ASSESSING THE

PERIPHERAL
VASCULAR SYSTEM
WHAT ARE THE STRUCTURES
AND FUNCTION OF
PERIPHERAL VASCULAR
SYSTEM?
STRUCTURES AND
FUNCTIONS: 1. ARTERIES- These
vessels carry oxygen-
rich blood away from
the heart to various
parts of the body.
STRUCTURES AND
FUNCTIONS: 1. CAPILLARIES- are tiny,
thin-walled vessels where
the exchange of gases,
nutrients, and waste
products occurs between
the blood and tissues.
STRUCTURES
AND Veins- return oxygen-
FUNCTIONS: depleted blood from the
body back to the heart.
Unlike arteries, veins have
thinner walls and less muscle
tissue.
STRUCTURES
AND
FUNCTIONS: Venules- These small vessels
collect blood from capillaries
and transport it to larger
veins.
STRUCTURES
AND Lymphatic Vessels: While not

FUNCTIONS:
directly part of the vascular
system, lymphatic vessels
parallel veins and help
transport lymph, a clear fluid
containing white blood cells,
throughout the body.
WHAT ARE THE MAJOR
ARTERIES?
ARTERIAL BRANCHES OF THE
AORTIC ARCH
❑Brachiocephalic trunk.
❑Left common carotid
artery
❑Left subclavian artery
❑Axillary artery
❑Brachial artery
❑Radial and ulnar arteries
ARTERIAL BRANCHES OF THE
ABDOMINAL AORTA
• Celiac trunk
• Superior mesenteric artery
• Renal arteries
• Gonadal arteries
• Lumbar arteries
• Inferior mesenteric artery
• Common iliac arteries
ARTERIES OF PELVIS AND
LOWER EXTREMITIES
• The common iliac artery supplies pelvis and
lower limb. At the level of the lumbosacral
joint it divides into:
1. Internal iliac that supplies urinary bladder,
pelvis, external genitalia, and medial side of
the thigh.
2. External iliac that supplies lower limb. It
penetrates abdominal wall and becomes
the femoral artery. The deep femoral artery.
that supplies the muscles of the thigh
branches off the femoral artery.
3. The femoral artery continues on the back
side of the femur and becomes the
popliteal artery, after it pierces through the
adductor magnus and crosses the popliteal
fossa. The popliteal artery divides into the
anterior tibial artery and the posterior tibial
artery
 AREAS FOR
ASSESSMENT
OF MAJOR
ARTERIES OF
UPPER AND
LOWER
EXTREMITIES
WHAT ARE THE MAJOR
VEINS?
VEINS DRAINING INTO THE
SUPERIOR VENA CAVA
• Radial and ulnar veins
• Cephalic vein
• Basilic vein
• Median cubital vein
• Subclavian vein
• Vertebral vein
• Internal jugular vein
• Brachiocephalic veins
• Azygos vein
VEINS DRAINING INTO THE
INFERIOR VENA CAVA
❑Tibial veins
❑Great saphenous veins
❑Common iliac vein
❑Gonadal vein
❑Renal veins
❑Hepatic portal vein
❑Hepatic veins
VEINS DRAINING INTO THE
INFERIOR VENA CAVA
❑Tibial veins
❑Great saphenous veins
❑Common iliac vein
❑Gonadal vein
❑Renal veins
❑Hepatic portal vein
❑Hepatic veins
ARTERY VS VEIN
LYMPHATIC SYSTEM FUNCTION

1. to drain excess fluid and plasma

proteins from bodily tissues and return
them to the venous system
2. major part of the immune system
defending the body against
microorganisms
3. to absorb fats (lipids) from the small
intestine into the bloodstream
 LYMPHATIC DRAINAGE AND
SUPERFICIAL LYMPH NODES OF UPPER
AND LOWER EXTREMITIES
 COLLECTING SUBJECTIVE DATA:
THE NURSING HEALTH HISTORY
• History of Present Health Concern
• Personal Health History
• Family History
• Lifestyle and Health Practices
 HISTORY OF PRESENT HEALTH
CONCERN
• Have you noticed any color, temperature, or texture changes in your skin?
• Do you experience pain or cramping in your legs? If so, describe the pain
(aching, cramping, stabbing). How often does it occur? Does it occur with
activity? Is the pain reproducible with same amount of exercise?
