Peripheral Vascular, Lymphatic, Heart & Neck Vessels – Review

Structure & Function of the Peripheral-Vascular (PV) & Lymphatic Systems

Three intertwined subsystems
- Arteries
- High-pressure conduits; walls rich in elastic & smooth muscle fibres
- Actively constrict/dilate ➜ regulate peripheral blood flow
- Each heartbeat launches a pressure wave → palpable pulse
- Obstruction ➜ tissue ischemia or necrosis
- Veins
- Low-pressure, capacitance vessels that return de-oxygenated blood + metabolic waste to heart
- Flow maintained by
  - Skeletal-muscle contractions (“calf pump”)
  - Thoracic pressure changes during breathing
  - One-way intraluminal valves
- Lymphatics
- Collect excess interstitial fluid ➜ return to bloodstream
- 3 major roles
  1. Conserve fluid & plasma proteins lost from capillaries
  2. Central component of immune defense
  3. Absorb lipids (chylomicrons) from small intestine
- Drain into two main trunks → empty into R & L subclavian veins

Major Peripheral Pulses & Landmarks

Temporal – anterior to ear
Carotid – groove between sternomastoid & trachea
Brachial – biceps–triceps furrow
Radial – medial to radius at wrist
Ulnar – medial side of wrist (often non-palpable)
Femoral – under inguinal ligament
Popliteal – popliteal fossa, knee flexed
Posterior tibial – posterior to medial malleolus (near Achilles)
Dorsalis pedis – dorsum of foot, lateral to extensor hallucis tendon
If pulse cannot be palpated ➜ use Doppler; never assume presence!

Major Veins (high-yield map)

Head/neck: internal & external jugular, subclavian, brachiocephalic → SVC
Upper limb: axillary → cephalic, basilic, brachial deep system
Abdomen/pelvis: common, internal & external iliacs (+ pelvic tributaries)
Lower limb: femoral (deep & superficial branches), popliteal, anterior/posterior tibial, fibular, great & small saphenous, plantar & dorsal venous arches

Lymph Nodes & Associated Organs

Regional nodes
- Cervical ➜ head & neck
- Axillary ➜ breast, upper arm
- Epitrochlear (antecubital fossa) ➜ hand, lower arm
- Inguinal (groin) ➜ lower extremity, external genitalia, anterior abdominal wall
Organs
- Spleen (LUQ): destroys aged RBCs, stores RBCs, filters microbes, produces antibodies
- Tonsils (palatine, pharyngeal, lingual): lymphoid tissue guarding GI/respiratory tracts
- Thymus (childhood) ➜ T-lymphocyte maturation
- Bone marrow ➜ origin & maturation site for B-lymphocytes

Aging-Related Changes (PV & Lymphatic)

Arteriosclerosis – vascular stiffening → ↑ systolic BP
Atherosclerosis – lipid plaque deposition ➜ PAD risk
Calf veins enlarge progressively
Fewer, smaller lymph nodes

Subjective Data – PV System (Pg 511)

Extremity pain; claudication distance ≈ # blocks/stairs to pain → PAD clue
Edema
- Bilateral → CHF or systemic cause
- Unilateral → obstruction, DVT, local inflammation
Node enlargement/tenderness
Skin changes: redness, pallor, cyanosis, brown spots, temperature differences
Medication & smoking history

Upper Extremity Assessment (Pg 513)

Normal
- Uniform skin/nailbed colour, symmetrical size
- Nail angle $160^\circ$ ; capillary refill <2\text{–}3\,\text{s}
- Flat, barely visible superficial veins
- No lesions, scars, edema; non-palpable epitrochlear node
Abnormal
- Clubbing (profile sign flat/convex) ↔ chronic hypoxia
- Refill >3\,\text{s} (↓ cardiac output) – interpret in context (cold room, smoking, anemia)
- Palpable epitrochlear node → infection/lymphoma
- Pulse grading: $0 = \text{absent},\; 1 = \text{weak},\; 2 = \text{normal},\; 3 = \text{full},\; 4 = \text{bounding}$ ; any deviation > or <2 significant
- Modified Allen Test
1. Occlude radial & ulnar arteries, have pt open/close fist
2. Release ulnar → colour should return <7\,\text{s}
3. Persistent pallor = inadequate collateral flow

Lower Extremity Assessment

Normal
- Colour consistent with ethnicity; even hair distribution
- Symmetric temperature & leg circumference
- Flat venous pattern; pulses $2+$ (femoral, popliteal, posterior tibial, dorsalis pedis)
- Inguinal nodes non-palpable; no lesions, scars, edema
Abnormal
- Pallor (vasoconstriction) | Erythema (vasodilation)
- Hair loss → malnutrition/PAD
- Edema
- Bilateral → CHF, renal, hepatic disease
- Unilateral → infection, DVT, lymphedema
Suspect arterial deficit?
1. Elevate legs $30\,\text{cm}$ for $30\,\text{s}$
- Normal: light pink/pale
- PAD: marked elevational pallor
1. Dangle legs; note colour return time
- Normal $\le10\,\text{s}$
- PAD: delayed return + dependent rubor (deep red)

Chronic Ulcer Types (Tbl 21.4)

Arterial (Ischemic)
- Intermittent claudication; pain ↑ with elevation
- Cool limb, diminished pulses, punched-out dry lesion, well-defined edges, no bleeding
Venous (Stasis)
- Pain worsens with activity/day’s end; relieved by elevation
- Edema, brown calf discolouration (hemosiderin), irregular borders, may ooze/bleed

Varicose Veins vs Deep Vein Thrombophlebitis (DVT)

