PV Flashcards
1
Q
Injury to vascular endothelial cells provokes…
A
thrombus formation, atheromas (fatty layers), and vascular lesions of HTN
2
Q
atheroma, pathogenesis
A
- begins in intima (inner layer of vessels) as lipid-filled foam cells and then becomes fatty streaks.
- Complex atheromas are thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken underlying media
- They have soft lipid core and fibrous cap of smooth muscle cells and collagen-riich matrix
- Plaque rupture may precede thrombosis
3
Q
location of brachial artery
A
bend of elbow just medial to biceps tendon
4
Q
location of radial artery
A
lateral flexor surface of forearm
5
Q
location ulnar artery
A
medial flexor surface of forearm
overlying tissues may obscure ulnar artery
6
Q
location femoral artery
A
just below inguinal ligament, midway between ASIS and symphysis pubis
7
Q
location popliteal artery
A
extension of femoral artery that passes medially behind femur, palpable just behind knee
DIvides into dorsalis pedis and posterior tibial
8
Q
location dorsalis pedis artery
A
dorsum of foot just lateral to extensor tendon of big toe
9
Q
ocation posterior tibial artery
A
behind medial malleolus of ankle.
An interconnecting arch between its two chief arterial branches protects circulation to the foot
10
Q
layers of arteries
A
3 concentric: intima, media, adventitia
11
Q
Where do the veins of the arms, upper trunk, head and neck drain?
A
SVC, which empties into the right atrium
12
Q
where do veins of legs and lower trunk drain?
A
upward into IVC
13
Q
Important characteristic of leg veins
A
weaker wall structure, susceptible to irregular dilation, compression, ulceration, invasion by tumors = warrant special attn
14
Q
intermittent claudication
A
symptomatic limb ischemia w/exertion
Present in atherosclerotic PAD
15
Q
neurogenic claudication
A
pain w/walking or prolonged standing, radiating from spinal area into buttocks, thighs, lower legs, or feet
increases likelihood of spinal stenosis if pain is relieved by sitting or bending forward or if bilateral buttock or leg pain is present
16
Q
PAD symptom location and site of arterial ischemia: buttock, hip
A
aortoiliac
17
Q
PAD symptom location and site of arterial ischemia: erectile dysfunction
A
iliac-pudendal
18
Q
PAD symptom location and site of arterial ischemia: thigh
A
common femoral or aortoiliac
19
Q
PAD symptom location and site of arterial ischemia: upper calf
A
superficial femoral
20
Q
PAD symptom location and site of arterial ischemia: lower calf
A
popliteal
21
Q
PAD symptom location and site of arterial ischemia: foot
A
tibial or peroneal
22
Q
abdominal pain, “food fear”, and weight loss suggest …
A
intestinal ischemia of the celiac or superior or inferior mesenteric arteries
23
Q
ABI
A
ankle divided by brachial BP
- >0.9 = normal
- <0.89 - > 0.60 = mild PAD
- <0.59 to >0.40 = moderate PAD
- <0.39 = severe PAD
24
Q
Key components of Peripheral Arterial Exam
A
- BP in both arms
- Carotids: palpate, auscultate
- Auscultate aortic, renal, femoral
- Palpate aorta & determine diameter
- Palpate brachila, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial arteries
- Inspect ankles & feet for color, temperature, skin integrity; not ulcerations, hair loss, trophic skin changes, hyper trophic nails
25
Prominent veins and edematous arm suggest...
venous obstruction
26
Grading of pulses
* 3+ bounding
* 2+ brisk, expected (normal)
* 1+ diminished, weaker than expected
* 0 absent, unable to palpate
27
warmth and redness over calf signal
cellulitis
28
atherosclerosis most commonly obstructs arterial circulation to...
the thigh. Normal femoral w/diminished to absent popliteal
29
Calf asymmetry, Differential Dx
* DVT
* muscle tear or trauma
* Baker's cyst (posterior knee)
* muscular atrophy
30
Characteristic of venous cause to edema
venous distention - bilateral present in heart failure, cirrhosis, nephrotic syndrome
31
ulcer location: arterial, venous
arterial: often anterior tibiae, dry or brown-black from gangrene
venous: brownish discoloration or ulcers just above malleolus
32
dependent rubor
suggests arterial insufficiency, but not reliable if veins are incompetent
33
Mapping varicose veins
patient standing. placepalpating fingers gently on vein. compress w/bottom hand - feel for wave in upper hand
34
Evaluating competency of venous valves
Retrograde filling (trendelenburg) test
* pt supine.
