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Peripheral Vascular And Lymphatic Systems

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Presentation on theme: "Peripheral Vascular And Lymphatic Systems"— Presentation transcript:

1 Peripheral Vascular And Lymphatic Systems
Chapter 20

2 Objectives Understand the components of a peripheral vascular assessment. What do abnormal findings indicate? Understand arterial and venous flow. What signs and symptoms would occur with abnormalities in either arterial or venous flow? Understand the lymphatic system. What do abnormal findings indicate? Apply nursing diagnoses to peripheral vascular abnormalities.

3 Peripheral Vascular Assessment
Color – Remember from skin? Temperature – Remember from skin? Capillary Refill Pulses Palpate and Doppler Peripheral Arterial Disease: Ankle-brachial index Edema Calf circumference Homan’s sign The peripheral vascular assessment will be grouped with your peripheral neuro assessment, but we haven’t learned neuro yet, so just focusing on vascular Peripheral vascular and peripheral neuro is called a CMS check Circulation – vascular Motion – neuro Sensation - neuro

4 Arterial Pulses Temporal Carotid Brachial Radial Ulnar
Brachial pulse in the antecubital fossa in the elbow on medial side. Radial pulse lies just medially to the radius at the wrist Ulnar pulse is just medially to the ulna, but is deeper and often difficult to feel, not routinely palpated. Palpate the radial and brachial pulses bilaterally. Note the rate, rhythm, and force It should be a regular rate (50-90 BPM), regular rhythm, a +2 force and equal bilaterally Force scale (Book uses 0-3+, you’ll see 0-4+ in practice, too) +3 increased, full, bounding - exercise, anxiety, fever, anemia, and hyperthyroidism +2 normal +1 weak - with shock 0 absent – you need to get a doppler and mark it as a D, if you can’t find with a doppler, get help. Brachial Radial Ulnar Rate, Rhythm and Force (0-3+)

5 Arterial Pulses Femoral (bruit) Popliteal Posterior tibial
Dorsalis pedis Arterial Deficit What does it look like? Motor Sensation Rate, Rhythm and Force (0-4+) Femoral (fem’-ral) artery is the major artery in the leg. It travels down the thigh, and at the lower thigh, it courses posteriorly. Femoral pulse can be felt at the groin Popliteal artery is the same as the femoral, but is differentiated by being posterior to the leg. Popliteal pulse is felt behind the knee. If it is difficult to palpate, you can turn the person prone and press your thumbs deeply. Below the knee, the popliteal artery divides and the anterior tibial artery comes between the tibia and the fibula to the anterior side of the lower leg The popliteal continues down the posterior lower leg as the posterior tibial artery, it can be palpated behind the medial malleolus and forms the plantar arteries in the foot The anterior tibial artery continues to the foot down the front of the leg, where it becomes the dorsalis pedis artery and can be palpated on the top of the foot In the lower extremities palpate the femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally. Note the rate, rhythm, and force It should be a regular rate (50-90 BPM), regular rhythm, and a +2 force and equal bilaterally, however the popliteal is difficult to palpate +3 with exercise, anxiety, fever, anemia, and hyperthyroidism +1 with shock, peripheral artery disease – hard to palpate, fades in/out, can obliterate with pressure Can use a Doppler to find weak peripheral pulses If the femoral pulse is weak or diminished, auscultate for a bruit. Why? Turbulance equals decreased blood flow here

6 Capillary Refill Squeeze the nail bed until it blanches, release and observe the time for the color to return Normal refill is less than 1-2 seconds, about the time it takes to say “capillary refill” Blanching Press down on the skin at the nailbed (fingers and toes) and it occludes the vessel– skin will turn white Normal capillary refill time is less than 1 to 2 seconds.

7 Ankle-brachial index (ABI)
Measurement of blood flow in your leg arteries. Compares systolic blood pressure in arm with ankle. A low ABI (<0.90) can indicate narrowing or blockage of the arteries in your legs (PAD) Normal=1.0 to 1.2. The Ankle-Brachial Index (ABI) determines the extent of peripheral arterial disease. Ankle pressure should be higher than brachial pressure (more pressure to get blood flow to legs that arms The normal ankle pressure is slightly greater than or equal to the brachial pressure, so a normal ABI is 1.0 to 1.2 140/120 = 1.16 105/120 = 0.875 An ABI of 0.90 or less indicates PAD 0.90 to 0.70 is mild claudication 0.70 to 0.40 is moderate to severe claudication 0.30 to 0.40 is severe claudication, usually with pain at rest (unless also diabetic neuropathy) <0.30 is ischemia with impending loss of tissue Lower extremity systolic pressure Brachial artery systolic pressure ABI =

8 Edema Fluid is leaking from capillaries. Bilateral pitting edema is seen with systemic illness such as heart failure and kidney failure – excess fluid Edema Grading – subjective scale +1 mild, slight indent +2 moderate, indent fades rapidly +3 deep, short time for indent +4 very deep, indent lasts a long time

