ch 21 Jarvis peripheral vascular & lymphatic sys Flashcards
contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole
Arteries
which control the amount of blood delivered to the tissues
-control the rate of blood flow.
muscle fibers (vascular smooth muscle [VSM])
is palpated in front of the ear
temporal artery
is palpated in the groove between the sternomastoid muscle and the trachea
carotid artery
major artery supplying the arm is the
-which runs in the biceps-triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon
brachial artery
below the elbow the brachial artery bifurcates into the
ulnar (difficult to feel) and radial arteries
ulnar and radial arteries run distally and form two arches supplying the hand
called the superficial and deep palmar arches.
, which passes under the inguinal ligament
femoral artery
travels down behind the medial malleolus and forms the plantar arteries in the foot.
back of the leg the posterior tibial artery
is a deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel.
Ischemia
affects noncoronary arteries and usually refers to arteries supplying the limbs. It usually is caused by atherosclerosis, and less commonly by embolism, hypercoagulable states, or arterial dissection.
Peripheral artery disease (PAD)
absorb CO2 and waste products from the periphery and carry them back to the heart
veins
Each arm has two sets of veins: .
superficial and deep
are in the subcutaneous tissue and are responsible for most of the venous return.
superficial veins
The legs have three types of veins
Veins in the Leg.
run alongside the deep arteries and conduct most of the venous return from the leg
- femoral
- popliteal
- As long as these veins remain intact, the superficial veins can be excised without harming the circulation.
- deep veins (Veins in the Leg.)
superficial veins are the great and small saphenous veins. The great saphenous vein, inside the leg, starts at the medial side of the dorsum of the foot.
- Blood flows from the superficial veins into the deep leg veins.
- superficial veins are the great and small saphenous (Veins in the Leg.)
are connecting veins that join the two sets. They also have one-way valves that route blood from the superficial into the deep veins and prevent reflux to the superficial veins.
- Perforators(Veins in the Leg.)
are a low-pressure system
-do not have a pump to generate their blood flow, they need a mechanism to keep blood moving
veins
(1) the contracting skeletal muscles that milk the blood proximally, back toward the heart;
(2) the pressure gradient caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase;
(3) the intraluminal valves, which ensure unidirectional flow. Each valve is a paired semilunar pocket that opens toward the heart and closes tightly when filled to prevent backflow of blood.
3 mechanism to keep blood moving
. When walking, the calf muscles alternately contract (systole) and relax (diastole). In the contraction phase the gastrocnemius and soleus muscles squeeze the veins and direct the blood flow proximally. Because of the valves, venous blood flows just one way—toward the heart.
calf pump or peripheral heart (in legs)
is lower, walls of the veins are thinner than those of the arteries.
venous pressure
Veins have a larger diameter and are more distensible; they can expand and hold more blood when blood volume increases. This is a compensatory mechanism to reduce stress (preload) on the heart. Because of this ability to stretch, veins are called
capacitance vessels.
depends on contracting skeletal muscles, competent valves in the veins, and a patent lumen
Efficient venous return
issue with efficient venous return (any 3 above)
venous stasis
are people who undergo prolonged standing, sitting, or bed rest because they do not benefit from the milking action that walking accomplishes.
risk for venous disease
Hypercoagulable states and vein wall trauma are other factors that increase
risk for venous disease
dilated and tortuous((twisted/bends) (varicose) veins create ?, wherein the lumen is so wide that the valve cusps cannot approximate
-condition increases venous pressure, which further dilates the vein
incompetent valves
genetic predisposition to
varicose veins
form a completely separate vessel system that retrieves excess fluid and plasma proteins from the interstitial spaces and returns them to the bloodstream
lymphatics
Without lymphatic drainage, fluid would build up in the interstitial spaces and produce
edema.
