Exam 4 - Peripheral Vascular System Flashcards
What is the purpose of the vascular system?
Transport fluid such as blood or lymph
Delivers oxygen and nutrients
Eliminates carbon dioxide and waste products
Function of the arteries
Pump O2 rich blood to all body tissues
What is a pressure wave?
Pulse.
Created by each heartbeat
Which makes the arteries expand and then recoil
The recoil propels blood through, like a wave
Accessible pulse locations:
Temporal Carotid Brachial Femoral Popliteal Dorsal is pedis Posterior tibial
Major artery to the leg
Femoral artery
Artery behind knee
Popliteal
Artery on dorsum of foot (spelling)
Dorsalis pedis
Artery behind medial malleolus and forms plantar arteries in the foot (spelling)
Posterior tibial
Function of veins
Absorb CO2 and waste products from periphery and carry them back to the heart
What is ischemia?
What is it caused by?
Deficient blood supply of oxygenated arterial blood to a tissue.
Caused by obstruction of blood vessel
What does a complete arterial blockage cause?
Death of distal tissue
What does a partial arterial blockage cause? And when does this become apparent?
Insufficient blood supply, and the ischemia may be apparent only at exercise when oxygen needs increase
Which arteries are affected with peripheral artery disease (PAD)?
Affects no coronary arteries and usually refers to arteries supplying the limbs
What usually causes PAD?
Atherosclerosis
Sometimes an embolism, hypercoagulable states, or arterial dissection
Veins accessible to examination
Jugular veins
Veins in the arm
Veins in the legs
What is intermittent claudication?
Cramping/pain in legs that comes and goes
What should you ask your patient about intermittent claudication?
“Does it get worse with walking and better after sitting (for 2 mins)?”
What is intermittent claudication a symptom of?
PAD (peripheral arterial disease)
What is claudication distance?
The distance pt can walk before having pain
Examples of skin changes we look for on arms or legs
Arteries not good at pumping to peripheries = cool, pale, cyanotic skin
Varicose veins: during pregnancy, obesity, or due to genetics
Main thing to note if pt has swelling
Unilateral or bilateral?
What can unilateral swelling be due to?
Injury
What can bilateral swelling be due to?
Cardiac related
Lymphedema
Blood clot
Infection
Which medications are we most concerned with regarding the peripheral vascular system?
Hormone replacement therapy
Birth control pills
(Can cause blood clots)
Function of the lymphatic system:
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
3- Absorb lipids from the small intestine
What can lymph node enlargement tell us?
If swollen, body may be fighting something above it (inguinal would mean something is going on with legs)
When should you examine pt’s arms and what position should they be in?
With vital signs while person is sitting
What position should pt be in while examining legs?
Examine while pt is still supine
Then stand person up to evaluate leg veins
What should the room temperature be during physical examination and why?
22C or 71F and free of drafts
To prevent vasodilation or vasoconstriction
What do we look at while inspecting skin on extremities?
Color
Capillary refill
Normal capillary refill
< 1-2 seconds
Abnormal capillary refill
> 2 seconds
What does capillary refill tell us?
An index of peripheral perfusion and cardiac output
What is profile sign?
Viewing the finger from the side to detect clubbing
Measurement of a normal nail bed
160 degrees
If a patient has clubbing, what could it mean?
Congenital cyanotic heart disease
Lung cancer
Pulmonary diseases (chronic lung inflammation)
What should you do if pt’s capillary refill is greater than 2 seconds?
If pt has 2+ pulse, don’t panic, just need to investigate further
What do we do during palpation?
Palpate pulses
Note rhythm
Elasticity of vessel wall
Check for equal force
Upper extremity pulses to palpate
Brachial
Radial
Ulnar
Which upper pulse do we use to note the rate of pulse?
Radial
What should you do if you can’t find ulnar pulse?
Hard to find, so test capillary refill. If that’s ok, have someone else come try to find pulse
How to grade force on a 3 point scale
3+ increased, full, bounding
2+ normal
1+ weak
0 absent
What could cause a 3+ pulse force?
Hyperthyroidism
Anxiety
Just finished exercise
When would a 1+ pulse force be considered normal?
