Health Assessment (Lecture)

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

Session # 1 5

LESSON TITLE: The Peripheral Vascular System and 6. Discuss risk factors for peripheral artery
Lymphatic System disease, chronic
venous status, and thromboembolic disease.
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can: Materials:
1. Identify the locations of the peripheral pulses; Book, pen and notebook, index card/class list
2. Obtain an accurate history of the peripheral vascular system;
3. Describe the structure and functions of arteries, veins,
lymphatic vessels and lymph nodes;
References: Bates’ Nursing Guide to Physical
4. Describe the equipment necessary to perform a peripheral
Examination and History Taking (Second Edition)
vascular examination;
by Beth Hogan-Quigley, Mary Louise Palm, and
5. Evaluate and interpret variations in heart rhythm, rate and
Lynn Bickley.
amplitude;

MAIN LESSON (60 minutes)

The students will study and read Chapter 15 of their book about this lesson:

The Health History

Common or Concerning
Symptoms:  Pain in
the arms or legs
• Intermittent claudication
• Cold, numbness, or pallor in the legs; hair loss
• Swelling in the calves, legs, or feet
• Swelling with redness and tenderness

Because most patients with peripheral vascular diseases report minimal symptoms, asking specifically about the
symptoms below is recommended, especially in patients older than 50 years and those with risk factors, especially
smoking, diabetes, hypertension, elevated cholesterol, or coronary artery disease:

● Do you have pain or cramping in your legs during walking or exertion?

(This is termed intermittent claudication.)
• These symptoms are caused by insufficient arterial supply to the legs, which may be caused by
atherosclerosis.
● Is it relieved by rest within 10 minutes?
● If present, identify the location and the distance the patient walks before symptoms occur.
● Do you have coldness, numbness, or pallor in the legs or feet?
● Do you have hair on your shins?
● Do you have aching or pain at rest in the lower leg or foot?
● Is pain alleviated by elevating the legs?
● Do you have fatigue or aching in the lower legs with prolonged standing?
● Do you have swelling of the feet or legs? If present, identify:
• Edema, varicose veins, and aching in the legs are symptoms of venous stasis.
● Location
● Time of day it is present
● Whether it is bilateral or unilateral ● Do you have any varicose veins?
● Where are they located?
● How long have you had them?

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 ● Do you have any discomfort from them?
● Do you have any wounds of the legs or feet that will not heal or heal very slowly?
• Ulcers may be of venous or arterial origin.
● Where is the wound located?
● How long have you had the wound?
● What precipitated the wound (e.g., an injury)?
● Do your fingertips or toes change color in cold weather?
• May be caused by Raynaud disease: the small arteries spasm in response to cold.
● Have you experienced erectile dysfunction?
• Poor blood supply to the penile arteries can cause erectile dysfunction.
● Do you have abdominal pain after meals?
● Does it prevent you from eating?
• Atherosclerosis of the mesenteric or celiac arteries can cause intestinal ischemia, producing
abdominal pain and “food fear,” where the patient is fearful of eating. ● Do you have
tender or swollen lymph nodes (glands)?
• Swollen nodes may indicate an infection or tumor.

PAST HISTORY

● Medications, especially oral contraceptives or hormone replacement

Therapy
• Estrogen use and pregnancy increase one’s risk for blood clots.
● Pregnancy or recent childbirth
● Inflammatory diseases such as lupus, rheumatoid arthritis, or irritable bowel disease
• Inflammation contributes to clot formation.
● Active cancer
● Coronary artery disease (CAD)
• Coronary artery disease and cerebral artery disease are also caused by atherosclerosis; an
individual with either is at risk for PAD.
● Heart attack
● Congestive heart failure
● Stroke (cerebral arterial disease)
● Clotting disorders
● Hypertension
● Diabetes
● Problems in circulation, such as blood clots, leg ulcers, swelling, or poor healing of wounds
● Major surgery or fracture of a long bone in the last 4 weeks

Risk factors
● Obesity
● Smoking
● Hyperlipidemia
● Constrictive clothing
● Central venous lines

FAMILY HISTORY
● Peripheral vascular disease
● Varicose veins
● Abdominal aortic aneurysm
● CAD
● Sudden death younger than 60 years of age
● Diabetes

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Lifestyle or Health Patterns
● Job requiring prolonged standing or sitting
● Sedentary lifestyle
● Decreased mobility such as paralysis or cast

Arms
Inspection. Inspect both arms from the fingertips to the shoulders. Note:
1. Their size, symmetry, swelling, and any lesions
• Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy.
2. The venous pattern
• Prominent veins in an edematous arm suggest venous obstruction
3. The color of the skin and nail beds and the texture of the skin

Palpation
1. Palpate the temperature of the arms and hands simultaneously with the backs of your fingers. Compare the
temperature of the arms simultaneously.
 In Raynaud disease, wrist pulses are typically normal, but spasm of more distal arteries causes
episodes of sharpy demarcated pallor of the fingers
2. Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. Partially
flexing the patient’s wrist may help you feel this pulse. Compare the pulses in both arms. Pulses may be
palpated simultaneously to facilitate comparison.

