Jarvis: Ch 20 Peripheral Vascular and Lymphatic System

Raynaud's phenomenon has associated progressive tricolor changes of the skin from ____ to ___ then to ___. State the mechanism for each of these color changes.

White --->Blue --> Red (1) white (pallor) in top figure from arteriospasm and resulting deficit in supply; (2) blue (cyanosis) in lower figure from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin; (3) finally, red (rubor) in heel of hand due to return of blood into the dilated capillary bed or reactive hyperemia. May have cold, numbness, or pain along with pallor or cyanosis stage; then burning, throbbing pain, swelling along with rubor. Lasts minutes to hours; occurs bilaterally. Several drugs predispose to the episodes, and smoking can increase the symptoms.

List the symptom areas to address during history-taking relating to the peripheral vascular system.

- Leg pain or cramps - Skin changes on arms or legs - Swelling in the arms or legs - Lymph node enlargement - Medication

Name the related organs in the lymphatic system.

- Spleen; (1) to destroy old red blood cells (2) to produce antibodies (3) to store red blood cells (4) to filter micro-organisms from the blood - Tonsils; respond to local inflammation - Thymus; important in developing the T lymphocytes if the immune in children

List the skin characteristics expected with arterial insufficiency to the lower legs.

-A difference in the temperature of the feet -Marked pallor

Describe the structure and function of arteries and veins

-Arteries contain elastic fibres which allow the walls to stretch with systole and recoil with diastole. Muscle fibres control the amount of blood delivered to the tissues. Carry oxygenated blood from the heart to the peripheries. Arterial walls stretch during systole and recoil during diastole resulting in a palpable pulse. -Veins drain deoxygenated blood and its waste products from tissues and return it to the heart. Low pressure

Describe the technique for using the Doppler ultrasound to detect peripheral pulses

-Position person supine, with legs externally rotated so you can reach the medial ankles easily -Place a drop of coupling gel on the end of the handheld transducer -Place the transducer over a pulse site, swivelled at a 45o angle. -Apply very light pressure, locate the pulse site by the swishing, whooshing sound

Name the related organs in the lymphatic system

-spleen -tonsils -thymus

Grading system for arterial pulse:

0 indicating no palpable pulse 1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more diminished pulse than normal; 3 + is a normal pulse; and 4 + indicating a bounding pulse.

Describe the 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 intestinal tract Without lymphatic drainage, fluid would build up in the interstitial spaces and produce oedema

Describe 3 mechanism that help return venous blood to the heart

1. Contracting skeletal muscles that milk the blood proximally, back towards the heart 2. Pressure gradient caused by breathing 3. one-way (intraluminal valves) ensure unidirectional flow

Describe three mechanisms that help return venous blood to the heart

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 increase 3. The intraluminal valves, which ensure unidirectional flow

The examiner wishes to asses for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and than having the person sit up and dangle the leg, the colour should return in:

10 seconds or less

LIST THE SYMPTOM AREAS YOU WOULD ADDRESS DURING HISTORY TAKING OF THE PERIPHERAL VASCULAR SYSTEM

AREAS-- ARMS, LEGS,EPITROCHLEAR NODE CHECK-- TEMP,SWELLING, SIZE OF EXTRIMITIES, LESIONS CHECK PULSES-- RADIAL, BRACHIAL, POPLITEAL,FEMORAL, POST TIBIAL, DORSALIS PEDIA CHECK INGUINAL AND EPITROCHLEAR NODES

COMPARE THE CHARACTERISTICS OF LEG ULCERS ASSOCIATED WITH ARTERIAL INSUFFUCIENCY TO ULCERS WITH VENOUS INSUFFICIENCY.

ARTERIAL INSUFFICIENCY-- COLD NUMBNESS TINGLING INTERMITTENT CLAUDICATION CRAMPS VENOUS INSUFFICIENCY-- ACHING, TIREDNESS, FEELING OF FULLNESS

Compare the characteristics of leg ulcers with arterial insufficiency to ulcers with venous insufficiency.

Arterial deficit, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli

List the risk factors for venous stasis

Elderly Diabetes Obesity Peripheral vascular disease Pregnancy Prolonged standing Inactive lifestyle Smoking Varicose veins Tight clothing

List the risk factors for venous stasis.

Elderly, diabetes, obesity, peripheral vascular disease, pregnancy, smoking, varicose veins, inactivity

Describe the function of the lymph nodes

Filter fluid before it is returned to the bloodstream and filter out pathogens

Grading scale for pitting odema:

Grading edema 1+: slight pitting/2 mm, disappears rapidly, 2+: somwehat deeper pit/4 mm, disappears in 10-15 sec 3+: deep pit/6 mm, may last > 1 minute; dep extremity swollen 4+: very deep pit/8 mm, lasts 2-5 min, dep extremity grossly distorted

A pulse with an amplitude of 3+ would be considered:

Increased

List the skin characteristics expected with arterial insufficiency to the lower legs.

Malnutrition, pallor and coolness occur with arterial insufficiency. Malnutrition: thin, shiny atrophic skin, thick-ridged nails, loss of hair, ulcers, gangrene

List the steps in performing the modified Allen test.

Modified Allen test is used to evaluate the adequacy of collateral circulation prior to cannulating the radial artery; (a) 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 (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 return to the hands normal colour in approximately 2-5 seconds. You must occlude the both arteries uniformly with 5kg (11lb) of pressure for the test to be accurate.

Describe the function of the lymph nodes.

Nodes filter the fluid before it is returned to the bloodstream and filter out the micro-organisms that could be harmful to the body.

