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© Endeavour College of Natural Health endeavour.edu.au
BIOE221
Session 02
Skin, Mucous Membrane
and Periphery Assessment
Bioscience Department
© Endeavour College of Natural Health endeavour.edu.au
Session Objectives
• Understand the physiology of blood pressure and how to measure blood pressure.
• Understand the surface anatomy of the upper and lower limb
• Understand the circulatory and lymphatic pathways of the upper and lower limb
• Be able to assess for skin integrity and vascular and
lymphatic changes associated with pathologies
• Understand the importance and rational for the
examinations the mucous membrane of the eyes
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Blood Pressure (BP)
• Blood pressure is the hydrostatic pressure exerted by blood on the
walls of the blood vessels during contraction of the ventricles. It is
recorded as systolic / diastolic mmHg.
– Systolic blood pressure - maximum pressure exerted on the
arterial wall during left ventricular contraction
– Diastolic blood pressure - minimum pressure exerted on the
arterial wall between contractions
– Pulse pressure - difference between systolic and diastolic and
reflects the stroke volume
– Mean arterial pressure - the pressure forcing blood into the
tissues
– Peripheral resistance the total resistance against which blood
must be pumped
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Blood Pressure
in various blood
vessels
(Tortora & Derrickson, 2009)
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Control of Blood Pressure• BP changes with daily activity/ position changes/
emotions
• Regulation mechanisms to maintain ‘normal’ blood pressure are– Cardiovascular centre in brain stem
• regulates heart rate/ force of contraction of ventricles/ blood vessel diameter
– Nervous system regulation• baroreceptors
• chemoreceptors
– Hormone regulation• adrenaline/ noradrenaline (↑ HR & vasoconstriction)
• ADH & ANP
– Autoregulation• local automatic adjustment of blood flow to match tissue needs
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5 Factors Affecting Blood
Pressure• Cardiac output (stroke volume x heart rate)
– as heart pumps more blood into blood vessels, the pressure on the vessel walls increases
• Peripheral vascular resistance– opposition to blood flow through arteries
– increased pressure needed to push blood through constricted blood vessels
• Circulating blood volume– the greater the volume of blood in the vessels, the higher the BP
• Blood viscosity– when blood is thicker, BP will increase
• Elasticity of arterial walls– decreased elasticity increases BP
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• Weight
– BP rises in the obese – more blood vessels
• Exercise
– BP increases proportionately with exercise
• Emotions
– BP rises with fear, anger, pain
– (SNS stimulation)
• Stress
– continual stress can elevate BP
Blood Pressure Readings
Average adult BP – approx 120/80 mmHg
Varies with;
• Age
– normally gradual rise through childhood into adulthood
• Gender
– females lower between puberty and menopause
• Race
– Afro-Americans - hypertension
• Diurnal rhythm
– early morning low
– peak late afternoon/ early evening
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BP Values and Hypertension
(National Heart Foundation of Australia 2008)
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Preparation for BP
measurement• You will need
– Sphygmomanometer with an appropriate cuff size for the patients arm.
– Stethoscope.
– Quiet, relaxing atmosphere.
– Chair / couch/ bed.
– Client must be seated or lying – arm exposed and supported at the level of the heart with legs uncrossed.
– Patient should be rested for at least 15 minutes before taking the blood pressure.
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BRACHIAL PULSE
Located medial to the
biceps tendon in the
antecubital fossa. The
stethoscope is placed
over the point where the
pulse is felt.
(Jarvis, C. 2004)
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Relationship of BP
changes
to cuff pressure
(Tortora & Derrickson 2009)
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Common errors affecting
accuracy of BP Measurement• Incorrect cuff position
• Too high inflation of cuff
• Too rapid deflation of cuff
• Erratic cuff deflation
• Pressing stethoscope on brachial artery too hard
• Defective equipment
• Noisy environment
• Hearing problems
• White coat syndrome
• Inappropriate timing of measurement the client may be – Stressed e.g. rushing in at the last minute
– Had caffeine consumption
– Been smoking
– Have been involved in heavy physical activity
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Auscultatory Gap
• The auscultatory gap is a brief period of time when the Korotkoff sounds can not be heard.
• This will most often occur in hypertensive patients and may result in the incorrect determination of a normotensive BP result.
