Ha Rle Lympha

Chapter 15
The Peripheral Vascular System

and Lymphatic System
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Anatomy and Physiology #1
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❖Arterial pulses: arm

o Brachial artery
o Radial artery
o Ulnar artery

❖Arterial pulses: legs

o Femoral artery
o Popliteal artery
▪ Dorsalis pedis
artery
▪ Posterior tibial
artery

❖Veins
o Deep and superficial:
legs
▪ Great saphenous vein
▪ Small saphenous
vein
▪ Perforating veins




❖The lymphatic system

and lymph nodes
o Vascular functions
o Immune functions
o Only superficial
nodes are accessible

❖Lymphatic system
o Inguinal system
▪ Superficial
▪ Horizontal
▪ Vertical

❖Fluid exchange and the capillary bed

o Hydrostatic pressure
o Interstitial colloid oncotic pressure
o Colloid oncotic pressure of plasma proteins

❖Edema
o Produced by four mechanisms
▪ Increased plasma volume from sodium
retention
▪ Increased capillary membrane permeability,
related to burns, snake bites, angioedema,
allergic reactions
▪ Low plasma protein levels caused by renal
disorders
▪ Blockage or inadequate removal of lymphatic
fluid (lymphedema)

❖Edema—(cont.)
o Nonpitting
Scale Depression
o Pitting (mm)
1+ 2
▪ “Pit” or
depression left for 2+ 4
5 to 30 seconds 3+ 6
4+ 8

Question #1
What is responsible to move the blood supply from

the feet toward the inferior vena cava?
A. Calf muscles
B. Arterial pulsations
C. Venous flow
D. Thigh muscles

Answer to Question #1
A. Calf muscles
The contraction and relaxation of the calf muscles
helps to move the blood from the feet toward the
trunk of the body.

The Health History #1
❖Common or concerning symptoms

o Pain in the arms or legs
o Intermittent claudication
o Cold, numbness, or pallor in the legs; hair loss
o Swelling in the calves, legs, or feet
o Swelling with redness or tenderness

❖Need to ask specific questions of certain individuals,

may not recognize some conditions as symptoms
o Patients over 50
o With certain risk factors
▪ Smoking
▪ Diabetes
▪ Hypertension
▪ Elevated cholesterol
▪ Coronary artery disease

❖Pain or cramping in legs?

❖Coldness, numbness, pallor in legs?
❖Hair on shins?
❖Aching or pain in lower leg or foot?
❖Fatigue or aching with prolonged standing?
❖Swelling of feet or legs?

❖Varicose veins?
❖Nonhealing or slow healing wounds?
❖Fingertips or toes change color in cold weather?
❖Erectile dysfunction?
❖Abdominal pain after eating?
❖Tender or swollen lymph nodes?

Some Peripheral Causes of Edema #1

Some Peripheral Causes of Edema #2
Lymphedema

Past History #1
❖Medications, especially oral contraceptives or

hormone replacement therapy?
❖Pregnancy or recent childbirth?
❖Inflammatory diseases?
❖Active cancer?
❖Coronary artery disease?
❖Heart attack?
❖Congestive heart failure?
❖Stroke?

Past History #2
❖Clotting disorders?
❖Hypertension?
❖Diabetes?
❖Problems in circulation?
❖Major surgery?
❖Fracture of a long bone in last 4 weeks?

Past History #3
❖Risk factors
o Obesity
o Smoking
o Hyperlipidemia
o Constrictive clothing
o Central venous lines

Family History
❖Peripheral vascular disease

❖Varicose veins
❖Abdominal aortic aneurysm
❖CAD
❖Sudden death younger than 60 years of age
❖Diabetes

Lifestyle
❖Job requiring prolonged standing or sitting

❖Sedentary lifestyle
❖Decreased mobility such as paralysis or cast

Question #2
The use of ________ has been associated with the

increased risk of clot formation in the legs.
A. Analgesics
B. Proton-pump inhibitors
C. Oral contraceptives
D. Cholesterol-lowering agents

C. Oral contraceptives
Research has shown that the use of oral
contraceptives has been connected to an increased
risk of developing deep venous thrombosis.

Physical Examination #1
❖Equipment
o Tape measure
o Doppler ultrasound device
o Tourniquet or blood pressure cuff
❖Position
o Lying down
o Properly draped to allow access to groin area to
access femoral artery
o Easy access to arms and legs

❖The arms ❖The legs

o Size, symmetry, o Size, symmetry,
skin color skin color,
o Radial pulse tenderness
o Brachial pulse o Femoral pulse and

inguinal lymph
o Epitrochlear lymph nodes
nodes
o Popliteal, dorsalis
pedis, and posterior
tibial pulses
o Peripheral edema

❖Arms (from fingertips to

shoulders)
❖Inspection
o Size, symmetry,
swelling, any lesions
o Venous pattern
o Color of skin and
nail beds
o Texture of skin

