Peripheral Vascular System

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Peripheral Vascular System lymphatic system
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Introduction

• Vascular system consists of vessels of body any
  disease in vascular system creates problems with
  delivery of O2 nutrients to tissues/elimination
  of waste products from cellular metabolism.

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- Arteries

• artery walls are strong, tough tense to
  withstand pressure demands. Stretch with systole
  recoil with diastole, vascular smooth muscle VSM
  contracts or dilates which changes the diameter
  of arteries to control the rate of blood flow.
  Each heart beat creates a pressure wave which
  makes arteries expand then recoil, recoil propels
  blood through like a wave or pulse, you can feel
  it only at body sites where the artery lies close
  to skin over bone.

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• 1)     Temporal artery
• 2)     Carotid artery
• 3)     Arteries in arm brachial artery
  bifurcates into ulnar radial artery__
  superficial deep arches
• 4)     Arteries in legs femoral- popliteal-
  dorsalis pedis- posterior tibial.

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-Veins

• its parallels arteries, but we have more veins
  lies closer to skin.
• 1)     Jugular veins
• 2)     Arm veins superficial deep
• 3)     Legs veins 3 types
• 1-    Deep veins alongside deep arteries
  conduct most of venous return from legs- femoral
  popliteal veins
• 2-    Superficial veins saphenous veins
• 3-    Perforators connecting veins, have valves

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Venous Flow

• drain deoxygenated blood waste from tissue
  return to heart. A low pressure system, dont
  have a pump system to generate blood flow need
  mechanism to keep blood moving, this accomplished
  by
• 1- contracting skeletal muscles that milk blood
  proximally back to heart
• 2- pressure from breathing (inspiration decrease
  thoracic pressure increase abdominal pressure
• 3- intraluminal valves unidirectional flow, open
  towards heart.

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• - In legs called calf pump or peripheral
  pump.
• - Venous structure differs from arterial
  structure, walls thinner, have valves, large
  diameter, more distensible that expand hold
  blood when blood volume increases (compensatory
  mechanism), this ability to stretch called
  capacitance vessels.
• - Efficient venous return is dependent on
  contracting muscles, competent valves patent
  lumen. Problems lead to venous stasis, risk for
  venous diseases are

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• Who undergoes prolonged standing, sitting, or
  bed-rest
•   Hypercoagulable states
• Veins trauma
•   Genetic predisposition
• Obesity pregnancy
• Dilated tortuous veins (varicose)

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- Lymphatics

• a completely separated vessel system retrieves
  excess fluid from tissue spaces returns it to
  bloodstream, without its drainage fluid would
  build up in interstitial spaces produces edema.
  
• Vessels drain into 2 main trunks, which empty
  into venous system at subclavian veins

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• 1)     Rt lymphatic duct empties into Rt
  subclavian vein, drain the Rt side of head neck,
  arm, thorax, lung, heart, liver.
• 2)     Thoracic duct drains the rest of body,
  empty into Lt subclavian vein.
• - Functions of lymphatic system
• 1- conserve fluid plasma proteins that leak
  out from capillaries.
• 2- part of immune system( by phagocytosis
  production of antibodies).
• 3- absorb lipids from intestinal tract.

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• Lymph flow is slow, propelled by contracting
  muscles by pressure of breathing by
  contracting of vessels itself.
• Lymph nodes are small oval clumps of lymphatic
  tissue arranged in groups, deep superficial
  (when exposed to microorganisms a local
  inflammation occurs its swollen tender).
  Cervical nodes- axillary nodes- epitrochlear
  node- inguinal nodes.

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- Related Organs

• spleen- tonsils- thymus aid lymphatic system.
• Spleen has functions 1- destroys RBC 2- store
  RBC 3- filter microorganisms from blood.
• Tonsils respond to local inflammation.
• Thymus a gland in superior mediastinum behind
  sternum, large in fetus children then atrophied
  at puberty develop T- lymphocytes.

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Subjective Data

• 1)     Leg pain or cramps
• 2)     Skin changes on arms or legs
• 3)     Swelling
• 4)     Lymph nodes enlargement
• 5)     Medication

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Objective Data

• Preparations examine arms when taking the V/S,
  examine legs after abdominal exam, then stand him
  up to evaluate leg veins, its include skin-
  musculoskeletal findings neurological findings,
  use inspection palpation, always compare your
  findings with the opposite extremity.

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INSPECT PALPATE THE ARMS

• Lift both persons hands in your hands, inspect,
  then turn them over, noting skin color nail
  beds, temperature, texture, turgor, lesions,
  edema, clubbing, profile sign, capillary refill.
  Note conditions can skew your findings as a cool
  room decrease body temperature, cigarette
  smoking, and edema. Two arms should be symmetric
  in size

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• Note scars on hands arms, palpate both radial
  pulses, note rate, rhythm, elasticity of vessel
  wall equal force (grades scale 4 bounding,3
  increased, 2 normal. 1 weak, 0 absent)
• Palpate the ulnar pulses
• Palpate brachial pulses- both
• Check epitrochlear lymph node in depression above
  behind medial condyle of humerus, do this by
  shaking hands reaching your other hand under
  persons elbow to the groove between biceps
  triceps muscles, normally not palpable.

