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Chapter 15
Blood Vessels
Physical Examination Preview
Blood Vessels
Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for the
following:
Rate
Rhythm
Contour
Amplitude
Auscultate the carotid, abdominal aorta, renal, iliac, and femoral arteries for bruits.
Blood Vessels (Cont.)
Measure the blood pressure in both arms, first seated and then, in patients at risk for orthostatic
hypotension, standing.
With the patient reclining at a 45-degree angle, inspect for jugular venous pulsations and
distention; differentiate jugular and carotid pulse waves, and measure jugular venous
pressure.
Blood Vessels (Cont.)
Inspect the extremities for sufficiency of arteries and veins through the following:
Color, skin texture, and nail changes
Presence of hair
Muscular atrophy
Edema or swelling
Varicose veins
Blood Vessels (Cont.)
Palpate the extremities for the following:
Warmth
Pulse quality
Tenderness along any superficial vein
Pitting edema
Anatomy and Physiology
Blood Circulation
Once it leaves the heart, blood flows through two circulatory systems:
Pulmonary
Systemic
Blood Circulation (Cont.)
Arteries are tougher, more tensile, and less distensible.
Veins are less sturdy and more passive.
Contain valves to keep blood flowing in one direction
If blood volume increases significantly, the veins can expand and act as a repository for
extra blood
Systemic Circulation
Arterial Pulse and Pressure
The palpable and sometimes visible arterial pulses are the result of ventricular systole.
Produces a pressure wave throughout the arterial system (arterial pulse)
Takes barely 0.2 second for the impact of this wave to be felt in the dorsalis pedis artery.
Takes considerably more than 2 seconds for a red blood cell to travel the same distance.
Arterial Pulse and Pressure (Cont.)
The following variables contribute to the characteristics of the pulses:
Volume of blood ejected (stroke volume)
Distensibility of the aorta and large arteries
Viscosity of the blood
Peripheral arteriolar resistance
Jugular Venous Pulse and Pressure
The activity of the right side of the heart is transmitted back through the jugular veins as a pulse
(visualized only) that has five identifiable components—three peaks and two descending
slopes.
Jugular Venous Pulse and Pressure (Cont.)
Five identifiable components—three peaks and two descending slopes.
a wave
c wave
v wave
x slope
y slope
Infants and Children
Cutting of umbilical cord necessitates breathing.
Respiration onset expands lungs.
Pulmonary vascular resistance drops; systemic resistance increases.
Ductus arteriosus closes in first 12 to 14 hours of life.
Foramen ovale closes after pressures shift.
Pregnant Women
Blood pressure decreases.
Systemic vascular resistance decreases.
Peripheral vasodilatation occurs.
Enlarging uterus causes compression of the vena cava and impaired venous return.
Hypotension
Dependent edema
Varicosities in legs and vulva
Hemorrhoids
Older Adults
Arteries calcify.
Arterial walls lose elasticity and vasomotor tone.
Superficial vessels become more prominent.
Increased peripheral vascular resistance elevates blood pressure.
Review of Related History
History of Present Illness
Leg pain or cramps
Onset and duration
Character
Continuous burning in toes, pain in thighs or buttocks
Skin changes
Limping
Waking at night with leg pain
History of Present Illness (Cont.)
Swollen ankles
Onset and duration
Related circumstances
Associated symptoms
Treatment attempted
Medication
Past Medical History
Cardiac surgery or hospitalization
Acute rheumatic fever, unexplained fever, swollen joints, vasculitis
Chronic illness
Family History
Hypertension (HTN)
Dyslipidemia
Diabetes
Heart disease
Thrombosis
Peripheral vascular disease (PVD)
Abdominal aortic aneurysm
Ages at time of illness and death
Personal and Social History
Employment
Tobacco use
Nutritional status
Usual diet
Weight
Exercise
Use of alcohol
Use of recreational drugs
Infants and Children
Hemophilia
Renal disease
Coarctation of the aorta
Leg pains during exercise
Pregnant Women
Blood pressure
Prepregnancy levels
Elevation during pregnancy
Associated symptoms and signs
Legs
Edema
Varicosities
Pain or discomfort
Older Adults
Leg edema
Interference with activities of daily living
Ability of the patient and family to cope with the condition
Claudication
Area involved, unilateral or bilateral, distance one can walk before its onset, sensation,
length of time required for relief
Medications used for relief
Examination and Findings
Procedures
Observe and palpate pulses.
