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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