse should inquire about the client's desire to quit, past attempts to quit, and the methods used. The nurse may ascertain nicotine dependence by asking questions such as the following:
• How soon after you wake up in the morning do you smoke?
• Do you find it difficult not to smoke in places where smoking is prohibited?
• Do you smoke when you are ill?
Three to four years after a client has stopped smoking, his or her cardiovascular risk appears to be similar to that of a person who has never smoked. The nurse asks clients who do not currently smoke whether they have ever smoked and when they quit.
A sedentary lifestyle is also considered a significant risk factor in the development of heart disease. Regular physical activity promotes cardiovascular fitness and produces beneficial changes in blood pressure and levels of blood lipids and clotting factors.
Unfortunately, few people in the
The nurse questions clients concerning the type of exercise in which they engage, the period for which they have participated in the exercise, and the frequency and intensity of the exercise.
Approximately 104 million Americans adults are overweight when defined as a body mass index (BMI) of 25 to 30. Another 42 million Americans are obese, which is defined as a BMI greater than 30 (AHA, 1998). Obesity in the American population has increased 36% in the last 30 years; it is particularly a problem for African-American females, Mexican Americans, and native Hawaiians (AHA, 1998).
Obesity is associated with hypertension, hyperlipidemia, and diabetes; all are known contributors to cardiovascular disease.
The nurse weighs the client, calculates the BMI, and examines the pattern of obesity, also known as the waist-hip ratio. Chapter 61 describes these assessments in detail.
Type A Personality
Researchers have identified that people with type A personalities are more vulnerable to the development of heart disease. Type A personalities are highly competitive, overly concerned about meeting deadlines, and are often hostile or angry. The nurse might ask the client: "Have you ever experienced road rage?" or "How do you respond when you have to wait for an appointment?" The chronic anger and hostility displayed by type A people appear to be most closely associated with cardiovascular disease. The constant arousal of the sympathetic nervous system as a result of anger may influence blood pressure, serum fatty acids and lipids, and clotting mechanisms. The nurse observes the client and determines his or her response to stressful situations.
n Should be warm (about 22°C) and draftless to prevent vasodilatation or vasoconstriction.
n Make sure the female’s breasts and client’s genitals remain draped.
n Order of exam
n Begin with observations peripherally and move toward the heart.
1. Pulse and blood pressure
2. Extremities – peripheral vascular assessment
3. Neck vessels
4. Precordium – (portion of body over heart and thorax)
n Equipment needed:
n Tourniquet or blood pressure cuff
n Paper tape measure
n Doppler ultrasonic stethoscope
Arteries accessible to examination on hand
Arteries accessible to examination on leg
Veins accessible to examination
v Jugular veins
v Veins in the arm:
Ø Superficial – in the subQ tissue, responsible for most of the venous return
v Veins in the leg:
Ø Deep veins: femoral, popliteal; responsible for most of the venous return
Ø Superficial: great and small saphenous
Ø Perforators: connecting veins that join the two sets. They have one-way valves ► blood ► into the deep veins.
Groups of peripheral lymph nodes:
1. Auricular: anterior and posterior
4. Cervical: anterior and posterior.
5. Supra- and subclavian.
n Inspection and palpation
n Amount in each group
n Movable/connected with surrounding tissues
n Signs of inflammation: swelling and redness above the node
The nurse assesses the client's hands, arms, feet, and legs for skin changes, vascular changes, clubbing, capillary filling, and edema. Skin mobility and turgor are affected by the fluid status of the client. Dehydration and aging reduce skin turgor, and edema decreases skin mobility. Vascular changes in an affected extremity may include paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss of hair distribution from a reduced blood supply.
Clubbing of the fingers and toes results from chronic oxygen deprivation in these tissue beds. Clubbing is characteristic in clients with advanced chronic pulmonary disease, congenital heart defects, and cor pulmonale. Clubbing can be identified by assessing the angle of the nail bed. The angle of the normal nail bed is 160 degrees. With clubbing, this angle increases to greater than 180 degrees, and the base of the nail becomes spongy.
Capillary filling of the fingers and the toes is an indicator of peripheral circulation. Pressing or blanching the nail bed of a finger or a toe produces a whitening effect; when pressure is released, a brisk return of color should occur. If color returns within 3 seconds, peripheral circulation is considered intact. If the capillary refill time exceeds 3 seconds, the lack of circulation may be due to arterial insufficiency from atherosclerosis or spasm. Older adults typically have a prolonged capillary refill. Rubor (dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency.
