PVS & Lymphatic System

Question 1

Any disease in the vascular system creates problems with what?

Answer 1

delivery of oxygen and nutrients to the tissues

OR

elimination of carbon dioxide and waste products from cellular metabolism.

Question 2

Arteries contain what type of fibers?

Answer 2

• Elastic fibers, which allow their walls to stretch with systole and recoil with diastole.
• Muscle fibers (vascular smooth muscle [VSM]), which control the amount of blood delivered to the tissues. The VSM contracts or dilates, which changes the diameter of the arteries to control the rate of blood flow.

Question 3

arteries that are accessible to examination

Answer 3

• Temporal artery ( is palpated in the front of the ear)
• Carotid artery (is palpated in the groove between the sternomastoid muscle and the trachea)
• Arteries in the arm (brachial artery, ulnar and radial arteries)
• Arteries in the leg ( femoral artery, popliteal artery, dorsalis pedis, & posterior tibial)
  pg. 500 in Jarvis

Question 4

Ischemia

Answer 4

deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel.

Question 5

veins that are accessible to examination

Answer 5

• Jugular veins
• Veins in the arm (each arm has two sets of veins: superficial and deep. The superficial veins are in the subcutaneous tissue and are responsible for most of the venous return)

-Veins in the leg
3 types of veins in the leg:
1. deep veins (femoral and popliteal veins), run alongside the deep arteries and conduct most of the venous return from the legs.
2. superficial veins (great & small saphenous veins)
3. perforators (connecting veins that join the two sets. They also have one-way valves that route blood from the superficial into the deep veins.)

p.501

Question 6

Mechanism to keep to blood flowing in the veins

Answer 6

(1) the contracting skeletal muscles that milk the blood proximally, back toward the heart.
(2) the pressure gradient caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increases
(3) the intraluminal valves, which ensure unidirectional flow

Question 7

lymphatics form a completely separate vessel system, which does what?

Answer 7

retrieves excess fluid from the tissue spaces and return it to the bloodstream.

Question 8

The vessels converge and drain into two main trunks, which empty into the venous system at the subclavian veins.
What are the two main trunks?

Answer 8

1. right lymphatic duct, empties into the right subclavian vein. it drains the right side of the head and neck, right arm, right side of the thorax, right lung and pleura, right side of the heat and right upper section of the liver.
2. thoracic duct, drains the rest of the body. it empties into the left subclavian vein.

Question 9

functions of the lymphatic system

Answer 9

1. to converse fluid and plasma proteins that leak out of the capillaries
2. to form a major part of the immune system that defends the body against disease
3. absorb lipids from the intestinal tract

Question 10

Lymph nodes

Answer 10

• small, oval clumps of lymphatic tissue located at intervals along the vessels.
• nodes filter the fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body.
• with local inflammation, the nodes in that area become swollen and tender

Question 11

The superficial groups of nodes are accessible to inspection and palpation and give clues to the status of the lymphatic system:

Answer 11

• cervical nodes, drain the head and neck
• axillary nodes, drain the breast and upper arm
• epitrochlear nodes, in the antecubital fossa and drains the hand and lower arm
• inguinal nodes, in the groin and drains most of the lymph of the lower extremity, the external genitalia and the anterior abdominal wall.

Question 12

What organs aid to the lymphatic system?

Answer 12

spleen, tonsils, and thymus

Question 13

Spleen

Answer 13

-located in the left upper quadrant of the abdomen.

• has 4 functions,
  1. to destroy old red blood cells
  2. to produce antibodies
  3. to store red blood cells
  4. to filter microorganisms from the blood

Question 14

tonsils

Answer 14

(palatine, pharyneal, and lingual)

located at the entrance to the respiratory and gastrointestinal tracts and respond to local inflammation

Question 15

thymus

Answer 15

• flat, pink-gray gland located in the superior mediasterinum behind the sternum and in front of the aorta.
• relatively large in the fetus and young child and atrophies after puberty

Question 16

the aging adult

Answer 16

• produces a progressive enlargement of the intramuscular calf vein.
• loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to a decrease in the size of remaining nodes.

