NR 304 Exam 1

NR 304 Exam 1

Student Name

Chamberlain University

NR-304: Health Assessment II

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Date

Peripheral Arterial Disease (PAD) and Related Conditions

Peripheral Arterial Disease (PAD) is primarily the result of atherosclerosis, a condition in which plaques accumulate on arterial walls. These plaques render the arteries rough and fragile, limiting blood supply and increasing resistance to flow. PAD may involve either the inflow arteries (such as the distal aorta and iliac arteries) or the outflow arteries (including femoral, popliteal, and tibial arteries). Contributing factors include cigarette smoking, diabetes mellitus, and hypertension.

Clinical Assessment

Subjective Findings:

• Complaints of leg pain or cramping
• Skin changes on limbs
• Limb swelling or palpable lymph nodes
• Medication history
• Smoking habits

Objective Findings:

• Evaluate skin color, temperature, texture, and turgor in the arms
• Inspect for edema, clubbing, capillary refill time
• Palpate radial and brachial pulses, noting elasticity and strength
• Observe lower limbs for color, hair pattern, size, and venous patterns
• Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses

Symptoms of PAD

• Burning or cramping during physical activity
• Pain relief when legs are positioned dependently
• Diminished capillary refill
• Hair loss on the lower extremities
• Palpable pulse reduction
• Cool, cyanotic extremities
• Dependent rubor (dusky-red coloration in dependent position)
• Presence of ulcers or gangrene on toes

Risk Factors and Special Populations

• Cigarette smoking is the most critical risk factor
• High cholesterol levels and obesity
• Women with depression are more susceptible
• African Americans are twice as likely to develop PAD
• Comprehensive screenings are necessary for high-risk groups
• Ankle Brachial Index (ABI) is a primary noninvasive screening tool

Example of PAD: Raynaud’s Syndrome

• Vasospasms in small arteries cause numbness and cold sensations, typically triggered by cold or stress
• More common in women and cold climates

Common Symptoms:

• Cold, discolored fingers or toes
• Numbness or stinging pain when warming
• Progressive skin color changes: white → blue → red

Developmental Considerations in Peripheral Health

Infants and Children

• Palpable lymph nodes are common
• Lymphoid tissues are well-developed at birth and grow until adolescence

Pregnant Women

• Bilateral pitting edema and varicose veins are expected
• Uterine pressure can impede venous return, increasing pressure

Older Adults

• Dorsalis pedis and posterior tibial pulses may be harder to detect
• Trophic skin changes occur (e.g., thinning, hair/nail changes)
• Increased incidence of PAD with age (20% in those >70 years, 50% in those >85 years)
• Delayed diagnosis due to reduced activity or comorbid conditions like arthritis

Arterial vs. Venous Disorders

Diagnostic Tests and Techniques

ABI (Ankle-Brachial Index)

• Non-invasive test using Doppler ultrasound
• Formula: Highest ankle systolic pressure ÷ Highest arm systolic pressure

Lymphatic System Overview

The lymphatic system is responsible for conserving plasma proteins, defending against pathogens, and absorbing lipids from the intestines. Without adequate lymphatic drainage, fluid accumulation results in edema.

Key Lymphatic Structures:

• Right Lymphatic Duct: Drains right side of the head, thorax, and right arm
• Thoracic Duct: Drains the rest of the body

Lymph Node Clusters:

• Cervical: Drains head and neck
• Axillary: Drains upper limbs and breast
• Epitrochlear: Drains lower arm and hand
• Inguinal: Drains lower extremities and genitalia

Associated Organs:

• Spleen: Filters blood, destroys old RBCs, stores RBCs, produces antibodies
• Tonsils: Respond to local infection
• Thymus: T-cell maturation in children

Lymphedema

Lymphedema is the accumulation of protein-rich fluid in tissues following breast surgery or lymph node removal. It presents as non-pitting edema with skin induration. Early interventions include compression garments, manual lymphatic drainage, and strengthening exercises.

Abnormal Findings and Clinical Indicators

Doppler Ultrasonography and Additional Testing

• Doppler Ultrasound: Detects weak peripheral pulses
• Allen Test: Checks arterial blood supply to the hand
• Monofilament Testing: Used to detect sensory loss in diabetic patients
• Bruit Detection: Indicates turbulent blood flow suggestive of arterial narrowing

Prevention and Management

• Smoking cessation is critical to PAD prevention
• Compression garments should be avoided in PAD patients
• Risk reduction includes managing hypertension, cholesterol, and diabetes
• Physical activity should be encouraged, except during acute DVT
• ABI should be routinely performed in high-risk populations

  Arterial Ulcers (Ischemic Ulcers)

Arterial ulcers, commonly associated with ischemia, arise due to reduced blood flow, often caused by atherosclerosis—the accumulation of fatty plaques within arterial walls. This condition results in vascular calcification and arterial hardening. Elevation of the affected limb can intensify pain, and rest pain typically signals disease progression. Clinically, patients may present with dependent rubor, pallor upon elevation, diminished peripheral pulses, and systolic bruits. Other signs include malnutrition of surrounding tissues, manifested as thin and shiny skin, thickened and ridged nails, muscle atrophy, and distal gangrene.

