1 Leg pain or cramps.

 Any leg pain (cramps)? Where?

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_ Describe the type of pain; is it burning, aching, cramping, stabbing? Did this come on gradually or suddenly?

_ Is it aggravated by activity, walking?

Peripheral vascular disease (PVD)—see pain profiles in Table 20-3, p. 521.

_ How many blocks (stairs) does it take to produce this pain?

Claudication distance

_ Has this amount changed recently?

_ Is the pain worse with elevation? Worse with cool temperatures?

Note sudden decrease in

claudication distance or pain not relieved by rest.

_ Does the pain wake you up at

night?

Night leg pain is common in a

ging adults. It may indicate the ischemic rest pain of PVD, severe night muscle cramping (usually the calf), or the restless leg syndrome.

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1 Leg pain or cramps.

_ Describe the type of pain; is it burning, aching, cramping, stabbing? Did this come on gradually or suddenly?

_ Is it aggravated by activity, walking?

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Peripheral vascular disease (PVD)—see pain profiles in Table 20-3, p. 521.

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Skin changes on arms or legs. Any skin changes on arms or legs? What color: redness, pallor, blueness, brown discolorations?

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1 Leg pain or cramps.

How many blocks (stairs) does it take to produce this pain?

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_ Has this amount changed recently?

_ Is the pain worse with elevation? Worse with cool temperatures?

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Claudication distance

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Note sudden decrease in claudication distance or pain not relieved by rest.

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_ Does the pain wake you up at night?

Night leg pain is common in aging adults. It may indicate the ischemic rest pain of PVD, severe night muscle cramping (usually the calf), or the restless leg syndrome.

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leg pain or cramps

_ Any recent change in exercise, a new exercise, increasing exercise?

_ What relieves this pain: dangling, walking, rubbing? Is the leg pain associated with any skin changes?

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Pain of musculoskeletal origin rather than vascular.

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What relieves this pain: dangling, walking, rubbing? Is the leg pain associated with any skin changes?

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leg pain or cramps

_ Is it associated with any change in sexual function (males)?

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Aortoiliac occlusion is associated with impotence (Leriche syndrome).

Any history of vascular problems, heart problems, diabetes, obesity, pregnancy, smoking, trauma, prolonged standing, or bedrest?

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skin changes on arms or legs.

skin changes

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_ Any change in temperature—excess warmth or coolness?

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_ Do your leg veins look bulging and crooked? How have you treated these? Do you use support hose?

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_ Any leg sores or ulcers? Where on the leg? Any pain with the leg ulcer?

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Coolness is associated with arterial disease.

`Varicose veins.

Leg ulcers occur with chronic arterial and chronic venous disease (see Table 20-4 p. 522).

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Swelling in the arms or legs. Swelling in one or both legs? When did this swelling start?

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_ What time of day is the swelling at its worst: morning, or after up most of the day?

_ Does the swelling come and go, or is it constant?

_ What seems to bring it on: trauma, standing all day, sitting?

_ What relieves swelling: elevation, support hose?

_ Is swelling associated with pain, heat, redness, ulceration, hardened skin?

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4 Lymph node enlargement. Any “swollen glands” (lumps, kernels)? Where in body? How long have you had them?

`_ Any recent change?

_ How do they feel to you: hard, soft?

_ Are the swollen glands associated with pain, local infection?

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Enlarged lymph nodes occur with infection, malignancies, and immunologic diseases.

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5 Medications. What medications are you taking (e.g., oral contraceptives, hormone replacement)?

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INSPECT AND PALPATE THE ARMS

Lift both the person's hands in your hands.

Inspect, then turn the person's hands over, noting color of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing.

Use the profile sign (viewing the finger from the side) to detect early clubbing.

The normal nail-bed angle is 160 degrees.

(See Chapter 12 for a full discussion of skin color, lesions, and clubbing.)

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Flattening of angle and clubbing (diffuse enlargement of terminal phalanges) occur with congenital cyanotic heart disease and cor pulmonale.

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inspect and palpate the arms

With the person's hands near the level of his or her heart, check capillary refill.

This is an index of peripheral perfusion and cardiac output. Depress and blanch the nail beds; release and note the time for color return.

Usually, the vessels refill within a fraction of a second.

Consider it normal if the color returns in less than 1 or 2 seconds. Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

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Refill lasting more than 1 or 2 seconds signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock).

The hands are cold, clammy, and pale.

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The two arms should be symmetric in size.

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Edema of upper extremities occurs when lymphatic drainage is obstructed, which may occur after breast surgery (see Table 20-2 on p. 520).

