gloves, centimeter tape stethoscope, doppler ultrasound, probe tourniquet

2. Explain Procedure to client

Explain I. P all 4 extermities, & groin, sit = arms, lie down = legs & groin, follow directions 4 several special assessment techniques. Explain in detail what doing answer any ?

Arms 1. Inspect bilaterally for size, presence of edema, and venous patterning

I. arm size & venous pattern also look for edema

3. I. fingertips 4 clubbing

I. 4 I. angle between nail base & the skin

arms 4. Palpate finger hands and arms for temp.

Using dorsal surface of fingers

Arms, 5 Determine Capillary refill time

compress nailbed /blanches. Release preassure, calculate time = color return

Arm 6. Palpate radial, ulnar & brachial pulses

P. radial = press radial artery against radius (P)Ulnar pulses=apply preassure w/ 1st 3 fingertips 2 medial aspects of inner wrist (P) Brachial = place 1st 3 fingertips (each Hand) @ clients right & L medial antecubital creases

Arm 7 Palpate 4 epitrochlear lymph nodes behind the elbow in groove between the biceps and triceps muscle

take clients left hand in (my ) right hand (shaking hands) flex client elbow ~90Degrees Use (my) left hand P behind the elbow. in groove between biceps & triceps muscle/ If nodes detected P 4 size, tenderness & consistancy. Repeat P opposite arm

Arm 8, Perform Allen's Test

occulding radial & ulnar arteries & observing for palm Pallor. Than release ulnar artery and watch 4 color to return to the hand

Legs 1 I bilaterally 4 skin color

client = supine drape groin area pillow under client head . I. Skin colr both legs fom toes 2 groin

Legs 3 Inspect for lesions or ulcers

I. note wheather margins are smooth and even, location such as @ pressure points, size, depth, drainage odor.

I. 4 edema unilateral or bilateral if valves r asymmetrical measure calf circumference 4 different areas midthigh, calf, above the ankle across the forefoot compare both extermities @ the same locations

Legs 5 If client has edema determine wheather it is pitting or nonpitting. If client has pitting edema rate on a 1+ to 4+ scale

P. edema area press with tips of fingers hold few seconds release. If depression does not rapidly refill & skin remains indented = pitting edema

Legs 6 P skin temperature

P. bilaterally 4 temp. of feet & legs using backs of fingers . Compare findings in the same areas bilaterally. Note location of any changes in temperature

Legs 7 P. superficial inguinal lymph nodes

P. superficial inguinal lymph nodes while keeping the genitials drapped. Feel over the upper medial thigh for the vertical and horizontal groups. If detected note size, mobility, or tenderness

Legs 8 P & A femoral pulses over artery. Listen 4 bruits

Ask client 2 bend knee and move it out 2 the side. Press deeply & slowly below & medial to the inguinal ligament. Use 2 hands if necessary. Release preassure until u feel the pulse. Repeat P. opposite leg. Compare amplitude bilaterally

Legs 9 P. Popliteal,Dorsalis Pedis, and Posterior tibial pulses

Popliteal Pulse = client flex knee, my thumbs on knee, apply preassure to locate the pulse (usually lateral 2 the medial tendon),Dorsalis Pedis,Pulse = Dorsiflex client foot apply light preassure lateral 2 and along the side of extensor tendon of the bi

client = supine position flex knee 5 degres quickly squeeze muscle against tibia

manual compression test

client = stand compress lower part of VV other hand 6-8 inches above hand feel 4 pulse in upper hand

client = supine. elevate clients legs 90 degrees appx 15 sec. apply tourniquet to upper thigh assist client 2 stand I venous filling remove tournaquet watch 4 sudden filling of VV from above

