Peripheral Vascular Peripheral Vascular System and System and

Lymphatic SystemLymphatic System

By InnaKorda, MD, By InnaKorda, MD, Institute of Nursing, TSMUInstitute of Nursing, TSMU

Direction of Blood FlowDirection of Blood Flow

Lecture objectives:Lecture objectives: Structure and function of vascular system:Structure and function of vascular system:

ArteriesArteries VeinsVeins LymphaticsLymphatics

Taking client’s complaints and history.Taking client’s complaints and history. Assessment techniques:Assessment techniques:

Inspection and palpation of the neck vesselsInspection and palpation of the neck vessels Inspection and palpation of the arms (radial pulse, lymph Inspection and palpation of the arms (radial pulse, lymph

nodes)nodes) Inspection and palpation of the legs (edema, Homans’ sign; Inspection and palpation of the legs (edema, Homans’ sign;

femoral, popliteal, dorsalis pedis pulses, manual compression femoral, popliteal, dorsalis pedis pulses, manual compression testtest

Additional techniques: Trendelenburg test, colour changes, Additional techniques: Trendelenburg test, colour changes, doppler ultrasonic stethoscope.doppler ultrasonic stethoscope.

Abnormal findings:Abnormal findings: Variations in arterial pulseVariations in arterial pulse Raynauld’s syndromeRaynauld’s syndrome Lymphedema Lymphedema ArteriosclerosisArteriosclerosis Superficial varicose veinsSuperficial varicose veins Peripheral artery disease: occlusions, aneurysmsPeripheral artery disease: occlusions, aneurysms

Structure And FunctionStructure And Function

The vascular system consists of the vessels The vascular system consists of the vessels of the body.of the body.

Vessels are tubes for transporting fluid, Vessels are tubes for transporting fluid, such as the blood or lymph.such as the blood or lymph.

Function - transporting the blood or lymph :Function - transporting the blood or lymph : Delivery of oxygen to the tissuesDelivery of oxygen to the tissues Delivery of nutrients to the tissuesDelivery of nutrients to the tissues Elimination of carbon dioxide from cellsElimination of carbon dioxide from cells Elimination of waste products from cellular metabolismElimination of waste products from cellular metabolism

Arteries.Arteries. Carry freshly oxygenated blood to tissuesCarry freshly oxygenated blood to tissues High-pressure systemHigh-pressure system Walls are strong, tough, and tense Walls are strong, tough, and tense

with elastic fibers ► stretch with systole, recoil with elastic fibers ► stretch with systole, recoil with diastolewith diastole

with muscle fibers (VSM) ► control the amount of with muscle fibers (VSM) ► control the amount of blood delivered to the tissues and the rate of blood blood delivered to the tissues and the rate of blood flowflow

Pulse is a pressure wave created by each Pulse is a pressure wave created by each heartbeat, palpable at body sites where the heartbeat, palpable at body sites where the artery lies close to the skin and over a bone.artery lies close to the skin and over a bone.

Arteries accessible to Arteries accessible to examinationexamination

Temporal artery (review chapter 13)Temporal artery (review chapter 13) Carotid arteryCarotid artery Arteries in the arm:Arteries in the arm:

BrachialBrachial RadialRadial Ulnar Ulnar

Arteries in the leg:Arteries in the leg: Femoral arteryFemoral artery PoplitealPopliteal Anterior tibial ► Anterior tibial ► dorsalis pedisdorsalis pedis Posterior tibialPosterior tibial ► plantar arteries ► plantar arteries

Ischemia is a is a deficient supply of deficient supply of oxygenated arterial oxygenated arterial

blood to a body part, blood to a body part, due to constriction or due to constriction or obstruction of a blood obstruction of a blood

vesselvessel

Arteries accessible to Arteries accessible to examinationexamination

Arteries Arteries accessiblaccessibl

e to e to examinatiexaminati

onon

Veins accessible to Veins accessible to examinationexamination

Jugular veinsJugular veins Veins in the arm: Veins in the arm:

Superficial – in the subQ tissue, responsible for Superficial – in the subQ tissue, responsible for most of the venous returnmost of the venous return

DeepDeep Veins in the leg:Veins in the leg:

Deep veins: femoral, popliteal; responsible for Deep veins: femoral, popliteal; responsible for most of the venous returnmost of the venous return

Superficial: great and small saphenousSuperficial: great and small saphenous Perforators: connecting veins that join the two Perforators: connecting veins that join the two

sets. They have one-way valves ► blood ► into the sets. They have one-way valves ► blood ► into the deep veins.deep veins.

Veins Veins accessible accessible

to to examinationexamination

Lymphatics.Lymphatics. A completely separate vascular system.A completely separate vascular system. It retrieves excess fluid from the tissue It retrieves excess fluid from the tissue

spaces and returns it to the blood stream.spaces and returns it to the blood stream.

