Health Assessment Lecture 8: Peripheral Vascular System & Lymphatic System Assessment PDF

Health Assessment Lecture 8 Peripheral Vascular System & Lymphatic System Assessment  Vascular System  Vascular System consists of the vessels of the body.  Vessels are tubes for transporting fluid such as the blood or lymph. Arteries: Elastic fibers & vascular...

Health Assessment Lecture 8 Peripheral Vascular System & Lymphatic System Assessment  Vascular System  Vascular System consists of the vessels of the body.  Vessels are tubes for transporting fluid such as the blood or lymph. Arteries: Elastic fibers & vascular smooth muscle- contract or dilates, high pressure system. Capillaries Veins: Closer to skin, low pressure system, walls thinner than arteries, larger diameter. Lymphatic Vessels: retrieves excess fluid from the tissue spaces and return it to the blood stream. The right lymphatic and thoracic duct  I- Subjective Data Leg pain or cramps Skin changes on arms or legs Swelling in arms or legs – Edema is bilateral when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation. Lymph node enlargement Medications Smoking history 4  II- Objective Data/ Preparation Privacy Adjust room temperature about 22o C Use Inspection and Palpation Compare findings with the opposite extremity  Equipment: Tape measure Tourniquet or Blood Pressure cuff Doppler ultrasonic stethoscope 5  Inspection & Palpation of Arms Color of skin and nailbeds Temperature Texture Turgor of skin Presence of lesions, edema, clubbing (Profile Sign: normal nail bed angel 160 degree). Capillary Refill: less than 1 or 2 seconds. Size of two Arms: should be symmetric in size  Abnormal Findings: Edema of upper extremities; lymphatic drainage is obstructed, after breast surgery. 6  Inspection & Palpation of Arms  Scars on hands or arms  Palpate both brachial & Radial Pulses Rate, Rhythm Amplitude (three-point scale): 2+ Normal and Elasticity of vessel. – 3+, Increased, full, bounding – 2+, Normal – 1+, Weak – 0, Absent  Ulnar Pulse: usually not necessary  Brachial Pulse  Epitrochlear lymph nodes: Normally not palpable.  Modified Allen test 7  Inspection & Palpation of Arms  Modified Allen Test- evaluates collateral circulation. 1. Firmly depress both ulnar & radial arteries of one hand while the patient makes a fist several times. 2. Ask patient to open his/her hand then release pressure on the ulnar artery while maintaining pressure on the radial artery. 3. Normally when patient opens fist, blood returns to normal (hand’s normal color) in approximately 2 – 5 seconds. 4. If pallor persists or a sluggish return to color suggests occlusion of the collateral circulation; avoid radial artery cannulation utile adequate circulation is shown. 8 Allen Test 9 Allen Test 10  Inspection & Palpation of Legs  Skin Color & Temperature: pallor & coolness occur with Arterial insufficiency.  Hair distribution  Venous pattern  Skin discoloration, lesions, ulcers, gangrenes: brown discoloration occurs with chronic venous stasis.  Size: symmetric without swelling or atrophy  If lower legs look asymmetric, measure the calf circumference with tape measure. 11  Inspection & Palpation of Legs Diffuse bilateral edema occurs with systemic illnesses. Acute, unilateral, painful swelling and asymmetry of calves of 1 cm or more is abnormal (DVT or lymphedema)  Inspection & Palpation of Legs  Homans’ Sign  Flex the person knee  Compress the calf muscle & check for calf tenderness or dorsiflex the foot toward tibia and check for calf pain.  Palpate Inguinal Lymph Nodes (size, tenderness, mobility)  Pulses ( Femoral [halfway between pubis and anterior superior iliac spine] , Popliteal [lateral to medial tendon], Posterior Tibial [behind medial malleolus], and Dorsalis Pedis [lateral and parallel with the tendon of big toe] ) 13  Assessing Peripheral Pulses Femoral pulse. Popliteal pulse Dorsalis Pedis and Posterior Tibial Pulse Sites  Inspection & Palpation of Legs  Check for Pretibial Edema  Firmly depress the skin over the tibia for 5 seconds and release.  Normally: your fingers should leave no indentation.  If pitting edema is present, grade it  Abnormal Findings: bilateral, dependent, pitting edema occurs with heart failure, diabetic neuropathy and hepatic cirrhosis. o Unilateral edema occurs with occlusion of a deep vein. o Unilateral or bilateral edema occurs with lymphatic obstruction. 16  Inspection & Palpation of Legs  Pitting Edema Scale  1+= Mild pitting, slightly indentation, no perceptible swelling of legs  2+= Moderate pitting, indentation subsides rapidly  3+= Deep pitting, indentation remains for a short time, leg looks swollen;  4+= Very deep pitting, indentation lasts a long time, leg is very swollen 17  Inspection & Palpation of Legs  Venous Pattern: in standing position, note any visible, dilated, and tortuous veins. Color Changes: To test Arterial Insufficiency (deficit) 1. With patient lying supine 2. Raise the legs 30 cm off the table 3. Ask the person to wag the feet (movement from side to side) for 30 seconds to drain off venous blood 4. Note skin color ?  Normal Findings: feet will look a little pale but still should be pink.  Abnormal Findings: elevational pallor (marked) indicates arterial insufficiency. 18  Inspection & Palpation of Legs  Color Changes  With Sitting position and legs are dangling: Compare color of both foot Note the time it takes for color return to feet (Normal ≤10 sec). Note the time it takes for superficial veins to fill (Normal 15 sec). Delayed venous filling also occurs with arterial insufficiency  The Doppler Ultrasonic Stethoscope – To detect weak peripheral pulse. 19  The Doppler Ultrasonic Stethoscope Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease.  Inspection & Palpation of Legs  Circulation Check  Also called Neuro-circulation check  Performed any time your patient have a possibility of compromised circulation to a body part (e.g., Cast, after Cardiac catheterization)  Assess for the 4 Ps  Pain  Pallor  Pulselessness  Paresthesia 21 ASSESSING ARTERIAL AND VENOUS INSUFFICIENCY Arterial Insufficiency Venous Insufficiency Aching pain in calf or lower leg Deep muscle pain in calf - Worse at end of the day & Pain or foot, Claudication (pain with prolonged standing or with walking) sitting - Coarse, thick, tough - Coolness, Pallor - Usually warm unless edema - Pallor when elevated Skin severe - Dry, shiny, thin - Pallor when elevated - Loss of hair brown pigment discoloration Present (may be difficult to Pulse Decreased or absent palpate with severe edema) 22 ASSESSING ARTERIAL AND VENOUS INSUFFICIENCY Arterial Insufficiency Venous Insufficiency - Only when constantly kept - Firm brawny edema Edema in dependent position - Moderate to severe dependent edema - At toes, heels, lateral - At medial malleolus ankle & pressure points (ankle), & anterior tibia - Pale ischemic base Ulcers - Bleeding - No bleeding - Irregular - Well defined edges - Pain not usually severe - Painful, & Circular (unless deep) 23 Acute Arterial Insufficiency 24 Venous Insufficiency 25 Arterial Insufficiency Venous Insufficiency  A: Arterial Ulcer, B: Gangrene Caused by Arterial Insufficiency and C: Venous Stasis Venous Insufficiency A- caused by arterial emboli; B-gangrene from severe arterial ischemia; C- Ulcer from venous stasis 27