chapter 21 PTT

Peripheral Vascular and Lymphatic System

Presenter: Melodie Daniels, PhD, RN, CNS, NPD-BC

Structure and Function

Arteries

  • Temporal artery: Supplies blood to the forehead and scalp.

  • Carotid artery: Major blood vessel supplying blood to the head and neck.

  • Arteries in the arm:

    • Brachial: Major artery of the upper arm; a pulse point used in blood pressure assessment.

    • Ulnar: Supplies the medial aspect of the forearm and hand.

    • Radial: Supplies the lateral aspect of the forearm and is commonly assessed for pulse.

  • Arteries in the leg:

    • Femoral: Major artery in the thigh, branching into several arteries below the knee.

    • Popliteal: Located behind the knee; supplies the lower leg.

    • Dorsalis pedis: Supplies the foot and is assessed for circulation.

    • Posterior tibial: Supplies the posterior aspect of the leg and plantar surface of the foot.

Veins

  • Jugular veins: Responsible for draining blood from the head and neck. (Drafter detailed in Chapter 17)

  • Veins in the arm: Return deoxygenated blood to the heart; include superficial and deep veins.

  • Veins in the leg:

    • Deep veins:

      • Femoral: Runs parallel to the femoral artery and is a large vein for blood return.

      • Popliteal: Drains the knee area and deep structures of the lower leg.

    • Superficial veins:

      • Great saphenous: Longest vein in the body, often used in coronary artery bypass grafts.

      • Small saphenous: Drains blood from the posterior aspect of the leg.

      • Perforators (connecting veins): Connect superficial veins to deep veins, facilitating blood flow.

Venous flow

The return of blood through veins primarily relies on one-way valves that prevent backflow, skeletal muscle contraction, and respiratory movements, contributing to efficient circulation.

Lymphatics

  • Right lymphatic duct: Drains lymph from the right upper body into the right subclavian vein.

  • Thoracic duct: Drains lymph from the rest of the body into the left subclavian vein.

Functions of the lymphatic system:

  • Filters lymph and fights infections through lymph nodes.

  • Lymph nodes: Act as filters for harmful substances and help in the immune response.

  • Related organs (e.g., spleen, thymus): Play a role in the immune function and lymphatic system health.

Subjective Data – Health History Questions

  • Leg pain or cramps: May indicate potential vascular issues such as peripheral artery disease.

  • Skin changes on arms or legs: Evaluate for color or temperature changes, which signal circulatory problems.

  • Swelling: Could suggest fluid retention or lymphatic obstruction, warranting further examination.

  • Lymph node enlargement: May indicate an active infection or malignancy requiring further investigation.

  • Medications: Assess for prescriptions affecting vascular health, such as anticoagulants or vasodilators.

Objective Data – The Physical Exam

Preparation

Ensure proper patient positioning and a comfortable, private environment to facilitate a thorough examination.

Equipment Needed

  • Paper tape measure: For measuring limb circumference and depth for assessing swelling.

  • Stethoscope: For auscultation of vascular sounds.

  • Doppler ultrasonic stethoscope (occasionally): For assessing blood flow in difficult-to-palpate vessels.

Arms – Inspect and Palpate

  • Skin: Observe color, texture, and temperature for signs of vascular issues.

  • Profile sign: Examine nail angle for signs of cardiovascular issues (normal nail angle is about 160 degrees).

  • Capillary refill: Assess peripheral perfusion; normal refill is within 2 seconds.

  • Symmetry: Compare both arms for size and any abnormalities.

  • Pulses:

    • Radial pulse: Check strength and regularity.

    • Ulnar pulse: Less commonly assessed but important for full arm circulation assessment.

    • Brachial pulse: Important for blood pressure measurement.

    • Epitrochlear lymph node: Palpate for enlargement, which may indicate systemic illness.

Legs – Inspect and Palpate

  • Skin and hair: Check for changes in texture, color, and hair distribution that may indicate vascular issues.

  • Symmetry: Note any differences between legs, which could indicate underlying problems.

  • Temperature: Assess with the back of the hand; coolness may indicate arterial insufficiency.

  • Calf muscle: Palpate for tenderness, which can indicate deep vein thrombophlebitis.

  • Inguinal lymph nodes: Check for enlargement, which may signify infection or malignancy.

  • Pulses:

    • Femoral pulse: Check for strength and equality.

    • Popliteal pulse: Difficult to palpate in some patients; requires proper positioning.

    • Posterior tibial pulse: Assess for peripheral perfusion.

    • Dorsalis pedis pulse: Important for assessing foot perfusion.

    • Pretibial edema: Assess for fluid accumulation by pressing and observing for pitting.

  • Leg veins: Examine while the patient stands to check for varicosities indicative of venous insufficiency.

Additional Techniques

  • Color changes: Assess for vascular compromise; pallor may indicate inadequate perfusion.

  • Doppler ultrasonic stethoscope: Provides deeper vascular assessment; useful for measuring blood flow in peripheral arteries.

  • Vmed III: Specific Doppler device monitor used for assessing venous and arterial health.

Abnormal Findings

Variations in Arterial Pulse

  • Weak, "thready" pulse: Indication of decreased perfusion (1+) or shock condition.

  • Full, bounding pulse: Possibly indicates increased blood volume or hypertension (3+ or 4+).

  • Pulsus paradoxus: Abnormal decrease in pulse amplitude with inspiration; may indicate severe cardiovascular or respiratory illness.

Peripheral Vascular Disease

Arms:

  • Raynaud’s syndrome: Characterized by spasmodic constriction of arteries, leading to color changes in fingers and toes.

  • Lymphedema: Swelling due to lymphatic obstruction, often after surgery or infection.

Legs:

  • Arteriosclerosis – ischemic ulcer: Lack of blood flow leading to tissue necrosis; often located on toes or pressure points.

  • Venous (stasis) ulcer: Caused by poor venous return; usually located around the ankles.

  • Superficial varicose veins: Dilated superficial veins, often appearing as blue or purple lines under the skin.

  • Deep vein thrombophlebitis: Inflammation of veins associated with blood clot formation, usually in the legs.

  • Occlusions: Blockages in the vascular system, potentially leading to ischemia.

  • Aneurysms: Localized dilation of an artery due to weakness in the arterial wall, posing a risk of rupture.