EXAM 2 PART 2 Flashcards
Vessels in the vascular system transport:
blood and lymph
When there is a disease in the vascular system, what occurs?
the delivery of O2 and nutrients to the cells and retards the elimination of CO2 and waste products from cellular metabolism
The pumping heart (arteries) is a:
high pressure system
Arteries contain:
Elastic fibers and muscle fibers that allow for stretching and recoil as well as control of the amount of blood delivered to tissues
What happens when vascular smooth muscle contracts?
changes occur to the diameter of the arteries to control the rate of blood flow
What happens during recoil?
blood is propelled
What is a pulse?
arteries pressure wave
Where is the temporal artery felt?
in front of the ear
Where is the carotid artery felt?
in the groove b/w the sternomastoid muscle and trachea
What major artery supplies the arm and runs in the biceps-triceps furrow of the upper arm, surfacing at the antecubital fossa in the elbow
brachial artery
What is the major artery in the leg?
femoral artery which passes under the inguinal ligament and travels down the thigh
When the femoral artery courses posteriorly at the lower thigh, it is called?
popliteal artery
What is the function of arteries?
to supply O2 and essential nutrients to the cells
______ is a deficient supply of O2 arterial blood to tissues caused by obstruction of a blood vessel
ischemia
A complete blockage leads to:
tissue death
A partial blockage leads to:
an insufficient supply of blood
_______ affects noncoronary arteries and refers to arteries supplying the limb, usually caused by atherosclerosis
Peripheral artery disease
What veins connect veins that join the two sets?
perforators
Veins drain _________ with its waste products from tissues and returns it to the heart
Deoxygenated blood
What type of system are veins?
low pressure system
When walking, inspiration decreases ______ and increases _______
thoracic pressure; abdominal pressure
What has a large diameter that is more distensible and can expand far enough to hold more blood and increase blood volume? (compensatory mechanism to reduce stress on the heart)
veins
What does efficient venous return depend on? What do issues with any of them lead to?
- contracting skeletal muscles
- competent valves in the veins
- a patent lumen
- venous stasis *
Who is at risk for venous disease?
those who undergo prolonged standing, sitting or bed rest (due to lack of milking action ) and those in hypercoagulable states and vein wall trauma
Venous pooling (varicose veins) occurs in:
- obese people
- women with multiple pregnancies
What would occur without lymphatic drainage?
fluid would build up and produce edema
What creates the force for colloid osmotic pressure that pulls interstitial fluid back into the venules or are captured by lymph vessels and returned to the bloodstream?
plasma proteins
How does the immune system detect and illuminate foreign pathogens?
by phagocytosis of the substances via neutrophils and monocytes/macrophages and by producing specific antibodies (specific immune responses by lymphocytes)
What are the organs of the lymphatic system?
- spleen
- tonsils
- thymus
Where is the spleen located and what it its function?
- LUQ
1. destroy old RBCs
2. produce antibodies
3. store RBC
4. filter microorganisms from the blood
Where are the tonsils located and what are their function?
- at the entrance of the respiratory and GI tracts
- to respond to local inflammation
List the different types of tonsils:
- palatine
- pharyngeal
- lingual
Where is the thymus located and what is its function?
- flat, prink-gray gland located in the superior mediastinum behind the sternum and in front of the aorta.
- develops the T lymphocytes of the immune system in children
Where do B lymphocytes originate from?
bone marrow but mature in the lymphoid tissue
________ occurs when peripheral blood vessels grow more rigid with age
Arteriosclerosis (produces rise in SBP)
________ is the deposition of fatty plaques on the intima of the arteries
atherosclerosis
_______ is under-diagnosed and undertreated but is a large cause of morbidity (painful walking/wound healing)
PAD
What is IC?
A pain in a specific muscle group that is brought on by walking and is relieved by rest
Many older adults suffer from:
- disability
- arthritis
- peripheral neuropathy
Aging produces a progressive enlargement of the _______
intramuscular calf veins
What increases an older persons risk for DVT and pulmonary embolism?
