Nursing Assessment of the Vascular System

by Samantha Rhea, MSN, RN

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    00:01 Now, let's talk about when we talk about cardiac, It is more than just your heart rate, your heart rhythm.

    00:07 We've got to think about that heart perfuses all the rest of our body.

    00:11 And this is going to be an assessment details that are important to include.

    00:16 Now, this is going to include your pulses, your jugular vein distension.

    00:20 And we'll get into that a little bit more.

    00:23 Capillary refill, and also checking the edema.

    00:25 So again, your vascular system tells us a lot about the cardiovascular and circulatory status of your patient.

    00:33 So we're talking about pulses.

    00:35 so palpating pulses, if you remember palpating the feeling that are central and distal.

    00:41 Now, it's important here that you're going to compare sides.

    00:45 We want to check the rate, we want to check the rhythm, and how regular it is just like that lub-dub.

    00:51 We want to check the tension.

    00:53 So if we talk about compressing an artery if you push on it, you should feel some like rebound, some flexibility.

    01:00 And there should be a certain amount of resistance.

    01:03 And also when we talk about strength or volume, we're looking here: Is it strong? Is it bounding? Is it weak? Can we barely feel it? These are all important things to note when we're talking about pulses.

    01:16 So if you take a look at this image here on our guy, you see there's pulses all over the place.

    01:21 We've got lots of pulse points starting in the neck with carotids, your brachial artery for blood pressure, your radial which is in the wrist, and your radial artery is very easy to find.

    01:33 So many times you're gonna gain a pulse rate from the radial artery.

    01:37 Your femoral artery, the popliteal behind the knee, and of course, those in the feet.

    01:42 All of these are really important, circulatory points.

    01:47 Now, when we're talking about palpating pulses, here's something to keep in mind, like, especially if you're teaching or learning how to assess a radial pulse.

    01:56 Many times when you see in new students assessing a pulse, you will see that they're pushing down, it's really best that you use your fingers and really try to lay them more flat and provide light compression.

    02:09 So if I'm finding my radial, for example, if I go down my thumb side, use my thumbs.

    02:15 And you notice I'm not here pushing down, I'm more flat, I can easily find my radial pulse.

    02:21 Now, one key note, don't use your thumb, your thumb has a pulsating in itself and this can give you an inaccurate reading and assessment.

    02:31 So next, let's talk about something we call JVD or Jugular Vein Distension.

    02:37 So this is a sign of increased venous pressure inside of our body.

    02:41 Now this can be a sign of a lot of issues.

    02:45 So this is really showing when we're talking about central venous pressure.

    02:49 It just tells us how much blood is flowing back into the heart, how well that heart can move into your body or through your body into your lungs and back into the rest of your body.

    02:59 But if you see this JVD, if you take a look at this image, you see we're here in the jugular, meaning the neck, you see this vein is all engorge and it's here to the surface, that indeed is jugular vein distension.

    03:14 That means we've got too much fluid in our circulatory system on board.

    03:19 And this can cause lots of issues.

    03:21 So if we assess that, we need to examine the client with the head of bed about 45 degrees.

    03:28 And so when we're looking at that vein in the neck, is it distended, engorge, and popping out like you see in this image, or is that pulsating? This is all something you want to report to the health care provider.

    03:40 Now another really easy and important vascular system assessment is capillary refill.

    03:47 So this is really helpful on diabetics and specially on feet and toes of a diabetic patient.

    03:53 Capillary refill is really simple and it's effective.

    03:57 Here we're just checking peripheral perfusion or blood flow to our extremities.

    04:02 So all we do here like you see in the image is take a finger, push down on the patient's fingernail.

    04:09 Now we should see normal color come back within three seconds.

    04:13 If it's any longer than three seconds, this is abnormal.

    04:17 This is a really easy test or practice you can do at home.

    04:20 And clearly if the patient has fingernail polish, you may have to remove this.

    04:25 Now, in next thing to talk about when you're talking about the vascular system, if you see any signs of what we call cyanosis, cyanosis is a bad thing.

    04:36 So if you see this bluish color, like you see in the image here, if you see it in the hands, the feet, the lips or the face, any of this have signs of cyanosis or this bluish color, we have low oxygenation.

    04:53 We are not perfusing, meaning we're not getting good blood flow to tissues and this is an emergency.

    04:59 You can lose tissues and this is a problem.

    05:02 And this is emergency we've got to report.

    05:06 Now next off, let's talk about something called edema.

    05:09 Now, edema can sometimes be a less serious issue.

    05:13 But again, this is going to vary depending on the reason why the edema is there.

    05:17 So if we take a look at this image, you see this patient's leg.

    05:21 So on the forside of the image, you see pretty normal sided L size leg, and then you see the other one that's large, and engorge.

    05:30 You can even see the skin maybe coming around the ankle, that is a edema.

    05:34 So just by assessing the patient on both sides, you can tell if one leg is larger than the other.

    05:41 Same thing here on the image of the feet.

    05:43 Notice one foot looks relatively normal.

    05:46 The other one, you see the little wrinkling almost around the ankle and the size of the foot? This is also noting edema.

    05:54 So we talk about edema, a lot of reasons.

    05:57 So fluid volume excess, and you could because there's a blood clot, it could be a lot of reasons or an infection that the patient's got edema.

    06:05 Now, we classify this in two different ways.

    06:08 One is called pitting edema, meaning when we push on it, it almost develops a little pit.

    06:14 And non-pitting, which is like, let's say you cut your finger and it gets red hot swollen and really tight.

    06:22 That's what we call non-pitting edema.

    06:24 So just to discuss how we rate edema, or discuss non-pitting edema, if you take a look at this image, you see how the nurse simply just takes their finger and pushes down into the edematous area.

    06:37 Now, this is kind of subjective, but we really just kind of count one, 1002, 1003, 1004, 1000.

    06:46 And let's say it takes up to one, 1002, 1000.

    06:51 to get back to normal, then we'll call it +2 pitting edema.

    06:56 So again, remember we only grade pitting edema, because you can push on it, make that pit like you see in the image.

    07:05 We're gonna count, and then see what we grade that and that is only on pitting edema.

    07:10 Now, other edema can be caused again from like DVTs, where it's red, hot, and swollen.

    07:15 This is called non-pitting, and you can't push down on that type of edema.

    About the Lecture

    The lecture Nursing Assessment of the Vascular System by Samantha Rhea, MSN, RN is from the course Assessment of the Cardiovascular System (Nursing).

    Included Quiz Questions

    1. Rate
    2. Tension
    3. Strength
    4. Viscosity
    1. Increased central venous pressure
    2. Fluid volume overload
    3. Decreased central venous pressure
    4. Fluid volume deficit

    Author of lecture Nursing Assessment of the Vascular System

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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