Elderly
Go to pulse to measure on babies
Brachial
Test used for checking collateral blood flow
Modified Allen test
What is the modified Allen test used for?
ABG (arterial blood gas) collection
Evaluate the adequacy of collateral circulation before cannulating the radial artery
Steps to perform the modified Allen test
1) 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)
2) 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)
What is a palmar blush?
Return to the normal color of the hand in less than 7 seconds
What do we look at for inspection of lower extremities?
Skin Hair distribution Venous pattern Size (any swelling or atrophy) Skin discoloration, ulcers, or gangrene
Why is it important to look at hair on lower extremities?
Need good blood flow for hair so if it’s sparse or missing, it means there is a problem with an artery
What do we do while palpating lower extremities?
Palpate pulses
Note rhythm
Elasticity of vessel wall
and Equal force
Which arteries do we palpate during lower extremity palpation?
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
How should we palpate the popliteal artery?
Pt sitting, cup behind knee
May be difficult to feel
When should you use a Doppler?
If you can’t find a pulse that should be easily felt
Where is pretibial edema found?
Over tibia or medial malleolus
How should you check for pretibial edema?
Firmly depress skin over tibia or medial malleolus for 5 seconds and release
Normal vs abnormal results of pretibial edema?
Normal: finger leaves no indentation
Abnormal: Pitting edema
Pitting may be normal if person has been standing all day or is pregnant
1+ edema
Mild pitting, slight indentation, no perceptible swelling of leg
2+ edema
Moderate pitting, indentation subsides rapidly
3+ edema
Deep pitting, indentation remains for short time, leg looks swollen
4+ edema
Very deep pitting, indentation lasts a long time, leg very swollen
What do you assess when a person is standing to assess venous system?
Note any visible, dilated, and tortuous veins (look like a rope)
What can varicose veins cause patient to feel?
Pain
Swelling
Fatigue
Cramping
What happens to arteries with arterial insufficiency?
Thickening and loss of elasticity of arterial walls
What does venous insufficiency cause?
Chronic incompetent valves in deep veins or clot
Risk of infection
Skin color with arterial insufficiency
Pale
Cyanotic
Mottled
Skin color with venous insufficiency
May be reddish-blue
Skin temperature with arterial insufficiency
Cool to cold
Skin temperature with venous insuffiency
Warm
Skin characteristics with arterial insufficiency
Thin, shiny skin
Dependent rubor
Elevation pallor of foot
Skin characteristics with venous insufficiency
Firm Brawny Brownish pigmentation in area between medial and lateral malleolus Skin thickened and tough Cyanosis when dependent
Nails with arterial insuffiency
Thickened and ridged
Nails with venous insufficiency
Not thickened
Distribution of hair with arterial insufficiency
Loss of hair over toes and dorsum of foot
Distribution of hair with venous insufficiency
Present
Edema with arterial insufficiency
None or minimal
Edema with venous insufficiency
Moderate to severe
Pitting
Ankle, foot, lower leg
Pulses with arterial insufficiency
Decreased or absent
Pulses with venous insufficiency
Present but may be difficult to palpate through edema
Type of pain with arterial insufficiency
Intermittent claudication (relieved by rest)
Type of pain with venous insufficiency
Aching
Cramping
Feeling of fullness
Relieved by elevation
Ulcers with arterial insufficiency
Between toes or tips of toes
Heels
Lateral malleolus
Well-defined edges
Deep
Circular ulcer base-black or gangrene
Non-bleeding
Ulcers with venous insufficiency
Medial malleolus
Lower leg
Uneven edges Superficial Ulcer base- granulation tissue - beefy red to yellow Bleeding May or may not be painful
What is raynaud phenomenon?
Episodes of abrupt, progressive tricolor change of the fingers in response to cold
What does Raynaud phenomenon look like?
1) White (pallor)
2) Blue (cyanosis)
3) Red (rubor)
What does Raynaud phenomenon feel like?
Pallor or cyanosis stage: cold, numbness, pain
Rubor stage: burning, throbbing pain, swelling
Most effective therapy of Raynaud phenomenon
Avoidance of cold
What is lymphedema?