There are two common systems for grading the amplitude of the arterial pulses. One system uses a scale of 0 to 3,
as below. The other system uses a scale of 0 to 4. You should check to see what scale your institution uses.

If you suspect arterial insufficiency, feel for the brachial pulse. Flex the patient’s elbow slightly, and palpate the artery
just medial to the biceps tendon at the antecubital crease. The brachial artery can also be felt higher in the arm in the
groove between the biceps and triceps muscles.

Feel for the epitrochlear nodes. With the patient’s elbow flexed to about 90° and the forearm supported by your hand,
reach around behind the arm and feel in the groove between the biceps and triceps muscles, about 3 cm above the
medial epicondyle. If a node is present, note its size, consistency, and tenderness. Epitrochlear nodes are difficult or
impossible to identify in most normal people.

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Legs
The patient should be lying down and draped so that the external genitalia are covered and the legs fully exposed. A
good examination is impossible through stockings or socks!

Inspection. Inspect both legs from the groin and buttocks to the feet.
Note:
1. Their size, symmetry, and edema. Measure leg circumferences in centimeters if discrepancy is suspected.
2. The venous pattern and any venous enlargement or varicosities
3. Pigmentation, rashes, scars, or ulcers
4. The color and texture of the skin and the color of the nail beds
5. The distribution of hair on the lower legs, feet, and toes.
6. Look for brownish areas (or increased pigmentation on dark-skinned clients) near the ankles. The brown
discoloration is caused by hemosiderin released from the red blood cells that seep into the skin with edema
and break down.
7. Note the location, size, and depth of any ulcers in the skin. Are the edges of the wound well demarcated? Is
there bleeding?

Palpation
1. Palpate the temperature of both legs and feet simultaneously with the backs of your hands. Compare the
temperature of the legs. Bilateral coolness is most often caused by a cold environment or anxiety. Coldness,
especially when unilateral or associated with other signs, suggests arterial insufficiency from inadequate arterial
circulation.
2. Palpate for edema. Compare one foot and leg with the other, noting their relative size and the prominence of
veins, tendons, and bones. Edema causes swelling that may obscure the veins, tendons, and bony prominences.

Palpate for pitting edema. Press firmly but gently with your thumb for at least 5 seconds (1) over the dorsum of each
foot, (2) behind each medial malleolus, and (3) over the shins. Look for pitting—a depression caused by pressure
from your thumb. Normally there is none. The severity of edema is graded on a four-point scale

Palpate the pulses to assess the arterial circulation.

● The femoral pulse. Press deeply, below the inguinal ligament and about midway between the anterior
superior iliac spine and the symphysis pubis. As in deep abdominal palpation, the use of two hands, one on top of
the other, may facilitate this examination, especially in obese patients.

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● The popliteal pulse. The patient’s knee should be somewhat flexed, with the leg relaxed. Place the
fingertips of both hands so that they meet in the midline behind the knee and press deeply into the popliteal fossa.
The popliteal pulse is often more difficult to find than other pulses. It is deeper and feels more diffuse. If you cannot
feel the popliteal pulse with this approach, try with the patient prone. Flex the patient’s knee to about 90°, let the
lower leg relax against your shoulder or upper arm, and press your two thumbs deeply into the popliteal fossa.
● The dorsalis pedis pulse. Feel the dorsum of the foot (not the ankle) just lateral to the extensor tendon of
the great toe. If you cannot feel a pulse, explore the dorsum of the foot more laterally.
● The posterior tibial pulse. Curve your fingers behind and slightly below the medial malleolus of the ankle.
(This pulse may be hard to feel in a fat or edematous ankle.)

ABNORMALITIES OF THE ARTERIAL PULSE AND PRESSURE WAVES:

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CHECK FOR UNDERSTANDING (10 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not
allowed. You are given 20 minutes for this activity:

Multiple Choice

1. Intermittent claudication is described as

a. Pain felt in the hands during a cold weather
b. Pain that radiates into the left shoulder and arm
c. Pain or cramping in the legs during walking or exertion
d. Pain felt in the feet due to edema

ANSWER: C
RATIONALE: Intermittent claudication is an aching, crampy, fatigued, and sometimes burning discomfort in
the legs that comes and goes. It is caused by inadequate blood circulation in the arteries of the legs and
often arises with walking and goes away with rest.

