bioe221 sn02 skinandmucousmembranes · · 2017-01-09© endeavour college of natural health...

© Endeavour College of Natural Health endeavour.edu.au

BIOE221

Session 02

Skin, Mucous Membrane

and Periphery Assessment

Bioscience Department


Session Objectives

• Understand the physiology of blood pressure and how to measure blood pressure.

• Understand the surface anatomy of the upper and lower limb

• Understand the circulatory and lymphatic pathways of the upper and lower limb

• Be able to assess for skin integrity and vascular and

lymphatic changes associated with pathologies

• Understand the importance and rational for the

examinations the mucous membrane of the eyes


Blood Pressure (BP)

• Blood pressure is the hydrostatic pressure exerted by blood on the

walls of the blood vessels during contraction of the ventricles. It is

recorded as systolic / diastolic mmHg.

– Systolic blood pressure - maximum pressure exerted on the

arterial wall during left ventricular contraction

– Diastolic blood pressure - minimum pressure exerted on the

arterial wall between contractions

– Pulse pressure - difference between systolic and diastolic and

reflects the stroke volume

– Mean arterial pressure - the pressure forcing blood into the

tissues

– Peripheral resistance the total resistance against which blood

must be pumped


Blood Pressure

in various blood

vessels

(Tortora & Derrickson, 2009)


Control of Blood Pressure• BP changes with daily activity/ position changes/

emotions

• Regulation mechanisms to maintain ‘normal’ blood pressure are– Cardiovascular centre in brain stem

• regulates heart rate/ force of contraction of ventricles/ blood vessel diameter

– Nervous system regulation• baroreceptors

• chemoreceptors

– Hormone regulation• adrenaline/ noradrenaline (↑ HR & vasoconstriction)

• ADH & ANP

– Autoregulation• local automatic adjustment of blood flow to match tissue needs


5 Factors Affecting Blood

Pressure• Cardiac output (stroke volume x heart rate)

– as heart pumps more blood into blood vessels, the pressure on the vessel walls increases

• Peripheral vascular resistance– opposition to blood flow through arteries

– increased pressure needed to push blood through constricted blood vessels

• Circulating blood volume– the greater the volume of blood in the vessels, the higher the BP

• Blood viscosity– when blood is thicker, BP will increase

• Elasticity of arterial walls– decreased elasticity increases BP


• Weight

– BP rises in the obese – more blood vessels

• Exercise

– BP increases proportionately with exercise

• Emotions

– BP rises with fear, anger, pain

– (SNS stimulation)

• Stress

– continual stress can elevate BP

Blood Pressure Readings

Average adult BP – approx 120/80 mmHg

Varies with;

• Age

– normally gradual rise through childhood into adulthood

• Gender

– females lower between puberty and menopause

• Race

– Afro-Americans - hypertension

• Diurnal rhythm

– early morning low

– peak late afternoon/ early evening


BP Values and Hypertension

(National Heart Foundation of Australia 2008)


Preparation for BP

measurement• You will need

– Sphygmomanometer with an appropriate cuff size for the patients arm.

– Stethoscope.

– Quiet, relaxing atmosphere.

– Chair / couch/ bed.

– Client must be seated or lying – arm exposed and supported at the level of the heart with legs uncrossed.

– Patient should be rested for at least 15 minutes before taking the blood pressure.


BRACHIAL PULSE

Located medial to the

biceps tendon in the

antecubital fossa. The

stethoscope is placed

over the point where the

pulse is felt.

(Jarvis, C. 2004)


Relationship of BP

changes

to cuff pressure

(Tortora & Derrickson 2009)


Common errors affecting

accuracy of BP Measurement• Incorrect cuff position

• Too high inflation of cuff

• Too rapid deflation of cuff

• Erratic cuff deflation

• Pressing stethoscope on brachial artery too hard

• Defective equipment

• Noisy environment

• Hearing problems

• White coat syndrome

• Inappropriate timing of measurement the client may be – Stressed e.g. rushing in at the last minute

– Had caffeine consumption

– Been smoking

– Have been involved in heavy physical activity


Auscultatory Gap

• The auscultatory gap is a brief period of time when the Korotkoff sounds can not be heard.