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Note the presence of any scars on hands and arms. Many occur normally with usual childhood abrasions or with occupations involving hand tools.

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Needle tracks in hands, arms, antecubital fossae occur with IV drug use; linear scars in wrists may signify past self-inflicted injury.

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Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force (Fig. 20-8). Grade the force (amplitude) on a 3-point scale:

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3+, increased, full, bounding

2+, normal

1+, weak

0, absent

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Full, bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever), anemia, and hyperthyroidism.

Weak, “thready” pulse (1+) occurs with shock and peripheral arterial disease. See Table 20-1 on p. 519 for illustrations of these and irregular pulse rhythms

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It usually is not necessary to palpate the ulnar pulses. If indicated, reach your hand under the person's arm and palpate along the medial side of the inner forearm (Fig. 20-9), although the ulnar pulses often are not palpable in the normal person.

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Palpate the brachial pulses—their force should be equal bilaterally (Fig. 20-10).

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Check the epitrochlear lymph nodes in the depression above and behind the medial condyle of the humerus.

 Do this by “shaking hands” with the person and reaching your other hand under the person's elbow to the groove between the biceps and triceps muscles, above the medial epicondyle (Fig. 20-11).

These nodes are not palpable normally.

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An enlarged epitrochlear node occurs with infection of the hand or forearm.

Epitrochlear nodes occur in conditions of generalized lymphadenopathy: lymphoma, chronic lymphocytic leukemia, sarcoidosis, infections, mononucleosis.

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The modified Allen test is used to evaluate the adequacy of collateral circulation before cannulating the radial artery (Fig. 20-12).

(A) Firmly occlude both the ulnar and radial arteries of one hand while the person makes a fist several times.

This causes the hand to blanch. (B) Ask the person to open the hand without hyperextending it; then release pressure on the ulnar artery while maintaining pressure on the radial artery.

Adequate circulation is suggested by a palmar blush, a return to the hand's normal color in approximately 2 to 5 seconds.

Although this test is simple and useful, it is relatively crude and subject to error—that is, you must occlude both arteries uniformly with 11 pounds of pressure for the test to be accurate.

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(C) Pallor persists or a sluggish return to color suggests occlusion of the collateral arterial flow. Avoid radial artery cannulation until adequate circulation is shown.

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Limitations of the modified Allen test are that it is subjective and requires patient cooperation that may not occur in emergency or critical care situations—just the times you need to cannulate the radial artery.

The laser Doppler gives a quantifiable measurement of blood flow that is recordable and reproducible.⁶

A small, flat probe is taped to the palm at the end of the patient's index finger.

A baseline value for blood flow is recorded and then compared for change when the two arteries are occluded.

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INSPECT AND PALPATE THE LEGS

Uncover the legs while keeping the genitalia draped.

Inspect both legs together, noting skin color, hair distribution, venous pattern, size (swelling or atrophy), and any skin lesions or ulcers.

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Pallor with vasoconstriction; erythema with vasodilation; cyanosis.

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inspect and palpate the legs

Normally, hair covers the legs. Even if leg hair is shaved, you will still note hair on the dorsa of the toes.

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Malnutrition: thin, shiny, atrophic skin; thick-ridged nails; loss of hair; ulcers; gangrene. Malnutrition, pallor, and coolness occur with arterial insufficiency.

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The venous pattern normally is flat and barely visible. Note obvious varicosities, although these are best assessed while standing.

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inspect and palplate the legs

Both legs should be symmetric in size without any swelling or atrophy.

If the lower legs look asymmetric or if deep venous thrombosis is suspected, measure the calf circumference with a non-stretchable tape measure (Fig. 20-13).

Measure at the widest point, taking care to measure the other leg in exactly the same place—the same number of centimeters down from the patella or other landmark.

If lymphedema is suspected, measure also at the ankle, distal calf, knee, and thigh. Record your findings in centimeters.

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Diffuse bilateral edema occurs with systemic illnesses.

Acute, unilateral, painful swelling and asymmetry of calves of 1 cm or more is abnormal; refer the person to determine whether deep venous thrombosis is present.

Asymmetry of 1 to 3 cm occurs with mild lymphedema; 3 to 5 cm with moderate lymphedema; and more than 5 cm with severe lymphedema (see Table 20-2).

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inspect and palpate the legs

In the presence of skin discoloration, skin ulcers, or gangrene, note the size and the exact location.

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Brown discoloration occurs with chronic venous stasis due to hemosiderin deposits from red blood cell degradation.

Venous ulcers occur usually at medial malleolus because of bacterial invasion of poorly drained tissues (see Table 20-4).

