Download Cardiovascular System

Assessment of the Thorax and
Lungs, Cardiovascular &
Peripheral Vascular Systems
Diagnostic Reasoning for Advanced Practice Nursing
FNP 431
2014
Crystal A. Smith, MSN, APN, CNP
A & P Thorax and Lungs
Note: each interspace is numbered by the rib above
it.
Ribs 1-7 articulate to
the sternum.
Ribs 8-10
articulate to the costal
cartilage just above them.
Ribs 11-12 “float” with no
anterior articulation. The
11th rib tip can be felt
laterally and the 12th rib
Felt posteriorly.
Note the costal angle usually
90 degrease at xiphoid, with
chronic overinflation angle increases
as with emphysema.
A & P Thorax and Lungs
Reference lines help us to pinpoint findings, describe
findings, and be aware of underlying anatomy.
Also use reference of Anterior and Posterior Axillary lines and
the Midsternal line (dotted lines).
Anterior View
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Lateral View
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Posterior View
A & P Thorax and Lungs
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Notes
◦ The left lung has no middle lobe.
◦ The anterior chest contains mostly upper and
middle lobe with very little lower lobe.
◦ The posterior chest contains almost all lower
lobe.
◦ Primary muscle-diaphragm
 Secondary muscles include scalenes and
parasternals
 Accessory muscles are used in exercise and with
certain diseases-the sternomastoids, the scalenes,
and the abdominal muscles assist and are much
more visible.
A & P Thorax and Lungs
The Pleurae is the thin (few millimeters)
envelope of slippery lubricating fluid between
the lungs and the chest wall. It has a vacuum
(negative pressure) and holds the lungs tightly
against the chest wall which allows for ease of
smooth respirations.
 The Trachea and the Bronchi

transport gasses between the environment and the
lung parenchyma.
 protect the lungs by screening the air for
environmental particulates and secreting mucus that
entraps the particles via the goblet cells that line the
bronchi.

A & P Thorax and Lungs
A & P Thorax and Lungs
Posterior View of Fields
A & P Thorax and Lungs
Lateral View of Fields
A & P Thorax and Lungs
Radiograph
Thorax and Lungs
Interviewing/Health Hx/Causes

Common Symptoms
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Chest Pain
Dyspnea and dyspnea on exertion
Wheezing
Cough
Hemoptysis
Initially open ended questions, then clarify
issue more and ask more specific
questions. OLD CART the issue.
Thorax and Lungs
Interviewing/Health Hx/Causes
Chest Pain-tease out cardiac vs thorax
and lung.
 Lung tissue has no pain fibers
 BUT

◦ an inflammatory process with the parietal
pleura from pulmonary infarction or
pneumonia causes pain.
◦ A muscle strain supporting the lung
parenchyma causes pain.
◦ An inflammatory process from anxiety or
tachycardia from anxiety causes pain.
Thorax and Lungs
Interviewing/Health Hx/Causes

Dyspnea
◦ Awareness that effort of breathing inappropriate.
◦ Occurs in chronic lung disease like COPD, cystic
fibrosis, and asthma.
◦ Make every effort to determine severity of
dyspnea based on the patient’s daily activities
 COPD-“Have you had to stop going upstairs to do
laundry because of being short of breath?”
 Anxious or tachycardic cause-dyspnea is usually
explained by inability to “get a deep or good
breath” often associated paresthesias around the lips or
in the extremities.
Thorax and Lungs
Interviewing/Health Hx/Causes
◦ Wheezing
 Musical respiratory sounds that are often audible to
the patient and others.
 Occur because of an obstruction in the airway due
to inflammation as in asthma, secretions, or a
foreign body.
◦ Cough
 Reflex response to irritants in the larynx, trachea,
or large bronchi.
 Internal irritants-mucus, blood, mucus, and puss
 External irritants-dust, foreign bodies, and hot or cold air.
Thorax and Lungs
Interviewing/Health History

Cough continued-Causes
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infection-viral URI being most common cause.
Inflammation of the parenchyma
Inflammation from a tumor or TB
Enlarged parabronchial lymph *
Cardiovascular causes-left ventricular heart
failure
◦ Esophageal causes-reflux
◦ Postnasal drip
◦ Chronic bronchitis
Thorax and Lungs
Interviewing/Health History
*Hilar
Thorax and Lungs
Interviewing/Health Hx/Causes

