hello professor king here today we're going to be talking about the peripheral vascular and the lymphatic systems in relationship to collecting data during our head to toe assessment and physical assessments so this is going to be just a quick review so the heart pumps freshly oxygenated blood through the arteries to all body tissues the function of the arteries is to supply oxygen and essential nutrients to tissues the pumping heart makes this a high pressure system arterial walls are strong tough and tense to withstand the pressure demands they contain elastic fibers which allows their walls to stretch with systole and recoil with diastole let me see ischemia is due to a deficient supply of oxygenated arterial blood to the tissues caused by an obstruction in the blood vessel a complete blockage will lead to the death of distal tissue and partial blockages creates an insufficient supply and ischemia may be apparent only at exercise when oxygen demands increase all right so the arteries in the arm the major artery supply in the arm is the brachial artery and i apologize if you can hear my dog in the background she's snoring today um the the brachial artery runs in the bicep and tricep furrow of the upper arm and it surfaces at the antecubital um phosphate at the elbow medial to the biceps tendon immediately below the elbow the brachial artery artery bifurcates into the ulnar and radial arteries these run distally and form two arches supplying the hand these are called superficial and deep palmar arches the radial pulse lies just medial to the radius of the wrist and the ulnar artery is in the same only in relation to the ulnar but it's deeper and often difficult to feel and if you recall we talked about all of these in our lab session last week right so for vessels of the legs um the arteries in the legs the major artery is your femoral artery which passes under the inguinal ligament the femoral artery travels down the thigh at the lower thigh it transitions posteriorly and then is termed the popliteal artery below the knee the popliteal artery divides anterior tibial artery travels down the front of the leg on the dorsum of the foot where it becomes the dorsalis pedis in the back of the leg the posterior tibial artery travels down the um down behind the medial malleolus and into the foot and it forms the posterior tibial pulse the body has more veins they lie closer to the skin surface veins drain deoxygenated blood and its waste products from the tissues and returns it to the heart unlike arteries veins are low pressure systems each arm has two sets of veins superficial and deep the superficial veins are in the subcutaneous tissue and are responsible for most of the venous return the legs have three types of veins deep veins which run alongside deep arteries and conduct most of the venous return from the legs these are the femoral and popliteal veins as long as these veins remain intact superficial veins can be excised without harming circulation and an example of that would be like your saphenous vein which is commonly used in coronary artery bypass grafts so they would strip that vein out of the leg and use it to create a bypass graft in the heart remember you just have to have a broad understanding of how these things work so that you can understand why a person may have edema or they may have weak pulses this is not an amp class this is just a broad overview alright so with venous flow veins drain deoxygenated blood and waste products from the tissues back to the heart they serve as a large reservoir for circulating blood veins also contain valves at periodic intervals to prevent blood from flowing backwards so with this low pressure system the mechanism mechanism to keep it moving forward is contracting skeletal muscles a pressure gradient caused by breathing and interluminal valves problems with any of these elements can lead to venous stasis venous structures differ from arterial structures because of the valves venous blood flows just one way towards the heart because venous pressure is low the walls of the veins are thinner than those of arteries hypercoagulable states and vein wall trauma are factors that increase the risk of venous disease or varicose veins create incompete um create incompetent valves or they're usually caused by incompetent valves where the lumen is so wide the valve cuffs cannot approximate anymore this condition increases venous pressure which then further dilates the veins some people have a pre predisposition a genetic predisposition to various coast veins but obesity and pregnancy are also risk factors that increase the risk for this the lymphatic system is a separate vessel system which retrieves excess fluid and plasma proteins from the interstitial spaces and returns into the bloodstream without lymphatic drainage fluid would build up in the interstitial spaces and produce edema when the fluid isn't drained off we see swelling and edema that is what i want you to get out of this the lower extremity arteries and veins depend on the lymph system to drain excess fluid if there is an issue with these systems then we would see swelling and edema in the legs it can also occur in the arms but is not as common because the legs hang down we get what we call that dependent edema also the vessels in the legs are much larger so we see issues with them much quicker the lymphatic system is part of our immune system processes of the immune system are complicated and are not fully understood the immune system detects and eliminates foreign pathogens both those that come in from the environment such as bacteria and viruses and those arising from inside so abnormal or mutant cells think cancer cells it accomplishes this by phagocytosis which is digestion of substances using neutrophils and monocytes macrophages and by production of specific antibodies or specific immune responses by the lymphocytes that's where you would see the swelling of the lymph nodes such as with strep throat often you will have a swollen lymph nodes behind your ears so you would know that you have a problem in the head and neck area this is just a slide showing on the lymphatic ducts and drainage patterns