2. Edema, varicose veins, and aching in the legs are symptoms of

a. Arterial stasis
b. Venous stasis
c. Arterial pooling
d. Atherosclerosis

ANSWER: B
RATIONALE: Skin thickening and lymphedema can occur as a result of persistent edema. Edema with
varicose veins, ankle telangiectasia, hyper pigmented dermatitis, white atrophy, cutaneous sclerosis, and
eczema or venous ulcers on the lower leg are all signs that the edema is venous in origin.

3. Which of the following findings in the fingertips and toes is usually associated with Raynaud disease?
a. Pallor or cyanosis in the fingertips and toes
b. Redness in the fingertips and toes
c. Clubbing of the fingers and toes
d. Any of the above

ANSWER: A
RATIONALE: Raynaud's disease is marked by intermittent peripheral vasoconstriction, which causes pallor,
cyanosis, and reactive vasodilation of the arterioles of the fingers and toes. These symptoms are
accompanied by chilly or hot sensations, soreness, and difficulties controlling the hands.

4. When asking the female patient about a possible risk for developing blood clots, which of the following
medications that the patient has previous taken should the nurse pay attention to?
a. Aspirin
b. Diphenhydramine
c. Oral contraceptives
d. Warfarin

ANSWER: C
RATIONALE: Medicines can interfere with the body's natural clotting function. Blood clots have been related
to medicines that include the feminine hormone estrogen. Birth control pills and hormone treatment are two
examples of drugs that may contain estrogen.

5. Which of the following type of jobs would increase the risk for the development of a peripheral vascular
disease like varicosities?
a. Truck driver

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 b. Traffic enforcer
c. Call center agent
d. Any of the above

ANSWER: B
RATIONALE: The type of job that would increase the risk for the development of a peripheral vascular
disease like varicosities is the traffic enforcer, because traffic enforcers stand for too long in which causes
varicose.

6. Nurse Mikasa is assessing the patient radial pulse. Upon placing her fingers, she has noted that the patient
has a bounding pulse. The nurse should grade this pulse on her chart as
a. 3+
b. 2+
c. 1+
d. 0

ANSWER: A
RATIONALE: The nurse should grade his pulse on her chart as the recommended grading in bounding pulse
which is 3+.

7. Nurse Sasha is assessing the patient bipedal edema. Upon indenting her finger unto the edema she has
measured for at least 6 mm depression that has lasted for more than a minute. Nurse Sasha must grade this
on her chart as
a. 1
b. 2+
c. 3+
d. 4+

ANSWER: C
RATIONALE: Nurse Sasha must grade on her chart 3+, because when measuring for at least 6mm and would
last for more than a minute then it is already considered as moderately severe pitting edema.

8. Which of the following is NOT a risk factor for the development of peripheral vascular disease?
a. Obesity
b. Smoking
c. Hyperlipidemia
d. Malnutrition

ANSWER: D
RATIONALE: Risk factor of peripheral vascular disease are obesity (overweight), smoking, and
hyperlipidemia (high cholesterol) while malnutrition is a risk factor of peripheral artery disease.

9. Which of the following definitions best describes paradoxical pulse?

a. There is a palpable decrease in the pulse’s amplitude with quiet inspiration.
b. This is caused by a normal beat alternating with a premature contraction
c. The pulse alternates in amplitude from beat to beat even though the rhythm is regular.
d. An increased arterial pulse with a double systolic peak

ANSWER: A
RATIONALE: During inspiration, pulsus paradoxus, also known as paradoxical pulse, is characterized by an
abnormally significant reduction in stroke volume, systolic blood pressure, and pulse wave amplitude. 

10. When the patient has a pulsus alternans, the nurse must suspect for which of the following in the patient?
a. Aortic stenosis
b. Hyperthyroidism

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 c. Pericardial tamponade
d. Left ventricular failure

ANSWER: D
RATIONALE: The nurse must suspect left ventricular failure, because pulsus alternans is most commonly
seen in severe left ventricular heart failure.

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help
you track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

CAT 3-2-1
After the instructor collects all papers, he/she will now summarize the topic. After the lesson, have each student
record three things he or she learned from the lesson. Next, have them record two things that they found interesting
and that they like to learn more about or ask students if they still have something to clarify or clarify about the topic.
After answering the question, station yourself at the door and collect the paper as students depart from the room.
Respond to students’ answer during the next class meeting or as soon as possible

*All these must be done giving importance to social distancing, hygienic practices, and wearing of mask at all times.

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