LymphatLymphatic ducts ic ducts

and and drainage drainage patternspatterns

Functions of the lymphatic Functions of the lymphatic system:system:

To converse fluid and plasma To converse fluid and plasma proteins that leak out of the proteins that leak out of the capillaries.capillaries.

To form the major part of the To form the major part of the immune system that defends body immune system that defends body against infection.against infection.

To absorb lipids from the intestinal To absorb lipids from the intestinal tract.tract.

Structure of the Structure of the lymphatic systemlymphatic system

Microscopic open-ended tubes Microscopic open-ended tubes (capillaries)(capillaries)

Vessels, like veins, have valvesVessels, like veins, have valves

Lymphatic ductsLymphatic ducts

Subclavian veinsSubclavian veins

Lymphoid tissue:Lymphoid tissue: Lymph nodes:Lymph nodes:

Filter the fluid before it comes back to the Filter the fluid before it comes back to the bloodstreambloodstream

Filter out microorganismsFilter out microorganisms Tonsils:Tonsils:

Pharyngeal (adenoid)Pharyngeal (adenoid) PalatinePalatine LingualLingual

SpleenSpleen Peyer’s patches (Lymphoid tissue in Peyer’s patches (Lymphoid tissue in

intestines)intestines) Tymus glandTymus gland Bone marrowBone marrow

Groups of peripheral lymph Groups of peripheral lymph nodes:nodes:

1.1. Auricular: anterior and Auricular: anterior and posteriorposterior

2.2. Sublingual.Sublingual.3.3. Submandibular.Submandibular.4.4. Cervical: anterior and Cervical: anterior and

posterior.posterior.5.5. Supra- and subclavian.Supra- and subclavian.6.6. Axillary.Axillary.7.7. Epithrochlear.Epithrochlear.8.8. Inguinal.Inguinal.9.9. Popliteal. Popliteal.

Assesment:Assesment: Inspection and Inspection and

palpationpalpation Amount in each groupAmount in each group SizeSize ShapeShape ConsistencyConsistency Movable/connected Movable/connected

with surrounding with surrounding tissuestissues

Pain/tendernessPain/tenderness Signs of inflammation: Signs of inflammation:

swelling and redness swelling and redness above the nodeabove the node

Taking client’s complaints Taking client’s complaints and history.and history.

Ask: “Any leg pain (cramps)? Where?”Ask: “Any leg pain (cramps)? Where?” Detail: pain type, onset (gradual/sudden), Detail: pain type, onset (gradual/sudden),

aggravating/ relieving factors (activity, aggravating/ relieving factors (activity, walking, dangling, rubbing), associated signs walking, dangling, rubbing), associated signs (skin changes, sexual malfunction), relation (skin changes, sexual malfunction), relation to time of day, claudication distance.to time of day, claudication distance.

Claudication distance is the number is the number of blocks walked or stairs climbedof blocks walked or stairs climbed

to produce pain.to produce pain.Note sudden dencrease in

claudication distance, or pain suddenly not relieved by rest.

Taking client’s complaints Taking client’s complaints and history.and history.

Edema is Edema is bilateralbilateral when when caused by a systemic caused by a systemic

problem (heart failure), problem (heart failure), or or unilateral unilateral when due to when due to

a local obstruction or a local obstruction or inflammation.inflammation.

Objective dataObjective dataPreparation:Preparation: EnvironmentEnvironment

Should be warm (about 22°C) and Should be warm (about 22°C) and draftless to prevent vasodilatation draftless to prevent vasodilatation or vasoconstriction. or vasoconstriction.

PrivacyPrivacy Make sure the female’s breasts and Make sure the female’s breasts and

client’s genitals remain draped. client’s genitals remain draped. Order of examOrder of exam

Begin with observations Begin with observations peripherally and move toward the peripherally and move toward the heart.heart.

1.1. Pulse and blood pressurePulse and blood pressure2.2. Extremities – peripheral vascular Extremities – peripheral vascular

assessmentassessment3.3. Neck vesselsNeck vessels4.4. Precordium – (portion of body over Precordium – (portion of body over

heart and thorax)heart and thorax)

Equipment Equipment needed:needed: Tourniquet or Tourniquet or

blood pressure cuffblood pressure cuff StethoscopeStethoscope Paper tape Paper tape

measuremeasure Doppler ultrasonic Doppler ultrasonic

stethoscopestethoscope

Assessing Neck VesselsAssessing Neck Vessels Carotid ArteryCarotid Artery

Palpate the carotid Palpate the carotid arteryartery

Avoid excessive pressure. Avoid excessive pressure. Excessive vagal Excessive vagal stimulation could slow stimulation could slow down heart rate.down heart rate.

