Lymphatic System & Peripheral Vascular

Question 1

Inspection technique of lymphatic system

Answer 1

• Visible nodes
• Edema
• Erythema
• Streaking

Question 2

Lymphatic palpation technique of…

Answer 2

• Lymph nodes: noting…
  
  • size
  • consistency
  • mobility: worse if unmovable and stuck to underlying tissue ⇒ indicates malignancy or chronic infections
  • borders
  • tenderness
  • warmth
• lower extremity specific nodes to palpate for…
  
  • inguinal nodes: can be enlarged due to STIs
  • popliteal

Question 3

Peripheral vascular technique of taking VS specifics…

Answer 3

• standard VS
• assess for orthostatic hypotension: drop in BP w/ change in position
  
  • Steps: measure BP and HR in 3 diff positions (laying down, sitting upright, standing up) w/ time between each measurement
    
    • causes: autonomic dysfunction, volume issues
• Ankle Brachial Pressure Index (ABI) Screening: for pts who have risk factors for PAD
  
  • steps: take BP on both arms brachial & get systolic #s → take BP on ankle above malleoli & get systolic #s → divide higher systolic pressure from legs from by higher brachial systolic pressure from arms = ABI (higher ankle systolic pressure/higher brachial systolic pressure)
  • norm: 0.8 - 1
  • abnorm: <0.6 / 0.7 ⇒ suggests ischemia (lower it is from 1 = more severe ischemia is

Question 4

peripheral vascular palpations of pulses…

Answer 4

• Carotid: If pt is middle age or older and suspect cerebrovascular disease ⇒ listen for bruit that suggests arterial narrowing and increases risk for CVA
• brachial
• radial
• femoral: Exaggerated, widened femoral pulse ⇒ suggests femoral aneurysm (pathologic dilation of artery)
  
  • Femoral aneurysm uncommon and usually caused by atherosclerosis and occurs mostly in >50 yo
• Popliteal: Exaggerated, widened popliteal pulse ⇒ suggests aneurysm of popliteal artery
  
  • Atherosclerosis (arteriosclerosis obliterans) commonly obstructs arterial circulation in thigh ⇒ femoral pulse normal but popliteal pulse decreased or absent
  • Popliteal aneurysm uncommon and usually caused by atherosclerosis and occur mostly in >50 yo men
  • If you have hard time feeling this pulse but can still feel pedal pulses ⇒ be assured that foot is still getting blood flow ⇒ so palpate distal pulses first then proximal
• posterior tibial
• dorsalis pedis: Decreased or absent pedal pulses (assuming in warm environment) w/ normal femoral and popliteal pulses ⇒ suggests occlusive disease in lower popliteal artery or its branches (often seen in DM)

Question 5

Auscultation for bruits in…

Answer 5

• Carotid artery
• Abdominal aorta
• Renal artery
• Iliac artery
• Femoral artery

Question 6

Lymphedema

Answer 6

• What: soft, pitting edema that becomes indurated, hard, non-pitting / inadequate lymph drainage leading to edema
• Causes:
  
  • Interstitial accumulation of protein-rich fluid when lymph channels and nodes are infiltrated or obstructed by tumor, fibrosis, or inflammation
  • Disrupted by axillary node dissection and/or radiation
  • Removal of lymph nodes
• Occurs often in: BIL in feet and toes

Question 7

Lymphedema Stages

Answer 7

• 0:
  
  • Have some internal changes– latent or subclinical condition where swelling not evident despite impaired lymph transport
  • Subtle alterations in tissue fluid/composition
  • Changes in subjective Sxs
• 1: Early accumulation of fluid relatively high in protein content that subsides w/ limb elevation
• 2: Pitting may or may not occur as tissue fibrosis develops + Limb elevation alone rarely reduces tissue swelling
• 3: Lymphostatic elephantiasis where pitting is absent + Trophic skin changes like acanthosis, alterations in skin character and thickness, fat deposits and fibrosis, warty overgrowths often develop

