NR 304 Exam 1

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Chamberlain University

NR-304: Health Assessment II

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Date

NR 304 Exam 1

Peripheral Arterial Disease (PAD) and Related Conditions

Peripheral Arterial Disease (PAD) is a progressive circulatory disorder caused primarily by atherosclerosis. This condition involves the buildup of lipid-rich plaques along arterial walls, leading to narrowing of the lumen, vessel rigidity, fragility, and obstruction of blood flow. Both inflow arteries (e.g., distal aorta, iliac arteries) and outflow arteries (e.g., femoral, popliteal, and tibial vessels) may be affected, reducing perfusion to the extremities.

Risk factors for PAD can be divided into modifiable and non-modifiable categories. Among modifiable factors, cigarette smoking remains the strongest predictor of disease. Other contributors include diabetes mellitus, hypertension, and hyperlipidemia, which accelerate vascular damage and endothelial dysfunction. Non-modifiable risks include advanced age, male gender, and family history of cardiovascular disease.

Clinical Assessment

Subjective Findings

Patient history plays a central role in PAD evaluation. Common complaints include:

Intermittent claudication – muscle pain or cramping in the legs during walking, relieved by rest.
Skin changes – such as pallor, dryness, or discoloration.
Limb swelling or localized discomfort.
History of smoking or comorbidities – such as diabetes and hypertension, which increase vascular risk.

Medication history and lifestyle habits are also critical to assess overall cardiovascular risk.

Objective Findings

A thorough physical examination includes inspection and palpation of extremities. Clinicians assess:

Skin color, temperature, and texture – PAD is often associated with cool, shiny skin.
Presence of edema – although less common than in venous disease, swelling may indicate comorbid pathology.
Capillary refill – delayed refill suggests impaired perfusion.
Pulse palpation – radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses are examined to detect diminished or absent blood flow.

Symptoms of PAD

Patients with PAD may exhibit a range of symptoms:

Burning, aching, or cramping pain during exertion.
Pain relief when the legs are in a dependent position.
Reduced capillary refill time.
Hair loss on the lower extremities.
Cool, cyanotic skin with dependent rubor.
Ulceration or gangrene, particularly on toes or areas exposed to trauma.
Diminished or absent peripheral pulses.

Risk Factors and Special Populations

Cigarette smoking is the most significant modifiable risk factor for PAD. Other contributors include hyperlipidemia, obesity, sedentary lifestyle, and uncontrolled diabetes.

Certain populations are at higher risk:

Women with depression – show a higher incidence of PAD due to hormonal and lifestyle factors.
African Americans – are nearly twice as likely to develop PAD compared to other ethnic groups.

The Ankle-Brachial Index (ABI) is considered the gold standard for screening individuals at high risk.

Example of PAD: Raynaud’s Syndrome

Raynaud’s Syndrome is a vasospastic disorder affecting small arteries, typically in the fingers and toes. Triggers include exposure to cold and emotional stress. It occurs more frequently in women and is prevalent in colder climates.

Symptoms of Raynaud’s Syndrome:

Cold or pale digits.
Numbness or tingling sensations during rewarming.
Characteristic skin color changes from white → blue → red.

Developmental Considerations in Peripheral Health

Infants and Children

Palpable lymph nodes are considered normal.
Lymphoid tissue is well-developed from birth and continues growing until adolescence.

Pregnant Women

Pregnancy often results in bilateral pitting edema and varicose veins.
Increased uterine pressure restricts venous return, contributing to swelling and discomfort.

Older Adults

Age-related changes include diminished peripheral pulses, thinning skin, brittle nails, and trophic alterations.
PAD prevalence rises with age, with up to 50% of adults over 85 years affected.
Reduced mobility and comorbid arthritis may mask or complicate diagnosis.

