NR 304 Exam 1
Student Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
Peripheral Arterial Disease (PAD) and Related Conditions
Peripheral Arterial Disease (PAD) is a circulatory disorder caused mainly by atherosclerosis, where lipid-rich plaques accumulate along arterial walls. Over time, these plaques cause arteries to become rigid, irregular, and fragile, reducing the diameter of the lumen and restricting blood flow to tissues. PAD can involve inflow arteries such as the distal aorta and iliac arteries, or outflow arteries such as the femoral, popliteal, and tibial vessels.
PAD results from a combination of modifiable and non-modifiable risk factors. Cigarette smoking is the most influential lifestyle risk factor, while systemic conditions such as diabetes mellitus, hypertension, and hyperlipidemia accelerate vascular injury.
Clinical Assessment
Subjective Findings
A detailed patient history is crucial for PAD assessment. Patients often report leg pain or cramping during walking (intermittent claudication), which improves with rest. Other complaints may include skin changes, limb swelling, and palpable lymph nodes. Clinicians should also gather information about medication use and smoking habits, as these factors influence disease progression.
Objective Findings
The physical examination includes assessment of the upper extremities for skin color, temperature, texture, and turgor. Edema, clubbing, and capillary refill time should be evaluated. Radial and brachial pulses are palpated for elasticity and strength. The lower limbs should be inspected for skin color, hair distribution, size symmetry, and venous patterns. Femoral, popliteal, posterior tibial, and dorsalis pedis pulses should be palpated to identify circulatory compromise.
Symptoms of PAD
Patients with PAD may experience:
- Burning or cramping pain during exertion
- Pain relief when legs are placed in a dependent position
- Reduced capillary refill time
- Hair loss on the lower extremities
- Diminished or absent pulses
- Cool, cyanotic skin
- Dependent rubor
- Ulcers or gangrene on the toes
Risk Factors and Special Populations
Cigarette smoking is the most significant modifiable risk factor for PAD. Other contributors include high cholesterol, obesity, and physical inactivity. Women with depression have a higher risk, and African Americans are twice as likely to develop PAD compared to other ethnic groups. High-risk individuals benefit from comprehensive screening, and the Ankle-Brachial Index (ABI) remains the preferred non-invasive tool.
Example of PAD: Raynaud’s Syndrome
Raynaud’s Syndrome is a vasospastic disorder affecting small arteries, particularly in the fingers and toes, and is often triggered by cold or emotional stress. It is more common in women and in colder climates.
Common symptoms include:
- Cold, pale, or discolored digits
- Numbness or stinging upon rewarming
- Skin color changes progressing from white to blue to red
Developmental Considerations in Peripheral Health
Infants and Children
Palpable lymph nodes are common in healthy children. Lymphoid tissue is well developed at birth and grows until adolescence.
Pregnant Women
Pregnancy often causes bilateral pitting edema and varicose veins due to increased uterine pressure, which reduces venous return and increases venous pressure.
Older Adults
Older adults may have diminished dorsalis pedis and posterior tibial pulses. Trophic skin changes such as thinning, hair loss, and brittle nails are common. PAD prevalence increases with age, reaching 20% in people over 70 and 50% in those over 85. Symptoms may be masked by reduced activity or other conditions such as arthritis.
Arterial vs. Venous Disorders
| Feature | Venous Disease | Arterial Disease |
|---|---|---|
| Cause | Valve incompetence, thrombi | Atherosclerosis, calcification |
| Pulse | Normal (2+–3+) | Diminished/absent (1+ or 0) |
| Temperature | Warm | Cool |
| Skin | Thickened | Shiny |
| Edema | Present | Absent |
| Hair | Present | Absent |
| Color | Red-brown | Pallor (elevated), rubor (dependent) |
| Pain | Worse with standing/sitting | Worse with exertion |
| Pain relief | Rest after prolonged standing | Rest quickly |
| Ulcer location | Medial malleolus | Toes, trauma points |
| Ulcer moisture | Moist, bleeding | Dry |
| Ulcer edges | Uneven | Smooth, well-defined |
| Ulcer base color | Red | Pale |
Diagnostic Tests and Techniques
The Ankle-Brachial Index (ABI) is a rapid, non-invasive test using Doppler ultrasound to compare ankle and arm systolic pressures.
Formula:
ABI = Highest ankle systolic pressure ÷ Highest arm systolic pressure
| ABI Score Range | Interpretation |
|---|---|
| 1.0 – 0.91 | Normal |
| 0.90 – 0.71 | Mild PAD |
| 0.70 – 0.41 | Moderate PAD |
| 0.40 – 0.30 | Severe PAD |
| < 0.30 | Ischemia |
Lymphatic System Overview
The lymphatic system maintains fluid balance, protects against pathogens, and absorbs lipids from the intestines. Poor lymphatic drainage causes edema due to protein-rich fluid accumulation.