Question 8

Lymphoma

Answer 8

• What: “liquid tumor” – cancer of immune system that affects lymphocytes T-cells and B-cells
• Hodgkins: B-cells affected and hits lymph nodes and moves on from one lymph nodes to next + has Reed-Sternberg cells
• Non-Hodgkins: B-cells and T-cells affected and can see cancer in any of the lymph tissues like spleen and lymph nodes

Question 9

HIV/AIDs

Answer 9

• What: someone newly infected w/ HIV can get generalized lymphadenopathy (enlarged lymph nodes from head to toe)
  
  • Lymphadenopathy: enlargement of nodes w/ or w/o tenderness
  • Ppl don’t know they’ve been infected during virus’ most infectious time range ⇒ contagious
• S&S: Flu-like symptoms

Question 10

Herpes Simplex (HSV)

Answer 10

• What: enlarged nodes of anterior cervical chain and submandibular node
  
  • HSV on mouth increases nasal, anterior cervical chain, and submandibular nodes ⇒ signs of infection
• S&S: Lymph nodes affected often tender but if nontender lymph nodes ⇒ suggests cancer

Question 11

5 Ps of arterial occlusion

Answer 11

• Pallor: bc of loss of blood flow
• Pain: bc of no O2 to tissues
• Pulselessness: bc of no blood flow thru arteries
• Paresthesias: numbness or tingling
• Paralysis: inability to move affected area

Question 12

acute arterial occlusion

Answer 12

• What: embolism or thrombosis that suddenly blocks peripheral artery
• Location of pain: distal pain usually foot and leg
• Onset: sudden + associated Sxs may occur w/o pain
• S&S: coldness, numbness, weakness, absent-distal pulses

Question 13

Chronic arterial occlusion (usually from atherosclerosis) ⇒ causes…

Answer 13

intermittent claudication

Question 14

Asymmetric diminished pulses occur with…

Answer 14

arterial occlusion from atherosclerosis or embolism

Question 15

Normal Pulse

Answer 15

• Pulse contour: smooth and rounded
• Notch on descending slope of wave isn’t palpable

Question 16

Small & Weak Pulse

Answer 16

• Diminished, weak, small pulse pressure
  
  • Upstroke may feel slowed + peak prolonged
• Causes:
  
  • Decreased SV like in HF, hypovolemia, severe aortic stenosis
  • Increased peripheral resistance like in exposure to cold and severe congestive HF

Question 17

Large & Bounding Pulse

Answer 17

• Increased, strong, bounding pulse pressure
  
  • rise and fall may feel rapid + peak brief
• Causes:
  
  • Increased SV, decreased peripheral resistance or both like in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, patent ductus arteriosus
  • Increased SV bc of slow HR like in bradycardia and complete heart block
  • Decreased compliance/Increased stiffness of aortic walls like in aging or atherosclerosis

Question 18

Bisferiens

Answer 18

• Increased arterial pulse w/ double systolic peak
• Causes:
  
  • Pure aortic regurgitation
  • Aortic stenosis w/ regurgitation
  • Increased arterial pulse

Question 19

Pulsus Altemans

Answer 19

• Alternates in amplitude from beat to beat even though rhythm is regular
• When difference between stronger and weaker beats is slight
• Cause: Left ventricular failure w/ left sided S3
• Can only be detected by sphygmomanometer

Question 20

Bigeminal

Answer 20

• Normal beat then premature contraction
• Has premature contraction rhythm mimicking pulsus alternans
• SV of premature beat diminished in relation to that of normal beats ⇒ Pulse varies in amplitude accordingly
• Cause: normal beat alternating w/ premature contraction

Question 21

Pulsus Paradoxus

Answer 21

• Can feel decrease in amplitude of pulse with inspiration (basically opposite of what you normally expect)
• Cause:
  
  • Cardiac tamponade
  • Pericarditis
  • Obstructive airway disease
  • Other serious life-threatening cardiac issues

Question 22

Peripheral Venous Disease (PVD)

Answer 22

• What: inadequate return of venous blood from extremities to heart ⇒ leads to too much fluid build up
• S&S:
  
