Peripheral Vascular System and Lymphatic System Chapter 20

Peripheral Vascular System and Lymphatic System Chapter 20 Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Chapter 20: Peripheral Vascular System and Lymphatic System Vascular System and Lymphatics Vascular system consists of vessels of body Vessels are tubes for transporting fluid, such as blood or lymph Ø Any disease in vascular system creates problems with delivery of oxygen and nutrients to tissues or elimination of waste products from cellular metabolism Ø The lymphatics form completely separate vessel system, which retrieves excess fluid from tissue spaces and returns it to the bloodstream Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -2

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function Arteries Ø Heart pumps freshly oxygenated blood through arteries to all body tissues • Pumping heart makes this a high-pressure system • 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 • Contain muscle fibers (vascular smooth muscle, or VSM), which control amount of blood delivered to tissues • VSM contracts or dilates, which changes the diameter of arteries to control the rate of blood flow Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -3

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Arteries (cont. ) Ø Each heartbeat creates a pressure wave, which makes arteries expand then recoil • It is recoil that propels blood through like a wave • All arteries have this pressure wave, or pulse, throughout their length, but it can only be felt at body sites where artery lies close to skin and over a bone • Arteries described in following sections are accessible to examination: Temporal artery: palpated in front of ear (chapter 13) Carotid artery: palpated in groove between sternomastoid muscle and trachea (chapter 19) Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -4

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Arteries (cont. ) Ø Arteries in the arm • Major artery supplying arm is brachial artery, which runs • • in biceps-triceps furrow of upper arm and surfaces at antecubital fossa in elbow medial to biceps tendon Immediately below elbow, brachial artery bifurcates into ulnar and radial arteries These run distally and form two arches supplying hand; these are called superficial and deep palmar arches Radial pulse lies just medial to radius at wrist Ulnar artery is in same relation to the ulna, but it is deeper and often difficult to feel Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -5

Chapter 20: Peripheral Vascular System and Lymphatic System Arteries in the Arm Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -6

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Arteries (cont. ) Ø Arteries in the leg • Major artery to leg is femoral artery, which passes under • • • inguinal ligament Femoral artery travels down thigh; at lower thigh, it courses posteriorly, then is termed popliteal artery Below knee, popliteal artery divides; anterior tibial artery travels down front of leg on to dorsum of foot, where it becomes dorsalis pedis In back of leg, posterior tibial artery travels down behind medial malleolus and in foot forms plantar arteries Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -7

Chapter 20: Peripheral Vascular System and Lymphatic System Vessels in the Leg Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -8

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Arteries (cont. ) Ø Function of arteries is to supply oxygen and essential nutrients to tissues • Ischemia is deficient supply of oxygenated arterial blood to tissue caused by obstruction of blood vessel • Complete blockage leads to death of distal tissue • Partial blockage creates an insufficient supply, and ischemia may be apparent only at exercise when oxygen needs increase Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -9

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Veins Ø Course of veins parallels that of arteries • Body has more veins, and they lie closer to skin surface • The following veins are accessible to examination: Jugular veins: assessment of the jugular veins presented in chapter 19 Veins in arm: each arm has two sets of veins: superficial and deep The superficial veins are in subcutaneous tissue and are responsible for most of venous return Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -10

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Veins (cont. ) Ø Veins in leg • Legs have three types of veins • Deep veins run alongside deep arteries and conduct most of venous return from the legs These are femoral and popliteal veins; as long as these veins remain intact, superficial veins can be excised without harming circulation Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -11

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Veins (cont. ) Ø Veins in leg (cont. ) • Superficial veins are great and small saphenous vein Great saphenous vein, inside leg, starts at medial side of dorsum of the foot; it can be seen as it ascends in front of medial malleolus; then it crosses tibia obliquely and ascends along medial side of thigh Small saphenous vein, outside leg, starts on lateral side of dorsum of foot, ascends behind lateral malleolus, up back of leg, where it joins popliteal vein • Perforators are connecting veins that join two sets They also have one-way valves that route blood from superficial into deep veins Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -12

