Nursing lecture

1. UNIT I: Assessment of the Peripheral
Vascular and Musculoskeletal
Systems
Acknowledged Shahzad Bashir &
Hugh Gelabert, M.D. Vascular Surgery Division UCLA School of Medicine
Abida Razzaq RN,RM,BScN,MSN
Vice Principal, ICoNM
Students’ Affairs
September,2020

2. 2
Objectives
• By the end of the unit, learners will be able to:
•Discuss the pertinent health history question
necessary to perform the assessment of Peripheral
Vascular System (PVS) and Musculoskeletal
System (MS) system.
• Discuss critical observations to assess PVS.
• Assess musculo - skeletal functions including
muscles strength, symmetry, size, contour, ROM
and its characteristics.
• Document findings.
• List the changes in the given systems that are
characteristics of aging process

3. 3
Musculoskeletal: Review Anatomy
& Physiology
• Skeleton: 206 bones
• Long: femur, humerus, radius
• Short: carpals, tarsals
• Irregular: vertebrae
• Bones protect, support, allow for
locomotion and mineral storage (Ca, Mg)

4. 4
Structure and Function (cont.)
• Components of musculoskeletal system:
• Nonsynovial or synovial joints
• Muscles
• Temporomandibular joint
• Spine
• Shoulder
• Elbow
• Wrist and Carpals
• Hip
• Knee
• Ankle and Foot

5. 5

6. 6
Musculoskeletal
• Joints: Range from joints that don’t
move to joints that freely move.
• Ligaments and tendons: stabilize joints
• Ligaments: attached from bone to bone
• Tendons: attached from muscle to bone
• Cartilage: ends on bones

7. Synovial Joint
7

8. Shoulder
8

9. 9

10. 10
Musculoskeletal
• Muscles: controlled by nervous system
• Fascia: surrounds muscles, divides
muscles, main blood vessels and nerves.
• Bursae: cushions moving parts
• Muscle tone: ability to resist force;
graded 0-5
• Atrophy: decrease size

11. Skeletal
Muscle
Movements
11

12. 12
Assessing: Subjective Data
• Joint pain:
• SLIDA: Severity, Location, Intensity,
Duration, Aggravating factors (alleviating
factors, associated symptoms)
• Stiffness
• Limited movement

13. 13
Assessing: Subjective Data
• RheumatoidArthritis (RA) chronic systemic
inflammatory disease involves symmetric
joints. Other MS disorders involve isolated or
unilateral joints.
– Rheumatoid arthritis
– Stiffness
– Swelling
– Limited ROM
– Movement decreases pain

14. 14
Assessing: Subjective Data
•Osteoarthritis: chronic degeneration
of joint cartilage caused by aging or
trauma
–Stiffness
–Swelling
–Limited ROM
–Heberden’s and Bouchard’s nodules

15. Assessing: Subjective Data
• Muscle Pain:
• SLIDA
• Aching/cramps
• Weakness
• Resistance 0-5
• Atrophy
15

16. Assessing: Subjective Data
• Bones pain:
• SLIDA
• Hx
• Deformity
• Trauma- limitations
as a result of trauma
2/26/2016 ShahzadBashir, NLCON,Karachi. 16

17. Assessing: Subjective Data
17
• FunctionalAssessment:
• ADL’s- does MS problem create limits:
• Bathing- getting in and out of tub, turning
faucets
• Toileting- getting on/off toilet, wiping self
• Dressing- buttons, zippers, tying shoes
• Grooming- shaving, brushing teeth, putting on
makeup
• Eating- cutting food, preparing meals etc…

18. Assessing: Subjective Data
• FunctionalAssessment:
• Mobility- walking up/down stairs,
in and out of car, out of house
• Communicating- talking, using
phone or computer, writing
• Occupational/Environmental- heavy
lifting, repetitive motions etc.
18