Carotid arteries should be Carotid arteries should be same bilaterallysame bilaterally

AuscultationAuscultation Listen for bruits – blowing, Listen for bruits – blowing,

swishing sounds indicating swishing sounds indicating blood flow turbulence. blood flow turbulence. Caused by atherosclerotic Caused by atherosclerotic narrowing (one half or two narrowing (one half or two thirds of artery).thirds of artery).

Assessing Neck VesselsAssessing Neck Vessels Jugular VeinsJugular Veins

Can be used to assess central venous pressure (CVP) Can be used to assess central venous pressure (CVP) and cardiac efficiencyand cardiac efficiency

Distended external jugular veins signify increased CVP, as with heart failure

Position the patient at 30-45 degree angle, wherever Position the patient at 30-45 degree angle, wherever pulsations can be seen best. Remove pillow to avoid pulsations can be seen best. Remove pillow to avoid flexion of head.flexion of head.

The higher the CVP, the higher the position you will needThe higher the CVP, the higher the position you will need Turn the pt’s head away from examiner’s sideTurn the pt’s head away from examiner’s side Distinguish from carotid artery pulsations. Internal Distinguish from carotid artery pulsations. Internal

jugular pulse is lower, varies with respiration, not jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting.palpable, and disappears as person is sitting.

Assessing Neck VesselsAssessing Neck Vessels Jugular Venous Pressure EstimateJugular Venous Pressure Estimate

Used to assess heart failureUsed to assess heart failure Position the patient at 30-45 degree angle. Place one Position the patient at 30-45 degree angle. Place one

ruler vertically at the manubriosternal angle. Place a ruler vertically at the manubriosternal angle. Place a second ruler perpendicular to the first and record the second ruler perpendicular to the first and record the height of pulsation of the internal jugular vein.height of pulsation of the internal jugular vein.

Normal pulsation is 2 cm or less above sternal angleNormal pulsation is 2 cm or less above sternal angle Pulsations 3 or more cm above sternal angle while at 45 Pulsations 3 or more cm above sternal angle while at 45

degrees occur with heart failuredegrees occur with heart failure Record height of pulsations and degrees of elevationRecord height of pulsations and degrees of elevation

Question Question The examiner has estimated the jugular The examiner has estimated the jugular

venous pressure. Identify the finding that venous pressure. Identify the finding that is abnormal.is abnormal.

1.1. Patient elevated to 30 degrees, internal jugular Patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle.vein pulsation at 1 cm above sternal angle.

2.2. Patient elevated to 30 degrees, internal jugular Patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal anglevein pulsation at 2 cm above sternal angle

3.3. Patient elevated to 40 degrees, internal jugular Patient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal anglevein pulsation at 1 cm above sternal angle

4.4. Patient elevated to 45 degrees, internal jugular Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal anglevein pulsation at 4 cm above sternal angle

Inspection and palpation of Inspection and palpation of the armsthe arms

Inspect for:Inspect for: Color of skin and nailbeds Color of skin and nailbeds Temperature, texture and turgor of skinTemperature, texture and turgor of skin Any lesions, edemaAny lesions, edema Nail clubbing. Nail clubbing. What is normal nail bed angle?What is normal nail bed angle? Use Use profile signprofile sign to detect early clubbing to detect early clubbing Capillary refillCapillary refill is an index of peripheral is an index of peripheral

perfusion and cardiac output. perfusion and cardiac output. Depress and blench the nail beds; release and Depress and blench the nail beds; release and

note the time for color return. Normally 1 to 2 note the time for color return. Normally 1 to 2 seconds.seconds.

160 degrees160 degrees

Inspection and palpation of Inspection and palpation of the armsthe arms

Palpate both radial pulses:Palpate both radial pulses: Symmetricity (equal force), rhythm, rate, Symmetricity (equal force), rhythm, rate,

elasticity.elasticity. Grade the force (amplitude) on a fore-point Grade the force (amplitude) on a fore-point

grade:grade: 0 – absent0 – absent 1+, weak1+, weak 2+, 2+, normalnormal 3+, increased3+, increased 4+, bounding4+, bounding

For ulnar pulse palpate along the medial For ulnar pulse palpate along the medial site of the inner forearm. Not palpable in site of the inner forearm. Not palpable in healthy person.healthy person.

Inspection and palpation of Inspection and palpation of the armsthe arms

Palpate the brachial pulses.Palpate the brachial pulses. Palpate the epitrochlear lymph nodePalpate the epitrochlear lymph node Modified Allen test: Modified Allen test: Normal 2 to 5 secondsNormal 2 to 5 seconds