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Venous flow Ø Veins drain deoxygenated blood and its waste products from tissues and return it to heart • Unlike arteries, veins are a low-pressure system • Venous flow mechanism keeps blood moving Contracting skeletal muscles that milk blood proximally, back toward heart Pressure gradient caused by breathing, in which inspiration makes thoracic pressure decrease and abdominal pressure increase Intraluminal valves ensure unidirectional flow; each valve is a paired semilunar pocket that opens toward heart and closes tightly when filled to prevent back flow of blood Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -13

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Venous flow (cont. ) Ø In the legs, this mechanism is called “calf pump, ” or “peripheral heart” • While walking, calf muscles alternately contract (systole) • • and relax (diastole) In contraction phase, gastrocnemius and soleus muscles squeeze veins and direct blood flow proximally Because of valves, venous blood flows just one way, toward heart Venous structure differs from arterial structure Because venous pressure is lower, walls of veins are thinner than those of arteries Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -14

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Venous flow (cont. ) Ø Veins have a larger diameter and are more distensible than arteries • Can expand hold more blood when blood volume increases, which is a compensatory mechanism to reduce stress on heart • Because of this ability to stretch, veins are called capacitance vessels • Efficient venous return is dependent on contracting skeletal muscles, competent valves in veins, and a patent lumen Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -15

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Venous flow (cont. ) Ø Problems with any of these three elements lead to venous stasis • Hypercoagulable states and vein wall trauma are factors that increase risk for venous disease • Dilated and tortuous (varicose) veins create incompetent valves, wherein the lumen is so wide, valve cusps cannot approximate This condition increases venous pressure, which further dilates vein • Some people have a genetic predisposition to varicose veins, but obesity and pregnancy are increased risk factors Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -16

Chapter 20: Peripheral Vascular System and Lymphatic System Venous Flow Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -17

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics Ø The lymphatics form a completely separate vessel system, which retrieves excess fluid from the tissue spaces and returns it to the bloodstream • During circulation of the blood, somewhat more fluid leaves capillaries than veins can absorb • Without lymphatic drainage, fluid would build up in interstitial spaces and produce edema Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -18

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Vessels drain into two main trunks, which empty into the venous system at the subclavian veins • Right lymphatic duct empties into right subclavian vein • It drains right side of head and neck, right arm, right side of thorax, right lung and pleura, right side of heart, and right upper section of liver • Thoracic duct drains rest of the body; it empties into left subclavian vein Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -19

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø The functions of lymphatic system are to: • Conserve fluid and plasma proteins that leak out of capillaries • Form a major part of immune system that defends body against disease • Absorb lipids from intestinal tract Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -20

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Processes of immune system are complicated and not fully understood • Immune system detects and eliminates foreign pathogens, both those that come in from environment and those arising from inside (abnormal or mutant cells) • It accomplishes this by phagocytosis (digestion) of substances by neutrophils and monocytes/macrophages and by production of specific antibodies or specific immune responses by the lymphocytes Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -21

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Lymphatic vessels have a unique structure • Lymphatic capillaries start as microscopic open-ended • • • tubes, which siphon interstitial fluid Capillaries converge to form vessels; vessels, like veins, drain into larger ones, have valves, and so flow one way from tissue spaces into bloodstream Many valves make vessels look beaded; flow of lymph is slow compared with that of blood Lymph flow is propelled by contracting skeletal muscles, by pressure changes secondary to breathing, and by contraction of vessel walls themselves Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -22

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Lymph nodes are small oval clumps of lymphatic tissue located at intervals along vessels • Most nodes are arranged in groups, both deep and superficial, in body • Nodes filter fluid before it is returned to bloodstream and filter out microorganisms that could be harmful to body • Pathogens are exposed to lymphocytes in lymph nodes • Lymphocytes mount an antigen-specific response to eliminate pathogens; with local inflammation, nodes in that area become swollen and tender Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -23

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Superficial groups of nodes are accessible to inspection and palpation giving clues to status of lymphatic system • Cervical nodes drain the head and neck and are • • • described in chapter 13 Axillary nodes drain the breast and upper arm and are described in chapter 17 Epitrochlear node is in antecubital fossa and drains hand lower arm Inguinal nodes in groin drain most of lymph of lower extremity, external genitalia, and anterior abdominal wall Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -24

Chapter 20: Peripheral Vascular System and Lymphatic System Lymphatic Ducts and Drainage Patterns Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -25