9 Deep Vein Thrombophlebitis (DVT) Evaluation
Homan’s Sign To Test: Dorsiflex the foot toward the tibia. Calf Circumference Measure at the widest point of the calf and compare to other calf. Acute, unilateral, painful swelling with asymmetry of the calves of 1 cm or more is abnormal, refer for DVT evaluation Occlusion of deep vein – thrombus (all of the venous risk factors) This clot can break and travel to lungs – pulmonary embolism Homan’s sign is positive in 35% of DVTs but can also be positive with superficial phlebitis, Achilles tendinitis, muscle injury Dorsiflex the foot toward the tibia Should not be tender or painful (negative; pain or tenderness is positive) Consider this with other findings like edema, redness, warmth of leg (blood flow can’t return to heart) Calf circumference

10 Chronic limb ischemia Looks like this.
Caused by blockage of arteries with symptoms >2 weeks Chronic limb ischemia The ulcer piece is what will differentiate. There’s been a decrease in blood flow for a while. Severe progression of PAD Most common cause is atherosclerosis Symptoms pertain to the individual’s diagnosis of PAD

11 Signs and Symptoms of CLI
Claudication Rest Pain Claudication – muscle cramping, pain or fatigue in legs due to inadequate blood flow to the muscles. Pain from too little blood flow. Ischemia from partial blockage of artery Typically occurs while walking or with any kind of exercise. Tissue needs oxygen, needs more blood flow. Can’t get more blood there, so there’s pain. Rest and tissue oxygen needs return to normal. Pain goes away, because inadequate blood flow is good enough at rest Rest pain – pain when legs are elevated or while sleeping. Pain is relieved when limb is dependent Hanging your limb down, helps blood get to a slightly blocked area because of gravity. Gravity isn’t helping when leg is flat or elevated.

12 Lymphedema Lymphedema is edema from impaired lymph node drainage. Surgical removal or damage from surgery or radiation to lymph nodes and vessels impedes the lymph drainage. Lymph builds up causing lymphedema. It is common after breast cancer treatment (42%) but usually mild. Lymphedema is chronic and progressive, so needs to be recognized and treated, such as with compression bandages. Obesity causes lymphedema because the sheer additional weight puts too much pressure on the lymph nodes in the groin area, compromising the system," she said. "This causes a fluid backup like a clogged drain. Skin can thicken, harden and become red, dry and warm to touch." In men you can see this in the scrotum. Palpate for edema It can be unilateral or bilateral. It is nonpitting and feels hard to the touch If unilateral, compare the size to the other extremity: Mild lymphedema causes an asymmetry of 1 to 3 cm Moderate lymphedema causes an asymmetry of 3 to 5 cm Severe lymphedema is an asymmetry of more than 5 cm

13 1. The nurse is assessing a patient’s risk for developing a deep vein thrombosis (DVT). The patient considered at the highest risk is a 60-year-old patient who: has been on bed rest for 3 days. has been receiving physical therapy for left knee replacement. has calf and thigh measurements that have less than an inch of variation on both legs. was admitted to the hospital with asthma exacerbation. The correct answer is 1. Bed rest and inactivity increase a patient’s risk of DVT. Answer 2 is incorrect because although this patient would be considered at risk, knee replacement patients are not the highest risk. Answer 3 is incorrect because this would be a normal assessment of calf and thigh for DVT. Answer 4 is incorrect because this patient would not be at high risk for DVT. Slide 2

14 2. The nurse is assessing the ankle-brachial index (ABI) of a patient with peripheral arterial disease (PAD). The nurse would be suspect of an ABI of: 1.1. 1.0. –1.1. 0.5. Correct answer is 4. An ABI of less than 0.5 indicates moderate PAD. The lower the number, the higher the risk for myocardial infarction and cerebrovascular accident. Answers 1 and 2 are incorrect because the ABI is normally between 1.0 and 1.2, because the pressure in the ankles is usually slightly higher than the pressure in the arms. Answer 3 is incorrect because a negative number is mathematically impossible. Slide 3

15 Case Studies For each case study: What do you think is going on? Why?
What do you need to ask and/or assess? Write a nursing diagnosis for the patient. Look at the outcomes/interventions that relate to this diagnosis.

