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

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 • Blood vessels can provide insight into the overall cardiovascular status Chapter 15 • Specifically, the detection of peripheral artery disease (PAD) associated with an increased risk of stroke and cardiovascular events Tracey A. Littrell, BA, DC, DACBR, DACO, CCSP 1 2 Blood Circulation Arterial Pulse and Pressure • Once it leaves the heart, blood flows through two • The palpable and sometimes visible arterial circulatory systems pulses are the result of ventricular systole • Pulmonary • Produces a pressure wave throughout the arterial • Systemic system (arterial pulse) • Arteries are tougher, more tensile, and less • Takes barely 0.2 second for the impact of this distensible wave to be felt in the dorsalis pedis artery—how does this affect the comparison of the radial • Veins are less sturdy and more passive artery palpation and dorsalis pedis artery • Contain valves to keep blood flowing in one direction palpation? • If blood volume increases significantly, the veins can expand and act as a repository for extra blood • Takes considerably more than 2 seconds for a red blood cell to travel the same distance 10 12 Jugular Venous Pulse Arterial Pulse and Pressure and Pressure • The following variables contribute to the • The activity of the right side of the heart is characteristics of the pulses transmitted back through the jugular veins as a pulse (visualized only) that has five • Volume of blood ejected (stroke volume) identifiable components—three peaks and • Distensibility of the aorta and large arteries two descending slopes • Obstruction of blood flow (e.g., narrowing of • a wave aortic valve [stenosis] or aorta [coarctation], • c wave vasculitis—blood vessel inflammation with narrowing—or PAD) • v wave • Peripheral arteriolar resistance • x slope • Viscosity of the blood • y slope 13 14 1

Venous Pulsations Infants and Children • a wave • Cutting of umbilical cord necessitates breathing • Result of a brief backflow of blood to the vena cava during right atrial contraction • Respiration onset expands lungs • c wave • Transmitted impulse from the vigorous backward push produced by closure of the • Pulmonary vascular resistance drops; systemic tricuspid valve during ventricular systole resistance increases • v wave • Caused by the increasing volume and concomitant increasing pressure in the • Ductus arteriosus closes in first 12 to 14 hours right atrium; it occurs after the c wave, late in ventricular systole of life • x slope • Caused by passive atrial filling • Foramen ovale closes after pressures shift • y slope • Reflects the open tricuspid valve and the rapid filling of the ventricle 16 17 Pregnant Women Older Adults • Blood pressure decreases, lowest in 2nd • Calcification and plaque buildup in the walls trimester of the arteries can cause stiffness as well as • Systemic vascular resistance decreases dilation of the aorta, aortic branches, and the • Peripheral vasodilatation occurs carotid arteries • Enlarging uterus causes compression of the • Arterial walls lose elasticity and vasomotor vena cava and impaired venous return tone • Hypotension • Dependent edema • Increased peripheral vascular resistance • Varicosities in legs and vulva elevates blood pressure • Hemorrhoids 18 19 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 Review of Related History buttocks • Skin changes • Swelling of the leg • Limping • Waking at night with leg pain 20 21 2

History of Present Illness Past Medical History (What symptoms might indicate vascular compromise?) • Swollen ankles • Cardiac surgery or hospitalization • Onset and duration • Chronic illness: hypertension (HTN), • Related circumstances bleeding disorder, hyperlipidemia, diabetes, • Associated symptoms thyroid dysfunction, stroke, vasculitis, • Treatment attempted thrombosis, transient ischemic attacks, • Medication coronary artery disease, atrial fibrillation, dysrhythmias 22 23 Personal and Social Family History History • HTN • Employment • Dyslipidemia • Tobacco use • Diabetes • Nutritional status • Heart disease • Usual diet • Weight • Thrombosis • Exercise • Peripheral vascular disease (PVD) • Use of alcohol • Abdominal aortic aneurysm • Use of illicit drugs • Ages at time of illness and death 24 25 Infants and Children Pregnant Women • Hemophilia • Blood pressure • Prepregnancy levels • Sickle cell disease • Elevation during pregnancy • Renal disease • Associated symptoms and signs • Legs • Coarctation of the aorta • Edema • Leg pains during exercise • Varicosities • Pain or discomfort 26 27 3

Older Adults • Leg edema • Interference with activities of daily living • Ability of the patient and family to cope with the Examination and Findings 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 28 29 Peripheral Arteries Peripheral Arteries • The amplitude of the pulse is described on a • Palpation • Palpate for artery characteristics • Carotid scale of 0 to 4 • Rate and rhythm • Brachial • 4: Bounding, aneurysmal • Pulse contour • Radial • 3: Full, increased (waveform) • Femoral • 2: Expected • Amplitude (force) • Popliteal • 1: Diminished, barely palpable • Symmetry • Dorsalis pedis • Obstructions • 0: Absent, not palpable • Posterior tibial • Variations 31 33 Assessment for Peripheral Peripheral Arteries Arterial Disease • Auscultation over arteries for bruits • Arteries in any location can become stenotic • Carotid • Diminished circulation to the tissues will lead • Subclavian to signs and symptoms that are related to • Abdominal aorta • Renal the following: • Iliac • Site • Femoral • Degree of stenosis • Ability of collateral channels to compensate • Bruit types • Radiation of murmurs • Rapidity with which the problem develops • Obstructive arterial disease • Evidence of local obstruction 34 36 4

Assessment for Peripheral Assessment for Peripheral Arterial Disease Arterial Disease • Pain that results from muscle ischemia is • After determining the distinguishing referred to as claudication characteristics of the pain, you should • Dull ache note the following: • Muscle fatigue and cramps • Pulses • Usually appears during sustained exercise, such • Bruits as walking a distance or climbing several flights • Loss of body warmth of stairs • Pallor or cyanosis • A few minutes of rest will ordinarily relieve it • Collapsed superficial veins • It recurs again with the same amount of activity • Atrophied skin and loss of hair • Continued activity causes worsening pain 37 38 Assessment for Peripheral Assessment for Peripheral Venous Disease Venous Disease • Examine for thrombosis • Redness, thickening, tenderness of a superficial vein • Symptoms of venous insufficiency: (thrombophlebitis) • Pain!!!! • Deep vein thrombosis has swelling and pain • Comes on during or after exercise • Homan’s sign over calf • Relieved by rest, but usually takes some time • Examine for varicosities • Greater variability than arterial pain in response to • Dilated and swollen, resulting from incompetence intensity and duration of exercise • If suspected, have the pt. stand on toes 10 times, • Swelling and tenderness of the muscles which increases palpable pressure • If the veins are competent, the dilation will disappear • Engorgement of superficial veins in a few seconds; varicosities will remain dilated • Erythema and/or cyanosis longer • Examine for edema 39 40 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 41 42 5