Vascular System - Consists of vessels which transports blood and lymph Functions: Vascular System ~Lymphatic System: Transports

FLUID ~Arteries and Veins: Transports BLOOD Disease of Vascular System Probelms with: ~delivering O and nutrients to tissues ~eliminating waste products Functions: Arteries Transports OXYGENATED blood; High Pressure System ~Contains elastic tissue and muscle fibers which allows them to STRETCH, DILATE and CONSTRICT ~Heartbeat creates pressure wave responsible for pulse Pulses to Assess ~Temporal artery ~Carotid artery ~Arteries of the arm (brachial, radial, ulnar) ~Arteries of the leg (femoral, popliteal, posterior tibial, dorsalis pedis) Veins to Assess ~Jugular Veins: assessed with Cardiac Assessment ~Veins in the ARMS: superficial and deep ~Veins in the LEGS: superficial, deep and COMMUNICATING veins (common place to see venous disease) Functions: Lymphatic System ~Conserve fluid and plasma: more fluid leaks out of capillaries than veins can absorb ~Part of the immune system: filters fluid before it returns, 'phagocytosis' ~Absorb lipids from the GI tract Lymphatic Ducts Lymph vessels drain into 2 main trunks: ~Right Lymphatic duct empties into R Subclavian Vein ~Thoracic duct (drains the rest of the body) empties into L Subclavian Vein Lymph Nodes Small clumps of lymphatic tissue located at intervals along vessels

Functions: Lymph Nodes Filter fluid before returned to bloodstream; Elicit antigen specific responses to eliminate pathogens Lymph Nodes to Assess Cervical Axillary Epitrochlear Inguinal Infants and Children ~Lymph tissue present at BIRTH ~Lymph reaches adult size at 6 yrs old and SURPASSES it by adolescents ~Lymph nodes LARGE

Pregnancy
~Uterus obstructs drainage of ILIAC veins and INFERIOR vena cava Aging Adult ~Peripheral blood vessels are more RIGID and NARROW ~ Mobility ~ Lymphatic tissue

Arteriosclerosis
Thickening, hardening and loss elasticity of the arteries Atherosclerosis Marked by cholesterol, lipid and calcium deposits of arterial walls Smoking Vasoconstriction ( O to tissues)

Obesity
incidence of CAD, Diabetes and inactivity ( circulation) Excessive Alcohol incidence of CAD, hyperlipidemia

Diabetes
incidence of CAD, hyperlipidemia, damage to micro-circulation Hypertension Vasoconstriction of arteries ( circulation) Lack of Exercise Pooling of the blood ( venous return) Leg Pain or Cramps ~Type: burning, aching, cramping, stabbing ~Gradual or sudden ~Effect of walking: how many blocks or stairs "Claudication distance" ~Effect of elevation (raising leg make pain go away or worse)

Assessment
Skin Changes Color: pale, redness, cyanosis Change in temperature (AI) Presence of veins, varicosities (VI) Presence of sores, ulcers (AI, VI)

Edema ~AM or PM? ~Unilateral or Bilateral ~Associated with heat, redness, hard skin Lymph Node Enlargement Where are they? How long has it been there? Is it painful? Is it moveable? We worry about fixed and nonmovable Past Medical History CAD, DM, pregnancy, smoking, trauma, prolonged sitting or standing, bedrest Medication History Oral contraceptives, estrogen replacement

Inspection: Arms
Color: pallor, redness Nailbeds: profile sign Capillary Refill: return in <3 seconds Temperature: check symmetry, dorsum of hand for temperature Texture: finger pads Turgor: check tenting Symmetry: equal

Palpation: Arms
~Palpate pulses: brachial, radial, ulnar ~Grade force of pulse 4+ bounding 2+ normal 0 absent ~Check epitrochlear node: groove btw BICEPS and TRICEPS ~Perform Allen's test

Inspection: Legs
Color ~Brown - hemosiderosis (occurs with venous stasis) VI ~Erythema (vasodilation) VI , infection ~Pallor - vasoconstriction, poor circulation (AI) Dependent Rubor - chronic hypoxia causes vasomotor tone, results in pooling of blood in the veins (AI)

Palpation: Legs
Temperature: warm bilaterally; coldnesss arterial insufficiency unilateralocclusion