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Related organs • Spleen, tonsils, and thymus aid lymphatic system • Located in left upper quadrant of abdomen, it has four functions: Destroy old red blood cells Produce antibodies Store red blood cells Filter microorganisms from blood Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -26

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function (cont. ) Lymphatics (cont. ) Ø Related organs (cont. ) • Tonsils (palatine, adenoid, and lingual) are located at entrance to respiratory and gastrointestinal tracts and respond to local inflammation • Thymus is flat, pink-gray gland located in superior mediastinum behind sternum and in front of aorta Relatively large in fetus and young child and atrophies after puberty Important in developing T lymphocytes of immune system in children, but it serves no function in adults T and B lymphocytes originate in bone marrow and mature in lymphoid tissue Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -27

Chapter 20: Peripheral Vascular System and Lymphatic System Immune-Related Organs Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -28

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function: Developmental Competence Infants and children Ø Lymphatic system has the same function in children as in adults • Lymphoid tissue has a unique growth pattern compared with other body systems • It is well developed at birth and grows rapidly until age 10 or 11 • By age 6, lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies • It is possible that excessive antigen stimulation in children causes early rapid growth Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -29

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function: Developmental Competence (cont. ) Infants and children (cont. ) Ø Lymph nodes are relatively large in children • Superficial nodes often palpable even when child is • • • healthy With infection, excessive swelling and hyperplasia occur Enlarged tonsils are familiar signs in respiratory infections Excessive lymphoid response also may account for common childhood symptom of abdominal pain with seemingly unrelated problems such as upper respiratory infections Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -30

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function: Developmental Competence (cont. ) Pregnant woman Ø Hormonal changes cause vasodilatation and a resulting drop in blood pressure • Growing uterus obstructs drainage of iliac veins and inferior vena cava • This condition causes low blood flow and increases venous pressure • This, in turn, causes dependent edema, varicosities in legs and vulva, and hemorrhoids Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -31

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function: Developmental Competence (cont. ) Aging adult Ø Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis • Produces rise in systolic blood pressure • Do not confuse this process with another one, atherosclerosis, or deposition of fatty plaques on intima of arteries • Aging produces a progressive enlargement of the intramuscular calf veins • Prolonged bed rest, prolonged sitting, and heart failure increase risk of deep venous thrombosis and subsequent pulmonary embolism Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -32

Chapter 20: Peripheral Vascular System and Lymphatic System Structure and Function: Developmental Competence (cont. ) Aging adult (cont. ) Care for myocardial infarction (MI) now includes early mobilization and low-dose anticoagulant medication, which reduce risk of pulmonary embolism Ø Loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to decrease in size of remaining nodes Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -33

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data Leg pain or cramps Skin changes on arms or legs Swelling Lymph node enlargement Medications Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -34

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data (cont. ) Leg pain or cramps Any leg pain (cramps)? Where? Ø Describe the type of pain; is it burning, aching, cramping, stabbing? Did this come on gradually or suddenly? Ø Is it aggravated by activity or walking? Ø How many blocks (stairs) does it take to produce this pain? Ø Has this amount changed recently? Ø Is pain worse with elevation or cool temperature? Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -35

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data (cont. ) Leg pain or cramps (cont. ) Does pain wake you up at night? Ø Have you had any recent change in exercise? Ø What relieves this pain: dangling, walking, rubbing? Is leg pain associated with any skin changes? Ø Is the leg pain associated with any change in sexual function (males)? Ø Do you have any history of vascular problems, heart problems, diabetes, obesity, pregnancy, smoking, trauma, prolonged standing, or bed rest? Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -36

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data (cont. ) Skin changes on arms or legs Any skin changes in arms or legs? What color: redness, pallor, blueness, brown discolorations? Ø Any change in temperature: excess warmth or coolness? Ø Do your leg veins look bulging and crooked? How have you treated these? Do you use support hose? Ø Any leg sores or ulcers? Where on leg? Any pain with leg ulcer? Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -37

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data (cont. ) Swelling in arms or legs Swelling in one or both legs? When did this start? Ø What time of day is swelling at its worst: morning, or after up most of day? Ø Does swelling come and go, or is it constant? Ø What seems to bring it on: trauma, standing all day, sitting? Ø What relieves swelling: elevation, support hose? Ø Is swelling associated with pain, heat, redness, ulceration, or hardened skin? Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -38

