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Learning Targets:
At the end of the module, students will be able to:

1. Obtain an accurate history of the cardiovascular
system;
2. Inspect, palpate, and auscultate the jugular veins,
carotid arteries, and the precordium to evaluate
cardiovascular status;
3. Discuss risk factors for coronary heart disease; and,
4. Discuss risk reduction and health promotion strategies
to
reduce coronary heart disease.
Auscultatory Sound
Auscultatory Sound
Auscultatory Sound
Location of Maximal Intensity
Learning Targets:
At the end of the module, students will be able to:
1. Identify the locations of the peripheral pulses;
2. Obtain an accurate history of the peripheral vascular system;
3. Describe the structure and functions of arteries, veins,
lymphatic vessels and lymph nodes;
4. Describe the equipment necessary to perform a peripheral
vascular examination;
5. Evaluate and interpret variations in heart rhythm, rate and
amplitude; and,
6. Discuss risk factors for peripheral artery disease, chronic
venous status, and thromboembolic disease.
COMMON OR CONCERNING SYMPTOMS OF THE PERIPHERAL
VASCULAR SYSTEM & LYMPHATIC SYSTEM
Pain in the arms or legs

Intermittent claudication
Cold, numbness, or pallor in the legs; hair loss
Swelling in the calves, legs, or feet
Swelling with redness and tenderness
Because most patients with peripheral vascular diseases report minimal symptoms, asking specifically about the
symptoms below is recommended, especially in patients older than 50 years and those with risk factors,
especially smoking, diabetes, hypertension, elevated cholesterol, or coronary artery disease:
Do you have pain or cramping in your legs during walking or exertion? (This is termed intermittent claudication.)
o These symptoms are caused by insufficient arterial supply to the legs, which may be caused by
atherosclerosis.
Is it relieved by rest within 10 minutes?
If present, identify the location and the distance the patient walks before symptoms occur.
Do you have coldness, numbness, or pallor in the legs or feet?
Do you have hair on your shins?
Do you have aching or pain at rest in the lower leg or foot?
Is pain alleviated by elevating the legs?
Do you have fatigue or aching in the lower legs with prolonged standing?
Do you have swelling of the feet or legs?
o Edema, varicose veins, and aching in the legs are symptoms of venous stasis.
o If present, identify:
Location
Time of day it is present
Whether it is bilateral or unilateral
Do you have any varicose veins?
o Where are they located?
o How long have you had them?
o Do you have any discomfort from them?
Do you have any wounds of the legs or feet that will not heal or heal very slowly?
o Ulcers may be of venous or arterial origin.
o Where is the wound located?
o How long have you had the wound?
o What precipitated the wound (e.g., an injury)?
Do your fingertips or toes change color in cold weather?
o May be caused by Raynaud disease: the small arteries spasm in response to cold.
Have you experienced erectile dysfunction?
o Poor blood supply to the penile arteries can cause erectile dysfunction.
Do you have abdominal pain after meals?
o Does it prevent you from eating?
o Atherosclerosis of the mesenteric or celiac arteries can cause intestinal ischemia,
producing abdominal
pain and “food fear,” where the patient is fearful of eating.
Do you have tender or swollen lymph nodes (glands)?
o Swollen nodes may indicate an infection or tumor.
Past History
Medications, especially oral contraceptives or hormone replacement therapy

o Estrogen use and pregnancy increase one’s risk for blood clots.
Pregnancy or recent childbirth
Inflammatory diseases such as lupus, rheumatoid arthritis, or irritable bowel disease
o Inflammation contributes to clot formation.
Active cancer
Coronary artery disease (CAD)
o Coronary artery disease and cerebral artery disease are also caused byatherosclerosis;
an individual with either is at risk for PAD.
Heart attack
Congestive heart failure
Stroke (cerebral arterial disease)
Clotting disorders
Hypertension
Diabetes
Problems in circulation, such as blood clots, leg ulcers, swelling, or poor healing of
wounds
Major surgery or fracture of a long bone in the last 4 weeks
Past History
Examination
Arms
Inspection: Inspect both arms from the fingertips to the shoulders. Note:
1. Their size, symmetry, swelling, and any lesions
Lymphedema of the arm and hand may follow axillary node dissection and
radiation therapy.
2. The venous pattern
Prominent veins in an edematous arm suggest venous obstruction
3. The color of the skin and nail beds and the texture of the skin
Palpation:
1. Palpate the temperature of the arms and hands simultaneously with the backs of your
fingers. Compare the temperature of the arms simultaneously.
In Raynaud disease, wrist pulses are typically normal, but spasm of more distal
arteries causes episodes of sharply demarcated pallor of the fingers
2. Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist
laterally. Partially flexing the patient’s wrist may help you feel this pulse. Compare the
pulses in both arms. Pulses may be palpated simultaneously to facilitate comparison.
Examination
• There are two common systems for grading the amplitude of the arterial pulses. One
system uses a scale of 0 to 3, as below.
• The other system uses a scale of 0 to 4. You should check to see what scale
• your institution uses.
• If you suspect arterial insufficiency, feel for the brachial pulse. Flex the patient’s elbow
slightly, and palpate the artery just medial to the biceps tendon at the antecubital
crease.
• The brachial artery can also be felt higher in the arm in the groove between the
biceps and triceps muscles.
• Feel for the epitrochlear nodes. With the patient’s elbow flexed to about 90° and the
forearm supported by your hand, reach around behind the arm and feel in the groove
between the biceps and triceps muscles, about 3 cm above the medial epicondyle. If
a node is present, note its size, consistency, and tenderness. Epitrochlear nodes are
difficult or impossible to identify in most normal people.
Examination
Examination
Legs
The patient should be lying down and draped so that the external genitalia are
covered and the legs fully exposed. A good examination is impossible through
stockings or socks!
Inspection: Inspect both legs from the groin and buttocks to the feet. Note:
1. Their size, symmetry, and edema. Measure leg circumferences in centimeters if
discrepancy is suspected.
2. The venous pattern and any venous enlargement or varicosities
3. Pigmentation, rashes, scars, or ulcers
4. The color and texture of the skin and the color of the nail beds
5. The distribution of hair on the lower legs, feet, and toes.
6. Look for brownish areas (or increased pigmentation on dark-skinned clients)
near the ankles.
The brown discoloration is caused by hemosiderin released from the red blood
cells that seep into the skin with edema and break down.
7. Note the location, size, and depth of any ulcers in the skin. Are the edges of the
wound well demarcated? Is there bleeding?
Examination
Palpation
1. Palpate the temperature of both legs and feet simultaneously with the
backs of your hands. Compare the
temperature of the legs. Bilateral coolness is most often caused by a cold
environment or anxiety. Coldness,
especially when unilateral or associated with other signs, suggests arterial
insufficiency from inadequate arterial
circulation.
2. Palpate for edema. Compare one foot and leg with the other, noting their
relative size and the prominence of
veins, tendons, and bones. Edema causes swelling that may obscure the
veins, tendons, and bony prominences.
Examination
Examination
Examination
THANKS

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Learning Targets:

At the end of the module, students will be able to:

Pain in the arms or legs

Medications, especially oral contraceptives or hormone replacement therapy

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