Lymphatic System & Peripheral Vascular Flashcards
1
Q
Inspection technique of lymphatic system
A
- Visible nodes
- Edema
- Erythema
- Streaking
2
Q
Lymphatic palpation technique of…
A
- Lymph nodes: noting…
- size
- consistency
- mobility: worse if unmovable and stuck to underlying tissue ⇒ indicates malignancy or chronic infections
- borders
- tenderness
- warmth
- lower extremity specific nodes to palpate for…
- inguinal nodes: can be enlarged due to STIs
- popliteal
3
Q
Peripheral vascular technique of taking VS specifics…
A
- standard VS
- assess for orthostatic hypotension: drop in BP w/ change in position
- Steps: measure BP and HR in 3 diff positions (laying down, sitting upright, standing up) w/ time between each measurement
- causes: autonomic dysfunction, volume issues
- Steps: measure BP and HR in 3 diff positions (laying down, sitting upright, standing up) w/ time between each measurement
- Ankle Brachial Pressure Index (ABI) Screening: for pts who have risk factors for PAD
- steps: take BP on both arms brachial & get systolic #s → take BP on ankle above malleoli & get systolic #s → divide higher systolic pressure from legs from by higher brachial systolic pressure from arms = ABI (higher ankle systolic pressure/higher brachial systolic pressure)
- norm: 0.8 - 1
- abnorm: <0.6 / 0.7 ⇒ suggests ischemia (lower it is from 1 = more severe ischemia is
4
Q
peripheral vascular palpations of pulses…
A
- Carotid: If pt is middle age or older and suspect cerebrovascular disease ⇒ listen for bruit that suggests arterial narrowing and increases risk for CVA
- brachial
- radial
- femoral: Exaggerated, widened femoral pulse ⇒ suggests femoral aneurysm (pathologic dilation of artery)
- Femoral aneurysm uncommon and usually caused by atherosclerosis and occurs mostly in >50 yo
- Popliteal: Exaggerated, widened popliteal pulse ⇒ suggests aneurysm of popliteal artery
- Atherosclerosis (arteriosclerosis obliterans) commonly obstructs arterial circulation in thigh ⇒ femoral pulse normal but popliteal pulse decreased or absent
- Popliteal aneurysm uncommon and usually caused by atherosclerosis and occur mostly in >50 yo men
- If you have hard time feeling this pulse but can still feel pedal pulses ⇒ be assured that foot is still getting blood flow ⇒ so palpate distal pulses first then proximal
- posterior tibial
- dorsalis pedis: Decreased or absent pedal pulses (assuming in warm environment) w/ normal femoral and popliteal pulses ⇒ suggests occlusive disease in lower popliteal artery or its branches (often seen in DM)
5
Q
Auscultation for bruits in…
A
- Carotid artery
- Abdominal aorta
- Renal artery
- Iliac artery
- Femoral artery
6
Q
Lymphedema
A
- What: soft, pitting edema that becomes indurated, hard, non-pitting / inadequate lymph drainage leading to edema
- Causes:
- Interstitial accumulation of protein-rich fluid when lymph channels and nodes are infiltrated or obstructed by tumor, fibrosis, or inflammation
- Disrupted by axillary node dissection and/or radiation
- Removal of lymph nodes
- Occurs often in: BIL in feet and toes
7
Q
Lymphedema Stages
A
- 0:
- Have some internal changes– latent or subclinical condition where swelling not evident despite impaired lymph transport
- Subtle alterations in tissue fluid/composition
- Changes in subjective Sxs
- 1: Early accumulation of fluid relatively high in protein content that subsides w/ limb elevation
- 2: Pitting may or may not occur as tissue fibrosis develops + Limb elevation alone rarely reduces tissue swelling
