Peripheral Assessment

Current Have you noticed any Color, Arterial insufficiency the skin is cold
symptoms temperature or texture changes in your and clammy on the extremities and thin
skin ,shiny skin with loss of hair especially
over lower legs
Venous insufficiency the skin is warm
with brown pigmentation are founded
around the ankles
Do you experience pain in your legs? Intermittent claudicating characterized
Does it a waken you from sleep by pain ,tension ,weakness that occurs
with activity and is relieved with rest
may indicate arterial disease
Heaviness and an aching sensation
That is aggravated by standing or
sitting for long periods of time and is
relieved by rest is associated with
venous disease
Do you have any leg veins that are Varicose vein are hereditary but may
ropelike, bulging or contorted? also develop from increased venous
pressure and venous pooling
Do you have any sores or open wounds Ulcers associated with arterial disease
on your legs? are usually painful and are often
located on the toes, foot or lateral
ankle
Venous ulcers are usually painless and
occur on the lower leg or medial ankle
Do you have any swelling edema in Peripheral edema swelling resulting
your legs or feet from obstruction in the lymphatic flow
or from venous insufficiency or deep
venous thrombosis
Do you have any swollen glands or Enlarged lymph nodes may indicate a
lymph nodes? Do you have tender local or systemic infection
Past Describe any problems you have in the A history of prior peripheral vascular
history past with circulation in your arms or disease increases the risk of recurrence
legs ( e.g. blood clots ,ulcers, coldness,
numbness, swelling or poor healing)
Have you had any heart or blood Previous surgeries may alter the
vessels surgeries or treatment appearance of skin and the underlying
tissues surrounding the blood vessels
family Do you have a family history of These disorders tendons to be
history diabetic hypertension CAD hereditary and cause damage to the
blood vessels
Life Style Do you smoke? How many backs of Cigarette smoking greatly increases the
and cigarette per day for how many years risk of chronic arterial insufficiency
Health
Practice
What type of stress do you have in Stress increase the heart rate and blood
your life pressure and contribute to vascular disease
 Do you exercise regular? What type of Regular exercise improves peripheral
exercise and how often vascular circulation and decrease
stress, pulse and blood pressure
How have problems with your Pain associated with arterial disease
circulation affected your ability to and heaviness associated with venous
function? disease may limit the clients' ability to
stand or walk for long time
Do leg ulcers or varicose veins affect If the client perceive the appearance of
how you feel about yourself? their legs as disfiguring their body
image or feeling about self-worth may
be negatively influenced

