Jarvis
Chapter 20
Circulation:
http://www.youtube.com/watch?v=PgI80UeAMo
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Chapter 20: Peripheral Vascular System and Lymphatic System
Learning Objectives

1. Relate normal & abnormal findings to the structure
& functions of the arteries & veins.
2. Discuss the lymphatic circulation system & related
organs.
3. Discuss arteriosclerosis & atherosclerosis in the
aging adult.
4. Discuss normal & abnormal subjective and
objective findings when assessing the peripheral
vascular system of an adult.
Chapter 20: Peripheral Vascular System and Lymphatic System
Key Terms
 Artery
 Arteriosclerosis
 Atherosclerosis
 Bruit
 Capillary refill
 Claudication
 Deep vein
thrombophlebitis
(DVT)
 Doppler ultrasound
 Ischemia/ischemic ulcer
 Lymph node
 Lymphedema
 Pitting edema
 Perfusion
 Pulsus paradoxus
 Raynaud’s phenomenon
 Varicose veins
 Vein
 Venous stasis ulcer
Chapter 20: Peripheral Vascular System and Lymphatic System
Peripheral Vascular System

 Arteries  carry blood away from the heart
 Heart pumps freshly oxygenated blood through the arteries to
all body tissues
 High pressure system, usually lie deep
 Have a pulse  accessible in certain areas  temporal, carotid,
brachial, femoral, popliteal, medial malleolus (post tibial), &
dorsalis pedis
 Veins  carry blood back to the heart
 Carry deoxygenated blood back to heart & lungs
 Low-pressure system  depends on skeletal muscle
contraction & one-way intraluminal valves to get blood back
to heart
 Do not pulsate, usually lie closer to surface
Chapter 20: Peripheral Vascular System and Lymphatic System
Arteries in the Peripheral Vascular
System
 Arteries in the head &
neck
Temporal artery
Carotid artery
 Arteries in the arm
Brachial
Ulnar
Radial

 Arteries in the leg
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Slide 20-5
Chapter 20: Peripheral Vascular System and Lymphatic System
Veins in the Peripheral Vascular
System
 Veins in the neck
 Internal & external
jugular (Ch. 19)
 Veins in the arm
 Basilic
 Cephalic
 Median

 Veins in the leg
 Deep veins
 Femoral
 Popliteal
 Superficial veins
 Great saphenous
 Small saphenous
 Superficial veins can be
resected for BPGs without
compromising leg circulation
if deep veins are healthy
Chapter 20: Peripheral Vascular System and Lymphatic System
Arteries in the Head & Neck
Chapter 20: Peripheral Vascular System and Lymphatic System
Arteries in the Arm
Vessels
of the
Arm
Slide 20-8
Chapter 20: Peripheral Vascular System and Lymphatic System
Vessels in the Leg
Slide 20-9
Chapter 20: Peripheral Vascular System and Lymphatic System
Venous Flow

 Drains deoxygenated blood from tissues & returns it
to heart & lungs for reoxygenation
 Venous flow back up to heart depends on:
 Skeletal muscle contraction
 Increased abdominal pressure from inspiration
 Intraluminal valves to ensure blood flow up to heart &
prevent back flow
 Problems with flow back to heart  venous stasis 
pitting edema  stasis ulcers
Chapter 20: Peripheral Vascular System and Lymphatic System
Venous
Flow
Chapter 20: Peripheral Vascular System and Lymphatic System
Lymphatic System

 Completely separate circulation system from the blood
circulation system
 Flow is slow compared to blood  has one-way valves
& depends on skeletal muscle contraction &
contraction of lymph vessels
Slide 20-12
Chapter 20: Peripheral Vascular System and Lymphatic System
Lymphatic System (cont’d)
 Functions:

 Drains excess fluid from tissue spaces (prevents edema)
& picks up plasma proteins that leak out of capillaries &
returns both to blood circulation system  Right
lymphatic duct empties into right subclavian vein;
thoracic duct empties into left subclavian vein
 Forms a major part of the immune system that defends
the body against disease
 Absorbs lipids from the intestinal tract
 http://www.youtube.com/watch?v=Q9gpDUooVwo
Slide 20-13
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Lymphatic System
• Lymph vessels
• Lymph nodes  filter out &
destroy pathogens before returning
collected fluid to blood circulation
•Related organs that aid the
lymphatic system with the immune
function:
•Tonsils
•Thymus
•Spleen
•Peyer’s patches on small
intestines
•Bone marrow
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Lymph Nodes
• Small clumps of
lymphatic tissue
•Filter & destroy
pathogens that may
harm the body
•Superficial nodes
may be palpable;
deep nodes are not
•With local
inflammation,
nodes in that area
become swollen &
tender
Chapter 20: Peripheral Vascular System and Lymphatic System
Changes in the Aging Adult