- 3: Lymphostatic elephantiasis where pitting is absent + Trophic skin changes like acanthosis, alterations in skin character and thickness, fat deposits and fibrosis, warty overgrowths often develop
8
Q
Lymphoma
A
- What: “liquid tumor” – cancer of immune system that affects lymphocytes T-cells and B-cells
- Hodgkins: B-cells affected and hits lymph nodes and moves on from one lymph nodes to next + has Reed-Sternberg cells
- Non-Hodgkins: B-cells and T-cells affected and can see cancer in any of the lymph tissues like spleen and lymph nodes
9
Q
HIV/AIDs
A
- What: someone newly infected w/ HIV can get generalized lymphadenopathy (enlarged lymph nodes from head to toe)
- Lymphadenopathy: enlargement of nodes w/ or w/o tenderness
- Ppl don’t know they’ve been infected during virus’ most infectious time range ⇒ contagious
- S&S: Flu-like symptoms
10
Q
Herpes Simplex (HSV)
A
- What: enlarged nodes of anterior cervical chain and submandibular node
- HSV on mouth increases nasal, anterior cervical chain, and submandibular nodes ⇒ signs of infection
- S&S: Lymph nodes affected often tender but if nontender lymph nodes ⇒ suggests cancer
11
Q
5 Ps of arterial occlusion
A
- Pallor: bc of loss of blood flow
- Pain: bc of no O2 to tissues
- Pulselessness: bc of no blood flow thru arteries
- Paresthesias: numbness or tingling
- Paralysis: inability to move affected area
12
Q
acute arterial occlusion
A
- What: embolism or thrombosis that suddenly blocks peripheral artery
- Location of pain: distal pain usually foot and leg
- Onset: sudden + associated Sxs may occur w/o pain
- S&S: coldness, numbness, weakness, absent-distal pulses
13
Q
Chronic arterial occlusion (usually from atherosclerosis) ⇒ causes…
A
intermittent claudication
14
Q
Asymmetric diminished pulses occur with…
A
arterial occlusion from atherosclerosis or embolism
15
Q
Normal Pulse
A
- Pulse contour: smooth and rounded
- Notch on descending slope of wave isn’t palpable
16
Q
Small & Weak Pulse
A
- Diminished, weak, small pulse pressure
- Upstroke may feel slowed + peak prolonged
- Causes:
- Decreased SV like in HF, hypovolemia, severe aortic stenosis
- Increased peripheral resistance like in exposure to cold and severe congestive HF
17
Q
Large & Bounding Pulse
A
- Increased, strong, bounding pulse pressure
- rise and fall may feel rapid + peak brief
- Causes:
- Increased SV, decreased peripheral resistance or both like in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, patent ductus arteriosus
- Increased SV bc of slow HR like in bradycardia and complete heart block
- Decreased compliance/Increased stiffness of aortic walls like in aging or atherosclerosis
18
Q
Bisferiens
A
- Increased arterial pulse w/ double systolic peak
- Causes:
- Pure aortic regurgitation
- Aortic stenosis w/ regurgitation
- Increased arterial pulse
19
Q
Pulsus Altemans
A
- Alternates in amplitude from beat to beat even though rhythm is regular
- When difference between stronger and weaker beats is slight
- Cause: Left ventricular failure w/ left sided S3
- Can only be detected by sphygmomanometer
20
Q
Bigeminal
A
- Normal beat then premature contraction
- Has premature contraction rhythm mimicking pulsus alternans
- SV of premature beat diminished in relation to that of normal beats ⇒ Pulse varies in amplitude accordingly
- Cause: normal beat alternating w/ premature contraction
21
Q
Pulsus Paradoxus
A
- Can feel decrease in amplitude of pulse with inspiration (basically opposite of what you normally expect)
- Cause:
- Cardiac tamponade
- Pericarditis
