Mosby 15 Flashcards
Effects on blood vasculature durign pregnancy
Vascular resistance decreases and peripheral vasodilatation
Cause of hypotension during preganancy
Compression of vena cava and venous return
What are vascular changes in elderly?
Calcifications leading to dilation and tortuosity
HPI for blood vasculature
Leg pain or cramps
Onset? Duration? Recent injurity/immobilization?
Character?
Burning feeling in toes/thigs/buttocks
Skin changes: cold, pallor, hair loss, sores, rednes, or warmth of vein, visible vein, darkened or ischemic skin
walking at night with leg pain
Swollen ankles
Onset and duration: present in the morning, appearing as the day progersses, sudden onset, insidious onset
RElated circumastance: recent airplane, travel to high elevations
Associated symptoms: onset of nocturia, increased frequncy of urination, increasing SOB
Treatment attempted
Rest, massage, heat, elevation
MEDs: heparin, warfarin diuuretics, antihypertensive, non prescrition (NSAID),
PMH for blood vasculature
Cardiac surgery / hospitalization, Congential Heart defect, vascular procedures
Acute rheumatic fever, unexplained fever, swollen joints, vasculitis
Chronic illness: hypertension, bleeding, hyperlipiedmia, DM, thyroid, storke, transiet ischemic attack, coronary artery disease, AF,
FH for blood vasculature
Cardiovascular system
HT
dyslipidemia
DM
Heart
Thrombosis
Peripheral vascular disease
Abdominal aortic aneurysm
SX for blood vasculature
Employment: physical demands, hazards: heat, chemicals, dust, stress
Tabacoo
Nutrition
Weight loss/gain
Exercise
Alcohol
Recreational drugs
History of infants for blood vasculature
Hemophilia
Renal disease
Coarctation of the aorta
Leg pain during exercise
Histor of pregnant women for blood vasculature
BP before pregnancy (and change)
Headaches, visual changes, nausea, vomiting, epigastric pain, right upper quadrant pain, oiligura, rapid onset edema, hyperreflexia, proteinuraia, too much brusiing
Legs: edema, aricositites, pain, discomfort
Preeclampsia
Pregnancy complication characterized by high blood pressure
Preeclampsia
Risk factors
40+ yo
First pregnancy
Preexisting chronic hypertension
Renal disease / DM
Familial history of preeclampsia
Previous preeclampsia
Obestiy
History in older adults
Leg edema: pattern, frequency, time of the day
Interference with normal activities
Ability to cope
Claudication - areaa involved, unilateral or bilateral, distance one can walk b4 onset, length of tiem required for relief
Meds for relief
Varicose veins
risk factors
Gender - women (during preganncy especally)
Genetic (irish or german, taking birth control)
Sedentary lifestyle
Age
Pulses
A Carotid
B Brachial
C Radial
D Femoral
E Popliteal
F Dorsalis pedis
G Posterior tibial
Pulse abnormalities
Alternating pulse (pulsus altenans) - left ventricular failure
Pulsus bisferiens - aortic stenosis combine with aortic insuficiency (percussion 1st and tidial wave)
Bigeminal pulse - disorder of rhythm, normal pulsation following premature contraction
Large bounding pulse - exercise, anxiety, fever, hyperthyrodism, aorti rigidity
Paradoxic pulse - premature cardiac contraction, tracheobrachail obstruction, bronchial asthma, emphysema, pericardial effusion, constrictive pericarditis
Water-hammer pulse - patent ductus arteriosus, aortic regurgtation
Allen test
Test for patency of the ulnary artery
Venous Hum vs. Carotid Artery Bruits
Venous Hum
median end of clavicle & anterior border of stechleidomastoid muscle
no clinical significant
confused w/ carotid vruit, patent ductus arteriosus, aortic regurgitation
Carotid Artery Bruits
Heard above medial end of clavicle and aterior margin of stenocledomastoid
Transmitted murmus: valvular aortic stenosis, ruptured chordate tendineae of mitrial valve, or severe aortic regurgitation
Stenosis disease in cervial arteries
Arterial Occlusion
Ps
Pallor
Pain
Pulselessness
Paresthesias
Paralysis
First symptoms of peripheral arterial disease (stenosis)
Pain - ischemia - claudication “dull w/ muscle cramp w/ exercise” that pain is distal to stenosis
Evaluate during stenosis
◆Pulses (weak and thready, or possibly absent)
◆ Possible systolic bruits over the arteries that may extend through diastole
◆ Loss of expected body warmth in the affected area
◆ Localized pallor and cyanosis
◆ Collapsed superficial veins, with delay in venous filling
◆ Thin, atrophied skin; muscle atrophy; or loss of hair (particularly in the case of long-term
insufficiency)
◆ Long-term insufficiency also accentuates skin mottling and increases the likelihood of
ulceration, localized anesthesia, and tenderness
To judge the degree of stenosis and the potential severity of the arterial insufficiency, perform
the following steps:
◆ Have the patient lie supine.
