Nursing 202

- carries oxygenated blood to peripheral tissues

decreased O2 delivery to distal tissues and tissue ischemia

tissue death and loss of limb

• Veins consist of superficial and deep veins.
• They return venous blood to the heart.

• 1. skeletal muscle contraction (moves blood proximally) ---BR decreases return
• 2. functional valves prevent backflow (valves open towards heart)
• 3. a patent lumen (to keep maximum forward flow)
• 4. respirations (help flow by decreasing thoracic pressure and increasing abdominal pressure)

• 1. Deep veins (femoral and popliteal veins)
• 2. Superficial veins (great saphenous vein (medial surface)--site for CABG
• - removal does not significantly compromise venous return since the deep
• veins
• 3. Perforators (connect the veins)

• - past history of vascular problems, inflammatory conditions, heart disease
• - enlarged lymph nodes (painful, chronic, acute)

• decreased arterial blood supply to the tissues.
• - intermittent claudication: muscle ischemia- usually affects gastrocnemius muscle
• - classic symptoms (calf pain with exercise; relieved by rest)
• - high occlusive disease may manifest as pain in thigh or buttock
• - smoking (vascoconstriction)

• decreased venous return.
• It is caused by swelling by:
• 1) unilateral vs bilateral
• - unilateral (e.g. venous occlusion)
• - bilateral (e.g. heart failure)
• 2) precipitating factors (prolonged standing/sitting, travel (airplanes)
• 3) associated symptoms (SOB, nocturia)- may be HF
• 4) nutritional status (hypoalbuminemia may lead to edema)
• 5) varicose veins
• 6) blood clots
• 7) hormonal contraceptives- increase risk of venous thrombosis

• 1. assess all palpable pulses
• 2. grade pulses
• 3. use doppler as needed (detects weak pulses)
• 4. auscultatory sites
• 5. assess capillary refill (normal=CRT < 2sec)
• 6. typical changes of arterial insufficiency

• 1) head and neck (temporal, carotid)
• 2) Arms (brachial, radial, ulnar)
• 3) Legs (femoral, popliteal, posterior tibial, dorsalis pedis)

• 4+ bounding
• 3+ full/increased; may be normal
• 2+ normal
• 1+ weak, barely palpable
• 0 absent

doppler

• temporal
• carotid aortic
• renal
• iliac
• femoral

- apply pressure to fingernail or toenail for a few seconds and assess blanch response of nailbed

- color should return in less than 2 seconds

• - color return greater than 2 sec indicates;
• - arterial occlusion
• - hypothermia shock

• 1. decreased or absent pulses
• 2. pallor of extremity
• 3. cool skin
• 4. thin, shiny atrophic skin
• 5. thick ridged nails
• 6. loss of hair (check dorsum of toes)
• 7. ulcers and gangrene

• 1. Leg elevation
• 2. Ankle-Brachial Index
• 3. Allen test

• - with pt supine, raise the leg until it blanches
• - then have pt sit and dangle legs (note the time of color return)
• - arterial occlusion = delay in color return of many seconds or minutes
• - severe disease= delay in color return of more than 2 minutes

• - the ratio of B/P in lower legs compared to arms.
• - A lower B/P in the leg is a sign of arterial occlusion

• - it assesses the patency of the radial and ulnar arteries
• 1. hold hand up and clench fist
• 2. occlude radial and ulnar arteries
• 3. release pressure on radial artery (should pink up immediately)
• * repeat procedure to test ulnar artery.

• 1. grade 1+ to 4+ (finger pressure against skin)
• 2. Pedal (foot)
• 3. Pretibial (anterior leg along tibia)- press directly over the bone
• 4. Dependent (feet, sacrum, etc.)
• 5. Anasarca (entire body)
• 6. pitting versus non pitting

• 1+ 2mm pit: disappears rapidly
• 2+ 4 mm pit: disappears in 10-15 sec
• 3 + 6mm pit: may last more than 1 minute
• 4+ 8 mm pit: lasts 2-5 minutes

redness (rubor) or brown discoloration, leg ulcers

redness, thickening, tenerness along a superficial vein

• may be life threatening, predisposes to a pulmonary embolis
• - pain, warmth, tenderness and swelling over a vein
• - asymmetric calf size
• - homan's sign is unreliable: it is better to assess with a venous doppler

• 1. bedrest or immobility (casted leg)- increased risk b/c of decreased skeletal muscle activity
• 2. trauma
• 3. hypercoagulable state (increased clotting)
• 4. varicosities (genetic, obesity, pregnancy)-creates incompetent valves
• 5. hormonal contraceptives (increased risk with smoking) -especially after 35

dilated and sollen vessels d/t incompetent venous valves or proximal vein obstruction

• Chronic arterial insufficiency Chronic Venous Insuffiency
• exercise pain with exercise; relieved by rest discomfort after exercise
• pulses diminished or absent not affected
• color pale if elevated; bluish if dependent brown hyperpigmentation
• skin smooth, thin, shiny, decreased hair may have varicose veins
• thick toenails
• ulcers lateral malleolus medial malleolus
• temp cool normal

• -palpate the epitrochlear nodes
• - palpate inguinal lymph nodes