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Nursing Care of Clients with
Peripheral Vascular Disorders
Anatomic and Physiologic Overview
Adequate perfusion oxygenates and nourishes body
tissues and depends in part on a properly functioning
cardiovascular syst...
Adequate blood flow depends on
1. the efficient pumping
   action of the heart
2. patent and responsive
   blood vessels
3...
Factors that influence the rate and adequacy of blood flow
  Nervous system activity
  blood viscosity
  metabolic needs o...
Anatomic and Physiologic Overview
 The vascular system consists of two interdependent systems.
   right side of heart pump...
Arteries distribute oxygenated blood from the left side of the
heart to the tissues, whereas the veins carry deoxygenated ...
ANATOMY OF THE VASCULAR
SYSTEM
Arteries and Arterioles
 Arteries
   thick-walled structures that carry blood from heart to tissues.
   Aorta : diameter o...
Layers or walls of arteries and
arterioles
1. Intima: an inner endothelial cell layer
2. Media : a middle layer of smooth ...
Layers or walls of arteries and
arterioles
1. Intima
   an inner endothelial
   cell layer
   a very thin layer,
   provid...
Layers or walls of arteries and
arterioles
2. Media
   a middle layer of smooth elastic tissue
   makes up most of the ves...
Layers or walls of arteries and
arterioles
3. Adventitia
   an outer layer of connective tissue.
   a layer of connective ...
What controls the diameter of the blood
                vessels?
 Smooth muscle controls the diameter of the
    vessels b...
Capillaries
 Capillary walls
  lack smooth muscle and adventitia
  composed of a single layer of endothelial cells.
  This...
Veins and Venules
 walls of veins are thinner and considerably less muscular.
 wall of the average vein amounts to only 10...
Veins have thin and less musculature. Is
        this an advantage or not?
            Why or why not?
  The thin, less mu...
What stimulates the veins to constrict?

         Sympathetic Nervous System
    innervates the vein musculature
    can s...
Contraction of skeletal muscles in extremities
 creates the primary pumping action to facilitate venous
              bloo...
Bicuspid valves.
Do veins have them?
 Some veins are equipped with valves.
 In general, veins that transport blood against...
Lymphatic Vessels
 are a complex network of thin-walled vessels similar to the
 blood capillaries.
 collects lymphatic flu...
Lymphatic Vessels
 converge into two main structures:
   (1) thoracic duct and (2) right lymphatic duct
   These ducts emp...
Assessment
Arms Assessment
     • Observe arm size and venous pattern; also look for edema
     • Observe for coloration of the hands...
Legs Assessment
     • Observe skin color while inspecting both legs from the
         toes to the groin
     •   Inspect ...
Legs Assessment
     • Palpate the superficial inguinal lymph nodes
     • Palpate the femoral pulses
     • Auscultate th...
Special Tests for Arterial or Venous
     Insufficiency
     • Position change test for arterial insufficiency
     • Ankl...
Assessment
 Health History and Clinical Manifestations
   Intermittent Claudication
   Changes in Skin Appearance and Temp...
Intermittent claudication
 A muscular, cramp-type pain in the extremities consistently
 reproduced with the same degree of...
Pathophy
 Caused by inability of arterial system to provide adequate
 blood flow to tissues in the face of increased deman...
Usually, about 50% of the arterial lumen or 75% of the
cross-sectional area must be obstructed before intermittent
claudic...
Rest pain
 Persistent pain in the forefoot when the patient is resting
 indicates a severe degree of arterial insufficienc...
The site of arterial disease can be deduced from the location
of claudication, because pain occurs in muscle groups below
...
Changes in Skin Appearance and
Temperature
 Adequate blood flow warms the extremities and gives them a rosy
 coloring.
 Pa...
Other changes
 Additional changes resulting from a chronically reduced
 nutrient supply include
   loss of hair
   brittle...
Edema                           Gangrene
 may be apparent bilaterally     appear after prolonged,
 or unilaterally        ...
