1. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Jarvis Chapter 20 Circulation: http://www.youtube.com/watch?v=PgI80Ue- AMo http://www.youtube.com/watch?v=PgI80Ue- AMo

2. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  1. Relate normal & abnormal findings to the structure & functions of the arteries & veins. 2. Discuss the lymphatic circulation system & related organs. 3. Discuss arteriosclerosis & atherosclerosis in the aging adult. 4. Discuss normal & abnormal subjective and objective findings when assessing the peripheral vascular system of an adult. Learning Objectives

3. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Key Terms  Artery  Arteriosclerosis  Atherosclerosis  Bruit  Capillary refill  Claudication  Deep vein thrombophlebitis (DVT)  Doppler ultrasound  Ischemia/ischemic ulcer  Lymph node  Lymphedema  Pitting edema  Perfusion  Pulsus paradoxus  Raynaud’s phenomenon  Varicose veins  Vein  Venous stasis ulcer

4. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Arteries  carry blood away from the heart  Heart pumps freshly oxygenated blood through the arteries to all body tissues  High pressure system, usually lie deep  Have a pulse  accessible in certain areas  temporal, carotid, brachial, femoral, popliteal, medial malleolus (post tibial), & dorsalis pedis  Veins  carry blood back to the heart  Carry deoxygenated blood back to heart & lungs  Low-pressure system  depends on skeletal muscle contraction & one-way intraluminal valves to get blood back to heart  Do not pulsate, usually lie closer to surface Peripheral Vascular System

5. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Slide 20-5 Arteries in the Peripheral Vascular System  Arteries in the head & neck  Temporal artery  Carotid artery  Arteries in the arm  Brachial  Ulnar  Radial  Arteries in the leg  Femoral  Popliteal  Dorsalis pedis  Posterior tibial

6. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Veins in the Peripheral Vascular System  Veins in the neck  Internal & external jugular (Ch. 19)  Veins in the arm  Basilic  Cephalic  Median  Veins in the leg  Deep veins  Femoral  Popliteal  Superficial veins  Great saphenous  Small saph enous  Superficial veins can be resected for BPGs without compromising leg circulation if deep veins are healthy

7. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System Arteries in the Head & Neck

8. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System Slide 20-8 Arteries in the Arm Vessels of the Arm

9. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System Slide 20-9 Vessels in the Leg

10. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Drains deoxygenated blood from tissues & returns it to heart & lungs for reoxygenation  Venous flow back up to heart depends on:  Skeletal muscle contraction  Increased abdominal pressure from inspiration  Intraluminal valves to ensure blood flow up to heart & prevent back flow  Problems with flow back to heart  venous stasis  pitting edema  stasis ulcers Venous Flow

11. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System Venous Flow

12. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Completely separate circulation system from the blood circulation system  Flow is slow compared to blood  has one-way valves & depends on skeletal muscle contraction & contraction of lymph vessels Slide 20-12 Lymphatic System

13. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Functions:  Drains excess fluid from tissue spaces (prevents edema) & picks up plasma proteins that leak out of capillaries & returns both to blood circulation system  Right lymphatic duct empties into right subclavian vein; thoracic duct empties into left subclavian vein  Forms a major part of the immune system that defends the body against disease  Absorbs lipids from the intestinal tract  http://www.youtube.com/watch?v=Q9gpDUooVwo http://www.youtube.com/watch?v=Q9gpDUooVwo Slide 20-13 Lymphatic System (cont’d)

14. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

15. Lymphatic System Lymph vessels Lymph nodes  filter out & destroy pathogens before returning collected fluid to blood circulation Related organs that aid the lymphatic system with the immune function: Tonsils Thymus Spleen Peyer’s patches on small intestines Bone marrow

16. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

17. Lymph Nodes Small clumps of lymphatic tissue Filter & destroy pathogens that may harm the body Superficial nodes may be palpable; deep nodes are not With local inflammation, nodes in that area become swollen & tender

18. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Arteriosclerosis  peripheral blood vessels grow stiff & less compliant  rise in systolic BP  Atherosclerosis  fat plaques deposited inside arteries  found in all ages, not just aging adults  Enlargement of calf veins  prolonged bedrest or sitting and heart failure  increased risk for deep vein thrombosis (DVT) and pulmonary embolus (PE)  Loss of lymphatic tissue with fewer lymph nodes & decreased size of lymph nodes – decreased immune function Slide 20-18 Changes in the Aging Adult

19. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Leg pain or cramps  claudication: leg/calf pain on walking or climbing stairs; pain resolves with rest  decreased perfusion (blood flow) results in ischemia (a deficient supply of oxygenated arterial blood to a tissue)  partial blockage creates insufficient supply w/pain on exercise, when oxygen needs increase  Skin changes on arm or legs  Edema (Swelling) (hard or pitting)  Lymph node enlargement (tender)  Medications Subjective Data— Health History Questions

20. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Slide 20-20 Objective Data—The Physical Exam Arms— Inspect and palpate  Skin  Profile sign  detects early clubbing of nails  Capillary refill (<2 sec.)  Symmetry  Edema  Radial pulse  Ulnar pulse (not usually palpable)  Brachial pulse  Modified Allen test (evaluates adequacy of collateral circulation before cannulating the radial artery)

21. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

22.  Slide 20-22 Objective Data—The Physical Exam (cont.) Legs— Inspect and palpate  Skin and hair  Symmetry  Temperature  Calf muscle  Inguinal lymph nodes  Pitting edema  grade on scale of 1+ (mild) to 4+ (severe)  Lymphedema (hard, nonpitting)  Capillary refill (<2 sec.)  Peripheral pulses (scale of 0-3+)  Femoral pulse  Popliteal pulse  Posterior tibial pulse (PT)  Dorsalis pedis pulse (DP)  Additional techniques  Color changes  Doppler ultrasonic stethoscope  Femoral bruit

23. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Slide 20-23 4+ Pitting Edema © Pat Thomas, 2006.

24. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Weak, “thready” pulse – 1+ ** Normal peripheral pulses are 2+  Full, bounding pulse – 3+  Pulsus paradoxus  Beats have weaker amplitude with inspiration, stronger with expiration. Best determined during BP measurement  reading decreases >10mm/Hg during inspiration & increases with expiration. Slide 20-24 Abnormal Findings Variations in Arterial Pulse

25. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Slide 20-25 Doppler Ultrasound (US) Stethoscope Used to detect weak peripheral pulse Pulse identified by swishing, whooshing sound

26. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System   Arms  Raynaud’s Phenomenon  Lymphedema (also often seen in legs)  Legs  Arteriosclerosis—ischemic ulcer  Venous (stasis) ulcer  Superficial varicose veins  Deep vein thrombophlebitis (DVT)  Lymphedema  Occlusions  Aneurysms Slide 20-26 Abnormal Findings Peripheral Vascular Disease (PVD)

27. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Manifestations (S/Sx) of PVD  Arterial Insufficiency  Pain, cramps, or numbness & tingling in lower extremity, usually calf muscle  Onset with exertion (walking or climbing stairs) or with elevation (severe)  Relieved by rest or dangling (severe)  Pale, cool skin  Weak or absent pulse  Foot or ankle ulcer  Venous Insufficiency  Feeling of fullness, aching in lower leg  Discomfort increases at end of day  Prolonged sitting or standing exacerbates discomfort  Elevation, lying or walking relieves  Edema, varicosities, weeping ulcers (stasis ulcers) at ankles

28. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System 2 Presentations of Raynaud’s Phenomenon

29. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

30.  Slide 20-30 Arterial Ischemic Ulcers

31. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

33. Slide 20-33 Manifestations of Venous Stasis with Ulcer Edema (hard or pitting) Tan/brown discoloration to lower leg Wet, draining ulcer

34. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System  Venous Stasis Ulcers

35. Chapter 20: Chapter 20: Peripheral Vascular System and Lymphatic System

39.  Slide 20-39 Sample Charting