19. Assessing: Subjective Data
19
• Self care behaviors:
• Exercise- type, frequency, warm up
• Pain during exercise? How tx?
• Recent weight gain ( puts stress on
musculoskeletal system) …usual daily diet
• Any meds- anti inflammatory, muscle
relaxants, pain relievers

20. Assessing: Subjective Data
• Additional hx.- Infants and
Children:
• Birth trauma
• Resuscitation at birth
• Motor milestones
• Bone deformity/spinal curvature
20

21. Assessing: Subjective Data
• Additional hx. forAdolescents:
• Sports (Assess safety)
• Special equipment? Training? Warm up?
• What does client do if injured/ ill
• How does sport fit in with other
demands/ activities
21

22. Assessing: Subjective Data
•Additional hx. for Aging adult:
•Use functional assessment to elicit any
loss of function, self care deficit or
safety risk:
•Weakness
•Falls/ Stumbling
•Mobility aids used
22

23. 23
Assessing: Objective Data
•Physical exam provides the nurse
with objective data
•Guidelines for Physical Exam include:
•Full visualization of part being examined
•Drape other parts for privacy
•Orderly approach: head to toe and
proximal to distal.

24. 24
Physical Examination Guidelines
•Joint being examined should be
supported.
•Compare paired joints, expect symmetry.
•When examining a painful area, use
firm support, gentle movement.
•Assess Range of Motion (ROM) of
each joint

25. 25
Physical Examination
•Assess gross motor movement and
posture
•Note patient’s gait
•Note any foot dragging, limping,
shuffling
•Note any spinal deformities
•Inspect skin and subcutaneous tissues

26. 26
Physical Examination
•Assess upper and lower extremities for:
•Overall size, symmetry
•Gross deformity
•Bony enlargement
•Alignment
•Symmetry of length and position

27. Physical Examination
•Bones, joints, muscles:
•Inspect swelling, deformity, condition
•Assess for stiffness, instability, pain,
crepitus, unusual joint movement
•Assess ROM
•Muscle strength
•Assess symmetry
27

28. 28
Physical Examination
•Head
•Temporomandibular Joint- crepitus and
pain with TMJ disorder
•Open mouth: 3-6 cm
•Move lower jaw from side to side
•Stick out lower jaw

29. Physical Examination
•Neck:
•ROM and muscle strength:
•Flexion- touch chin to chest
•Extension- tilt head backward
•Cervical rotation- turn head to R and L.
•Lateral bending- touch ear to R. and
L. shoulders
•Retraction and Protraction
29

30. 30
Physical Examination
•Shoulder: Note posture erect, hunched.
•Assess symmetry and position of clavicles.
•Palpate clavicles toward shoulders,
palpate deltoid muscle.
•ROM and muscle strength:
•Flexion and Extension and Hyperextension
•Abduction and Adduction
•Rotation

31. 31

32. Physical Examination
•Elbow- bend elbow 70 degrees, inspect
and palpate posterior surface
•Note- medial and lateral condyles of
humerus and olecranon process of ulna
•ROM and muscle strength:
•Flexion and Extension
•Supination and Pronation
32

33. Bones of Hand
33

34. 34
Physical Examination
•Wrist- Grasp wrists, assess body
processes of radius (thumb side)
and the ulna. Palpate radio - carpal
joint and remaining wrist joints.
•ROM and muscle strength:
•Flexion and Extension and Hyperextension
•Radial and ulnar wrist deviation
•Circumduction

35. Phalen’s Test
2/26/2016 ShahzadBashir, NLCON,Karachi. 35

36. 36

37. 37
Physical Examination
•Hand- Use thumb and forefinger to palpate
the metacarpophalangeal and
interphalangeal joints.
•ROM and muscle strength:
•Flexion and Extension and Hyperextension
•Abduction- have patient spread fingers apart
•Adduction- have pt. hold fingers together.
•Thumb/Finger Opposition

