Hello, this is Dr. Patterson and this lecture includes the peripheral vascular and lymphatic systems. I just wanted to quickly review a little anatomy and physiology with you. This is a representation of the arterial pulses in the arm. You can see the brachial artery which runs medial down the arm.
It then branches into the radial and ulnar arteries. The radial artery is usually easily palpable along the inner aspect of the wrist aligning with the thumb. The major arterial pulses of the leg includes the femoral artery, popliteal artery behind the knee, and the pedal pulses.
If you are unable to feel a pulse, a doctor may be used to help locate the pulse. When thinking about perfusion, while a pulse is indicative of blood flow, other indicators of circulation include checking for normal temperature, sensation, and color of the extremity being assessed. The dorsalis pedis pulse runs along the dorsal part of the foot and the posterior tibial pulse can be felt directly under the medial malleolus. The posterior tibial pulse will typically be weaker than the dorsalis pedis pulse.
You can also check capillary refill on the toes and compare on each side. In lab we will be reviewing the lymph nodes of the head and neck. However, it is important to know that there are lymph nodes in other locations of the body.
The lymphatic system encompasses both vascular functions and immune functions. The deeper the lymph nodes, the harder it is to palpate. There are also a number of factors that may impact the ability to feel lymph nodes.
Infection can cause lymph nodes to be more prominent and or tender. And also like amplitude of pulses, lymph node size can vary between each individual. Understanding how to identify normal or benign lymph nodes versus potentially malignant lymph nodes is essential.
Normal or benign lymph nodes will be slightly tender and movable with palpation. Potentially malignant lymph nodes will be fixed, non-movable, and non-tender. We don't want to cause panic in our patients, but we do want to report these findings to a provider.
In all things with assessment, we want to report subjective findings from our patients and objecting findings on the assessment. We do not need to provide medical diagnoses to the patient or chart a medical diagnosis without the confirmation from a provider or further diagnostic testing. In this picture, you can see the placement of the femoral artery and location to the horizontal and vertical chains.
Lower extremity edema is one of the top problems that is diagnosed and treated in my adult and geriatric populations. Edema is sometimes caused by increased plasma volume from sodium retention, increased capillary membrane permeability related to burns, snake bites, angioedema, which can be caused by some ACE inhibitors, allergic reaction, and is often proximal to the site of injury. Renal disorders such as chronic kidney disease due to decreased filtration and expulsion of waste, nutritional deficiencies may also cause edema. A patient with a low albumin level may indicate that a dietary consult is needed to assist the patient with increasing protein in their diet. There are a host of medications that can cause edema, but in my experience, the most likely offender has been Imlodipine or Norvasc, a calcium channel blocker.
Also, lymphedema can occur with the inadequate removal of lymphatic fluid or blockage. Heart failure is a major cause. This can be verified with an echocardiogram and other diagnostics.
And diuretics such as Lasix can be added to assist with diuresis. Another cause is a DVT or DVTs. This likely will be unilateral swelling with possible warmth and or tenderness. However, although rare, I have seen bilateral DVTs where both legs were swollen. I ordered a Doppler ultrasound on both just to be safe because there were no other additional causes.
and found multiple DVTs in both legs. So never exclude DVTs just because the edema is bilateral, especially if the findings are acute. These were successfully treated with anticoagulation.
When thinking about potential DVTs, think about a patient's risk factors. Pregnancy, sedentary, post-surgical, or certain inflammatory conditions. All can put a patient at higher risk.
While it does not exclude a DVT, DVTs are less likely in patients who are already on anticoagulants such as Coumadin or Eliquis. Health history findings that could indicate peripheral vascular disease or peripheral artery disease are pain in the upper and lower extremities. History of intermittent claudication, which is prevalent in peripheral artery disease or PAD, cold, numbness, or pallor, unintended hair loss, edema in lower extremities, tenderness, and redness, are all symptoms of potential vascular problems and need further follow-up. Other findings that warrant follow-up related to vascular or lymphatic problems are varicose veins, non-healing or slow healing wounds, fingertips or toes that change color in cold weather, erectile dysfunction, GI pain after eating, or tender and swollen lymph nodes.
