ACTIVITY 1
Health Assessment Lecture / Midterm Requirement
Submitted By : Mary Harry L. Dela Cruz (BSN 1 -1)
NAME OF THE TEST INDICATIONS PROCEDURE
ABPI Test Diagnosis of Peripheral
Arterial Disease (PAD) – In 1. Measure Brachial
patients with leg pain, Pressure:
cramping, or ulcers,
especially in diabetics and - Place the blood pressure
smokers. cuff around the upper arm.
Evaluation of Claudication
– For individuals - Use the Doppler
experiencing pain or ultrasound device to locate
cramping in the legs while the brachial artery.
walking (intermittent
- Inflate the cuff and
claudication).
measure the systolic blood
Assessment of Critical Limb
pressure using the Doppler
Ischemia – In cases of rest
device.
pain, non-healing ulcers, or
gangrene. - Record the brachial
Screening in High-Risk pressure.
Patients – Those with
diabetes, hypertension, 2. Measure Ankle Pressure:
smoking history, high
cholesterol, or coronary artery - Place the blood pressure
disease. cuff around the ankle.
Preoperative Vascular
Assessment – Before - Use the Doppler
procedures like bypass ultrasound device to locate
grafting or amputation. the dorsalis pedis artery (or
Monitoring of PAD posterior tibial artery).
Progression – To assess
treatment effectiveness, - Inflate the cuff and
including lifestyle changes, measure the systolic blood
medications, or interventions. pressure using the Doppler
device.
- Record the ankle pressure.
3. Calculate ABPI:
- Divide the ankle pressure
by the brachial pressure.
- Calculate the ABPI ratio
for both legs.
- Note the findings and
document the results for
interpretation if normal or
how severe the patient’s care
is.
Allen Test Before Radial Artery Patient Preparation:
Cannulation – To ensure 1. Ensure the patient is seated
adequate blood supply before comfortably with their arm
placing an arterial line. relaxed and supported.
Prior to Radial Artery 2. Explain the procedure to
Harvesting – For coronary the patient.
artery bypass grafting
(CABG) or other vascular Part 1: Compression
procedures. 1. Ask the patient to clench
Assessment of Hand their fist.
Ischemia – In patients with 2. Compress both the radial
suspected Raynaud’s and ulnar arteries at the wrist
phenomenon, thromboangiitis using your thumbs.
obliterans (Buerger’s 3. Hold the compression for
disease), or arterial occlusion. about 5-10 seconds.
Preoperative Evaluation for
Hemodialysis Access – Part 2: Release and
Ensuring adequate blood flow Observation
before creating an 1. Release the compression
arteriovenous fistula. on the ulnar artery while
Checking for Vascular maintaining compression on
Injury – After trauma to the the radial artery.
wrist or forearm affecting 2. Ask the patient to open
arterial supply their hand and extend their
fingers.
3. Observe the hand and
fingers for:
- Return of blood flow
(flushing or pink color)
- Capillary refill time
4. Repeat steps 1-3, releasing
the compression on the radial
artery while maintaining
compression on the ulnar
artery.
Interpretation:
- Normal: Blood flow returns
to the hand and fingers within
5-10 seconds after releasing
the compression.
- Abnormal:
- Delayed or absent blood
flow return indicates possible
radial or ulnar artery
occlusion.
- Pallor, coolness, or
decreased capillary refill time
may indicate compromised
blood flow.
Post-Test:
1. Release any remaining
compression.
2. Discuss the results with the
patient.
3. Document the findings in
the patient's medical record.
Perthes Test Evaluation of Deep Venous Equipment needed:
Patency – To determine if the - Tourniquet or blood
deep veins are functioning pressure cuff
properly before considering - Sphygmomanometer
surgery for varicose veins. (optional)
Assessment of Deep Venous
Thrombosis (DVT) – To Patient Preparation:
check for obstruction in deep 1. Ensure the patient is seated
veins. comfortably with their leg
Differentiating Superficial elevated.
vs. Deep Venous 2. Explain the procedure to
Insufficiency – Helps the patient.
identify whether varicose
veins are due to deep venous Step-by-Step Procedure:
incompetence or superficial 1. Inflating the Tourniquet:
vein valve failure. - Place the tourniquet or
Preoperative Assessment blood pressure cuff around
for Varicose Vein Surgery – the mid-thigh.
