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Table 6-5. Continued

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Test

Description

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Ankle-brachial index (ABI)

Systolic blood pressures are taken in both upper extremities at the brachial arter

§

ies and both lower extremities above the ankle, followed by Doppler evaluation of dorsalis pedis or posterior tibialis pulses. The higher of the lower

§

extremity pressures is rhen divided by the higher of rhe upper-extremity pres

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sures (e.g., an ankle pressure of 70 mm Hg and a brachial pressure of 140 mm

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Hg will yield an AB) of 0.5).

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Normal ASI for foO[ arteries is 0.95-1.20. with indexes below 0.95 indicating

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arterial obstruction.

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Exercise testing

Exercise testing is performed to assess the nature of claudication by measuring

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ankle pressures and PVRs after exercise.

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A drop in ankle pressures can occur with arterial disease.

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This type of testing provides a controlled method to document onset. severity,

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and location of claudication.

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Screening for cardiorespiratory disease can also be performed, as patients with

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peripheral vascular disease often have concurrent cardiac or pulmonary disor

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ders (see Chapter I).

Computed tomography (CT)

CT is used ro provide visualization of the arterial wall and its Structures.

Indications for CT include diagnosis of abdominal aortic aneurysms and pOStoperative complications of graft infections, occlusions, hemorrhage, and abscess.

Magnetic resonance imaging (MRI)

MRI has multiple uses in evaluating the vascular system and is now morc commonly used to visualize the arterial system than arteriograms. Specific uses for MRI include detection of deep venous thrombosis and evaluation of cerebral

edema.

Serial MRls can also be used to help detemline me optimal operative time for patients

with cerebrovascular accidents by monitoring their progression.

Magnetic resonance angiography

MRA uses blood as a physiologic contrast medium to examine the structure

(MRA)

and location of major blood vessels and the flow of blood through these vessels. The direction and rate of flow can also be quantified. MRA minimizes complications that may be associated with contrast medium injection.

Sources: Data from JM Black, E l\tatassarin-Jacobs (cds). Luckmann and Sorensen's Medical-Surgical Nursing: A PsychophYSiOlogic Approach (4th cd). Philadelphia: Saunders, 1993; P Lanzer, J Rosch (cds). Vascular Diagnostics: Noninvasive and Invasive Techniques, Peri-Interventional Evaluations. Berlin: Springer-Verlag, 1994; KL McCance, SE Huether (cds). Pathophysiology: The Biological Basis for Disease in Adults and Children (2nd ed). St. Louis: Mosby, 1994; JL Kee (cd). Laboratory and Diagnostic Tests with Nursing Impli

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cations (5th cd). Stamford: Appleton & Lange, 1999,606; VA Fahey (cd). Vascular Nursing (3rd ed). Philadelphia: Saunders, 1999j76, r;:

86; and LM Malarkey, ME Morrow (cds). Nurses Manual of Laboratory Tests and Diagnostic Procedures (2nd ed). Philadelphia: Saun

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den. 2000;359.

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376 Acme CARE HANDBOOK FOR PHYSICAL THERAJlISTS

•

Frequent vital sign monitoring with pulse assessments.

•

If a patient has been on heparin before angiography, the drug is

not resumed for a minimum of 4 hours.s

The following are complications associated with angiography,·s.6:

•

Allergic reactions to contrast dye

• Thrombi formation

• Vessel perforation with or without pseudoaneurysm formation

• Hematoma formation

• Hemorrhage

•

Infections at the injection site

• Neurologic deficits from emboli dislodgment

• Contrast-induced renal failure (refer to Chapter 9)

Hematologic Evaluation

The medical work-up of the patient with a suspected hematologic

abnormality emphasizes the patient history and laboratory studies, in

addition to the patient's clinical presentation.

History

In addition to the general charr review (see Appendix I-A), the following questions are especially relevant in the evaluation of the patient with a suspected hematologic disorder7-':

• What are the presenting symptoms?

• Was the onset of symptoms gradual, rapid, or associated with

trauma or other disease?

•

Is the patient unable to complete daily activities secondary to

fatigue?

•

Is there a patient or family history of anemia or other blood disorders, cancer, hemorrhage, or systemic infection?

•

Is there a history of blood transfusion?

VASCULAR SYSTEM AND HEMATOLOGY

377

•

Is there a history of chemotherapy, radiation therapy, or other

drug therapy?

• Has there been an environmental or occupational exposure to

toxins?

• Have there been night sweats, chills, or fever?

• Is the patient easily bruised?

• Is wound healing delayed?

• Is there excessive bleeding or menses?

Other relevant data include rhe patient's diet (for the evaluation of

vitamin- or mineral-deficiency anemia), history of weight loss (as a

warning sign of cancer or altered metabolism), whether the patient

abuses alcohol (a cause of anemia with chronic use), and race

(some hematologic conditions have a higher incidence in certain

races)_

Inspection

During the hematologic evaluation, the patient is observed for the

following7:

• General appearance (for lethargy, malaise, or apathy)

•

Degree of pallor or flushing of the skin, mucous membranes,

nail beds, and palmar creases

• Presence of petechiae (purplish, round, pinpoint, nonraised

spotS caused by intradermal or subcuraneous hemorrhage)'o or

ecchymosis (bruising)

• Respiratory rate

Palpation

The examination performed by rhe physician includes palpation

of lymph nodes, liver, and spleen as parr of a general physical

examination. For specific complaints, the patient may receive

more in-deprh examinarion of a body system. Table 6-6 summarizes rhe abnormal hematologic findings by body system on physical examinarion. The physical rherapist may specifically examine the following:

378 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 6-6. Signs and Symproms of Hematologic Disorders by Body System

Body System

Sign/Symptom

Associated Condition

Cardiac

Tachycardia

Anemia, hypovolemia

Palpitations

Anemia, hypovolemia.

Murmur

Anemia, hypovolemia

Angina.

Anemia, hypovolemia

Respirarory

Dyspnea

Anemia, hypovolemia

Orthopnea

Anemia, hypovolemia

Musculoskeletal

Back pain

Hemolysis

Bone pain

Leukemia

Joint pain

Hemophilia

Sternal tenderness

Leukemia, sickle-cell disease

Nervous

Headache

Severe anemia, polycythemia,

metastatic tumor

Syncope

Severe anemia, polycythemia

Vertigo, tinnitus

Severe anemia

Paresthesia

Vitamin BI1 anemia, malignancy

Confusion

Severe anemia,

malignancy, infection

Visual

Visual disturbances

Anemia, polycythemia

Blindness

Thrombocytopenia, anemia

Gastrointestinal,

Dysphagia

Iron-deficiency anemia

urinary, and

Abdominal pain

Lymphoma, hemolysis, sickle-cell

reproductive

disease

Spleno- or

Hemolytic anemia

hepatomegaly

Hematemesis, melena Thrombocytopenia and clotting

disorders

Hematuria

Hemolysis and clotting disorders

Menorrhagia

Iron-deficiency anemia

Integumentary

Petechiae

Iron-deficiency anemia

Ecchymosis

Hemolytic, pernicious anemia

Flushing

Iron-deficiency anemia

Jaundice

Hemolytic anemia

Pallor

Conditions with low hemoglobin

Source: Data from JM Bbck, E Matassarin-Jacobs (eds). Medical-Surgical Nursing

Clinical Management for Conrinuity of Care (5th cd). Philadelphia: Saunders, 1997.