Stack #35746

Help!

Assessment Skill Step #

Assessment Procedure

Rational

Normal Findings

Abnormal Findings

FYI

1. Gather equiptment

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 ?

Ease client anxiety

(blank)

🗑

3. Ask Client 2 gown

(blank)

🗑

Arms

(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)

🗑

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)

🗑

Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.

To hide a column, click on the column name.

To hide the entire table, click on the "Hide All" button.

You may also shuffle the rows of the table by clicking on the "Shuffle" button.

Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.

Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

Normal Size Small Size show me how

Created by: garrowcousino