With arterial deficit, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli.

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inspect and palpate the legs

Palpate for temperature along the legs down to the feet, comparing symmetric spots (Fig. 20-14).

The skin should be warm and equal bilaterally.

Bilateral cool feet may be due to environmental factors such as cool room temperature, apprehension, and cigarette smoking.

If any increase in temperature is present higher up the leg, note if it is gradual or abrupt.

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A unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with arterial deficit.

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Flex the person's knee, and then gently compress the gastrocnemius (calf) muscle anteriorly against the tibia; no tenderness should be present.

Or you may sharply dorsiflex the foot toward the tibia.

Flexing the knee first exerts pressure on the posterior tibial vein.

Normally this does not cause pain.

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Calf pain with these maneuvers is a positive Homan sign, which occurs in about 35% of cases of deep vein thrombosis.

It is not specific for this condition because it occurs also with superficial phlebitis, Achilles tendinitis, gastrocnemius and plantar muscle injury, and lumbosacral disorders.

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Palpate the inguinal lymph nodes.

It is not unusual to find palpable nodes that are small (1 cm or less), movable, and nontender.

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Enlarged nodes, tender, or fixed in area.

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Palpate these peripheral arteries in both legs: femoral, popliteal, dorsalis pedis, and posterior tibial.

 Grade the force on the 3-point scale.

Locate the femoral arteries just below the inguinal ligament halfway between the pubis and anterior superior iliac spines (Fig. 20-15).

To help expose the femoral area, particularly in obese people, ask the person to bend his or her knees to the side in a froglike position.

Press firmly and then slowly release, noting the pulse tap under your fingertips.

If this pulse is weak or diminished, auscultate the site for a bruit.

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A bruit occurs with turbulent blood flow, indicating partial occlusion (see Table 20-5).

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The popliteal pulse is a more diffuse pulse and can be difficult to localize.

 With the leg extended but relaxed, anchor your thumbs on the knee and curl your fingers around into the popliteal fossa (Fig. 20-16).

Press your fingers forward hard to compress the artery against the bone (the lower edge of the femur or the upper edge of the tibia).

Often it is just lateral to the medial tendon.

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If you have difficulty, turn the person prone and lift up the lower leg (Fig. 20-17).

Let the leg relax against your arm, and press in deeply with your two thumbs.

Often a normal popliteal pulse is impossible to palpate.

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For the posterior tibial pulse, curve your fingers around the medial malleolus (Fig. 20-18).

You will feel the tapping right behind it in the groove between the malleolus and the Achilles tendon.

If you cannot, try passive dorsiflexion of the foot to make the pulse more accessible.

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The dorsalis pedis pulse requires a very light touch.

Normally it is just lateral to and parallel with the extensor tendon of the big toe (Fig. 20-19).

Do not mistake the pulse in your own fingertips for that of the person.

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In adults older than 45 years, occasionally either the dorsalis pedis or the posterior tibial pulse may be hard to find, but not both on the same foot.

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Check for pretibial edema. Firmly depress the skin over the tibia or the medial malleolus for 5 seconds and release (Fig. 20-20, A).

Normally, your finger should leave no indentation, although a pit commonly is seen if the person has been standing all day or during pregnancy.

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Bilateral, dependent pitting edema occurs with heart failure, diabetic neuropathy, and hepatic cirrhosis (

Fig. 20-20,

B

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If pitting edema is present, grade it on the following scale:

1+ Mild pitting, slight indentation, no perceptible swelling of the leg

2+ Moderate pitting, indentation subsides rapidly

3+ Deep pitting, indentation remains for a short time, leg looks swollen

4+ Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

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Unilateral edema occurs with occlusion of a deep vein.

Unilateral or bilateral edema occurs with lymphatic obstruction.

With these factors, it is “brawny” or nonpitting and feels hard to the touch.

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Ask the person to stand so that you can assess the venous system. Note any visible, dilated, and tortuous veins.

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Varicosities occur in the saphenous veins (see Table 20-5).

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Manual Compression Test

While the person is still standing, test the length of the varicose vein to determine whether its valves are competent (Fig. 20-21).

Place one hand on the lower part of the varicose vein, and compress the vein with your other hand about 15 to 20 cm higher.

Competent valves will prevent a wave transmission, and your distal (lower) fingers will feel no change.

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A palpable wave transmission occurs when the valves are incompetent.

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Color Changes

If you suspect an arterial deficit, raise the legs about 30 cm (12 inches) off the table and ask the person to wag the feet for about 30 seconds to drain off venous blood (Fig. 20-22).

