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Peripheral Vascular

System and Lymphatic


System

Direction of Blood Flow

Lecture objectives:

Structure and function of vascular system:

Taking clients complaints and history.


Assessment techniques:

Arteries
Veins
Lymphatics

Inspection and palpation of the neck vessels


Inspection and palpation of the arms (radial pulse, lymph nodes)
Inspection and palpation of the legs (edema, Homans sign; femoral,
popliteal, dorsalis pedis pulses, manual compression test
Additional techniques: Trendelenburg test, colour changes, doppler
ultrasonic stethoscope.

Abnormal findings:

Variations in arterial pulse


Raynaulds syndrome
Lymphedema
Arteriosclerosis
Superficial varicose veins
Peripheral artery disease: occlusions, aneurysms

Structure And Function

The vascular system consists of the vessels of


the body.
Vessels are tubes for transporting fluid, such as
the blood or lymph.
Function - transporting the blood or lymph :

Delivery of oxygen to the tissues


Delivery of nutrients to the tissues
Elimination of carbon dioxide from cells
Elimination of waste products from cellular metabolism

Arteries.

Carry freshly oxygenated blood to tissues


High-pressure system
Walls are strong, tough, and tense

with elastic fibers stretch with systole, recoil with diastole


with muscle fibers (VSM) control the amount of blood
delivered to the tissues and the rate of blood flow

Pulse is a pressure wave created by each heartbeat,


palpable at body sites where the artery lies close to the
skin and over a bone.

Arteries accessible to examination

Temporal artery (review chapter 13)


Carotid artery
Arteries in the arm:

Brachial
Radial
Ulnar

Arteries in the leg:

Femoral artery
Popliteal
Anterior tibial dorsalis pedis
Posterior tibial plantar arteries

Ischemia is a
deficient supply of
oxygenated arterial
blood to a body part,
due to constriction or
obstruction of a blood
vessel

Arteries accessible to examination

Arteries
accessible to
examination

Veins accessible to examination

Jugular veins
Veins in the arm:

Superficial in the subQ tissue, responsible for most of the


venous return
Deep

Veins in the leg:

Deep veins: femoral, popliteal; responsible for most of the


venous return
Superficial: great and small saphenous
Perforators: connecting veins that join the two sets. They
have one-way valves blood into the deep veins.

Veins accessible
to examination

Lymphatics.

A completely separate vascular system.


It retrieves excess fluid from the tissue spaces and
returns it to the blood stream.

Lymphatic
ducts and
drainage
patterns

Functions of the lymphatic system:

To converse fluid and plasma proteins that leak


out of the capillaries.
To form the major part of the immune system
that defends body against infection.
To absorb lipids from the intestinal tract.

Structure of the lymphatic system


Microscopic open-ended tubes (capillaries)
Vessels, like veins, have valves

Lymphatic ducts
Subclavian veins

Lymphoid tissue:

Lymph nodes:

Tonsils:

Filter the fluid before it comes back to the bloodstream


Filter out microorganisms
Pharyngeal (adenoid)
Palatine
Lingual

Spleen
Peyers patches (Lymphoid tissue in intestines)
Tymus gland
Bone marrow

Groups of peripheral lymph nodes:


1.

2.
3.
4.
5.
6.
7.
8.
9.

Auricular: anterior and posterior


Sublingual.
Submandibular.
Cervical: anterior and posterior.
Supra- and subclavian.
Axillary.
Epithrochlear.
Inguinal.
Popliteal.

Assesment:
Inspection and palpation

Amount in each group


Size
Shape
Consistency
Movable/connected with
surrounding tissues
Pain/tenderness
Signs of inflammation:
swelling and redness
above the node

Claudication distance is the number


of blocks walked or stairs climbed
to produce pain.
Note sudden dencrease in
claudication distance, or pain
suddenly not relieved by rest.

Taking clients complaints and history.

Ask: Any leg pain (cramps)? Where?


Detail: pain type, onset (gradual/sudden), aggravating/
relieving factors (activity, walking, dangling, rubbing),
associated signs (skin changes, sexual malfunction),
relation to time of day, claudication distance.