◆ Elevate the extremity.
◆ Note the degree of blanching.
◆ Have the patient sit on the edge of the bed or examining table in order to lower the
extremity.
Korotkoff sounds
Conditions where BP is difficult to take
Cardiac dysrhythmias (infrequent odd beats ignored)
Aortic regurgitation (sound no dissapearing)
VEnous conestion (lower systolic/higher diastolic)
Valve replacement
Jugular Venous Pressure
difficult cases
Obesity
Volume depletion
Right hear failure, tricuspid insufficiency, constrictive pericarditis, cardiac tamponade
Jugular veins vs. Carotid artery
Waves
Respiration
Venous compression
Abdominal pressure (hepatojugular reflux)
3 vs. 1
Decreases on inspiration and increase on expiration / no effect
Elimiates / no effects
Increase prominence / no effect
Venous Obstruction
Symptoms
Constant pain
Swelling and tenderness over the muscles
Engorgement of superficial veins
Erythema and/or cyanosis
Venous Obstruction
signs
thrombosis, varicose veins, or edema
Homan sign
Flex the patient’s knee slightly with one hand and, with the other, dorsiflex the foot.
The complaint of calf pain with this procedure is a positive sign and may indicate venous thrombosis
Pitting edema levels
1+ Slight pitting, no visible distortion, disappears rapidly
2+ A somewhat deeper pit than in 1+, but again no readily detectable distortion, and it
disappears in 10 to 15 seconds
3+ Noticeably deep pit that may last more than a minute; the dependent extremity looks
fuller and swollen
4+ Very deep pit that lasts as long as 2 to 5 minutes, and the dependent extremity is grossly
distorted
Inspection for varicose veins
Stand 10 times on toues
Dependent position
Vessels disorders
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
An inflammatory disease of the branches of the aortic arch including the temporal arteries
PATHOPHYSIOLOGY
Inflammatory infiltrates develop in the thoracic aorta and neighboring arterial structures
Arterial intimal thickening and thrombosis can lead to ischemia ofsupplied structures such as the masseter muscle, tongue, or optic nerve
SUBJECTIVE
Usually affects persons older than 50 years of age
Flulike symptoms (e.g., low-grade fever, malaise, anorexia) may be accompanied by polymyalgia involving the hips and shoulders
Headache in the temporal region on one or both sides, although the headache can occur in other regions
Ocular symptoms, including loss of vision, are common
Ischemia can also cause tongue pain and jaw claudication
OBJECTIVE
Area over the temporal artery can become red, swollen, tender, and nodular
Temporal pulse may be variously strong, weak, or absent
Vessels Disorders: Arterial Aneurysm
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
An aneurysm is a localized dilation, generally defined as 1.5 times the diameter of the normal artery, caused by a weakness in the arterial wall
PATHOPHYSIOLOGY
Usually the result of atherosclerosis; with family history, tobacco use, and hypertension playing important roles
Abdominal aneurysms are four times more common in men than in women
SUBJECTIVE
Generally asymptomatic until they dissect or compress an adjacent structure
With dissection, the patient may describe a severe ripping pain
OBJECTIVE
Pulsatile swelling along the course of an artery
Occurs most commonly in the aorta, although renal, femoral, and popliteal arteries are also common sites
A thrill or bruit may be evident over the aneurysm
Vessels Disorders: Arteriovenous fistula
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
An arteriovenous fistula is a pathologic communication between an artery and a vein
PATHOPHYSIOLOGY
May be congenital or acquired
Damage to vessels caused by catheterization is the most common acquired etiology
If the fistula is large, there may be significant arterial-to-venous shunting of blood
SUBJECTIVE
Patients may present with lower extremity edema, varicose veins, or claudication due to ischemia
If severe, high output cardiac failure can develop
OBJECTIVE
May result in an aneurysmal dilation
A continuous bruit or thrill over the area
of the fistula suggests its presence
Edema or ischemia may develop in the
involved extremity
Vessels Disorders:Peripheral Arterial Disease
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Stenosis of the blood supply to the extremities by atherosclerotic plaques
PATHOPHYSIOLOGY
Most common cause is peripheral atherosclerosis
Diabetes, hypertension, dyslipidemia, and tobacco use are all risk factors
Can also be a result of vascular trauma, radiation therapy, or vasculitis
SUBJECTIVE
Intermittent claudication produces pain, ache, or cramp in the exercised muscle that is receiving an inadequate blood supply
The amount of exercise necessary to cause the discomfort is predictable (e.g., occurring each time the same distance is walked)
OBJECTIVE
Limb appears healthy, but pulses are weak or absent