• To avoid this:-
– For all patients for whom you are not familiar with, always obtain the systolic pressure by palpation first, before obtaining the BP by auscultation.
– If you find an auscultatory gap be sure to document this in the patients clinical notes. By doing so you can account for the auscultatory gap in future blood pressure readings without the need for the palpatorysystolic first.
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Lying & Standing BP
measurement• Performed when the patient presents with a
history of dizziness or fainting. Used to
determine orthostatic (Postural) hypotension
– Causes:
• Abrupt idiopathic vasodilation
• Postural changes following prolonged bed-rest
• Elderly
• Hypovolaemia (blood loss or dehydration)
• Medications (antihypertensives)
• Neurological conditions
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Abnormalities in Blood Pressure
• Hypotension – abnormally low BP
– In normotensive adults - < 95/60 mmHg
– In hypertensive adults – the person’s average reading, but may be > 95/60 mmHg
• Orthostatic hypotension (postural hypotension)
– Drop in systolic BP > 20mmHg (+/- increase in pulse of 20 bpm) with quick change to standing position
• Hypertension
– Common, often asymptomatic disorder characterisedby elevated blood pressure persistently exceeding 140/90mmHg
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Vascular CirculationThe vascular circulation is comprised of the Venous and the Arterial vessels
• Venous circulation
– the course of veins parallels that of arteries
– the body has more veins than arteries and they lie closer to the surface
– There are both superficial and deep veins throughout the body
– Perforators are veins that connect the superficial veins to the deep veins
– Circulation within veins moves from superficial to deep and is facilitated by:
• Muscle contractions
• Transluminal One-way valves
• Alternation of abdominal and thoracic pressures during breathing
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Venous Circulation
Lower Extremities
(Tortora & Derrickson 2009)
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Conditions affecting venous
circulationMost commonly conditions affecting venous circulation will
occur in the legs.
• Varicose Veins
– Dilated, tortuous veins with valve incompetence.
Thrombosis may occur.
• Deep Vein Thrombosis
– Venostasis in the deep veins results in thrombosis
which may form emboli.
• Venous Ulceration
– Prolonged venostasis, particularly in superficial veins,
may lead to tissue necrosis and ulcer formation
18
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Arterial Circulation
As the heart contracts oxygenated blood is carried via the
arteries towards the periphery.
• Arteries are elastic and muscular to allow them to
withstand greater pressure.
• Pulse pressure wave causes the arteries to expand and
recoil to facilitate arterial circulation.
• This pressure wave can be felt at specific points around
the body known as pulse points.
19
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Carotid Artery
(Tortora & Derrickson 2010)
Clinical Exam Session 2
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Arterial Supply –
Upper Extremity
Aorta –
brachiocephalic –
subclavian – axillary –
brachial – radial and
ulnar
(Tortora & Derrickson 2009)
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Arterial Supply
Lower Extremity
Thoracic aorta –
abdominal aorta –
common iliac – external
iliac – femoral –
popliteal – posterior
tibial and dorsalis pedis
(Tortora & Derrickson 2010)
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Pulse Locations
• The pulse rate is usually taken at the radial artery as part
of the vital signs
• Other locations in the body are used to determine the
arterial circulation to tissues distal to those pulse points
• The pulse points we will learn are:
– Carotid, brachial, radial, ulnar
– Popliteal, posterior tibial, dorsalis pedis
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Carotid Pulse (Jarvis 2004)
Used to assess blood flow
to the head.
The carotid pulse is
located between the
sternocleidomastoid (SCM)
muscle and trachea at
approximately the level of
the larynx
© Endeavour College of Natural Health endeavour.edu.au
Used to assess blood
flow to the arm and for
blood pressure.
Located medial to the
biceps tendon in the
antecubital fossa. The
stethoscope is placed
over the point where the
pulse is felt.
(Jarvis 2004)
Brachial Pulse
© Endeavour College of Natural Health endeavour.edu.au
Radial Pulse(Jarvis 2004)
Used to assess blood flow
to the hand and for
obtaining the pulse rate as
part of vital signs
Located between the radius
and the palmaris longus
tendon on the lateral side
of the wrist.
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Ulnar Pulse(Jarvis 2016)
Used to assess blood flow
to the hand
Located between the flexor
carpi ulnaris and flexor
digitorum profundus
tendons on the medial side
of the wrist
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Popliteal Pulse
(Jarvis 2004)
Used to assess blood flow to
the leg.