49   Maria Carmela Domocmat, RN, MSN   9/9/2012
Pulses
 Determine presence or absence & quality of peripheral
 pulses is important in assessing the status of peripheral
 ...
How do you assess pulse?
 Pulses should
   be palpated bilaterally and simultaneously
   comparing both sides for symmetry...
How can you prevent committing the
      mistake of taking your own pulse for
              that of the patient?

  Use li...
Diagnostic Evaluation
Diagnostic Evaluation
 Doppler ultrasound flow studies
 Duplex ultrasonography
 Exercise testing
 Computed tomography (CT)...
Doppler ultrasound flow studies
 When pulses cannot be reliably palpated, use of a
 microphone-like, hand-held Doppler ult...
Procedure
 supine position with head of bed elevated 20 to 30 degrees
 legs are externally rotated, if possible, to permit...
CW Doppler
 is more useful as a clinical tool when combined with ankle
 blood pressures, which are used to determine the a...
Measuring the ankle systolic pressure with a continuous-wave Doppler
probe, pneumatic cuff and gauge.
This reading would b...
ABI
        supine position (not seated) for at least 5 minutes.
        appropriate- sized BP cuff is applied to ankle ab...
To calculate ABI, the ankle systolic pressure for each foot is
divided by the higher of the two brachial systolic pressure...
Let’s practice!
 Compute the ABI for patient M who has the ff systolic
 pressures:
   Right brachial: 160 mm Hg
   Left br...
Let’s practice!
 Compute the ABI for patient M who has the ff systolic pressures:
   Right brachial: 160 mm Hg
   Left bra...
Normal findings
  In general, systolic pressure in ankle of a healthy person is same
  or slightly higher than brachial sy...
Doppler ultrasonography
 used to measure brachial pressures in both arms.
 Both arms are evaluated because the patient may...
Exercise testing
 used to determine how long a patient can walk and to
 measure the ankle systolic blood pressure in respo...
Duplex ultrasonography
       is a combination of the Doppler technology with pulse-echo
       imaging.
        After sen...
Duplex ultrasonography
 helps determine level and extent of disease
 Is universally employed to evaluate the venous system...
Duplex ultrasonography
 noninvasive
 requires no patient preparation.
 equipment is portable, making it useful anywhere fo...
Duplex ultrasonography
Transverse view of an abdominal
                                          aortic aneurysm.
Longitudinal scan of an atheros...
Duplex ultrasonography
         Carotid and Vertebral Scan             Detection for Deep Vein
            Indications: St...
Computed tomography (CT)
 provides cross-sectional images of soft tissue and can identify
 area of volume changes to an ex...
In spiral (also called volumetric) CT scan
  the scan head moves circumferentially around the patient as the
  patient pas...
Computed tomographic angiography
(CTA)
 a spiral CT scanner and rapid intravenous infusion of contrast
 agent are used to ...
Magnetic resonance angiography
(MRA)
 performed with a standard MRI scanner but with image-
 processing software specifica...
Angiography
 An arteriogram produced by angiography may be used to
 confirm the diagnosis of occlusive arterial disease
 w...
Risks/ complications
 immediate or delayed allergic reaction to the iodine
 contained in the contrast agent.
   Manifestat...
Air plethysmography (APG)
 Is a pneumatic plethysmograph designed for non-
 invasively measuring venous function and absol...
Influence of high-heeled shoes on venous
 function in young women
http://www.sciencedirect.com/science/article/pii/S074152...
Air-
     Air-Plethysmography (APG)
        Detection for Chronic Venous Obstruction
        Measurement of Venous Reflux
...
Contrast phlebography
 Also known as venography
 involves injecting radiographic contrast media into the
 venous system th...
Lower limb phlebography
 (two projections): Contrast material fills the deep veins of the leg and passes
 through the perf...
Lymphangiography
Lymphangiogram
 used to evaluate the possible spread of cancers and the
 effectiveness of cancer therapy.