- prolonged bed rest
- prolonged immobilization
- heart failure
What medication reduces the risk for venous thromboembolism?
low dose anticoagulant
Loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to a:
decrease in the size of remaining nodes
What are risk factors for PAD?
- smoking
- diabetes
- HTN
- high cholesterol
- obesity
- depression (for women)
What is the first line noninvasive test for PAD?
the ankle brachial index
PVD includes:
PAD and venous disease
Why do people with PAD experience claudication (muscle fatigue or pain) when walking)?
because blood flow cannot match muscle demand
__________ is the number of blocks walked or stairs climbed to produce pain
claudication distance
Night leg pain is common in _______ and may indicate ischemic rest pain of PAD, severe night muscles cramping (usually in the calf) or restless leg syndrome
older people
What is aortoiliac occlusion associated with?
erectile dysfunction (leriche syndrome)
What are risk factors for PVD?
- smoking
- diabetes
What occurs with PAD and what should be avoided?
- coolness
- varicose veins
- avoid compression stocking since they impede blood flow
______ occurs with chronic arterial and venous disease
leg ulcers
When do lymph nodes become enlarged?
with infection, malignancies, and immunologic diseases
What medications are used to prevent blood clots in some people?
- low dose aspirin
- clopidogrel
Use the ______ to detect early clubbing
profile sign
Normal nail beds have a ______ degree angle
160
How quick should capillary refill occur?
3 seconds
What may prevent capillary refill?
- a cool room
- decreased body temperate
- smoking
- peripheral edema
- anemia
Flattening of an angle and clubbing occur with:
congenital cyanotic heart disease and cor pulmonale
What does capillary refill lasting longer than 3 seconds signify?
- vasoconstriction or decreased CO (hypovolemia, heart failure, shock)
What can occur after breast surgery or radiation?
Swelling of the upper extremity due to lymphatic drainage being obstructed
When does a full bounding pulse (3+) occur?
- hyperkinetic states (exercise, anxiety, fever)
- anemia
- hyperthyroidism
When does a weak, thready pulse (1+) occur?
- shock
- PAD
An enlarged ________ occurs with infection of the hand or forearm
epitrochlear node
This test evaluates the adequacy of collateral circulation before cannulating the radial artery.
modified allen test
What is adequate circulation in the modified allen test suggested by?
a palmar brush, a return to the normal color of the hand in less than 7 seconds
If a DVT is suspected, you should:
measure the calf circumference
If lymphedema is suspected, you should:
measure at the ankle, distal calf, knee and thigh
- thin, shiny, atrophic skin
- thick-ridged nails
- hair loss
- ulcers
- gangrene
are all signs of?
malnutrition
What occurs with arterial insufficiency?
- malnutrition
- pallor
- coolness
What are the signs of an abnormal calf muscle?
- acute, unilateral, painful swelling
- asymmetry of 1 cm or more
What occurs with DVT?
asymmetric calf swelling of >2cm
Brown discoloration occurs with:
chronic venous stasis caused by hemosiderin deposits from RBC degradation
Where do venous ulcers occur and why?
At medial malleolus because of bacterial invasion of poorly drained tissues
Where do ulcers occur with arterial deficit?
- tips of toes
- metatarsal heads
- lateral malleoli
The unilateral cooling of a foot or leg or sudden temperate drop as you move down the leg occurs with:
arterial ischemia
If you cannot locate the posterior tibial pulse, what can you do?
try passive, dorsiflexion of the foot to make the pulse more accessible
How can you check for pretibial edema?
firmly press the skin over the tibia or the medial malleolus for 5 seconds and release
What is the grading scale for pitting 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
Unilateral edema occurs with _________. Unilateral or bilateral edema occurs with _______. With these factors, it is brawny or nonpitting and feels hard to the touch
occlusion of a deep vein; lymphatic obstruction
What does bilateral pitting edema call for and why?
examination of the neck veins to see if they are abnormally distended. if so, the peripheral edema may be related to heart disease or pulmonary HTN. If normal, edema may be caused by another disease.
