i bc27f85be50b71b1 (113 page)

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AClITE CARF HANDBOOK FOR l'HYSICAL TJ-IFRAPlqs

Table 6-3. Blood Cell Types

Cell

Description

Erythrocyte (red

Contains hemoglobin molecules responsible for oxygen

blood cell) (RBC)

rranspon w tissues.

Composed of four protein chains (two alpha and twO

beta chains) bound w four iron pigment complexes.

An oxygen molecule attaches ro each iron J,wm W

become oxyhemoglobin.

Leukocyte (whire

Five types of \�'BCs (neutrophils, basophils, eosinophils,

blood cell) (WBC)

lymphocytes, and monocytes) are responsible for

launching immune defenses and fighting infection.

WBCs leave the circulation [0 gain access to a site of

infection.

Thrombocyte

Cell fragment responsible for dar formarian.

(platelet)

Source: Data from The Cardiovascular System: Blood. In EN Maricb, Human AnalOmy

and Physiology (3rd cd). Redwood City, CA: Bcnjamm·Cummings, 1995.

2.

The transport of carbon dioxide and merabolic waste

products to the lungs and kidneys, respectively

3.

The rransport of hormones from endocrine glands to tar-

get organs

4.

The maintenance of body temperature via conduction and

dispersal of heat

5.

The maintenance of pH with buffers freely circulating in

the blood

6.

The formation of clots

7.

The prevention of infection with white blood cells

(WBCs), antibodies, and complement

The vascular and hematologic systems are intimately linked, and

the examination of these systems is often similar. For the purpose of

this chapter, however, the evaluation of the vascular and hematologic

systems is discussed separately.

VASCULAR SYSTEM AND HEMATOLOGY

367

Physical Examination

Vascular Evalt/atio"

History

In addition to the general chart review (see Appendix I-A), the following information is important to gather during the examination of the patiem with a suspected vascular disorder]:

• Relevant medical history that includes diabetes mellitus, hypertension, syncope or vertigo, and non healing ulcers.

• Relevant social history that includes exercise and dietary habits,

as well as the use of tobacco or alcohol.

• Presence of intermittent claudication (leg pain that occurs with

walking). When (onset) and where (location) does it OCCUt, and

what makes it better?

• Presence or history of peripheral edema. Is it acute or chronic? If

chronic, what is the patient'S baseline level of edema?

•

Precautions, such as weight bearing or blood pressure parameters after vascular surgery.

Clinical Tip

Intermittent claudication is often abbreviated in the clinical setting as Ie.

Inspection

Observation of the following features can help delineate the location

and severity of vascular disease and help determine whether these

manifestations are arterial or venous in origin i.]:

• Skin color. (Note the presence of any discoloration of the distal

extremities, which is indicative of decreased blood flow---e.g.,

mottled skin.)

• Hair distribution. (Patchy hair loss on the lower leg may indicate arterial insufficiency.)

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AClJrE CARE HANDBOOK FOR PHYSICAL THERAPISTS

•

Venous pattern (dilation or varicosities).

•

Edema or atrophy. (Peripheral edema from right-sided congestive heart failure occurs bilaterally in dependent areas; edema from trauma, lymphatic obstruction, or chronic venous

insufficiency is generally unilateral.) Refer to Table 1-6, Pitting

Edema Scale.

•

Presence of cellulitis.

•

Presence of petechiae (small, purplish, hemorrhagic Spots on

the skin).

•

Skin lesions (ulcers, blisters, or scars).

•

Digital clubbing (could be indicative of poor arterial oxygenation or circulation).

•

Gait abnormalities.

Palpation

During the palpation portion of the examination, the physical

therapist can assess the presence of pain and tenderness, strength

and tate of peripheral pulses, respiratory rate, blood pressure, skin

temperature, and limb girth (if edematous). Changes in heart rate,

blood pressure, and respiratory rate may correspond to changes in

the fluid volume status of the patient. For example, a decrease in

fluid volume may result in a decreased blood pressure that results

in a compensatory increase in heart and respiratory rates. The

decreased fluid volume and resultant increased heart rate in this

situation may then result in a decreased strength of the peripheral

pulses on palpation. In patients with suspected or diagnosed

peripheral vascular disease, monitoring distal pulses is more

important than monitoring central pulses in the larger, more proximal vessels.3

The following are twO systems used to grade peripheral pulses:

1.

On the scale of 0-3 as'

0 Absent

+1 Weak and thready pulse

+2 Normal

+3 Full and bounding pulse

VASCULAR SYSTEM AND HE.MATOLOGY

369

2.

On rhe scale of 0-4 as'

0

Absent

1

Markedly diminished

2

Moderately diminished

3 Slightly diminished

4

Normal

Peripheral pulses can be assessed in the following arteries (see

Figure 1-6):

• Temporal

• Carotid

• Brachial

• Ulnar

• Radial

• Femoral

• Popliteal

• Posterior tibial

• Dorsalis pedis

Clinical Tip

• Peripheral pulse grades are generally denoted in the

medical record by physicians in the following manner:

dorsalis pedis +1.

• A small percentage of the adult population may normally have absent peripheral pulses-for example, 10-

17% lack dorsalis pedis pulses.'

•

In patients who have disorders resulting in vascular

compromise (e.g., diabetes mellitus, peripheral vascular

disease, or hypertension), pulses should be monitored

before, during, and after activity not only to determine

any rate changes, but, more important, to determine any

changes in the strength of the pulse.

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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

•

Notation should be made if the strength of pulses is correlated to complaints of pain, numbness, or tingling of the