* elevate one leg to about 90 degrees to empty it of venous blood.
* occlude great saphenous vein in upper thigh by manual compression, using enough pressure to occlude this vein but not deeper vessels.
* Ask pt to stand while you keep vein occluded.
* Watch for refilling of leg. Should refill from below, takes about 35 seconds
* After 20 seconds of standing, release compression and look for sudden additional venous filling - normally there is none - competent saphenous valves should obstruct retrograde flow
* both steps normal? negative-negative
*difficult w/older - may want doppler study instead*
35
lymphedema
soft in early stages, then indurated, nonpitting.
skin markedly thickened, ulceration rare, no pigmentation
d/t lymph channels blocked by tumor, fibrosis, inflammation
36
Allen Test
* Ask pt to make tight fist w/one hand, then compress both radial and ulnar arteries firmly between your thumbs and fingers
* Ask pt to open the hand into a relaxed, slightly flexed position. Palm is pale
* Release pressure over ulnar artery, if patent, palm flushes w/in 3-5 seconds
*important b/c collateral arches must be patent*
37
Cap Refill
* Blanch the beds and release
* Normal capillary refill time is within 3 second
* \>5 seconds indicates arterial vascular insufficiency
38
VTE
venous thromboembolism
an umbrella term classifying PEs (1/3) and DVTs (2/3)
39
Vascular Arches
-connect the radial and ulnar arteries protecting the distal circulation in the hand from arterial occlusion
40
Veins in the Legs
41
Rubor indicative of
arterial disease - ruddy color
42
Great saphenous vein
originates on the dorsum of the foot passing anterior to the medial malleolusèup the medial aspect of the leg joining the femoral vein of the deep venous system below the inguinal ligament
43
Small Saphenous Vein
begins at side of footètravels upward along the posterior calf joining the deep venous system in the popliteal fossa
44
What does the loss of a femoral pulse represent?
adult/gero vs pedi
* adult/gero: is it acute or chronic? may be increase in insufficiency, look for intermittent claudication, trophic changes in skin, postural color changes.
* Pedi: coarctation of the aorta, congenital abnormalities in arterial blood flow, diastolic HTN
45
Coarctation of the Aorta
* congenital narrowing of aorta, causes severe obstruction. Most often picked up in first days, but can be later in life. Branches must be perfused by collateral blood flow
* common in Turner syndrome, some birth defects, may also have VSD
* Clinically: femoral pulse is weak or absent. BP is weaker in legs than arms, possibly w/HTN
46
Arterial vs venous insufficiency
47
warmth over vein may be...
thrombophlebitis
may have read streak, may have low-grade fever...
48
Dependent rubor and cyanosis of the 1st digit are characteristic of
arterial insufficiency
49
5 Ps of arterial occlusion
* Pain
* Pallor
* Poikilothermia (coolness)
* Pulselessness
* Paresthesia
* Paralysis
*Pain often involves the foot
Sudden onset*
50
Raynaud’s Phenomenon
* Episodic spasm of the small arterioles
* Effects one or more fingers/toes
* Numbness and tingling +
* Pain may be present
* Trigger-emotions, exposure to cold
* Color changes to distal fingers, blanching --\> cyanosis --\> redness *(as fills up again)*
* Warm climate *(will move b/c so bad)*; Ca+ blockers *(can help if very bad)*
* Suggest: hands under warm water*
51
pregnancy and thrombosis
hormones, etc., can predispose
52
Venous Stasis vs venous insufficiency
Stasis:
* Pigmentation
* Dermatitis
* Ulceration
* Thrombus formation
* Cellulitis
Insufficiency: obstruction in forward movement - can cause clots, varicose veins. Dusky brown, ulcerations
53
Superficial Thrombophlebitis
-acute episode of clot with local redness, tenderness and swelling with a palpable cord of superficial vein, most often sapehnous; may be febrile
54
Deep Venous Thrombosis
-clot in a deep vein; unilateral; tense muscle; may NOT have pain; aggravated by walking; relieved with elevation; may have swelling of calf and foot; previous hx of DVT-high risk factor
55
Chronic Venous Insufficiency
-chronic venous engorgement secondary to venous occlusion or incompetent venous valves; aching along let; chronic, worsening as day wears on; aggravating by prolonged standing; relieved with elevation; chronic edema, pigmentation, may have ulcers
56
Concerns associated with the PV System
* Arteries, veins, or lymphatics
* Occlusion
* Atherosclerosis
* Aneurysm
* Valvular insufficiency
* Infection
* Malignancy
57
Meds common to those w/PVD
* Insulin
* Antiglycemics
* Diuretics
* Antihypertensives
* Lipid Therapy
* Oral Contraceptive Pills (OCP)/HRT
* Anticoagulation
* NSAIDs
* Complementary/Alternative Therapy
58
The Lymphatic System: components
* Lymph nodes
* Tonsils and adenoids
* Thymus gland
* Spleen
* Intestines known as Peyer’s patches
Lymph tissue
* Bone marrow
* Stomach mucosa
* Appendix
* Lungs
59
Most common cause of chronic arterial occlusive dz of lower extremities
* chronic arterial insufficiency. Caused by arterial narrowing or obstruction, reducing blood flow. Leads to intermittent claudication, usually in calf.
