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Nursing 314: Assessing and Promoting Wellness > Exam 2: Assessment of peripheral circulation & lymphatics > Flashcards

Exam 2: Assessment of peripheral circulation & lymphatics Flashcards

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1
Q

Tunica intima

A

Innermost layer

the endothelium

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2
Q

Tunica media

A

Middle layer

Elastic fibers and smooth muscle

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3
Q

Tunica externa

A

Outermost layer

thin layer of elastic & collagen fibers

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4
Q

Arteries

A

Walls are thicker than vein walls

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5
Q

Arteries are more

A

Elastic: stretch & recoil

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6
Q

Veins are not designed to

A

withstand high pressure

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7
Q

Veins are distensible to

A

adapt to variations in blood volume and pressure

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8
Q

Veins have

A

Valves to prevent back flow

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9
Q

Subjective &/or objective data for peripheral circulation

A 
Leg pain/cramps 
skin changes on arm or legs 
Swelling: bilateral or unilateral 
Lymph node enlargement 
Medications 
Smoking history 
Prior diagnosis, procedures, surgeries 
Use of compression devices, elevating legs, etc.
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10
Q

Peripheral arteries can be assessed with

A

Ultrasound stethoscope

Tissue perfusion

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11
Q

Peripheral veins can be assessed with

A

Varicosities
Peripheral edema (pitting edema)
Phlebitis (inflammation)

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12
Q

What to inspect and palpate

A 
Patches 
Pulses 
Appearance 
Temperature 
Capillary refill 
Hardness 
Edema 
Sensation
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13
Q

Assess all pulses:

A

Central and peripheral

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14
Q

What should be assessed for pulses

A

Elasticity of vessel (arterial)
Rhythm (electrical impulse)
Symmetry (perfusion problems)
Strength

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15
Q

Arteries or veins: where can you hear/have a pulsation

A

Arteries have pulsations and you will be able to hear it

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16
Q

How would you assess tissue perfusion for arteries

A 
Cap refill (3 seconds or less) 
Tissue color (impaired would be cyanosis) 
Temperature
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17
Q

Appearance: color

A

Pallor
Cyanosis
Dependent Rubor (arteries)
Brown pigmentation on lower shin/calf/ankles (venous)

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18
Q

Pallor:

A

Vasoconstriction (also decreased RBCs)

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19
Q

Cyanosis:

A

Poor circulation or poor oxygenation

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20
Q

Dependent rubor

A

Redness leaves when dependent raises (arterial)

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21
Q

Other things to look for in appearance

A 
Hair distribution or lack thereof
Venous pattern 
Size/symmetry of extremities 
Thickened toenails 
Ulcers on bony prominences & toes 
Shiny skin 
Dependent pitting edema 
Thick, hardened skin of lower leg
Lesions/necrosis/gangrene
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22
Q

If swelling is unilateral, worry about

A

Clot

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23
Q

If swelling it bilateral, worry about

A

Overall systemic circulation

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24
Q

When assessing temperature,

A

Assess and compare bilaterally

The back of your hand is more sensitive to temperature

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25
Q

Capillary refill measures

A

Perfusion status

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26
Q

Normal capillary refill should be

A

less than 3 seconds

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27
Q

Hardness is due to

A

Edema: fluid retention in interstitial spaces

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28
Q

Firm/brawny edema

A

Non-pitting edema

— lymphedema

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29
Q

Soft edema

A

Pitting edema

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30
Q

Soft edema/pitting edema can show

A

Venous insufficiency
Heart failure
Hepatic cirrhosis

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31
Q

Hair loss can mean

A

Arterial insufficiency

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32
Q

Edema is

A

Fluid retention in interstitial spaces

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33
Q

Edema assessment

A

Usually noted in legs, ankles, feet
Can be in face, arms, and anywhere else
Unilateral or bilateral?

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34
Q

ulcers on toes mean

A

arterial problems

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35
Q

Ulcers on shins mean

A

Venous problem

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36
Q

assessing sensation

A

Light touch with cotton ball. monofilament

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37
Q

How to assess superficial pain

A

Sharp point (not a needle of blade)

    • broken tongue blade
  • -unwound paper clip
    • sharp and dull ends
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38
Q

Intermittent claudication pain caused by

A

Exercise (claudication = limping)

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39
Q

Intermittent claudication pain usually felt in

A

Calf muscle during walking

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40
Q

Intermittent claudication pain is relieved by

A

rest

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41
Q

Intermittent claudication pain is impaired circulation to

A

Arterial

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42
Q

Doppler assessment

A

Uses ultrasound to detect pulses

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43
Q

circulation 5 P’s

A 
Pain 
Pulse 
Pallor 
Paresthesia (altered sensation) 
Paralysis (altered movement)
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44
Q

Edema is associated with

A

Venous!