within our body this slide shows um the related organs your spleen is located in the left upper quadrant of the abdomen and it has four functions it destroys old red blood cells it produces antibodies it stores red blood cells and it filters microorganisms from the blood while the spleen plays an important role in your immune system you can actually live without your spleen it may have been removed because of trauma or cancer and just know that these patients may be more prone to getting infections um the other organ that you know we're commonly aware of is tonsils and your adenoids they are located at the entrance to the respiratory and gastrointestinal tracts and they respond to local inflammation and once again those can be removed without any issues as well all right so um some of our considerations with our older adults is um that the peripheral blood vessels grow more rigid with age resulting in arterial sclerosis with increased prevalence of peripheral artery disease so i want you to remember that arterial sclerosis produces a rise in systolic blood pressure and do not confuse this with atherosclerosis which is a deposit of flat fatty pox excuse me fatty plaques um on the intima of the arteries both of these processes can be present with peripheral artery disease intermittent claudication is pain in the calf muscles brought on by walking and it is usually relieved by rest and that's why it's important to ask the questions what aggravates your pain and what relieves your pain aging produces a progressive enlargement of the intra muscular caffeines so prolonged bed rest prolonged sitting and heart failure increase the risk of dvts and subsequent pulmonary embolisms because of these veins being enlarged don't forget to refer to your tubloski book for the normal changes of aging it's a really really good resource for you all right so now we're going to talk about our subjective data so you're going to be asking your patient whether or not they have leg pain or cramps skin changes on their arms or legs they've noted any swelling if they've noticed any lymph node enlargement you're going to ask them about their medications and their smoking history and we're going to kind of go through all of these so with your leg pain and cramps you want to know where remember that intermittent claudication is a vascular related pain that develops in the muscles when walking you want them to describe their pain you know is it burning aching cramping stabbing did this come on gradually or sudden is it aggravated by activity or walking how many blocks can you walk or how many stairs can you climb does can you produce pain does it produce pain when you're doing these activities has the amount changed recently is the pain worse with elevation or cool temperatures does the pain wake you up at night have you had any recent changes in your ability to exercise and then once again you want to ask about what relieves this pain when you dangle your feet does walking rubbing what helps it is this leg pain associated with any skin changes is that area red hardened does this impact your activities of daily living do you have a history of vascular problems heart problems diabetes obesity pregnancy smoking trauma prolonged standing or bed rest these are all good questions to ask you don't have to ask them all they will be tailored to what your patient's response is at the time all right so subjective data um that applies towards your skin changes so um you want to know what color are they is there redness powder blueness brown discolorations any changes in the temperature excess warmth or coolness for your legs how have you treated these do you wear support hose where on the leg is it you want to look at it is there any pain with a leg ulcer because some leg ulcers are painful and some are not and we'll get more into those a little bit later on the arms or legs you want to ask about the skin changes related to color and temperature any changes in appearance the use of support hose and treatments we've talked about the ulcers any presence of swelling and associated symptoms with that and then once again it's always very important to note alleviating factors so if they've noticed color changes if they elevate their legs does the color change go go back to normal so with swelling you want to look at it and decide is it in one leg or both legs what seems to bring it on is it only when they're sitting for long periods of time with their legs dangling down does it occur after a long day at work you know what relieves the swelling does it go away with elevation when did it start what time of day is the swelling worst is it in the morning or after you've been up most of the day the swelling come and go or is it constant have you had any trauma you want to talk about you know what they do for a living if they're still working to kind of get an idea if they're standing all day or sitting all day is it relieved with elevation or support hose and is the swelling associated with any pain heat redness ulceration or hardening of the skin you want to think about dvts all right so with lymph node enlargement you want to note the location size and the associated symptoms where in the body are they swollen how long has it been swollen how do you how do they feel to you are they hard are they soft swollen glands are associated with pain or local infection so you want to think about that you want to inquire about what kind of medications they're taking medications will always be important to know i know at this point in health assessment you're not going to know what kinds of medications are related to what type of side effects but as you move forward in the program and have farm and begin to take care of patients in the hospital you will be able to put all of this together you will see that there are certain medications that are used for treatments of issues like edema and then you'll see that there are some medications that it will cause edema as a side effect ask them if they've started a new medication think could this be a side effect even if you do not understand why this patient's um skin is different colors or has edema you want to recognize