Peripheral edema is a common finding in clients with cardiovascular problems. The location of edema helps the nurse to determine its potential cause. Bilateral edema of the legs may be seen in clients with heart failure or chronic venous insufficiency. Abdominal and leg edema can be seen in clients with heart disease and cirrhosis of the liver. Localized edema in one extremity may be the result of venous obstruction (thrombosis) or lymphatic blockage of the extremity (lymph-edema). Edema may also be noted in dependent areas, such as the sacrum, when a client is confined to bed.
The nurse documents the location of edema as precisely as possible (e.g., midtibial or sacral) and the number of centimeters from an anatomic landmark. Although some health care severe (or 1 + , 2+, 3 + , or 4+), there is no universal scale. In addition, these values are not precise and are subjective. Instead of using a grading scale, the nurse determines whether the edema is pitting (the skin can be indented) or nonpitting, the depth of the pit (in millimeters), and the amount of time the pit lasts (in seconds).
Arterial blood pressure is measured indirectly by sphygmomanometry.
Normal blood pressure in adults older than 45
years of age ranges from 90 to
A blood pressure less than 90/60 mm Hg may be inadequate for providing proper and sufficient nutrition to body cells. In certain circumstances, such as shock and hypotension, the Korotkoff sounds are less audible or are absent. In these cases the nurse might palpate the blood pressure, use an ultrasonic device (Doppler device), or obtain a direct measurement by arterial catheter. When blood pressure is palpated, the diastolic pressure is usually not obtainable.
Postural Blood Pressure
Clients may report dizziness or
lightheadedness when they move from a flat, supine position to a sitting or a
standing position at the edge of the bed. Normally these symptoms are
transient and pass quickly; pronounced symptoms may be due to orthostatic
(postural) hypotension. Postural hypotension occurs when blood pressure
is not adequately maintained while moving from a lying to a sitting or standing
position. It is defined as a decrease of more than
To detect orthostatic changes in blood pressure, the nurse first measures the blood pressure when the client is supine. After remaining supine for at least 3 minutes, the client changes position to sitting or standing. Normally systolic pressure drops slightly or remains unchanged as the client rises, whereas diastolic pressure rises slightly. After the position change, a time delay of 1 to 5 minutes should be permitted before auscultating blood pressure and palpating the radial pulse. The cuff should remain in the proper position on the client's arm. The nurse observes and records any signs or symptoms of distress. If the client is unable to tolerate the position change, he or she is returned to the previous position of comfort.
Paradoxical Blood Pressure
Paradoxical blood pressure is defined as an exaggerated decrease in
systolic pressure by more than
decrease slightly. However, the decreased fluid volume in the ventricles resulting from these pathologic conditions produces an exaggerated or marked reduction in cardiac output.
Hepatojugular reflux is determined by locating the internal jugular vein after positioning the client with the head of the bed elevated to 45 degrees. The nurse compresses the right upper abdomen for 30 to 40 seconds. Sudden distention of the neck veins after abdominal compression is usually indicative of right-sided heart failure.
The difference between the systolic and
diastolic values is referred to as pulse pressure. A normal pulse pressure for
an adult is 30 to
Proportional pulse pressure = (Systolic blood pressure - Diastolic blood pressure)/ Systolic blood pressure
A proportional pulse pressure less than 25% usually indicates a cardiac index of less than 2.2, as well as a critically low cardiac output (Stevenson & Braunwald, 1998). Narrowed pulse pressure is rarely normal and results from increased peripheral vascular resistance or decreased stroke volume in clients with heart failure, hypovolemia, or shock. Narrowed pulse pressure can also be seen in clients who have mitral stenosis or regurgitation. An increased pulse pressure may be seen in clients with slow heart rates, aortic regurgitation, atherosclerosis, hypertension, and aging.
Ankle Brachial Index
The ankle brachial index (ABI) can be used to assess the vascular status of the lower extremities. The nurse applies a blood pressure cuff to the lower extremities just above the malleoli and measures the systolic pressure by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ankle brachial index:
Normal values for ABI are 1 or higher, because blood pressure in the legs is usually higher than blood pressure in the arms. ABI values less than 0.80 usually indicate moderate vascular disease, whereas values less than 0.50 indicate severe vascular compromise.
VENOUS AND ARTERIAL PULSATIONS
The nurse observes the venous pulsations in the neck to assess the adequacy of blood volume and central venous pressure (CVP). The nurse can assess jugular venous pressure (JVP) to estimate the filling volume and pressure on the right side of the heart . The right internal jugular vein is usually used to estimate JVP.
