Physical Exam: Vasculature

I. Blood Pressure

• Reflects relationship between cardiac output, peripheral vascular resistance, blood volume and viscosity and arterial elasticity
• Factors influencing Blood Pressure: age, stress, race, drugs, diurnal (day-night) variations, gender
• Alterations in Blood Pressure: Hypotension, Hypertension
• Range of Normal Blood Pressure:

1. Child under age 2 weighing at least 2700 grams - use flush technique, 30-60 mmHg
2. Child over age two - 85-95/50-65 mmHg
3. School age - 100-110/50-65 mmHg
4. Adolescent - 110-120/65-85 mmHg
5. Adult - <130 mmHg systolic/ <85 mmHg diastolic

Common Mistakes during Upper Extremity Blood Pressure Checks

• Too wide bladder or cuff produces false low reading
• Too narrow bladder or cuff produces false high reading
• Cuff wrapped too loosely produces false high reading
• Deflating cuff too slowly produces false high reading
• Deflating cuff too quickly produces false low systolic and false high diastolic reading
• Inaccurate inflation level produces false low systolic reading
• Taking the blood pressure in lower extremities

Peripheral Blood Pressure Measurement in the Legs

• Use the popliteal artery behind knee as stethoscope ausculatory site
• Position the client prone or sitting with knees slightly flexed
• Use wide, long cuff; wrap it so that the bladder is over the posterior aspect of midthigh
• Systolic blood pressures in legs are 20-40 mmHg higher than in the brachial artery
• Diastolic pressure in the legs is about the same as in the brachial artery

II. Internal Carotid Arteries in the Neck

• Palpate each separately along margin of sternocleidomastoid muscle
• Normal findings: strong thrusting pulse
• Auscultate both sides
• Normal findings: no sound heard
• Constriction cause bruit

III. Jugular Veins

• Client in supine position with head elevated at 45 degrees
• Normal findings: pulsations not evident
• Jugular Venous Pressure (JVP): not to exceed 3 cm above level of sternal angle

IV. Peripheral Arteries and Veins

PULSE

Location of Pulses

Head and Neck

• Temporal: over temporal bone lateral to eye
• Carotid: over the carotid artery in neck

Chest

• Apical: between 4th and 5th intercostal space usually mid-clavicular line

Arm

• Brachial: in anterocubital area of arm
• Radial: on thumb side of wrist
• Ulnar: medial wrist

Leg

• Femoral: below the inguinal ligament
• Popliteal: behind knee
• Posterior Tibial: on inner side of each ankle
• Dorsalis Pedis: along top of foot

Normal Peripheral Pulse Range

• Infants: 120-160 beats per minute
• Toddlers: 90-140 beats per minute
• Preschool/School-age: 74-110 beats per minute
• Adolescent/Adult: 60-100 beaths per minute

Factors Affecting Rate

• Exercise
• Temperature
• Stress
• Drugs
• Hemorrhage
• Postural changes
• Pulmonary conditions causing poor oxygenation

Rhythm - regular (normal) or irregular

Strength

• Reflects volume of blood ejected with each beat
• Grading system

Pulse Grading Scale

• No Pulse = 0
• Weak Pulse = 1+
• Difficult to Palpate = 2+
• Normal = 3+
• Bounding = 4+

Equality

Alterations

Dysrhythmias

Tissue Perfusion

• Temperature
• Color: cyanosis
• Clubbing
• Skin and nail texture
• Hair distribution on lower extremities
• Presence of ulcers
• Edema

Pittine Edema Grading Scale

• 4+ = Indentation of >10 mm; greater than 1 inch (Severe)
• 3+ = Indentation of 5-10 mm; 1/2 to 1 inch pitting (Severe)
• 2+ = Indentation of <5mm; 1/4 to 1/2 inch pitting (Moderate)
• 1+ = Barely detectable; 0 to 1/4 inch pitting (Mild)

POINTS TO REMEMBER:

• Compare blood pressure in arms left versus right
• Compare blood pressure with client lying, sitting and standing