To evaluate deep vein - Inflate the tourniquet to a
function before ligation or pressure of 40-60 mmHg (or
stripping of superficial veins. 10-15 mmHg above the
patient's systolic blood
pressure).
2. Patient Exercise:
- Ask the patient to exercise
their leg by dorsiflexion and
plantarflexing their foot
10-15 times.
3. Observing for Symptoms:
- Observe the patient's leg
for signs of pain, swelling, or
discomfort.
- Ask the patient to report
any symptoms.
4. Releasing the Tourniquet:
- Release the tourniquet and
observe the leg for:
- Return of blood flow
(flushing or pink color)
- Swelling or edema
- Pain or discomfort.
Trendelenburg Test Evaluation of Venous Valve Patient Preparation:
Competency – To - Ensure that the environment
differentiate between is safe and that the patient is
superficial and deep venous wearing appropriate clothing
insufficiency. to allow for assessment of the
Diagnosis of Varicose Veins hip and pelvis.
– To determine if the - Explain the procedure to the
saphenous vein valves are patient and obtain their
functioning properly. consent.
Assessment of Chronic
Venous Insufficiency (CVI) Positioning:
– Helps evaluate venous - Have the patient stand
reflux in patients with leg upright with their feet
swelling, pain, or ulcers. shoulder-width apart on a flat
Preoperative Assessment surface.
for Varicose Vein Surgery –
To check the function of Initial Observation:
venous valves before surgical - Observe the patient for any
interventions like vein asymmetry in the iliac crests
stripping or ligation. (the bony projections on the
pelvis) while standing.
Single-leg Stance:
- Instruct the patient to
elevate one leg off the
ground, bending the knee to
lift the foot, while
maintaining the other leg
straight and weight-bearing.
Typically, the patient is asked
to stand on one leg for about
10 seconds.
Other Test Assessment:
- As the patient lifts one leg,
observe the position of the
pelvis.
- A normal finding is that the
pelvis remains level or only
slightly tilted.
- If the pelvis drops on the
side of the raised leg, this
indicates weakness in the hip
abductor muscles
(specifically the gluteus
medius) on the
weight-bearing side.
Repeat:
You may want to repeat the
test on the opposite leg to
compare results.
Interpretation:
- Positive Trendelenburg Test:
A drop of the pelvis on the
side opposite to the standing
leg indicates dysfunction of
the hip abductor muscles on
the weight-bearing side.
- Negative Trendelenburg
Test: The pelvis remains level
or very slightly tilted during
the test.
Considerations:
- While performing the test,
ensure the patient does not
compensate with trunk
bending or other muscular
strategies to maintain
stability.
Manual Compression Test Evaluation of Varicose Preparation:
Veins – To check for valve 1. Ensure the patient is seated
incompetence in the comfortably with their leg
superficial veins. elevated.
Assessment of Venous 2. Explain the procedure to
Reflux – Helps determine if the patient.
venous blood is flowing
backward due to valvular Step-by-Step Procedure:
insufficiency. 1. Locate the vein:
Diagnosis of Chronic - Identify the vein to be
Venous Insufficiency (CVI) tested (e.g., great saphenous
– Useful in patients with leg vein).
swelling, pain, heaviness, or - Palpate the vein to
ulcers. determine its location and
Preoperative Evaluation for size.
Varicose Vein Surgery – 2. Compress the vein:
Helps decide if surgical - Using your fingers or the
intervention, such as vein heel of your hand, compress
stripping or ablation, is the vein against the
needed. underlying muscle or bone.
Post-Treatment Monitoring - Apply gentle but firm
– To check the effectiveness pressure.
of treatments like 3. Observe for symptoms:
sclerotherapy or laser - Ask the patient to report
ablation. any pain, discomfort, or
sensation of pressure.
- Observe the vein for signs
of distension, swelling, or
redness.
4. Release compression:
- Release the compression
and observe the vein for:
- Return of blood flow
(flushing or pink color)
- Swelling or edema
- Pain or discomfort
Post-Test:
1. Document the findings in
the patient's medical record.
2. Discuss the results with the
patient.