  • Edema that might make pulse harder to palpate
  • Can get wounds but not black eschar wounds
  • Achy cramping in legs w/ pain worsening when standing and improves w/ elevation and activity
  • Sores w/ irregular borders
  • Yellow slough or ruddy skin

Question 23

Peripheral Arterial Disease (PAD)

Answer 23

• What: narrowing or blockage of vessels that deliver blood from heart to extremities
• Cause: atherosclerosis– build up of fatty plaque in arteries
• S&S:
  
  • Intermittent claudication: cramping muscle pain that comes w/ movement of legs or arms during exercise and relieved by resting
  • Pallor bc of loss of O2
    
    • As it increases ⇒ will impact pulse and it’ll go from regular to weaker to no pulse ⇒ risk for limb loss
  • Black eschar from poor oxygen circulation
  • Loss of hair bc of lack of O2
  • Round, smooth, shiny leg
  • NO edema

Question 24

What are the Specific Disease of Peripheral Venous

Answer 24

• Chronic Venous Stasis/Insufficiency
• Varicose Veins
• Deep Vein Thrombosis (DVT)
• Pitting Edema

Question 25

Chronic Venous Stasis/Insufficiency (Advanced)

Answer 25

- What: more severe form of chronic venous disease w/ chronic venous engorgement from venous occlusion or incompetency of venous valves - If it’s a problem with veins (periphery) ⇒ blood pools and doesn’t return to heart ⇒ lungs and other areas swell bc fluid goes to 3rd space - Causes - Incompetent vein valves secondary to DVT - Prolonged increased venous pressure as seen in prolonged standing or pregnancy ⇒ can lead to varicose veins and skin changes - S&S - Generalized/Diffuse aching of legs, esp at end of day - Decreased wound healing - Weak pulse due to edema making it harder to find - Chronic edema - Pigmentation - Swelling - Ulceration esp if old age, pregnant, increased weight, prior Hx, trauma - Onset: chronic, increasing as day goes on - Aggravating factors: prolonged standing or sitting w/ legs dependent - Relieving factors: pressure stockings, leg elevation, anything to get blood back to where it needs to be

Question 26

Varicose Veins

Answer 26

- What: dilated and tortuous where their walls may feel somewhat thickened - Many varicose veins can be seen in leg - Common in backside of legs - Tested by having pt rise on tiptoes and inspecting backside of legs to see if veins pop out - Is a Sx or result of venous stasis/insufficiency - S&S: Can become painful as they grow and go untreated

Question 27

Deep Vein Thrombosis (DVT)

Answer 27

- What: when blood clot forms in deep vein, accompanied by inflammatory response in vein wall - Common in lower leg, thigh, pelvis ⇒ risk for pulmonary embolism (PE) ⇒ blocks blood flow to lungs ⇒ life-threatening emergency because it impairs oxygenation 🚩 - Avoid firm palpation or massage over DVT because it may dislodge clot ⇒ causes pulmonary embolism or death - S&S: - Painful calf swelling w/ erythema but can be painless - Edema: Extent of edema suggests location of occlusion - Ie. Popliteal vein may be location when lower leg or ankle is swollen - Ie. iliofemoral vein may be location when entire leg is swollen - Tx: remove clot or medicate so thrombus can break apart on its own - Aggravating factors: immobilization or recent surgery, lower extremity trauma, pregnancy, postpartum state, hypercoagulable state - Relieving factors: antithrombotic and thrombolytic therapy

Question 28

What are the Specific Diseases of the Peripheral Arteries?