Question 17

prolonged bedrest, prolonged immobility, and heart failure increase the risk….

Answer 17

for deep venous thrombosis and subsequent pulmonary embolism.

These conditions are common in aging and also with malignancy and MI.

Question 18

what reduces the risk of venous thromboembolism?

Answer 18

low-dose anticoagulant

Question 19

claudication distance

Answer 19

the number of blocks walked or stairs climbed to produce pain.

Question 20

night leg pain is common with aging adults. It may indicate what?

Answer 20

the ischemic rest pain of PVD, severe night muscle cramping (usually the calf), or the restless leg syndrome.

Question 21

Asking the patients if any recent changes in exercise, a new exercise, increasing exercise. what is the rationale?

Answer 21

pain of the musculoskeletal origin rather than vascular.

Question 22

Any changes in temperature on arms or legs– excess warmth or coolness. what is the rationale?

Answer 22

Coolness is associated with arterial disease.

Question 23

Do your leg veins look bulging and crooked? how have you treated these? Do you use support hose?
what is the rationale?

Answer 23

Varicose veins

Question 24

leg ulcers occur with what diseases?

Answer 24

chronic arterial and venous disease

Question 25

Edema in the legs… bilateral means? unilateral means?

Answer 25

bilateral when the cause is generalizes (heart failure)

unilateral when it is the result of a local obstruction or inflammation

Question 26

Enlarged lymph nodes occur with?

Answer 26

infection, malignancies, and immunologic diseases

Question 27

Examination of the arms and legs includes..

What should the room temp be?

Answer 27

peripheral vascular characteristics, the skin, musculoskeletal findings, and neurologic findings.

Room temp should be about 72 F and draftless to prevent vasodilation and vasoconstriction.

Question 28

The normal nail-bed angle is

Answer 28

160 degrees

Question 29

Flattening of angle and clubbing occur with

Answer 29

congential cyanotic heart disease and con pulmonale

Question 30

Capillary refill

Answer 30

index of peripheral perfusion and cardiac output.

with the person’s hands near the level of his or her hearts, depress and blanch the nail bed; release and note the time for color return.

usually, the vessels refill within a fraction of a second. consider it normal if the color returns in less than 1 to 2 seconds.

Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

Question 31

Capillary refill lasting more than 1 or 2 seconds signifies..

Answer 31

vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock) The hands are cold, clammy and pale.

Question 32

Edema of the upper extremities occurs..

Answer 32

when lymphatic drainage is obstructed, which may occur after breast surgery.

Question 33

Are ulnar pulses palpable in the “normal” person?

Answer 33

they are often not palpable. it is usually not necessary to palpate the ulnar pulses.

If you do palpate, reach you hand under the person’s arm and palpate along the medial side of the inner forearm.

Question 34

How would you check the epitrochlear lymph nodes?

Enlarged epitrochlear node means?

Are they normally palpable or not palpable?

Answer 34

Do this by “shaking hands” with the person and reaching you other hand under the persons elbow to the groove between the biceps and triceps muscles, above the medial epicondyle.

Enlarged epitrochlear node occurs with infection or the hand or forearm.

The epitrochlear nodes are NOT palpable normally.

They occur in conditions of generalized lymphadenopathy: lymphoma, chronic lymphocytic leukemia, sarcoidosis, infections, mononucleosis.

Question 35

Modified allen test

Answer 35

used to evaluate the adequacy of colllateral circulation before cannulating the radial artery.

(a) Firmly occulude both the ulnar and radial arteries of one hand while the person makes a fist several times. this causes the hand to blanch.
(b) 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 palmer blush, a return to the hand’s normal color in approx. 2 to 5 seconds.

You must occlude both arteries uniformly with 11 pounds of pressure for the test to be accurate.

Question 36

Abnormal finding in modified allen test

Answer 36

pallor persists or a sluggish return to color suggest occlusion of the collateral arterial flow.

Question 37

If the lower legs looks asymmetric or if DVT is suspected, you should…

If lymphedema is suspected, you should..