 X-rays may also...
Lymphangiography
 Procedure
  a lymphatic vessel in each foot (or hand) is injected with
  contrast agent.
  A series of x...
Lymphoscintigraphy
            is a technique that is used to determine the sentinel lymph
            node
            Ak...
Lymphoscintigraphy
            Procedure
                A radioactively labeled colloid is injected subcutaneously in the...
Abnormal
Normal lymphoscintigram   lymphoscintigram
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3
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Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 1 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 2 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 3 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 4 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 5 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 6 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 7 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 8 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 9 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 10 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 11 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 12 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 13 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 14 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 15 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 16 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 17 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 18 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 19 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 20 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 21 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 22 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 23 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 24 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 25 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 26 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 27 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 28 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 29 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 30 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 31 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 32 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 33 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 34 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 35 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 36 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 37 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 38 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 39 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 40 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 41 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 42 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 43 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 44 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 45 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 46 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 47 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 48 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 49 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 50 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 51 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 52 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 53 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 54 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 55 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 56 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 57 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 58 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 59 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 60 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 61 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 62 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 63 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 64 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 65 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 66 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 67 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 68 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 69 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 70 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 71 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 72 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 73 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 74 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 75 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 76 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 77 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 78 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 79 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 80 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 81 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 82 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 83 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 84 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 85 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 86 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 87 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 88 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 89 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 90 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 91 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 92 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 93 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 94 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 95 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 96 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 97 Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3  Slide 98
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Peripheral Vascular Disorders: Review of Anatomy and Physiology of Blood vessels, and Assessment

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Nursing Care of Clients with Peripheral Vascular Disorders Part 1 of 3

  1. 1. Nursing Care of Clients with Peripheral Vascular Disorders
  2. 2. Anatomic and Physiologic Overview
  3. 3. Adequate perfusion oxygenates and nourishes body tissues and depends in part on a properly functioning cardiovascular system.
  4. 4. Adequate blood flow depends on 1. the efficient pumping action of the heart 2. patent and responsive blood vessels 3. and adequate circulating blood volume
  5. 5. Factors that influence the rate and adequacy of blood flow Nervous system activity blood viscosity metabolic needs of tissues
  6. 6. Anatomic and Physiologic Overview The vascular system consists of two interdependent systems. right side of heart pumps blood through lungs to pulmonary circulation left side of heart pumps blood to all other body tissues through systemic circulation. The blood vessels in both systems channel the blood from the heart to the tissues and back to the heart Contraction of the ventricles is the driving force that moves blood through the vascular systems.
  7. 7. Arteries distribute oxygenated blood from the left side of the heart to the tissues, whereas the veins carry deoxygenated blood from the tissues to the right side of the heart. Capillary vessels, located within the tissues, connect the arterial and venous systems and are the site of exchange of nutrients and metabolic wastes between the circulatory system and the tissues. Arterioles and venules immediately adjacent to the capillaries, together with the capillaries, make up the microcirculation. The lymphatic system complements the function of the circulatory system. Lymphatic vessels transport lymph (a fluid similar to plasma), and tissue fluids (containing smaller proteins, cells, and cellular debris) from the interstitial space to systemic veins.
  8. 8. ANATOMY OF THE VASCULAR SYSTEM
  9. 9. Arteries and Arterioles Arteries thick-walled structures that carry blood from heart to tissues. Aorta : diameter of approximately 25 mm (1 inch) divide into smaller arteries that are about 4 mm (0.16 inch) in diameter by the time they reach the tissues. Within the tissues, the vessels divide further, diminishing to approximately 30 µm in diameter; these vessels are called arterioles.
  10. 10. Layers or walls of arteries and arterioles 1. Intima: an inner endothelial cell layer 2. Media : a middle layer of smooth elastic tissue 3. Adventitia :an outer layer of connective tissue.
