Venous Pulsations Infants and Children a wave Cutting of - - PDF document

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Blood Vessels

Chapter 15

Tracey A. Littrell, BA, DC, DACBR, DACO, CCSP

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Blood Vessels

• The physical examination of the venous and

arterial structures of the vascular system is a critical component of the patient’s evaluation

• Blood vessels can provide insight into the
• verall cardiovascular status
• Specifically, the detection of peripheral artery

disease (PAD) associated with an increased risk of stroke and cardiovascular events

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Blood Circulation

• Once it leaves the heart, blood flows through two

circulatory systems

• Pulmonary
• Systemic
• 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

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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—how does this affect the comparison of the radial artery palpation and dorsalis pedis artery palpation?

• Takes considerably more than 2 seconds for a

red blood cell to travel the same distance

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Arterial Pulse and Pressure

• The following variables contribute to the

characteristics of the pulses

• Volume of blood ejected (stroke volume)
• Distensibility of the aorta and large arteries
• Obstruction of blood flow (e.g., narrowing of

aortic valve [stenosis] or aorta [coarctation], vasculitis—blood vessel inflammation with narrowing—or PAD)

• Peripheral arteriolar resistance
• Viscosity of the blood

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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

• a wave
• c wave
• v wave
• x slope
• y slope

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Venous Pulsations

• a wave
• Result of a brief backflow of blood to the

vena cava during right atrial contraction

• c wave
• Transmitted impulse from the vigorous

backward push produced by closure of the tricuspid valve during ventricular systole

• v wave
• Caused by the increasing volume and

concomitant increasing pressure in the right atrium; it occurs after the c wave, late in ventricular systole

• x slope
• Caused by passive atrial filling
• y slope
• Reflects the open tricuspid valve and the

rapid filling of the ventricle

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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
• f life
• Foramen ovale closes after pressures shift

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Pregnant Women

• Blood pressure decreases, lowest in 2nd

trimester

• 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

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Older Adults

• Calcification and plaque buildup in the walls
• f the arteries can cause stiffness as well as

dilation of the aorta, aortic branches, and the carotid arteries

• Arterial walls lose elasticity and vasomotor

tone

• Increased peripheral vascular resistance

elevates blood pressure

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Review of Related History

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History of Present Illness

(What symptoms might indicate vascular compromise?)

• Leg pain or cramps
• Onset and duration
• Character
• Continuous burning in toes; pain in thighs or

buttocks

• Skin changes
• Swelling of the leg
• Limping
• Waking at night with leg pain

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• Swollen ankles
• Onset and duration
• Related circumstances
• Associated symptoms
• Treatment attempted
• Medication

History of Present Illness

(What symptoms might indicate vascular compromise?)

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Past Medical History

• Cardiac surgery or hospitalization
• Chronic illness: hypertension (HTN),

bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, stroke, vasculitis, thrombosis, transient ischemic attacks, coronary artery disease, atrial fibrillation, dysrhythmias

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Family History

• HTN
• Dyslipidemia
• Diabetes
• Heart disease
• Thrombosis
• Peripheral vascular disease (PVD)
• Abdominal aortic aneurysm
• Ages at time of illness and death

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Personal and Social History

• Employment
• Tobacco use
• Nutritional status
• Usual diet
• Weight
• Exercise
• Use of alcohol
• Use of illicit drugs

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Infants and Children

• Hemophilia
• Sickle cell disease
• Renal disease
• Coarctation of the aorta
• Leg pains during exercise

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Pregnant Women

• Blood pressure
• Prepregnancy levels
• Elevation during pregnancy
• Associated symptoms and signs
• Legs
• Edema
• Varicosities
• Pain or discomfort

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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

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Examination and Findings

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Peripheral Arteries

• Palpation
• Carotid
• Brachial
• Radial
• Femoral
• Popliteal
• Dorsalis pedis
• Posterior tibial
• Palpate for artery

characteristics

• Rate and rhythm
• Pulse contour

(waveform)

• Amplitude (force)
• Symmetry
• Obstructions
• Variations

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Peripheral Arteries

• 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

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Peripheral Arteries

• Auscultation over arteries for bruits
• Carotid
• Subclavian
• Abdominal aorta
• Renal
• Iliac
• Femoral
• Bruit types
• Radiation of murmurs
• Obstructive arterial disease
• Evidence of local obstruction

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Assessment for Peripheral Arterial Disease

• Arteries in any location can become stenotic
• 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

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Assessment for Peripheral Arterial Disease

• 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

• f stairs
• A few minutes of rest will ordinarily relieve it
• It recurs again with the same amount of activity
• Continued activity causes worsening pain

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Assessment for Peripheral Arterial Disease

• 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

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Assessment for Peripheral Venous Disease

• Symptoms of venous insufficiency:
• Pain!!!!
• Comes on during or after exercise
• Relieved by rest, but usually takes some time
• Greater variability than arterial pain in response to

intensity and duration of exercise

• Swelling and tenderness of the muscles
• Engorgement of superficial veins
• Erythema and/or cyanosis