• This will most often occur in hypertensive patients and may result in the incorrect determination of a normotensive BP result.

• To avoid this:-

– For all patients for whom you are not familiar with, always obtain the systolic pressure by palpation first, before obtaining the BP by auscultation.

– If you find an auscultatory gap be sure to document this in the patients clinical notes. By doing so you can account for the auscultatory gap in future blood pressure readings without the need for the palpatorysystolic first.


Lying & Standing BP

measurement• Performed when the patient presents with a

history of dizziness or fainting. Used to

determine orthostatic (Postural) hypotension

– Causes:

• Abrupt idiopathic vasodilation

• Postural changes following prolonged bed-rest

• Elderly

• Hypovolaemia (blood loss or dehydration)

• Medications (antihypertensives)

• Neurological conditions


Abnormalities in Blood Pressure

• Hypotension – abnormally low BP

– In normotensive adults - < 95/60 mmHg

– In hypertensive adults – the person’s average reading, but may be > 95/60 mmHg

• Orthostatic hypotension (postural hypotension)

– Drop in systolic BP > 20mmHg (+/- increase in pulse of 20 bpm) with quick change to standing position

• Hypertension

– Common, often asymptomatic disorder characterisedby elevated blood pressure persistently exceeding 140/90mmHg


Vascular CirculationThe vascular circulation is comprised of the Venous and the Arterial vessels

• Venous circulation

– the course of veins parallels that of arteries

– the body has more veins than arteries and they lie closer to the surface

– There are both superficial and deep veins throughout the body

– Perforators are veins that connect the superficial veins to the deep veins

– Circulation within veins moves from superficial to deep and is facilitated by:

• Muscle contractions

• Transluminal One-way valves

• Alternation of abdominal and thoracic pressures during breathing


Venous Circulation

Lower Extremities



Conditions affecting venous

circulationMost commonly conditions affecting venous circulation will

occur in the legs.

• Varicose Veins

– Dilated, tortuous veins with valve incompetence.

Thrombosis may occur.

• Deep Vein Thrombosis

– Venostasis in the deep veins results in thrombosis

which may form emboli.

• Venous Ulceration

– Prolonged venostasis, particularly in superficial veins,

may lead to tissue necrosis and ulcer formation

18


Arterial Circulation

As the heart contracts oxygenated blood is carried via the

arteries towards the periphery.

• Arteries are elastic and muscular to allow them to

withstand greater pressure.

• Pulse pressure wave causes the arteries to expand and

recoil to facilitate arterial circulation.

• This pressure wave can be felt at specific points around

the body known as pulse points.

19


Carotid Artery


Clinical Exam Session 2


Arterial Supply –

Upper Extremity

Aorta –

brachiocephalic –

subclavian – axillary –

brachial – radial and

ulnar



Arterial Supply

Lower Extremity

Thoracic aorta –

abdominal aorta –

common iliac – external

iliac – femoral –

popliteal – posterior

tibial and dorsalis pedis



Pulse Locations

• The pulse rate is usually taken at the radial artery as part

of the vital signs

• Other locations in the body are used to determine the

arterial circulation to tissues distal to those pulse points

• The pulse points we will learn are:

– Carotid, brachial, radial, ulnar

– Popliteal, posterior tibial, dorsalis pedis


Carotid Pulse (Jarvis 2004)

Used to assess blood flow

to the head.

The carotid pulse is

located between the

sternocleidomastoid (SCM)

muscle and trachea at

approximately the level of

the larynx


Used to assess blood

flow to the arm and for

blood pressure.

Located medial to the

biceps tendon in the

antecubital fossa. The

stethoscope is placed

over the point where the

pulse is felt.

(Jarvis 2004)

Brachial Pulse


Radial Pulse(Jarvis 2004)


to the hand and for

obtaining the pulse rate as

part of vital signs

Located between the radius

and the palmaris longus

tendon on the lateral side

of the wrist.


Ulnar Pulse(Jarvis 2016)


to the hand

Located between the flexor

carpi ulnaris and flexor

digitorum profundus

tendons on the medial side

of the wrist


Popliteal Pulse

(Jarvis 2004)

Used to assess blood flow to

the leg.

Located deep within the

popliteal fossa in between the

femoral condyles.