Assessment of arterial pulsations gives the nurse information about vascular integrity and circulation.
For clients with suspected or actual vascular disease, all major peripheral pulses, including the temporal, carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis pulses, need to be assessed for presence or absence, amplitude, contour, rhythm, rate, and equality. The nurse examines the peripheral arteries in a head-to-toe approach with a side-to-side comparison.
A hypokinetic pulse is a weak pulsation indicative of a narrow pulse pressure. It is seen in clients with hypovolemia, aortic stenosis, and decreased cardiac output.
A hyperkinetic pulse is a large, "bounding" pulse caused by an increased ejection of blood. It is seen in clients with a high cardiac output (with exercise or thyrotoxicosis) and in those with increased sympathetic system activity (with pain, fever, or anxiety).
In pulsus alternans, a weak pulse alternates with a strong pulse despite a regular heart rhythm. It is seen in clients with severely depressed cardiac function. Clients may be asked to hold their breath to exclude any false readings. The nurse may palpate the brachial or radial arteries to assess this condition, but it is more accurately assessed by auscultation of blood pressure.
Auscultation of the major arteries (e.g., carotid and aorta) is necessary to assess for bruits. Bruits are swishing sounds that may develop in narrowed arteries and are usually associated with atherosclerotic disease. The nurse can assess for the absence or presence of bruits by placing the bell of the stethoscope over the skin of the carotid artery while the client holds his or her breath. Normally there are no sounds if the artery has uninterrupted blood flow. A bruit may develop when the internal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Severity is determined by Doppler flow studies and arteriography.
Assessment of the peripheral vascular system is a continuation of the cardiovascular assessment. A nursing admission assessment form is an excellent tool to use for this purpose (Fig. 7.1). An accurate history of the patient's symptoms, including past and present illnesses, and a description of the chief complaint focus attention on problem areas. The symptomatology varies with the site of the problem. History recording should include information about:
1. General appearance, sex, age, and eating, drinking, and smoking habits;
2. Recent complaints such as weight gain, dependent edema, extremity pain, bruising;
3. Changes in limb temperature, hot or cold upper or lower extremities;
4. Pulse like palpitations or lightheadedness;
5. Previous injuries to an extremity;
6. Medication regimen, antihypertensives, anticoagulants;
7. Major illnesses such as diabetes, heart disease, anemia, thrombophlebitis, varicosities, hypertension;
8. Any numbness or tingling experienced.
Continue the history with information about the chief complaint. Ask the patient to describe the location and the character of the problem. Add information about:
1. What causes it to occur? How is it relieved? Is it constant or occasional?
2. Does any medication bring relief? What about temperature changes or extremity positioning?
3. Are leg pains a problem when walking or running? Does rest bring relief?
Explore references to changes of hand temperatures; Raynaud's disease may be the problem. For the admitted smoker, the leg pains may be a symptom of Buerger's disease. Bruising can result from prescribed anticoagulants or over-the-counter medications such as aspirin. Information about antihypertensive medications may explain the presence of edema.
Figure 7.1 Nurses' admission assessment
Pain is the most common chief complaint of the patient with peripheral vascular disease. Pain at rest, often during sleep, is a frequently described problem for these patients. Burning, tingling, and toe numbness are reported. Sleeping in an upright position is frequently the only relief found. It is believed that the pain results from ischemic neuritis due to decreased perfusion. Intermittent claudication is a condition in which there is an absence of pain at rest, but exercise, especially walking, brings about pain and weakness to the point that it is impossible to continue the activity. Rest again dissipates the pain. This problem is most commonly found in the lower extremities. Pain may be described in the calf muscles, hip, thigh, or lower back. This problem is believed to result from production of toxic waste with decreased oxygen rather than ischemia.
In Leriche's syndrome, a disease caused by obstruction of the terminal aorta affecting the aortoiliac vessels, intermittent claudication is described in the thighs, hips, calves, and buttocks. Diagnosis requires a very thorough assessment because this problem is easily confused with sciatic nerve pain. The syndrome is found mostly in males. Impotence due to reduced blood flow to the internal pudendal artery is often a finding that requires a careful history.
On completion of the history, a physical examination follows, with inspection, palpation, and auscultation.
Observe the patient initially to determine acute distress, unusual coloring, or protrusions in either extremity. Have the patient walk to observe for changes in skin color. Vasodilatation resulting from the muscular activity of walking draws circulation from the skin of the foot, producing a more pronounced pallor in the presence of arterial disease. Color changes are usually more pronounced in one limb or the other. It is necessary to compare one to the other.
