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Readiness to change

  • Delve into why someone's not ready to change

Peripheral vasculature

  1. Pants off, down to underwear, full leg exposure, access to the groin
  2. Inspection: ankle/foot/toe swelling, varicosities, trophic changes (especially in the skin - infarction, necrosis/black, hair loss (sometimes a line on the leg where it stops), flaky, shinyness that doesn't look good, discolouration/pigmentation, ulcer (late sign)), scars, other evidence of vascular problems (e.g. vein stripping for bypass grafts)
  3. Palpation:
    • Oedema (medial side of lower aspect of tibia, push for a few seconds, then release pressure to look/feel for indentation). If found, check further up the leg
    • Use backs of fingers at various points up the limb to feel differences in temperature
  4. Pulses (bilaterally); note for presence and strength (unlike radial pulse; just measuring vitality of vascular supply)
    • Femoral pulse
    • Popliteal pulse (reach fingers up to midline behind the knee; fingers directly behind inferior border of patella)
    • Dorsalis pedis (lateral to extensor hallucis longus; rest fngers flat)
    • Posterior tibial (posterior to medial malleolus; tarsal tunnel)
  5. Auscultation
    • Femoral artery
    • Listen for bruits (turbulent flow through the vessel) (you do this over the carotids as well); high pitched whooshing noise due to constricted blood flow through a tortuous vessel; shouldn't hear noise because normal laminar flow

Murmur = turbulent flow across a heart valve

Bruit = turbulent flow within a vessel (esp. artery)

Motivational interviewing steps

  • Provide opening structure
  • Ask open ended questions
  • Listen reflectively
  • Affirm
  • Identify motivators for/against 'problem behaviour'
  • Identify impact and implications of problematic behaviour on patient/others
  • Elicit self-motivational statements
  • Summarise key issues

Involve them in it: "from my point of view, losing weight by exercising/eating less is a good idea, what do you think?" "what small changes could you make?"

  • This gets them to tell themselves what to do.
  • Get them to talk about pros and cons
  • What is the worst thing that might happen if you don't change?
  • What has to happen to make you change?
  • What is the next change you need to make?
  • Tap into self-efficacy: "how have you been successful in the past?". Remind them that they've had successes in the past, and that it's possible for them to succeed again
  • Move from contemplation to action
  • Get them to come up with a goal and commit to it.
  • To assess self-efficacy, get them to reflect on the things that have made it difficult for them to change.
  • "Where did you see yourself being at this stage when you were young? How does this differ to how you are?"