and note that is not the normal for them and then of course you want as we've discussed smoking history is always important to know um as well as their tuberculosis history and whether or not they've been tested for that okay so we know that subjective data is what the patient was telling us now we're going to begin to collect our objective data this is going to be from our assessment so it's going to be things that we see and that we inspect and feel okay so as part of our preparation you always want to do proper hand hygiene you want to make sure that the environment is of a comfortable temperature and then you'll always do a bilateral comparison you'll compare the left to the right one to another during a complete physical examination you'll examine the arms at the very beginning when you're checking vital signs and the person is sitting examination of the arms and legs includes your peripheral vascular characteristics musculoskeletal findings and neurologic findings so you'll want to begin with your inspection you'll lift both hands into your hands you'll inspect them you'll turn the person's hands over noting the color of the skin and the nail beds you'll be able to note the temperature the texture of their skin the turgor and the presence of any lesions edema or clubbing we talked about clubbing before remember that clubbing of the fingers is a result of long standing oxygen deprivation and we really want to take a good look at the patient's arms and legs so you'll want to note any presence of scars on the hands or arms many occur normally with usual childhood abrasions or with occupations involving hand tools you want to palpate both radial pulses noting the rate rhythm the elasticity of the vessel wall and an equal force okay with the person's hands near the level of the heart you'll want to check their capillary refill and we'll go over how to do these things in lab you'll want to look at the hands from the side to detect clubbing the normal nail bed angle is 160 degrees um you want to check for when you're checking for the capillary refill you want to note um the brick briskness versus the sluggishness of it and when checking radial pulses you'll grade the amplitude on a three-point scale meaning three plus is increased fully bounding and two plus is normal one plus is weak and a zero is absent all right so inspecting and palpating the legs you want to uncover the legs while maintaining patient privacy so you don't want to expose there is no need to expose the patient's genitals during this you want to look at their legs normally hair covers the legs even if the legs are shaved you will note hair still being on the dorsa of the toes but also you need to understand that as a person gets older they have less and less hair on their legs venous patterns normally are flat or barely visible you want to note any obvious very varicosities on your varicose veins these are usually best assessed standing because of that blood pooling in those veins when you have really really bad ones they'll be very obvious even when the patient's laying down both legs should be symmetric in size without any swelling or atrophy this can be easily assessed by standing at the foot of the bed and looking at both legs at the same time carefully comparing one to the other diffused bilateral edema may indicate systemic illness acute painful unilateral edema may indicate a dvt if the lower legs look asymmetric you want to measure the leg at the widest point using a non-stretchable measuring tape taking care to measure the other leg in the exact same place with the exact same centimeters down from the patella or other landmark that you've used if lymphedemia is suspected um you can measure also at the ankle the distal calf knee and thigh you will always record your findings in centimeters in the presence of skin discoloration skin ulcers or gangrenous toes you want to note the size and exact location skin should be warm and equal bilaterally bilateral cool feet may be due to environmental factors such as a cool room temperature apprehension cigarette smoking or even cardiovascular disease if you have any increased temperature that presents higher up on the leg you want to know whether it's gradual or abrupt you want to make sure that there's no calf tenderness okay these are all indicative of possible dvt brown discoloration is associated with venostasis and i'll show you some pictures later on about that dependent ruber which is a blue red color occurs with severe arterial insufficiency you want to palpate the pulses and you learned where to find all these pulses in lab last week if you have a weak peripheral pulse you can use adult excuse me a doppler ultrasound probe for this and i'll try to remember to bring one to lab so that you guys are familiar with what that instrument is the skin color reflects only um the contribution of the arterial blood so you want to keep that in mind light skinned persons feet normally will look pale but should still have like a pink tone to it darker skinned persons feet are a little bit more difficult to evaluate but you can always look at the soles of their feet and the palms of their hands because those are where you're going to see extreme color changes you want to check for pre-tibial edema and to do this you'll firmly depress the skin over the tibia or the medial malleolus for five seconds and then release normally your fingers should leave no indentation although with um pitting edema you'll commonly see it in persons if they've been um standing for a long period of time so many nurses experience this and this is why um a lot of times we'll wear compression stockings or you'll see it in your pregnant patients and once again we are not covering pregnancy in this class but it's just information to know if pitting edema is present you want to grade it on a scale and we have an example of the scale remember that the scale is subjective as well as qualitative and bilateral dependent edema occurs with heart failure diabetic neuropathy and hepatic cirrhosis all right so this is an example of venous insufficiency venous insufficiency is a condition in which the veins have problems sending