❖Arms—(cont.)
o Palpation
▪ Temperature
▪ Radial pulse


❖Arms—(cont.)
o Palpation—(cont.)
▪ Epitrochlear
nodes

❖Legs
o Inspection
▪ Size, symmetry, and edema
⮚Measure leg circumferences
▪ Venous pattern, enlargement or varicosities
▪ Pigmentation, rashes, scars, or ulcers
▪ Color and texture of skin and color of nail
beds
▪ Distribution of hair on lower legs, feet, and
toes

❖Legs—(cont.)
o Inspection—(cont.)
▪ Brownish areas or increased pigmentation
near ankles
▪ Location, size, and depth of any ulcers

Chronic Insufficiency of Arteries and
Veins

Common Ulcers of the Ankles and Feet #1

Common Ulcers of the Ankles and Feet #2
Neuropathic Ulcer

❖Legs—(cont.)
o Palpation
▪ Temperature



❖Legs—(cont.)
▪ Thickness of skin
▪ Areas of local
redness
▪ Assess arterial
circulation
⮚Femoral pulse


❖Legs—(cont.)
▪ Dorsalis pedis
pulse
▪ Posterior tibial
pulse

❖Legs—(cont.)
▪ Tips for feeling difficult pulses
⮚Position your body and examining hand
comfortably
⮚Position your hand properly and linger
there, varying the pressure of your fingers
⮚Do not confuse the patient’s pulse with
your own

Abnormalities of the Arterial Pulse and
Pressure Waves #1

Pressure Waves #2

Pressure Waves #3

Pressure Waves #4

❖Legs—(cont.)
▪ Superficial
inguinal nodes
o At the end, ask
patient to stand to
inspect the
saphenous system
for varicosities

Recording Your Findings
❖Lymph nodes (as covered in Chapter 10)

❖Carotid pulse (as covered in Chapter 14)
❖The peripheral vascular system
o Documenting:
Radial Brachial Femoral Popliteal Dorsalis Posterior

Pedis Tibial
RT 2+ 2+ 1+ 1+ 1+ 1+
LT 2+ 2+ 1+ 1+ 1+ 1+

Question #3
A normal pulse is given which grade in

documentation?
A. 0
B. 1+
C. 2+
D. 3+

C. 2+
A grade of 2+ is considered brisk and expected or
normal. A “0” indicates absent or unable to palpate;
1+ is diminished, weaker than expected, and 3+ is
bounding.

Special Techniques #1
❖Evaluating the arterial

supply to the hand
o Ulnar pulse

❖Evaluating arterial
supply to the hand
o Allen test

❖Evaluating arterial
supply to the legs
o Look for pallor

❖Ankle-brachial index
o Noninvasive method to assess lower extremity
arterial blood flow
o Compares systolic blood pressure in the ankle
versus the arm
o Equipment
▪ Doppler device and gel
▪ Blood pressure cuff for arm and leg

❖Ankle-brachial index—(cont.)
o No caffeine, tobacco, or heavy activity at least 1
hour prior
o Quiet, warm environment
o Empty bladder
o Remove tight clothing, shoes, and socks

❖Ankle-brachial index—
(cont.)
o Use Doppler to
obtain arm arterial
systolic pressure in
both arms
o Use Doppler to
obtain leg arterial
systolic pressure
(cuff just above
malleoli) in both
legs

o Calculation
▪ Divide the higher systolic pressure from each
leg by the higher brachial systolic pressure

o Interpretation
ABI Interpretation
>1.4 Calcification/artery hardening
1.0-1.4 Normal
0.9-1.0 Acceptable
0.8-0.9 Some arterial disease
0.5–0.8 Moderate arterial disease
<0.5 Severe arterial disease

❖Evaluating the competency of venous valves

o Retrograde filling (Trendelenburg) test
o Pulsus alternans
o Paradoxical pulse

Health Promotion and Counseling #1

Health Promotion and Counseling #2

Question #4
Prevention is always the best policy when treating our

patients. One of the best “treatments” for preventing
DVT is to encourage our patients to:
A. Move their legs.
B. Wear compression stockings.
C. Proper nutrition.
D. Always lie down with their feet higher than their
head.

A. Move their legs.

Moving their legs is an important measure to
encourage, even if it is just to contract and relax the
legs when lying in bed. Patients should avoid
prolonged sitting and standing and engage in some
form of movement to encourage the movement of
blood through the veins and help prevent the
development of any thrombus, at least hourly.

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Chapter 15

The Peripheral Vascular System

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Arterial pulses: arm

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Arterial pulses: legs

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖The lymphatic system

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Fluid exchange and the capillary bed

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

What is responsible to move the blood supply from

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Common or concerning symptoms

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Need to ask specific questions of certain individuals,

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Pain or cramping in legs?

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Medications, especially oral contraceptives or

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Peripheral vascular disease

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖Job requiring prolonged standing or sitting

Copyright © 2022 Wolters Kluwer • All Rights Reserved

The use of ________ has been associated with the

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

❖The arms ❖The legs

o Brachial pulse o Femoral pulse and

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❖Arms (from fingertips to

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Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved

Copyright © 2022 Wolters Kluwer • All Rights Reserved