Inspection
Observe arm size, -Arms are bilaterally symmetric - prominent of venous patterning
venous pattern, no edema or prominent of venous with edema may indicate venous
presence of edema patterning obstruction
Observe coloration Color veins depending on clients' Raynaud's' disease characteristic
of the hands and skin tone rapid changes of color (pallor,
arms The color should be the same cyanosis and rashes, swelling, pain
bilaterally numbness, tingling, burning
thumbing and coldness)
Palpate
Palpate client's Skin is warm to the touch A cool extremity may be a sign of
turgor hands and bilaterally from fingertips to upper arterial insufficiency
arms. arms Cold finger and hands are common
Note the findings with Raynaud's disease.
temperature
Palpate to assess Capillary beds refill and color Capillary refill time exceeds 2
capillary refill return in 2 seconds seconds may indicate
Assess peripheral vasoconstriction ,decreases COP,
perfusion and hypothermia
reflect cardiac
output
Palpate redial Redial pulse has equal strength Increased radial pulse volume
pulse bilaterally indicates a hyperkinetic state.
Diminished or absent pulse
suggests partial or complete arterial
occlusion
Palpate ulnar pulse ulnar pulse may not be detectable Lack of resilience of the artery wall
because they are located deeper may indicate arteriosclerosis
than the radial pulse
Palpate brachial Brachial pulse has equal strength Brachial pulse increased
pulse bilaterally diminished or absent
Palpate the
Epitrochlear
Lymph Nodes
Flex the client's' Normally epitrochlear lymph nodes Epitrochlear lymph nodes may
elbow about 90 are not palpable infection in the hand or forearm.
degree
Perform the Allen
Test
The Allen Test. Pink coloration returns to the palms With arterial insufficiency or
Evaluate patency within 3 to 5 second if the ulnar occlusion of the ulnar artery or
of the radial or artery and radial artery radial artery, pallor persist
ulnar arteries (individually are present)
Inspect and Uncover the leg while keeping the
palpate the legs genitalia draped.
Inspect both legs together for:
Discoloration. Skin hair
distribution.
Observe the skin Pink color for lighter skinned client Pallor, especially when elevated
color in both legs and pink or red tones visible under and rubor when dependent
from the toes to darker pigmented skin. ,suggested arterial insufficiency
the groin There should be no change in Cyanosis when dependent
pigmentation ,suggested venous insufficiency
A rusty or brownish pigmentation
around the ankles indicates venous
insufficiency
Inspect for lesions Legs are free of lesions or Ulcers from arterial insufficiency
or ulcers ulceration are smooth even margins that
occurs at pressure areas such as
toes or and lateral ankle
Ulcers from venous insufficiency
have irregular edges, bleeding and
possible bacterial infection
Inspect for edema Identical size and shape bilaterally Bilateral edema may be detected
Compare with No swelling or atrophy by the absence of visible veins
extremities at the ,tendons or bony prominences and
same location usually indicates systemic
problems as CHF, Lymph edema
Unilateral edema caused by venous
stasis
Difference in measurement
between legs may be due to
muscular atrophy results from
disuse due to being in cast for long
time
Palpate Edema No edema pitting or non-pitting in Bilateral edema associated with
determine if it is the legs systematic problems such as CHF
pitting or non- or hepatic cirrhosis
pitting Or local causes as venous stasis
due to insufficiency or obstruction
or prolonged standing or sitting
(orthostatic edema) A 1+ to 4+
scale is used to grade the severity
of edema
Palpate Skin Toes, feet, legs are equally warm Generalized coolness in one or
Palpate bilaterally bilaterally change in temperature from warm
for temperature of to cool as you move down the legs
the feet and legs suggest arterial insufficiency
Increased warmth in the leg may be
caused by superficial
thrombophlebitis resulting from a
secondary inflammation in the
tissue around the vein
Palpate Superficial Non tender movable lymph nodes Lymph nodes larger than 2 cm with
Inguinal Lymph up to 1 or 2 cm are commonly or without tenderness
nodes palpated (lymphadenopathy) may be from a
local infection or generalized
lymphadenopathy
Fixed nodes may be indicating
malignancy
Palpate the femoral pulses Strong and equal Weak or absence Femoral pulses
femoral pulses bilaterally indicate partial or complete arterial
Assess the pulses occlusion
and compare the
amplitude
bilaterally
Auscultator No sound auscultator over femoral Bruit over one or both femoral
femoral pulses arteries arteries suggested partial
Listen for bruit by obstruction of the vessels and
bell diminished blood flow to lower
extremities
Palpate the It is not unusual for popliteal pulses Although normal popliteal arteries
popliteal pulses To be difficult or impossible to may be non-palpable ,an absent
usually detected detect and yet for circulation to be pulse may also be the result of an
lateral to the normal occluded artery,
medial tendon Further circulation assessment
(temperature and color) to the
popliteal artery assists in determine
the significant of an absent pulse
Palpate the dorsalis pads pulse Are bilaterally A weak or absent pulse may
dorsalis pads pulse indicate impaired arterial
Assess both feet at circulation
the same time to Further circulation assessment
aid in making (temperature and color) are
comparisons warranted to determine the
assess amplitude significant of an absent pulse
bilaterally
Palpate the posterior tibial pulse Are bilaterally A weak or absent pulse may
posterior tibial indicate partial or complete
pulse Assess both obstruction arterial circulation
feet at the same
time to aid in
making
comparisons
assess amplitude
bilaterally
Inspect for
Varicosities and
thrombophlebitis
If superficial Vein are flat and barely seen under Varicose vein may appear as a
thrombophlebitis surface of skin distended nodular bulging tortuous
Is present note Varicosities common on the older depending on severity.
redness or adult Varicose vein may Result from
discoloration on incompetent valves in the veins,
skin surface over weak veins walls or an obstruction
the vein Above Varicosities.
Aching or cramping may occur
with walking or dorsiflexion of the
foot (Positive Homans' sign)
Check for No pain or tenderness elicited with Calf pain and tenderness elicited
Homans' Sign this maneuvers .Homans' sign with this maneuver is positive
Homans Sign.
A positive sign may indicate Deep
vein thrombosis or superficial
thrombophlebitis
Special Tests for
Arterial or Venous
Insufficiency
Position Changes Feet pink to slightly pale in color in Marked pallor with legs elevated is
Test for arterial the light skinned client with an indications of arterial
insufficiency elevation. insufficiency .Return to pink color
Raise legs about It is more difficult to see the subtle that takes longer than 10 second to
12 inches above color changes in darker skin fill suggest Arterial insufficiency
the level of heart
Manual No pulsation is palpated if the You will feel a pulsation with your
Compression test client has competent valves upper fingers if the valves in the
to assess the veins are incompetent
competence of the
veins' valve
Trendelenburg test Saphenous vein fills from below in Filling from above with the
to determine the 30 second. tourniquet in place and client
competence of the No rapid filling of the varicose standing suggest incompetent
saphenous vein veins from above (retrograde valves in the saphenous
valves and the filling) after removal of tourniquet Rapid filling of the superficial
retrograde filling if valves are competent varicose veins from above after the
of the superficial tourniquet has been removed also
veins indicates retrograde filling past
incompetent valves in the veins