These ulcers frequently appear at distal locations such as the toes, metatarsal heads, heels, and lateral malleoli. They are characterized by a pale, ischemic base, sharply defined edges, and absence of bleeding—giving them a dry and “punched-out” appearance. Individuals with a history of smoking, diabetes mellitus, hyperlipidemia, or hypertension are at greater risk.

Venous Ulcers (Stasis Ulcers)

Venous ulcers, also known as stasis ulcers, commonly develop following deep vein thrombosis (DVT) or chronic venous insufficiency. The discomfort typically worsens with prolonged standing or sitting and alleviates upon limb elevation. Associated symptoms include itching due to stasis dermatitis and lower leg edema that is often resistant to diuretic therapy.

Physical findings include firm, brawny edema, coarse, thickened skin, and brown pigmentation caused by hemosiderin deposition. Pulses are usually palpable. The pathology involves venous hypertension that forces red blood cells into the dermis, where they disintegrate. Resulting ulcers tend to be shallow, moist, and are often accompanied by granulation tissue and pruritic dermatitis.

Neuropathic Ulcers

Neuropathic ulcers are primarily seen in individuals with diabetes mellitus and are classified under arterial ischemic ulcers. These ulcers result from a generalized dysfunction of the peripheral arterial system affecting sensory, autonomic, and motor functions. Sensory neuropathy causes diminished sensation, autonomic involvement reduces sweating and impairs skin integrity, and motor dysfunction leads to foot deformities.

These ulcers often occur at sites of repetitive pressure and trauma. Notably, approximately half of diabetic foot ulcers become infected, with up to 20% progressing to amputation. Symptoms may include numbness, tingling, burning pain, allodynia, decreased reflexes, impaired proprioception, and muscle wasting.

Table: Comparison of Ulcer Types

Superficial Varicose Veins

Superficial varicose veins result from chronic venous pressure, often due to obesity or multiple pregnancies. Incompetent valves cause backward blood flow, leading to vein dilation. These are more common in women and older adults, with vessels ranging from 1 mm to 1 cm and varying in color from red to bluish-purple.

Subjectively, patients may report aching, heaviness, cramping, burning, or restless legs. Objectively, the veins appear dilated, tortuous, and are found both on the surface and deeper within tissues.

Deep Vein Thrombophlebitis (DVT)

DVT involves thrombus formation within deep veins, leading to inflammation, blocked venous return, cyanosis, and edema. It is often triggered by immobility, trauma, varicose veins, cancer, or hormone use. Patients face an elevated risk of pulmonary embolism.

Clinically, there is sudden onset of sharp, deep muscle pain, increased warmth, erythema, swelling, and tenderness to palpation. DVT in the upper extremities is becoming more common due to the frequent use of central venous catheters.

Occlusions

Arterial occlusions arise from progressive atherosclerosis, leading to fibrous plaque and thrombus formation. This narrows the vessel lumen, compromising oxygen and nutrient delivery to tissues. Risk factors include obesity, smoking, hypertension, diabetes, high cholesterol, and sedentary lifestyle.

Aneurysms

Aneurysms are localized arterial dilations due to weakening of the vessel wall, often caused by atherosclerosis. Blood pressure exerts force on the stretched wall, creating a balloon-like outpouching. The aorta is the most commonly affected site. Incidence increases significantly in men over 55 and women over 70, occurring 4 to 5 times more often in men.

Liver Examination

Pain during abdominal palpation may be unilateral and localized. This discomfort can intensify with increased intra-abdominal pressure, such as when attempting to sit up. The liver, a major organ in the right upper quadrant (RUQ), is evaluated through palpation techniques aimed at assessing size, consistency, and tenderness.

To palpate the liver:

• Position the patient supine and place your left hand under the posterior lower rib cage (11th and 12th ribs) to support the abdominal contents.
• Place your right hand on the RUQ, fingers parallel to the midline.
• Instruct the patient to breathe slowly.
• During exhalation, press your fingers deeper and move up 1 to 2 cm.
• Normally, the liver edge may be felt as a smooth, firm ridge during inhalation.

In cases such as chronic emphysema, the liver may be displaced downward due to lung hyperinflation, yet remain within normal size limits.

NR 304 Exam 1

Hooking Technique

An alternative liver palpation method involves:

• Standing at the patient’s shoulder and turning toward their feet.
• Hooking your fingers under the right costal margin.
• Asking the patient to take a deep breath, attempting to feel the liver edge tap your fingertips.

Abnormal Findings

Tenderness may indicate localized inflammation, peritonitis, or organ enlargement. If the liver edge extends more than 1 to 2 cm below the costal margin, further investigation is warranted. A firm consistency may suggest cirrhosis. Document the liver’s descent in centimeters and evaluate for pain and texture.