What should you do if you suspect a arterial deficit in the legs?
raise the legs about 30 cm off the table and ask the person to wag their feet for 30 seconds to drain off venous blood
Elevational pallor indicates:
arterial insufficiency
What is the normal time it takes for color to return to the feet?
10 seconds or less
What is the normal time it takes for superficial veins around the feet to fill?
15 seconds or less
What results from loss of vasomotor tone and pooling of blood in the veins?
chronic hypoxia
Delayed venous filling occurs with:
arterial insufficiency
Sensory loss occurs with:
arterial deficit, especially diabetes
What is the doppler ultrasonic probe used for?
to detect a weak peripheral pulse to monitor BP or measure a low BP or BP in a lower extremity
What score can be used to validate presence of a DVT?
Wells score system
A score of 1-2 on the wells system indicates:
moderate probability
A score of 3+ on the wells system indicates:
high probability of DVT
In the aging adult, which pulses may be difficult to find?
DP and PT
________ occurs normally with age:
trophic changes associated with arterial insufficiency
This pulse is greater than normal force that collapses suddenly and is associated with aortic valve regurgitation and patent ductus arteriosus
water-hammer pulse 3+
This pulse is hard to palpate and results from decreased CO, PAD or aortic valve stenosis
weak thready pulse 1+
This pulse is easily palpable and results from hyperkinetic states
full bounding pulse 3+
This condition is episodes of abrupt progressive tricolor change of the fingers in response to cold, vibration and stress
Raynaud phenomenon
What occurs during the pallor or cyanotic stage of raynaud phenomenon?
- cold
- numbness
- pain
What occurs during the rubor stage of raynaud phenomenon?
- burning
- throbbing
- swelling
Whats is the most effective therapy for raynaud phenomenon?
- avoid cold
- avoid drugs and smoking
- rewarm hands by putting on gloves and place them in warm water (or using chemical rewarming)
- after rewarming the hands, the attack should be gone by 15-20 minutes *
This condition is the accumulation of protein rich fluid in the interstitial spaces of the arm following breast surgery or treatment; resulting from axillary lymph node removal, radiation therapy, fibrosis or inflammation
lymphedema
Acute lymphedema:
- within the first 18 months
- treatable if no tissue damage occurred
Chronic lymphedema:
- difficult, can lead to pain, disfigurement, mobility dysfunction, etc
Lymphedema objective data includes:
- unilateral swelling
- measurement of arm volume
- nonpitting brawny edema
- overlying skin indurated
This condition causes deep muscle pain in the calf, lower leg, or dorsum of foot that feels like a cramp, numbness and tingling or feeling of coldness. It worsens with activity and elevation but is relieved with rest. It can also cause cool, pale skin and diminished pulse with pallor on elevation
chronic PAD
This condition causes pain in various areas distal to occlusion and may be the entire leg. It can be throbbing pain with sudden onset and causes pallor, pulselessness, parasthesia, poikilothermia, and paralysis
acute PAD
Who is most at risk for chronic PAD?
- older middle aged adults
- blacks
- smokers
- those with HTN, diabetes, hypercholesterolemia, obesity and vascular disease
Who is most at risk for acute PAD?