Chapter 20: Peripheral Vascular System and Lymphatic System Subjective Data (cont. ) Lymph node enlargement Ø Any “swollen glands” (lumps, kernels)? Where in body? How long have you had them? • Any recent change? • How do they feel to you: hard, soft? • Are swollen glands associated with pain, or local infection? Medications Ø What medications are you taking, e. g. , oral contraceptives, hormone replacement? Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -39

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Preparation Ø During a complete physical examination, examine arms at very beginning when you are checking vital signs and person is sitting • Examine legs directly after abdominal examination while • • person is still supine; then stand person up to evaluate leg veins Examination of arms and legs includes peripheral vascular characteristics Room temperature should be about 22° C (72° F) and free of drafts to prevent vasodilatation or vasoconstriction Use inspection and palpation Compare your findings with opposite extremity Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -40

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Equipment needed Ø Occasionally need: • Paper tape measure • Tourniquet or blood pressure cuff • Stethoscope • Doppler ultrasonic stethoscope Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -41

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the arms Ø Lift both person’s hands in your hands • Inspect, then turn person’s hands over, noting color of skin and nailbeds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing • Use profile sign (viewing finger from side) to detect early clubbing • Normal nail bed angle is 160 degrees Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -42

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the arms (cont. ) Ø With person’s hands near level of their heart, check capillary refill • An index of peripheral perfusion and cardiac output • Depress and blanch nail beds; release and note time for • • color return Usually, vessels refill within a fraction of a second Normal if color returns in less than 1 or 2 seconds Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia The two arms should be symmetric in size Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -43

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the arms (cont. ) Ø Note presence of any scars on hands and arms • Many occur normally with usual childhood abrasions or with occupations involving hand tools • Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force • Grade force (amplitude) on a three-point scale: 3+, increased, full, bounding 2+, normal 1+, weak 0, absent Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -44

Chapter 20: Peripheral Vascular System and Lymphatic System Radial Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -45

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the arms (cont. ) Ø It usually is not necessary to palpate ulnar pulses • If indicated, palpate along medial side of inner forearm, although ulnar pulses often are not palpable in normal person • Palpate the brachial pulses: their force should be equal bilaterally • Check epitrochlear lymph node in depression above and behind medial condyle of humerus Do this by “shaking hands” with person and reaching your other hand under person’s elbow to groove between biceps and triceps muscles, above medial epicondyle This node is not palpable normally Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -46

Chapter 20: Peripheral Vascular System and Lymphatic System Ulnar Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -47

Chapter 20: Peripheral Vascular System and Lymphatic System Brachial Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -48

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the arms (cont. ) Ø Modified Allen test used to evaluate collateral circulation prior to cannulating radial artery • Firmly occlude both ulnar and radial arteries of one hand while person makes a fist several times; this causes hand to blanch • Ask person to open hand without hyperextending it; then release pressure on ulnar artery while maintaining pressure on radial artery • Adequate circulation is suggested by a return to hand’s normal color in approximately 2 to 5 seconds • Although test is simple and useful, it is relatively crude and subject to error Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -49

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs Ø Uncover the legs while keeping genitalia draped • Inspect both legs together, noting skin color, hair • • • distribution, venous pattern, size (swelling or atrophy), and any skin lesions or ulcers Normally hair covers legs; even if leg hair is shaved, you will still note hair on dorsa of toes Venous pattern normally flat and barely visible; note obvious varicosities, but are best assessed standing Both legs should be symmetric in size without any swelling or atrophy Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -50

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø If lower legs look asymmetric, measure leg at widest point, taking care to measure other leg in exactly same place, same number of centimeters down from patella or other landmark • If deep venous thrombosis suspected, measure calf circumference with nonstretchable tape measure • If lymphedema suspected, measure also at ankle, distal calf, knee, and thigh • Record findings in centimeters Ø In presence of skin discoloration, skin ulcers, or gangrene, note size and exact location Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -51