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- Modified Allen test

• evaluate the adequacy of collateral circulation
  prior to cannulation the radial artery,
• 1- firmly occlude both ulnar radial arteries
  of one hand while person makes a fist several
  times this cause hand to blanch
• 2-ask him to open hand without hyperextending it,
  then release pressure on the ulnar artery while
  maintaining pressure on radial artery, adequate
  circulation is suggested by a return to normal
  color in 2-5 seconds.

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INSPECT PALPATE THE LEGS

• Uncover legs, inspect both legs together, noting
  color, hair distribution, venous pattern, size
  (swelling or atrophy), lesions or ulcers, note
  varicosities (assessed while standing), both legs
  should be symmetric in size, if DVT suspected,
  measure calf circumference at widest point,
  measure the other leg in exactly same place
  (equal), if lymphedema suspected measure also
  ankle, distal calf, knee thigh, record findings.

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• If note ulcer or gangrene note the size exact
  location.
• Palpate temperature along legs down to feet,
  comparing symmetrically, skin should be warm,
  equal bilaterally, if any increase in temperature
  present higher up the leg, note if it is gradual
  or abrupt
• Flex his knee gently compress calf muscle, no
  tenderness. OR dorsiflex foot toward tibia,
  flexing knee first exerts pressure on posterior
  tibial vein, normally no pain.

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Palpate

• Homans Sign calf pain with dorsiflexion (may
  be due to DVT)
• Palpate Grade the Pulses
• Pitting Edema Bilateral occurs w/ CHF, Diabetic
  neuropathy, Hepatic cirrhosis (scale of 1 to
  4)

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• Palpate inguinal lymph nodes, its not unusual to
  find palpable nodes small, movable non tender.
• Palpate femoral, popliteal, dorsalis pedis
  posterior tibial, grade the force on scale, press
  firmly then slowly release, Auscultate the site
  for a bruit

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• Popliteal pulse more diffuse, difficult to
  localize, leg extend relaxed anchor your thumb
  on the knee curl your fingers around into
  popliteal fossa, press fingers forward hard to
  compress artery against bone. If you have
  difficulty turn him prone lift up lower leg,
  let leg relax against your arm press in deeply
  with your 2 thumbs, a normal is impossible to
  palpate.

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• Posterior tibial pulse curve fingers around
  medial malleolus, feel tapping in groove between
  malleolus Achilles tendon, if you cant try
  dorsiflextion of foot.
• Dorsalis pedis pulse very light touch, lateral
  parallel with extensor tendon of big toe, over
  45 years either dorsalis pedis or posterior
  tibial hard to find but not both of them.

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• Check for pretibial edema, firmly depress skin
  over tibia or medial malleolus for 5 second
  release, normally your fingers leave no
  indentation, if petting edema is present, grade
  it on scale
• 1 __mild pitting, slight indentation, no
  swelling
• 2 __ moderate pitting. Indentation subsides
  rapidly
• 3 __ deep pitting. Indentation remain for a
  short time, leg swollen
• 4 __ very deep pitting, indentation last a long
  time, leg very swollen

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• This scale subjective qualitative, may classify
  by measuring depth of pitting in cm or mm or time
  remain after release pressure, ask person to
  stand so that you can assess venous system, and
  note any visible dilated tortuous veins.

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Manual compression test

• person still stand-in, test length of varicose
  vein to determine valves competent, place one
  hand on the lower part of varicose vein compress
  vein with your other hand about 20 cm higher,
  competent valves will prevent a wave
  transmission, distal hand will feel nothing.

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Trendelenburg test

• when varicosities present, use this test to
  determine valve competency. Supine position,
  elevate involved leg 90 degree until veins empty
  place a tourniquet on thigh, help person to
  stand up watch for venous filling, should be
  slowly in 30 seconds. After 30 seconds remove
  tourniquate observe whether or not the varicose
  veins fill suddenly from above, normally no
  sudden filling occurs.

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Color change

• if suspect arterial deficit, raise legs 30 cm
  off table ask him to wag the feet to drain off
  venous blood, will look a little pale but still
  should be pink, now let him sit up with legs over
  the side, compare color of both feet, note the
  time it takes for color to return, normally 10
  seconds or less, note the time for superficial
  veins around feet to fill, normally 15 seconds
• Blue-red color, delayed venous filling, motor
  sensory loss with arterial deficits in DM

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Deep Vein Thrombosis (DVT)

• Deep vein occluded bythrombus/clot
• Sudden onset, pain w/dorsiflexion
• Positive Homans sign
• accurate lt ? of the time
• Risk for PE (Pulmonary Embolism)

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Aneurysm

• Usually caused by atherosclerosis which weakens
  lining of vessel
• Aorta most common site
• Effects of Blood Pressure causes ballooning of
  the vessel
• More common in males and men over 55 women over
  70

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The Aging Adult

• Arteriosclerosis blood vessel become more rigid
  causing a rise in systolic B/P
• Atherosclerosis Fatty plaque accumulation in
  the intima of arteries
• Progressive enlargement of calf veins w/prolonged
  inactivity heart failure leads to risk of DVT
  Pulm. embolism