Progressive stenosis results in severe ischemia, in which the foot or leg is painful at rest, is cold and numb, and has skin changes (e.g., dry and scaling, with poor hair and nail growth)
Edema seldom accompanies this disorder, but ulceration is common in severe disease, and the muscles may atrophy
Vessels Disorders:Raynaud Phenomenon
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
This is the exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure
PATHOPHYSIOLOGY
Primary Raynaud phenomenon occurs most commonly in young, otherwise healthy individuals, most commonly women, with no evidence of underlying cause
Secondary Raynaud phenomenon is associated with an underlying connective tissue disease such as scleroderma or systemic lupus erythematosus
SUBJECTIVE
Involved areas will feel cold and achy, which improves on rewarming
In secondary Raynaud, there can be intense pain and digital ischemia with necrosis at the tips
OBJECTIVE
With primary Raynaud phenomenon, there is a triphasic demarcated skin pallor (white), cyanosis (blue), and reperfusion (red) within the extremities The vasospasm may last from minutes to less than an hour
In secondary Raynaud, ulcers may appear on the tips of the digits and eventually the skin over the digits can appear smooth, shiny, and tight from loss of subcutaneous tissue
Vessels Disorders:Arterial Embolic Disease
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Atrial fibrillation can lead to clot formation within the atrium; if the clot is unstable, emboli may be dispersed throughout the arterial system
PATHOPHYSIOLOGY
Emboli can also be caused by atherosclerotic plaques, infectious material from fungal and bacterial endocarditis, and atrial myxomas
SUBJECTIVE
Pain is the most common symptom
Paresthesias may also develop
OBJECTIVE
Occlusion of small arteries and necrosis of the tissue supplied by that vessel
With endocarditis, you can see splinter hemorrhages in the nail beds
Vessels Disorders:Venous Thrombosis
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Thrombosis can occur suddenly or gradually and with varying severity of symptoms; it can be the result of trauma or prolonged immobilization
PATHOPHYSIOLOGY
Risk factors for venous thrombosis include prolonged immobilization, malignancy, trauma, use of birth control medication, and history of previous thrombosis
SUBJECTIVE
Tenderness along the iliac vessels or the femoral canal, in the popliteal space, or over the deep calf veins
Deep vein thrombosis in the femoral and pelvic circulations may be asymptomatic
Pulmonary embolism may occur without warning
OBJECTIVE
Swelling may be distinguished only by measuring and comparing the circumference of the upper and lower
legs bilaterally
There may be minimal ankle edema; low-grade fever; and tachycardia
Homan sign can be helpful but is not absolutely reliable in suggesting deep vein thrombosis
Vessels Disorders: Hypertension
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Hypertension is one of the most common diseases in the world; it is often responsible for stroke, renal failure, and congestive heart failure
PATHOPHYSIOLOGY
Hypertension continues to be defined as a blood pressure consistently at 140/90 mm hg or higher
For essential hypertension, the pathogenesis remains poorly understood
SUBJECTIVE DATA
Essential hypertension is asymptomatic unless it is malignant, where patients may present with headache, visual symptoms, or encephalopathy
OBJECTIVE DATA
In addition to checking the blood pressure, you should assess for any end-organ damage that may be present
This includes papilledema and evidence of
heart failure
Jugular Venous Pressure Disorders: Tricuspid Regurgitation
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
The backflow of blood into the right atrium during systole; a mild degree of tricuspid regurgitation can be seen in up to 75% of the normal adult population
PATHOPHYSIOLOGY
Most commonly due to conditions that lead to dilation of the right ventricle (e.g., hypertension, pulmonary thrombosis)
Less frequently it can also result from primary valvular disease
SUBJECTIVE
With mild to moderate tricuspid regurgitation, there are typically no symptoms
With severe disease, you may see symptoms of right-sided heart failure such as ascites or peripheral edema
OBJECTIVE
The v wave is much more prominent and occurs earlier, often merging with the c wave (Fig. 15-20; see also Fig. 15-7)
A holosystolic murmur in the tricuspid region, a pulsatile liver, and peripheral edema
Jugular Venous Pressure Disorders: Atrial Fibrillation
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
This arrhythmia, seen more commonly in older adults, may result in decreased cardiac output and atrial thrombus formation
with subsequent embolization
PATHOPHYSIOLOGY
