1. Peripheral Vascular System and Lymphatic System
By InnaKorda, MD,
Institute of Nursing, TSMU

2. Direction of Blood Flow

3. Lecture objectives: Structure and function of vascular system:
Arteries
Veins
Lymphatics
Taking client’s complaints and history.
Assessment techniques:
Inspection and palpation of the neck vessels
Inspection and palpation of the arms (radial pulse, lymph nodes)
Inspection and palpation of the legs (edema, Homans’ sign; femoral, popliteal, dorsalis pedis pulses, manual compression test
Additional techniques: Trendelenburg test, colour changes, doppler ultrasonic stethoscope.
Abnormal findings:
Variations in arterial pulse
Raynauld’s syndrome
Lymphedema
Arteriosclerosis
Superficial varicose veins
Peripheral artery disease: occlusions, aneurysms

4. Structure And Function
The vascular system consists of the vessels of the body.
Vessels are tubes for transporting fluid, such as the blood or lymph.
Function - transporting the blood or lymph :
Delivery of oxygen to the tissues
Delivery of nutrients to the tissues
Elimination of carbon dioxide from cells
Elimination of waste products from cellular metabolism

5. Arteries. Carry freshly oxygenated blood to tissues
High-pressure system
Walls are strong, tough, and tense
with elastic fibers ► stretch with systole, recoil with diastole
with muscle fibers (VSM) ► control the amount of blood delivered to the tissues and the rate of blood flow
Pulse is a pressure wave created by each heartbeat, palpable at body sites where the artery lies close to the skin and over a bone.

6. Arteries accessible to examination
Temporal artery (review chapter 13)
Carotid artery
Arteries in the arm:
Brachial
Radial
Ulnar
Arteries in the leg:
Femoral artery
Popliteal
Anterior tibial ► dorsalis pedis
Posterior tibial ► plantar arteries
Ischemia is a deficient supply of oxygenated arterial blood to a body part, due to constriction or obstruction of a blood vessel

7. Arteries accessible to examination

8. Arteries accessible to examination

9. Veins accessible to examination
Jugular veins
Veins in the arm:
Superficial – in the subQ tissue, responsible for most of the venous return
Deep
Veins in the leg:
Deep veins: femoral, popliteal; responsible for most of the venous return
Superficial: great and small saphenous
Perforators: connecting veins that join the two sets. They have one-way valves ► blood ► into the deep veins.

10. Veins accessible to examination

12. Lymphatics. A completely separate vascular system.
It retrieves excess fluid from the tissue spaces and returns it to the blood stream.

13. Lymphatic ducts and drainage patterns

14. Functions of the lymphatic system:
To converse fluid and plasma proteins that leak out of the capillaries.
To form the major part of the immune system that defends body against infection.
To absorb lipids from the intestinal tract.

15. Structure of the lymphatic system
Microscopic open-ended tubes (capillaries)
Vessels, like veins, have valves
Lymphatic ducts
Subclavian veins

16. Lymphoid tissue: Lymph nodes: Tonsils: Spleen
Filter the fluid before it comes back to the bloodstream
Filter out microorganisms
Tonsils:
Pharyngeal (adenoid)
Palatine
Lingual
Spleen
Peyer’s patches (Lymphoid tissue in intestines)
Tymus gland
Bone marrow

18. Groups of peripheral lymph nodes:
Auricular: anterior and posterior
Sublingual.
Submandibular.
Cervical: anterior and posterior.
Supra- and subclavian.
Axillary.
Epithrochlear.
Inguinal.
Popliteal.
Assesment:
Inspection and palpation
Amount in each group
Size
Shape
Consistency
Movable/connected with surrounding tissues
Pain/tenderness
Signs of inflammation: swelling and redness above the node

19. Taking client’s complaints and history.
Claudication distance is the number
of blocks walked or stairs climbed
to produce pain.
Note sudden dencrease in
claudication distance, or pain
suddenly not relieved by rest.
Taking client’s complaints and history.
Ask: “Any leg pain (cramps)? Where?”
Detail: pain type, onset (gradual/sudden), aggravating/ relieving factors (activity, walking, dangling, rubbing), associated signs (skin changes, sexual malfunction), relation to time of day, claudication distance.

20. Taking client’s complaints and history.
Edema is bilateral when caused by a systemic problem (heart failure), or unilateral when due to a local obstruction or inflammation.
Taking client’s complaints and history.

21. Objective data Preparation: Environment Equipment needed: Privacy
Should be warm (about 22°C) and draftless to prevent vasodilatation or vasoconstriction.
Privacy
Make sure the female’s breasts and client’s genitals remain draped.
Order of exam
Begin with observations peripherally and move toward the heart.
Pulse and blood pressure
Extremities – peripheral vascular assessment
Neck vessels
Precordium – (portion of body over heart and thorax)
Equipment needed:
Tourniquet or blood pressure cuff
Stethoscope
Paper tape measure
Doppler ultrasonic stethoscope

22. Assessing Neck Vessels
Carotid Artery
Palpate the carotid artery
Avoid excessive pressure. Excessive vagal stimulation could slow down heart rate.
Carotid arteries should be same bilaterally
Auscultation
Listen for bruits – blowing, swishing sounds indicating blood flow turbulence. Caused by atherosclerotic narrowing (one half or two thirds of artery).

23. Assessing Neck Vessels
Jugular Veins
Can be used to assess central venous pressure (CVP) and cardiac efficiency
Distended external jugular veins signify increased CVP, as with heart failure
Position the patient at degree angle, wherever pulsations can be seen best. Remove pillow to avoid flexion of head.
The higher the CVP, the higher the position you will need
Turn the pt’s head away from examiner’s side
Distinguish from carotid artery pulsations. Internal jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting.
Internal jugular vein pulsation significance??????

24. Assessing Neck Vessels
Jugular Venous Pressure Estimate
Used to assess heart failure
Position the patient at degree angle. Place one ruler vertically at the manubriosternal angle. Place a second ruler perpendicular to the first and record the height of pulsation of the internal jugular vein.
Normal pulsation is 2 cm or less above sternal angle
Pulsations 3 or more cm above sternal angle while at 45 degrees occur with heart failure
Record height of pulsations and degrees of elevation
P 503 fig 19-18

25. Question
The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal.
Patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle.
Patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle
Patient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle
Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

26. Inspection and palpation of the arms
Inspect for:
Color of skin and nailbeds
Temperature, texture and turgor of skin
Any lesions, edema
Nail clubbing.
What is normal nail bed angle?
Use profile sign to detect early clubbing
Capillary refill is an index of peripheral perfusion and cardiac output.
Depress and blench the nail beds; release and note the time for color return. Normally 1 to 2 seconds.
160 degrees

27. Inspection and palpation of the arms
Palpate both radial pulses:
Symmetricity (equal force), rhythm, rate, elasticity.
Grade the force (amplitude) on a fore-point grade:
0 – absent
1+, weak
2+, normal
3+, increased
4+, bounding
For ulnar pulse palpate along the medial site of the inner forearm. Not palpable in healthy person.

28. Inspection and palpation of the arms
Palpate the brachial pulses.
Palpate the epitrochlear lymph node
Modified Allen test: Normal 2 to 5 seconds