advanced vascular exam voice

Peripheral Vascular Examination : Peripheral Vascular Examination Dr. Michael Zychowicz Nurse Practitioner Associate Professor of Nursing Mount Saint Mary College

Blood vessels : Blood vessels

Pain (buttock to foot) : Pain (buttock to foot) Intermittent claudication (IC) Atherosclerosis Can progress to pain at rest IC with erectile dysfunction Severe atherosclerosis at aortic bifurcation Called Leriche’s syndrome Consider lumbar radiculopathy

Vascular Examination : Vascular Examination Inspect Symmetry of limbs Skin color, size, shape edema neck veins hair distribution Ulcerations varicosities

Edema : Edema Right heart failure Decreased heart pumping Increased hydrostatic pressure Dependent edema, JVD, enlarged liver Hypoalbumienemia Decreased osmotic pressure Feet, leg, eyelid edema initially

Edema : Edema Salt and water retention Dependent edema Increased interstitial fluid Venous stasis Obstructed or incompetent veins Blockage leads to edema of extremity

Edema : Edema Lymphedema Damaged, obstructed, inflammed, or fibrosed lymph vessels Nonpitting edema of that extremity Increased capillary permeability Burns, allergy, inflammation Local/ dependent edema Orthostatic edema Sitting or standing for long time Little to no muscle contraction to move lymph Dependent edema

Arterial / venous insufficiency : Arterial / venous insufficiency ARTERIAL Claudication/ pain at rest Decreased pulse Pale color Cool skin Absent or mild edema Hair loss/ thick nails/ thin shiny skin Ulcers usually on toes or trauma spots on feet Gangrene may occur VENOUS No pain to achiness Normal pulse Normal or cyanotic/ Normal temp Marked edema May have petechiae/ brown pigmentation/ thick skin Ulcers usually on ankles Gangrene does not occur

Arterial insufficiency : Arterial insufficiency

Venous insufficiency : Venous insufficiency

Neuropathic ulcer : Neuropathic ulcer Diabetes is a frequent cause Ulcers usually occur on pressure points Calloused skin around the ulcer No pain May develop gangrene

Vascular Examination : Vascular Examination Palpate Pulses Radial, brachial, carotid, abdominal aorta Femoral, popliteal, dorsalis pedis, post. Tibial Grade 0-4+ (2+=normal) skin temperature pitting/ non-pitting edema Capillary refill Usually 3-5 sec Arterial insufficiency or hypovolemia

Carotid pulse : Carotid pulse

Brachial pulse : Brachial pulse

Radial pulse : Radial pulse

Femoral pulse : Femoral pulse

Popliteal pulse : Popliteal pulse

Posterior tibial pulse : Posterior tibial pulse

Dorsal pedal pulse : Dorsal pedal pulse

Pitting edema scale : Pitting edema scale

Auscultate for bruits : Auscultate for bruits Carotid, temporal, abd. Aorta, Renals, femoral, iliacs

Homan’s sign : Homan’s sign Assess for DVT Rapidly dorsiflex foot/ ankle May have pain if DVT Many false negatives

Allen’s Test : Allen’s Test Radial artery Ulnar Artery

Evaluate arterial supply to leg : Evaluate arterial supply to leg Pt lies supine Elevate leg 60-90 degrees for 60 sec. Drain venous blood Active plantar/dorsiflexion to assist Grade time to develop pallor 0=no pallor 1=some at 60 sec 2=30-60sec 3=<30 sec 4=without elevation Normally color returns in 10-15 sec Longer helps confirm arterial disease

Lymphatic system : Lymphatic system Lymph nodes Usually in groups As large as 0.5 – 1 cm Superficial vs. deep

Lymphatic System : Lymphatic System Physical exam (inspect/ palpate) General info Look at the body part for the obvious Nodes, swelling, erythema, red streaking, or skin lesions Palpate with finger pads Only superficial nodes palpable Note findings Consistency, mobility, tenderness, size, warmth, location, shape, fixation

Lymphatic system : Lymphatic system Lymphadenopathy Enlargement/disease of the nodes Lymphadenitis Inflammation of nodes Enlarged nodes Look for obvious malignancy or infection Infection/ inflammation Warm, tender, enlarged nodes Infectious path of drainage through lymphatic system Malignancy (cancer) May have hard, non-tender, non-mobile

Lymphatic system exam : Lymphatic system exam Head/ neck – bend forward/ to side slightly

Lymphatic systemphysical exam : Lymphatic systemphysical exam Supraclavicular nodes Enlarged LEFT supraclavicular node possible abdominal or thoracic malignancy Axilla Shaped like apex of a pyramid Use one are to support pt’s arm and use other to palpate Epitrochlear nodes Located above and posterior to medial humoral condyle Inguinal Palpate with patient supine and hips/knees flexed