• If you have pain with walking, how far and how fast do you walk prior to the
pain starting? Is the pain relieved by rest? Are you able to climb stairs? If so,
how many stairs can you climb before you experience pain? Does the pain
wake you from sleep?
• Do you have any leg veins that are rope-like, bulging, or contorted?
HISTORY OF PRESENT HEALTH
CONCERN
PAD VS PVD
• Arterial:
• Cool to the touch
• Thin, dry/scaly skin
• Hairless
• Thick toenails
• “Dr. EP”
• Dangle legs = Rubor
• Elevate legs = Pale
• Venous:
• Warm to the touch
• Thick, tough skin
• Brownish colored
 HISTORY OF PRESENT HEALTH
CONCERN
• Do you have any leg veins that are rope-like, bulging, or contorted?
• Do you have any sores or open wounds on your legs? Where are they
located? Are they painful?
• Do you have any swelling (edema) in your legs or feet? At what time of day
is swelling worst? Is there any pain with swelling?
HISTORY OF PRESENT HEALTH
CONCERN
People who have DVT may have:
❑been in bed for long periods, such as when in
hospital
❑been inactive, such as during a long flight
❑had major surgery recently
❑had an injury, such as a fracture
❑had a major illness such as cancer, heart
failure, or a serious infection
❑been taking the oral contraceptive pill or
hormone replacement therapy containing
estrogen
 HISTORY OF PRESENT HEALTH
CONCERN
• Do you have any swollen glands or lymph nodes? If so, do they feel tender,
soft, or hard?
• For male clients: Have you experienced a change in your usual sexual
activity? Describe.
• RATIONALE: Erectile dysfunction (ED) may occur with decreased blood
flow or an occlusion of the blood vessels such as aortoiliac occlusion
(Leriche’s syndrome). Men may be reluctant to report or discuss
difficulties in achieving or maintaining an erection.
 PERSONAL HEALTH HISTORY
• Describe any problems you had in the past with the circulation in your arms
and legs (e.g., blood clots, ulcers, coldness, hair loss, numbness, swelling, or
poor healing).
• Have you had any heart or blood vessel surgeries or treatments such as
coronary artery bypass grafting, repair of an aneurysm, or vein stripping?
 FAMILY HISTORY
• Do you, or does your family, have a history of diabetes, hypertension,
coronary heart disease, intermittent claudication, or elevated cholesterol or
triglyceride levels?
 LIFESTYLE AND HEALTH PRACTICES
• Do you (or did you in the past) smoke or use any other form of tobacco?
How much and for how long? If you use tobacco currently, are you willing to
quit?
• Do you exercise regularly?
• For female clients: Do you take oral or transdermal (patch) contraceptives?
• RATIONALE: Oral or transdermal contraceptives increase the risk for
thrombophlebitis, Raynaud’s disease, hypertension, and edema.
• Are you experiencing any stress in your life at this time?
• How have problems with your circulation (i.e., peripheral vascular system)
affected your ability to function?
 LIFESTYLE AND HEALTH PRACTICES
• Do leg ulcers or varicose veins affect how you feel about yourself?
• Do you regularly take medications prescribed by your physician to improve your
circulation?
• RATIONALE: Drugs that inhibit platelet aggregation, such as cilostazol (Pletal) or
clopidogrel (Plavix), may be prescribed to increase blood flow. Aspirin also prolongs
blood clotting and is used to reduce the risks associated with PVD. Pentoxifylline
(Trental) may be prescribed to reduce blood viscosity, improving blood flow to the
tissues, thus reducing tissue hypoxia and improving symptoms. Clients who fail to take
their medications regularly are at risk for developing more extensive peripheral
vascular problems. These clients require teaching about their medication and the
importance of taking it regularly.
• Do you wear support hose to treat varicose veins?
COLLECTING OBJECTIVE
DATA
 PREPARING THE CLIENT
1. Ask the client to put on an examination gown and to sit upright on an examination
table
2. Make sure that the room is a comfortable temperature (about 72 F), without
drafts. This helps to prevent vasodilation or vasoconstriction.
3. Before you begin the assessment, inform the client that it will be necessary to
inspect and palpate all four extremities and that the groin will also need to be
exposed for palpation of the inguinal lymph nodes as well as palpation and
auscultation of the femoral arteries.