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45
Q

Brown pigment near ankles are associated with

A

Venous

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46
Q

Venous color, temp, pulse

A

ALL NORMAL

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47
Q

Color arterial

A

Pale, worse w/ elevation, dusky red when lowered

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48
Q

Temp arterial

A

Cool

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49
Q

Pulse arterial

A

Decreased or absent

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50
Q

Edema arterial

A

Absent or mild

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51
Q

Skin for arterial

A

Thin, shiny; decreased hair, thickened nails

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52
Q

Peripheral vascular diseases can involve either the

A

Venous or arterial system or BOTH

53
Q

Peripheral vascular risk factors

A 
Obesity 
hypertension 
Diabetes 
Inactivity 
Smoking/stress
Hyperlipidemia 
Transplant recipient 
Familial disposition 
Advancing ages 
Gender 
Kidney disease
54
Q

Post common type of peripheral vascular disease

A

Peripheral artery disease

55
Q

Peripheral Artery Disease: Arterial problems

A

Distal to the aortic arch

56
Q

What is calculated when a patient has PAD

A

Ankle-brachial index

57
Q

How is ankle-brachial index score calculated

A

dividing the ankle systolic pressure by the brachial pressure

58
Q

In general, poor sensation is often associated with

A

Arterial

59
Q

Peripheral Vascular disease involving the venous system means

A

POOR RETURN

60
Q

Venous insufficiency may be caused by

A

Varicose veins
Incompetent valves
Obesity
Pregnancy

61
Q

Peripheral Vascular Disease: Arterial

A 
Intermittent Claudication pain (exercise) 
No Edema 
No pulse or weak 
No drainage 
Round smooth sores
Black eschar
COLD
62
Q

Location of sores for arterial problems

A

Toes and feet

63
Q

Peripheral vascular disease: Venous

A 
Dull, achy pain 
Lower leg edema 
Pulse present 
Drainage 
Sores with irregular borders 
Yellow slough or ruddy skin
64
Q

Location of sores for venous problems

A

Ankles

65
Q

For arterial problem, pain gets better if

A

Dangle foot off the bed

66
Q

For arterial problem, pain gets worse if

A

elevating feet

67
Q

Most common etiology of peripheral artery disease

A

Atherosclerosis

68
Q

Carotid bruit

A

Narrowed blood vessel creates turbulence, causes blowing/swishing sound

69
Q

carotid bruit increases patient risk of

A

stroke

70
Q

jugular venous distension indicates

A

Increased central venous pressure

71
Q

jugular venous distension is influenced by

A

blood volume, capacity of right atrium to receive blood, ability of right ventricle to contract & move it forward

72
Q

jugular venous distension is often seen in

A

right sided heart failure

73
Q

Thrombosis is

A

Clotting of blood

74
Q

Thrombus is

A

Stationary blood clot in the Cardiovascular system (venous or arterial)

75
Q

Predisposing factors for thrombus formation

A

Virchow triad (any/all present)

76
Q

Virchow’s triad

A

Vessel wall injury to abnormality
Venous stasis: (circulation/immobility)
Hypercoagulability

77
Q

sudden onset symptoms for deep vein thrombosis

A

Intense/sharp pain, tenderness, swelling, warmth, redness

78
Q

Deep vein thrombosis measurement of limb diameter:

A

Asymmetric

79
Q

Homan’s sign

A

no longer considered reliable on its own. discarded by many, may still see it done

80
Q

Deep vein thrombosis risk factors

A 
Injury/trauma 
History of venous disease 
pregnancy 
obesity 
oral contraceptives 
smoking 
heart failure 
family history DVT surgery 
Immobility: Bed, car, plane, office 
Blood dycrasias: blood disease/disorder 
Malignancies/neoplastic disease 
Inflammatory bowel disease
81
Q

Deep Vein Thrombosis prevention

A

Avoid sitting/lying: after surgery get moving as soon as possible
don’t cross left, which can hamper blood flow
Traveling by car, stop periodically
If you can’t move, then exercise lower legs with heel pumps: raise/lower heels with toes
Compression wraps/stockings
Lifestyle: Weight loss/smoking cessation/exercise

82
Q

How can deep vein thrombosis be diagnosed

A

Ultrasound, CT, MRI
D dimer blood test: almost all DVT have an elevated blood level!!
Venography: Dye injected into large vein and X-ray creates an image of the veins in your legs and feet

83
Q

Deep vein thrombosis treatment

A

Blood thinners
clot busters
filters
Compression wraps/stockings

84
Q

Clubbing

A

Building/bulbous nailed tissue; loss of normal angle between nail and nail bed

85
Q

Clubbing is associated with

A

pulmonary, Cardiovascular, infectious, neoplastic, and other disorders associated with hypoxia

86
Q

Schamroth sign

A

Loss of the normal diamond shaped window formed when right and left thumbs are opposed in a person with clubbing of the fingers