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Assessment for Peripheral Venous Disease

• Examine for thrombosis
• Redness, thickening, tenderness of a superficial vein

(thrombophlebitis)

• Deep vein thrombosis has swelling and pain
• Homan’s sign over calf
• Examine for varicosities
• Dilated and swollen, resulting from incompetence
• If suspected, have the pt. stand on toes 10 times,

which increases palpable pressure

• If the veins are competent, the dilation will disappear

in a few seconds; varicosities will remain dilated longer

• Examine for edema

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Peripheral Veins

• Jugular venous pressure
• The jugular pulse can only be visualized; it

cannot be palpated

• 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

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Peripheral Veins

• Hepatojugular reflux
• The hepatojugular reflux is exaggerated when

right heart failure is present and its measurement is used to evaluate that condition

• 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

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Evaluation of hand veins

• You will need good tangential lighting for this exam
• Place the patient in a semi-recumbent position with

the hands on the table (may also be performed with the patient standing)

• Examine and palpate the veins of the hands (which

should be engorged) for compressibility and thrombosis

• Slowly raise the hand until the veins collapse
• Confirm this level by repeating the exam
• Note the level, which should be identical to the JVP

measured earlier

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Infants

• Brachial, radial, femoral pulses easily

palpable

• Evaluate capillary refill
• Very rapid (less than 1 second)
• Prolonged (longer than 2 seconds)

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Children

• Venous hum is common and has no pathologic

significance

• Caused by the turbulence of blood flow in the

internal jugular veins

• Venous thrombosis occurs less commonly in

children than in adults and is most often associated with placement of venous access devices

• They can occur in any peripheral vessel and

cause swollen, painful extremities

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Pregnant Women

• With increasing cardiac output beginning in

the first trimester, the pulse may be more easily palpated with an abrupt rise and rapid fall

• With increasing blood volume in the second

trimester, jugular a and v waves may be easier to see

• Jugular venous pressure should remain

normal

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Pregnant Women

• Peripheral edema is a common finding as

the pregnancy progresses

• Varicose veins can develop during

pregnancy and in the postpartum period

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Older Adults

• Dorsalis pedis and posterior tibial pulses

may be more difficult to find

• Superficial vessels are more apt to appear

tortuous and distended

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Abnormalities

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Vessel Disorders

• Temporal arteritis (giant cell arteritis)
• An inflammatory disease of the branches of the

aortic arch including the temporal arteries

• Arterial aneurysm
• Localized dilation, generally defined as 1.5 times

the diameter of the normal artery, caused by a weakness in the arterial wall

• Arteriovenous fistula
• Pathologic communication between an artery and

a vein

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Vessel Disorders

• Peripheral arterial disease
• Stenosis of the blood supply to the extremities by

atherosclerotic plaques

• Raynaud phenomenon
• Exaggerated spasm of the digital arterioles

(occasionally in the nose and ears) usually in response to cold exposure

• Arterial embolic disease
• Atrial fibrillation can lead to clot formation within

the atrium, which may be dispersed throughout the arterial system

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Vessel Disorders

• Venous thrombosis
• Sudden or gradual with varying severity of

symptoms

• Can be the result of trauma or prolonged

immobilization

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Spider veins

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Varicose veins

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Thrombophlebitis

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Thrombophlebitis

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Thrombophlebitis

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Embolic phenomenon

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Embolic phenomenon

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Cholesterol emboli

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Venous insufficiency or obstruction

• Examine for edema
• Pitting edema:
• 1+: slight pitting, disappears rapidly, 2 mm
• 2+: deeper pitting, disappears in 10-15 sec, 4 mm
• 3+: noticeably deeper, last 60 sec, 6 mm
• 4+: very deep, lasts 2-5 min, 8 mm or more
• Brawny edema:
• Rock hard edema which does not pit; caused by

fibrosis of the underlying tissue

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Capillary refill time

• The time it takes to refill a capillary bed after
• cclusion gives some indication of the health
• f the capillary system
• Compress the fingernail or toenail bed

between your fingers for approximately 2 seconds

• Compress enough to get blanching of the nail
• Release the pressure and watch for return of

the blood and the color to return

• This should take less than 2 seconds

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Jugular Venous Pressure Disorders

• Tricuspid regurgitation
• Backflow of blood into the right atrium during

systole

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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 small vessel 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

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Pregnant Women

• Preeclampsia-eclampsia
• Syndrome specific to pregnancy
• Determined by hypertension that occurs after

the 20th week of pregnancy and the presence

• f proteinuria
• Eclampsia is preeclampsia with seizures

when no other cause for the seizures can be found

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Older Adults

• Venous ulcers
• Result from chronic venous insufficiency in

which lack of venous flow leads to lower extremity venous hypertension

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Audience Response Questions

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• 1. 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
• E. Distensibility of aorta

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• 2. The term claudication refers to:
• A. Pain from muscle ischemia
• B. Lack of palpable pulsations
• C. Visible extremity changes of arterial
• cclusion
• D. Numbness and tingling in toes and fingers
• E. Constriction or narrowing of a vessel