 Arteriosclerosis  peripheral blood vessels grow stiff &
less compliant  rise in systolic BP
 Atherosclerosis  fat plaques deposited inside arteries 
found in all ages, not just aging adults
 Enlargement of calf veins  prolonged bedrest or sitting
and heart failure  increased risk for deep vein thrombosis
(DVT) and pulmonary embolus (PE)
 Loss of lymphatic tissue with fewer lymph nodes &
decreased size of lymph nodes – decreased immune
function
Slide 20-18
Chapter 20: Peripheral Vascular System and Lymphatic System
Subjective Data—
Health History Questions

 Leg pain or cramps  claudication: leg/calf pain on
walking or climbing stairs; pain resolves with rest
 decreased perfusion (blood flow) results in
ischemia (a deficient supply of oxygenated arterial
blood to a tissue)  partial blockage creates
insufficient supply w/pain on exercise, when
oxygen needs increase
 Skin changes on arm or legs
 Edema (Swelling) (hard or pitting)
 Lymph node enlargement (tender)
 Medications
Chapter 20: Peripheral Vascular System and Lymphatic System
Objective Data—The Physical Exam

 Radial pulse
Arms—Inspect and palpate
 Skin
 Profile sign  detects
early clubbing of nails
 Capillary refill (<2
sec.)
 Symmetry
 Edema
 Ulnar pulse (not
usually palpable)
 Brachial pulse
 Modified Allen test
(evaluates adequacy
of collateral
circulation before
cannulating the
radial artery)
Slide 20-20
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Objective Data—The Physical Exam (cont.)
Legs—Inspect and palpate
 Skin and hair
 Symmetry
 Temperature
 Calf muscle
 Inguinal lymph nodes
 Pitting edema  grade
on scale of 1+ (mild) to
4+ (severe)
 Lymphedema (hard,
nonpitting)
 Capillary refill (<2 sec.)
 Peripheral pulses (scale of
0-3+)




Femoral pulse
Popliteal pulse
Posterior tibial pulse (PT)
Dorsalis pedis pulse (DP)
 Additional techniques
 Color changes
 Doppler ultrasonic
stethoscope
 Femoral bruit
Slide 20-22
Chapter 20: Peripheral Vascular System and Lymphatic System
4+ Pitting Edema

© Pat Thomas, 2006.
Slide 20-23
Chapter 20: Peripheral Vascular System and Lymphatic System
Abnormal Findings
Variations in Arterial Pulse

 Weak, “thready” pulse – 1+
** Normal peripheral pulses are 2+
 Full, bounding pulse – 3+
 Pulsus paradoxus  Beats have weaker amplitude
with inspiration, stronger with expiration. Best
determined during BP measurement  reading
decreases >10mm/Hg during inspiration &
increases with expiration.
Slide 20-24
Chapter 20: Peripheral Vascular System and Lymphatic System
Doppler Ultrasound (US)
Stethoscope

•Used to detect
weak peripheral
pulse
•Pulse identified
by swishing,
whooshing sound
Slide 20-25
Chapter 20: Peripheral Vascular System and Lymphatic System
Abnormal Findings
Peripheral Vascular Disease (PVD)

 Arms
 Raynaud’s Phenomenon
 Lymphedema (also often seen in legs)
 Legs





Arteriosclerosis—ischemic ulcer
Venous (stasis) ulcer
Superficial varicose veins
Deep vein thrombophlebitis (DVT)
Lymphedema
 Occlusions
 Aneurysms
Slide 20-26
Chapter 20: Peripheral Vascular System and Lymphatic System
Manifestations (S/Sx) of PVD
 Arterial Insufficiency
 Pain, cramps, or numbness &
tingling in lower extremity,
usually calf muscle
 Onset with exertion (walking
or climbing stairs) or with
elevation (severe)
 Relieved by rest or dangling
(severe)
 Pale, cool skin
 Weak or absent pulse
 Foot or ankle ulcer

 Venous Insufficiency
 Feeling of fullness, aching in
lower leg
 Discomfort increases at end of
day
 Prolonged sitting or standing
exacerbates discomfort
 Elevation, lying or walking
relieves
 Edema, varicosities, weeping
ulcers (stasis ulcers) at ankles
Chapter 20: Peripheral Vascular System and Lymphatic System
2 Presentations of Raynaud’s Phenomenon
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Arterial Ischemic Ulcers

Slide 20-30
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Manifestations of Venous Stasis with Ulcer
•Edema (hard or
pitting)
•Tan/brown
discoloration to
lower leg
•Wet, draining
ulcer
Slide 20-33
Chapter 20: Peripheral Vascular System and Lymphatic System
Venous Stasis Ulcers

Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Chapter 20: Peripheral Vascular System and Lymphatic System
Sample Charting

Slide 20-39