Questions to ask regarding the cough
◦ Duration
 Acute-lasting less than 3 weeks
 URI most commonly, asthma, foreign body, acute bronchitis,
left sided heart failure
 Subacute-lasting 3-8 weeks
 Postinfection cough-reactive airway, bacterial sinusitis,
asthma
 Chronic-lasting more than 8 weeks
 Postnasal drip, asthma, chronic bronchitis, bronchiectasis
Thorax and Lungs
Interviewing/Health Hx/Causes
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Is the cough dry or productive?
If productive
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Sputum volume
Color
Consistency
Odor
Other questions to ask:
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Fever
CP
Dyspnea
Orthopnea
Change in ADL’s to accommodate
wheezing
Thorax and Lungs
Interviewing/Health Hx/Causes
Large volume-lung abscess, CF or any
bronchiectasis
 Mucoid sputum is clear, white, or grey
 Purulent sputum is yellow or green
 Hemoptysis rare in children, common
with CF, cause may be post nasal, lung, or
stomach (darker)
 Malodorous-anaerobic lung abscess or to
some extent any bacterial process

Thorax and Lungs
Interviewing/Health Hx/Causes

Asking about smoking-calculate smoking pack-years:
◦ –Divide the number of cigarettes smoked per day by 20
(the number of cigarettes in a pack)
◦ –Then multiply by the number of years smoked
(70cigarettes/day ÷20 cigarettes/pack) X 10years =
35pack-years
 (35cigarettes/day ÷20 cigarettes/pack) X 20years =
35pack-years
 (10cigarettes/day ÷20 cigarettes/pack) X 35years =
17.5pack-years
 (10cigarettes/day for 10 years and 30 cigarettes a
day for 15 years)=10cig ÷ 20poss x 10years= 5 pack
years; 30cig ÷ 20poss x 15 years=22.5 pack years+
5 pack years = 27.5 pack years in total.

Thorax and Lungs
Interviewing/Health Hx/Causes
Knowing ABC’s
A=Airway (midline, patent
B = Bones (fractures, lytic lesions)
C = Cardiac Silhouette size (should
be less than 50%)
D = Diaphragm (flat or elevated
hemidiaphragm?)
E = Edges (borders) of heart
F = Fields (lung fields well inflated; no
effusions, infiltrates, or nodules noted)
G = Gastric Bubble
H = Hilum (nodes, masses)
I = Instrumentation
Normal
Thorax and Lungs
Interviewing/Health Hx/Causes

Pneumonia: lung infection caused by
bacteria, a virus or fungi.
Thorax and Lungs
Interviewing/Health Hx/Causes
Bronchiectasis
abnormal dilatation of the bronchial tree
congenital- congenital bronchiectasis, CF
post infective- (most common)
necrotizing bacterial pneumonia e.g Staph aureus,
Klebsiella, B pertussis, granulomatous diseasetuberculosis, MAIC, histoplasmosis, allergic over
immune response, measles.
cancer or chronic foreign body
It is largely considered
irreversible
Note- tram track opacities
or bronchovascular
markings/rings
Lung and Thorax Health Promotion

Tobacco cessation
◦ 5 A’s
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ASK about use of tobacco
ADVISE to quit
ASSESS willingness to make a quit attempt
ASSIST in quit attempt
Arrange follow-up
◦ More than 80% of smokers who try to quit on
their own resume within 30 days, only 3% success
@ 1 year
◦ Increase risk with tobacco use: CA, COPD, CAD,
Stroke, PVD, URI’s, Ear infections, lung infections,
birth defects and complications…
Lung and Thorax Health Promotion

Immunizations
◦ See CDC recommendations for influenza and for strep
pneumococcal-at risk, immunocompromised
◦ Influenza deaths vary greatly by year and severity-4,000 to
36,000 Estimate Number of deaths 2012: 1,532
 About 40% U.S. immunized with lowest stat being 18-26 year olds
at 25%
◦ Step pneumo cause of pneumonia and meningitis
 CDC Pneumonia stats 2012: Percent of adults 65 years and over
who had ever received a pneumococcal vaccination: 59.9%,
Number of deaths: 52,294

Exercise
◦ Increased oxygenation
◦ Increased blood flow and with that decreased infection
◦ Increased stamina and function
Techniques of Exam

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Inspect, palpate, percuss, auscultate
Inspect
◦ Patient sitting posterior and anterior-arms folded.
◦ Anterior with the patient supine
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Respirations per minute normals
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Adults 14-20
Newborn to 6 months 30-60
6-12 months 24-30
1 to 5 years 20–30
6 to 12 years12–20
Techniques of Exam
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Inspection
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color for cyanosis
neck for use of accessory muscles
trachea to see if midline
listen for wheezing or quality of cough
Observe for shape of the chest AP diameter
increases with aging and with COPD
◦ Deformities or asymmetry of the chest
expansion or impaired respiratory movement.
Techniques of Exam