  11. 11. Layers or walls of arteries and arterioles 1. Intima an inner endothelial cell layer a very thin layer, provides a smooth surface for contact with the flowing blood
  12. 12. Layers or walls of arteries and arterioles 2. Media a middle layer of smooth elastic tissue makes up most of the vessel wall in the aorta and other large arteries of the body. composed chiefly of elastic and connective tissue fibers that give the vessels considerable strength and allow them to constrict and dilate to accommodate the blood ejected from the heart (stroke volume) and maintain an even, steady flow of blood.
  13. 13. Layers or walls of arteries and arterioles 3. Adventitia an outer layer of connective tissue. a layer of connective tissue that anchors the vessel to its surroundings. much less elastic tissue in the smaller arteries and arterioles, and the media in these vessels is composed primarily of smooth muscle.
  14. 14. What controls the diameter of the blood vessels? Smooth muscle controls the diameter of the vessels by contracting and relaxing. What influence the activity of smooth muscle? Chemical, hormonal, and nervous system factors influence the activity of smooth muscle.
  15. 15. Capillaries Capillary walls lack smooth muscle and adventitia composed of a single layer of endothelial cells. This thin-walled structure permits rapid and efficient transport of nutrients to the cells and removal of metabolic wastes. Distribution varies with the type of tissue. skeletal tissue, which is metabolically active, has a denser capillary network than does cartilage, which is less active.
  16. 16. Veins and Venules walls of veins are thinner and considerably less muscular. wall of the average vein amounts to only 10% of the vein diameter, in contrast to 25% in the artery. Walls are composed of three layers, although these layers are not as well defined.
  17. 17. Veins have thin and less musculature. Is this an advantage or not? Why or why not? The thin, less muscular structure of the vein wall allows these vessels to distend more than arteries. Greater distensibility and compliance permit large volumes of blood to be stored in the veins under low pressure. Approximately 75% of total blood volume is contained in the veins. That is why veins are also called Capacitance vessels
  18. 18. What stimulates the veins to constrict? Sympathetic Nervous System innervates the vein musculature can stimulate venoconstriction thereby reducing venous volume and increasing the volume of blood in the general circulation
  19. 19. Contraction of skeletal muscles in extremities creates the primary pumping action to facilitate venous blood flow back to the heart. What facilitate venous blood flow back to the heart?
  20. 20. Bicuspid valves. Do veins have them? Some veins are equipped with valves. In general, veins that transport blood against the force of gravity, as in the lower extremities, have one-way bicuspid valves that interrupt the column of blood to prevent blood from seeping backward as it is propelled toward the heart. Valves are composed of endothelial leaflets, the competency of which depends on the integrity of the vein wall.
  21. 21. Lymphatic Vessels are a complex network of thin-walled vessels similar to the blood capillaries. collects lymphatic fluid from tissues and organs and transports the fluid to the venous circulation.
  22. 22. Lymphatic Vessels converge into two main structures: (1) thoracic duct and (2) right lymphatic duct These ducts empty into the junction of the subclavian and the internal jugular veins. The right lymphatic duct conveys lymph primarily from the right side of the head, neck, thorax, and upper arms. The thoracic duct conveys lymph from the remainder of the body. Peripheral lymphatic vessels join larger lymph vessels and pass through regional lymph nodes before entering the venous circulation. The lymph nodes play an important role in filtering foreign particles.