Posterior tibial pulse(Jarvis 2004)


the foot.

Located between the medial

malleolus and the Achilles

tendon.


Dorsalis pedis pulse(Jarvis 2012)


the distal foot.

Located lateral to the

extensor hallucis longus

tendon at the high point of

the foot.


Some vascular manifestations

31


Raynaud’s Phenomenon(Jarvis 2008)


Peripheral Vascular Disease(Jarvis 2008)

Ischaemic ulcer - arterial Venous (stasis) ulcer


Diabetes Mellitus – (Dry)

Gangrene(McCance & Huether 2006)

Foot Ulceration

(& Digit Amputation)


Varicose Veins Varicose Ulcer


Examination of the Upper

Extremities• Inspect & palpate the arms

• Lift both hands together/ inspect/ turn them over, noting:– Temperature

– Texture (see notes – Skin, hair, nails)

– Turgor (and mobility) of the skin (see notes – Skin, hair, nails

– Symmetry

– Colour of skin & nail beds(see extra handout notes – Skin, hair, nails)

– Any lesions, scars, oedema

– Finger clubbing (see notes later)

– Note any abnormality of joints - check bilaterally

• Check capillary refill (see later slide)

• Check brachial and radial pulses


Examination of the Lower

Extremities• Inspect and palpate the legs (usually lying down)

• Uncover the legs & inspect both together, noting and comparing:

– Colour

• Pallor with vasoconstriction

• Erythema with vasodilation

• Cyanosis

• Areas of discolouration

– Gangrene – arterial insufficiency

– Brown discolouration medial lower leg (with ulcers) -chronic venous insufficiency

– Hair distribution

– Venous pattern

• Assess varicosities when standing


Examination of the Lower Extremities

– Size (swelling/ oedema or atrophy) & symmetry

– Lesions/ ulcers

• Medial aspect lower leg/ medial malleoli – venous

insufficiency

• Lateral malleoli/ metatarsal heads/ tips of toes –

arterial insufficiency

– Temperature

• Unilaterally cool – arterial insufficiency

• Bilaterally cool – environment / smoking / ?arterial

• Check the posterior tibial and dorsalis pedis pulses

• Check for pretibial oedema


Ankle-Brachial Pressure Index

The Ankle-Brachial Pressure Index (ABPI) is a

simple way to determine the potential for

peripheral vascular disease.

39

Note that the procedure described in

your text book uses Doppler ultrasound.

However, studies have shown that

obtaining ABPI by palpation is a reliable

indicator of potential peripheral vascular

disease. (Migliacci et al, 2008)

All abnormal results require referral

for further investigation.



Simplified Procedure:

1. Obtain an accurate systolic blood pressure on

each arm.

2. Obtain an accurate systolic blood pressure on

each ankle using either the posterior tibial or

dorsalis pedis pulse.

3. Calculate the ABPI for the left side and the right

side separately.

40



Calculation:

Ankle Systolic / Arm Systolic = ABPI

41

>1.3 Potential arterial stiffness

1.0-1.3 No peripheral artery disease

0.9-1.0 Borderline peripheral artery disease

0.7-0.9 Mild peripheral artery disease

0.4-0.7 Moderate peripheral artery disease

0.3-0.4 Severe peripheral artery disease

<0.3 Ischemia (Emergency referral required)

(Jarvis. 2016, p.525)


Skin ExaminationSkin is the largest organ in the body.

• Comprised of:

– Epidermis

– Dermis

– Nails and accessory structures

• Functions:

– Physical, chemical and thermal barrier

– Sensation

– Temperature regulation

– Excretion and absorption

– Synthesis of Vitamin D

42


Skin Examination

When performing a general examination of

the skin assess:

• Skin colour (Pallor, Cyanosis, jaundice, erythema, rash,

pigmentation, scars, wounds, moles)

• Skin health (looks, moisture, oiliness, integrity)

• Skin turgor (Elasticity and hydration)

• Skin appendages (hair distribution and nail health

(See additional handouts)

43


Skin Turgor

• Mobility & turgor– Mobility – skin’s ease of rising

– Turgor – ability to return to place promptly when released (elasticity)

– Decreased mobility with oedema/ scleroderma

– Poor turgor with severe dehydration/ extreme weight loss

• Skin turgor testing for dehydration is unreliable in:• The elderly – use the oral mucous membranes