Arterial vs. Venous Disorders

Feature	Venous Disease	Arterial Disease
Cause	Valve incompetence, thrombus formation	Atherosclerosis, calcification
Pulse	Normal (2+–3+)	Diminished or absent (1+ or 0)
Temperature	Warm	Cool
Skin	Thickened	Shiny, thin
Edema	Present	Absent
Hair	Present	Absent
Color	Red-brown discoloration	Pallor (elevated), rubor (dependent)
Pain	Worse with prolonged standing or sitting	Worse with exertion (claudication)
Pain Relief	Rest after extended standing	Rest quickly with inactivity
Ulcer Location	Medial malleolus	Toes, pressure or trauma points
Ulcer Moisture	Moist, often bleeding	Dry
Ulcer Edges	Irregular and uneven	Smooth, well-defined
Ulcer Base Color	Red granulation tissue	Pale

Diagnostic Tests and Techniques

The Ankle-Brachial Index (ABI) is a simple, non-invasive test that uses Doppler ultrasound to compare systolic pressures at the ankle and arm.

Formula:

$ABI=Highest ankle systolic pressureHighest arm systolic pressureABI = \frac{\text{Highest ankle systolic pressure}}{\text{Highest arm systolic pressure}}$

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	Critical ischemia

Lymphatic System Overview

The lymphatic system plays a key role in fluid regulation, immune defense, and lipid absorption.

Right lymphatic duct: drains right head, thorax, and arm.
Thoracic duct: drains the remainder of the body.

Lymph node clusters include:

Cervical – drains head and neck.
Axillary – drains breast and upper limbs.
Epitrochlear – drains forearm and hand.
Inguinal – drains lower limbs and genitalia.

Associated lymphatic organs:

Spleen – filters blood and produces antibodies.
Tonsils – trap pathogens entering via the oral cavity.
Thymus – supports T-cell maturation in children.

Lymphedema

Lymphedema results from impaired lymphatic drainage, causing protein-rich interstitial fluid to accumulate. It is characterized by non-pitting edema and skin thickening.

Management strategies include:

Manual lymph drainage.
Compression therapy (contraindicated in PAD).
Exercise and physical therapy.

Abnormal Findings and Clinical Indicators

Condition	Indicator Example
Thready pulse (1+)	Seen in PAD or shock
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	Long-standing PAD or aging
Intermittent claudication	Ischemic muscle pain with exertion

Comparison of Ulcer Types

Type of Ulcer	Common Causes	Characteristics	Common Locations	Risk Factors
Arterial	Atherosclerosis, smoking	Pale base, well-defined edges, dry	Toes, heels, lateral ankle	Smoking, diabetes, hypertension
Venous	DVT, venous insufficiency	Shallow, moist, granulation tissue	Lower legs, medial ankle	Immobility, obesity, pregnancy, DVT
Neuropathic	Diabetic neuropathy	Painless, pressure points, deformities	Plantar surface	Diabetes, neuropathy, deformities

Other Vascular Disorders

Superficial varicose veins – dilated veins due to valve incompetence, often linked to pregnancy or obesity.
Deep vein thrombophlebitis (DVT) – thrombus in deep veins causing swelling, warmth, and tenderness; risk of pulmonary embolism.
Arterial occlusions – narrowing that decreases tissue oxygenation.
Aneurysms – localized arterial dilation due to vessel wall weakness, frequently in the abdominal aorta.

Abdominal and Organ Examination

Palpation of abdominal organs (liver, spleen, kidneys, and aorta) helps detect enlargement, tenderness, or abnormal pulsations. A widened or laterally pulsating aorta may suggest an abdominal aortic aneurysm.

Ascites Evaluation

Ascites refers to fluid accumulation in the peritoneal cavity. Clinical assessment includes the fluid wave test and shifting dullness, although ultrasound remains the gold standard.

Causes include:

Cirrhosis.
Heart failure.
Abdominal cancers.
Tuberculosis and pancreatitis.

Key Prevention and Management Principles

Smoking cessation is the most crucial preventive strategy.
Maintain blood pressure, cholesterol, and glucose control.
Avoid compression garments in PAD patients.
Encourage safe and regular physical activity.
Screen high-risk individuals using the ABI test.

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.

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.

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