Inspect veins.
Measure blood pressure.
Peripheral Arteries
Palpation
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Peripheral Arteries (Cont.)
Palpate for artery characteristics:
Rate and rhythm
Pulse contour (waveform)
Amplitude (force)
Symmetry
Obstructions
Variations
Peripheral Arteries (Cont.)
The amplitude of the pulse is described on a scale of 0 to 4:
4: Bounding, aneurysmal
3: Full, increased
2: Expected
1: Diminished, barely palpable
0: Absent, not palpable
Peripheral Arteries (Cont.)
Auscultation over arteries for bruits
Temporal
Carotid
Subclavian
Abdominal aorta
Renal
Iliac
Femoral
Peripheral Arteries (Cont.)
Bruit types
Radiation of murmurs
First noted during the cardiac examination
Obstructive arterial disease
Evidence of local obstruction
Assessment for Peripheral Arterial Disease
Arteries in any location can become stenotic (narrowed).
Diminished circulation to the tissues will lead to signs and symptoms that are related to the
following:
Site
Degree of stenosis
Ability of collateral channels to compensate
Rapidity with which the problem develops
Assessment for Peripheral Arterial Disease (Cont.)
Three P’s of occlusion
Pain
Pallor
Pulselessness
Assessment for Peripheral Arterial Disease (Cont.)
Pain that results from muscle ischemia is referred to as claudication.
Dull ache
Muscle fatigue and cramps
Usually appears during sustained exercise, such as walking a distance or climbing
several flights of stairs
Few minutes of rest will ordinarily relieve it.
It recurs again with the same amount of activity.
Continued activity causes worsening pain.
Assessment for Peripheral Arterial Disease (Cont.)
After determining the distinguishing characteristics of the pain, you should note the following:
Pulses
Bruits
Loss of body warmth
Pallor or cyanosis
Collapsed superficial veins
Atrophied skin and loss of hair
Blood Pressure
Systolic
100 to 140 mm Hg
Diastolic
60 to 90 mm Hg
Pulse pressure
Difference between the systolic and diastolic pressure
Peripheral Veins
Jugular venous pressure
The jugular pulse can only be visualized; it cannot be palpated.
Peripheral Veins (Cont.)
Jugular venous pressure
Conditions that make the examination more difficult.
Severe right heart failure, tricuspid insufficiency, constrictive pericarditis, and
cardiac tamponade
Severe volume depletion
Obesity, the overlying adipose tissue, obscures the jugular venous pulsations
Peripheral Veins (Cont.)
Hepatojugular reflux
Hepatojugular reflux is a sign of right heart failure
All patients will have elevation of the JVP with this maneuver
Exaggerated when right heart failure is present
Peripheral Veins (Cont.)
Evaluation of hand veins
Useful in the absence of thrombosis or arteriovenous fistula in that arm, and in the
absence of the superior vena cava syndrome
Peripheral Veins (Cont.)
Assessment for venous obstruction and insufficiency
An acute process may result from injury, external compression, or thrombophlebitis.
In the affected area, pain occurs simultaneously with the following:
Swelling and tenderness over the muscles
Engorgement of superficial veins
Erythema and/or cyanosis
Peripheral Veins (Cont.)
Assessment for venous obstruction and insufficiency (Cont.)
Thrombosis
Homan sign
Calf pain with passive dorsiflexion of the foot
Varicose veins
Peripheral Veins (Cont.)
Assessment for venous obstruction and insufficiency (Cont.)
Edema
Grading 1 through 4+
Infants
Brachial, radial, femoral pulses are easily palpable.
Try using upper arm or thigh for blood pressure measurements.
Evaluate capillary refill.
Very rapid (less than 1 second)
Prolonged (longer than 2 seconds)
Children
Venous hum is common and has no pathologic significance.
Caused by the turbulence of blood flow in the internal jugular veins
Blood pressure is easy to measure in children older than 2 to 3 years of age.