• Infants – use the fontanelles on the head


Skin Turgor

(The New York Times Company 2007)


Finger Clubbing• Four criteria confirm clubbing

– Loss of normal angle between the nail and nail bed (>160o)

– Increased nail bed fluctuation

– Increased nail curvature in later stages

– Increased bulk of the soft tissues over the terminal phalanges

• Occurs with

– Congenital chronic cyanotic heart disease

– Chronic obstructive pulmonary disease• Emphysema/ chronic bronchitis

– Cor pulmonale ([R] heart failure)

– Subacute bacterial endocarditis

– Other lung pathologies

– Sometimes serious liver, bowel and kidney diseases


Finger Clubbing

(Science Daily 2009)


Capillary RefillThis is an assessment of the peripheral perfusion and cardiac

output

Procedure

• Depress & blanch nail beds

• Release & note time for colour return

– normal if the colour returns in <1-2 seconds

– > 1-2 seconds

• signifies vasoconstriction or decreased cardiac output

• hands are cold, clammy & pale

• Note conditions that can skew your findings e.g.

– cool room/ decreased body temperature

– cigarette smoking

– peripheral oedema/ anaemia


Oedema• Interstitial fluid balance is regulated by:

• Blood Hydrostatic Pressure (BHP) which pushes fluid towards the

interstitium

• Interstitial Fluid Hydrostatic Pressure (IFHP) which pushes fluid back

towards the capillaries.

• Blood Colloidal Osmotic Pressure (BCOP) which pulls fluid into the

capillaries

• Interstitial Fluid Osmotic Pressure (IFOP) which pulls fluid into the

interstitium

• Oedema is excess accumulation of fluid in the interstitial

spaces of tissues

• Fluid from the interstitium is usually drained via the veins

and lymphatic vessels


Causes of Oedema

• Generalized (bilateral) oedema– disorders of the heart, kidneys, liver or GIT or may be

nutritional in origin (hypoproteinaemia/ fluid overload)

• Localized (unilateral or bilateral) oedema– may arise from venous or lymphatic obstruction, allergy or

inflammation

• Postural oedema– relatively common is the lower limbs of inactive patients

and those who have been on their feet all day

• If fluid retention is generalized, its distribution is determined by gravity– e.g. usually found in legs, backs of thighs and

lumbosacral area


Rating of Oedema

• Oedema– Fluid accumulation in the interstitial (extracellular)

spaces – not normally present

– 1+ mild pitting• slight indentation/ no noticeable swelling of legs

– 2+ moderate pitting• indentation subsides rapidly

– 3+ deep pitting• indentation remains for short time/ leg look swollen

– 4+ very deep pitting• indentation lasts long time/ leg very swollen


Oedema

Testing for pitting oedema Pitting oedema

(Jarvis 2016, p.523)


Lymphoedema

(Jarvis 2008)


Bringing it all together

• Your general survey should include:

– Vital signs

– Physical appearance, structure, mobility & behaviour

– General peripheral examinations of skin, hair, nails and eyes.

• Specific peripheral examinations such as oedema, capillary refill & ABPI should be consideration in relation to specific clinical indications of relevant local or systemic disease/disorders.

54


ResourcesJarvis, C. (2016) Physical Examination and Health Assessment, 7th

edn. Saunders, Missouri.

Tortora, GJ & Derrickson, B 2014, Principles of Anatomy and Physiology, 14th edn, John Wiley, Hoboken,NJ.

National Heart Foundation (National Blood Pressure and Vascular Disease Advisory Committee), 2008, Guide to Management of Hypertension 2008, Updated December 2010.

Migliacci, R, Nasorri, R, Ricciarini, P, & Gresele, P, 2008, Ankle-brachial index measured by palpation for the diagnosis of peripheral arterial disease, Family Practice, Vol. 25, p. 228-232

McCance, K, Huether, S, Brashers, V, & Rote, N, 2010, Pathophysiology: The Biological Basis for Disease in Adults and Children, 6th edn, Mosby Elsevier, Philadelphia


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bioe221 sn02 skinandmucousmembranes · · 2017-01-09© endeavour college of natural health...

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