4. Explain that the client can sit for examination of the arms but will need to lie down
for examination
5. of the legs and groin, and will need to follow your directions for several special
assessment techniques toward the end of the examination.
6. As you perform the examination, explain in detail what you are doing and answer
any questions the client may have. This helps to ease any client anxiety.
 EQUIPMENT
• Centimeter tape
• Stethoscope
• Doppler ultrasound device
• Conductivity gel
• Tourniquet
• Gauze or tissue
• Waterproof pen
• Blood pressure cuff
ASSESSMENT PROCEDURE
1. Observe arm size and
venous pattern; also look
for edema.
2. Observe coloration of the
hands and arms
3. Palpate the client’s
fingers, hands, and arms,
and note the
temperature.
4. Palpate to assess capillary
refill time.
UPPER EXTREMITIES
ASSESSMENT PROCEDURE
6. Palpate the radial pulse.
7. Palpate the ulnar pulses.
8. You can also palpate the
brachial pulses if you
suspect arterial
insufficiency
9. Palpate the epitrochlear
lymph nodes.
ASSESSMENT PROCEDURE
10. Perform the Allen test
LOWER EXTREMITIES
INSPECTION, PALPATION, AND
AUSCULTATION
11. Ask the client to lie supine. Then drape the groin
area and place a pillow under the client’s head
for comfort. Observe skin color while inspecting
both legs from the toes to the groin.
12. Inspect distribution of hair.
13. Inspect for lesions or ulcers.
14. Inspect for edema.
CLINICAL TIP
Taking a measurement in centimeters
from the patella to the location to be
measured can aid in getting the exact location
on both legs. If additional readings are
necessary, use a felt-tipped pen to ensure
exact placement of the measuring tape.
INSPECTION, PALPATION, AND
AUSCULTATION
15. Palpate edema.
16. Palpate bilaterally for
temperature of the feet and
legs.
17. Palpate the superficial
inguinal lymph nodes.
INSPECTION, PALPATION, AND
AUSCULTATION
18. Palpate the femoral pulses.
19. Auscultate the femoral pulses.
20. Palpate the popliteal pulses.
CLINICAL TIP
• If you cannot detect a pulse, try
palpating with the client in a
prone position. Partially raise the
leg, and place your fingers deep
in the bend of the knee. Repeat
palpation in opposite leg, and
note amplitude bilaterally
 INSPECTION, PALPATION, AND
AUSCULTATION
18. Palpate the dorsalis pedis pulses.
CLINICAL TIP
• It may be difficult or impossible to palpate a
pulse in an edematous foot. A Doppler
ultrasound device may be useful in this
situation.
18. Palpate the posterior tibial pulses.
CLINICAL TIP
• Edema in the ankles may make it difficult or
OLDER ADULT CONSIDERATIONS impossible to palpate a posterior tibial pulse.
In this case, Doppler ultrasound may be used
Varicosities are common in the older to assess the pulse.
client.
19. Inspect for varicosities and thrombophlebitis
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Perform position change test for arterial insufficiency
• If pulses in the legs are weak,
• further assessment for arterial insufficiency is warranted. The client should be
in a supine position.
• Place one forearm under both of the client’s ankles and the other forearm
underneath the knees.
• Raise the legs about 12 inches above the level of the heart. As you support
the client’s legs, ask the client o pump the feet up and down for about a
minute to drain the legs of venous blood, leaving only arterial blood to color
the legs
SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Perform position change test for
arterial insufficiency
• At this point, ask the client to sit
up and dangle legs off the side of
the examination table.
• Note the color of both feet and
the time it takes for color to return
CLINICAL TIP
This assessment maneuver will not
be accurate if the client has PVD of
the veins with incompetent valves.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Determine ankle-brachial index (ABI),
If the client has symptoms of arterial occlusion, the ABPI should be used to
compare upper- and lower limb systolic blood pressure. The ABI is the ratio of
the ankle systolic blood pressure to the arm (brachial) systolic blood pressure.
The ABI is considered an accurate objective assessment for determining the
degree of peripheral arterial disease. It detects decreased systolic pressure
distal to the area of stenosis or arterial narrowing and allows the nurse to
quantify this measurement.
SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Determine ankle-brachial index (ABI),
If the client has symptoms of arterial occlusion,
the ABPI should be used to compare upper-
and lower limb systolic blood pressure. The ABI
is the ratio of the ankle systolic blood pressure
to the arm (brachial) systolic blood pressure.