Located deep within the
popliteal fossa in between the
femoral condyles.
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Posterior tibial pulse(Jarvis 2004)
Used to assess blood flow to
the foot.
Located between the medial
malleolus and the Achilles
tendon.
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Dorsalis pedis pulse(Jarvis 2012)
Used to assess blood flow to
the distal foot.
Located lateral to the
extensor hallucis longus
tendon at the high point of
the foot.
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Peripheral Vascular Disease(Jarvis 2008)
Ischaemic ulcer - arterial Venous (stasis) ulcer
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Diabetes Mellitus – (Dry)
Gangrene(McCance & Huether 2006)
Foot Ulceration
(& Digit Amputation)
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Examination of the Upper
Extremities• Inspect & palpate the arms
• Lift both hands together/ inspect/ turn them over, noting:– Temperature
– Texture (see notes – Skin, hair, nails)
– Turgor (and mobility) of the skin (see notes – Skin, hair, nails
– Symmetry
– Colour of skin & nail beds(see extra handout notes – Skin, hair, nails)
– Any lesions, scars, oedema
– Finger clubbing (see notes later)
– Note any abnormality of joints - check bilaterally
• Check capillary refill (see later slide)
• Check brachial and radial pulses
© Endeavour College of Natural Health endeavour.edu.au
Examination of the Lower
Extremities• Inspect and palpate the legs (usually lying down)
• Uncover the legs & inspect both together, noting and comparing:
– Colour
• Pallor with vasoconstriction
• Erythema with vasodilation
• Cyanosis
• Areas of discolouration
– Gangrene – arterial insufficiency
– Brown discolouration medial lower leg (with ulcers) -chronic venous insufficiency
– Hair distribution
– Venous pattern
• Assess varicosities when standing
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Examination of the Lower Extremities
– Size (swelling/ oedema or atrophy) & symmetry
– Lesions/ ulcers
• Medial aspect lower leg/ medial malleoli – venous
insufficiency
• Lateral malleoli/ metatarsal heads/ tips of toes –
arterial insufficiency
– Temperature
• Unilaterally cool – arterial insufficiency
• Bilaterally cool – environment / smoking / ?arterial
• Check the posterior tibial and dorsalis pedis pulses
• Check for pretibial oedema
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Ankle-Brachial Pressure Index
The Ankle-Brachial Pressure Index (ABPI) is a
simple way to determine the potential for
peripheral vascular disease.
39
Note that the procedure described in
your text book uses Doppler ultrasound.
However, studies have shown that
obtaining ABPI by palpation is a reliable
indicator of potential peripheral vascular
disease. (Migliacci et al, 2008)
All abnormal results require referral
for further investigation.
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Ankle-Brachial Pressure Index
Simplified Procedure:
1. Obtain an accurate systolic blood pressure on
each arm.
2. Obtain an accurate systolic blood pressure on
each ankle using either the posterior tibial or
dorsalis pedis pulse.
3. Calculate the ABPI for the left side and the right
side separately.
40
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Ankle-Brachial Pressure Index
Calculation:
Ankle Systolic / Arm Systolic = ABPI
41
>1.3 Potential arterial stiffness
1.0-1.3 No peripheral artery disease
0.9-1.0 Borderline peripheral artery disease
0.7-0.9 Mild peripheral artery disease
0.4-0.7 Moderate peripheral artery disease
0.3-0.4 Severe peripheral artery disease
<0.3 Ischemia (Emergency referral required)
(Jarvis. 2016, p.525)
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Skin ExaminationSkin is the largest organ in the body.