* ABI usually \<0.9
* Treat w/aspirin, w/exercise therapy. More severe - angioplasty, stenting, surgical grafts...
60
Lymphatic movement
Peripherally-lymphatic capillaries --\> centrally, thin vascular channels --\> collecting ducts --\> major neck veins
61
Role of lymph nodes
Aid in maturation of lymphocytes and monocytes, using phagocytosis and filtration
62
varicosities on back of calves/lower legs
if on feet a lot, age
PVD
63
Lymphocytes
* Found in bone marrow, lymph nodes, spleen, tonsils, adenoids
* B-lymphocytes: bone marrow
* T-lymphocytes: thymus
64
Lymph nodes of lower extremities
Heel and outer aspect of the foot drain into the lesser saphenous vein to the deep popliteal space
65
Pitting Edema
* Press firmly x at least 2 seconds
* Check dorsum
* Check medial malleolus
* Shins
* Grade (1-4+pitting)-slight to very marked
* Unilateral or bilateral?
* Measure circumference; note _extension_
* Prominent veins?
* Color/ulcers/thickness?
66
preauricular nodes
Eye, middle ear and parotids
67
postauricular nodes
Both inner & outer ear
68
occipital nodes
scalp, outer ear
69
Tonsillar nodes
Tonsillar and posterior pharyngeal regions. Also includes the mouth, larynx, thyroid, & trachea
70
submandibular nodes
mouth-mucosa, floor of mouth, face, nose, maxillary sinus
71
Submental nodes
Anterior portion of the mouth and lower lip, and teeth
72
Anterior cervical nodes
Internal structures of the throat, posterior pharynx, tonsils. Also the mouth, tongue, thyroid, trachea
73
posterior cervical nodes
Mono/ other viral illness or respiratory infections
74
Infraclavicular nodes
Upper limb
75
Supraclavicular nodes
* (Think malignancy)
* Right: Esophagus, Mediastinum, lungs, GI
* Left: Virchow’s node – Thorax, abdomen, lymphoma, thoracic or retroperitoneal cancer, bacterial/fungal infection
76
axillary nodes
central, subscapular/posterior, anterior/pectoral, brachial/lateral
Infection of the upper extremity, chest wall, breast tissue of affected side, intrathoracic lesions, neck
77
epitrochlear nodes
Malignancy (non-hodgkin's lymphoma), infection of 3, 4,& 5 digits
78
Superior superficial inguinal nodes (horizontal)
rectum, anus, genitals, buttocks, and abd wall below umbilicus.
79
Inferior superficial inguinal
(vertical-drains Leg)
80
visual for documenting pulses
81
What if you can't palpate the dorsalis pedis?
ask them to flex their big toe toward ceiling - shows extensor tendon & you can palpate lateral to extensor tendon
82
characteristics of lymph nodes
soft, nontender, mobile
83
Shotty nodes
spray of lymph nodes in one area - d/t viral illness, etc. Should go away, if not, concerning
84
2 areas w/no lymphatic system
placenta & brain
