Neck Vessels & Peripheral vascular Chapter 15 Seidel’s Guide to Physical Examination

Objectives To identify major neck vessels To explain difference between systemic and pulmonic circulation To identify methods to exam neck vessels To identify arteries in arms and legs To identify veins in legs To explain venous obstruction or insufficiency To identify risk factors for DVT To identify prevention for DVT To learn subjective and objective assessment data To know how to inspect arms and legs

Key Words Peripheral Artery Disease (PAD) Pulmonic circulation Systemic circulation Carotid artery Jugular venous pulse Arteries of arms/leg Veins of legs Venous obstruction or insufficiency Allen’s test Deep vein thrombosis (DVT)

Anatomy & Physiology Vessels circulate blood to and from body & lungs Great vessels Aorta Pulmonary artery Superior/inferior vena cavae Pulmonary veins

Anatomy & Physiology: circulatory systems Two circulatory systems distribute oxygen to the body Pulmonic- lungs>left atrium and ventricle>arteries Systemic-right atrium & ventricle>pulmonary artery https://www.youtube.com/watch?v=oHMmtqKgs50

Neck Vessels Carotid artery, jugular veins Carotid artery pulse – ventricular systole Level of jugular venous pressure reflects right atrial (central venous) pressure

Jugular Venous Pulse Wave

EXAMINATION NECK VESSELS Inspection Observe the jugular venous pulse Evaluate jugular venous pressure Auscultation and palpation Auscultate the carotid arteries Palpate the carotid arteries External Jugular Vein Distention https://www.youtube.com/watch?v=oka-hEH7Gzo Auscultation Carotid Arteries https://www.youtube.com/watch?v=tz_UBbSgdKo https://www.youtube.com/watch?v=aTub9RP7Uuk

Assessment Summary Carotid Artery Evaluate JVD & observes JVD Pulse Vessel elasticity Thrills Evaluate JVD & observes JVD Auscultates for bruits before palpation of carotid arteries using the bell of stethoscope Bruit sound- similar sound to a murmur

Peripheral Vessels

Arteries of Arm Carry oxygenated, nutrient-rich blood from heart to capillaries Major arteries of arm: brachial, ulnar, radial

Arteries of Leg Major arteries of leg: popliteal, femoral, dorsalis pedis, posterior tibial

Veins of Legs Carry deoxygenated, nutrient-depleted, waste-laden blood from tissues back to heart Three types of veins: deep, superficial, perforator Femoral, popliteal, and saphenous veins

Venous obstruction or insufficiency Pain: aching or cramping Swelling and tenderness over the muscles Engorgement of superficial veins Erythema and/or cyanosis Inspect extremities for thrombosis, varicose veins, and edema Edema 1+, 2+, 3+ or 4+ Homan’s sign https://www.youtube.com/watch?v=vY-HWMG5UrU Positive Homan’s sign not positive diagnosis DVT Negative Homan’s sign does not rule out diagnosis DVT

Peripheral vascular disease Strokes (cerebral vascular accidents (CVA))- MRI Transient ischemic attacks (TIA)- MRI Deep vein thrombosis (DVT) - ultrasound Pulmonary embolism – VQ scan Aortic aneurysm- MRI Varicose veins

Peripheral Vascular assessment Inspects extremities for color, hair distribution swelling, and symmetry Inspects peripheral veins Drapes patient appropriately Assess BILATERAL peripheral pulses Carotid Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial

Pulse amplitude and bruits Pulse Amplitude: Rated on a scale of 0 – 4 4 = bounding, aneurysmal 3 = full, increased 2 = expected 1 = diminished, barely palpable 0 = absent, not palpable Auscultate sites for bruits Temporal Carotid Subclavian Abdominal aorta Renal/iliac/femoral arteries

Allen’s test Elevate hand and make fist for 30 seconds Apply pressure over radial and ulnar arteries to occlude them Still elevated, open hand – should be blanched (pallor) at finger nails Ulnar pressure released, color returns in 7 seconds Inference: ulnar blood supply is sufficient and safe to puncture radial artery If color does not return or returns 7-10 seconds, suspect ulnar artery insufficiency and do not puncture radial artery

Arterial insufficiency Pain - intermittent claudication: a clinical diagnosis given for muscle pain (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest. to sharp, unrelenting, constant pain Pulses: diminished or absent Skin color: dependent rubor- redness, cardinal sign inflammation

Deep Vein Thrombosis (DVT): Risk Factors Conditions that increase blood clotting- medications: birth control or hormones Low blood flow to deep veins due to surgery, immobilizations, injury, and constriction Some cancers and cancer treatments Vascular conditions such as varicose veins Sitting for long periods – car or plane Pregnancy, especially first 6 weeks after birth Obesity Placement central venous catheter More than one risk factor

Deep vein Thrombosis (DVT): prevention If sitting long periods: stand up and move around every hour Ambulate after surgery as soon as possible Take anticoagulants ordered by physician Report tenderness, pain, swelling, warmth, or redness calf or thigh

Subjective data: current symptoms Skin changes Leg pain or heaviness or aching Leg veins Leg sores or open wounds Leg swelling Men – change in sexual activity Swollen glands or nodules

Subjective data: lifestyle & health Tobacco use Regular exercise Oral contraceptives Stress Medication Peripheral vascular problems interfere with ADLs Support hose

Subjective data: history Past Previous problems circulation legs/arms Heart or blood vessel surgeries Family Diabetes Varicose veins Hypertension Coronary heart disease High cholesterol levels

Arms Inspection Palpation Size, edema, venous patterning Skin color Fingertips clubbing Palpation Fingers, hands, & arms for temperature Capillary refill Radial, ulnar, & brachial pulses Allen’s test Epitrochlear lymph nodes Most readily felt over bony prominences

Legs Inspection Palpation Skin color Distribution of hair Lesions or ulcers Edema Palpation Temperature Superficial inguinal lymph nodes Femoral pulse Popliteal, dorsalis pedis, posterior tibial pulses Pedal pulses are not always palpable

Summary To identify major neck vessels To explain difference between systemic and pulmonic circulation To identify methods to exam neck vessels To identify arteries in arms and legs To identify veins in legs To explain venous obstruction or insufficiency To identify risk factors for DVT To identify prevention for DVT To learn subjective and objective assessment data To know how to inspect arms and legs