The ABI is considered an accurate objective
assessment for determining the degree of
peripheral arterial disease. It detects
decreased systolic pressure distal to the area
of stenosis or arterial narrowing and allows the
nurse to quantify this measurement.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Measure ABI.
Use the following steps to measure ABI:
• Have the client rest in a supine position for at least 5 minutes.
• Apply the blood pressure (BP) cuff to first one arm and then the other to
determine the brachial pressure using the Doppler.
• First palpate the pulse and use the Doppler to hear the pulse. The
“whooshing” sound indicates the brachial pulse.
• Pressures in both arms are assessed because asymptomatic stenosis in the
subclavian artery can produce an abnormally low reading and should not be
used in the calculations.
• Record the higher reading.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Measure ABI.
Use the following steps to measure ABI:
• Apply the BP cuff to the right ankle,
• then palpate the posterior tibial pulse at the medial aspect of the ankle and
the dorsalis pedis pulse on the dorsal aspect of the foot.
• Using the same Doppler technique as in the arms, determine and record both
systolic pressures.
• Repeat this procedure on the left ankle
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Measure ABI.
If you are unable to assess these pulses, use the peroneal artery
CLINICAL TIPS
• Make sure to use a correctly sized BP cuff. The bladder of the cuff should be
20% wider than the diameter of the client’s limb.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Measure ABI.
If you are unable to assess these pulses, use the peroneal artery
• Document BP cuff sizes used on the nursing plan of care (e.g., “12-cm BP cuff used for
brachial pressure: 10-cm BP cuff used for ankle pressure”). This minimizes the risk of
shift-to-shift discrepancies in ABIs.
• Inflate the BP cuff enough to ensure complete closure of the artery. Inflation should
be 20–30 mm Hg beyond the point at which the last arterial signal was detected.
• Avoid deflating the BP cuff too rapidly. Instead, try to maintain a deflation rate of 2–4
mm Hg/sec for clients without arrhythmias and 2 mm Hg/sec or slower for clients with
arrhythmias. Deflating the cuff more rapidly than that may cause you to miss the
client’s highest pressure and record an erroneous (low) blood pressure measurement.
SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
• Be suspicious of arterial
pressure recorded at less
than 40 mm Hg. This may
mean that the venous
signal was mistaken for the
arterial signal. If you
measure arterial pressure,
which is normally 120 mm
Hg at below 40 mm Hg,
ask a colleague to
double-check your
findings before you record
the arterial pressure.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
ABI calculation.
Use the following formula to calculate ABI:
• Divide the higher ankle pressure for each foot by the higher brachial
pressure. For example,
• you may have measured the highest brachial pulse as 160, the highest pulse
in the right ankle as 80, and the highest pulse in the left ankle as 94. Dividing
each of these ankle pressures by 160 (the highest brachial pressure; 80/160
and 94/160) will result in a right ABI of 0.5 and a left ABI of 0.59.
SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Manual compression test
❑If the client has varicose veins, perform manual
compression to assess the competence of the
vein’s valves.
❑Ask the client to stand.
❑Firmly compress the lower portion of the varicose
vein with one hand.
❑Place your other hand 6–8 inches above your first
hand.
❑Feel for a pulsation to your fingers in the upper
hand.
❑Repeat this test in the other leg if varicosities are
present.
 SPECIAL TESTS FOR ARTERIAL OR
VENOUS INSUFFICIENCY
Trendelenburg test.
If the client has varicose veins, perform the Trendelenburg test to determine the
competence of the saphenous vein valves and the retrograde (backward) filling of the
superficial veins.
❑The client should lie supine.
❑Elevate the client’s leg 90 degrees for about 15 seconds or until the veins empty.
❑With the leg elevated, apply a tourniquet to the upper thigh.
❑Assist the client to a standing position and
CLINICAL TIP
➢ Arterial blood flow is not occluded if there are arterial pulses distal to the tourniquet.
❑observe for venous filling.
❑Remove the tourniquet after 30 seconds, and
❑watch for sudden filling of the varicose veins from above.
CHARACTERISTICS OF ARTERIAL
AND VENOUS INSUFFICIENCY
CHARACTERISTICS OF ARTERIAL
AND VENOUS INSUFFICIENCY
TYPES OF PERIPHERAL EDEMA
END