Chapter 13: Blood Vessels

Question 1

BV: Physical exam

Answer 1

Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for rate, rhythm, contour, amplitude.

Auscultate the carotid, abdominal aorta, renal, iliac, and femoral arteries for bruits.

With the patient reclining at a 45-degree angle, inspect for jugular venous pulsations and distention; differentiate jugular and carotid pulse waves, and measure jugular venous pressure.

Inspect the extremities for sufficiency of arteries and veins for color, skin texture, and nail changes; presence of hair; muscular atrophy; edema or swelling; varicose veins.

Palpate the extremities for warmth, pulse quality, tenderness along any superficial vein, pitting edema

Question 2

Grading of pitting edema

Answer 2

1+ 2mm depression

2+ 4mm depression

3+ 6mm depression

4+ 8mm depression

Question 3

HPI: BV

Answer 3

Leg pain or cramps
-Onset and duration; character; continuous burning in toes, pain in thighs or buttocks; skin changes; swelling of leg; limping; waking at night with leg pain
Swollen ankles
-Onset and duration, related circumstances ,associated symptoms, treatment attempted, medication

Question 4

HPI children

Answer 4

Hemophilia

Sickle cell disease

Thalassemias

Renal disease

Coarctation of the aorta: Femoral pulses stronger than brachial

Leg cramps during exercise

Question 5

HPI: preg

Answer 5

BP

Legs

Question 6

HPI: older adults

Answer 6

Leg edema

Impact on ADL

Coping abilities

Claudication

Medications

Question 7

PMH: BV

Answer 7

Cardiac surgery or hospitalization; chronic illness

Blood cancers

Question 8

FMH

Answer 8

Family member risk factors; morbidity/mortality; cardiac; metabolic disorders; blood cancers

Question 9

PMH/SMH

Answer 9

Employment, tobacco, nutritional status/diet/weight; exercise; alcohol/recreational drugs

Question 10

Peripheral art. Physical exam

Answer 10

Palpation of arteries
-Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

Palpate for artery characteristics
-Rate and rhythm, pulse contour (waveform), amplitude (force),symmetry, obstructions, variations

Amplitude scale
-4: Bounding, aneurysmal
-3: Full, increased
-2: Expected
-1: Diminished, barely palpable
-0: Absent, not palpable

Auscultation over arteries for bruits
-Carotid, Subclavian, Abdominal aorta, Renal, Iliac, Femoral

Question 11

Pulse abnormalities

Answer 11

Alternating pulse (pulsus alternans)
-alt of a pulsation of small amp with the pulsation of large amp while the rhythm is regular
-poss cause: L vent failure (more sig if pulse slow)

Pulsus Bistriens
-best detected by palpation of the carotid artery. 2 main peaks. 1st percussion wave (pulse pressure), 2nd tidal wave (reverberation from periphery)
-poss cause- aortic stenosis combined with aortic insufficiency

Bigenminal pulse
-normal pulsation followed by a premature contraction
- the amp of the pulsation of the premature contraction is less than that of the normal
-poss cause: disorder of rhythm

Large, bounding pulse:
-hyperkinetic or strong pulse. Readily palpation. Does not fade out. Not easily obliterated. 3+
-poss cause: exercise anxiety, fever, hyperthyroidism, aortic ridigity or atherosclerosis

Paradoxic pulse (pulsus paradoxus)
-exaggerated decrease (>10mmHG) him the amp of the pulsation during inspiration and increase amp during expiration
-poss cause: premature cardiac contraction, trachobronchial obstruction, bronchial asthma, emphysema, pericardial effusion, constrictive pericarditis

Water-hammer pulse (corrigan)
-collapsing pulse
-greater amp than expected, a rapid rise to a narrow summit, and a sudden descent
-poss cause: patent ductus arteriosus, aortic regurgitation.

Question 12

Phys exam for PAD

Answer 12

Arteries in any location can become narrowed.
Diminished circulation signs and symptoms affect:
-Site
-Degree of narrowing
-Ability of collateral channels to compensate
-Rapidity with which the problem develops

Claudication pain
-Dull ache
-Muscle fatigue and cramps
-Usually appears during sustained exercise
-Few minutes of rest will ordinarily relieve it
-It recurs again with the same amount of activity
-Continued activity causes worsening pain

Site of pain is distal to the narrowing. After assessing pain, note:
-Pulses
-Possible systolic bruits that may extend through diastole
-Loss of body warmth in affected area
-Localized pallor and cyanosis
-Collapsed superficial veins
-Atrophies skin and muscle; thin skin

Question 13

Peripheral vein physical exam

Answer 13

Jugular venous pressure
-The jugular pulse can only be visualized; it cannot be palpated.
-Several conditions make the examination more difficult.