- Obstructive airway disease
- Other serious life-threatening cardiac issues
22
Q
Peripheral Venous Disease (PVD)
A
- What: inadequate return of venous blood from extremities to heart ⇒ leads to too much fluid build up
- S&S:
- Edema that might make pulse harder to palpate
- Can get wounds but not black eschar wounds
- Achy cramping in legs w/ pain worsening when standing and improves w/ elevation and activity
- Sores w/ irregular borders
- Yellow slough or ruddy skin
23
Q
Peripheral Arterial Disease (PAD)
A
- What: narrowing or blockage of vessels that deliver blood from heart to extremities
- Cause: atherosclerosis– build up of fatty plaque in arteries
- S&S:
- Intermittent claudication: cramping muscle pain that comes w/ movement of legs or arms during exercise and relieved by resting
- Pallor bc of loss of O2
- As it increases ⇒ will impact pulse and it’ll go from regular to weaker to no pulse ⇒ risk for limb loss
- Black eschar from poor oxygen circulation
- Loss of hair bc of lack of O2
- Round, smooth, shiny leg
- NO edema
24
Q
What are the Specific Disease of Peripheral Venous
A
- Chronic Venous Stasis/Insufficiency
- Varicose Veins
- Deep Vein Thrombosis (DVT)
- Pitting Edema
25
Q
Chronic Venous Stasis/Insufficiency (Advanced)
A
- What: more severe form of chronic venous disease w/ chronic venous engorgement from venous occlusion or incompetency of venous valves
- If it’s a problem with veins (periphery) ⇒ blood pools and doesn’t return to heart ⇒ lungs and other areas swell bc fluid goes to 3rd space
- Causes
- Incompetent vein valves secondary to DVT
- Prolonged increased venous pressure as seen in prolonged standing or pregnancy ⇒ can lead to varicose veins and skin changes
- S&S
- Generalized/Diffuse aching of legs, esp at end of day
- Decreased wound healing
- Weak pulse due to edema making it harder to find
- Chronic edema
- Pigmentation
- Swelling
- Ulceration esp if old age, pregnant, increased weight, prior Hx, trauma
- Onset: chronic, increasing as day goes on
- Aggravating factors: prolonged standing or sitting w/ legs dependent
- Relieving factors: pressure stockings, leg elevation, anything to get blood back to where it needs to be
26
Q
Varicose Veins
A
- What: dilated and tortuous where their walls may feel somewhat thickened
- Many varicose veins can be seen in leg
- Common in backside of legs
- Tested by having pt rise on tiptoes and inspecting backside of legs to see if veins pop out
- Is a Sx or result of venous stasis/insufficiency
- S&S: Can become painful as they grow and go untreated
27
Q
Deep Vein Thrombosis (DVT)
A
- What: when blood clot forms in deep vein, accompanied by inflammatory response in vein wall
- Common in lower leg, thigh, pelvis ⇒ risk for pulmonary embolism (PE) ⇒ blocks blood flow to lungs ⇒ life-threatening emergency because it impairs oxygenation 🚩
- Avoid firm palpation or massage over DVT because it may dislodge clot ⇒ causes pulmonary embolism or death
- S&S:
- Painful calf swelling w/ erythema but can be painless
- Edema: Extent of edema suggests location of occlusion
- Ie. Popliteal vein may be location when lower leg or ankle is swollen
- Ie. iliofemoral vein may be location when entire leg is swollen
- Tx: remove clot or medicate so thrombus can break apart on its own
- Aggravating factors: immobilization or recent surgery, lower extremity trauma, pregnancy, postpartum state, hypercoagulable state
- Relieving factors: antithrombotic and thrombolytic therapy
28
Q
What are the Specific Diseases of the Peripheral Arteries?
