Examination of the Peripheral Vascular System 2023 PDF

Examination of the Peripheral Vascular System Pat Kenney-Moore EdD, PA-C Physical Diagnosis Block II OHSU PA Program Peripheral Vascular System  Definition   know the System of vessels which route Definition oxygenated blood from the heart, do through the peripheral circulation, and then back thr...

Examination of the Peripheral Vascular System Pat Kenney-Moore EdD, PA-C Physical Diagnosis Block II OHSU PA Program Peripheral Vascular System  Definition   know the System of vessels which route Definition oxygenated blood from the heart, do through the peripheral circulation, and then back through the heart Provides critical information about the circulatory system, from which inferences about the cardiac and vascular health can be made Anatomy of the PV System Arteries – thicker, muscular walls advance the bolus of blood toward the capillary beds  Veins – thinner walls, can accommodate large blood volume under low pressure. Vasoconstriction and vasodilation control venous return  Chart I Structure of Arteries and Veins know differen dioxgnated bloodinto heart Capillary Beds and Fluid cell layers Exchange single thin Gas  Consist of a single endothelial cell layer that allows diffusion of O2, nutrients, CO2 into the interstitial space vasueler system Examination of the Peripheral Vascular System  Inspect extremities Lose of hair Hair pattern, venous pattern, periphera Sduseane varicosities, color (rubor, pallor, brown), pigmentation, dermatologic findings – rashes, scars, ulcerations, gangrene  Note location of any abnormalities as location can point to etiology rubor  rownarand antes Heraticamund ankle Venus alterations rash pattern varicosities aretoral HP brown purple color chronic immflattion b o f f m f Examination of the Peripheral Vascular System  Palpate the extremities dorsalofuse  Temperature – needs start at foot then up back Warm implies an intact circulation of warm blood Cool implies diminished circulation or vasoconstriction due to cold external temperature Note temperature with the back of your hand, starting from the distal point and moving centrally lower extermity Heart failure Examination of the for edema Peripheral Vascular System  Check for Edema –  swelling from system localized or Heart failure systemic etiology overload Fluid swelling t know into push ski pt Measure and record amount of edema, and presence or absence of pitting Try to go over chart Venus system low pressure system bony area pitting non You pitting will see a inside of skin edema brawny Example of SOAP bilateral pitting unable to into skin pit rock hard Examination of the PV System know  Edema / Dependent Edema how to do Check using 2 fingers  Press firmly over a bony prominence  Begin distally and move centrally  Compare “like” areas  Record where edema ends using surface topographic references  In a bedbound patient, check sacrum  pittins i Examination of the PV System access bilateral  Assess Peripheral Arterial Pulses Focus on pulses that are located close the surface of the body and course over a bony prominence  Use the digital pad of fingers – index and long finger are most sensitive  Compare pulses side to side simultaneously (except the carotids!)  pads of your fingers fine touch Examination of the PV System  Characteristics of the pulses Stroke volume – amount of blood ejected venntridefush outs  Viscosity of the blood the older you  Peripheral resistance get  Distensibility of aorta and large arteries  Rate of cardiac emptying  Examination of the PV System scale for the Grading pulse  Grade accessible pulses on a pulse grading scale and quantify in records a put plus A 0=no palpable pulse after  1=diminished pulse scale  2=normal / expected grading  3=full / increased normal  4=bounding hyperdianamic  Examination of the PV where you palpate System scale for pulse grading  Documentation Example –    Radial, ulnar, brachial, posterior tibial and dorsalis pedis pulses 2+ and equal bilaterally Right radial pulse irregular, weak and thready Quantify numerically and identify location Assessment of Pulses  Peripheral Pulses Upper Extremity look for  Brachial a pulse closet to chest   Radial Ulnar allen test Hold arm out press on radial Ulnar Havethem artery fistfewtimes 00 O putamen I Assessment of Pulses  Peripheral Pulses Lower Extremity  Popliteal  Posterior Tibialis  Dorsalis Pedis behindtheknee seated legflexed Examination of the PV System  Central Pulses – more likely to be maintained in times of shock in order to protect vital organs    Carotid In the neck left right Aortic abdomal supine position side left the to width runs measure the of Femoral crease in the le Examination of the PV System    Turbulent blood flow Auscultate is body through Arteries for  Carotid (have patient Bruits hold breath) called Normal arteries Bruif are patent and  Aortic belly sound bell therefore silent overbelly 2  Iliac Abnormal arteries intens have turbulent from an blood flow and will  Renal quads upper create sound kidney  Femoral Examination of the PV System  Measure Abdominal Aorta   Normal should be less than 2.5 cms in width standard Enlarged aorta signals potential aneurysm – may present as a pulsatile mass with a bruit Examination of the PV System  deoxygenated Assess Jugular Venous System  Jugular Venous Distention (JVD) visual Distention of external jugular veins suggests poor right heart function, but may be present in athletes able to see on Infigntent in 871st  Jugular Venous Pressure (JVP) neck measurement A means of estimating right atrial pressure. Venous pressure will rise when right heart fails and is unable to successfully empty heart failure right Jugular Venous System  Make sure you distinguish between JVD – which assesses the external jugular vein in a seated position, and JVP which assesses the internal