Arteries of the Arm and Leg

• Arteries carry oxygenated, nutrient-rich blood from the heart to the capillaries, functioning as a high-pressure system.
• Arterial walls must be thick, strong, and elastic to withstand the pressure from each heartbeat.
• The surge of blood through the arteries creates the arterial pulse, which is felt by compressing a superficial artery against bone.
• Peripheral arteries accessible for examination include the major arteries of the arms and legs.

Major Arm Arteries

• The brachial artery supplies the arm, with its pulse palpable medial to the biceps tendon in the elbow.
• The brachial artery divides into the radial and ulnar arteries near the elbow, both supplying blood to the hand.
• The radial pulse is palpated on the lateral wrist, while the ulnar pulse, located medially, may be harder to feel.
• The radial and ulnar arteries connect to form the superficial and deep palmar arches, providing protection against arterial occlusion.

Major Leg Arteries

• The femoral artery is a major blood supplier to the legs, its pulse palpable under the inguinal ligament.
• The popliteal artery is what the femoral artery becomes as it crosses to the back of the thigh, with its pulse palpable behind the knee.
• The popliteal artery branches into the anterior and posterior tibial arteries below the knee.
• The dorsalis pedis artery, a pulse from the anterior branch, can be palpated on top of the foot on the great-toe side.
• The posterior tibial pulse can be palpated behind the medial malleolus of the ankle.
• The dorsalis pedis and posterior tibial arteries form the dorsal arch, similar to the palmar arches of the hand, and provides protection from arterial occlusion.

Veins

• Veins carry deoxygenated, nutrient-depleted, waste-laden blood back to the heart.
• Arm, upper trunk, head, and neck veins carry blood to the superior vena cava, while lower trunk and leg blood drains into the inferior vena cava.
• Veins hold approximately 70% of the body's blood volume and have thinner walls than arteries due to lower pressure.
• They are larger in diameter than arteries and can expand to accommodate increased blood volume and reduce the heart's workload.
• Deep veins (femoral and popliteal), superficial veins (great and small saphenous), and perforator veins are the three types of veins in the legs.
• The femoral and popliteal veins account for 90% of venous return from the lower extremities.
• The great saphenous vein is the longest, extending from the foot's medial dorsal aspect to the groin's medial aspect, where it joins the femoral vein.
• The small saphenous vein runs from the foot's lateral dorsal aspect up the back of the leg to meet the popliteal vein.
• Perforator veins connect superficial veins to deep veins.

Venous System Mechanics

• Blood flow in the low-pressure venous system of the legs relies on one-way valves, muscular contraction, and pressure gradients created by breathing.

One-Way Valves

• Deep, perforator, and superficial veins contain one-way valves to prevent backflow and facilitate blood flow to the heart.

Muscular Contraction

• Skeletal muscles contract with movement and squeeze blood to the heart.

Pressure Gradient

• Breathing creates a pressure gradient as inspiration decreases intrathoracic pressure and increases abdominal pressure.

Venous Stasis

• Venous return that is impaired leads to venous stasis, which can be caused by prolonged standing, sitting, lying down, varicose veins, and vein wall damage.

Capillaries and Fluid Exchange

• Capillaries connect arterioles and venules, maintaining equilibrium between vascular and interstitial spaces.
• Hydrostatic force, generated by blood pressure, drives the fluid diffusion out of capillaries and into tissue spaces.
• Interstitial fluid delivers oxygen, water, and nutrients and picks up waste products.
• Fluid reenters capillaries through osmotic pressure, and excess fluid is removed by lymphatic capillaries.

Lymphatic System

• The lymphatic system drains excess fluid and plasma proteins from tissues, returning them to the venous system.
• Lymphatic capillaries absorb fluids and proteins, forming lymph, that pass through lymph nodes.
• Microorganisms, foreign materials, dead blood cells, and abnormal cells are trapped and destroyed within lymph nodes.
• Filtered lymph is drained by the right lymphatic duct or the thoracic duct back into venous circulation via the subclavian veins.
• Lymph nodes are part of the immune system and also absorb fats from the small intestine.
• Superficial lymph nodes accessible for examination in the arms and legs include the epitrochlear and superficial inguinal nodes.
• Epitrochlear nodes are located above the elbow on the inner arm and drain the lower arm and hand.
• Superficial inguinal nodes consist of horizontal and vertical chains, draining the legs, external genitalia, and lower abdomen and buttocks.

Health Assessment: Subjective Data

• Assess the peripheral vascular system by asking about symptoms that clients see as inconsequential.
• Ask about personal and family history of vascular disease.
• Evaluate client lifestyle and health affecting vascular health.

Health Assessment: Key Questions and Rationales

• Cold, pale, clammy skin is often associated with arterial insufficiency. Warm skin and brown pigmentation is associated with venous insufficiency.
• Leg pain or cramping may come from the weakness, cramping, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity; may also be venous disease.
• Rope-like, bulging or contorted veins may be hereditary, or result from increased venous pressure and venous pooling
• Sores or open wounds on legs are ulcers, that may be arterial or venous
• Swelling in legs or feet may be peripheral edema, resulting from an obstruction of the lymphatic flow or from venous insufficiency
• Enlarged Lymph nodes indicate a local or systemic infection
• Changes in usual sexual activity may indicate erectile dysfunction (ED) caused by decreased blood flow

Health Assessment: Personal Health History Questions and Rationales

• Problems with circulation in your arms and legs increases person's risk for recurrence
• Previous surgeries may alter the skin surrounding/underlying the blood vessels

Health Assessment: Family History Questions and Rationales

• History of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated cholesterol or triglyceride levels may indicate hereditary defects that may damage blood vessels

Health Assessment: Lifestyle and Health Practices Questions and Rationales

• Smoking increase the risk for chronic arterial insufficiency
• Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure
• Oral/transdermal contraceptives increase risk for thrombophlebitis, Raynaud's disease, hypertension, and edema
• Stress increases heart rate and blood pressure, that may contribute to vascular disease
• Medications that improve circulation may include drugs that inhibit platelet aggregation (cilostazol, or clopidogrel), aspirin, or Pentoxifylline
• Support hose help reduce venous pooling and increase blood return to heart

Health Promotion and Disease Prevention: Peripheral Artery Disease (PAD)

• Peripheral artery disease is present in approximately 20% of adults, and is expected to be 7 million Americans by 2020
• PAD is a major cause of impaired ambulation, lower-extremity wounds, and amputations; may be the first sign of atherosclerotic buildup of vessels
• Primary symptom is intermittent claudication, calf pain being most common; other symptoms may include numbness, weakness, coldness, sores on toes, change in skin color of legs, hair loss or slow growth on legs, shiny skin, slow-growing toenails, diminished pulses in legs and feet, and erectile dysfunction in men

PAD Screening Recommendations

• Recommendations stress that ankle-brachial index (ABI) should be performed as an effective strategy for diagnosing at-risk people.
• Screening should start at age 65, or 50 with history of diabetes or smoking, or anyone under 50 with diabetes and obesity or high blood pressure.

PAD Risk Assessment

• Risk factors include: age, smoking, atherosclerosis, history of diabetes or smoking, obesity, hyperlipidemia, high blood pressure, family history