Edema is bilateral when


caused by a systemic
problem (heart failure),
or unilateral when due to
a local obstruction or
inflammation.

Taking clients complaints and history.

Objective data
Preparation:
Environment

Privacy

Should be warm (about 22C) and draftless


to prevent vasodilatation or
vasoconstriction.
Make sure the females breasts and clients
genitals remain draped.

Order of exam

Begin with observations peripherally and


move toward the heart.
1.
2.
3.
4.

Pulse and blood pressure


Extremities peripheral vascular
assessment
Neck vessels
Precordium (portion of body over heart
and thorax)

Equipment needed:

Tourniquet or blood
pressure cuff
Stethoscope
Paper tape measure
Doppler ultrasonic
stethoscope

Assessing Neck Vessels

Carotid Artery

Palpate the carotid artery

Avoid excessive pressure.


Excessive vagal stimulation
could slow down heart rate.
Carotid arteries should be
same bilaterally

Auscultation

Listen for bruits blowing,


swishing sounds indicating
blood flow turbulence.
Caused by atherosclerotic
narrowing (one half or two
thirds of artery).

Assessing Neck Vessels

Jugular Veins

Can be used to assess central venous pressure (CVP) and cardiac


efficiency

Position the patient at 30-45 degree angle, wherever pulsations can


be seen best. Remove pillow to avoid flexion of head.

Distended external jugular veins signify increased CVP, as with heart failure

The higher the CVP, the higher the position you will need

Turn the pts head away from examiners side


Distinguish from carotid artery pulsations. Internal jugular pulse
is lower, varies with respiration, not palpable, and disappears as
person is sitting.

Assessing Neck Vessels

Jugular Venous Pressure Estimate

Used to assess heart failure


Position the patient at 30-45 degree angle. Place one ruler vertically
at the manubriosternal angle. Place a second ruler perpendicular to
the first and record the height of pulsation of the internal jugular
vein.
Normal pulsation is 2 cm or less above sternal angle

Pulsations 3 or more cm above sternal angle while at 45 degrees occur with


heart failure

Record height of pulsations and degrees of elevation

Question

The examiner has estimated the jugular venous


pressure. Identify the finding that is abnormal.
1.
2.
3.
4.

Patient elevated to 30 degrees, internal jugular vein


pulsation at 1 cm above sternal angle.
Patient elevated to 30 degrees, internal jugular vein
pulsation at 2 cm above sternal angle
Patient elevated to 40 degrees, internal jugular vein
pulsation at 1 cm above sternal angle
Patient elevated to 45 degrees, internal jugular vein
pulsation at 4 cm above sternal angle

Inspection and palpation of the arms

Inspect for:
Color of skin and nailbeds
Temperature, texture and turgor of skin
Any lesions, edema
Nail clubbing.
160 degrees
What is normal nail bed angle?
Use profile sign to detect early clubbing
Capillary refill is an index of peripheral perfusion
and cardiac output.

Depress and blench the nail beds; release and note the
time for color return. Normally 1 to 2 seconds.

Inspection and palpation of the arms

Palpate both radial pulses:


Symmetricity (equal force), rhythm, rate, elasticity.
Grade the force (amplitude) on a fore-point grade:

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

For ulnar pulse palpate along the medial site of


the inner forearm. Not palpable in healthy
person.

Inspection and palpation of the arms

Palpate the brachial pulses.


Palpate the epitrochlear lymph node
Modified Allen test: Normal 2 to 5 seconds

Inspection and palpation of the legs

Inspect for:
Color of skin and nailbeds
Temperature, texture and
turgor of skin
Any lesions, edema
Capillary refill
Hair distribution
Size (swelling or atrophy)

Inspection and palpation of the legs

Palpate the inguinal lymph nodes


Palpate these peripheral arteries in both legs:
femoral
popliteal
dorsalis pedis
posterior tibial

Grade the force on a fore-point grade

Inspection and palpation of the legs

Check for pretibial edema


Is pitting edema is present, grade it:
1+ Mild pitting, slide indentation, no perceptible
swelling on 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

Inspection and palpation of the legs

Assess venous system. Note


any visible, dilated, and
tortuous veins
Perform Manual
compression test
Perform Trendelenburg test