The skin color now reflects only the contribution of arterial blood.

A light-skinned person's feet normally will look a little pale but still should be pink.

A dark-skinned person's feet are more difficult to evaluate, but the soles should reveal extreme color change.

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Now have the person sit up with the legs over the side of the table (Fig. 20-23, A).

Compare the color of both feet.

Note the time it takes for color to return to the feet—the normal time is 10 seconds or less.

Note also the time it takes for the superficial veins around the feet to fill—the normal time is about 15 seconds.

This test is unreliable if the person has concomitant venous disease with incompetent valves.

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Elevational pallor (marked) indicates arterial insufficiency.

Dependent rubor (deep blue-red color) occurs with severe arterial insufficiency (Fig. 20-23, B).

Chronic hypoxia produces a loss of vasomotor tone and a pooling of blood in the veins.

Delayed venous filling occurs with arterial insufficiency.

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Test the lower legs for strength (see Chapter 22).

Test the lower legs for sensation (see Chapter 23).

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Motor loss occurs with severe arterial deficit.

Sensory loss occurs with arterial deficit, especially diabetes.

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The Doppler Ultrasonic Stethoscope

Use this device to detect a weak peripheral pulse, to monitor blood pressure in infants or children, or to measure a low blood pressure or blood pressure in a lower extremity (Fig. 20-24).

The Doppler stethoscope magnifies pulsatile sounds from the heart and blood vessels.

Position the person supine, with the legs externally rotated so you can reach the medial ankles easily.

Place a drop of coupling gel on the end of the handheld transducer.

 Place the transducer over a pulse site at a 90-degree angle.

Apply very light pressure; locate the pulse site by the swishing, whooshing sound.

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The Ankle-Brachial Index (ABI)

Use of the Doppler stethoscope is a highly specific, noninvasive, and readily available way to determine the extent of peripheral arterial disease (PAD).

The patient is supine.

Apply a regular arm blood pressure cuff above the ankle and determine the systolic pressure in either the posterior tibial or dorsalis pedis artery.

Then divide that figure by the systolic pressure of the brachial artery.

(Take brachial systolic pressures in both arms and use the higher measurement.)

The normal ankle pressure is slightly greater than or equal to the brachial pressure; thus a normal ABI is usually 1.0 to 1.2. For example,

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[image]

In people with diabetes mellitus, the ABI is less reliable because of calcification (which makes their arteries non-compressible) and may give a falsely high ankle pressure.

 Thus the presence or severity of PAD may be underestimated.

⁸

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An ABI of 0.90 or less indicates peripheral arterial disease (PAD):

_ 0.90 to 0.70—mild claudication

_ 0.70 to 0.40—moderate to severe claudication

_ 0.40 to 0.30—severe claudication, usually with rest pain except in the presence of diabetic neuropathy

_ <0.30—ischemia, with impending loss of tissue

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the aging adult

The dorsalis pedis and posterior tibial pulse may become more difficult to find. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick-ridged nails; loss of hair on lower legs) also occur normally with aging.

Raynaud's Phenomenon

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Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress:

(1) white (pallor) in top figure from arteriospasm and resulting deficit in supply;

(2) blue (cyanosis) in lower figure from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin;

(3) finally, red (rubor) in heel of hand due to return of blood into the dilated capillary bed or reactive hyperemia.

May have cold, numbness, or pain along with pallor or cyanosis stage; then burning, throbbing pain, swelling along with rubor. Lasts minutes to hours; occurs bilaterally.

Several drugs predispose to the episodes, and smoking can increase the symptoms.

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Lymphedema

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Lymphedema is high-protein swelling of the limb, most commonly due to breast cancer treatment.

Surgical removal of lymph nodes or damage to lymph nodes and vessels with radiation therapy impedes drainage of lymph.

Protein-rich lymph builds up in the interstitial spaces, which further raises local colloid oncotic pressure and promotes more fluid leakage.

Stagnant lymphatic fluid increases risk for infection, delayed wound healing, chronic inflammation, and fibrosis of surrounding tissue.

Lymphedema after breast cancer is common (42%)¹³ but usually mild.

Early symptoms include self-reported sensations of a tired, thick, heavy arm, jewelry too tight, swelling, or tingling.

Objective data include a unilateral swelling, nonpitting brawny edema, with overlying skin indurated.

