7. Assessment of the Peripheral Vascular System

HISTORY

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:

General appearance, sex, age, and eating, drinking, and smoking habits;
Recent complaints such as weight gain, dependent edema, extremity pain, bruising;
Changes in limb temperature, hot or cold upper or lower extremities;
Pulse like palpitations or lightheadedness;
Previous injuries to an extremity;
Medication regimen, antihypertensives, anticoagulants;
Major illnesses such as diabetes, heart disease, anemia, thrombophlebitis, varicosities, hypertension;
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:

What causes it to occur? How is it relieved? Is it constant or occasional?
Does any medication bring relief? What about temperature changes or extremity positioning?
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.

Please circle the appropriate answer or fill in the blanks. Write NA (not applicable) where it applies

DATE: TIME:

ROOM: WARD:

MODE: Ambulatory, wheelchair, stretcher

VALUABLES: Sent home, in hospital safe, kept in room
List personal belongings:

VITAL SIGNS: Temp _________________ Pulse _______________ Resp ________________
B/P: Rt arm __________ Lft arm __________ Height ____________
Weight ____________________ Abdominal girth _________________
Glasses: yes/no. Contacts: yes/no.
Dentures: uppers, lowers, partials, none
Prosthetic devices: ___________________________________________________
Instructions given regarding: smoking, bathroom.
ID band correct: yes/no. Age ________. DOB _________________

ALLERGIES: Yes/no. To what?.

NEXT OF KIN: ___________________________________________________________________________
Phone:__________________. Other contact
With whom do you live?_________________________________________________________

MEDICATIONS: NAME How many/ how often Last dose

_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

DISPOSITION OF: Sent home, sent to pharmacy

MEDS BROUGHT TO: Sent home, sent to pharmacy

HOSPITAL: Sent home, sent to pharmacy

GENERAL APPEARANCE: Thin, undernourished, well nourished, obese, edema (where_______), good color, cyanotic, pale, jaundiced, alert, drowsy, comatose, clear speech, slurred speech, unable to speak. Oriented to: time, person, place. Communication problems? Language other than English?__________________________.

SKIN CONDITION: Clean, dry, moist, rash? (where______________________), Bruises? (where______________________). Poor circulation, cold hands, cold feet, broken skin?______________________. Bleeding?______________________. Pressure areas ______________________. Pressure sores? ______________________.

LUNGS: Dry cough, productive cough, spitting up blood, shortness of breath, wheezing, sleeping with head elevated, no problems breathing

GASTROINTESTINAL: Problems with: diet, nausea, vomiting, diarrhea, constipation, heartburn, indigestion, stomach ulcers, vomiting blood, dark, tarry stools?

GENITOURINARY: Problems with: urinating frequently, urgency, burning, difficulty starting stream, frequent urinating at night, inability to urinate, blood in urine, impotence?

CARDIOVASCULAR: Have you had heart problems? yes/no.
Heart attack? yes/no. If yes, when? ___________________________________.
How many?____. Were you hospitalized? yes/no.
Have you had chest pain? yes/no.
If yes, what relieves it?___________________________________________.
How does your chest pain start? working, resting, sleeping. How long does it last? minutes, seconds, hours.
Does the pain cause you to sweat? yes/no. How often do you have chest pain? every day, every week.
Describe the pain: pressure, dull, sharp, squeezing. Does the pain radiate? yes/no.
To where?__________________________________________________.
Do you have problems with unusually long bleeding? yes/no. Nosebleeds? yes/no. Do you have high B/P, low B/P? Do you take B/P medicine? yes/no. Have you recently gained weight? yes/no. Lost weight? yes/ no. How much?_____________________________________________.
Over what period of time?__________
Are you supersensitive to heat, cold? yes/no.

MUSCULOSKELETAL: Do you have muscle pain, swelling, redness, pain in joints, back problems, old injuries such as broken bones or pulled tendons? Do you have numbness, tingling, balance problems, weakness, deformities, limited motion?

NEUROLOGIC: Have you had a head injury? yes/no. Problems with frequent headaches? yes/no. Convulsions, seizures (flts), fainting spells, dizziness, tremors, twitches, loss of feeling, paralysis?

ENDOCRINE: Are you diabetic? yes/no. Is your diabetes controlled with diet, insulin? What type of insulin?________. Who gives you your insulin?________. How do you check your sugar at home?_______. Have you had excessive thirst, excessive urination, excessive eating? If yes, for how long?__________________________________________________.

HABITS: Do you or have you ever used tobacco? yes/no. How many packs per day?________. How long have you smoked?________. Do you drink any alcoholic beverages? yes/no. How much do you drink?________. Each day?________. Each week?________. Have you ever had DTs? yes/no. Do you take any drugs not ordered by the doctor? yes/no. What?_______________.

PREVIOUS HOSPITALIZATION: List and tell when (the year), where, and why
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

What is the reason for this admission?

Signature: ____________________________________________________________________ Date: ______________________

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.

PHYSICAL ASSESSMENT

Inspection

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

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:

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.
The brachial pulse is palpated in the upper arm on the medial side of the elbow by compression against the humerus.
The radial pulse is palpated on the inner surface of the wrist, laterally.
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:

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.
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.
The posterior tibial pulse is palpated immediately above and posterior to the medial malleolus (inner ankle bone).
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.

Auscultation

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.