Another assessment is for skin color change when both legs are elevated about 12 inches above the heart for 2 or 3 minutes. Arterial insufficiency is suspected when the heels, toes, and soles of the feet develop pallor within 30 seconds. Another method to test lower extremities for arterial insufficiency is to elevate both legs and instruct the patient to move the feet up and down for 30 seconds, draining venous blood, then having legs lowered. If prolonged pallor results, the problem is poor arterial blood supply to the legs. Follow this test with the patient sitting up, with legs in a dependent position. Observe for the return of normal color to the toes. Normal filling time requires about 10 seconds. A longer period is an indication of arterial insufficiency. "Lobster foot" describes a color change phenomenon that occurs when the foot is again in the dependent position. The previous elevation withdrew perfusion, causing vasodilatation in the arterioles with an accompanying rubor. As the blood flow is restored, perfusion to the extremity causes a red coloring. Venous filling is measured when the feet are again in the dependent position. Normal filling time is 15 seconds. If ischemia is present, venous filling is delayed. Lower extremities of the patient with chronic arterial insufficiency often appear reddened and edematous.13
Additional lower extremity assessment should include a description of hair distribution, pigmentation, ulceration, or edema. A shiny appearance with diminished hair growth is an indicator of reduced arterial flow. Ulceration over the anterior surface of the tibia occurs in patients with sickle cell anemia due to a combination of trauma and inadequately perfused tissues following vascular thrombosis. Extremity edema is assessed by firm thumb pressure over a bony surface for 5-10 seconds. When the pressure creates a notable depress, it is termed pitting edema.
The four extremities should be examined for size, symmetry, shape, skin color, temperature, numbness, and any changes indicative of decreased blood flow.
Describe edema or swelling in one or both arms. Edema in just one arm may result from a problem of the axillary lymph nodes or circulation. Edema in both arms may be the result of obstruction of the superior vena cava. Examination of the hands for color may lead to a diagnosis of reduced blood flow. Cyanosis in the nailbeds indicates the hemoglobin molecule is surrendering more oxygen into the tissues. Capillary filling time is tested by depressing the tip of a finger or toenail. The nailbed will blanch. Release should return color quickly. Slow return of color indicates a diminished peripheral flow.16
A cold environment may produce hand pallor normally, but it is a pathologic occurrence in problems of reduced peripheral vascular blood flow. Pallor in the hands can be the result of anemia, arterial spasm, or increased peripheral vascular pressure. The hands are normally warm and dry. Peripheral vasoconstriction can be diagnosed by cold and clammy extremities.
Inspection includes a description of the size and symmetry of the limbs. A detailed description of any atrophy noted by comparing the symmetry of muscles of arms, legs, groin, and buttocks is necessary to measure muscle loss as a result of reduced arterial perfusion. Gluteal muscle loss is an important assessment finding in Leriche's syndrome. Signs of chronic vascular disease frequently noted on inspection are: (1) decreased hair distribution, particularly on legs and toes; (2) atrophied skin; and (3) thickened nailbeds. The general inspection should include notations of any of these findings of arterial problems. A brown discoloration circling the ankles suggests venous insufficiency.
Palpation of the peripheral pulses is an important assessment tool in determining vascular function. Pulses are evaluated for rate and rhythm as well as quality, configuration of the pulse wave, and bilateral symmetry. Following exercise, pulse rates can vary in individuals from a constant normal of 48-50 for joggers and runners to a normal of 88-100 or higher in others. Athletes frequently develop enlarged hearts due to the increased oxygen demand of the activity. Larger heart chambers produce greater stroke volume. This, in turn, allows for a reduced heart rate to maintain circulatory function. Pulses should be assessed in a calm atmosphere with the patient at rest. The rate may vary in regularity and normally increases with inspiration and decreases with expiration. The latter is referred to as sinus arrhythmia and is frequently seen in young people. Although this problem is not usually noted in extremity assessments, when the pulse rate varies noticeably, the cause should be investigated. Missed beats cause an irregular peripheral pulse, referred to as a pulse deficit—the actual difference between the heart rate at the apex (apical rate) and the palpated pulse in the periphery. Cardiac arrhythmias may be noted by pulse deficit.
The pulse is described as normal, diminished, or absent. These terms relate to the quality or amplitude of the pulse. A numerical classification in common use is the 0-4 scale, with differing descriptors:
0 = absent pulse/impalpable pulse
+1 = marked impairment/feeble pulse/barely palpable pulse thready, weak, fades in and out
+2 = moderate impairment/decreased pulse/diminished pulse difficult to palpate
+3 = slight impairment/full pulse/normal pulse
+4 = bounding pulse
The major problem with use of the rating scale classification is the subject! veness of the evaluator. Examiners may differ in defining impairment. It is better to use descriptors with the numbered scale.