Use correct cuff size.
Children (Cont.)
Hypertension (HTN) is seen in 1% to 3% of children.
Early detection and treatment by physical examination are essential.
HTN most often caused by kidney disease, renal disease, coarctation, or
pheochromocytoma.
Venous thrombosis is less common in children.
Blood pressure varies with gender and height.
Pregnant Women
Blood pressure gradually falls until 16 to 20 weeks of gestation, then gradually rises to
prepregnant levels.
Sustained systolic pressure greater than 140 or diastolic pressure greater than 90 may indicate
pregnancy-induced hypertension (PIH).
Older Adults
Dorsalis pedis and posterior tibial pulses may be more difficult to find.
Loss of vessel elasticity may cause increased systolic pressure.
HTN in older patients is pressure greater than 140/90.
Abnormalities
Pulse abnormalities
Vessel Disorders
Temporal arteritis (giant cell arteritis)
An inflammatory disease of the branches of the aortic arch, including the temporal
arteries
Arteriovenous fistula
Pathologic communication between an artery and a vein
Vessel Disorders (Cont.)
Arterial aneurysm
Localized dilation, generally defined as 1.5 times the diameter of the normal artery,
caused by a weakness in the arterial wall
Vessel Disorders (Cont.)
Peripheral arterial disease
Stenosis of the blood supply to the extremities by atherosclerotic plaques
Arterial embolic disease
Atrial fibrillation can lead to clot formation within the atrium, which may be dispersed
throughout the arterial system.
Vessel Disorders (Cont.)
Raynaud phenomenon
Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in
response to cold exposure
Vessel Disorders (Cont.)
Venous thrombosis
Sudden or gradual with varying severity of symptoms
Can be the result of trauma or prolonged immobilization
Hypertension
One of the most common diseases in the world
Responsible for stroke, renal failure, and congestive heart failure
Jugular Venous Pressure Disorders
Tricuspid regurgitation
Backflow of blood into the right atrium during systole
Atrial fibrillation
Arrhythmia seen more commonly in older adults resulting in decreased cardiac output
and atrial thrombus formation with subsequent embolization
Jugular Venous Pressure Disorders (Cont.)
Cardiac tamponade
Accumulation of fluid within the pericardial space leading to compression and dysfunction
of the heart chambers
Constrictive pericarditis
Results from chronic inflammation and subsequent scarring of the pericardium
Children
Coarctation of the aorta
Stenosis seen most commonly in the descending aortic arch near the origin of the left
subclavian artery and ligamentum arteriosum
Kawasaki disease
Acute vasculitic illness of uncertain cause affecting young males more often than females
Critical concern is cardiac involvement in which aneurysms of a coronary artery may
develop.
Pregnant Women
Preeclampsia-eclampsia
Syndrome specific to pregnancy
Determined by hypertension that occurs after the 20th week of pregnancy and the
presence of proteinuria
Eclampsia is preeclampsia with seizures when no other cause for the seizures can be
found
Older Adults
Venous ulcers
Results from chronic venous insufficiency in which lack of venous flow leads to lower
extremity venous hypertension
Question 1
When examining the radial pulse, you note a full and increased pulse. Your documentation
demonstrates:
A. Radial pulse +4
B. Radial pulse +3
C. Radial pulse +2
D. Radial pulse +1
Question 2
The characteristics of arterial pulses are directly affected by all of the following except:
A. The volume of blood ejected
B. Peripheral arterial resistance
C. Venous valvular competence
D. Blood viscosity
Question 3
A positive hepatojugular reflux maneuver is indicative of:
A. Right heart failure
B. Left heart failure
C. Elevated arterial pressure
D. Liver failure
Question 4
The term claudication refers to:
A. Pain from muscle ischemia
B. Lack of palpable pulsations
C. Visible extremity changes of arterial occlusion
D. Numbness and tingling in toes and fingers
Question 5
Triphasic demarcated skin pallor, cyanosis, and reperfusion occurs in which of the following:
A. Kawasaki disease
B. Venous thrombosis
C. Peripheral arterial disease
D. Raynaud phenomenon