Diagnostic Evaluation (vascular disorder and problems in peripheral circulation) I.

Introduction Doppler UTZ flow Studies Doppler ultrasonography evaluates blood flow in the major blood vessels of the arms and legs and in the extracranial cerebrovascular system. A handheld transducer directs highfrequency sound waves to the artery or vein being tested. The sound wave strike moving red blood cells and are reflected back to the transducer at frequencies that corresponds to blood flow velocity through the vessel. The transducer then amplifies the sound waves to permit direct listening and graphic recording of blood flow. Measurement of systolic pressure helps detect the presence, location, and extent of peripheral arterial occlusive disease. Pulse volume recorder testing may be performed along with Doppler ultrasonography to yield a quantitative recording of changes in blood volume or flow in extremity or organ. Purpose of Doppler Ultrasonography

To help diagnose venous insufficiency and superficial and deep vein thrombosis (popliteal, femoral, and iliac). To help diagnose peripheral artery disease and arterial occlusion. To monitor the patient who has had arterial reconstruction and bypass grafts. To detect abnormalities of carotid artery blood flow associated with such conditions as aortic stenosis. To evaluate possible arterial trauma.

Management Purpose of Doppler Ultrasonography

To help diagnose venous insufficiency and superficial and deep vein thrombosis (popliteal, femoral, and iliac). To help diagnose peripheral artery disease and arterial occlusion. To monitor the patient who has had arterial reconstruction and bypass grafts. To detect abnormalities of carotid artery blood flow associated with such conditions as aortic stenosis. To evaluate possible arterial trauma.

Implementation 1. Doppler ultrasonography is performed bilaterally.

2. The patient is assisted into the supine position on the examination table with his arms at his sides. Peripheral arterial evaluation 1. For peripheral arterial evaluation in the leg, the usual test sites are the common and superficial femoral, popliteal, posterior tibial, and dorsalis pedis arteries. 2. For peripheral arterial evaluation in the arm, the usual test sites are the subclavian, brachial, radial, and ulnar arteries. 3. Brachial blood pressure is measured, and the transducer is placed at various points along the test arteries. 4. The signals are monitored, and the waveforms are recorded for later analysis. 5. The blood flow velocity is monitored and recorded over the test artery. 6. Segmental limb blood pressures are obtained to localize arterial occlusive disease. Peripheral venous evaluation 1. For peripheral venous evaluation in the leg, the usual test sites are the popliteal, superficial and common femoral veins, and posterior tibial vein. 2. For extracranial cerebrovascular evaluation, usual test sites are the supraorbital artery; the common, external, and internal carotid a arteries; the vertebral arteries; and the brachial, axillary, subclavian, and jugular veins. 3. The transducer is placed over the appropriate vessel, waveforms are recorded, and respiratory modulations are noted. 4. Proximal limb compression maneuvers are performed. 5. Augmentation after release of compression is noted to evaluate venous valve competency. 6. For test involving the legs and feet, the patient is asked to perform Valsalvas maneuver, and venous blood flow is recorded. Nursing Interventions 1. Remove the conductive gel from the patients skin. 2. Assist the patient to a comfortable position. Interfering Factors

Unknown

Precautions

Bradyarrhythmias may occur if the probe is placed near the carotid sinus.

Make sure that the Doppler probe isnt placed over an open or draining lesion.

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrpregnant/dfs.html http://nursingcrib.com/medical-laboratory-diagnostic-test/doppler-ultrasonography/ B. Exercise Testing An exercise test (also called a treadmill test) is a diagnostic test that measures blood flow in your arteries before and after you exercise. Exercise testing can diagnose PAD in the legs in women who have a normal Ankle-Brachial Index (ABI) at rest, but may still have PAD. In some women, PAD symptoms are not apparent at rest and only show up when the legs need more blood than usual, such as during exercise. The exercise test measures the ability of your arteries to provide enough blood to your muscles when they are working hard (or stressed). Who might have an exercise test? in women with a normal ABI at rest, but whose doctor still suspects she may have PAD. In women who have been diagnosed with PAD (evaluate how PAD is affecting their walking capacity and determine a safe level of exercise) All women with PAD should have an exercise test before starting a rehabilitation program that includes exercise. Who should not have an exercise test? if you have very limited blood flow to your legs (pain at rest or sores on your feet) Women with symptoms caused by disease in the coronary arteries (such as chest pain) who have severe aortic disease or very high blood pressure women who have a suspected blood clot in the veins of the legs (deep vein thrombosis, or DVT) - Squeezing of the leg during an ABI can cause the clot to break off and travel to the lungs, causing a potentially deadly pulmonary embolism.

