Cardiovascular & Lymphatic Assessment – Lecture Review

Circulatory & Lymphatic System – Full Lecture Notes

Overview of Cardiovascular Function

• Two main transport networks
  • Blood (high-pressure arterial + low-pressure venous)
  • Lymphatics (one-way vacuum system that returns excess interstitial fluid & plasma proteins to the blood after filtration)
• Impairment → ↓ delivery of O2 & nutrients + ↓ removal of CO2 & metabolic waste → ischemia → tissue death

Arterial System ("High-Pressure")

• Arteries are muscular, elastic; expand & recoil with each heartbeat → palpable pulse wave
• Occlusion (clot, plaque) → downstream ischemia (brain, heart, limbs, digits)
• Palpation landmarks (feel where vessel crosses bone/superficial area)
  • Temporal (anterior to ear, one side at a time)
  • Carotid (mid-neck, never palpate both simultaneously – risk of ↓ cerebral perfusion)
  • Brachial (medial biceps-triceps groove, antecubital fossa)
  • Radial (lateral to flexor carpi radialis tendon at wrist)
  • Ulnar (medial wrist, harder to feel; used for Allen test)
  • Femoral (below inguinal ligament, midway ASIS–pubic symphysis)
  • Popliteal (knee flexed, deep in popliteal fossa)
  • Posterior tibial (behind medial malleolus)
  • Dorsalis pedis (lateral to extensor hallucis longus tendon on dorsum of foot)
• If pulse not palpable → Doppler assessment – never assume patency
  • Critical post-orthopedic surgery d/t tourniquet/clot risk

Venous System ("Low-Pressure")

• Major veins: internal & external jugular, subclavian, brachiocephalic, SVC, axillary, brachial, cephalic, basilic, IVC etc.
• Venous return mechanisms
  • Skeletal-muscle pump (especially calf)
  • Respiratory pump (thoraco-abdominal pressure changes)
  • Intraluminal valves prevent backflow
• Failure → venous stasis → edema, stasis dermatitis, ulcers
• Veins a.k.a. “capacitance vessels” (hold ~70% blood volume)

Lymphatic System

• Completely separate vessel tree; open-ended capillaries → larger trunks
• 3 core functions
  1. Conserve fluid & plasma proteins that leak from capillaries
  2. Major component of immune defense (filters pathogens before re-entry to blood)
  3. Absorb lipids (chylomicrons) from small intestine
• Drainage
  • Right lymphatic duct → right subclavian v. → drains R head/neck, R arm, R thorax, R lung, R heart, R upper liver
  • Thoracic duct → left subclavian v. → drains rest of body
• Propelled by skeletal-muscle contraction, pressure changes, valves (same as veins)
• Primary lymphoid organs
  • Bone marrow – origin of B-lymphocytes; hematopoiesis
  • Thymus (retro-sternal) – T-lymphocyte maturation until puberty → involutes to fat
• Secondary lymphoid organs
  • Spleen (LUQ) – destroys old RBCs, stores RBCs, produces antibodies, filters microbes
  • Tonsils (palatine, pharyngeal/adenoid, lingual) – local immune response at airway/GI entry
• Surface lymph nodes (normally soft, non-tender, non-palpable)
  • Head/neck: pre- & post-auricular, occipital, tonsillar, submandibular, submental, anterior & posterior cervical, deep cervical chain, supraclavicular
  • Arm: epitrochlear (antecubital fossa) – drains hand & forearm
  • Axillary (central, pectoral, lateral, subscapular) – breast & upper limb drainage
  • Inguinal – lower extremity, external genitalia, anterior abdominal wall
  • Palpable, fixed, >1 ext{ cm}, hard → infection or malignancy

Aging Considerations

• Arteriosclerosis = vessel wall stiffening → ↑ systolic BP, widened pulse pressure
• Atherosclerosis = intimal plaque/fat deposition → PAD risk
• Fewer/smaller lymph nodes, sluggish immune response
• Prominent calf veins, ↑ orthostatic hypotension, ectopic beats

Peripheral Vascular Assessment

• Subjective Hx: limb pain, claudication distance (# blocks/stairs), cold/numbness, skin changes (color, hair loss), swelling (uni vs bilateral), lymph node enlargement, meds, smoking
• Inspection/Palpation – Upper extremity
  • Nail profile sign: normal 160^{\circ}; \ge 180^{\circ} = clubbing (chronic hypoxia)
  • Capillary refill < 2\text{ s} (book) / 3\text{ s} (traditional). Delayed from cool room, smoking, edema, anemia, ↓CO
  • Pulses graded 0 (absent) → 1+ (weak) → 2+ (normal) → 3+ (full) → 4+ (bounding). Report \ne 2+
• Modified Allen Test (collateral hand circulation)
  1. Pt makes fist several times → occlude radial & ulnar arteries
  2. Hand becomes pale
  3. Release ulnar (or radial) → color should return < 7\text{ s}
  4. Persistent pallor = inadequate collateral flow – avoid arterial puncture.
• Edema grading (pitting)
  • 1+: depth \approx 2\text{ mm}, instant rebound
  • 2+: \approx 4\text{ mm}, rebounds < 15\text{ s}
  • 3+: \approx 6\text{ mm}, rebounds 15–30\text{ s}
  • 4+: \approx 8\text{ mm}, rebounds > 30\text{ s}
• Ankle circumference (non-stretch tape, \approx 7\text{ cm} above medial malleolus) more reliable than pitting scale – mark site for consistency.

