Assessment of the Peripheral System

8/6/2019 Assessment of the Peripheral System

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Vascular System- Consists of vessels which transports blood and lymph

Functions: Vascular System~Lymphatic System: Transports FLUID

~Arteries and Veins: Transports BLOOD

Disease of Vascular SystemProbelms with:~delivering O and nutrients to tissues

~eliminating waste products

Functions: Arteries

Transports OXYGENATED blood; High Pressure System

~Contains elastic tissue and muscle fibers which allows them to STRETCH, DILATE and

CONSTRICT

~Heartbeat creates pressure wave responsible for pulse

Pulses to Assess~Temporal artery

~Carotid artery

~Arteries of the arm (brachial, radial, ulnar)

~Arteries of the leg (femoral, popliteal, posterior tibial, dorsalis pedis)

Veins to Assess~Jugular Veins: assessed with Cardiac Assessment

~Veins in the ARMS: superficial and deep~Veins in the LEGS: superficial, deep and COMMUNICATING veins (common place to see venous

disease)

Functions: Lymphatic System

~Conserve fluid and plasma: more fluid leaks out of capillaries than veins can absorb

~Part of the immune system: filters fluid before it returns, 'phagocytosis'

~Absorb lipids from the GI tract

Lymphatic Ducts

Lymph vessels drain into 2 main trunks:

~Right Lymphatic duct empties into R Subclavian Vein

~Thoracic duct (drains the rest of the body) empties into L Subclavian Vein

Lymph Nodes

Small clumps of lymphatic tissue located at intervals along vessels


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Functions: Lymph Nodes

Filter fluid before returned to bloodstream; Elicit antigen specific responses to eliminate pathogens

Lymph Nodes to Assess

CervicalAxillary

Epitrochlear

InguinalInfants and Children

~Lymph tissue present at BIRTH

~Lymph reaches adult size at 6 yrs old and SURPASSES it by adolescents~Lymph nodes LARGE

Pregnancy~Uterus obstructs drainage of ILIAC veins and INFERIOR vena cava

Aging Adult

~Peripheral blood vessels are more RIGID and NARROW~ Mobility

~ Lymphatic tissueArteriosclerosisThickening, hardening and loss elasticity of the arteries

Atherosclerosis

Marked by cholesterol, lipid and calcium deposits of arterial wallsSmoking

Vasoconstriction ( O to tissues)

Obesity incidence of CAD, Diabetes and inactivity ( circulation)

Excessive Alcohol incidence of CAD, hyperlipidemia

Diabetes incidence of CAD, hyperlipidemia, damage to micro-circulation

Hypertension

Vasoconstriction of arteries ( circulation)

Lack of ExercisePooling of the blood ( venous return)

Leg Pain or Cramps

~Type: burning, aching, cramping, stabbing

~Gradual or sudden

~Effect of walking: how many blocks or stairs "Claudication distance"~Effect of elevation (raising leg make pain go away or worse)

AssessmentSkin Changes

Color: pale, redness, cyanosisChange in temperature (AI)

Presence of veins, varicosities (VI)

Presence of sores, ulcers (AI, VI)


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Edema

~AM or PM?

~Unilateral or Bilateral

~Associated with heat, redness, hard skin

Lymph Node Enlargement

Where are they?How long has it been there?

Is it painful?

Is it moveable?

We worry about fixed and nonmovable

Past Medical HistoryCAD, DM, pregnancy, smoking, trauma, prolonged sitting or standing, bedrest

Medication HistoryOral contraceptives, estrogen replacement

Inspection: ArmsColor: pallor, redness

Nailbeds: profile sign

Capillary Refill: return in


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Compress gastronemius muscle: without tenderness or hardness (r/o phlebitis)

Homan's sign - sharply dorsiflex the foot (+ Homan's in 35% of DVT)

Check Inguinal nodes - not unusual to feel palpable nodes that are SMALL < 1cm, MOVABLE and

NON-TENDER

Palpate pulses and record on a 4+ scaleCheck for edema on a 4+ scale

Bilateral Edema

Edema associated w/ SYSTEMIC condition

Heart failure

Hepatitis

CirrhosisKidney Problems

Unilateral Edema

Brawny edema (non-pitting); LOCALIZED problem

Occlusion of a deep vein or lymphatic obstruction

Venous Test for Lower Legs

~Used with VARICOSE VEINS

~1 hand on lower part of a varicose vein~Other hand compress top part (15-20 cm higher)