Types of Peripheral edema

Items Edema associated with Edema associated with Chronic
Lymphedema Venous Insufficiency
Causes Caused by abnormal or blocked Caused by obstruction or insufficiency
lymph vessels of deep vein
Character No pitting Pitting documented as
=+1, =+2, =+3, =+4
Site Usually bilateral may be unilateral Usually unilateral, may be bilateral
Skin condition No skin ulceration or pigmentation Skin ulceration and pigmentation may
be present

Characteristic of venous and arterial leg ulcers

Characteristic venous ulcers arterial ulcers
Pulses Present Diminished
Capillary refill Less than 3 second Greater than 3 second
Skin temperature Warm \no temperature gradient Cool\temperature gradient
Ulcers location Typically near medial malleolus Tips of toes ,foot or lateral malleolus
Ulcer tissue Dark —red granulation Black Escher or pale-pink
Granulation tissue
Ulcer drainage Moderate to large amount Minimal
Periulcer Bronze-brown pigmentation thick Pale thin friable and shiny; thick
hardened and indurate toenails elevation pallor dependent
rubor
Dermatitis Frequency occur Rarely occur
Pruritus Frequency occur Rarely occur
Edema Moderate to sever Minimal unless leg constantly in
dependent position
Pain Often painful especially if infected Intermittent claudication ulcer not
painful

Comparison between venous and arterial insufficiency of lower extremities

Items Venous Arterial
Pulses Present Decreased \absent
Color of the skin Pink to cyanotic Brown Pale on elevation
pigmentation at ankles Dusky rubor on dependency
Temp Warm Cool-cold
Edema present Non
Skin Ulcers on ankles, discolored scaly Shiny skin thick nails absence of
hair ulcers on toes gangrene may
develop
Sensation Leg pain by long standing or sitting Leg pain when exercise and relieved
and relieved by elevating the legs, with rest.
lying down or walking Pressure or cramps in calves during
walking paresthesia

 Bruit: soft blowing sound suggestive of narrowing and blood flow restriction when heard
in a blood vessel
 A thrill which is a palpable vibration to a cat purr, which is associated with heart
murmurs ,usually suggests a valvular dysfunction
 For a comprehensive assessment and documentation
technique for veins and arteries following the device called
PATCHES
P Pulse Assess the patients' affected extremity first
A Appearance Pale ,cyanotic ,discolored, red, black or brown ,
Document areas of necrosis, bleeding, size, depth and location of
ulcers
T Temperature Feel cool (arterial) abnormal warm (venous)
C Capillary Refill Normally less than 2 second, toes fingers
H Hardness Palpate the extremity to determine if the tissues are supply or soft or
hard and inelastic
Hardness may indicate long standing PVD
E Edema Pitting :acute assessed by edema scale indicate venous insufficiency
Non pitting :chronic assessed by measuring the circumference
S Sensation Abnormal sensation ,numbness or tingling result from vascular
peripheral tissue ischemia ( DM)

The 7P's for rapid peripheral vascular assessment

P Pain increase in active or passive motion
P Pallor
P paresthesias or numbness
P Polar temperature is an extremity cold compared with other
P Puffiness: from edema or hematoma
P Pulselessness
P Paralysis

Arterial Pulse Amplitude -Grading Scale

0= Absent
1= Diminished, weaker than expected
2= Brisk, expected (normal)
3=1ncrease
4= Bounding
Edema Scale
0 Non present
1+ 0-1\4 inch indentation disappear rapidly
2+ 1/4-1/2 inch indentation disappear in 10-15 seconds
3+ 1\2-1 inch indentation disappear in 1-2 minutes
4+ More than 1 inch indentation disappear after 5 minutes