peripheral vascular-lymphatic

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Post on 20-Jan-2015



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2. 2 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) 3. 3 Outcomes Document peripheral-vascular and lymphatic assessment findings. Identify actual/potential health problems stated as nursing diagnosis. Differentiate between normal and abnormal findings. 4. 4 Structures Peripheral vascular: arteries veins Lymphatic system: lymph nodes tonsils thymus spleen Peyers Patches 5. 5 Functions What are the functions of Peripheral-vascular structures: Arteries: carry blood away from heart Veins: carry blood to heart (Continued) 6. 6 Functions What are the functions of Lymphatic structures: Lymph nodes: filter microorganisms and foreign substances from lymph Tonsils: lymphatic tissue in oropharynx destroys microorganisms and foreign substances (Continued) 7. 7 Functions What are the functions of Thymus: secretes thymosin, helps with T-cell differentiation Spleen: filters blood and produces lymphocytes and monocytes Peyers patch: clusters of lymphoid tissue found in small intestines 8. 8 Relationship to Other Systems What is the relationship of the lymphatic system to other systems? 9. 9 10. 10 Developmental Variations 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 11. 11 Cultural Variations What cultural variations of the P-V and lymphatic system might you see with: African Americans HTN; AIDS Native Americans SCIDS 12. 12 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 13. 13 History What 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 14. 14 15. 15 Symptoms What symptoms would signal a P-V or lymphatic system problem? Swelling Limb pain Changes in sensation Fatigue 16. 16 Pertinent History Findings + smoker (22 pack-years) + family history of CV disease Husband supportive; baby to be discharged soon (Continued) 17. 17 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 18. 18 Physical Assessment Anatomical landmarks: pulse sites and lymph nodes Approach: inspection, palpation, and auscultation Position: Supine and sitting 19. 19 Physical Assessment Tools: stethoscope with bell and diaphragm, B/P cuff, thermometer, watch, ruler, tape measure, light General survey and head-to-toe scan 20. 20 Pulse Sites Pulse sites: Temporal Ulnar Carotid Femoral Brachial Popliteal Radial Dorsalis pedis Posterior tibialis 21. 21 Lymph Nodes Lymph node sites: Cervical Axillary Epitrochlear Inguinal 22. 22 Inspection Upper extremities: color, edema, erythema, lesions, capillary refill Abdomen: ascites Lower extremities: color, edema, lesions, hair distribution, varicosities 23. 23 Palpation Pulses Pulses: Rate Rhythm Equality Amplitude (0 - 4, with 2 as normal) 24. 24 Palpation of Lymph Nodes Nodes: size shape mobility tenderness consistency warmth delineation erythema location increased vascularity 25. 25 Auscultation Arteries for bruits Blood pressure 26. 26 Pertinent Physical FindingsTemperature 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 27. 27 Nursing Diagnosis What actual or potential problems can you identify for Mrs. Jordan? 28. 28 Insufficiencies Arterial Intermittent claudication Pulses decreased/absent Pale elevated Dusky red dependent Temp is cool Skin is thin/shiny/hair loss Nails thick and ridged If ulcersaround toes Severe painunless neuropathy masks it Gangrene may develop Venous Prominent leg veins (rope-like, spider-like) Lower leg edema Leg is hard and leathery Pulses normal Normal temp Brownish pigmentation Ulcersoccur at ankles Pain not severe Eczema or stasis dermatitis No gangrene