Answer 37

measure the calf circumference with a non-stretchable tape measure.
–acute, unilateral, painful sweeling and asymmetry of calves of 1 cm or more is abnomal; refer the person to determine whether DVT is present.

measure also at the ankle, distal calf, knee, and thigh
–asymmetry of 1 to 3 cm occurs with mild lymphedema; 3 to 5 cm with moderate lymphedema; and more then 5 cm with severe lymphedema.

Question 38

When palpating for tempature along the legs down to the feet.. what is normal and abnormal?

Answer 38

• skin should be warm and equal bilaterally
• bilaterally cold feet may be due to enviromental factors such as cool room temperatures, apprehension, and cigarette smoking.

-a unilateral cool foot or leg or a sudden tempature drop as you move down the leg occurs with arterial deficit.

Question 39

When palpating the inguinal lymph nodes…

Answer 39

it is not unusual to find palpable nodes that are small ( 1cm or less) , moveable and nontender.

Question 40

Homan sign

Answer 40

calf pain with flexing the knee and gently compressing the calf is a positive for homan sign.

occurs in about 35% of cases of DVT. it is not specfic for this condition because it occurs also with superficial phlebitis, achilles tendinitis, gastrocniemius and planter muscle injury, and lumbosacral disorders.

Question 41

When palpating the inguinal lymph node,

Answer 41

it is not unusual to find a palpable node that is small ( 1cm or less), movable and nontender.

Question 42

popliteal pulse

Answer 42

is more diffuse pulse and can be difficult to localize.

often a normal popliteal pulse is impossible to palpate.

Question 43

posterior tibial pulse

Answer 43

curve your fingers around the medial malleolus. you will feel tapping right behind it in the groove between the malleolus and the Achilles tendon.

If you cannot, try passive dorsiflexion of the foot to make the pulse more accessible

Question 44

dorsalis pedis pulse

Answer 44

requires a very light touch. normally it is just lateral to and parallel with the extensor tendon of the big toe.

do not mistake the pulse for your own fingertip for that of the person

Question 45

bilateral, dependent pitting edema occurs with?

Answer 45

heart failure, diabetic neuropathy, and hepatic cirrhorsis

Question 46

occasionally either the dorsalis pedis or the posterior tibial pulse may be hard to find, but not on the same foot. who does this occur on?

Answer 46

adults older than 45 years.

Question 47

if pitting edema is present, grade it on the following scale:

Answer 47

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 last a long time, leg is grossly swollen and distorted

Question 48

Manual compression test

Answer 48

while the person is standing, test the length of the varicose vein to determine whether it valves are competent. place one hand on the lower part of the varicose vein, and compress the vein with your other hand about 15 to 20 cm higher. competent valves will prevent wave transmission and your lower fingers will feel no change.

Question 49

motor loss in the legs occurs with..

sensory loss in the legs occurs with..

Answer 49

severe arterial deficit

arterial deficit, especially diabetes

Question 50

Doppler ultrasonic stethoscope

Answer 50

use this device to detect a weak peripheral pulse, to monitor BP in infants or children, or to measure low BP or BP in a lower extremity.

Question 51

the use of _____ is a highly specific, noninvasive, and readily available way to determine the extent of peripheral artery diease.

Answer 51

doppler stethscope

Question 52

a normal ankle-brachial index (ABI) is usually?

Answer 52

1.0 to 1.2

in people with diabetes mellitus, the ABI is less reliable because of the calcification and may give a falsely high ankle pressure.

the pr

Question 53

weak, “thready” pulse, +1

Answer 53

hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure

associated with: decreased cardiac output, peripheral arterial disease, aortic valve stenosis

Question 54

full, bounding pulse, 3+

Answer 54

easily palpable, pounds under your fingertips

associated with: hyperkinetic states (exercise,anxiety, fever), anemia, hyperthroidism

Question 55

water-hammer (corrigan) pulse 3+

Answer 55

greater than normal force, then collapse suddenly.

associated with: aortic valve regurgitation, patent ductus arteriosus

Question 56

pulsus bigeminus

Answer 56

rhythm is coupled, every other beat comes early, or normal beat followed by premature beat. force of premature beat is decreased because of shortened cardiac filling time.