- those w/a history of vascular surgery
- emboli
- trauma
This condition causes aching, tiredness, and feeling of fullness and is generally located in the calf/lower leg. It is chronic pain that increases at the end of the day and worsens with prolonged standing or sitting but is relieved with elevation, lying and walking. It can cause edema, varicosities and weeping ulcers at ankles
chronic venous
This condition causes pain in the calf and feels moderate to intense sharpness, deepness and the muscle is tender to touch. It has a sudden onset and the pain may increase with palpation but be relieved with pain medicine. It is accompanied by redness, warmth and edema
acute venous (DVT)
This condition is a buildup of fatty plaques on intima (atherosclerosis) plus hardening, calcification of arterial wall (arteriosclerosis).It occurs at the toes, metatarsal heads, heels and lateral ankle and is common in smokers, diabetics, hyperlipidemia and HTN
arterial ischemic ulcer
This condition occurs after acute DVT or chronic incompetent valves in deep veins and accounts for 80% of lower leg ulcers. It occurs at medial malleolus and tibia and is characterized by bleeding, uneven edges
venous stasis ulcer
Sensory neuropathy causes:
loss of protective sensation
Autonomic neuropathy cause:
decreases sweating and dry skin
What is the most common site and cause of an aneurysm?
aorta; atherosclerosis
Who is at risk for an aneurysm?
men older than 55 and women older than 70 (4 to 5 times more frequent in men)
Why are older adults at an increased risk for varicose veins?
due to thinning of elastic lamina of veins and degeneration of vascular smooth muscle
Varicose veins can be what size and color?
- 1 mm to 1 cm in diameter
- red to blue or purple
DVT increases the risk for:
pulmonary embolism
What joins together the ventral abdominal wall?
the linea alba
_______ forms a strip extending the length of the midline with edges that are palpable
rectus abdominis
______ is a double envelope of serous membrane that lines the abdominal wall and covers the surface of most abdominal organs
peritoneum
The ______ is a specialized fatty mesentery that overlies the ventral abdomen
greater omentum
What organ is a soft mass of lymphatic tissue on the left posterolateral wall of the abdomen cavity immediately under the diaphragm?
the spleen
What organ is to the left of the midline in the upper part of the abdomen and descents behind the peritoneum, 2 cm below the belly button it bifurcates into the R and L common iliac arteries
aorta
What organ is a soft, lobulated gland located behind the stomach, stretching obliquely across the posterior abdominal wall to the LUQ?
pancreas
Where are the kidneys located?
behind the peritoneal cavity along the posterior abdominal wall
Where does the right kidney lie?
at the costovertebral angle at the 11th and 12th rib and rest 1-2 cm lower than the left kidney due to placement of the liver
______ is the area between the costal margins
epigastric
______ is the area above the pubic bone
hypogastric/suprapubic
After middle age, where does fat accumulate for women and why?
in the suprapubic area as a result of decreased estrogen levels
Age related changes occur in the GI system but dont affect function as long as:
disease is not present
What changes occur with older adults?
- salivation decreases (dry mouth and decreased sense of taste)
- esophageal emptying is delayed
- gastric acid secretion decreases –> pernicious anemia, iron deficiency anemia and malabsorption of Ca
- incidence for gallstones increase (esp. in women)
- liver size decreases by 25% resulting in impaired drug metabolism due to blood flow decreasing
- chronic constipation (2-3x more likely in women)
What is liver metabolism responsible for?
enzymatic oxidation, reduction and hydrolysis of drugs which is substantially decreased with age
Benzodiazepines cause an increase for _____ in the elderly resulting in _______
falls; hip fracture
Constipation is defined by:
- reduced stool frequency (<3 BM/wk)
- straining, lumpy or hard stool
- feeling incomplete or anorectal blockage
Is constipation a physiological consequence of aging?
NO
Causes of constipation include:
- decreased physical activity
- inadequate water intake
- low fiber diet
- medication side effects
- IBS
- bowel obstruction
- hypothyroidism
- inadequate toilet facilities
______ is the digestive enzyme needed for absorption of carbohydrate lactose
lactase
Lactose intolerance results in:
- abdominal pain
- bloating
- flatulence when milk products are consumed
______ is an autoimmune disorder affecting less than 1% of the population but persons are permanently intolerant to gluten
celiac disease
Those with celiac disease
should avoid:
- wheat
- barley
- rye
- commercially produced oats
How is celiac disease
tested for?
through serology and small bowel biopsy
Gluten free diets may result in deficiencies of:
- fiber
- vitamin D
- vitamin B12
- folate
- iron
- zinc
- magnesium
- calcium
_____ results in bloating or excessive gas
food intolerance
______ is heartburn, a burning sensation in the esophagus and stomach from reflux of gastric acid
pyrosis
Visceral abdominal pain feels:
dull, general and is poorly localized
Parietal pain from inflammation of overlying peritoneum feels:
sharp and is aggravated by movement but is precisely localized
Acute pain occurs with what conditions?
