BIOE221. Session 02. Skin, Mucous Membrane and Periphery Assessment. Bioscience Department. Endeavour College of Natural Health endeavour.edu.

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1 BIOE221 Session 02 Skin, Mucous Membrane and Periphery Assessment Bioscience Department

2 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

3 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

4 Blood Pressure in various blood vessels (Tortora & Derrickson, 2009)

5 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

6 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

7 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 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

8 BP Values and Hypertension (National Heart Foundation of Australia 2008)

9 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.

10 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)

11 Relationship of BP changes to cuff pressure (Tortora & Derrickson 2009)

12 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

13 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 palpatory systolic first.

14 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

15 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 characterised by elevated blood pressure persistently exceeding 140/90mmHg

16 Vascular Circulation The 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

17 Venous Circulation Lower Extremities (Tortora & Derrickson 2009)

18 Conditions affecting venous circulation Most 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

19 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

20 Carotid Artery Clinical Exam Session 2 (Tortora & Derrickson 2010)

21 Arterial Supply Upper Extremity Aorta brachiocephalic subclavian axillary brachial radial and ulnar (Tortora & Derrickson 2009)

22 Arterial Supply Lower Extremity Thoracic aorta abdominal aorta common iliac external iliac femoral popliteal posterior tibial and dorsalis pedis (Tortora & Derrickson 2010)

23 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

24 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

25 Brachial Pulse 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)

26 Radial Pulse (Jarvis 2004) Used to assess blood flow 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.

27 Ulnar Pulse (Jarvis 2016) Used to assess blood flow to the hand Located between the flexor carpi ulnaris and flexor digitorum profundus tendons on the medial side of the wrist

28 Popliteal Pulse (Jarvis 2004) Used to assess blood flow to the leg. Located deep within the popliteal fossa in between the femoral condyles.

29 Posterior tibial pulse (Jarvis 2004) Used to assess blood flow to the foot. Located between the medial malleolus and the Achilles tendon.

30 Dorsalis pedis pulse (Jarvis 2012) Used to assess blood flow to the distal foot. Located lateral to the extensor hallucis longus tendon at the high point of the foot.

31 Some vascular manifestations 31

32 Raynaud s Phenomenon (Jarvis 2008)

33 Peripheral Vascular Disease (Jarvis 2008) Ischaemic ulcer - arterial Venous (stasis) ulcer

34 Diabetes Mellitus (Dry) Gangrene (McCance & Huether 2006) Foot Ulceration (& Digit Amputation)

35 Varicose Veins Varicose Ulcer

36 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

37 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

38 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

39 Ankle-Brachial Pressure Index The Ankle-Brachial Pressure Index (ABPI) is a simple way to determine the potential for peripheral vascular disease. 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. 39

40 Ankle-Brachial Pressure Index 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

41 Ankle-Brachial Pressure Index Calculation: Ankle Systolic / Arm Systolic = ABPI >1.3 Potential arterial stiffness No peripheral artery disease Borderline peripheral artery disease Mild peripheral artery disease Moderate peripheral artery disease Severe peripheral artery disease <0.3 Ischemia (Emergency referral required) (Jarvis. 2016, p.525) 41

42 Skin Examination Skin 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

43 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

44 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

45 Skin Turgor (The New York Times Company 2007)

46 Finger Clubbing Four criteria confirm clubbing Loss of normal angle between the nail and nail bed (>160 o ) 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

47 Finger Clubbing (Science Daily 2009)

48 Capillary Refill This 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

49 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

50 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

51 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

52 Oedema Testing for pitting oedema Pitting oedema (Jarvis 2016, p.523)

53 Lymphoedema (Jarvis 2008)

54 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

55 Resources Jarvis, C. (2016) Physical Examination and Health Assessment, 7 th 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 Migliacci, R, Nasorri, R, Ricciarini, P, & Gresele, P, 2008, Anklebrachial index measured by palpation for the diagnosis of peripheral arterial disease, Family Practice, Vol. 25, p McCance, K, Huether, S, Brashers, V, & Rote, N, 2010, Pathophysiology: The Biological Basis for Disease in Adults and Children, 6 th edn, Mosby Elsevier, Philadelphia

56 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Endeavour College of Natural Health pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice.

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