associated with: conduction disturbance (e.g premature ventricular contraction, premature atrial contraction)

Question 57

pulsus alternans

Answer 57

rhythm is regular, but force varies with alternating beats of large and small amplitudes

Associated with: when HR is normal, pulsus alternans occurs with severe left ventricular failure, which in turn is due to ischemic heart disease, valvular heart disease, chronic hypertension, or cardiomyopathy

Question 58

pulsus paradoxus

Answer 58

beats have weaker amplitude with inspiration, stronger with expiration. best determined during BP measurement; reading decreases (>10 mmHg) during inspiration and increases expiration.

associated with: a common finding in cardiac tramponade (pericardial effusion in which high pressure compresses the heart and blocks cardiac output); also in severe bronchospasm of acute asthma.

Question 59

pulsus bisferiens

Answer 59

each pulse has two strong systolic peaks, with a dip in between. best assessed at the carotid artery.

associated with: aortic valve stenosis plus regurgitation

Question 60

Raynaud’s phenomenon

Answer 60

• episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress
  1. white(pallor) in top fingers from arteriospasm and resulting deficit in supply
  2. blue (cyanosis) in lower fingers from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin
  3. red (rubor) in heel of hand due to return of blood into the dilated capillary bed or reactive hyperemia.

Question 61

in Raynaud’s phenomenon, during the cyanosis stage & rubor stage.. what other symptoms will the patient have?

Answer 61

cyanosis stage- cold, numbness, or pain

rubor stage- burning, throbbing pain, and swelling

Question 62

lymphedema

Answer 62

high-protein swelling of the limbs, most commonly due to breast cancer treatment.

is common with breast cancer patient (42%) but usually mild.

objective data include unilateral swelling, nonpitting brawny edema, with overlying skin indurated.

without treatment , lymphedema is chronic and progressive, which is psychologically demoralizing as a threat to body image and constant reminder to cancer.

obje

Question 63

arterial- ischemic ulcers

Answer 63

buildup of fatty plaque or intima (atheroscerosis) plus hardening and calcification of arterial wall (arteriosclerosis).

S: deep muscle pain in calf or foot, claudication (pain with walking), pain at rest indicating worsening of condition

O: coolness, pallor, elavational palllor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition ( thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangrene

usually occur at toes, metatarsal heads, heels, lateral ankle, and are characterized by pale ischemic base, well-defined edges, and no bleeding.

Question 64

Venous (stasis) Ulcer

Answer 64

after a deep vein thrombosis or chronic incompetent valves in deep veins.

S: aching pain in calf or lower leg, worse at end of the day, worse with prolonged standing or sitting

O: firm, brawny edema; coarse, thickned skin; pulses normal; brown pigment discoloration; petechiae; dermatitis. venous stasis causes increased venous pressure ,which then causes RBCs to leak out of veins and into the skin. the RBCs break down and leave hemosiderin (iron deposits) behind, which are the brown pigment deposits. a weepy, pruritic stasis dermatitis may be present.

ulcers occur at medical malleolus and are characterized by bleeding, uneven edges.

Question 65

superficial varicose veins

Answer 65

incompetent valves permit reflux of blood, producing dilated, tortuous veins.

over age 45, occurence is 3xs more common in women then in men

S: aching, heaviness in calf, easy fatigability, night leg or foot cramps.

O: dilated, tortuous veins.

Question 66

deep vein thrombophlebitis (DVT)

Answer 66

a deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema.

Virchow’s triad is the 3 factors that promote thrombogenesis.

causes may be prolonged bedrest; history of varicose veins; trauma; infection; cancer; and in younger women, the use of oral estrogenic contraceptives.

requires emergency referral because risk of pulmonary embolism

upper-extremity DVT is increasingly common due to frequent use of invasive lines such as central venous catheters.

Question 67

DVT
S:
O:

Answer 67

S: sudden onset of intense,sharp,deep muscle pain; may increase with sharp dorsiflexion of foot.

O: increased warmth; swelling (to compare swelling, observe the usual shoe size); redness; dependent cyanosis is mild or may be absent; tender to palpation; homan sign is preset only in a few cases.