Palpation
◦ Tender areas and visible abnormalities
◦ Test chest expansion (excursion)
 Place thumbs at level of 10th ribs, fingers loosly
grasping and parallel to the lateral rib cage
 Slide them medially just enough to raise a loose fold
of skin along the spine
 Tell patient “take a nice deep breath” and watch the
distance between thumbs as they move apart with
inspiration
 Unilateral decrease found with CF, pleural effusion, lobar
pneumonia, pleural pain
Techniques of Exam

Palpation
◦ Feel for tactile fremitus (vibrations transmitted
through the bronchopulmonary tree-have the
patient say “ninety-nine” as you palpate with the
ulnar surface of your hand.
◦ Fremitus more prominent interscap and lower
lungs (pg. 308 Daines)
◦ Note increased, decreased, or absent fremitus.
 Fremitus decreased or absent when the voice is high
pitched or soft, in a person with a thick chest wall, with an
obstructed bronchus, COPD, pleural effusion, CF,
pneumothorax, or tumor
 Fremitus increased with pneumonia from the increased
transmission of sound through consolidated tissue.
Techniques of Exam
Anterior and Posterior areas for Tactile fremitus
Techniques of Exam

Percussion
◦ Hyperextending the 3rd digit of the hand and
press the DIP firmly on the surface to be
percussed avoiding any other surface contact
by the hand. With a striking motion and
relaxed wrist strike the DIP with the tip of
the other hands 3rd digit. Move briskly.
◦ Resonance is NORMAL
Techniques of Exam
◦ Percussion abnormals
 Dullness replaces resonance when fluid or solid
tissue replaces air
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Lobar pneumonia when alveoli have fluid and blood in them
Pleural accumulation of fluid as with pleural effusion
Blood-hemothorax, pus-empyema
Fibrous tissue or tumor
 Flatness heard with large fluid mass
 Hyperresonance heard
 Hyperinflated lungs of COPD or asthma- excessive air
 Large pneumothorax
 Tympany-high, hollow, drum like sound heard over
the stomach usually-in the lungs indicates a
pneumothorax
Techniques of Exam
Areas for Percussion and Auscultation
Techniques of Exam

Auscultation
◦ Vesicular or soft and low pitched heard through
inspiration, continue without pause through expiration,
and then fade away about one third of the way through
expiration.
 Heard over most of the lung fields
◦ Bronchovesicular inspiratory and expiratory sounds equal
 Heard over the 1st and 2nd intercostal spaces anteriroly and
between the scaps posteriorly.
◦ Bronchial-louder, harsher and hight in pitch, with a short
silence between inspiration and expiration sounds.
Expiration longer.
 Heard over the manubrium
◦ Tracheal-inspiratory and expiratory sounds are equal
 Very loud over the trachea in the neck
Techniques of Exam
Auscultation continued
 http://www.practicalclinicalskills.com/lungsounds.aspx

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Nonmusical or discontinuous
◦ Crackles (generally high-pitched, discontinuous sounds)
 Coarse: loud, low-pitched sounds
 Fine: soft, high-pitched sounds
◦ Pleural friction rubs (grating sound)

Musical or continuous
◦ Wheezes high-pitched sounds that are musical in quality
◦ Rhonchi low pitched with a “snoring” or “gurgling” quality
◦ Stridors sounds heard over the trachea
Techniques of Exam
Techniques of Exam
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Any time that the spoken word is louder with
auscultation think-consolidation
Any time with wheezing-think narrowed
airways-asthma, allergic reaction, emphesema
Any time there is tracheal deviation, inability
to breath well with CP think- pneumothorax
Any time cough associated with febrile illness
and exam shows consolidation thinkpneumonia and check chest x-ray
See table 8-7 in Daines, pgs 330-331
Techniques of Exam
A and P of the CV system

Provide to tissues
◦ oxygen, nutrients, hormones, vitamins

Gets rid of from tissues
◦ heat, CO2, nitrates, water

Closed system
◦ Interconnected organs and tubing (easy to
add fluid)
◦ Difficult to get rid of extra fluid - must
depend on the kidneys
A and P of the CV system