The example on the left is considered pitting edema, where you can see the indentation. Be sure that you look at the classification chart for pitting edema. On the right is an example of classic chronic venous insufficiency. You may see some brown or light red staining caused by the leakage of iron, also called hemocytin staining.
You will likely see pitting edema, although I have seen non-pitting as well. You may also see some ulcers, weeping, and possible bulla if severe. However, in lymphedema, you will mostly see non-pitting edema.
We touched on a few of these previously, but I wanted to reiterate conditions and medications that can increase risk of clotting like DVTs or even types of CVAs like ischemic strix. Medications, especially oral contraceptives or hormone replacement therapy, especially those with higher estrogen content, pregnancy or recent pregnancy, and certain inflammatory conditions. Inflammation can cause damage to the lining of the veins and arteries. causing narrowing, potentially setting off the clotting cascade.
Other conditions include active cancer, coronary artery disease, which, side note, can also lead to carotid stenosis, which you will hear with a brewery, which you will hear a brewery with the bell of the stethoscope, history of a heart attack, stroke, hypertension, CHF, recent surgery or fractures of the long bones, you can all... lead to hypercoagulable states. Potential family risk factors may include relatives with a history of peripheral vascular disease or peripheral artery disease, varicose veins, abdominal aortic aneurysm, also known as a triple A.
You could possibly hear a bruit when listening to the abdomen, but we will talk more about this later, but I wanted to mention it here. A history of coronary artery disease. sudden cardiac death less than 60, and diabetes.
Lifestyle factors such as prolonged standing and sitting, long airplane rides, sedentary lifestyle, and decreased mobility or paralysis, casting, or other orthopedic appliances may contribute to the development of thrombosis. The use of blank has been associated with the increased risk of clot formation in the legs. A.
Analgesics, B. Proton pump inhibitors, C. Oral contraceptives, or D. Cholesterol lowering agents. The answer is C.
Oral contraceptives. Research has shown that the use of oral contraceptives has been connected to an increased risk of developing deep brain thrombosis. Certain equipment you may need for a peripheral vascular or lymphatic assessment is a tape measure. for measuring the circumference of an endematous extremity for comparison purposes, or a Doppler ultrasound to help with locating non-palpable pulses. Lying down, if possible, may be helpful to view and access arms and legs.
Remember to drape the patient to ensure privacy. In both the upper and lower extremities, while you have different pulses to assess, you are still looking for the same attributes such as size, symmetry, swelling, Lesions like blisters, scars, or moles, pigmentation, tenderness, skin color, texture, temperature, nail beds, capillary refill, and edema. This is just the chart for the recommended grading of pulses, with 0 being absent or unable to palpate to 3+, which is bounding.
This is an example of a venous ulcer on the left and an arterial ulcer on the right. Make sure you review the different characteristics of these in your book. In this picture, you can see multiple bluish rays superficial varicosities caused by damage or weakened vein walls and valves.
Sometimes these cause no symptoms at all and some can be very painful and warrant intervention. Question 3 says, a normal pulse is given which grade in documentation? A. 0 B. 1+, C.
2+, or D. 3+. The answer is C, 2+. A grade of 2 plus is considered brisk, unexpected, or normal.
A zero indicates absent or unable to palpate. One plus is diminished, weaker than expected, and three is bounding. Important health promotion and counseling topics are preventative measures such as smoking cessation, obtaining a healthy BMI, exercise, hypertension control, lipid control, possibly the addition of a statin, dietary changes, diabetes management, decreasing alcohol use if in excess, and proper foot care especially if diabetic or decreased sensation. That concludes our peripheral vascular and lymphatic lecture.
Please let us know if you have any questions.