NR 304- Health Assessment II Final
Exam
Palpation of radial pulse - answer Palpate both pulses noting the rate, rhythm, elasticity
of vessel wall and equal force
grading pulse - answer3+ full bounding
2+ normal
1+ weak
0 absent
brachial pulse - answer palpate this pulse if you suspect arterial insufficiency
modified Allen's test - answer tests for ulnar arterial insufficiency by occluding both the
radial and ulnar artery
normal results: normal color of hand should reappear approximately 2-5 seconds
abnormal results: pallor persists or a sluggish return to color suggest occlusion of the
collateral arterial flow
temporal artery - answer palpated in front of the ear
carotid artery - answerpalpated in the groove b/t the sternomastoid muscle and the
trachea
brachial artery - answermajor artery supplying the arm
radial artery - answerlies medial to the radius and wrist supplies blood to the hand
ulnar artery - answerlies lateral to the ulna. Deeper and often difficult to feel. Supplies
blood to the hand
femoral artery - answermajor artery in the leg. Palpated in the inguinal area
popliteal artery - answerartery in the knee. Located posterior to the patella. Divides into
the anterior and posterial tibial artery
anterior tibial - answertravels down the front of the leg on to the dorsal of the foot
becomes the dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the foot
posterior tibial - answertravels down behind the medial malleolus and forms the plantar
arteries in the foot.
,carries blood to the posterior compartment of the leg and plantar surface of the foot
dorsalis pedis - answera blood vessel of the lower limb that carries oxygenated blood to
the dorsal surface of the foot
claudication distance - answerthe number of blocks walked or stairs climbed to produce
pain
arterial claudication - answerpain in the calf, thigh or hip or muscle fatigue that occurs
when walking a certain distance related to peripheral arterial disease (PAD)
peripheral perfusion - answerchecking for capillary refill by blanching the nail beds and
noting the time for color return
normal is less than 1-2 seconds
doppler - answerused if pulses are too weak to detect by palpation, monitor blood
pressure in infants or children, measure low blood pressure or blood pressure in the
lower extremities
A noninvasive test using sound waves to detect blood flow through blood vessels
ex. competent valves (varicosities)
edema - answerfluid build up in the interstitial space
PVD - answercirculation disorder in which narrowed blood vessels reduce blood flow to
the limbs. Caused by arteriosclerosis (hardening of arteries caused by plaque build up)
Inspect skin for ulcers, temperature and color
lymphedema - answerswelling in the arms or legs caused by a blockage of the
lymphatic system , causes a build up of lymph fluid in tissues
intermittent claudication - answera condition in which cramping pain in the leg is
induced by exercise, typically caused by obstruction of the arteries
5 P's - answerPain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema - answer+1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion - answer-5 P's
-Mottling
, - Bluish/cyanosis
- decrease capillary refill
- cold temperature
arterial insufficiency - answer- skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
venous insufficiency - answer- normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
-edema
-brawny color
arterial ulcers - answer-intermittent claudication pain
-no edema
-no pulse or weak pulse
-no drainage
-round smooth sores
-black eschar
-location on toes and feet
venous ulcers - answer-dull achy pain
-lower leg edema
-pulse present
-drainage
- sores w/ irregular borers
- yellow slough or ruddy skin
-location on ankles
vascular bruit - answeran audible vascular sound associated w/ turbulent blood flow
heaves - answerlift, a sustained forceful thrusting of the ventricle during systole. Occurs
w/ ventricular hypertrophy as a result of increased workload
right ventricular is seen at the sternal border
left ventricular is seen at the apex
thrill - answerpalpable vibration. Feels like the throat of a purring cat.
Signifies turbulent blood flow and directs you to the location of the origin of loud
murmurs
Exam
Palpation of radial pulse - answer Palpate both pulses noting the rate, rhythm, elasticity
of vessel wall and equal force
grading pulse - answer3+ full bounding
2+ normal
1+ weak
0 absent
brachial pulse - answer palpate this pulse if you suspect arterial insufficiency
modified Allen's test - answer tests for ulnar arterial insufficiency by occluding both the
radial and ulnar artery
normal results: normal color of hand should reappear approximately 2-5 seconds
abnormal results: pallor persists or a sluggish return to color suggest occlusion of the
collateral arterial flow
temporal artery - answer palpated in front of the ear
carotid artery - answerpalpated in the groove b/t the sternomastoid muscle and the
trachea
brachial artery - answermajor artery supplying the arm
radial artery - answerlies medial to the radius and wrist supplies blood to the hand
ulnar artery - answerlies lateral to the ulna. Deeper and often difficult to feel. Supplies
blood to the hand
femoral artery - answermajor artery in the leg. Palpated in the inguinal area
popliteal artery - answerartery in the knee. Located posterior to the patella. Divides into
the anterior and posterial tibial artery
anterior tibial - answertravels down the front of the leg on to the dorsal of the foot
becomes the dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the foot
posterior tibial - answertravels down behind the medial malleolus and forms the plantar
arteries in the foot.
,carries blood to the posterior compartment of the leg and plantar surface of the foot
dorsalis pedis - answera blood vessel of the lower limb that carries oxygenated blood to
the dorsal surface of the foot
claudication distance - answerthe number of blocks walked or stairs climbed to produce
pain
arterial claudication - answerpain in the calf, thigh or hip or muscle fatigue that occurs
when walking a certain distance related to peripheral arterial disease (PAD)
peripheral perfusion - answerchecking for capillary refill by blanching the nail beds and
noting the time for color return
normal is less than 1-2 seconds
doppler - answerused if pulses are too weak to detect by palpation, monitor blood
pressure in infants or children, measure low blood pressure or blood pressure in the
lower extremities
A noninvasive test using sound waves to detect blood flow through blood vessels
ex. competent valves (varicosities)
edema - answerfluid build up in the interstitial space
PVD - answercirculation disorder in which narrowed blood vessels reduce blood flow to
the limbs. Caused by arteriosclerosis (hardening of arteries caused by plaque build up)
Inspect skin for ulcers, temperature and color
lymphedema - answerswelling in the arms or legs caused by a blockage of the
lymphatic system , causes a build up of lymph fluid in tissues
intermittent claudication - answera condition in which cramping pain in the leg is
induced by exercise, typically caused by obstruction of the arteries
5 P's - answerPain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema - answer+1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion - answer-5 P's
-Mottling
, - Bluish/cyanosis
- decrease capillary refill
- cold temperature
arterial insufficiency - answer- skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
venous insufficiency - answer- normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
-edema
-brawny color
arterial ulcers - answer-intermittent claudication pain
-no edema
-no pulse or weak pulse
-no drainage
-round smooth sores
-black eschar
-location on toes and feet
venous ulcers - answer-dull achy pain
-lower leg edema
-pulse present
-drainage
- sores w/ irregular borers
- yellow slough or ruddy skin
-location on ankles
vascular bruit - answeran audible vascular sound associated w/ turbulent blood flow
heaves - answerlift, a sustained forceful thrusting of the ventricle during systole. Occurs
w/ ventricular hypertrophy as a result of increased workload
right ventricular is seen at the sternal border
left ventricular is seen at the apex
thrill - answerpalpable vibration. Feels like the throat of a purring cat.
Signifies turbulent blood flow and directs you to the location of the origin of loud
murmurs