38. 38

39. Arthritis: Heberdens nodules &
Bouchards nodules
39

40. 40

41. 41
Physical Examination
•Hip- palpate hip joint and surrounding
structures. Position pt. side lying and
palpate iliac crest, greater trochanter, hip,
thigh and buttock muscles
•ROM and muscle strength:
•Flexion and Extension and Hyperextension
•Adduction andAbduction
•External rotation and Internal rotation

42. Landmarks of Knee
42

43. Physical Examination
•Knee- have pt. sitting, dangling.
Inspect- note alignment, deformity,
contour of quadricep muscle.
•Palpate the suprapatellar pouch and
note any tenderness, edema.
•ROM and muscle strength:
•Flexion and Extension
43

44. Patella ballottement
44

45. Bulge sign
45

46. Ankle and Foot
46

47. 47

48. 48
Physical Examination
•Ankle: Compare the contour of R. and L.
ankles. Palpate ankle and achilles tendons.
•ROM and muscle strength:
• Dorsiflexion- point toes upward.
•Plantar Flexion- point toes downward.
•Inversion- turn soles of feet inward.
• Eversion- turn soles of feet outward.
•Circumduction

49. Physical Examination
•Foot: inspect skin integrity, condition
of nails and any deformities.
•Palpate the metatarsal bones and
joints, squeeze each foot.
•ROM and muscle strength:
•Flexion and Extension
•Abduction and Adduction
49

50. Landmarks of Spine
50

51. Physical Examination
•Spine: Have pt. bend a waist, note
curvature, ease of mobility.
•Palpate vertebral column with
fingertips, note tenderness or bony
deformities.
•Lightly fist palpate length of spine
(ulnar surface of hand) Note any
tenderness.
•Lateral bending and spinal rotation.
51

52. Summary Musculoskelatal Exam
•Inspect body parts
•Palpate each joint
•Assess ROM of each joint
•Assess muscle strength
52

53. Muscle Strength
O'Neill S, Jaszczak SLT, Steffensen AKS, Debrabant B. Using 4+ to grade near-normal muscle strength does not improve
agreement. Chiropr Man Therap. 2017;25:28. [PMC free article] [PubMed] [Reference list] Medical Research Council scale

54. Sample Charting
54

55. ARTERIAL ANATOMY
Vascular System Components
• Arteries
• Veins: Deep veins of the legs carry 90% of the
venous return from the lower extremities
• Including great saphenous , small saphenous,
and communicating veins
• Lymphatic and lymph nodes

56. Goals
• Establish presence and quality of pulses
•Establish presence or absence of findings:
aneurysms,
arterial bruit,
signs of ischemia,
signs of venous disease
Arterial Anatomy
Vascular Physical Exam

57. ARTERIAL ANATOMY

58. ARTERIAL ANATOMY

59. Arms
• -Size, symmetry, skin color, temperature, edema
• Radial and brachial pulse
• Epitrochlear lymph nodes
• Allen’s Test (radial and ulner patency), venous filling
Legs
• Size, symmetry, skin color, temperature
• Femoral pulse, bruit, and inguinal lymph nodes
• Popliteal , Dorsalis Pedis pulse,
Posterior Tibia pulse
• Peripheral edema, ulcers/lesions
Peripheral Vascular Exam

60. Posterior Tibialis
Dorsalis Pedis
Vascular Physical Exam

61. Femoral Artery
Popliteal Pulse
Vascular Physical Exam

62. Aortic Aneurysm Exam
Vascular Physical Exam

63. Subclavian Artery Exam
Vascular Physical Exam

64. Carotid Artery Exam
Vascular Physical Exam

65. Sound made by vibrating arterial wall
Caused by turbulent blood flow making arterial
wall vibrate
Indicates the presence of an arterial lesion
Bruit
Vascular Physical Exam