Color Tests for Arterial Sufficiency

• Elevation pallor: raise legs 30^{\circ} x 30\text{ s}
  • Normal → light pink hue
  • Ischemia → snow white
• Dependent rubor: sit up & dangle
  • Normal → pink < 10\text{ s}
  • Arterial insufficiency → dusky red-purple (rubor)

Peripheral Vascular Disorders

• Intermittent claudication – calf pain with walking, relieved by rest (PAD)
• Venous stasis ulcer – medial malleolus, irregular border, brown hemosiderin staining, edema, pain worse end of day & ↓ with elevation
• Arterial ischemic ulcer – “punched-out”, well-defined edge, distal toes, cool, pale, diminished pulses, pain ↑ with elevation
• Lymphedema – non-pitting, unilateral, d/t lymph node removal (post-mastectomy)
• Varicose veins – dilated, tortuous saphenous channels; aching/heaviness; cause = chronic ↑ venous pressure → valve incompetence
• Deep Vein Thrombophlebitis (DVT) – acute unilateral pain, warmth, erythema, edema; risk of PE

Patient Teaching – Foot & Vascular Care

• Inspect feet daily (mirror if needed); wash/dry between toes
• Mild soap, thin lotion then blot excess (prevent fungal growth)
• No bathroom surgery; toenails trimmed/filed by podiatry if vascular disease/DM
• Well-fitting shoes, cotton socks, avoid barefoot
• Leg/calf exercises, compression stockings, avoid prolonged standing/sitting
• Smoking cessation, weight control, glycemic & lipid management

Cardiac Anatomy & Physiology

• Heart in precordium: 2^{\text{nd}} \rightarrow 5^{\text{th}} intercostal space (ICS), R sternal border → L mid-clavicular line (MCL)
• Great vessels
  • SVC/IVC → right atrium (RA)
  • Pulmonic artery → lungs
  • 4 pulmonary veins → left atrium (LA)
  • Aorta → systemic circulation
• Valves
  • Atrioventricular (AV): Tricuspid (R), Mitral/Bicuspid (L)
  • Semilunar (SL): Pulmonic (R), Aortic (L)

Cardiac Cycle & Heart Sounds

• Systole (S₁ – “lub”)
  • Closure of AV valves (mitral & tricuspid)
  • Contraction → blood ejected to PA & aorta
• Diastole (S₂ – “dub”)
  • Closure of SL valves (aortic & pulmonic)
  • Relaxation → passive ventricular filling
• Extra Sounds
  • S₃ (ventricular gallop) – early diastole; volume overload/CHF; “Ken-tuc-ky”
  • S₄ (atrial gallop) – late diastole; stiff ventricle/HTN; “Ten-nes-see”
  • Murmur = turbulent flow → “gentle, blowing, swooshing”
  • Causes: ↑ velocity (\uparrow flow), ↓ viscosity (anemia), structural defect (stenosis/regurgitation)
• Describe sounds by frequency (pitch), intensity (loudness 1/6 → 6/6), duration, timing (systolic/diastolic)

Conduction System (brief)

• SA → AV → Bundle of His → R/L bundle branches → Purkinje

Neck Vessel Assessment

• Carotid artery
  • Palpate one side at a time; normal = 2+, brisk
  • Auscultate with bell for bruit (turbulence) while pt holds breath; palpable vibration = thrill
• Jugular veins
  • Observe JVD at >45^{\circ}; unilateral = aneurysm, bilateral = ↑ volume/CHF

Precordial Inspection & Palpation

• Apical impulse (PMI): 4th–5th ICS, L MCL; size \le 1\times2\text{ cm}, short tap
  • Best felt in L lateral decubitus (heart falls forward)
  • PMI displaced/increased = LV hypertrophy, high output states
• Thrill = palpable murmur (cat-purr) → turbulent flow

Auscultation – “APE To Man”

• Use diaphragm first (higher-pitch), then bell for low-pitch gallops/bruits — ALWAYS same sequence.

Heart Failure Patterns

Left-Sided ("Left → Lungs")

• Pulmonary congestion: crackles, wheezes, blood-tinged sputum
• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
• Restlessness, confusion, fatigue, tachycardia
• Cyanosis, ↓ capillary wedge

Right-Sided ("Right → Away/Systemic")

• Peripheral, dependent edema, weight gain
• JVD, hepatosplenomegaly, ascites
• GI distress, anorexia, fatigue, increased peripheral venous pressure

Cardiovascular Risk Factors

• Non-modifiable: age, sex, genetics/family hx, race/ethnicity
• Modifiable: dyslipidemia, HTN, diabetes, tobacco, obesity (especially abdominal), sedentary lifestyle, poor diet, alcohol, psychosocial stress

Health Promotion & Patient Education

• Control BP, lipids, glucose
• Adhere to prescribed medications (do not stop when BP normal)
• Heart-healthy diet (DASH/Mediterranean), ↓ sodium, ↑ fruits–veggies–fiber
• ≥150 min/week moderate exercise; compression socks for prolonged standing
• Weight management, smoking cessation, moderate or no alcohol
• Prompt evaluation of chest pain, new edema, color changes, sudden dyspnea