Key structures:
- Right lymphatic duct drains the right head, thorax, and arm
- Thoracic duct drains the rest of the body
Lymph node clusters:
- Cervical drains head and neck
- Axillary drains upper limbs and breast
- Epitrochlear drains lower arm and hand
- Inguinal drains lower limbs and genitalia
Associated organs:
- Spleen filters blood, stores red cells, and produces antibodies
- Tonsils respond to localized infections
- Thymus supports T-cell maturation in children
Lymphedema
Lymphedema is swelling due to accumulation of protein-rich lymph fluid after lymph node damage or removal. It presents as non-pitting edema with thickened skin. Early management includes compression therapy (avoided in active PAD), manual lymphatic drainage, and targeted exercise.
Abnormal Findings and Clinical Indicators
| Condition | Indicator Example |
|---|---|
| Thready pulse (1+) | Shock, PAD |
| Bounding pulse (3+) | Hyperthyroidism, fever, anxiety |
| Pitting edema (1+–4+) | Heart failure, hepatic cirrhosis |
| Unilateral swelling | DVT, lymphatic obstruction |
| Discoloration with ulcers | Chronic PAD or venous insufficiency |
| Trophic skin changes | Aging, long-standing PAD |
| Intermittent claudication | Ischemic muscle pain from PAD |
Comparison of Ulcer Types
| Type of Ulcer | Common Causes | Characteristics | Common Locations | Risk Factors |
|---|---|---|---|---|
| Arterial Ulcer | Atherosclerosis, smoking | Pale base, well-defined edges, dry, no bleeding | Toes, heels, lateral ankle | Smoking, diabetes, hypertension, hyperlipidemia |
| Venous Ulcer | DVT, venous insufficiency | Shallow, moist, granulation tissue, pigmentation | Lower legs, medial ankle | Immobility, obesity, pregnancy, DVT |
| Neuropathic Ulcer | Diabetic neuropathy | Painless, at pressure points, foot deformities | Plantar surface | Diabetes, neuropathy, deformities |
Other Vascular Disorders
Superficial varicose veins are caused by valve incompetence from prolonged venous pressure, common in obesity and pregnancy.
Deep vein thrombophlebitis (DVT) involves clot formation in deep veins, causing swelling, redness, warmth, and tenderness, with a risk of pulmonary embolism.
Arterial occlusions result from narrowing of arteries, reducing oxygen delivery to tissues.
Aneurysms are localized dilations of arteries caused by weakened vessel walls, most often affecting the aorta.
Abdominal and Organ Examination
The liver, spleen, kidneys, and aorta require careful palpation. Abnormal findings include tenderness, enlargement, and abnormal pulsations. An abdominal aortic aneurysm may be suspected with widened or laterally pulsating vessels.
Ascites Evaluation
Ascites is detected clinically through the fluid wave and shifting dullness tests, but ultrasound is the diagnostic gold standard. Causes include cirrhosis, heart failure, cancers, tuberculosis, and pancreatitis.
Key Prevention and Management Principles
- Smoking cessation is critical for PAD prevention
- Control hypertension, cholesterol, and diabetes
- Avoid compression garments in PAD patients
- Encourage safe physical activity
- Use ABI routinely for high-risk patients
References
American Heart Association. (2020). Understanding Peripheral Artery Disease (PAD). https://www.heart.org/en/health-topics/peripheral-artery-disease
Bickley, L. S. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
NR 304 Exam 1
Centers for Disease Control and Prevention. (2021). Peripheral Arterial Disease (PAD). https://www.cdc.gov/heartdisease/PAD.htm
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
National Heart, Lung, and Blood Institute. (2022). Raynaud’s Phenomenon. https://www.nhlbi.nih.gov/health/raynauds
National Institute for Health and Care Excellence. (2023). Chronic venous leg ulcers: Management guidelines. https://www.nice.org.uk
Runyon, B. A. (2009). Introduction to the revised American Association for the Study of Liver Diseases practice guideline: Management of adult patients with ascites due to cirrhosis. Hepatology, 49(6), 2087–2107.
NR 304 Exam 1
Trowbridge, R. L., Rutkowski, N. K., & Shojania, K. G. (2007). Does this patient have splenomegaly? JAMA, 297(17), 1944–1951.
Wound, Ostomy and Continence Nurses Society. (2021). Guideline for management of wounds. https://www.wocn.org