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Health Assessment Ch. 20 - Peripheral Vascular System and Lymphatic System

Terms in this set (49)

- Peripheral blood vessels grow more rigid with age, termed arteriosclerosis. This condition produces the rise in systolic blood pressure

- Atherosclerosis is the deposition of fatty plaques on the intima of the arteries.

- Both processes are present with PAD in aging adults.

- PAD is underdiagnosed and undertreated, yet is a large cause of mobidity (painful walking, poor wound healing) and mortality in the United States.

- It increases dramatically with age and is present in 29% of those over 70 years and in those between 50-69 years with a history of cigarette smoking or diabetes.

- During the middle-aged years, more men have PAD than women.

- In people over 85 years, the prevalence in women is 39% compared to 27% of men

- When women do develop PAD, they also may have arthritis or peripheral neuropathy, that masks their symptoms and delays diagnosis. (If you are old, are disabled, and cannot walk, you will not show leg pain)

- Despite its prevalence and the risk for coronary artery disease (CAD), only 70% to 80% of those diagnosed with PAD are treated with antiplatelet or lipid lowering drugs; and the rest are untreated, many more are undiagnosed

A- Aging produces a progressive enlargement of the intramuscular calf veins.

A- Prolonged bed rest, prolonged immobilization, and heart failure increase the risk for deep vein thrombosis (DVT) and subsequent pulmonary embolism

- DVT and subsequent pulmonary embolism are common in aging and also with malignancy and myocardial infarction (MI). Low dose anticoagulants medication reduces the risk for venous thromboembolism

A- Loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and a decrease in the size of remaining nodes
A1-leg pain or cramps
- Rational - Peripheral vascular disease (PVD) includes PAD and venous disease
- With PAD, blood flow cannot match muscle demand exercise; therefore people feel muscle fatigue or pain when walking (claudication). But only 10% of those with PAD have this classic symptom 40% do not have leg pain, and 50% have varying symptoms
- Claudication distance - is the number of blocks walked or stairs climbed to produce pain
-Night leg pain is common in aging adults. It may indicate the ischemic rest pain of PVD, severe night muscle cramping (usually the calf), or restless leg syndrome.
-Pain of musculoskeletal origin rather than vascular
A-Aortoiliac occlusion is associated with erectile dysfunction (Leriche Syndrome).
-Risk factors for PVD. Diabetes and smoking are stronger risk factors for PVD than they are even for heart disease.

A2- Skin Changes on arms or legs
-Rational - Coolness occurs with PAD
-Varicose veins
-Avoid compression stockings with PAD since they further impede blood flow. They are indicated to prevent leg swelling in standing workers or thrombus formation.
-Leg ulcers occur with chronic arterial and venous disease

3- Swelling in arms or legs
-Rational -Edema is bilateral when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation.

4- Lymph node enlargement
-Rational - Enlarged lymph nodes occur with infection, malignancies, and immunologic diseases.

5- Medications
-Rational - These may cause hypercoagulable state. Also note that low-dose aspirin or clopidogrel are used to prevent blood clots in selected people

6- Smoking history
-Rational - Tobacco contricts arteries, increases coagulability, injures endothelium, and promotes inflammation. Smoking is the strongest risk factor for PAD; starting smoking at <16 years or more than doubles future PAD risk.
Check for
- Color of Skin
- Color of nail beds
- Temp
- Texture
- Turgor (Stiffness) of skin

- Use the profile sign (viewing the finger from the side) to detect early clubbing

- Normal nail bed angle is 160 degrees

- Normal capillary refill is less than 1 or 2 seconds

- Two arms should be symmetric in size

-Abnormal Findings-
- Flattening of angle and clubbing occur with congenital cyanotic heart disease and cor pulmonale (Pulmonary Heart Disease)

Check for
- Scars on hands and arms (Many occur normally with usual child hood abrasions or occupations involving hand tools)
A- Radial pule
A- Rate
A- Rhythm
A- Elasticity of vessel wall
A- Force (Grade force on a 3-point scale)
3+ - Increased, full, bounding
A2+ - Normal
1+ - Weak
0 - Absent

- Not necessary to palpate the ulnar pulses, if needed palpate along side the medial side of the inner forearm (although the ulnar pulses are often not palpable in the healthy person).

- Needle tracks in hands, arms, antecubital fossae occur with intravenous drug use
- Linear scars in wrists may signify past self-inflicted injury
- Full bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever), anemia, and hyperthyroidism.
- Weak "thready" pulse (1+) occurs with shock and PAD

-Palpate brachial pulse their force should be equal bilaterally

Lymph Nodes
- Check epitrochlear lymph nodes in the depression above and behind the medial condyle of the humerus
- These nodes normally are not papable

- Enlarged epitrochlear node occurs with infection of the hand or forearm.
- Generalized lymphadenopathy
- Palpable in 25%-30% of lymphoma, chronic lymphoctic leukemia, sarcoidosis and up to 55% in mononucleosis conditions
Check for
- Skin color
- Hair distribution
- Venous pattern
- Size (swelling or atrophy)
- Skin lesions
- Ulcers
A- Skin should be warm and equal bilaterally
-Venous pattern normally is flat and barely visible
If legs look asymmetric or of DVT is suspected, measure the calf circumference
- Measure at the widest point, taking care to measure the other leg in exactly the same place

- Pallor with vasoconstriction
- Erythema with vasodilation
- Cyanosis
- Malnutrition
- Thin, shiny, atrophic skin
- Thick-ridged nails
- Loss of hair
- Ulcers
- Gangrene
(Malnutrition, pallor, and coolness occur with arterial insufficiency)
- Bilateral edema occurs with systemic illnesses
- Acute, unilateral, painful swelling and asymmetry of calves of 1cm or more is abnormal; refer the person to determine whether DVT is present

- 1 to 3cm occurs with mild lymphedema
- 3 to 5cm with moderate lymphedema
- More than 5cm with severe lymphedema

- Brown discoloration occurs with chronic venous stasis caused by hemosiderin deposits from red blood cell degradation
- Venous ulcers occur usually at medial malleolus because of bacterial invasion of poorly drained tissues
- Arterial deficit, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli
- Unilateral cool foot or leg occurs with arterial deficit
- Calf pain occurs in 35% of cases of DVT
- Nodes that are enlarged, tender, or fixed in area
- Bruits occurs with trubulent blood flow, indicating partial occlusion

- Popliteal pulse is a more diffuse pulse and can be difficult to localize
- Often a normal popliteal pulse is impossible to palpate
- The dorsalis pedis pulse requires a very light touch
- In adults older than 45 years, occasioanlly either the dorsalis pedis or the posterior tibial pulse may be hard to find, but not both on the same foot

A-Check for pretibial edema
- Firmly depress the skin over the tibia or the medial malleolous for 4 seconds
- A pit is commonly seen if the person has been standing all day or during pregnancy