66. Generally related to
Blockage of blood vessel
Dilatation of blood vessel
Subsequent events
Ischemic tissue
Gangrenous tissue
Vascular Findings
Vascular Physical Exam

67. Ischemia
Decreased blood supply results in metabolic
compromise.
Grades of severity reflect acuity of condition
as well as the magnitude of the reduction in
circulation.
Vascular Physical Exam

68. 5 ‘P’s
Pulseless
Pain
Pallor
Paresthesia
Paralysis
Poikilothermia (Cold)
Acute Ischemia
Vascular Physical Exam
ACUTE vs CHRONIC

69. Acute Ischemia
ACUTE vs CHRONIC

70. Acute Ischemia
An abrupt disruption of the normal blood
supply to a vascular bed.
Example:
Gunshot wound
Fracture
Tourniquette
Embollus
Vascular Physical Exam
ACUTE vs CHRONIC

71. Acute Ischemia
Implies that without prompt restoration of
blood supply there will be significant
permanent damage to tissues.
Susceptibility to Acute Ischemic Injury
Nerve +++
Muscle ++
Tendon and Bone +
Vascular Physical Exam
ACUTE vs CHRONIC

72. Chronic Ischemia
A process where the gradual onset and
magnitude of ischemia has allowed the body
time to compensate for the decreased blood
supply.
Key Concept: “Collateral Circulation”
Compensation is never as good as original.
The vascular bed survives with less blood.
Vascular Physical Exam
ACUTE vs CHRONIC

73. Chronic Ischemia
Changes in the Limbs
Skin …………………...Growth slowed
Nails beds…………… Growth slowed
Hair follicles…….Lost
Sebaceous glands ……Lost
Result: Thin, dry, skin with loss of
hair, abnormal nail growth / fungal
infections.
Vascular Physical Exam
ACUTE vs CHRONIC

74. Capillary Refill
The time required for capillary system to
refill following compression of the nail
bed or finger pad.
Normal should be rapid (1 sec or less)
Decreased
Normal physiologic response (eg. cold)
Abnormal vasomotor tone (eg. Raynaud’s)
Acute Ischemia
Chronic Ischemia
Vascular Physical Exam
ACUTE vs CHRONIC

75. Capillary Refill
In the chronic ischemic limb:
Pallor on Elevation
Insufficient arterial pressure to perfuse
when leg elevated above level of heart.
Limb drains of blood.
Dependent Rubror
Blood pooling in maximally dilated
capillary bed
Cyanosis -- when blood is de-oxygenated
Vascular Physical Exam
ACUTE vs CHRONIC

76. Tissue Refill
Buerger’s test
Venous Guttering

77. Capillary Refill
In Acute Ischemia
Cyanosis noted because blood hemoglobin
is desaturated of oxygen
Compression of digit results in evacuation
of blood from capillaries
Refill of blood is sluggish because of
decreased arterial pressure.
In severe cases the blood in capillaries may
thrombose and will not blanch on palpation
Vascular Physical Exam

78. Cyanosis with acute ischemia

79. Ulceration
A discontinuity in the integrity of the
skin which persists despite sufficient
time for healing.
Must be able to distinguish three
types: Arterial, Venous, Neuropathic.
Vascular Physical Exam

80. Ulcers
Differential Presentation of Ulcers
Arterial Venous Neuropathic
Location distal maleolar plantar
Symptoms painful + / - no pain
Outline Sharp irregular punched
Assoc findings Art sx CVI sx other Dx
No pulse OK pulse OK pulse

81. What kind of
ulcer ?

82. Answer:
Neuropathic
Plantar
location
Punched
Out
margins
Insensate

83. What kind of
ulcer ?

84. Arterial Ulcer
Distal
location
Sharp
margins
Painful

85. What kind of ulcer ?

86. Venous Ulcer
Maleolar
location
Irregular
margins
Insensate
or Painful

87. Ulcers
DIABETIC
VENOUS
ARTERIAL

88. Decubitus Eschar
Gangrene:
Necrosis or death of tissue.

89. Gangrene
Death of tissue
Related to absence of blood supply
Infections
Tissue Toxins
Radiation, Trauma
WET Gangrene vs DRY Gangrene
Bacterial superinfection
Mumefaction or mumyfication
Vascular Physical Exam