  23. 23. Assessment
  24. 24. Arms Assessment • Observe arm size and venous pattern; also look for edema • Observe for coloration of the hands and arms • Palpate the client’s fingers, hands, arms, and note the temperature • Palpate to assess for capillary refill time • Palpate for radial pulse • Palpate the ulnar pulse • palpate the brachial pulses if suspect arterial insufficiency • Palpate the epitrochlear lymph nodes • Perform the Allen Test 34 Maria Carmela Domocmat, RN, MSN 9/9/2012
  25. 25. Legs Assessment • Observe skin color while inspecting both legs from the toes to the groin • Inspect distribution of hair • Inspect for lesions or ulcers • Inspect for edema • Palpate edema • Palpate bilaterally from temperature of feet and legs 35 Maria Carmela Domocmat, RN, MSN 9/9/2012
  26. 26. Legs Assessment • Palpate the superficial inguinal lymph nodes • Palpate the femoral pulses • Auscultate the femoral pulses • Palpate the popliteal pulses • Palpate the dorsalis pedis pulses • Palpate the posterior tibial pulses • Inspect for varicosities and thrombophlebitis • Check for Homan’s sign 36 Maria Carmela Domocmat, RN, MSN 9/9/2012
  27. 27. Special Tests for Arterial or Venous Insufficiency • Position change test for arterial insufficiency • Ankle-Brachial pressure index (ABPI) • Manual compression test • Trendelenburg test 37 Maria Carmela Domocmat, RN, MSN 9/9/2012
  28. 28. Assessment Health History and Clinical Manifestations Intermittent Claudication Changes in Skin Appearance and Temperature Pulses Diagnostic Evaluation
  29. 29. Intermittent claudication A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest experienced by patients with peripheral arterial insufficiency.
  30. 30. Pathophy Caused by inability of arterial system to provide adequate blood flow to tissues in the face of increased demands for nutrients during exercise. As the tissues are forced to complete the energy cycle without the nutrients, muscle metabolites and lactic acid are produced. Pain is experienced as the metabolites aggravate the nerve endings of the surrounding tissue.
  31. 31. Usually, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced. When the patient rests and thereby decreases the metabolic needs of the muscles, the pain subsides. The progression of the arterial disease can be monitored by documenting the amount of exercise or the distance a patient can walk before pain is produced.
  32. 32. Rest pain Persistent pain in the forefoot when the patient is resting indicates a severe degree of arterial insufficiency and a critical state of ischemia. is often worse at night and may interfere with sleep. frequently requires that the extremity be lowered to a dependent position to improve perfusion pressure to the distal tissues.
  33. 33. The site of arterial disease can be deduced from the location of claudication, because pain occurs in muscle groups below the disease. As a general rule, the pain of intermittent claudication occurs one joint level below the disease process. Calf pain may accompany reduced blood flow through the superficial femoral or popliteal artery, whereas pain in the hip or buttock may result from reduced blood flow in the abdominal aorta or the common iliac or hypogastric arteries.
  34. 34. Changes in Skin Appearance and Temperature Adequate blood flow warms the extremities and gives them a rosy coloring. Pallor Due to inadequate blood flow whiter or more blanched appearance (esp when the extremity is elevated) Rubor reddish blue discoloration of the extremities, may be observed within 20 seconds to 2 minutes after the extremity is dependent. suggests severe peripheral arterial damage in which vessels that cannot constrict remain dilated. Even with rubor, the extremity begins to turn pale with elevation. Cyanosis a bluish tint on the skin is manifested when the amount of oxygenated hemoglobin contained in the blood is reduced.
  35. 35. Other changes Additional changes resulting from a chronically reduced nutrient supply include loss of hair brittle nails dry or scaling skin Atrophy Ulcerations
  36. 36. Edema Gangrene may be apparent bilaterally appear after prolonged, or unilaterally severe ischemia and is related to the affected represent tissue necrosis. extremity’s chronically In elderly patients who are dependent position inactive, gangrene may be because of severe rest pain. the first sign of disease.
  37. 37. 49 Maria Carmela Domocmat, RN, MSN 9/9/2012
  38. 38. Pulses Determine presence or absence & quality of peripheral pulses is important in assessing the status of peripheral arterial circulation Absence of a pulse indicate that site of stenosis is proximal to that location. Ex: Occlusive arterial disease
  39. 39. How do you assess pulse? Pulses should be palpated bilaterally and simultaneously comparing both sides for symmetry in rate, rhythm, and quality.
  40. 40. How can you prevent committing the mistake of taking your own pulse for that of the patient? Use light touch avoid using only the index finger for palpation, because this finger has the strongest arterial pulsation of all the fingers. The thumb should not be used for the same reason.