Early recognition is important because there is evidence to support effective interventions, such as complete decongestive physiotherapy, compression bandaging, and others.¹⁸

Without treatment, lymphedema is chronic and progressive, which is psychologically demoralizing as a threat to body image and constant reminder of the cancer.

location: deep muscle pain, usually in calf, but may be lower leg or dorsum of foot

character: intermittent claudication, feels like "cramp," "numbness and tingling," "feeling of cold"

onset and duration: chronic pain, onset gradual after exertion

aggravating factors: activity; " Claudication distance” is specific number of blocks, stairs it takes to produce pain

Elevation (rest pain indicates severe involvement)

relieving factors: Rest (usually within 2 min [e.g., standing])

Dangling (severe involvement)

associated symptoms: Cool, pale skin

those at risk: Older adults, more males than females, inherited predisposition, history of hypertension, smoking, diabetes, hypercholesterolemia, obesity, vascular disease

location: Varies, distal to occlusion, may involve entire leg

character: Throbbing

onset and duration: Sudden onset (within 1 hr)

associated symptoms: Six Ps: pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), paralysis (indicates severe)

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those at risk: History of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including injured arteries; chronic atrial fibrillation

chronic venous symptoms

location: Calf, lower leg

character: Aching, tiredness, feeling of fullness

onset and duration:Chronic pain, increases at end of day

aggravating factors: Prolonged standing, sitting

relieving factors: Elevation, lying, walking

associated symptoms: Edema, varicosities, weeping ulcers at ankles

those at risk: Job with prolonged standing or sitting; obesity; pregnancy; prolonged bedrest; history of heart failure, varicosities, or thrombophlebitis; veins crushed by trauma or surgery

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location: Calf

character; Intense, sharp; deep muscle tender to touch

onset and duration: Sudden onset (within 1 hr)

aggravating factors; Pain may increase with sharp dorsiflexion of foot

associated factors: Red, warm, swollen leg

Arterial—Ischemic Ulcer

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Buildup of fatty plaques on intima (atherosclerosis) plus hardening and calcification of arterial wall (arteriosclerosis).

S:Deep muscle pain in calf or foot, claudication (pain with walking), pain at rest indicates worsening of condition.

O:Coolness, pallor, elevational pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangrene.

Ulcers occur at toes, metatarsal heads, heels, lateral ankle, and are characterized by pale ischemic base, well-defined edges, and no bleeding.

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After acute deep vein thrombosis or chronic incompetent valves in deep veins.

S:Aching pain in calf or lower leg, worse at end of the day, worse with prolonged standing or sitting.

O:Firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration; petechiae; dermatitis.

Venous stasis causes increased venous pressure, which then causes red blood cells (RBCs) to leak out of veins and into the skin.

The RBCs break down and leave hemosiderin (iron deposits) behind, which are the brown pigment deposits.

A weepy, pruritic stasis dermatitis may be present.

Ulcers occur at medial malleolus and are characterized by bleeding, uneven edges.

Diabetes

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hastens changes described with ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retina, kidney.

 Peripheral involvement is associated with diabetic neuropathy.

Without careful vigilance of pressure points on the feet, ulcer may go unnoticed.

Pain and sensation are decreased, and surrounding skin is calloused.

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Superficial Varicose Veins

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Incompetent valves permit reflux of blood, producing dilated, tortuous veins.

Unremitting hydrostatic pressure causes distal valves to be incompetent and causes worsening of the varicosity.

Over age 45 years, occurrence is three times more common in women than in men.

S:Aching, heaviness in calf, easy fatigability, night leg or foot cramps.

O:Dilated, tortuous veins.

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Deep Vein Thrombophlebitis (DVT)

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A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema.

Virchow's triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction.¹⁶

Cause may be prolonged bedrest; history of varicose veins; trauma; infection; cancer; and, in younger women, the use of oral estrogenic contraceptives.

Requires emergency referral because of risk for pulmonary embolism.

Note that upper-extremity DVT is increasingly common due to frequent use of invasive lines such as central venous catheters.

¹⁰

S:Sudden onset of intense, sharp, deep muscle pain; may increase with sharp dorsiflexion of foot.

O:Increased warmth; swelling (to compare swelling, observe the usual shoe size as in above photo); redness; dependent cyanosis is mild or may be absent; tender to palpation;

Homan sign is present only in few cases.

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Occlusions in the arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation.

This reduces blood flow with vital oxygen and nutrients.

Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol, sedentary lifestyle, and family history of hyperlipidemia.

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An aneurysm is a sac formed by dilation in the artery wall.

Atherosclerosis weakens the middle layer (media) of the vessel wall.

 This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloon enlargement.

The most common site is the aorta, and the most common cause is atherosclerosis.

The incidence increases rapidly in men older than 55 years and women older than 70 years; the overall occurrence is four to five times more frequent in men.

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