• Comprised of:
– Epidermis
– Dermis
– Nails and accessory structures
• Functions:
– Physical, chemical and thermal barrier
– Sensation
– Temperature regulation
– Excretion and absorption
– Synthesis of Vitamin D
42
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Skin Examination
When performing a general examination of
the skin assess:
• Skin colour (Pallor, Cyanosis, jaundice, erythema, rash,
pigmentation, scars, wounds, moles)
• Skin health (looks, moisture, oiliness, integrity)
• Skin turgor (Elasticity and hydration)
• Skin appendages (hair distribution and nail health
(See additional handouts)
43
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Skin Turgor
• Mobility & turgor– Mobility – skin’s ease of rising
– Turgor – ability to return to place promptly when released (elasticity)
– Decreased mobility with oedema/ scleroderma
– Poor turgor with severe dehydration/ extreme weight loss
• Skin turgor testing for dehydration is unreliable in:• The elderly – use the oral mucous membranes
• Infants – use the fontanelles on the head
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Skin Turgor
(The New York Times Company 2007)
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Finger Clubbing• Four criteria confirm clubbing
– Loss of normal angle between the nail and nail bed (>160o)
– Increased nail bed fluctuation
– Increased nail curvature in later stages
– Increased bulk of the soft tissues over the terminal phalanges
• Occurs with
– Congenital chronic cyanotic heart disease
– Chronic obstructive pulmonary disease• Emphysema/ chronic bronchitis
– Cor pulmonale ([R] heart failure)
– Subacute bacterial endocarditis
– Other lung pathologies
– Sometimes serious liver, bowel and kidney diseases
© Endeavour College of Natural Health endeavour.edu.au
Capillary RefillThis is an assessment of the peripheral perfusion and cardiac
output
Procedure
• Depress & blanch nail beds
• Release & note time for colour return
– normal if the colour returns in <1-2 seconds
– > 1-2 seconds
• signifies vasoconstriction or decreased cardiac output
• hands are cold, clammy & pale
• Note conditions that can skew your findings e.g.
– cool room/ decreased body temperature
– cigarette smoking
– peripheral oedema/ anaemia
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Oedema• Interstitial fluid balance is regulated by:
• Blood Hydrostatic Pressure (BHP) which pushes fluid towards the
interstitium
• Interstitial Fluid Hydrostatic Pressure (IFHP) which pushes fluid back
towards the capillaries.
• Blood Colloidal Osmotic Pressure (BCOP) which pulls fluid into the
capillaries
• Interstitial Fluid Osmotic Pressure (IFOP) which pulls fluid into the
interstitium
• Oedema is excess accumulation of fluid in the interstitial
spaces of tissues
• Fluid from the interstitium is usually drained via the veins
and lymphatic vessels
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Causes of Oedema
• Generalized (bilateral) oedema– disorders of the heart, kidneys, liver or GIT or may be
nutritional in origin (hypoproteinaemia/ fluid overload)
• Localized (unilateral or bilateral) oedema– may arise from venous or lymphatic obstruction, allergy or
inflammation
• Postural oedema– relatively common is the lower limbs of inactive patients
and those who have been on their feet all day
• If fluid retention is generalized, its distribution is determined by gravity– e.g. usually found in legs, backs of thighs and
lumbosacral area
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Rating of Oedema
• Oedema– Fluid accumulation in the interstitial (extracellular)
spaces – not normally present
– 1+ mild pitting• slight indentation/ no noticeable swelling of legs
– 2+ moderate pitting• indentation subsides rapidly
– 3+ deep pitting• indentation remains for short time/ leg look swollen
– 4+ very deep pitting• indentation lasts long time/ leg very swollen
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Oedema
Testing for pitting oedema Pitting oedema
(Jarvis 2016, p.523)
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Bringing it all together
• Your general survey should include:
– Vital signs
– Physical appearance, structure, mobility & behaviour
– General peripheral examinations of skin, hair, nails and eyes.
• Specific peripheral examinations such as oedema, capillary refill & ABPI should be consideration in relation to specific clinical indications of relevant local or systemic disease/disorders.
54
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ResourcesJarvis, C. (2016) Physical Examination and Health Assessment, 7th
edn. Saunders, Missouri.
Tortora, GJ & Derrickson, B 2014, Principles of Anatomy and Physiology, 14th edn, John Wiley, Hoboken,NJ.
National Heart Foundation (National Blood Pressure and Vascular Disease Advisory Committee), 2008, Guide to Management of Hypertension 2008, Updated December 2010.
Migliacci, R, Nasorri, R, Ricciarini, P, & Gresele, P, 2008, Ankle-brachial index measured by palpation for the diagnosis of peripheral arterial disease, Family Practice, Vol. 25, p. 228-232
McCance, K, Huether, S, Brashers, V, & Rote, N, 2010, Pathophysiology: The Biological Basis for Disease in Adults and Children, 6th edn, Mosby Elsevier, Philadelphia
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