- appendicitis
- cholecysitis
- bowel obstruction
- perforated organ
Chronic pain of gastric ulcers occur on a _______ but pain of duodenal ulcers occurs _______ after a meal and is relieved by more food
empty stomach; 2-3 hours
_______ is common with GI diseases, medications and pregnancy
nausea and vomiting
_______ occurs with stomach or duodenal ulcers and esophageal varices
hematamesis
Tarry black stools may be due to:
occult blood (melena) from GI bleeding (or non-tarry from iron medications)
Gray stools occurs with:
Hepatitis
Red blood in stools occurs with:
GI bleeding or localized bleeding around the anus (hemorrhoids)
This disease occurs with frequent use of NSAIDS, alcohol, smoking and helicobacter pylori infection
peptic ulcer disease
What is a useful tool when assessing diet?
Nutritional assessment via 24 hour recall
Why may older adults have risk for nutritional deficit?
- limited access to grocery stores
- limited income or cooking facilities
- physical disability
- live alone, social isolation and depression
With older adults you should assess:
week long diary of intake opposed to 24 hours recall because daily patterns may vary
What does the contour of the abdomen describe?
the nutritional state and ranges from flat to rounded
_______ abdomen caves in while _______ abdomen indicates abdominal distention
scaphoid; protuberant
______ is the protrusion of abdominal viscera through abnormal openings in muscle walls
hernia
_______ is a hard nodule in umbilicus that occurs with metastatic stomach cancer, large intestine, ovary or pancreas
sister mary joseph nodule
The umbilicus is everted with:
hernia, ascites or underlying mass
The umbilicus is deeply sunken in with:
Obesity
When does a bluish periumbilical color occur?
rare but with intraperitoneal bleeding (cullen sign)
What are some abnormalities of the skin?
- redness with inflammation
- jaundice
- skin glistening and taut with ascites
- striae with ascites
______ are silvery white, linear, jagged marks about 1-6 cm long that occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching of the skin
striae
What color are recent striae?
pink or blue
With what syndrome does striae appear purple-blue and why?
cushing syndrome due to excess adrenocortical hormone that causes the skin to be fragile and easily broken from normal stretching
________ are circumscribed brown macular or papular areas common on the abdomen
pigmented nevi (moles)
Moles should NOT be:
Unusual color or experience change in shapes
When are veins more visible and why?
With malnutrition because of thinned adipose tissue
What indicates intestinal obstruction?
visible peristalsis together with distended abdomen
Restlessness and constant turning to find comfort occurs with:
colicky pain or gastroenteritis or bowel obstruction
What occurs with pain of peritonitis?
absolute stillness, resisting any movement
What other signs indicate pain?
- knees flexed up
- facial grimacing
- rapid, uneven respirations
What is the order for proper assessment of the abdomen?
- inspection
- auscultation
- percussion
- palpation
Normal bowel sounds are:
high pitched, gurgling, cascading sounds occurring anywhere from 5-30 time/minute
What hyperactive bowel sound is common?
Borborygmus or Hyper-peristalsis (when you feel your stomach growling)
What is more reliable to determine the return of GI function after abdominal surgery?
the passage of flatus and stool as well as the tolerance of oral intake
How long must you listen if you think bowel sounds are completly absent?