87
Q

Lymph

A

Fluid formed in tissue spaces transported by way of specialized lymphatic vessels and returns them to the circulatory system

88
Q

The lymphatic system has important role in

A

Fluid homeostasis, immunity, and fat absorption

89
Q

Where does lymph come from

A

Blood plasma filters out of capillaries into the microscopic spaces between tissue cells because of HYDROSTATIC PRESSURE generated by the pumping action go the heart

90
Q

Where does interstitial flip go

A

Goes back to the blood through capillary membrane

91
Q

Interstital fluid is pulled by

A

Plasma oncotic pressure

92
Q

Where does the remainder of the interstitial fluid enter before going to heart

A

Enters the lymphatic system before it returns to the heart

93
Q

lymphatic vessels are more

A

Porous than capillaries and allow larger molecules to enter the vessel along the fluid to the general circulation

94
Q

Milking action of the skeletal muscles

A

Skeletal muscles contract and squeeze the surrounding lymph vessels: pushing lymph toward the heart

95
Q

What causes changes in the intrathoracic pressure?

A

Contraction and relaxation of the chest muscles

96
Q

What increases the flow of lymph

A

Intrathoracic pressure

97
Q

What causes lymph to flow

A

Rhythmic contraction of the smooth muscle in the lymphatic vessels

98
Q

lymphatic vessels contain valves which prevent

A

Backflow of lymph: one way/ NOT circular like blood

99
Q

Lymphoid organs

A

Lymph nodes, tonsils, thymus gland, and spleen

100
Q

Lymph nodes/glands

A

Patches of lymphoid tissue located to filter lymph as it flows through the lymphatic vessels

101
Q

What generates an immune response to antigens

A

Lymphocytes and macrophages

102
Q

As lymphatic passes, particulate is removed by

A

Phagocytic cells

103
Q

Abnormal cells within the lymph like neoplastic cells, can also

A

be trapped within the lymph node

104
Q

Tonsils

A

Patches of lymphoid tissue; protective ring for nose/oral cavity

105
Q

Palatine tonsils (usually removed during tonsillectomy) are in the

A

posterior opening of the oral cavity

106
Q

Pharyngeal tonsils (adenoids) are located near

A

opening of nasal cavity

107
Q

Lingual tonsils located on

A

the back surface of tongue at its base

108
Q

Lymphatic system assessment: lower extremities

A

Assess during examination of vascular system or genital examination

109
Q

Lymphatic system assessment: upper extremities

A
  • Palpate the epitrochlear nodes, located on the medial aspect of the arms
  • Assess proximal portion during breast examination
110
Q

Lymph nodes drain

A

Lymph and tend to appear in clusters

111
Q

Cervical nodes drains

A

Drain head and neck

112
Q

Cervical nodes often

A

accompany upper respiratory infections

113
Q

Axillary nodes drain

A

upper extremities, shoulders, and breast areas

114
Q

Cancer cells that escape from the breast are often found

A

in the axillary lymph nodes

115
Q

Inguinal nodes drain

A

from the lower extremities and external genitalia

116
Q

lymph nodes usually not

A

palpable, if they are, they should be soft, mobile, and equal bilaterally

117
Q

Common lymph node abnormalities

A

Enlarged, tender firm & mobile are often associated with inflammation/infection

118
Q

Suspicious of malignancy/Cancer for lymph nodes

A

Asymmetric, hard, fixed, and non-tender

119
Q

Nodes of a person with HIV are

A

enlarged, firm, non-tender, mobile, usually generalized

120
Q

Many cancers metastasize through

A

Lymphatic vessels

121
Q

Breast cancer commonly to

A

Axillary nodes

122
Q

For breast cancer, what nodes are removed and biopsied

A

Breast and associated axillary lymph nodes

123
Q

Removal of axillary lymph nodes frequently impairs

A

drainage

124
Q

removal of axillary lymph may cause person to develop

A

lymphedema of the affected arm/shoulder

125
Q

Lymphedema occurs when

A

There is blockage or interruption of the flow of lymph through the lymphatic system
(NO BP ON MASTECTOMY ARM )

126
Q

lymphedema is often caused by

A

Congenital condition, valvular incompetence, infection, malignancy, surgical intervention, trauma, radiation

127
Q

Symptoms of post breast cancer lymphedema

A 
Pain 
Fatigue 
Decreased ROM 
Skin changes 
Sensations of tightness, heaviness, burning, or numbness in the affected areas
128
Q

Lymphedema treatment

A

Prevent trauma and injury
prevent infection
prevent muscle strain
avoid restrictions: clothing sleeves, tight bras, watches, jewelry

129
Q

Promote lymph drainage

A
  • – exercises
  • – elevation
  • – compression
  • – weight maintenance

Nursing 314: Assessing and Promoting Wellness (26 decks)

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