Superficial Varicose Veins
- Chronically high venous pressure → valve incompetence → dilated, tortuous veins
- Symptoms: ache, heaviness, burning, throbbing
DVT
- Occluded deep vein → inflammation, edema, cyanosis
- Sudden sharp pain, unilateral warmth & swelling; possible redness/blue hue

Lifestyle Education – Peripheral Health

Inspect feet daily; diabetics must be especially vigilant
Wash/dry between toes; mild soap/lotion (no oils in baths)
Trim nails straight; file edges
Encourage exercise, properly fitted shoes

Cardiovascular (Heart & Neck Vessels) Anatomy

Heart behind precordium (2-5th ICS, R sternal border → L mid-clavicular line)
Two circulatory loops: Pulmonary & Systemic
Chambers & valves recap: RA → tricuspid → RV → pulmonic valve → lungs → LA → mitral → LV → aortic valve → systemic

Cardiac Cycle

Systole (S1) – AV valves close; ventricular contraction ejects blood
Diastole (S2) – Semilunar valves close; ventricles relax & fill
Extra sounds
- S3 (ventricular gallop): early rapid filling; fluid overload, CHF
- S4 (atrial gallop): late diastole; stiff ventricle, CAD, HTN
- Murmur: turbulent flow due to ↑ velocity, ↓ viscosity, or structural defect (stenosis/regurgitation, septal defect)

Heart Sound Characteristics

Frequency (high/low pitched)
Intensity (loud/soft)
Duration (brief vs silence)
Timing (systolic vs diastolic)

Cardiac Conduction Pathway

SA node (pacemaker) → atrial depolarisation P wave
AV node → Bundle of His → R/L bundle branches → Purkinje fibres → ventricular depolarisation QRS, repolarisation T wave
Intervals (ECG): $PR, QRS, ST, QT$ monitor electrical integrity

Neck Vessels

Carotid arteries (R & L common)
Jugular veins
- Internal (deep) & External (visible over SCM)

Aging Adult – Cardiovascular

↑ systolic BP, widened pulse pressure
↑ AP chest diameter
Dysrhythmias: supraventricular, ventricular, ectopic beats
Orthostatic hypotension common
Presence of S4 may be normal

Subjective Data – CV System (Pg 467)

Angina, dyspnea, orthopnea, cough, fatigue, cyanosis/pallor, edema, nocturia
Cardiac history (personal & family)
Enumerate risk factors

CVD Risk Factors

Modifiable: abnormal lipids, smoking, HTN, diabetes, abdominal obesity, psychosocial stress, poor diet, alcohol, sedentary lifestyle
Non-modifiable: genetics, race/ethnicity, gender, family history

Neck Vessel Examination

Carotid Palpation
- One side at a time; gentle to avoid vagal ↓HR or ↓cerebral flow
Carotid Auscultation
- Use bell at angle of jaw, mid-neck, base; pt holds breath
- Bruit = swishing, indicates stenosis/atherosclerosis
Jugular Venous Pulse
- Pt supine 30-45°, head turned opposite side, tangential lighting
- > $3\,\text{cm}$ above sternal angle suggests ↑ right atrial pressure (CHF)

Apical Impulse (PMI) Palpation

Pt exhales/holds breath, rolled to left side
Use fingertip: 4th/5th ICS, MCL; diameter $1\text{–}2\,\text{cm}$ , short, gentle
Abnormal: sustained, enlarged (>2 cm), multiple spaces ➜ ↑ cardiac output, cardiomegaly
Thrill = palpable murmur (turbulent flow)

Auscultation Sites – "APE To Man"

Aortic: 2nd R ICS, sternal border
Pulmonic: 2nd L ICS
Erb’s Point: 3rd L ICS
Tricuspid: L lower sternal border
Mitral (Apex): 5th L ICS, MCL

Technique

Pt sitting; listen base ➜ apex in "Z" pattern
Diaphragm then bell; for S3/S4/diastolic murmurs position pt L lateral
Determine rate (60-100) & rhythm (regular vs irregular)
Identify S1/S2 individually; listen for extras or murmurs

Abnormal Findings

Pulse deficit (apical-radial difference): arrhythmia, HF
Diminished heart sounds: emphysema, obesity, pericardial effusion
Extra sounds: S3 (fluid), S4 (CAD)
Murmur documentation
- Timing, loudness (Grades I-VI), pitch, pattern (crescendo, decrescendo), quality (blowing, harsh), location, radiation
Regurgitation vs Stenosis diagram: incompetent valve allows backflow vs narrowed valve obstructs forward flow

Chest Pain Assessment (Tbl 20.2)

Character: pressure, squeezing, stabbing, burning, dull
Location: substernal, epigastric, unilateral, etc.
Timing: effort-related or rest
Severity: $0\text{–}10$ scale
Radiation: jaw, neck, shoulder, arm, back
Associated Sx (red-flag cardiac): diaphoresis, N/V, dyspnea, fatigue, palpitations

Heart Failure Syndromes

Left-sided
- Pulmonary congestion: cough, crackles, wheeze, pink sputum
- Dyspnea, orthopnea, PND, tachycardia, fatigue, cyanosis
Right-sided (Cor Pulmonale)
- Systemic venous congestion: JVD, peripheral edema, ascites, hepatosplenomegaly, GI distress
- Often secondary to pulmonary disease

Health Promotion – Cardiovascular (Pg 481)

Control blood pressure; medication adherence
Smoking cessation
Lifestyle modifications: heart-healthy diet (low Na⁺/saturated fat), regular physical activity, weight management