Peripheral vascular assessment
This assessment is comprised of looking at the pt extremities, determining circulation,mobility and sensation. It is really a meshing of neuro,mobility and musculoskeletal assessment in part, which shows how interrelated our body really is!
I am using PMS Causes Tension as my mneumonic.
P-Pulses. feel the most distal pulse possible on the assigned limbs BILATERALLY because this is a comparative assessment!. If, for instant the person has an amputation below the knee on one side, then you would palpate the popiliteal pulses bilaterally AND the pedal pulse on the remaining limb.A Doppler may be necessary to find pulses on the severely compromised and "may use doppler" will be written on the Kardex. The CE will procure the device.
M- Mobility is assessed by simply asking a person to move the limb or in a young child/non communicative adult, observing spontaneous movement.
S-Sensation.Elicit the pt response to touch of the distal part of the extremity. Ssk them to differential wheather they feel the pressure of the actual touch or numbness ,etc.
C-Color OR Capillary refill to assess perfusion. Squeeze the nail bed and time the color return OR look for paleness,cyanosis,pinkness etc.
T-temperature can be checked when sensation is being tested.
All imformation needs to be accurately recorded bilaterally with a comparison of the extremities.The most common pt who will be assigned this AOC will be the one with a cast/traction or other peripheral vascular impairments.
What other impairments are there you ask?? Well what a great question!!!
There are many , many who are afflicted with either Arterial insufficiency or Venous insufficiency. Defining symptoms and nursing interventions differ , so it is good to be aware of it!
Arterial Insufficiency is when the heart is not getting enough blood TO the legs and the result is coolness, pale skin ,diminished pulses,tingling,decreased sensation, and claudication which is a $5 word for lameness and a gimpy walk. What do we do about this malady??We have the legs in the dependant position as much as possible to help get that blood and oxygen do that compromised tissue and prevent necrosis/tissue death!
Venous Insufficiency is when the blood does not return to the heart in a timely manner.I have heard lay folk call this "pooling". Symptoms include edema,red, itchy skin , pain,normal to slightly war skin temp.The interventions include periods of leg elevation and excercise which will increase the venous return and decrese edema and possible ulceration.
A sample care plan for this AOC may go as follows:
Diagnosis: Ineffective tissue perfusion
Outcome: Pt will identify factoers to increase peripheral circulation ( use this because in the hour or so you are in the room there is no way you will be able to assess improved circulation)
Interventions: Assess the pt knowledge about what causes decreased blood flow to their limbs
Teach Pt ways to improve circulation to extremity.
A diagnosis that goes hand in hand with this is acute pain since so many do have that co morbidity factor.
easy as pie!