90. Wet Gangrene

91. Dry Gangrene

92. Gangrene
A dynamic process develops
where tissues becomes ischemic
with acute necrosis, autolysis and
liquefaction.
In the absence of superinfection
the tissue gradually dessicates
and becomes mummyfied. Later,
eschar separation and auto-amputation take place.

93. Digital Embolization

94. Method to
Prepare your patient for Physical Exam
be sure room temperature is correct
be sure limb position is as needed
be sure privacy is respected
place patient in correct position: supine on
exam table is generally best
uncover area to be examined
Vascular Physical Exam

95. Methods:
Discuss what you are about to do
Introduce yourself
Inform patient of intention of
examination
Explain how exam will be conducted
Ask to Conduct Exam
Vascular Physical Exam

96. Methods:
Prepare Yourself for the Exam
Approach exam systematically
LOOK and Compare bilaterally
Review patient complaints as exam progresses
Expose the patient’s lower limbs and upper limbs
Ask if the patient has ANY pain
Vascular Physical Exam

97. Methods:
Follow Exam Sequence
Observe
Auscultate
Lightly touch
Palpate
Compress
Vascular Physical Exam

98. Specific Observations
PULSES
-- should note 17 pulses.
-- quality (-, +, ++)
Temporal x 2
Carotid x 2
Brachial x 2
Radial x 2
Aorta x 1
Femoral x 2
Popliteal x 2
Dorsalis Pedis x 2
Posterior Tibialis x 2
Vascular Physical Exam

99. BRUIT
-- should listen for 5 bruit.
Carotid x2
Aorta x1
Femoral x2
Specific Observations
Vascular Physical Exam

100. SIGNS OF ISCEMIA
-- look for 6 Ischemic Signs in each limb.
Color Temperature
Capillary Refill Ulceration
Eschar Location
Specific Observations
Vascular Physical Exam

101. Student Worksheet -- Specific Observations
1. Pulses -- should note quality (-, +, ++)
right left
_____ _____ Superficial Temporal
_____ _____ Common Carotid
_____ _____ Brachial
_____ _____ Radial
_____ Aorta
_____ _____ Common Femoral
_____ _____ Popliteal
_____ _____ Dorsalis Pedis
_____ _____ Posterior Tibialis
2. Aneurysms (yes, no)
right left
_____ Aorta
_____ _____ Common Femoral
_____ _____ Popliteal
3. Bruit (yes, no)
right left
_____ _____ Common Carotid
_____ Aorta
_____ _____ Common Femoral
4. Ischemic Signs -- signs of arterial disease.
(normal, abnormal; yes, no; If yes, location)
right left
_____ _____ Color
_____ _____ Temperature
_____ _____ Capillary Refill
_____ _____ Ulceration
_____ _____ Eschar
Location
5. Venous Signs -- signs of venous disease.
(yes, no. If yes, location)
_____ _____ Brawny Color
_____ _____ Varicose Veins
_____ _____ Ulceration
_____ _____ Edema
Location
Examination Instrument
Vascular Physical Exam

102. Any Questions?
Thank you.

103. 10
3
References
1. Bickley, L. S., Szilagyi, P.G., & Bates, B.
(2007). Bates' guide to physical examination
and history taking (11th Edi). Philadelphia:
Lippincott Williams & Wilkins. Chapter
No.06 & 07 p.n 171-250
2. Weber, Kelley's. (2007). Health Assessment
in Nursing, 3rd Ed: North American Edition.
Lippincott Williams & Wilkins. Chapter
No.14 &15 p.n 239-294