  41. 41. Diagnostic Evaluation
  42. 42. Diagnostic Evaluation Doppler ultrasound flow studies Duplex ultrasonography Exercise testing Computed tomography (CT) Computed tomographic angiography (CTA) Magnetic resonance angiography (MRA) Angiography Air plethysmography Contrast phlebography Lymphangiography Lymphoscintigraphy
  43. 43. Doppler ultrasound flow studies When pulses cannot be reliably palpated, use of a microphone-like, hand-held Doppler ultrasound device, called a transducer or probe, may be helpful in detecting and assessing peripheral flow. Continuous-wave (CW) Doppler ultrasound device
  44. 44. Procedure supine position with head of bed elevated 20 to 30 degrees legs are externally rotated, if possible, to permit adequate access to the medial malleolus. Acoustic gel is applied to the patient’s skin to permit uniform transmission of the ultrasound wave (electrocardiogram gel is not used because it contains sodium, which may dissolve the epoxy that covers the transducer’s tip). tip of Doppler transducer is positioned at a 45- to 60-degree angle over the expected location of the artery and angled slowly to identify arterial blood flow. Excessive pressure is avoided because severely diseased arteries can collapse with even minimal pressure.
  45. 45. CW Doppler is more useful as a clinical tool when combined with ankle blood pressures, which are used to determine the ankle- brachial index (ABI), aka: ankle-arm index (AAI). ABI is the ratio of ankle systolic BP to the arm systolic BP. an objective indicator of arterial disease that allows the examiner to quantify the degree of stenosis. With increasing degrees of arterial narrowing, there is a progressive decrease in systolic pressure distal to the involved sites.
  46. 46. Measuring the ankle systolic pressure with a continuous-wave Doppler probe, pneumatic cuff and gauge. This reading would be compared with that at the brachial artery. Since pressure drops with increasing arterial stenosis, an ankle-brachial index of less than 0.95 would be considered abnormal.
  47. 47. ABI supine position (not seated) for at least 5 minutes. appropriate- sized BP cuff is applied to ankle above malleolus. Identify arterial pulse at posterior tibial and dorsalis pedis obtain systolic ankle pressures in both feet. If pressure in these arteries cannot be measured, pressure can be measured in the peroneal artery, which can also be assessed at the ankle . Diastolic pressures cannot be measured with a Doppler.
  48. 48. To calculate ABI, the ankle systolic pressure for each foot is divided by the higher of the two brachial systolic pressures;
  49. 49. Let’s practice! Compute the ABI for patient M who has the ff systolic pressures: Right brachial: 160 mm Hg Left brachial: 120 mm Hg Right posterior tibial: 80 mm Hg Right dorsalis pedis: 60 mm Hg Left posterior tibial: 100 mm Hg Left dorsalis pedis: 120 mm Hg ABI =highest systolic pressure for each ankle / highest brachial pressure
  50. 50. Let’s practice! Compute the ABI for patient M who has the ff systolic pressures: Right brachial: 160 mm Hg Left brachial: 120 mm Hg Right posterior tibial: 80 mm Hg Right dorsalis pedis: 60 mm Hg Left posterior tibial: 100 mm Hg Left dorsalis pedis: 120 mm Hg The highest systolic pressure for each ankle (80 mm Hg for right, 120 mm Hg for left) would be divided by the highest brachial pressure (160 mm Hg). Right: 80/160 mm Hg = 0.50 ABI Left: 120/160 mm Hg = 0.75 ABI
  51. 51. Normal findings In general, systolic pressure in ankle of a healthy person is same or slightly higher than brachial systolic pressure, resulting in an ABI of about 1.0 (no arterial insufficiency). ABI of 0.95 to 0.50 : mild to moderate insufficiency patients with ischemic rest pain have an ABI of less than 0.50, and patients with severe ischemia or tissue loss have an ABI of 0.25 or less.