2-sided pump
◦ Left side works harder than right side
◦ Left side is under more pressure
◦ Atria contraction responsible for 25% of
ventricular filling
◦ Right ventricle occupies most of the anterior
cardiac surface
◦ The “base of the heart” refers to the superior
aspect of the heart at the right and left 2nd
interspace next to the sternum.
A and P of the CV system
Blood pathway
Superior/Inferior Vena
Cavas → RA →
Tricuspid→ RV →
Pulmonic valve → Lungs
→ Pulmonary vein → LA
→ Mitral valve → LV →
aortic valve → Body
Note: Pulmonary vein is
the only vein to carry
oxygenated blood.
A and P of the CV system

The right side of the heart collects
venous blood and pumps it to the lungs
via the pulmonary artery; the blood
returns via four pulmonary veins to the
left atrium, then it is pumped from the left
ventricle to the body. Events happen
simultaneously on the right and left side.
Heart Sounds
“Noises” (heart sounds) due to closure of valves (healthy valves make no
noise when opening)
Opening “snaps” = usually bad valve
Lubb
Dubb
Lubb
S1 →→→ S2 →→→ S1 →→→
↓
↓ S3
S4
↓
↓
Closing of
Mitral
Aortic
Valves
Tricuspid
Pulmonic
MT
Dubb
S2
AP
Left valves (M and A) are under the most pressure
Heart Sounds

S1
◦ synchronous with the carotid (So if not sure
of which sound is S1, feel for carotid at the
same time)

Splitting of S1
◦ mitral under more pressure, more likely to
close first. No clinical significance.
Heart Sounds
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Split S2 = aortic closes first (“Lubb-spit”)
= physiological splitting (more common
than paradoxical) due to more pressure in
left side
Heart Sounds
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Paradoxical splitting of S2 (“opposite”) =
pulmonic valve closes first (still sounds like
“Lubb-spit”).
◦ When patient blows air out, physiological split
stops due to change in the intrathoracic
pressure/blood flow.
◦ The paradoxical splitting will not stop (can’t be
“blown away”).
◦ Then take deep breath in and split S2 goes away =
Paradoxical splitting
◦ Causes:
 Left bundle branch block (LBBB)
 Aortic stenosis (having trouble closing, common in
elderly)
Heart Sounds

Fixed splitting S2: Can’t get it to go away
with inspiration, expiration, turning, or
moving
◦ Causes: Atrial -Septal Defect (ASD) - more
common in women
Previously: as patients aged with ASD, they
had pulmonary hypertension and enlarged
hearts, and usually died by 60.
 Now: often fixed before having any
symptoms

Heart Sounds

S3 = ventricular gallop secondary to
ventricle “shuddering”
◦ Ventricle is being overworked, but tries to give
one more push of blood out.
Ken - tuc - ky
Lubb - dubb - dubb
(S3)


S3 = normal in children
In adults, S3 means CHF!!!
Heart Sounds
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S4 = atrial gallop, made by atria giving one more “umph” (push) to
push blood out
◦ Usually by the time S4 appears, atria are not in too good of shape
◦ Difficult to hear
Tenn - ess – ee
Lubb-lubb-dubb
(S4)
May have S4 in:
post-MI
hyperthyroidism
aortic stenosis (very common in the elderly - valve worn
out; pt. faints from blood not getting to brain, has
carotid bruits)
Most common cause: chronic hypertension (whether
treated or not)
Heart Sounds

S3 more serious than S4
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Summation gallop ◦ a combination S3, S4 (both present)
◦ atrial contraction superimposed on ventricular
filling
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Hear splits best in pulmonic area
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Hear S3, S4, S1 best at apex
Heart Sounds
“Silences” are also important:
Lubb
Dubb
S1
S2
S3
Systole
Lubb
S1
S4
Diastole
-------One Cardiac Cycle------S3 and S4 occur during diastole.
Dubb
S2
Heart Sounds
Systolic murmurs involves S1, S2
Some are pathologic
 Diastolic murmurs - all are pathologic
“Bad things happen in the diastolic phase”.
 Tap out the “Lubb-Dubb” with your fingers

◦ If there is a noise between Lubb and Dubb =
systolic sound
◦ If there is a noise after Dubb = diastolic sound
Interviewing/Health Hx/Causes
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Chief Issues
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Chest pain
Palpitations
Shortness of breath (PND)
Edema
Syncope
History of present illness
◦ OLDCART
Interviewing/Health Hx/Causes
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Review of systems
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Past medical history
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Inquire about any raised blood pressure, heart problems, fainting,
dizziness or shortness of breath.
Any heart attacks, any history of angina, any cardiac procedures or
operations (type and date of intervention and outcome)?
Previous levels of lipids if ever checked or known.
Any history of rheumatic fever or heart problems as a child?
General: any other operations or illnesses, especially history of
myocardial infarction, hyperlipidaemia, hypertension, strokes,
diabetes?
Interviewing/Health Hx/Causes

Family history
◦ Ask about hypertension, ischaemic heart disease, strokes,
diabetes, hyperlipidaemia, congenital heart disease, early
deaths (before the age of 60) in the family.

