Peripheral Vascular System
What is the purpose of the peripheral vascular system?
Transport blood, oxygen, nutrients, and hormones
What is arterial and venous insufficiency?
Arterial - thickening and loss of elasticity of arterial walls
Venous - Chronic incompetent valves in deep veins or clot, risk of infection
Fine and coarse crackles
Fine (rales) - not cleared by coughing, sounds like rubbing hair together; indicative of heart failure, pulmonary edema, pneumonia, idiopathic pulmonary fibrosis
Coarse - sounds like velcro, decreased with sectioning or coughing but will come back; indicative of pneumonia, pulmonary edema, COPD, bronchiectasis
What are the AV valves and what are their "jobs"?
Tricuspid (R)
Mitral (L)
Allow blood into heart chambers, open during filling (diastole), close during ejection (systole) louder
How do you assess S3 and S4?
Patient rolls to left side, use bell of stethoscope, listen for low pitched murmurs
What are the accessible pulse locations? (8)
Temporal, carotid, brachial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial
What are the characteristics of the skin in each insufficiency?
Arterial - pale, cyanotic, cold, thin and shiny, elevation pallor of foot
Venous - reddish-blue, warm, firm/tough and brownish pigmentation in area between medial and lateral malleolus, cyanosis when dependent
Pleural friction rub
Sounds like leather rubbing together, low pitch; indicative of pleurae inflamed and lose lubricating fluid, pleurisy, pneumonia, pulmonary embolism, cancer
What are the SL valves and what are their "jobs"?
Pulmonic (R)
Aortic (L)
Allow blood to enter lungs/periphery, open during ejection (systole)
Where will you hear splitting if present and why does it occur?
End of inspiration, only heard at pulmonic valve area
Occurs when aortic valve closes earlier than pulmonic valve
What do the arteries and veins do?
Arteries - pump O2 rich blood to all body tissues
Veins - absorb O2 and waste products from periphery and carry them back to the heart
Characteristics of nails, hair and edema for each insufficiency
Arterial - Thickened nails, loss of hair over toes and dorsum of foot, none or minimal edema
Venous - Nails not thickened, hair is present, moderate to severe edema; pitting in ankle, foot, lower leg
Stridor
Sounds like breathing after suffocating (gasping), crowing sound, can be life threatening, high pitched; indicative of upper airway obstruction from inflammation, croup
What is S1 and S2 caused by and what period in the cardiac cycle do they occur? Where are they best heard? What heart sounds are caused by valves opening?
S1 - AV valves closing - early systole (loudest at apex, coincides with carotid pulse)
S2 - SL valves closing - end of systole (loudest at base)
NO heart sounds are caused by valves opening
How do you perform a cardiac exam? How long do you count apical pulse for?
Patient is supine, listen over all areas of chest with diaphragm, one sound at a time, identify S1 and then S2, any splitting rate & rhythm, count apical pulse for 60 seconds
What does the modified allen test evaluate and how do you perform it?
Collateral circulation
1. Depress radial and ulnar arteries - pt opens and closes fist
2. Normal - blood returns via ulnar artery
3. Occluded ulnar artery - no blood return
What are the pulses in each insufficiency?
Arterial - decreased or absent
Venous - Present but may be difficult to palpate through edema
Wheeze
Whistle sound, high pitched, I < E; indicative of air being squeezed through narrowed passageways
Preload, Afterload, Contractility, Cardiac Output, Stroke Volume
Preload (volume): ventricular stretch prior to next contraction
Afterload (pressure): amount of resistance ventricles overcome
Contractility: strength of myocardial muscle fiber
Cardiac Output (CO): amount of blood pumped thru the circulatory system in 1 minute
Stroke Volume (SV): amount of blood ejected with each contraction
APE To Man and locations
A - aortic valve, 2nd R ICS
P - pulmonic valve, 2nd L ICS
E - erb's point, 3rd L ICS
T - tricuspid valve, L lower sternal border, 4-5th ICS
M - mitral valve, 5th ICS, left MCL (apex)
What is the homan sign?
Pain behind the knee upon dorsiflexion of the foot, helps assess for DVT
What are the characteristics of pain and ulcers in each insufficiency?
Arterial - intermittent claudication (legs hurt when walking, relieved by rest), ulcers between toes, heels, lateral malleolus; well-defined edges, deep circular ulcer base - black or gangrene, non-bleeding
Venous - aching, cramping, feeling of fullness, relieved by elevation; ulcers in medial malleolus and lower leg, uneven edges, superficial, granulation tissue - beefy red to yellow, bleeding, may or may not be painful
Sonorous rhonchi
Sounds like blowing bubbles in liquid, low pitch, snoring, moaning, I < E, may clear somewhat by coughing; indicative of airflow obstruction, bronchitis
Diastole and Systole
Diastole - ventricles relax and fill with blood (2/3 of cycle), AV valves open; pressure in atria is higher than in ventricles -> blood pours rapidly into ventricles; toward end of diastole, atria contract and push last of blood into ventricles (atrial kick)
Systole - ventricular pressure higher than in atria, AV valves close; AV valve closure contributes to S1 and signals the beginning of systole (2 milliseconds); for a brief moment all 4 valves are closed and ventricular walls contract
What is the process of bloodflow through the heart?
SVC/IVC -> RA -> TV -> RV -> PV -> PA -> lungs -> PV -> LA -> MV -> LV -> AV -> Aorta