Health Assessment Lecture 8: Vascular System

Health Assessment Lecture 8: Peripheral Vascular & Lymphatic System Assessment

• Vascular System: Consists of the body's vessels, which transport fluids like blood and lymph.
• Arteries: Contain elastic fibers and smooth muscle, enabling them to contract and dilate for a high-pressure system.
• Capillaries: Microscopic vessels.
• Veins: Located closer to the skin, with thinner walls than arteries and a lower pressure system. They have a larger diameter.
• Lymphatic Vessels: Collect excess fluid from tissues and return it to the bloodstream. The right lymphatic and thoracic ducts are key components.

Subjective Data

• Leg pain or cramps: A symptom to note.
• Skin changes (arms or legs): Changes in appearance.
• Swelling (arms or legs): Edema, which can be bilateral (generalized) or unilateral (local obstruction or inflammation).
• Lymph node enlargement: Assess for swollen lymph nodes.
• Medications: Include medications in the patient's history.
• Smoking history: A risk factor to document.

Objective Data/Preparation

• Privacy: Ensure patient privacy.
• Room temperature: Adjust to approximately 22°C.
• Inspection and palpation: Visual and tactile examination.
• Compare extremities: Examine both sides of the body.
• Equipment: Needed for assessment: Tape measure, tourniquet/blood pressure cuff, Doppler ultrasound stethoscope.

Inspection & Palpation of Arms

• Color of skin and nailbeds: Important for identifying changes.
• Temperature: Measure temperature and note any differences.
• Texture: Note skin texture.
• Turgor of skin: Assess skin elasticity.
• Lesions, edema, clubbing: Look for abnormal findings.
• Capillary refill: Time it takes for color return, less than 1–2 seconds is normal.
• Arms size: Should be symmetric in size.
• Abnormal findings: Edema of upper extremities, potentially due to obstructed lymphatic drainage (like after breast surgery).
• Scars, Radial Pulses, Brachial Pulses Assess for any visible scars or abnormal pulses.

Inspection & Palpation of Arms Continued

• Rate and rhythm of pulses: Palpate brachial and radial pulses for normal rate and rhythm.
• Amplitude (scale 0-3+): Assess the strength of the pulse (normal = 2+, increased = 3+, weak = 1+, absent = 0).
• Elasticity: Check the elasticity of the vessel.
• Pulse assessment of Brachial and Radial: Assess the presence and strength (amplitude) of these pulses. Ulnar pulse is typically not necessary.
• Epitrochlear lymph nodes: Usually not palpable.
• Modified Allen Test: Checks collateral circulation. Steps and normal findings.

Inspection & Palpation of Legs

• Skin color and temperature: Check for pallor (paleness) and coolness, often seen in arterial insufficiency.
• Hair distribution: Note any abnormalities.
• Venous pattern: Assess for visible, dilated or tortuous veins in a standing position.
• Skin discoloration/lesions/ulcers/gangrene: Note any discoloration, lesions, ulcers, or gangrene, especially associated with chronic venous stasis.
• Symmetric size Assess for symmetry.
• Calf circumference: Measure in case of asymmetry.

Inspection & Palpation of Legs Continued

• Diffuse bilateral edema: Occurs with systemic illness.
• Acute unilateral painful swelling: Possible indications of DVT or lymphedema.
• Homans' sign: A test for calf pain, tenderness, or pain when dorsiflexing the foot. Note any tenderness or calf pain during this test.
• Inguinal lymph nodes: Palpate for size, tenderness, and mobility.
• Peripheral pulses: Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses.

Checking for Pretibial Edema

• Procedure: Firmly depress the skin over the tibia for 5 seconds and release. Note if there's an indentation.
• Normal: No indentation.
• Pitting edema: Grade the severity if present (e.g., 1+ to 4+).
• Abnormal findings: Can indicate heart failure, diabetic neuropathy, hepatic cirrhosis, deep vein occlusion, or lymphatic obstruction.

Pitting Edema Scale

• 1+: Mild pitting, slight indentation; no noticeable swelling.
• 2+: Moderate pitting, indentation quickly subsides.
• 3+: Deep pitting, indentation remains for a short time; leg looks swollen.
• 4+: Very deep pitting, indentation lasts a long time; leg significantly swollen.

Testing for Arterial Insufficiency

• Procedure: Have the patient lie supine, elevate the legs 30cm, and ask the patient to move their feet side-to-side.
• Observe Color Return Time: Note the time it takes for color return to the feet after the movement (normal is ≤10 seconds).
• Abnormal findings: Marked elevational pallor suggests suspected arterial insufficiency.

The Doppler Ultrasonic Stethoscope

• Used to detect weak peripheral pulses. Continuous-wave Doppler ultrasound detects blood flow.

Other assessments

• Neuro-circulation check (circulation check): Done any time there's a possibility of compromised blood circulation (post-surgery/surgery procedures, use of casts, etc.)
• Assess for 4 Ps: Pain, Pallor, Pulselessness, Paresthesia.
• Arterial & venous insufficiency: Differentiate symptoms and findings related to arterial and venous problems, include information like pain, skin changes, edema, pulses, and ulcers.

Important Additional Points

• Assessment details: Focus on specific details of each assessment technique.
• Normal vs. abnormal findings: Clearly distinguish between normal and abnormal results/findings, with corresponding conditions/diagnosis if possible.
• Patient information: Patient history regarding smoking, medications, and past medical conditions.
• Documentation: Importance of accurate documentation in patient records.