Hepatojugular reflux
-Sign of right heart failure
-Exaggerated when right heart failure is present

Evaluation of hand veins
-useful in the absence of thrombosis or arteriovenous fistula in that arm, and in the absence of the superior vena cava syndrome

Assessment for venous obstruction and insufficiency
-An acute process may result from injury, external compression, or thrombosis.
-In the affected area, pain occurs simultaneously with: Swelling and tenderness over the muscles, Engorgement of superficial veins, Erythema and/or cyanosis

Thrombosis

Edema

Varicose veins

Question 14

Physical exam infants and children

Answer 14

Infants
-Brachial, radial, femoral pulses are easily palpable.
-Rapid capillary refill times

Children
-Venous hum
-Venous thrombosis can occur with placement of central venous access devices.

Question 15

Physical exam: preg

Answer 15

Pulse is easily palpated with abrupt rise and fall.

JVP remains normal.

Peripheral edema occurs.

Varicose veins occur

Question 16

Physical exam: older adult

Answer 16

Superficial vessels are tortuous and distended.

Dorsalis pedis and posterior tibial pulses become difficult to find

Question 17

Abnormalities of vessels

Answer 17

Temporal arteritis (giant cell arteritis)
-An inflammatory disease of the branches of the aortic arch, including the temporal arteries

Arterial aneurysm
-Localized dilation, generally defined as 1.5 times the diameter of the normal artery, caused by a weakness in the arterial wall

Arteriovenous fistula
-Pathologic communication between an artery and vein

Peripheral arterial disease
-Stenosis of the blood supply to the extremities by atherosclerotic plaques

Raynaud phenomenon
-Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually inresponse to cold exposure

Arterial embolic disease
-Emboli that are dispersed throughout the arterial system

Venous thrombosis
-Sudden or gradual with varying severity of symptoms; can be the result of trauma or prolonged immobilization

Tricuspid regurgitation
-Back flow of blood into the right atrium during systole; a mild degree of tricuspid regurgitation can be seen inup to 75% of the normal adult population

Question 18

Vessel abnormalities in children

Answer 18

Coarctation of the aorta
-Stenosis is seen most commonly in the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum.

Kawasaki disease
-Acute small vessel vasculitic illness that may result in the development of coronary artery aneurysms
-Cause unknown

Question 19

Vessel abN in preg

Answer 19

Preeclampsia-eclampsia
-Syndrome specific to pregnancy with hypertension that occurs after the 20th week of pregnancy and the presence of proteinuria; eclampsia is preeclampsia with seizures when no other cause for the seizures can be found

Question 20

Vessel abN in older adults

Answer 20

Venous ulcers
-Results from chronic venous insufficiency in which lack of venous flow leads to lower extremity venous hypertension

Question 21

When examining the radial pulse, you note a full and increased pulse. Your documentation demonstrates:

Radial pulse +4
Radial pulse +3
Radial pulse +2
Radial pulse +1

Answer 21

ANS: B

Rationale: The +4 pulse is described as bounding or aneurysmal; +3 pulse is described as full, increased; +2 pulse is described as expected; +1 pulse is described as diminished, barely palpable; and 0 is an absent, nonpalpable pulse.

Question 22

The characteristics of arterial pulses are directly affected by all of the following except:

The volume of blood ejected
Peripheral arterial resistance
Venous valvular competence
Blood viscosity

Answer 22

ANS: C

Rationale: Arterial pulses are affected by stroke volume (volume of blood ejected), distensibility of the aorta and large arteries, viscosity of the blood, and peripheral arteriolar resistance. Venous valvular competence contributes to the venous blood flow back to the heart.

Question 23

A positive hepatojugular reflux maneuver is indicative of:

Right heart failure
Left heart failure
Elevated arterial pressure
Liver failure

Answer 23

ANS: A

Rationale: Hepatojugular reflex is exaggerated when right heart failure is present, and its measurement is used to evaluate that condition.

Question 24

The term claudication refers to:

Pain from muscle ischemia
Lack of palpable pulsations
Visible extremity changes of arterial occlusion
Numbness and tingling in toes and fingers

Answer 24

ANS: A

Rationale: Claudication is known as pain that results from muscle ischemia. This pain is described as a dull ache with muscle fatigue and can often be accompanied by cramping.