Social/Personal history Lifestyle and Risk Factors
◦ Smoking
◦ Obesity: calculate body mass index (BMI); acute weight
increase may indicate fluid retention and heart failure.
◦ Diet: healthy or unhealthy.
◦ Employment: sedentary? Stress?
◦ Home life: stress? Change of ADL’s to accommodate issue?
◦ Recreation and exercise
Interviewing/Health Hx/Causes
 Other
questions one might explore:
◦ Dyspnea on exertion is the most common type
of dyspnea and may precede other evidence of
heart failure.
◦ Orthopnea: does the patient have to sleep
propped up at night, and if so with how may
pillows?
◦ Edema? Asking about tight rings, shoes, belts
Interviewing/Health Hx/Causes

Continued-Other questions to explore
◦ Any paroxysmal nocturnal dyspnea or
breathlessness at rest? These may last from
minutes to hours and be accompanied by
wheezing, sweating, distress, and cough with
frothy or bloodstained sputum. This is
commonly termed “cardiac asthma.”
◦ Cheyne-Stokes or periodic breathing: this
often occurs during sleep, with a long cycle
time, and may be found in chronic pulmonary
edema or poor cardiac output.
Interviewing/Health Hx/Causes
Continued-Other questions to explore
 Palpitations-do not necessarily indicate any
underlying cardiac pathology but may be
presentation of a cardiac arrhythmia.

◦ Description may be bumping, throbbing, or
thumping.
◦ Duration: sudden short episodes suggest
paroxysmal tachycardia; longer duration with
irregularities suggests atrial dysrhythmia.
◦ Associated symptoms: pain, dyspnea, feeling faint
or syncope.
Interviewing/Health Hx/Causes

Other history to explore
◦ Drugs/medication: prescribed, over-thecounter, or illegal drug abuse.
◦ Associated cough:
 Duration, paroxysms or constant, dry or
productive?
CV Health Promotion


Screen for Family history risks
Screenings for hypertension
 2014 Evidence-Based Guideline for the Management
of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint
National Committee (JNC 8)
 Screen for risk for: CAD, CVD-TIA/stroke using online risk
calculators
 Screen for individual risk factors: Dyslipidemia, HTN, DM,
metabloci syndrome, smoking, obesity
Analyze which factors are modifiable and
promote lifestyle and risk factor
modification.
 Highest rates of death from CV issues in America
are in African decent.

CV Health Promotion

Ideal cardiovascular health
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Total cholesterol <200mg/dl untreated
BP < 120/80 untreated
Fasting glucose < 100mg/dl untreated
BMI< 25
Nonsmoker
Physical activity: > 150 minutes/wk moderate
intensity, > 75 minutes/week vigorous
intensity, or combination
◦ Healthy diet
Cardiovascular Assessment

SEE Handout
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Inspection
•Inspect color of the limbs, hair loss, ulcers,
scars, sores, muscle wasting
•With client seated check for dependent rubor
•With client standing check for varicosities
Peripheral Vascular Assessment

Palpation
◦ Run the back of your hand down both limbs
◦ Compare sides
◦ Warm or cold and point of temperature
changes
◦ Capillary refill time
◦ Pulses
◦ Allen test
◦ Inguinal Nodes
◦ Palpate for edema
Peripheral Vascular Assessment

Pulses
◦ Upper limbs
 Carotid, brachial, radial, ulnar,
 Allen’s test-for patency of ulnar and radial arterieswhile patient clenches fists-examiner occludes
radial or ulnar arteries. If normal the palm turns
pink when released.
 capillary refill-press fingernail to produce blanching.
Release to note remove for color to return.
◦ Lower Limb
 femoral (mid inguinal point), popliteal,Dorsalis pedis,
posterior tibial
Peripheral Vascular Assessment

Grading pulses
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◦
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4+ bounding
3+ Increased
2+ Brisk-expected
1+ Diminished, weaker than expected
0 Absent
◦ Some people have congenitally absent dorsalis
pedis pulsation
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment
Peripheral Vascular Assessment

Palpate calf for phlebitis
◦
◦
◦
◦
Note tenderness
Note firmness
Muscle tension
Pain with dorsiflexion of the foot

See Varicose Vein Talk
by Dr. Bohn and Dr. Neilson