jugular vein in a semi-recumbent position JVD - is observed  JVP - is measured  Jugular Venous Distention external vein antomical landmarks from right side of the Jugular Venous Pulsations – a way to measure Jugular Venous Pressure    A reflection of the movement and activity of the heart radiated up through the jugular vein hea t Area over the right internal jugular vein is observed for fluttering movement - it is closest to the right atrium Not a “true” pulse and different from the carotid pulse! reflection of a true heartmovement looking for a fluttering movement 1 Jugular Venous Pulsations  to related Has 5 identifiable components cardiac  A wave – first and dominant upstroke Eivity     signifying right atrial contraction X descent – represents atrial relaxation and passive atrial filling C wave – upstroke from closure of the tricuspid valve during systole V wave – coincides with apex of the carotid pulse with increasing pressure in right atrium – occurs just after c wave in systole Y descent – opening of tricuspid valve during diastole – follows c wave Measuring JVP  https://www.youtube.com/watch?v =MZKSkVSbH8k Look at video again How hight flattering is on the neck Jugular Venous Pressure cook opSCM move heed of bed about 30 450 alwayspoint measuredevice to ceiling Jugular Venous Pressure watch osomis video on this Jugular Venous Pressure     Position patient with the head of the bed at approximately 30-45° Observe jugular venous pulsations Measure from the sternal angle to the top of the visible oscillations over the internal jugular vein A measurement of 3-4 cms or more, or a total of 9 cms is indicative of increased central venous pressure Measurement of the JVP on of angle louie chart create Distinguishing Venous from Arterial located right atrum area Determining the Central Venous Pressure without a Central Line    Central Venous Pressure (CVP) can be estimated by taking the distance from the right atrium (where venous pressure is zero) to the sternum (5 centimeters regardless of patient size or position) and adding the measurement obtained for JVP step 1 step 2 CVP=JVP+5 Normal CVP is 7 cm or less - upper limit for CVP is 9 cm abnormal  ma soap note 2 ways to document JVP = “#cms above the sternal angle” so it isn’t confused with CVP OR “CVP by JVP = x.” How to look at pressures Signs & Symptoms of Abnormalities illness Chromy work you Chronic  Arterial pain when artries  Chronic Arterial Insufficiency – inadequate arterial circulation May be manifested by pain, intermittent claudication, rest pain, absent or diminished pulses, pallor on elevation, rubor on dependency, ulcerations, coldness, gangrene tip offingers pain at rest serious of toes tip Signs & Symptoms of Abnormalities  Arterial  veins flatten out Acute Arterial Occlusion EMERGENCY! - manifests as pain, numbness, tingling, weakness, pallor, mottling, superficial vasculature collapse Distal pulses are absent Associated with atherosclerotic disease or arterial clot emanating from the heart can be in the heart Venous Anatomy Signs & Symptoms of Abnormalities  Venous  Varicosities visuable get worse standing with Dilated, tortuous alterations in the saphenous veins and tributaries Dull, aching pain and heaviness Hereditary and exacerbated by pregnancy and obesity Signs & Symptoms of Abnormalities  Venous  Acute Superficial Thrombophlebitis Partial or complete occlusion of a vein by a thrombus with secondary inflammatory reaction causing scarring of the vascular wall Tender, swollen, erythematous area overlying a corded superficial vein May occur after mild injury causes bumping leg on table n Signs & Symptoms of Abnormalities for long period  Venous time  Chronic Venous Insufficiency poor reins History of phlebitis, leg injury, chronic stasis Manifests with brawny ankle edema and induration, stasis pigmentation, varicosities, ankle ulcerations pitting edema around color brown ankle Signs & Symptoms of Abnormalities  Venous Mobilization  Deep Vein Thrombosis (DVT) EMERGENCY! coat in deep veins Pain and swelling in ankle, calf or thigh associated with a blood clot in the deep venous system Associated with OCPs, immobilization, bedrest May progress to Pulmonary Embolism Getts bigger of time Ican can Neath Important slide Difference problems Comparison of Pain Between Musculoskeletal Disorders and Vascular Insufficiencies  Arterial Pain    Comes on quickly during exercise Relieved quickly by rest Degree of pain correlates to intensity and duration of exercise  skip Venous and Musculoskeletal Pain     Comes on during or after exercise Relieved by rest but after hours or days Pain tends to be constant Greater variability in pain that in arterial pain Special Tests of the PV System limited Look up how to do this  Homan sign  Calf measurement bilaterally both palpate the calf dorsal flex  Assesses for possible deep vein the foot see it it thrombosis (DVT) in calf veins causes pain   >1cm difference is significant Allen test Look  this up more than a 1cm Checks for collateral circulation in hand and palmar arch – used prior to Arterial Blood Gas (ABG) and surgical procedures Special Tests of the PV write this darn System  Observation of postural color changes associated with chronic arterial insufficiency (AI)   Raise both legs to 60° while pt is supine until maximum pallor. Marked pallor on elevation suggests arterial insufficiency Have pt sit up and dangle feet, observing for return of color – normally to pinkness in 10 seconds. Delay in return or presence of rubor suggests arterial insufficiency. Dependent rubor is indicative of severe AI Examination of the Peripheral Vascular System  Provides useful data on the status of the cardiovascular system as abnormalities in the periphery imply similar or identical problems within the heart itself  Don’t forget the power of the grocery store! GO LOOK!