Fluid moves according to a
pressure gradient (filtration)
arterial end the ? is caused by the pumping action of the heart and pushes somewhat more fluid out of the capillaries than the venules can absorb.
hydrostatic pressure
fluid is vacuumed out of the interstitial spaces by the
lymph vessels
Substances pass around the microcirculation by a
concentration gradient (diffusion)
plasma proteins are too big to be pushed out of the arterioles; they remain and create the force for colloid osmotic pressure that pulls interstitial fluid back into the venules.
colloid osmotic pressure
vessels converge and drain into two main trunks, which empty into the venous system at the
subclavian veins
empties into the right subclavian vein. It drains the right side of the head and neck, right arm, right side of the thorax, right lung and pleura, right side of the heart, and right upper section of the liver.
right lymphatic duct
drains the rest of the body. It empties into the left subclavian vein.
thoracic duct
to (1) conserve fluid and plasma proteins that leak out of the capillaries, (2) form a major part of the immune system that defends the body against disease, and (3) absorb lipids from the small intestine.
lymphatic system functions
phagocytosis (digestion) of the substances by neutrophils and monocytes/macrophages and by production of specific antibodies or specific immune responses by the lymphocytes
immune system (protect body)
start as microscopic open-ended tubes, which siphon interstitial fluid
- capillaries converge to form vessels and drain into larger ones
- vessels have valves
Lymphatic capillaries
is propelled by contraction of the skeletal muscles, by pressure changes secondary to breathing, and by contraction of the vessel walls themselves.
Lymph flow
are small, oval clumps of lymphatic tissue located at intervals along the vessels.
Lymph nodes
filter the fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body
Nodes
are exposed to B and T lymphocytes in the lymph nodes, and these mount an antigen-specific response to eliminate the pathogens
pathogens
drain the head and neck
Cervical nodes
drain the breast and upper arm
Axillary nodes
is in the antecubital fossa and drains the hand and lower arm.
epitrochlear node
in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall.
inguinal nodes
spleen, tonsils, and thymus aid the
lymphatic system
is located in the left upper quadrant of the abdomen.
(1) to destroy old red blood cells;
(2) to produce antibodies;
(3) to store red blood cells;
(4) to filter microorganisms from the blood.
spleen ( It has four functions)
(palatine, pharyngeal, and lingual) are located at the entrance to the respiratory and gastrointestinal tracts and respond to local inflammation.
tonsils
is the flat, pink-gray gland located in the superior mediastinum behind the sternum and in front of the aorta
- large in the fetus and young child and atrophies after puberty
thymus
important in developing the T lymphocytes of the immune system in children
thymus
originate in the bone marrow and mature in the lymphoid tissue.
B lymphocytes
of age the lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies(waste away)
6 years
growing uterus obstructs drainage of the iliac veins and the inferior vena cava. This condition causes low blood flow and increases venous pressure. This in turn causes dependent edema, varicosities in the legs and vulva, and hemorrhoids.
pregnant woman
Peripheral blood vessels grow more rigid with age, termed
-produces the rise in systolic blood pressure
arteriosclerosis (aging adult)
, or the deposition of fatty plaques on the intima of the arteries.
atherosclerosis
is pain in a specific muscle group (i.e., calf muscles) that is brought on by walking and is relieved by rest. IC impairs both walking distance and the person’s quality of life
IC intermittent claudication(cramping pain in leg)
produces a progressive enlargement of the intramuscular calf veins
Aging
Prolonged bed rest, prolonged immobilization, and heart failure increase the risk for
-common in aging and also with malignancy (cancer) and myocardial infarction (MI)
deep vein thrombosis (DVT) and subsequent pulmonary embolism
smoking, blood pressure, total cholesterol, BMI, glucose, healthy diet, and physical activity.
women-depression leads PAD
poor score in 3 or more of the health indicators increased the risk for PAD
is the first-line noninvasive test for PAD
ankle-brachial index (ABI)
is the number of blocks walked or stairs climbed to produce pain.
Claudication distance
Night leg pain is common in aging adults. It may indicate the ischemic rest pain of PAD, severe night muscle cramping (usually the calf), or restless legs syndrome.
-Coolness occurs with PAD.
ischemic rest pain of PAD
is associated with erectile dysfunction (Leriche syndrome)
Aortoiliac occlusion (men)
occur with chronic arterial and venous disease
Leg ulcers
is bilateral when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation.
Edema
occur with infection, malignancies, and immunologic diseases.