Preparation You should not smoke, eat, or drink anything other than water for 2 hours before a treadmill exercise test Tell your doctor about any medications or dietary supplements you are taking because these may affect the accuracy of the test. wear loose, comfortable clothing and shoes appropriate for exercising. Nursing Action: Instruct patient that he/she can already eat, drink, and resume normal activities immediately following an exercise test. The patient will be you will be closely monitored and the test will be stopped if there is any sign of a problem.

http://www.hearthealthywomen.org/tests-diagnosis/peripheral-vascular-disease/exercisestress-tests-for-pad.html

C. Angiography An angiography is an x-ray of an artery or arteries in the body. In order to actually see the arteries, a special dye, referred to as a contrast dye, is injected through the artery. Once the dye is flowing through the artery, an x-ray can be taken to determine whether or not blood is flowing normally through the vessel. Angiography is used to detect abnormalities or blockages in the blood vessels (called occlusions) throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumors; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to hemorrhage), tumor, blood clot, or arteriovenous malformations (abnormals tangles of arteries and veins) in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate "map" of the heart prior to open-heart surgery, or of the brain prior to neurosurgery. Management Preparation: advised to stop eating and drinking eight hours prior to the procedure remove all jewelry before the procedure and change into a hospital gown shaving may be required(If the arterial puncture is to be made in the armpit or groin area) sedative may be administered - to relax the patient for the procedure IV line inserted - in case medication or blood products are required during the angiogram Inform the patient about the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form.

Aftercare An overnight stay in the hospital (Because life-threatening internal bleeding is a possible complication of an arterial puncture) Patient is typically kept under close observation for a period of at six to 12 hours before being released The patient will be instructed to keep his leg straight and relatively immobile during the observation period if the arterial puncture was performed in the femoral artery Monitor v/s and the puncture site Pain medication if Rx if patient is experiencing discomfort. Cold compress to reduce swelling on the site Inform patient that bruises and sore for several weeks is normal.

Patient must seek for medical attention if experiencing continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure.

http://medical-dictionary.thefreedictionary.com/angiography D. Air Plethysmography From the Greek word "plethysmo", to increase, and "graphos" to write It is the recording of changes in the volume of a limb of digit as blood moves in and out of it with each cardiac cycle. Pneumatic plethysmogaphy uses a pneumatic cuff wrapped around an extremity or digit. By standardizing the injected volume of air and therefore the pressure inside the cuff, momentary volume changes are detected by a transducer and displayed as waveforms also called "pulse volume recordings." These waveforms correspond closely with the waveforms obtained by intra-arterial recording at the same level. Air Plethysmography in medicine and physiology, a method of continuous graphic recording of variations in the volume of a human or animal organ as modified by the circulation of blood. Plethysmography is used to study cardiovascular function and changes in the distribution of blood caused by physical and mental work, fatigue, and emotional responses; it is also used to determine the effects of heat, cold, and tactile and other stimuli and of hypotensive and hypertensive agents. Plethysmography is used in clinical analysis to evaluate vascular tonus and elasticity, pulse volume, and central nervous system function and to investigate corticovisceral functioning by registering the reaction of blood vessels to stimuli. The most useful data are the limb systolic blood pressure and the ABI(ankle-brachial index), which is diagnostic for <0.90 for arterial occlusive disease. Air Plethysmography is usually performed than Doppler vascular studies. This procedure needs a concent Clinical Implication and Indication 1. Diagnoses peripheral vascular disease, arterial occlusive disease, arterial embolus, smallvessel diabetic changes, arterial trauma, and Raynauds disease. 2. Diagnoses venous thrombosis and thrombophlebitis. Management Test procedure:

1. Place the patient in a supine position 2. Plethysmography cuffs are put on the extremity to be measured, and the patients lie quietly while the machine takes measurements. Anxiety or lesions may alter the result. Nursing Care: Before test: Explain the test procedure and the purpose of the test. Assess the patients knowledge of the test Instruct the patient to refrain from smoking, alcohol or caffeine for at least 2 hours before the test. Explain that there is no pain in the test

During test: Adhere to standard precautions. Instruct patient to refrain from talking or moving during the test.

Interfering factors: Anxiety Environmental temperature Talking Inability to remain still Ingestion of stimulants Depressants Vasoconstrictive substances Shock Low cardiac output Low blood pressure

False positives can occur in people with CHF or arterial insufficiency. False negatives can occur with collateral circulation.

Nursing Considerations: Pregnancy: Compression of pelvic veins by the fetus during pregnancy may alter the result. Pediatric: Infants and children will need assistance in remaining still during the procedure and age-appropriate comfort measures following the test.

Gerontology: The older may find it difficult to maintain positions when required to do so for lengthy periods of time during the plethysmography. http://encyclopedia2.thefreedictionary.com/air-cuff+plethysmography http://www.tos-syndrome.com/old1/air.htm http://books.google.com.ph/books?id=A_SB5ItZPDwC&pg=PA674&lpg=PA674&dq=nursing+ management+for+plethysmography&source=bl&ots=Zev_Gj2Zcc&sig=s1fOMnV2fTE0C4Fqm 5EZcarmF4&hl=tl&ei=0ciNTqeyDauciAfBmPH3DQ&sa=X&oi=book_result&ct=result&resnum =3&ved=0CC8Q6AEwAg#v=onepage&q&f=false