A
- Arterial Aneurysm
- Raynaud’s Disease
29
Q
Arterial Aneurysm
A
- What: weakness in arterial wall ⇒ stretched artery intima and media ⇒ problem is when it ruptures/opens arterial wall ⇒ blood gets to periphery
- Aorta is vulnerable place to have aneurysm ⇒ huge blood loss
- Brain is vulnerable place to have aneurysm ⇒ blood will become trapped and can’t go anywhere
- Popliteal and femoral aneurysm uncommon and usually caused by atherosclerosis and occur mostly in >50 yo men
- Exaggerated, widened femoral pulse ⇒ suggest femoral aneurysm
- Tx: surgery if stretched arterial wall is >5 cm
30
Q
Raynaud’s Disease
A
- What in General: small arteries in fingers and toes spasm in response to cold or stress ⇒ causes them to turn blue and numb (basically just spasms in vasculature)
- Primary Raynaud’s: you just have Raynaud’s
- What: episodic reversible vasoconstriction in fingers and toes, triggered by cold temp
- S&S: distinct digital color changes of pallor, cyanosis, hyperemia (redness)
- Secondary Raynaud’s: you have Raynaud’s but there’s another cause of it
- What: S&S related to autoimmune diseases– scleroderma, lupus, mixed connective tissue disease, cryoglobulinemia, occupational vascular injury, drugs
- S&S: more severe w/ ischemia, necrosis, loss of digits, distorted capillary loops
- Causes: stress, cold temp, emotional upset
- S&S:
- Can be very painful
- Affected area gets pale and loose color ⇒ turns cold and blue (if warmth returns to affected part it’ll turn rlly red)
- Can develop other wounds like gangrenous area from decreased O2
- Commonly affects: hands and fingers but other parts of body like toes and ears can be affected
- Management/Prevention: stress management, limit cold exposure
31
Q
Pitting Edema
A
- What: third spacing of fluids
- Generalized edema is called anasarca
- Causes:
- HF, esp right side bc it causes increase in fluid build up in lower extremities
- Kidney failure
- Peripheral vascular problems: Venous insufficiency, DVT
- Common in: lower extremities
32
Q
Lymphatic Age-related considerations
A
- Infants: Recurrent infections, trauma, failure to thrive, immunization Hx, maternal HIV, etc. ⇒ suspect problem with lymph system
- Children: Post auricular and occipital nodes more palpable in <2 yo
- Older Adults
- Delayed healing normal bc of slowing and aging of IS
- Trauma, autoimmune disease ⇒ suspect problem with lymph system
- Hx of malignancy ⇒ increases risk for cancer
- Pregnant Women
- Earlier weeks of gestation more sensitive to fetus so exposure to infectious diseases during this time is dangerous
- Avoid exposure to cats/cat feces bc they’re toxic to fetus
33
Q
Peripheral Vascular Age-related Considerations
A
- Infants: Brachial, radial, femoral pulses normally easily palpated
- Children
- Most HTN in children due to renal diseases, NOT primary HTN (usual assumption in most adults)
- Child w/ high BP ⇒ suspect kidney disease and not primary HTN (usual assumption in most adults)
- Most HTN in children due to renal diseases, NOT primary HTN (usual assumption in most adults)
- Pregnant Women
- BP fluctuations:
- BP ↓ til wk 16-20
- 2nd trimester: > 125/75 abnormal
- 3rd trimester: >130/80 abnormal
- BP should be back to norm during term/delivery time
- BP fluctuations:
- Geriatrics
- Pedal pulses harder to palpate bc vessels become more tortuous and distended
- If you can’t feel pedal pulse ⇒ feel for temp, color, cap refill, and size differences to find out if they still have circulation
- Systolic BP (SBP) ↑
- Pedal pulses harder to palpate bc vessels become more tortuous and distended
34
Q
Pulse Grading
A
- 0: Absent: absent pulse + unpalpable
- 1+ : weak:
- Diminished pulse
- Weaker than expected pulse
- Asymmetric diminished pulses occur w/ arterial occlusion from atherosclerosis or embolism
- 2+: normal: brisk pulse
- 3+: bounding: Bounding, carotid, radial, femoral pulses occur w/ aortic insufficiency
35
Q
Pitting Edema Measurement Scale
A
- 1+ / 2mm: Barely noticeable pit
- 2+ / 4mm: deeper pit + rebounds in few secs
- 3+ / 5-6mm: deep pit + rebounds in 10-20secs
- 4+ / 8mm: deeper pit + rebounds in >30secs
36
Q
General Documentation of Lymph Nodes
A
- If lymph node not palpable ⇒ state “nonpalpable” + location of lymph node
- If lymph node palpable ⇒ state location, size, shape, consistency, mobility, tenderness