Compress gastronemius muscle: without tenderness or hardness (r/o phlebitis) Homan's sign - sharply dorsiflex the foot (+ Homan's in 35% of DVT) Check Inguinal nodes - not unusual to feel palpable nodes that are SMALL < 1cm, MOVABLE and NON-TENDER Palpate pulses and record on a 4+ scale Check for edema on a 4+ scale Bilateral Edema Edema associated w/ SYSTEMIC condition Heart failure Hepatitis Cirrhosis Kidney Problems Unilateral Edema Brawny edema (non-pitting); LOCALIZED problem Occlusion of a deep vein or lymphatic obstruction Venous Test for Lower Legs ~Used with VARICOSE VEINS ~1 hand on lower part of a varicose vein ~Other hand compress top part (15-20 cm higher) ~No Wave with top hand competent valve ~Wave feltincompetent valve Trendelenburg Test ~Pt is supine ~Elevate legs 90, place tourniquet ~Have pt stand and check for VENOUS filling ~Used with VARICOSITIES ~Vein should fill from BELOW Ankle Brachial Index ~Arterial test to determine the extent of peripheral vascular disease ~BP over ankle ~Check systolic pressure of TIBIAL or DORSALIS PEDIS Results: 90% or less - presence of PV disease 30 - 40% - severe claudication < 30% - ischemia, will have tissue loss Color Change Test ~Pt is supine ~Raise legs 12 inches and wiggle toes to drain venous blood ~Sit up

~Color should return in 10 sec. ~Elevational pallor indicates ARTERIAL insufficiency Raynaud's Syndrome Happens with exposure to COLD; ~Pallor Arteriospasms ~CyanosisPoor blood supply ~RuborDilated capillaries (painful; burns and throbs) Lymphedema ~REMOVAL of lymph nodes ~protein rich lymph fluid in the interstitial space ~ oncotic pressure fluid ~stagnant fluid leads to infection and poor wound healing ~Leads to "brawny edema" 48 Arterial Insufficiency Chronic build up of FATTY PLAQUES in the arteries; Reduces blood flow w/ vital O and nutrients to tissues Location of pain: DEEP muscles, usually the CALF and FOOT Character of pain: "Intermittent Claudication" - WORSE with exercise Click to flip Arterial Insufficiency Aggravating factors: Walking "claudication distance", Elevational pain Relieving factors: Rest or Dangling Associated Symptoms: Cool pale skin, pulses, sensation, hair loss Arterial Insufficiency Whose at risk? More MEN, hx of DM, HTN, smoking, lipids, obesity Relief: REST (standing position), dangling (severe involvement) 6 P's of Arterial Occlusion Pain Pallor Pulselessness Paresthesia Paralysis Perishing Cold Click to fl Trophic Changes: Arterial Insufficiency ~Nails: onychodystrophy ~Diminished HAIR of lower extremities ~Skin is THIN ~ATROPHY of muscles

All 2 poor nutrition of the tissues Click to flip Lesions: Arterial Insufficiency Toes, Heels, Lateral Ankles Pale ischemic base Well-defined edges No bleeding Venous Insufficiency Follows DVT or chronic INCOMPETENT valves in deep veins Location of pain: CALF, LOWER LEGS Character of pain: ACHING, TIREDNESS, feeling of FULLNESS Click to flip Venous Insufficiency Onset and Duration: chronic pain, at the end of the day Aggravating: PROLONGED standing or sitting Relieving factors: Elevation, lying down or walking Associated Symptoms: edema, varicosities, weeping ulcers at ankles (bleeding) Click to flip Venous Insufficiency Whose at risk? Prolonged standing Obesity Pregnancy Prolonged bed rest Varicosities Thrombophlebitis Lesions: Venous Insufficiency Ulcers on Medial malleolus Bleeding, uneven edges Varicose Veins Incompetent veins; 3x more common in women Subjective Complaints: ACHING, HEAVINESS in legs, easy FATIGABILITY Objective Symptoms: DILATED, TORTUOUS veins Venous Disease in the Legs Click to flip Deep Vein Thrombosis DEEP VEIN occluded by CLOT causes by bedrest, hx of varicosities, trauma, infection, use of estrogens Subj. Complaints: SUDDEN onset of pain, with DORSIFLEXION

Obj. Complaints: warmth, edema, rubor, dependent cyanosis, tender on palpation, + Homan's sign Venous Disease in the Legs Click to flip Occlusions Occurs with atherosclerosis, thrombus formation, OCCLUDES the blood flow Risk factors: obesity, smoking, HTN, DM, cholesterol, sedentary lifestyle 6 P's Peripheral Artery Disease Click to flip Aneurysms Is a sac formed by dilitation in the arterial wall, balloon enlargement Causes: atherosclerosis WEAKENS the MIDDLE layer of the vessel wall, BP stretches it out Common site: Aorta Incidence: males > 70, females > 55