5 minutes
________ are loud, high pitched, rushing, tinkling sounds that signal increased motility
hyperactive sounds
______ follow abdominal surgery or with inflammation of the peritoneum
hypoactive or absent sounds
Where may a normal bruit originate in healthy people?
the celiac artery
Why is the auscultation method no longer used to determine correct placement of a NG tube?
it can be very inaccurate and cause serious harm (even death) if NG tube-feeding is in the lung and not the stomach; x-ray is the only acceptable confirmation method
When is the upper liver border overestimated?
if chronic obstructive lung disease is present and both upper and lower edges are obscured if obesity or ascites is present
What is palpation used for and how far should you palpate?
to judge the size, location and consistency of certain organs and screen for an abnormal mass or tenderness; depress about 1 cm
When does tenderness occur during palpation?
- local inflammation
- inflammation of the peritoneum or underlying organ
- enlarged organ whose capsule is stretched
When can a liver be considered enlarged?
except with a depressed diaphragm, when it is palpated more than 1-2 cm below the right costal margin
An abnormally firm liver may indicate:
cirrhosis
Is the spleen palpable?
No unless it is enlarged 3 times its normal size
When does the spleen enlarge?
with mononucleosis, trauma, leukemia and lymphomas, portal HTN, malaria and HIV,
When palpating the kidney, how should your hands be and what can you expect to feel?
in duck bill position and a round, smooth mass
The _______ kidney sits 1 cm higher than the _______ kidney and is not palpable
left; right
How wide is the aorta in an adult and what direction does it pulsate?
2.5cm-4cm wide and in a anterior direction
What confirms rebound tenderness? And what is it a sign of?
pain on the release of pressure; peritoneal inflammation (which accompanies appendicitis)
What is the blumberg sign and what does it indicate?
when rebound tenderness occurs in the RLQ when pressure is applied to the LLQ and it may indicate appendicitis
A positive murphy sign test will result in:
Inflamed gallbladder that results in sharp pain and a abrupt stop in inspiration
25% of people who are older than 60 do not experience:
abdominal tenderness
When should you perform the iliopsoas muscle test?
when appendicitis is suspected
A score of _______ on the alvarado score decreases the probability of _________
<4; appendicitis
What muscle is irritated when the appendix is inflamed?
obturator muscle
In an older adult, what happens to the abdominal musculature?
it is thinner and has less tone, therefore, in the absence of obesity you may note peristalsis
Why are organs easier to palpate in older adults?
because of thinner, softer abdominal wall
Where will you feel the liver edge in older adults?
at or below the costal margin unless lungs are distended and the diaphragm is depressed, then you will palpate the liver lower at 1-2 cm below the costal margin with inhalation
__________ with acute abdominal conditions is less common in aging and there are less complaints of pain
abdominal rigidity
How are Hep B and C spread
through blood and body fluids
Can Hep B and C be cleared?
yes, or they can cause long term chronic infection (very common in Hep. C)
What can chronic hepatitis cause?
liver failure due to liver scarring and increase risk for liver failure
Hyperactive bowel sounds result in:
early bowel obstruction
Hypoactive or silent bowel sounds result in:
late bowel obstruction
Hepatitis is mild-moderate dull pain in the RUQ and is accompanied with:
- anorexia
- nausea
- malaise
- low grade fever
GERD is burning pain in the midepigastrium or behind the lower sternum that radiates upward (heartburn). When does it occur?
30-60 minutes after eating and is worsened by lying down or bending over
Cholecystitis pain is in the RUQ but may radiate to the:
right or left scapula and normally occurs after eating fatty foods, alcohol or caffeine
Pancreatitis has acute pain that radiates to the:
back and sometimes left scapula
Duodenal ulcer has a dull aching gnawing pain that:
does not radiate and may be relieved ny food
Gastric ulcer pain is dull, aching and gnawing, usually caused by food and radiates to the:
back or substernal area
Appendicitis starts as dull, diffusing pain that shifts to sever, sharp persistent pain and local tenderness in the RLQ. It is aggravated by:
movement, coughing deep breathing
Kidney stones cause sudden onset of severe, colicky flank pain in the:
lower abdominal area