  52. 52. Doppler ultrasonography used to measure brachial pressures in both arms. Both arms are evaluated because the patient may have an asymptomatic stenosis in the subclavian artery, causing brachial pressure on the affected side to be 20 mm Hg or more lower than systemic pressure. The abnormally low pressure should not be used for assessment.
  53. 53. Exercise testing used to determine how long a patient can walk and to measure the ankle systolic blood pressure in response to walking. walks on a treadmill at 1.5 mph with a 10% incline for a maximum of 5 minutes. normal response : little or no drop in ankle systolic pressure after exercise. (+) claudication : ankle pressure drops Combining this hemodynamic information with the walking time helps the physician determine whether intervention is necessary.
  54. 54. Duplex ultrasonography is a combination of the Doppler technology with pulse-echo imaging. After sending off ultrasound pulses into the tissue, the instrument converts the echoes received from various locations into dots of varying strength, forming an image of the blood vessel. The gold standard for diagnosing venous thrombosis http://www.surgery.hku.hk/vdc_diagnostics.php
  55. 55. Duplex ultrasonography helps determine level and extent of disease Is universally employed to evaluate the venous system. image and assess blood flow evaluate the runoff status of the distal vessels locate the disease (stenosis versus occlusion), determine anatomic morphology and the hemodynamic significance of plaque causing stenosis.
  56. 56. Duplex ultrasonography noninvasive requires no patient preparation. equipment is portable, making it useful anywhere for initial diagnosis or follow-up evaluations.
  57. 57. Duplex ultrasonography
  58. 58. Transverse view of an abdominal aortic aneurysm. Longitudinal scan of an atherosclerotic plaque in the internal carotid artery.
  59. 59. Duplex ultrasonography Carotid and Vertebral Scan Detection for Deep Vein Indications: Stroke Thrombosis Transient ischaemic attack Indication: lower limb oedema / High risk screening pain Abdominal Scan Evaluation of Venous Valve Indications: Severe hypertension Competence Abdominal aortic aneurysm Indications: Varicose vein Graft Surveillance Venous ulcer Stent Surveillance http://www.surgery.hku.hk/vdc_diagnostics.php
  60. 60. Computed tomography (CT) provides cross-sectional images of soft tissue and can identify area of volume changes to an extremity and compartment where changes take place. CT of a lymphedematous arm or leg, for example, demonstrates a characteristic honeycomb pattern in the subcutaneous tissue.
  61. 61. In spiral (also called volumetric) CT scan the scan head moves circumferentially around the patient as the patient passes through the scanner, creating a series of overlapping images that are connected to one another in a continuous spiral Scan times are short; however, the patient is exposed to x- rays, and contrast agent usually must be injected to adequately visualize the blood vessels. Using computer software, the slicelike images are reconstructed into three-dimensional images that can be rotated and viewed from multiple angles.
  62. 62. Computed tomographic angiography (CTA) a spiral CT scanner and rapid intravenous infusion of contrast agent are used to image very thin (1-mm) sections of the target area; the results are configured in three dimensions so that the image closely resembles a regular angiogram CTA shows the aorta and main visceral arteries better than it shows smaller branch vessels. Scan times are usually between 20 and 30 seconds. Requires large volume of contrast agent limits the usefulness of this study in patients with allergy to the contrast agent or with significantly impaired renal function.
  63. 63. Magnetic resonance angiography (MRA) performed with a standard MRI scanner but with image- processing software specifically programmed to isolate the blood vessels. The images are reconstructed to resemble a standard angiogram, but because the images are reassembled in three dimensions, they can be rotated and viewed from multiple angles. no contrast agent is necessary useful in patients with poor renal function or allergy to contrast agent. Scan time is long, and motion artifacts are common, restricting the use of the test to relatively short segments of the vascular system
  64. 64. Angiography An arteriogram produced by angiography may be used to confirm the diagnosis of occlusive arterial disease when considering surgery or other interventions. involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. The location of a vascular obstruction or an aneurysm (abnormal dilation of a blood vessel) and the collateral circulation can be demonstrated. Usually, patients experience a temporary sensation of warmth as the contrast agent is injected, and local irritation may occur at the injection site.