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Palpate for temperature along legs down to feet, comparing symmetric spots • Skin should be warm and equal bilaterally; bilateral cool feet may be due to environmental factors such as cool room temperature, apprehension, and cigarette smoking • If any increase in temperature present higher up leg, note if it is gradual or abrupt • Flex person’s knee, then gently compress gastrocnemius (calf) muscle anteriorly against tibia; no tenderness should be present Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -52

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Or you may sharply dorsiflex foot toward tibia • Flexing knee first exerts pressure on posterior tibial vein; • • • normally this does not cause pain Palpate inguinal lymph nodes; not unusual to find palpable nodes that are small (1 cm or less), movable, and nontender Palpate these peripheral arteries in both legs: femoral, popliteal, dorsalis pedis, and posterior tibial Grade force on 4 -point scale Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -53

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Locate femoral arteries just below inguinal ligament halfway between pubis and anterior superior iliac spines • To help expose femoral area, particularly in obese people, ask person to bend his or her knees to side in a froglike position • Press firmly and then slowly release, noting pulse tap under your fingertips • Should this pulse be weak or diminished, auscultate site for a bruit Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -54

Chapter 20: Peripheral Vascular System and Lymphatic System Femoral Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -55

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Popliteal pulse more diffuse and difficult to localize • With leg extended but relaxed, anchor your thumbs on • • • knee, and curl your fingers around into popliteal fossa Press your fingers forward hard to compress artery against bone (lower edge of femur or upper edge of tibia); often it is just lateral to the medial tendon If you have difficulty, turn person prone and lift up lower leg; let leg relax against your arm and press in deeply with your two thumbs Often normal popliteal pulse is impossible to palpate Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -56

Chapter 20: Peripheral Vascular System and Lymphatic System Popliteal Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -57

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø For posterior tibial pulse, curve your fingers around medial malleolus • Feel the tapping right behind it in groove between malleolus and Achilles tendon Ø Dorsalis pedis pulse requires a very light touch • Normally it is just lateral to and parallel with extensor tendon of big toe • Do not mistake pulse in your own fingertips for person’s • In adults over 45 years, occasionally either dorsalis pedis or posterior tibial pulse may be hard to find, but not both on the same foot Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -58

Chapter 20: Peripheral Vascular System and Lymphatic System Posterior Tibial Pulse Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -59

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø For posterior tibial pulse, curve your fingers around medial malleolus • Feel the tapping right behind it in groove between malleolus and Achilles tendon Ø Dorsalis pedis pulse requires a very light touch • Normally it is just lateral to and parallel with extensor tendon of big toe • Do not mistake pulse in your own fingertips for person’s • In adults over 45 years, occasionally either dorsalis pedis or posterior tibial pulse may be hard to find, but not both on the same foot Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -60

Chapter 20: Peripheral Vascular System and Lymphatic System Dorsalis Pedis Pulse © Pat Thomas, 2006. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -61

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Check for pretibial edema • Firmly depress skin over tibia or medial malleolus for 5 seconds and release • Normally, your finger should leave no indentation, although a pit commonly is seen if person has been standing all day or during pregnancy • If pitting edema is present, grade it on following scale: 1+ Mild pitting, slight indentation, no perceptible swelling 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains, leg looks swollen 4+ Very deep pitting, indentation lasts long time, leg very swollen Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -62

Chapter 20: Peripheral Vascular System and Lymphatic System Pitting Edema From Bloom A, Watkins PH, Ireland J: Color atlas of diabetes, ed 2, St. Louis, 1992, Mosby. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -63

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Scale is subjective and qualitative • The amount of pressure used is arbitrary, as is judgment • • of depth and rate of pitting Clinicians need a standard quantified scale to ensure consistent clinical measurements and management Many classify the edema by measuring the depth of the pitting in centimeter Some measure with a millimeter scale, others by an increase in weight; still others try to quantify rate of time pitting remains after release of pressure Check with your institution to determine a consistently used scale Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -64

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Inspect and palpate the legs (cont. ) Ø Ask the person to stand so that you can assess venous system • Note any visible, dilated, and tortuous veins Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -65

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Manual compression test Ø While person is still standing, test length of varicose vein to determine whether its valves are competent • Place one hand on lower part of varicose vein, and compress vein with your other hand about 15 to 20 cm higher • Competent valves prevent a wave transmission and your distal (lower) fingers will feel no change Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -66

