Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
Peripheral Arterial Disease (PAD) is a chronic circulatory disorder primarily caused by atherosclerosis. In this condition, lipid-rich plaques accumulate along arterial walls, leading to narrowing of the lumen, rigidity, fragility, and obstruction of blood flow. PAD affects both inflow arteries such as the distal aorta and iliac arteries and outflow arteries such as the femoral, popliteal, and tibial vessels.
Risk factors for PAD are both modifiable and non-modifiable. Cigarette smoking is the most significant lifestyle factor, while diabetes mellitus, hypertension, and hyperlipidemia accelerate vascular damage.
Patient history is essential for PAD evaluation. Common complaints include intermittent claudication (leg pain or cramping during walking that improves with rest), skin changes, limb swelling, and palpable lymph nodes. Medication use and smoking history are critical components for risk evaluation.
Physical examination involves inspection and palpation of the upper and lower extremities. Skin color, temperature, texture, edema, and capillary refill should be assessed. Radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses are palpated to detect circulatory compromise.
Patients may present with:
Burning or cramping pain during exertion
Pain relief when legs are dependent
Reduced capillary refill time
Hair loss on lower extremities
Diminished or absent pulses
Cool, cyanotic skin
Dependent rubor
Ulcers or gangrene on toes
Cigarette smoking remains the strongest modifiable risk factor. Other contributors include hyperlipidemia, obesity, and inactivity. Women with depression are at increased risk, and African Americans are twice as likely to develop PAD compared with other groups. The Ankle-Brachial Index (ABI) is the preferred screening tool for high-risk patients.
Raynaud’s Syndrome is a vasospastic condition affecting small arteries, usually in the fingers and toes, and triggered by cold or emotional stress. It is more prevalent in women and in colder climates.
Symptoms include:
Cold or pale digits
Numbness or stinging during rewarming
Skin color changes (white → blue → red)
Palpable lymph nodes are common and considered normal. Lymphoid tissue is well developed from birth until adolescence.
Pregnancy often causes bilateral pitting edema and varicose veins due to uterine pressure restricting venous return.
Older adults frequently present with diminished pulses, thinning skin, hair loss, brittle nails, and trophic changes. PAD prevalence increases with age, with up to 50% of individuals over 85 affected. Reduced mobility or arthritis may mask symptoms.
| Feature | Venous Disease | Arterial Disease |
|---|---|---|
| Cause | Valve incompetence, thrombi | Atherosclerosis, calcification |
| Pulse | Normal (2+–3+) | Diminished/absent (1+ or 0) |
| Temperature | Warm | Cool |
| Skin | Thickened | Shiny |
| Edema | Present | Absent |
| Hair | Present | Absent |
| Color | Red-brown | Pallor (elevated), rubor (dependent) |
| Pain | Worse with standing/sitting | Worse with exertion |
| Pain relief | Rest after prolonged standing | Rest quickly |
| Ulcer location | Medial malleolus | Toes, trauma points |
| Ulcer moisture | Moist, bleeding | Dry |
| Ulcer edges | Uneven | Smooth, well-defined |
| Ulcer base color | Red | Pale |
The Ankle-Brachial Index (ABI) is a non-invasive diagnostic tool using Doppler ultrasound to compare ankle and arm systolic pressures.
Formula:
ABI = Highest ankle systolic pressure ÷ Highest arm systolic pressure
| ABI Score Range | Interpretation |
|---|---|
| 1.0 – 0.91 | Normal |
| 0.90 – 0.71 | Mild PAD |
| 0.70 – 0.41 | Moderate PAD |
| 0.40 – 0.30 | Severe PAD |
| < 0.30 | Ischemia |
The lymphatic system helps maintain fluid balance, protects against pathogens, and absorbs lipids.
Key Structures:
Right lymphatic duct: drains right head, thorax, and arm
Thoracic duct: drains the rest of the body
Lymph Node Clusters:
Cervical: drains head and neck
Axillary: drains upper limbs and breast
Epitrochlear: drains lower arm and hand
Inguinal: drains lower limbs and genitalia
Associated Organs:
Spleen: filters blood and produces antibodies
Tonsils: respond to localized infection
Thymus: supports T-cell development in children
Lymphedema results from impaired lymphatic drainage, leading to protein-rich fluid accumulation. It presents as non-pitting edema with thickened skin. Early management includes manual lymph drainage, compression therapy (not in PAD), and exercise.
| Condition | Indicator Example |
|---|---|
| Thready pulse (1+) | Shock, PAD |
| Bounding pulse (3+) | Hyperthyroidism, fever, anxiety |
| Pitting edema (1+–4+) | Heart failure, hepatic cirrhosis |
| Unilateral swelling | DVT, lymphatic obstruction |
| Discoloration with ulcers | Chronic PAD or venous insufficiency |
| Trophic skin changes | Aging, long-standing PAD |
| Intermittent claudication | Ischemic muscle pain from PAD |
| Type of Ulcer | Common Causes | Characteristics | Common Locations | Risk Factors |
|---|---|---|---|---|
| Arterial Ulcer | Atherosclerosis, smoking | Pale base, well-defined edges, dry, no bleed | Toes, heels, lateral ankle | Smoking, diabetes, hypertension |
| Venous Ulcer | DVT, venous insufficiency | Shallow, moist, granulation tissue, pigmentation | Lower legs, medial ankle | Immobility, obesity, pregnancy, DVT |
| Neuropathic Ulcer | Diabetic neuropathy | Painless, pressure points, deformities | Plantar surface | Diabetes, neuropathy, deformities |
Superficial varicose veins: Result from valve incompetence due to prolonged venous pressure (common in pregnancy, obesity).
Deep vein thrombophlebitis (DVT): Involves clot formation in deep veins, with swelling, redness, warmth, and tenderness; risk of pulmonary embolism.
Arterial occlusions: Narrowing reduces oxygen delivery to tissues.
Aneurysms: Localized arterial dilation from weakened vessel walls, often in the aorta.
Palpation of the liver, spleen, kidneys, and aorta helps identify abnormalities such as tenderness, enlargement, or abnormal pulsations. Abdominal aortic aneurysm may present with widened or laterally pulsating vessels.
Ascites is detected clinically through fluid wave and shifting dullness tests; however, ultrasound remains the gold standard for diagnosis. Causes include cirrhosis, heart failure, cancers, tuberculosis, and pancreatitis.
Smoking cessation is the most critical preventive measure
Control blood pressure, cholesterol, and diabetes
Avoid compression garments in PAD patients
Encourage safe physical activity
Use ABI routinely in high-risk patients
American Heart Association. (2020). Understanding Peripheral Artery Disease (PAD). https://www.heart.org/en/health-topics/peripheral-artery-disease
Bickley, L. S. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Centers for Disease Control and Prevention. (2021). Peripheral Arterial Disease (PAD). https://www.cdc.gov/heartdisease/PAD.htm
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
National Heart, Lung, and Blood Institute. (2022). Raynaud’s Phenomenon. https://www.nhlbi.nih.gov/health/raynauds
National Institute for Health and Care Excellence. (2023). Chronic venous leg ulcers: Management guidelines. https://www.nice.org.uk
Runyon, B. A. (2009). Introduction to the revised American Association for the Study of Liver Diseases practice guideline: Management of adult patients with ascites due to cirrhosis. Hepatology, 49(6), 2087–2107.
Trowbridge, R. L., Rutkowski, N. K., & Shojania, K. G. (2007). Does this patient have splenomegaly? JAMA, 297(17), 1944–1951.
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