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Stack #35746

Assessment Skill Step #	Assessment Procedure	Rational	Normal Findings	Abnormal Findings	FYI
1. Gather equiptment	gloves, centimeter tape stethoscope, doppler ultrasound, probe tourniquet	na	na	na
2. Explain Procedure to client	Explain I. P all 4 extermities, & groin, sit = arms, lie down = legs & groin, follow directions 4 several special assessment techniques. Explain in detail what doing answer any ?	Ease client anxiety	(blank)	(blank)
3. Ask Client 2 gown	(blank)	(blank)	(blank)	(blank)	(blank)
Arms	(blank)	(blank)	(blank)	(blank)	(blank)
Arms 1. Inspect bilaterally for size, presence of edema, and venous patterning	I. arm size & venous pattern also look for edema	Base line = compare arm size, shape, edema etc.	Arms = bilaterally, minimal variation in size & shape, no edema or prominebt venous patterning	usually affects only 1 extermity = swealling & edema, Proment venous patterning w/ edema = venous obstruction	(blank)
Arms 2. Inspect bilaterally 4 skin color	I. coloration of hands , arms	skin color changes bilaterally can = vasoconstriction /vasospasm of fingers	color = bilaterally	Raynauds Disease = vascular disorder, rapid changes of color, commonly occurs bilaterally	(blank)
3. I. fingertips 4 clubbing	I. 4 I. angle between nail base & the skin	clubbing ~hypoxia	160 degree angle between nail base & skin	early clubbing= 180 Degree angle, late clubbing= > !80 degree angle	hypoxia =is a state of oxygen deficiency in the body which is sufficient to cause an impairment of function
arms 4. Palpate finger hands and arms for temp.	Using dorsal surface of fingers	cool ~ arterial insufficiency	skin = warm bilaterally from tips 2 upper arms	cool extermity, cold fingers & hands	cold fingers & hands common findings in Raynauds Disease
Arms, 5 Determine Capillary refill time	compress nailbed /blanches. Release preassure, calculate time = color return	indicates peripheral perfusion and reflects cardiac output	capillary beds refill = color return 2seconds or,<	cap refill > 2 sec.	cap refill > 2 sec. ~ vasoconstriction, - cardiac output, shock, arterial occulusion, or hypothermia
Arm 6. Palpate radial, ulnar & brachial pulses	P. radial = press radial artery against radius (P)Ulnar pulses=apply preassure w/ 1st 3 fingertips 2 medial aspects of inner wrist (P) Brachial = place 1st 3 fingertips (each Hand) @ clients right & L medial antecubital creases	+ = hyperkinetic state - or absent ~ arterical occulsion	(Radial Pulse)= strength bilaterally (2+) Ulnar pulses= may not be detectable Brachial pulses= strength bilaterally	(Radial Pulse)= increased or decreased Ulnar pulses=- of resilience / inelasticity Brachial = + - or absent	hyperkinetic state
Arm 7 Palpate 4 epitrochlear lymph nodes behind the elbow in groove between the biceps and triceps muscle	take clients left hand in (my ) right hand (shaking hands) flex client elbow ~90Degrees Use (my) left hand P behind the elbow. in groove between biceps & triceps muscle/ If nodes detected P 4 size, tenderness & consistancy. Repeat P opposite arm	enlarged Epitrochlear lymph nodes ~infection, ~ lymphadenopasthy ~ lesions in area	Epitrochlear lymph nodes R not P	enlarged Epitrochlear lymph nodes	lymphadenopasthy
Arm 8, Perform Allen's Test	occulding radial & ulnar arteries & observing for palm Pallor. Than release ulnar artery and watch 4 color to return to the hand	evaluates patency of the radial or ulnar arteries	Ulnar artery Patent =Pink color = palms 3-5 sec. Radial artery patent = Pink color return 3-5 seconds	(blank)	Patent
Legs	(blank)	(blank)	(blank)	(blank)	(blank)
Legs 1 I bilaterally 4 skin color	client = supine drape groin area pillow under client head . I. Skin colr both legs fom toes 2 groin	Pallor, rudor,~arterial insufficiency.cyanosis ~ venous insufficiency. rusty brownish pigmentation arounf ankles ~ venous insufficiency	Lighter skin = pink darker pigmented skin = pink red tones no change in pigmentation	Pallor, rudor,cyanosis, rusty brownish pigmentation arounf ankles	(blank)
Legs 2 I. bilaterally 4 distributation of hair	I. distributation of hair	loss of hair on legs ~ venous insufficiency often thin shiny skin is noted as well	hair covers skin on legs & appears on dorsal surface of toes	loss of hair on legs	Hair loss on lower extermities occurs w/ aging not an absolute sign of arterial insufficiency in the older client