Chapter 20: Peripheral Vascular System and Lymphatic System Manual Compression Test Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -67

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Color changes Ø If you suspect an arterial deficit, raise legs about 30 cm (12 inches) off table and ask person to wag feet for 30 seconds to drain off venous blood • Skin color now reflects only contribution of arterial blood • Light-skinned person’s feet normally will look a little pale • • • but still should be pink Dark-skinned person’s feet are more difficult to evaluate, but soles should reveal extreme color change Now have person sit up with legs over side of table Compare color of both feet and note time it takes for color to return to feet; normally, this is 10 seconds or less Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -68

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Color changes (cont. ) Ø Note also time it takes for superficial veins around feet to fill • Normal time is about 15 seconds • This test is unreliable if person has concomitant venous disease with incompetent valves • Test lower legs for strength (chapter 22) • Test lower legs for sensation (chapter 23) Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -69

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Doppler-ultrasonic stethoscope Ø Use this device to detect a weak peripheral pulse, to measure low blood pressure or blood pressure in lower extremity • Doppler stethoscope magnifies pulsatile sounds from • • • heart and blood vessels Position person supine, with legs externally rotated so you can reach medial ankles easily Place drop of coupling gel on end of handheld transducer Place transducer over pulse site, swiveled at a 45 -degree angle; apply very light pressure; locate pulse site by the swishing, whooshing sound Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -70

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data (cont. ) Ankle-brachial index (ABI) Ø Use Doppler stethoscope • Highly specific, noninvasive, and readily available way to • • • determine extent of peripheral vascular disease Apply a regular arm blood pressure cuff above ankle and determine systolic pressure in either posterior tibial or dorsalis pedis artery Divide that figure by systolic pressure of brachial artery Normal ankle pressure slightly greater than or equal to brachial pressure; normal ABI is usually 1. 0 to 1. 2 In people with diabetes mellitus, ABI may be less reliable because of calcification (which makes their arteries noncompressible) and may give falsely high measure Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -71

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data: Developmental Competence (cont. ) Infants and children Ø Transient acrocyanosis and skin mottling at birth discussed in chapter 12 • Pulse force should be normal and symmetric; pulse force • • • also should be same in upper and lower extremities Palpable lymph nodes occur often in healthy infants and children; they are small, firm (shotty), mobile, and nontender May be sequelae of past infection: inguinal nodes from a diaper rash or cervical nodes from a respiratory infection Vaccinations can produce local lymphadenopathy; note characteristics of palpable nodes, local or generalized Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -72

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data: Developmental Competence (cont. ) Pregnant woman Expect diffuse bilateral pitting edema in lower extremities, especially at end of day and into third trimester Ø Varicose veins in legs common in third trimester Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -73

Chapter 20: Peripheral Vascular System and Lymphatic System Objective Data: Developmental Competence (cont. ) Aging adult Dorsalis pedis and posterior tibial pulse may become more difficult to find Ø Trophic changes associated with arterial insufficiency; thin, shiny skin; thick-ridged nails; and loss of hair on lower legs also occur normally with aging Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -74

Chapter 20: Peripheral Vascular System and Lymphatic System Sample Charting Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -75

Chapter 20: Peripheral Vascular System and Lymphatic System Sample Charting (cont. ) Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -76

Chapter 20: Peripheral Vascular System and Lymphatic System Sample Charting (cont. ) Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -77

Chapter 20: Peripheral Vascular System and Lymphatic System Abnormal Findings: Variations in Arterial Pulse Weak, “thready” pulse, 1+ Full, bounding pulse, 3+ Water-Hammer (Corrigan’s) pulse, 3+ (collapses suddenly) Pulsus bigeminus Pulsus alternans Pulsus paradoxus Pulsus bisferiens Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -78

Chapter 20: Peripheral Vascular System and Lymphatic System Abnormal Findings: Peripheral Vascular Disease Arms Raynaud phenomenon Ø Lymphedema Ø Legs Arterial-ischemic ulcer Ø Venous (stasis) ulcer Ø Superficial varicose veins Ø Deep vein thrombophlebitis Ø Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -79

Chapter 20: Peripheral Vascular System and Lymphatic System Abnormal Findings: Peripheral Vascular Disease (cont. ) Aneurysms Occlusions Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 20 -80