Accumulation of protein-rich fluid in interstitial spaces of arm, following breast surgery or treatment
Resulting of axillary lymph node removal
What causes varicose veins?
Chronic increased venous pressure, and incompetent valves
What is deep vein thrombophlebitis?
What does it cause?
A deep vein is occluded by a thrombus
Causing inflammation, blocked venous return, cyanosis, and edema
Conditions that can cause deep vein thrombosis?
Prolonged bed rest History of varicose veins Trauma Infection Cancer Obesity Immobility Heart failure Use of estrogen hormones
What should you do if a pt has deep vein thrombophlebitis?
Emergency referral because of risk for pulmonary embolism
What would a capillary refill of over 1-2 seconds signify?
Which diseases could this be a symptom of?
Vasoconstriction or decreased cardiac output
Hypovolemia, heart failure, or shock
What would cause edema of upper extremities?
When lymphatic drainage is obstructed after breast surgery or radiation
Where are the epitrochlear lymph nodes located?
In the depression 2-3 cm above and behind the medial condyle of the humerus
How do you check a patient’s epitrochlear lymph nodes?
Shake hands with the person and reach other hand under person’s elbow and feel with fingers
Nodes are normally not palpable
What would an enlarged epitrochlear node indicate?
Infection of hand or forearm
What conditions cause enlarged epitrochlear nodes?
Conditions with generalized lymphadenopathy:
- lymphoma
- chronic leukemia
- infectious mononucleosis
- HIV infection
How long does it take to show an occlusion while doing the modified Allen test?
Over 15 seconds
How long does a normal result take during the modified Allen test?
8 to 14 seconds
When does diffuse bilateral edema of legs occur?
With systemic illness
What should you do if pt has acute, unilateral, painful swelling and asymmetry of calves 1 cm or more?
Abnormal
Refer pt to determine whether DVT is present
What is edema with of 1-3 cm with asymmetry in legs called?
Mild lymphedema
What is edema of 3-5 cm with asymmetry in legs called?
Moderate lymphedema
What is edema of 5 or more cm with asymmetry in legs called?
Severe lymphedema
What is a symptom of DVT?
Asymmetric calf swelling of 2 cm or more
What causes brown discoloration on legs?
Chronic venous stasis
Caused by hemosiderin deposits from red blood cell degradation
Where and why do venous ulcers usually occur?
At medial malleolus because of bacterial invasion of poorly drained tissues
Why do ulcers typically form?
With arterial deficit
Where do ulcers typically form on lower extremities?
Tips of toes
Metatarsal heads
Lateral malleoli
What could a unilateral cool foot or leg mean?
Arterial ischemia
Where are the femoral arteries located?
Just below inguinal ligament, halfway between the pubis and anterior superior iliac spines
How should you palpate the popliteal pulse?
Leg extended but relaxed
Anchor thumbs on knee and curl fingers around popliteal fossa
Press fingers forward hard to compress artery against the bone
Is usually just lateral to the medial tendon
How should you palpate the posterior tibial pulse?
Curve fingers around medial malleolus
Press softly
Tapping will be right behind it in the groove between the malleolus and Achilles’ tendon
If you can’t feel the posterior tibial pulse, what should you do?
Have pt do dorsiflexion of the foot
Where is the Dorsalis pedis pulse?
Just lateral to and parallel with the extensor tendon of the big toe
Use very light touch
Conditions that could cause bilateral, dependent pitting edema?
Heart failure
Diabetic neuropathy
Hepatic cirrhosis
What could cause unilateral edema?
Occlusion of a deep vein
What is brawny?
Unilateral or bilateral edema that is no pitting and feels hard to the touch
What should happen next if pt has bilateral pitting edema?
Exam in the neck veins
What if pt has bilateral pitting edema and neck veins are abnormally distended?
May be related to heart disease or pulmonary hypertension
Which veins do varicosities occur?
Saphenous veins
How is valvular incompetency examined?
By Doppler
What does elevational pallor indicate?
Arterial insufficiency
What causes dependent rubor?
Severe arterial insufficiency
What causes delayed venous filling?
Arterial insufficiency