Legs 3 Inspect for lesions or ulcers	I. note wheather margins are smooth and even, location such as @ pressure points, size, depth, drainage odor.	Ulcers smooth even margins that occur @ preassure areas (toes/ lateral ankles)= arterial insufficiency. Ulcers w/ irregular edges bleeding and possible bacterial infection that occur on the medial ankle = venous insufficiency	Legs oare free of lesions or ulcers.	ulcers, lesions	(blank)
Legs 4 I. 4 edema	I. 4 edema unilateral or bilateral if valves r asymmetrical measure calf circumference 4 different areas midthigh, calf, above the ankle across the forefoot compare both extermities @ the same locations	Bilateral edema,~systemic problem unilateral edema ~ venous stasis	Identical size & shape bilaterally no swealling or atrophy	Bilateral edema, unilateral edema	(blank)
Legs 5 If client has edema determine wheather it is pitting or nonpitting. If client has pitting edema rate on a 1+ to 4+ scale	P. edema area press with tips of fingers hold few seconds release. If depression does not rapidly refill & skin remains indented = pitting edema	(blank)	No edema present in legs	pitting edema, edema	a 1+ -4+ scale is used to grade the severity of the edema
Legs 6 P skin temperature	P. bilaterally 4 temp. of feet & legs using backs of fingers . Compare findings in the same areas bilaterally. Note location of any changes in temperature	Abnormal findings `arterial insufficiency, superficial thrombophlebitis	Toes , feet, & legs =ly warm bilaterally	generalized coolness in 1 leg or change in temp. from warm 2 cool {moving down the leg}	(blank)
Legs 7 P. superficial inguinal lymph nodes	P. superficial inguinal lymph nodes while keeping the genitials drapped. Feel over the upper medial thigh for the vertical and horizontal groups. If detected note size, mobility, or tenderness	Enlarged node Lymphadenopathy ~ local infection, generalized Lymphadenopathy. Fixed nodes ~ malignancy	nontender moveable lymph nodes up to 1 or 2 cm	Lymph nodes > than 2 cm. w or w/o tenderness. Fixed nodes	(blank)
Legs 8 P & A femoral pulses over artery. Listen 4 bruits	Ask client 2 bend knee and move it out 2 the side. Press deeply & slowly below & medial to the inguinal ligament. Use 2 hands if necessary. Release preassure until u feel the pulse. Repeat P. opposite leg. Compare amplitude bilaterally	weak or absent femoral pulses ~partial or complete arterial occlusion	Femoral pulses strong and = bilaterally	weak or absent femoral pulses	(blank)
Legs 9 P. Popliteal,Dorsalis Pedis, and Posterior tibial pulses	Popliteal Pulse = client flex knee, my thumbs on knee, apply preassure to locate the pulse (usually lateral 2 the medial tendon),Dorsalis Pedis,Pulse = Dorsiflex client foot apply light preassure lateral 2 and along the side of extensor tendon of the bi	Pulse findings + further circulatory assessment (temp & Color) are warranted to determine the significance of an absent pulse	Popliteal,Pulse may not be detected.Dorsalis Pedis,= bilaterally strong and Posterior tibial pulses = strong bilaterally	Popliteal Pulses = absent Dorsalis Pedis,pulse = weak or absent and Posterior tibial pulses =weak or absent pulse	Posterior tibial pulses found by P behind & just below the medial malleolus
I for varicosities and Thrombophlebitis	ask client to stand	varicose veins R not as pronounced when client = supine	veins are flat and barly seen under skin surface	distended nodular, bulging tortous,	(blank)
check 4 holmans sign	client = supine position flex knee 5 degres quickly squeeze muscle against tibia	check for arterial or venous -	Holmans sign =-	Holmans sign =+	(blank)
manual compression test	client = stand compress lower part of VV other hand 6-8 inches above hand feel 4 pulse in upper hand	check 4 valve competency	no pulse palpated	you will feel pulses in your fingers if the valves in the veins are incompetent	(blank)
trendelenberg test	client = supine. elevate clients legs 90 degrees appx 15 sec. apply tourniquet to upper thigh assist client 2 stand I venous filling remove tournaquet watch 4 sudden filling of VV from above	determine competence of saphenous vein valves & check ror retrograde filling of the superficial veins. Saphenous vein fills from below in 30 seconds	No retrograde filling = compent valves	filling from above= incompontent valves	(blank)

Created by: garrowcousino

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