Configuration is best described by palpation of the carotid artery rather than a smaller artery. Aortic valve problems may be confirmed by noting a sharp rise of the pulse wave with an abrupt fall, indicative of insufficiency, or by noting a feeble pulse with narrowed pulse pressure, indicative of stenosis. Normally, the pulse is present with regular rate and rhythm, consistent intensity, and bilateral symmetry. Comparison is made of peripheral pulses by palpating the right and left arterial branches simultaneously. Differences occur with stenosis or obstruction of a vessel.
Pulses are palpated in areas where arteries can easily be compressed against bone or firm musculature, near a skin surface. Assessment is conducted in a position of comfort for patient and examiner. Two or three fingertips are used to compress the artery, with care not to occlude.
Various mechanical methods of assessing blood flow are used. A transducer (Chapter 4) is used to measure the amount of blood flowing through a vessel. The Doppler ultrasound, an extremely sensitive instrument, can measure directional flow antegrade or retrograde. It can sense a weak pulsation when arterial pulses cannot be palpated. It is sometimes necessary to assess the pulse with the Doppler when a palpated pulse cannot be discerned.5
The following upper extremity pulses are palpated:
1. The common carotid pulse is palpated in the neck just below the mandible and anterior to the sterno-cleidomastoid muscle. When comparing the carotid pulses, very faint pressure is used to avoid bilateral compression leading to bradycardia or cardiac arrest.
2. The brachial pulse is palpated in the upper arm on the medial side of the elbow by compression against the humerus.
3. The radial pulse is palpated on the inner surface of the wrist, laterally.
4. The ulnar pulse is palpated on the inner surface of the wrist, medially.
A test frequently used to determine radial or ulnar artery occlusion is the Alien's test. The examiner places one thumb lightly over the radial artery and the other thumb over the ulnar artery. The patient is then told to clench his or her fist to express blood from the palm and fingers. The examiner increases pressure on both arteries. The examiner then releases either the radial or the ulnar artery to checking filling. This procedure is repeated to test patency of the opposite artery. This test should be used before arterial blood gases are drawn when the radial artery is to be used.
The vasculature of the lower extremities is assessed in the same fashion. The following major arteries are palpated:
1. The femoral pulse is found in the upper aspect of the femoral triangle, approximately 1 inch below the inguinal ligament. Femoral pulses should be equal and normal. Assessment of occlusive disease is established when there is increased amplitude of the pulse. This usually occurs proximal to the site of an occlusion. Absence of this pulse indicates aortic-iliac occlusive disease.
2. The popliteal pulse is palpated deep in the medial aspect of the popliteal fossa behind the knee. This is a difficult pulse to palpate. The patient should flex the knee while the examiner uses both hands to palpate for this pulse. The popliteal pulse is absent in the patient with occlusive superficial femoral artery disease.
3. The posterior tibial pulse is palpated immediately above and posterior to the medial malleolus (inner ankle bone).
4. The dorsalis pedis pulse is palpated on the dorsal surface of the foot, usually on the lateral side of the first metatarsal.
The venous system of the lower extremities cannot be assessed by palpating. Observation should reveal veins that are smooth and full. Veins that show dilation or tortuosity are abnormal and are classed as varicosities. Homans' sign, dorsiflexion of the foot with the leg flat, is another lower extremity examination. If pain occurs in the calf, phlebitis is suspected.
Assessment of the vascular system is not completed until a stethoscope is applied to the vessels. Auscultation of these structures is performed to determine the absence or presence of bruits or venous hums. Bruits are abnormal sounds or murmurs heard in the peripheral arteries. Abdominal aneurysms are frequently detected by a blowing sound heard over the aorta and are found in the midline of the upper abdomen down to the level of the umbilicus. Venous hums are continuous blowing, singing, or humming sounds heard over the right jugular vein. Anemia may be the problem when this sound occurs, because of the low viscosity of the blood. Bruits are heard as medium- to high-pitched sounds and are best heard with the bell of the stethoscope; hums are low- to medium-pitched sounds. Pressure to the jugular veins at the base of the neck will stop a venous hum, Although venous hums are rarely significant, they should be described and differentiated from bruits, which indicate more serious problems. Stenotic and occluded vessels are identified by the turbulent sounds produced by an increased resistance to flow within the vessel.