Typically occurs in patients with some underlying heart disease that results in the atrial pathology such as enlargement or elevated pressures
SUBJECTIVE
While many episodes are asymptomatic, patients may describe palpitations, lightheadedness, or dyspnea
OBJECTIVE
The a wave is absent and the pulse is irregularly irregular
There are only two venous pulsations for each arterial pulsation, and the time interval between v waves is variable
Jugular Venous Pressure Disorders: Cardiac Tamponade
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
The accumulation of fluid within the pericardial space leading to compression and dysfunction of the heart chambers
PATHOPHYSIOLOGY
Pericardial fluid can accumulates from a number of etiologies (e.g., infection, malignancy, autoimmune disease)
The pressure within this space increases such that it compresses the heart chambers, decreasing their volume, allowing less filling, and compromising cardiac output
SUBJECTIVE
The history will depend on the rapidity of the pericardial fluid collection; in acute settings, there may
be sudden onset chest pain and dyspnea
If more chronic in development, there may be the insidious development of symptoms of heart failure
OBJECTIVE
The Y-descent is abolished and the JVP is markedly elevated (15 to 25 cm H2O) The JVP fails to fall with inspiration as it usually does and may actually increase (Kussmaul sign) Pulsus paradoxus (decrease in systolic blood pressure greater than 10 mm Hg with inspiration) may be present (see Box 15-5, Fig. 14-23)
Jugular Venous Pressure Disorders: Constrictive Pericarditis
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Results from chronic inflammation and subsequent scarring of the pericardium
PATHOPHYSIOLOGY
Chronic inflammation leads to pericardial thickening and inelasticity
This results in diminished cardiac filling and output
SUBJECTIVE
Symptoms of progressive cardiac insufficiency such as worsening of lower extremity edema or dyspnea
OBJECTIVE
The JVP is elevated, just as with cardiac tamponade, but there is a prominent Y-descent
Signs of severe right heart failure such as ascites and severe peripheral edema (Fig. 15-21) may develop
Jugular Venous Pressure Disorders: Coarctation of the aorta (children)
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Coarctation of the aorta is a stenosis seen most commonly in the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum
SUBJECTIVE
Most patients are asymptomatic unless severe hypertension or vascular insufficiency develops
In those settings, patients may develop symptoms of heart failure or vascular insufficiency of an involved upper extremity with activity
OBJECTIVE
Differences in systolic blood pressure readings when the radial and femoral pulses are palpated simultaneously
Jugular Venous Pressure Disorders: Kawasaki Disease (children)
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
An acute vasculitic illness of uncertain cause affecting young males more often than females; the critical concern is cardiac involvement in which aneurysms of a coronary artery may develop
PATHOPHYSIOLOGY
The etiology of the vasculitis is unknown
Immune-mediated blood vessel damage can result in both vascular stenosis and aneurysm formation
SUBJECTIVE
The symptoms are diffuse and typified by fever lasting a few days to several weeks
The effects of a systemic vasculitic illness, such as weight loss, fatigue, myalgias, as well as arthritis, may develop
OBJECTIVE
Findings may include conjunctival injection, strawberry tongue, and edema of the hands and feet
Lymphadenopathy and polymorphous nonvesicular rashes (Fig. 15-23)
Preeclampsia-Eclampsia
DESCRIPTION
Preeclampsia-eclampsia defines a syndrome specific to pregnancy; it is determined by 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
PATHOPHYSIOLOGY
Theorized to result from a combination of vascular and immunologic abnormalities within the uretoplacental circulation
SUBJECTIVE DATA
May be diagnosed without proteinuria if other systemic symptoms are present (e.g., visual changes, headache, abdominal pain, pulmonary edema
OBJECTIVE
Sustained elevation of the blood pressure (systolic >160 mm Hg, diastolic > 110 mm Hg)
Jugular Venous Pressure Disorders: Venous Ulcers (elderly)
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
This results from chronic venous insuffiency in which lack of venous flow leads to lower extremity venous hypertension
PATHOPHYSIOLOGY
Obstruction of venous flow may
result from incompetent valves,
obstruction of blood flow, or loss of
the pumping effect of the leg muscles
SUBJECTIVE
Frequently asymptomatic in the early stages
Patients may describe a leg heaviness and discomfort progressing to edema and ulceration
OBJECTVIE
Ulcers are generally found on the medial or lateral aspects of the lower limbs
Induration, edema, and hyperpigmentation are common associated findings
