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Vascular Assessment: Comprehensive Evaluation of Upper and Lower Extremities, Lecture notes of Health sciences

De La Salle University (DLSU)Health sciences

A detailed overview of the vascular assessment process, including the equipment required, preparation of the client, and a comprehensive examination of the upper and lower extremities. It covers key inspection and palpation techniques, as well as specialized tests for assessing arterial and venous insufficiency. The document also includes a section on documenting objective data and identifying potential nursing diagnoses related to vascular health. This comprehensive guide is valuable for healthcare professionals, particularly nurses, who need to conduct thorough vascular assessments as part of their clinical practice. The detailed information and step-by-step approach make it a useful resource for both educational and clinical settings.

Typology: Lecture notes

2022/2023

Available from 10/27/2024

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EQUIPMENT
Centimeter ruler
Stethoscope
Doppler ultrasound device
Conductivity gel
Tourniquet
Gauze or tissue
Waterproof pen
Blood pressure cuff
PREPARING THE CLIENT
1. Have the client wear an examination gown and
sit upright on an examination table.
2. Make sure the room has a comfortable
temperature without drafts.
3. Inform the client that it will be necessary to
inspect and palpate all four extremities and the
groin area.
4. Explain that the client can sit for examination of
the arms but will need to lie down for examination
of the legs and groin.
5. Explain in detail what you are doing and answer
any questions the client may have.
HEALTH HISTORY
Has the client had previous problems with
varicose veins, diabetes, hypertension, pain in
the extremities, injury to an extremity
(describe), or edema of the hands or feet?
Are there problems with lymph node swelling
or tenderness, claudication (pain in legs with
walking relieved by resting), numbness or
coldness of an extremity, discoloration or
ulceration on extremities (especially feet and
ankles), hair loss over an extremity; nail
changes?
Has the client ever had any vascular tests, such
as Doppler studies (results)?
Ask what type of hose the client wears (e.g.,
support hose). Does the client use garters or
other means of securing the hose?
Does the client spend prolonged periods of
time standing?
ASSESSMENT FINDINGS
Upper Extremities
INSPECTION
NORMAL
ABNORMAL
Arm Size
Bilaterally
symmetric with
minimal
variations in
size and shape
Lymphedema
Venous Pattern
Varicosities
No edema or
prominent
venous
patterning
Venous
Obstruction
Color
Depending on
the skin tone
Raynaud’s
Disease
PALPATION
NORMAL
ABNORMAL
Temperature
Warm to touch
Arterial
insufficiency
Raynaud’s
Disease
Capillary Refill
Time
2-3 seconds or
less
>2 seconds
Peripheral
Pulse
Equal strength,
bilaterally
strong
Buerger’s dse.,
Compartment
Syndrome
Scleroderma
Arterial
occlusion
Arteriosclerosis
Absent /
Diminished
Lymph Nodes
Non-palpable
Infection on
the hand or
forearm /
lesion
Palpation
Assess capillary refill time
Palpate the radial pulse
Palpate the ulnar pulse
Palpate the brachial pulses if arterial
insufficiency is suspected
pf3

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Download Vascular Assessment: Comprehensive Evaluation of Upper and Lower Extremities and more Lecture notes Health sciences in PDF only on Docsity!

EQUIPMENT

 Centimeter ruler  Stethoscope  Doppler ultrasound device  Conductivity gel  Tourniquet  (^) Gauze or tissue  Waterproof pen  Blood pressure cuff PREPARING THE CLIENT

  1. Have the client wear an examination gown and sit upright on an examination table.
  2. Make sure the room has a comfortable temperature without drafts.
  3. Inform the client that it will be necessary to inspect and palpate all four extremities and the groin area.
  4. Explain that the client can sit for examination of the arms but will need to lie down for examination of the legs and groin.
  5. Explain in detail what you are doing and answer any questions the client may have. HEALTH HISTORY  Has the client had previous problems with varicose veins, diabetes, hypertension, pain in the extremities, injury to an extremity (describe), or edema of the hands or feet?  (^) Are there problems with lymph node swelling or tenderness, claudication (pain in legs with walking relieved by resting), numbness or coldness of an extremity, discoloration or ulceration on extremities (especially feet and ankles), hair loss over an extremity; nail changes?  Has the client ever had any vascular tests, such as Doppler studies (results)?  Ask what type of hose the client wears (e.g., support hose). Does the client use garters or other means of securing the hose?  Does the client spend prolonged periods of time standing?

ASSESSMENT FINDINGS

Upper Extremities INSPECTION NORMAL ABNORMAL Arm Size Bilaterally symmetric with minimal variations in size and shape Lymphedema Venous Pattern Varicosities No edema or prominent venous patterning Venous Obstruction Color Depending on the skin tone Raynaud’s Disease PALPATION NORMAL ABNORMAL Temperature Warm to touch Arterial insufficiency Raynaud’s Disease Capillary Refill Time 2-3 seconds or less

2 seconds Peripheral Pulse Equal strength, bilaterally strong Buerger’s dse., Compartment Syndrome Scleroderma Arterial occlusion Arteriosclerosis Absent / Diminished Lymph Nodes Non-palpable Infection on the hand or forearm / lesion Palpation  Assess capillary refill time  Palpate the radial pulse  Palpate the ulnar pulse  Palpate the brachial pulses if arterial insufficiency is suspected

 (^) Palpate the epitrochlear lymph nodes (size, tenderness, consistency)  Allen test Abnormal findings: Persistence of pallor for more than 5 seconds Arterial insufficiency or occlusion of the ulnar / radial artery Lower Extremities INSPECTION NORMAL ABNORMAL Leg size Bilaterally symmetric with minimal variations in size and shape Lymphedema Pattern Varicosities / Thrombophlebitis / Ulcers / Lesions No edema or prominent venous patterning No ulcers / Lesions Arterial insufficiency (smooth, even margins that occur at pressure areas) Venous insufficiency (irregular edges, bleeding and possible bacterial infection that occur in the medial ankle) Bilateral / Unilateral Edema Color Depending on the skin tone Pallor (Arterial insufficiency) Cyanosis / Brownish pigmentation (Venous Insufficiency) PALPATION NORMAL ABNORMAL Temperature Warm to touch Arterial / Venous Insufficiency (Generalized coolness in one leg or change in temperature from warm to cool as you move down the leg or Increased warmth) Edema No edema CHF or hepatic cirrhosis Peripheral Pulse Equal strength, bilaterally strong Absent / Diminished (Partial or complete arterial occlusion) Lymph Nodes Non-palpable Local Infection Inspection Abnormal Findings:  Bilateral and Unilateral edema  Varicose veins Palpation  Palpate bilaterally for temperature of the feet and legs  (^) Palpation of femoral pulses  Palpate the popliteal pulses  Palpate the dorsalis pedis pulses  Palpate the posterior tibial pulses Abnormal Findings:  Partial or complete arterial occlusion  Check for Homan’s sign Abnormal Findings:  CHF or hepatic cirrhosis Auscultation  Auscultate the femoral pulses Abnormal Findings:  Bruit TESTS FOR ARTERIAL AND VENOUS INSUFFICIENCY Normal Abnormal Buerger’s Test (arterial Insuficiency Test) Feet pink to slightly pale in color in the Marked pallor.

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