  65. 65. Risks/ complications immediate or delayed allergic reaction to the iodine contained in the contrast agent. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the physician at once; treatment may include the administration of one or more of epinephrine (adrenaline), antihistamines, or corticosteroids. Additional risks include vessel injury, bleeding, and CVA (brain attack, stroke).
  66. 66. Air plethysmography (APG) Is a pneumatic plethysmograph designed for non- invasively measuring venous function and absolute volume changes in the lower extremities. Changes in volume are measured with the patient’s legs elevated, with the patient supine and standing, and after the patient performs toe-ups (patient extends ankle while standing; stands on tip-toes). provides information about venous filling time, functional venous volume, ejected volume, and residual volume. useful in evaluating patients with suspected valvular incompetence or chronic venous insufficiency.
  67. 67. Influence of high-heeled shoes on venous function in young women http://www.sciencedirect.com/science/article/pii/S0741521412001176
  68. 68. Air- Air-Plethysmography (APG) Detection for Chronic Venous Obstruction Measurement of Venous Reflux Indications: Varicose veins Venous ulcer Quantifies volume change in a limb caused by alterations in BP. This information would indicate the presence of obstruction by venous thrombosis and the degree of venous reflux in the lower limb as a result of chronic venous insufficiency. http://www.surgery.hku.hk/vdc_diagnostics.php
  69. 69. Contrast phlebography Also known as venography involves injecting radiographic contrast media into the venous system through a dorsal foot vein. If a thrombus exists, the x-ray image discloses an unfilled segment of vein in an otherwise completely filled vein. Injection of the contrast agent may cause a brief but painful inflammation of the vein. generally performed if patient is to undergo thrombolytic therapy
  70. 70. Lower limb phlebography (two projections): Contrast material fills the deep veins of the leg and passes through the perforate branches (arrow) into the superficial veins (double arrow). The veins are dilated in the region of the varicosity.
  71. 71. Lymphangiography
  72. 72. Lymphangiogram used to evaluate the possible spread of cancers and the effectiveness of cancer therapy. X-rays may also help determine the cause of swelling in an arm or leg and check for parasitic diseases. performed by injecting blue dye into an area to be tested. blue dye helps to locate the lymphatic vessels where the catheter will be placed. Once the lymph vessels are found, contrast medium is injected through the catheter and X-rays are taken to monitor its progress as it spreads through the lymph system up the legs, into the groin, and along the back of the abdominal cavity. The next day, another set of X-rays is taken.
  73. 73. Lymphangiography Procedure a lymphatic vessel in each foot (or hand) is injected with contrast agent. A series of x-rays are taken at the conclusion of the injection, 24 hours later, and periodically thereafter, as indicated. The failure to identify subcutaneous lymphatic collection of contrast agent and the persistence of contrast agent in the tissue for days afterward help to confirm a diagnosis of lymphedema.
  74. 74. Lymphoscintigraphy is a technique that is used to determine the sentinel lymph node Aka: lymphoscintigram, lymphangiogram a reliable alternative to lymphangiography. used to diagnose lymphedema and lipedema. http://breastcancer.about.com/od/breastcancerglossary/g/lymphoscintig.htm
  75. 75. Lymphoscintigraphy Procedure A radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at preset intervals. a computer records the path of the radioactive material towards the draining lymph nodes. The blue dye will assist the surgeon in finding the sentinel lymph nodes, which will be removed and tested for metastasis. No adverse reactionshave been reported. http://breastcancer.about.com/od/breastcancerglossary/g/lymphoscintig.htm
  76. 76. Abnormal Normal lymphoscintigram lymphoscintigram
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Peripheral Vascular Disorders: Review of Anatomy and Physiology of Blood vessels, and Assessment

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