the blood from the legs back up to the heart it can cause ulcerations to develop around the ankle pulses are present but may be hard to find because of the edema the food the foot may look cyanotic when it's dependent normally valves in your deep leg veins keep blood moving toward the heart with chronic venous insufficiency the vein walls are weakened and the vowels are damaged this causes the veins to stay filled with blood you'll hear the term pooling especially when you are standing chronic venous insufficiency is a long-term condition it's most commonly due to the malfunctioning of veins in the legs it may also occur as the result of past blood clots in the legs okay so risk factors include age family history female genders and this is related to the levels of the hormone progesterone if they've had a history of a dvt obesity pregnancy standing or sitting for a long period of times so if you think about our first responders law enforcement or ambulance drivers where they're prone to sitting and driving for long periods of time you may see them in that population and then somebody that is very tall symptoms include dull aching heaviness or cramping in the legs itching and tingling the pain may get worse with standing pain that gets better with with legs that are raised swelling of the legs redness of the legs and ankles skin color changes around the ankles um varicose veins on the surface and thickening and hardening of the skin on the legs and the ankles and this is a picture related to arterial insufficiency so arterial insufficiency pulses may be decreased or absence the skin is cool to the touch it's pale shiny they'll have hair loss in the area and pain in the legs and feet ulcers are around the toes and the lateral malleoli foot turns deep red when dependent and nails become thick and rigid alter arterial ulcers result from arterial occlusive diseases arterial insufficiency is a condition that slows or stops the flow of blood through your arteries remember arteries are the blood vessels that carry blood from the heart to the places in your body one of the most common causes of arterial insufficiency is atherosclerosis this is the hardening of the arteries fatty material called plaque builds up on the walls of your arteries this causes them to become narrow and stiff and as a result it's hard for the blood to flow through the arteries blood flow may be suddenly stopped due to a blood clot clots can form on the plaque or travel from another place in the heart or artery this is called an ambulance embolus arterial ulcers usually occur at the toes metatarsal heads heals the lateral ankle they are characterized by pale ischemic base smooth well-defined borders and no bleeding and the risk factors include your older adults african americans smoking hypertension diabetes high cholesterol obesity and vascular disease and this is an example of gangrene due to a lack of oxygen burgers disease affects blood vessels in the body most commonly in the arms and legs blood vessels swell which prevent the blood flow causing clots to form this can lead to pain tissue damage and even gangrene as this is an extreme example here and the major risk factor for this is smoking all right so this is the pitting edema pitting edema edema may be pitting or non-pitting so shown here is an example of pitting pressure forces fluid into the underlying tissues causing an indentation that slowly fills to determine the severity you want to estimate the indentations depth in centimeters and you've seen this slide before and this is just an example of some of the scales that you use so you would want to check with your facility to see what scale they use for it and then there's another example of the pitting edema okay all right so some um considerations that we want to think about for our older adult is that the dorsalis pedis and the posterior tibial pulse may become difficult to find due to the rigidity rigidity of their vessels and decreased peripheral circulation you will see changes in their skin and nails so once again you need to know what the normal changes are so that you can identify abnormal changes so make sure that you're referring to your tabloski book all right so abnormal findings include renaud's phenomena lymphedemia and then we have our arterial ulcers our venous ulcers our varicose veins and dvts your jarvis book has some good pictures of these abnormal findings this is not something that you're going to be tested on you will learn more about these conditions in med-surg so this is an example of a venus ulcer um they are a wound that is slow to heal they have an irregular border they're shallow and characterized by bleeding they can occur on the tibia and the medial malleolus venous ulcers account for 80 percent of leg ulcers and then this is an example of your arterial ulcer um they usually occur on the toes you know as we said before and then on the lateral ankle they are characterized by pale ischemic base they have smooth well-defined borders you'll hear people refer to the fact that it looks like it was punched out and no bleeding risk factors include your older adults african americans smoking hypertension diabetes high cholesterol obesity and vascular disease again this is an example of subjective charting and this is what your patient has stated to you the patient states no leg pain no skin changes no swelling or lymph node enlargement no past history of heart or vascular problems diabetes or obesity they do not smoke and they're on no medications so this is just a very normal subjective assessment health history okay so here's an example of sample charting of objective data objective is what you are inspecting now these are things that you will see during your assessment so upon inspection extremities have a pink tan color without redness cyanosis or any skin lesions the extremity size is symmetric without swelling or atrophy upon palpitation the temperature is warm dry and equal bilateral all pulses present two plus and equal bilateral so these are just things that you will note during your assessment of the patient and that concludes our lecture for today and i will see you in class thank you