~No Wave with top hand competent valve

~Wave feltincompetent valve

Trendelenburg Test~Pt is supine

~Elevate legs 90, place tourniquet

~Have pt stand and check for VENOUS filling~Used with VARICOSITIES

~Vein should fill from BELOW

Ankle Brachial Index

~Arterial test to determine the extent of peripheral vascular

disease

~BP over ankle~Check systolic pressure of TIBIAL or DORSALIS PEDIS

Results:90% or less - presence of PV disease

30 - 40% - severe claudication

< 30% - ischemia, will have tissue loss

Color Change Test

~Pt is supine

~Raise legs 12 inches and wiggle toes to drain venous blood~Sit up


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~Color should return in 10 sec.

~Elevational pallor indicates ARTERIAL insufficiency

Raynaud's Syndrome

Happens with exposure to COLD;~Pallor Arteriospasms

~CyanosisPoor blood supply

~RuborDilated capillaries (painful; burns and throbs)Lymphedema

~REMOVAL of lymph nodes

~protein rich lymph fluid in the interstitial space~ oncotic pressure fluid

~stagnant fluid leads to infection and poor wound

healing

~Leads to "brawny edema"48

Arterial Insufficiency

Chronic build up of FATTY PLAQUES in the arteries; Reduces blood flow w/ vital O and nutrients to

tissues

Location of pain: DEEP muscles, usually the CALF and FOOT

Character of pain: "Intermittent Claudication" - WORSE with exerciseClick to flipArterial Insufficiency

Aggravating factors: Walking "claudication distance", Elevational pain

Relieving factors: Rest or Dangling

Associated Symptoms:

Cool pale skin, pulses, sensation, hair loss

Arterial InsufficiencyWhose at risk?

More MEN, hx of DM, HTN, smoking, lipids, obesity

Relief: REST (standing position), dangling (severe involvement)6 P's of Arterial Occlusion

Pain

PallorPulselessness

Paresthesia

ParalysisPerishing Cold

Click to fl

Trophic Changes: Arterial Insufficiency

~Nails: onychodystrophy~Diminished HAIR of lower extremities

~Skin is THIN

~ATROPHY of muscles


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All 2 poor nutrition of the tissues

Click to flipLesions: Arterial Insufficiency

Toes, Heels, Lateral Ankles

Pale ischemic baseWell-defined edges

No bleedingVenous InsufficiencyFollows DVT or chronic INCOMPETENT valves in deep veins

Location of pain: CALF, LOWER LEGS

Character of pain: ACHING, TIREDNESS, feeling of FULLNESS

Click to flip

Venous Insufficiency

Onset and Duration: chronic pain, at the end of the day

Aggravating: PROLONGED standing or sitting

Relieving factors: Elevation, lying down or walking

Associated Symptoms: edema, varicosities, weeping ulcers at ankles(bleeding)

Click to flipVenous Insufficiency

Whose at risk?Prolonged standing

Obesity

PregnancyProlonged bed rest

Varicosities

ThrombophlebitisLesions: Venous Insufficiency

Ulcers on Medial malleolus

Bleeding, uneven edgesVaricose Veins

Incompetent veins; 3x more common in women

Subjective Complaints: ACHING, HEAVINESS in legs, easy FATIGABILITY

Objective Symptoms: DILATED, TORTUOUS veins

Venous Disease in the LegsClick to flip

Deep Vein Thrombosis

DEEP VEIN occluded by CLOT causes by bedrest, hx of varicosities, trauma, infection, use of

estrogens

Subj. Complaints: SUDDEN onset of pain, with DORSIFLEXION


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Obj. Complaints: warmth, edema, rubor, dependent cyanosis, tender on palpation, + Homan's sign

Venous Disease in the LegsClick to flip

Occlusions

Occurs with atherosclerosis, thrombus formation, OCCLUDES the blood flow

Risk factors: obesity, smoking, HTN, DM, cholesterol, sedentary lifestyle

6 P's

Peripheral Artery Disease

Click to flipAneurysms

Is a sac formed by dilitation in the arterial wall, balloon enlargement

Causes: atherosclerosis WEAKENS the MIDDLE layer of the vessel wall, BP stretches it out

Common site: AortaIncidence: males > 70, females > 55

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Assessment of the Peripheral System