16 E. A. has come to the health care provider with complaints of a sudden onset of throbbing pain in the hands. Radial pulses are absent, and the extremities are cold and pale. Acute Limb Ischemia with complete blockage Why? P signs What else? Pain – Sudden, throbbing – (PQRSTU) Pulselessness – Radial pulses are absent - Get the doppler Pallor – Extremities are pale – What other color? = necrosis Paresthesia – Need to ask Paralysis – Need to ask Polar – Extremities are cold Check cap refill Nursing dx: ALI – no suggestions Acute pain r/t lack of arterial blood flow secondary to acute limb ischemia aeb patient complains of a “sudden onset of throbbing pain in the hands.” Pulses – absent Ineffective peripheral tissue perfusion r/t interruption of arterial flow aeb absent radial pulses, cold, pale hands and black fingertips and sudden onset of throbbing pain. Client will demonstrate adequate tissue perfusion – palpable, radial pulses, warm and pink skin, no pain. Interventions are what you did for the assessment - Check pulses, Check skin color/temp, Assess pain, Check cap refill Keep hands warm. Are you going to want to apply a hot pack? Won’t be able to tell if it’s burning them. Risk for peripheral neurovascular dysfunction r/t – has signs, so she isn’t at risk Pallor Ineffective peripheral tissue perfusion r/t interruption of vascular flow Tissue damage Impaired tissue integrity r/t interruption of arterial blood flow aeb necrotic fingertips. Interventions will focus more on assessing/healing the wound – this will be important once arterial problem is fixed.

17 E. H., age 77 years, comes to the clinic because she has been experiencing leg pain at night that “wakes me up out of a dead sleep.” She never notices any problems during the day. Ischemic rest pain of PAD Having legs dependent helps blood flow in PAD, so pain at night is from decreased blood flow (ischemia) What will you want to ask/assess? Pain – Does she have pain when she’s walking? Describe it? Cramping, throbbing Pulselessness – Check her pulses. Grade? +1, 0 or doppler Pallor – Look at her legs Legs will be pale when elevated, will become red when dangling (helps blood flow return) Paresthesia – numbness/tingling Paralysis – problems with movement Polar - cold Check capillary refill – will be prolonged Have an ABI done – will be < 0.9 Nursing dx: Peripheral Vascular Disease = lots Pain

18 D. S. is a 51-year-old nurse who has been having problems with her lower legs. She says that after a long shift she feels an aching heaviness in her calves and she can hardly bear to stand up toward the end of her shifts. The nurse notes a dilated, tortuous vein in the upper calf areas on both legs. Varicose veins Prolonged standing is dilating veins, so valves aren’t big enough to close and venous flow stagnates – pools Pain – aching, heaviness What would relieve this pain? Elevating her legs to aid in venous return (opposite with arterial disease) What else might you see? Edema Nursing dx: Ineffective peripheral tissue perfusion r/t venous stasis aeb report of “aching heaviness in her calves and she can hardly bear to stand up” and presence of dilated, tortuous veins on lower legs. Interventions are going to focus on venous side now.

19 M. H. is recovering from a very prolonged surgery
M. H. is recovering from a very prolonged surgery. During the morning assessment, he complains of pain when the left knee is flexed and the left foot is dorsi flexed. The calf circumference is 37 cm on the right and 40 cm on the left. The left calf is tender to palpation. DVT- clot in deep vein (thrombus) Is the Homan’s sign the most accurate indicator? No, combine it with edema, temperature, color How do we do calf circumference? Indicates edema – blockage of venous return What else might you notice? Warmth, redness Notify the MD – Why? Thrombus can travel and occlude pulmonary vessels – pulmonary embolism Doppler ultrasound will show where there are clots in veins Nursing dx: DVT

20 A. M. has come to the health practitioner with complaints of leg wounds that have persisted for 4 weeks. He works on a production line and is on his feet all day. On examination, the wounds are irregular, with a bright red wound base, and are not especially painful. There is moderate to heavy exudate and peripheral edema. Risk factors are for a venous problem – standing Wear compression stockings (TED hose) Increased pressure in veins causes fluid leaking - edema Over medial malleous Irregular wound, will have exudate (think leaking of fluid) See all of those brown deposits – RBCs leaking out of veins into skin – leaving iron deposits What are you going to expect with his pulses? No problem Nrsg dx: edema, stasis ulcer Impaired tissue integrity r/t chronic venous congestion

21 B. D. has been referred to the home health agency for a painful wound on the dorsal aspect of the right foot. The wound is round, measuring 3 cm in diameter. The wound base is pale with well-defined edges, and exudate is minimal. Arterial ischemic ulcer Blood can’t get through Need to return arterial blood flow Toes, heels, lateral ankle Clear edges Not weeping or bleeding (blood doesn’t easily flow to area) Pulses – decreased or absent 1+, 0, doppler Capillary refill – prolonged time ABI - <0.9 Nrsg dx: arterial insufficiency

22 O. S. is a 45-year-old woman who has been diagnosed with type II diabetes mellitus. She is extremely obese, and during a teaching session, the nurse notes that O. S. cannot reach the bottom of her feet to inspect them. Diabetes hastens changes described with ischemic ulcers. Impaired sensation, so ulcer isn’t noticed. Think of sugar deposits occluding artery Nrsg dx: diabetes, obesity


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