Download - Peripheral vascular-lymphatic
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ASSESSING THE PERIPHERAL-VASCULAR AND LYMPHATIC SYSTEMS
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Outcomes Identify pertinent peripheral-
vascular and lymphatic history questions.
Obtain a peripheral-vascular and lymphatic history.
Perform a peripheral-vascular and lymphatic physical assessment. (Continued)
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Outcomes Document peripheral-vascular and lymphatic assessment findings.
Identify actual/potential health problems stated as nursing diagnosis.
Differentiate between normal and abnormal findings.
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StructuresPeripheral vascular: arteries
veins
Lymphatic system: lymph nodes tonsils thymus spleen Peyer’s Patches
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FunctionsWhat are the functions of…
Peripheral-vascular structures:
Arteries: carry blood away from heart
Veins: carry blood to heart
(Continued)
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FunctionsWhat are the functions of…
Lymphatic structures:
Lymph nodes: filter microorganisms and foreign substances from lymphTonsils: lymphatic tissue in oropharynx destroys microorganisms and foreign substances (Continued)
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FunctionsWhat are the functions of…
Thymus: secretes thymosin, helps with T-cell differentiation
Spleen: filters blood and produces lymphocytes and monocytes
Peyer’s patch: clusters of lymphoid tissue found in small intestines
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Relationship to Other SystemsWhat is the relationship of the
lymphatic system to other systems?
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DevelopmentalVariations
What developmental variations of the lymphatic system might you see with:
Children Increased
Lymphoid tissue Interatrial
Foramen Ovale closes
Pregnant clients Delay in initial
maternal responses to infection
Peripheral vasodilation (Palmer Erythema & Telangiectasis)
Older adults Decreased lymph
nodes (size & #) Decreased venous
elasticity & Increased arterial plaques
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Cultural VariationsWhat cultural variations of the P-V
and lymphatic system might you see with:
African AmericansHTN; AIDS
Native AmericansSCIDS
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Case Study Tasha Jordan, 38- year-
old African American, married, secretary
c/o increasing pain and tenderness in left leg since she delivered premature baby 1 week ago.
Pain: dull, throbbing, swelling of leg
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HistoryWhat can the history tell you about the P-V and lymphatic system? Biographical data Current health status Past health history Family history Review of systems Psychosocial history
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SymptomsWhat symptoms would signal a P-V or lymphatic system problem?
Swelling Limb pain Changes in sensation Fatigue
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Pertinent History Findings + smoker (22 pack-years) + family history of CV disease Husband supportive; baby to be
discharged soon
(Continued)
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Pertinent History Findings Dull, throbbing pain; swelling left
leg; increases with standing and walking
Prolonged bed rest before delivery and 50 # weight gain during pregnancy
More tired than usual
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Physical AssessmentAnatomical landmarks: pulse sites and
lymph nodes
Approach: inspection, palpation, and auscultation
Position: Supine and sitting
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Physical AssessmentTools: stethoscope with bell and
diaphragm, B/P cuff, thermometer, watch, ruler, tape measure, light
General survey and head-to-toe scan
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Pulse Sites
Pulse sites: Temporal Ulnar Carotid Femoral Brachial Popliteal Radial Dorsalis pedis Posterior tibialis
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Lymph Nodes
Lymph node sites:CervicalAxillaryEpitrochlearInguinal
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Inspection
Upper extremities: color, edema, erythema, lesions, capillary refill
Abdomen: ascites
Lower extremities: color, edema, lesions, hair distribution, varicosities
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Palpation Pulses
Pulses: Rate Rhythm Equality Amplitude (0 - 4, with 2 as normal)
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Palpation of Lymph NodesNodes: size shape mobility tenderness consistency warmth delineation erythema location increased vascularity
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AuscultationArteries for bruits
Blood pressure
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Pertinent Physical Findings Temperature 99.8 Left leg warm, tender, edematous from
popliteal to ankle Left pedal pulses difficult to locate Calf circumference left > right + Homan sign No palpable lymph nodes
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Nursing Diagnosis
What actual or potential problems can you identify for Mrs. Jordan?
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InsufficienciesArterial
Intermittent claudicationPulses decreased/absent
Pale elevatedDusky red dependent
Temp is coolSkin is thin/shiny/hair loss
Nails thick and ridgedIf ulcers—around toesSevere pain—unless
neuropathy masks itGangrene may develop
VenousProminent leg veins (rope-like, spider-like)
Lower leg edemaLeg is hard and leathery
Pulses normalNormal temp
Brownish pigmentationUlcers—occur at ankles
Pain not severeEczema or stasis
dermatitisNo gangrene