Answer 28

- Arterial Aneurysm - Raynaud's Disease

Question 29

Arterial Aneurysm

Answer 29

- What: weakness in arterial wall ⇒ stretched artery intima and media ⇒ problem is when it ruptures/opens arterial wall ⇒ blood gets to periphery - Aorta is vulnerable place to have aneurysm ⇒ huge blood loss - Brain is vulnerable place to have aneurysm ⇒ blood will become trapped and can’t go anywhere - Popliteal and femoral aneurysm uncommon and usually caused by atherosclerosis and occur mostly in >50 yo men - Exaggerated, widened femoral pulse ⇒ suggest femoral aneurysm - Tx: surgery if stretched arterial wall is >5 cm

Question 30

Raynaud’s Disease

Answer 30

- What in General: small arteries in fingers and toes spasm in response to cold or stress ⇒ causes them to turn blue and numb (basically just spasms in vasculature) - Primary Raynaud’s: you just have Raynaud’s - What: episodic reversible vasoconstriction in fingers and toes, triggered by cold temp - S&S: distinct digital color changes of pallor, cyanosis, hyperemia (redness) - Secondary Raynaud’s: you have Raynaud’s but there’s another cause of it - What: S&S related to autoimmune diseases– scleroderma, lupus, mixed connective tissue disease, cryoglobulinemia, occupational vascular injury, drugs - S&S: more severe w/ ischemia, necrosis, loss of digits, distorted capillary loops - Causes: stress, cold temp, emotional upset - S&S: - Can be very painful - Affected area gets pale and loose color ⇒ turns cold and blue (if warmth returns to affected part it’ll turn rlly red) - Can develop other wounds like gangrenous area from decreased O2 - Commonly affects: hands and fingers but other parts of body like toes and ears can be affected - Management/Prevention: stress management, limit cold exposure

Question 31

Pitting Edema

Answer 31

- What: third spacing of fluids - Generalized edema is called anasarca - Causes: - HF, esp right side bc it causes increase in fluid build up in lower extremities - Kidney failure - Peripheral vascular problems: Venous insufficiency, DVT - Common in: lower extremities

Question 32

Lymphatic Age-related considerations

Answer 32

- Infants: Recurrent infections, trauma, failure to thrive, immunization Hx, maternal HIV, etc. ⇒ suspect problem with lymph system - Children: Post auricular and occipital nodes more palpable in <2 yo - Older Adults - Delayed healing normal bc of slowing and aging of IS - Trauma, autoimmune disease ⇒ suspect problem with lymph system - Hx of malignancy ⇒ increases risk for cancer - Pregnant Women - Earlier weeks of gestation more sensitive to fetus so exposure to infectious diseases during this time is dangerous - Avoid exposure to cats/cat feces bc they’re toxic to fetus

Question 33

Peripheral Vascular Age-related Considerations

Answer 33

- Infants: Brachial, radial, femoral pulses normally easily palpated - Children - Most HTN in children due to renal diseases, NOT primary HTN (usual assumption in most adults) - Child w/ high BP ⇒ suspect kidney disease and not primary HTN (usual assumption in most adults) - Pregnant Women - BP fluctuations: - BP ↓ til wk 16-20 - 2nd trimester: > 125/75 abnormal - 3rd trimester: >130/80 abnormal - BP should be back to norm during term/delivery time - Geriatrics - Pedal pulses harder to palpate bc vessels become more tortuous and distended - If you can’t feel pedal pulse ⇒ feel for temp, color, cap refill, and size differences to find out if they still have circulation - Systolic BP (SBP) ↑

Question 34

Pulse Grading

Answer 34

- 0: Absent: absent pulse + unpalpable - 1+ : weak: - Diminished pulse - Weaker than expected pulse - Asymmetric diminished pulses occur w/ arterial occlusion from atherosclerosis or embolism - 2+: normal: brisk pulse - 3+: bounding: Bounding, carotid, radial, femoral pulses occur w/ aortic insufficiency

Question 35

Pitting Edema Measurement Scale

Answer 35

- 1+ / 2mm: Barely noticeable pit - 2+ / 4mm: deeper pit + rebounds in few secs - 3+ / 5-6mm: deep pit + rebounds in 10-20secs - 4+ / 8mm: deeper pit + rebounds in >30secs

Question 36

General Documentation of Lymph Nodes

Answer 36

- If lymph node not palpable ⇒ state “nonpalpable” + location of lymph node - If lymph node palpable ⇒ state location, size, shape, consistency, mobility, tenderness