Enlarged lymph nodes
oral contraceptives, hormone replacement
may cause a hypercoagulable state
Flattening of angle and clubbing (nail bend w/finger) (diffuse enlargement of terminal phalanges) occur with
congenital cyanotic heart disease and cor pulmonale.
signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock). The hands are cold, clammy, and pale.
Refill lasting more than 1 or 2 seconds
occurs when lymphatic drainage is obstructed after breast surgery or radiation
Edema of upper extremities
occurs with hyperkinetic states (exercise, anxiety, fever), anemia, and hyperthyroidism
Full, bounding pulse (3+)
occurs with shock and PAD
Weak, “thready” pulse (1+)
occur in conditions of generalized lymphadenopathy: lymphoma; chronic leukemia; infectious mononucleosis; HIV infection.
Epitrochlear nodes
is used to evaluate the adequacy of collateral circulation before cannulating the radial artery . A, Firmly occlude both the ulnar and radial arteries of one hand while the person makes a fist several times. This causes the hand to blanch. B, Ask the person to open the hand without hyperextending it; then release pressure on the ulnar artery while maintaining pressure on the radial artery. Adequate circulation is suggested by a palmar blush, a return to the normal color of the hand in less than 7 seconds.
modified Allen test (test circulation) (subjective)
Pallor that persists or a sluggish return to color suggests occlusion of the collateral arterial flow. An equivocal result is 8 to 14 seconds; ≥15 seconds is a negative result. Avoid radial artery cannulation until adequate circulation is shown
modified Allen test (test circulation) results
: thin, shiny, atrophic skin; thick-ridged nails; loss of hair; ulcers; gangrene. Malnutrition, pallor, and coolness occur with arterial insufficiency.
Malnutrition
Asymmetric calf swelling of ≥2 cm occurs with
- calf pain not specified w/ dvt bc it occurs also with superficial phlebitis, Achilles tendinitis, gastrocnemius and plantar muscle injury, and lumbosacral disorders.
DVT, (calf)
Asymmetry of 1 to 3 cm occurs with mild lymphedema; 3 to 5 cm with moderate lymphedema; and more than 5 cm with severe lymphedema
lymphedema (calf)
occurs with chronic venous stasis caused by hemosiderin deposits from red blood cell degradation
Brown discoloration
occur usually at medial malleolus because of bacterial invasion of poorly drained tissues
Venous ulcers
, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli.
arterial deficit
unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with
arterial ischemia.
occurs with turbulent blood flow, indicating partial occlusion
bruit
Bilateral, dependent pitting edema occurs with heart failure, diabetic neuropathy, and hepatic cirrhosis
-Normally your finger should leave no indentation
pretibial edema
occurs with occlusion of a deep vein. Unilateral or bilateral edema occurs with lymphatic obstruction. With these factors it is “brawny” or nonpitting and feels hard to the touch.
Unilateral edema
1+, Mild pitting, slight indentation, no perceptible swelling of the leg
2+, Moderate pitting, indentation subsides rapidly
3+, Deep pitting, indentation remains for a short time, leg looks swollen
4+, Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted
if pitting edema is present, grade it on the following scale:
Bilateral pitting edema calls for an examination of the neck veins neck veins are abnormally distended, the peripheral edema may be related to heart disease or pulmonary hypertension).14 If neck veins are normal, something else may cause the edema (e.g., liver disease, nephrosis, chronic venous insufficiency, antihypertensive or hormonal medications).
Bilateral pitting edema
occur in the saphenous veins
Varicosities
occurs with severe arterial insufficiency
Dependent rubor (deep blue-red color)
history of diabetes, PAD, or HIV, test for sensation on the sole of the foot using a
monofilament
detect a weak peripheral pulse, to monitor blood pressure in infants or children, or to measure a low blood pressure or blood pressure in a lower extremity
Doppler Ultrasonic Probe
An ABI between 0.91 and 1 is borderline cardiovascular risk.1
An ABI of 0.90 or less indicates PAD:
• 0.90 to 0.71—Mild PAD
• 0.70 to 0.41—Moderate PAD
• 0.40 to 0.30—Severe PAD, usually with rest pain except in the presence of diabetic neuropathy
• <0.30—Ischemia, with impending loss of tissue
Ankle-Brachial Index - for PAD testing
Score of 1 or 2 = moderate probability; score of 3 points or more = high probability of DVT.