Ulcer

Open skin lesion extending into dermis with sloughing of necrotic inflammatory tissue

Describe the function of the lymphatic system.

Retrieves excess fluid from the tissue spaces and returns it to the bloodstream. During circulation of the blood, somewhat more fluid leaves the capillaries than the veins can absorb. Without lymphatic drainage, fluid would build up in the interstitial spaces and produce edema.

List the pulse sites accessible to examination.

Temporal artery, carotid artery, brachial artery, femoral artery, popliteal artery, dorsalis pedis, posterior tibial

Describe the structure and function of arteries and veins.

The heart pumps freshly oxygenated blood through the arteries to all body tissues. Artery walls are strong, tough, and tense to withstand pressure demands; contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole. Veins are parallel that of arteries, but the body has more veins, and lie closer to the skin. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart. Arteries are more muscular than veins; veins are often closer to the skin and contain valves to help keep blood flowing toward the heart, while arteries carry blood away from the heart.

Ms T has come for a prenatal visit. She complains of dependent edema, varicosities in the legs, and haemorrhoids. The best response is:

The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy

Describe the procedure for doing the modified Allen's Test.

To perform this test, the clinician instructs the patient to make a tight fist. Then compress both the radial and ulnar arteries. Now instruct the patient to open and relax his fist, revealing a blanched palm and fingers. Then release the pressure over the ulnar artery while observing the patient's palm for changes in color. If collateral flow is adequate, the patient's hand will "pink up" within 10 to 15 seconds; this constitutes a positive Allen's test. A positive result documents that collateral blood flow is adequate and that the radial artery is an acceptable puncture site. If the test is negative (the palm does not pink up rapidly), the radial artery is not an acceptable site for puncture. In such cases, the other wrist is evaluated or the brachial artery is used for the puncture site.

Define the term capacitance vessels and explain its significance.

Veins have a larger diameter and are more distensible; they can expand and hold more blood when blood volume increases. This is a compensatory mechanism to reduce stress on the heart; this ability to stretch, veins are called capacitance vessels.

Pulsus Paradoxus

beats have weaker amplitue with respiratory inspiration, stronger with expirtion

Bruit

blowing swooshing sound heard through a stethoscope when an arter is partially occluded

Homans Sign

calf pain that occurs when the foot is sharply dorisflexed (pushed up toward the knee); may occur with deep vein thrombosis, phlebitis, Achilles tendinitis, or muscle injury

Aneurysm

defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect

Ischemia

deficiency of arterial blood to a body part due to constiction or obstruction of a blood vessel

Allen Test

determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery

Varicose Vein

dilated tortuous veins with incompetent valves

A 54 year old woman with five children has varicose veins of the lower extremities. Her most characteristic sign is:

dilated, tortuous superficial bluish vessels

Cyanosis

dusky blue mottling of the skin and mucous membranese due to excessive amount of reduced hemoglobin in the blood

Inspection of a person's right hand reveals a red, swollen are. To further assess for infection, you would palpate the

epitrochlear node

Pitting Edema

indentation left after examiner depresses the skin over swollen edematous tissue

Thrombophlebitis

inflammation of the vein associated with thrombus formation

Pulsus Bigeminus

irregular rhythm, every other beat is premature; premature beats have weakened amplitude

In order to screen for deep vein thrombosis, you would

measure the widest point with a tape measure

Intermittent claudication is:

muscular pain brought on by exercise

Brawny edema is:

nonpitting

A known risk factor for venous ulcer development is:

obesity

Atherosclerosis

plaques of fatty deposits formed in the inner layer (intima) of the arteries

Pulse

pressure wave created by each heartbeat, palpable at body sites where the artery lies close to the skin and over a bone

During the examination of the lower extremities, you are unable to palpate the popliteal pulse, you should:

proceed with the examination. It is often impossible to palpate this pulse

Tachycardia

rapid heart rate, >90 beats per minute in the adult

Pulsus Alernans

regular rhythm, but force of pulse varies with alternating beats of large and small amplitude

Bradycardia

slow heart rate, <50 beats per minute in the adult

Lymph Nodes

small oval clumps of lymphatic tissue located at grouped intervals along lymphatic vessels

The organs that aid the lymphatic system are:

spleen, tonsils, thymus

Lymphedema

swelling of exterminty due to obstructed lymph channel, nonpitting

Describe the term capacitance vessels and explain its significance

the distensibility of blood vessels located within the body; it is inversely related to elasticity. Reduce stress on the heart. They can expand and hold more blood when blood volume increases.

Diastole

the hearts filling phase

Systole

the hearts pumping phase

Arteriosclerosis

thickening and loss of elasticity of the arterial walls

Atrophic skin changes that occur with peripheral arterial insufficiency include:

thin, shiny skin with loss of hair

A function of the venous system is:

to hold more blood when blood volume increase

Arrhythmia

variation from the hearts normal rhythem

While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The best description of they type of edema is:

very deep pitting, indentation lasts a long time

Profile Sign

viewing the finger from the side to detect early clubbing

Fill in the grading scale for assessing the force of an arterial pulse:

• 0 = absent • 1+ , weak • 2+, normal • 3+, increased, • 4+ full, bounding

Fill in the description of the grading scale for pitting edema:

• 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 lasts a long time, leg is very swollen

List the pulse sites accessible to examination

-Temporal (in front of ear) -Carotid (neck) -Brachial (elbow) -Ulnar (wrist) -Radial (wrist) -Femoral (thigh) -Popliteal (behind knee) -Dorsalis pedis (top of foot) -posterior tibial (ankle)