University:
University of Alberta
Course:
NURS 125 | Nursing Practice - Health Assessment
Academic year:

2024
Views:

438

Pages:

2
Author:

Ali O

Chapter 20: Peripheral Vascular and Lymphatic Assessment Focused Health History · risk and protective factors · analysis of signs and symptoms: ↳ pain ↳ numbness or tingling ↳ cramping ↳ changes in skin ↳ edema ↳ function · personal history · medications · family history Physical Assessment · inspection · palpation · capillary refill · pulses · skin temperature · turgor · edema · lymphedema · lymphatic assessment Modelling Skin · colour and appearance · varicose veins · skin temperature ↳ use dorsum (back) of hands · skin turgor ↳ check all fingers and toes ↳ <3 sec Peripheral Vascular & Lymphatics ① inspect · extremities bilaterally · skin, hair, and nails ② palpate · distal to proximal * A · skin texture · turgor test · capillary refill <3 sec · edema (grade it!) · pulses (grade it, compare bilaterally) Sunset sign → issues with arterial perfusion Poor venous return Palpation: Lymphatics ① epitrochlear nodes · support forearm with elbow flexed, use finger pads between biceps & triceps (3cm above medial epicondyle) Grading Edema · usually not palpable ② inguinal nodes · grading scale 1+-4+ · press firmly with the thumb for 5 seconds on the · generally around the groin dorsum of each foot, over each medial malleolus · maybe palpable? Peripheral Pulses · compare and grade peripheral pulses ↳ radial ↳ brachial ↳ carotid ↳ femoral ↳ popliteal ↳ posterior tibial ↳ dorsalis pedis · Doppler Stethoscope ↳ assesses weak peripheral pulses ↳ ultrasonic gel 6 P's of Limb Ischemia: · pain (usually worse distally) · pallor · pulselessness · polar sensation/poikilothermia · Paresthesia (burning, tingling, numbness) · paralysis Red Flags · Deep vein thrombosis (DVT) ↳ pain, edema, warmth · Risk of pulmonary embolism (PE) ↳ acute dyspnea, chest pain, tachycardia, diaphoresis, anxiety · Compartment syndrome ↳ facial enclosed compartments of blood vessels, nerves, muscles ↳ pain and paresthesia ↳ > 6 hours permanent damage Expected Findings: · skin dry & pink throughout, equal and even hair distribution to extremities, capillary refill <3 seconds on all digits, no edema, peripheral pulses palpable and equal bilaterally (2+)