0= low probability dvt
Wells Score for Leg Deep Vein Thrombosis
Weak pulses occur with vasoconstriction of diminished cardiac output.
infant / children
Full, bounding pulses occur with patent ductus arteriosus from the large left-to-right shunt.
infant / children
Diminished or absent femoral pulses but normal upper-extremity pulses suggest .
coarctation of aorta
Enlarged, warm, tender nodes indicate
current infection
generalized edema plus hypertension, which suggests preeclampsia, a dangerous obstetric condition.
- Expect diffuse bilateral pitting edema in the lower extremities, especially at the end of the day and into the third trimester
- Varicose veins in the legs also are common in the third trimester.
preeclampsia (pregnant woman)
Palpable lymph nodes occur often in healthy infants and children. They are small, firm (shotty), mobile, and nontender
healthy infants
DP and PT pulses may become more difficult to find. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick-ridged nails; loss of hair on lower legs) also occur normally with aging
Aging adult
Hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure.
-Decreased cardiac output, peripheral arterial disease, aortic valve stenosis (narrowing)
Weak, “Thready” Pulse—1+ (
Variations in Pulse Contour)
Easily palpable, pounds under your fingertips. -Hyperkinetic states (exercise, anxiety, fever), anemia, hyperthyroidism
Full, Bounding Pulse—3+ (
Variations in Pulse Contour)
Greater than normal force, then collapses suddenly. -Aortic valve regurgitation, patent ductus arteriosus
Water-Hammer (Corrigan) Pulse—3+ (
Variations in Pulse Contour)
Rhythm coupled, every other beat comes early, or normal beat followed by premature beat;
force of premature beat decreased because of shortened cardiac filling time Conduction disturbance (e.g., premature ventricular contraction, premature atrial contraction)
Pulsus Bigeminus
Rhythm regular, but force varies, with alternating beats of large and small amplitude
When heart rate (HR) is normal, pulsus alternans occurs with severe left ventricular failure, caused by ischemic heart disease, valvular heart disease, chronic hypertension, or cardiomyopathy
Pulsus Alternans
Beats have weaker amplitude with inspiration, stronger with expiration; best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration
-Common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks cardiac output) and in severe bronchospasm of acute asthma
Pulsus Paradoxus
Each pulse has two strong systolic peaks with a dip in between; best assessed at the carotid artery
-Aortic valve stenosis plus regurgitation
Pulsus Bisferiens
Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress: (1) white (pallor) in top figure from sympathetic-mediated vasoconstriction and resulting deficit in supply; (2) blue (cyanosis) in lower figure from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin; (3) finally red (rubor) in heel of hand caused by return of blood into the dilated capillary bed or reactive hyperemia.
Raynaud Phenomenon ( Peripheral Vascular Disease in the Arms)
accumulation of protein-rich fluid in the interstitial spaces of the arm following breast surgery or treatment. It results from axillary lymph node removal, radiation therapy, fibrosis, or inflammation. Once protein-rich lymph builds up in the interstitial spaces, it further raises local colloid oncotic pressure, which promotes more fluid leakage
-Risk factors of lymphedema include age, obesity, extent of axillary surgery, axillary radiation, infection, whether surgery occurred on dominant or nondominant side, and failure to use exercise and other activities to prevent lymphedema.8
Lymphedema
Deep muscle pain, usually in calf, but may be lower leg or dorsum of foot
feels like “cramp (IC)
numbness and tingling,” “feeling of cold”
Chronic pain, onset gradual after exertion
claudication distance
low ankle–brachial index; cool, pale skin; diminished pulses, pallor on elevation
Peripheral Vascular Disease (Chronic Arterial Symptoms)
Older and middle-age adults; African Americans have twice the incidence as other racial/ethnic groups; smoking is strongest risk, also hypertension, diabetes, hypercholesterolemia, obesity, vascular disease13
Risk for Peripheral Vascular Disease (Chronic Arterial Symptoms)
Varies, distal to occlusion, may involve entire leg
Throbbing
Sudden onset (within 1 hr)
Six Ps: pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), paralysis (indicates severe)
History of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including injured arteries; chronic atrial fibrillation
Peripheral Vascular Disease(Acute Arterial Symptoms)
Calf Moderate to intense, sharp; deep muscle tender to touch Sudden onset (within 1 hr) Pain may increase with palpation Pain medication Red, warm, swollen leg
Venous disease causes symptoms and signs of metabolic waste buildup (-Acute Venous Symptoms (DVT))
Calf, lower leg
Aching, tiredness, feeling of fullness
Chronic pain, increases at end of day
Prolonged standing, sitting
Elevation, lying, walking
Edema, varicosities, weeping ulcers at ankles
Job with prolonged standing or sitting; obesity; multiple pregnancies; prolonged bed rest; history of heart failure, varicosities, or thrombophlebitis; veins crushed by trauma or surgery
Venous disease causes symptoms and signs of metabolic waste buildup (Chronic Venous Symptoms)
Buildup of fatty plaques on intima (atherosclerosis) plus hardening, calcification of arterial wall (arteriosclerosis).
- toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base, well-defined edges, and no bleeding; they look dry and punched out.
- more common in those with smoking, diabetes, hyperlipidemia, and hypertension.
Arterial (Ischemic) Ulcer//Chronic Arterial Insufficiency
After acute DVT or chronic incompetent valves in deep veins. Venous ulcers account for 80% of lower leg ulcers.
-Ulcers occur at medial malleolus and tibia; characterized by bleeding, uneven edges.
Venous (Stasis) Ulcer (Chronic Venous Insufficiency)
hastens changes described with arterial ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, and renal. Peripheral diabetic ulcer has its pathogenesis in sensory neuropathy with loss of protective sensation, autonomic neuropathy with decreased sweating and dry skin, and motor neuropathy with foot deformity.2 Ulcers then occur with repetitive stress over these at-risk areas. Over half of diabetic ulcers become infected, and about 20% of these infections lead to some level of amputation.2
Diabetes//Neuropathic Ulcer
Symptoms include numbness and tingling, pain, weakness, loss of balance, falling, allodynia. Signs include decreased reflexes, loss of proprioception, loss of vibration sensation, small muscle wasting, loss of warm and cold sensation and pinprick, decreased reflexes, poor blood flow, and cold feet.22 Without careful vigilance of pressure points on feet, ulcer may go unnoticed.
Diabetes//Neuropathic Ulcer
Normal leg veins have dilated as a result of chronic increased venous pressure (obesity, multiple pregnancies) and incompetent valves that permit reflux of blood back toward leg instead of forward toward heart. Varicose veins are 3 times more common in women than men. Older age increases risk as a result of thinning of elastic lamina of veins and degeneration of vascular smooth muscle. Size ranges from 1 mm to 1 cm in diameter; color ranges from red to blue or purple.
Aching, heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping.
O: Dilated, tortuous veins. New varicosities sit on surface of muscle or bone; older ones are deep and feel spongy.
Superficial Varicose Veins//Chronic Venous Disease(Peripheral Vascular Disease in the Legs)
A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. Virchow triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction
- Cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or the use of estrogen hormones. Requires emergency referral because of risk for pulmonary embolism.
- upper-extremity DVT is increasingly common as a result of frequent use of invasive lines such as central venous catheters.
- Sudden onset of intense, sharp, deep muscle pain
Deep Vein Thrombophlebitis//Acute Venous Disease (Peripheral Vascular Disease in the Legs)
arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation. This reduces blood flow with vital oxygen and nutrients. Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol, sedentary lifestyle, and family history of hyperlipidemia.
Occlusions(Peripheral Artery Disease)
sac formed by dilation in the artery wall. Atherosclerosis weakens the middle layer (media) of the vessel wall. This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloon enlargement. The most common site is the aorta, and the most common cause is atherosclerosis. The incidence increases rapidly in men older than 55 years and women older than 70 years; the overall occurrence is 4 to 5 times more frequent in men.
Aneurysms(Peripheral Artery Disease)