Scratch Test

This traditional method detects the liver’s lower border when palpation is difficult (e.g., due to obesity or guarding).

Procedure:

• Place the stethoscope over the xiphoid process.
• Lightly stroke the skin upward along the midclavicular line (MCL) starting from the right lower quadrant.
• A magnified sound indicates contact with the liver edge.

This technique is beneficial when standard palpation is not feasible (Trowbridge et al., 2007).

Spleen Examination

The spleen is typically non-palpable unless enlarged at least threefold.

Palpation Technique:

• Use your left hand to support the posterior lower left ribs.
• Position your right hand obliquely in the left upper quadrant (LUQ), fingers pointed toward the left axilla.
• Push deeply under the left costal margin and ask the patient to breathe deeply.

An enlarged spleen may slide out and touch your fingers. If suspected, roll the patient onto their right side and repeat the palpation.

Abnormal Findings

If splenomegaly is detected, avoid repeated palpation due to the risk of rupture. Use imaging for confirmation and measure the distance it extends below the costal margin (Bickley, 2021).

Kidney Examination

Palpation focuses on the right kidney, which may occasionally be felt.

Palpation Technique:

• Use a bimanual approach (duck-bill shape) at the right flank.
• Ask the patient to inhale deeply.
• A normal response is no detectable mass.

The left kidney, positioned 1 cm higher, is usually non-palpable. Support from behind and deep pressure in the LUQ may occasionally detect the lower pole.

Abnormal Findings

Enlarged kidneys may suggest hydronephrosis, tumors, or polycystic kidney disease.

Aortic Palpation

To assess the aorta:

• Use your thumb and forefinger to palpate slightly left of the midline in the upper abdomen.
• A normal width ranges from 2.5 to 4 cm with anterior pulsations.

Abnormal Findings

Widening or lateral pulsations may suggest an abdominal aortic aneurysm (AAA). The pulsations may separate your fingers. However, palpation accuracy may be limited due to adipose tissue or deep vessel positioning.

NR 304 Exam 1

Percussion for Ascites

Ascites, an abnormal accumulation of fluid in the peritoneal cavity, presents with abdominal distention, bulging flanks, and a downward-displaced umbilicus.

Fluid Wave Test

• Position a hand on the abdomen’s midline.
• Strike the left flank while placing your opposite hand on the right flank.
• A fluid wave felt on the left hand suggests ascites.

Shifting Dullness Test

• With the patient supine, percuss from the midline toward the flanks.
• A change from tympany to dullness indicates fluid accumulation.
• Mark the fluid level.

Common Causes of Ascites

Although these tests are indicative, ultrasound remains the gold standard for diagnosis (Runyon, 2009).

Palpation for Rebound Tenderness

Rebound tenderness indicates peritoneal irritation and is assessed last due to discomfort.

Procedure:

• Choose an area distant from the pain.
• Push down deeply at 90 degrees and release quickly.

A positive result (pain upon release) may indicate appendicitis or peritonitis. The Blumberg sign (pain in the RLQ with LLQ palpation) is a specific indicator of appendicitis.

Murphy’s Sign

Used to detect gallbladder inflammation.

Procedure:

• Press under the liver border and ask the patient to inhale.
• A positive test is indicated by sudden pain or halted inspiration.

Accuracy may decline in older adults, with 25% of individuals over 60 not reporting tenderness (Jensen et al., 2011).

Abdominal Distention Causes

References

Bickley, L. S. (2021). Bates’ Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer.

Jensen, M. D., et al. (2011). Gallbladder disease in older adults. Gastroenterology Clinics, 40(3), 507-517.

Runyon, B. A. (2009). Introduction to the revised American Association for the Study of Liver Diseases practice guideline management of adult patients with ascites due to cirrhosis. Hepatology, 49(6), 2087-2107.

Trowbridge, R. L., Rutkowski, N. K., & Shojania, K. G. (2007). Does this patient have splenomegaly? JAMA, 297(17), 1944-1951.

Bickley, L. S. (2020). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.

McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.

NR 304 Exam 1

National Institute for Health and Care Excellence (NICE). (2023). Chronic venous leg ulcers: Management guidelines. Retrieved from https://www.nice.org.uk

Wound, Ostomy and Continence Nurses Society (WOCN). (2021). Guideline for management of wounds. Retrieved from https://www.wocn.org

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier Health Sciences.

Centers for Disease Control and Prevention (CDC). (2021). Peripheral Arterial Disease (PAD). https://www.cdc.gov/heartdisease/PAD.htm

American Heart Association (AHA). (2020). Understanding Peripheral Artery Disease (PAD). https://www.heart.org/en/health-topics/peripheral-artery-disease

National Heart, Lung, and Blood Institute. (2022). Raynaud’s Phenomenon. https://www.nhlbi.nih.gov/health/raynauds