ASSESSING PERIPHERAL VASCULAR SYSTEM artery (extending down the little-finger

side of the arm)

Structure and Function - Both arteries provide blood to the
hand
Arteries
- These are blood vessels that carry Major Arteries of the Leg
oxygenated, nutrient-rich blood from the ● Femoral artery
heart to the capillaries - Major supplier of blood to the legs
- A high-pressure system - Pulse palpated under the inguinal
- Arterial pulse ligament
➔ The surge of blood as a result from a ● Popliteal artery
heartbeat which forces blood through the - Pulse palpated behind the knee
arterial vessels under high pressure
● Dorsalis pedis artery
Major Arteries of the Arm - Pulse palpated on the great-toe side of
● Brachial artery the top of the foot
- Major artery that supplies the arm ● Posterior tibial artery
- Palpated medial to the biceps tendon - Palpated behind the medial malleolus
in and above the bend of the elbow of the ankle
- Divides near the elbow to become the Veins
radial artery (extending down the - Carry deoxygenated, nutrient depleted,
thumb side of the arm) and the ulnar waste-laden blood from the tissues back to the
heart
 - The veins of the arms, upper trunk, head, and 3 mechanisms of venous function
neck carry blood to the superior vena cava, ● 1st mechanism
where it passes into the right atrium - Structure of the veins
- Blood from the lower trunk and legs drains ● 2nd mechanism
upward into the inferior vena cava - Muscular contraction
- Contains nearly 70% of the body's blood ● 3rd mechanism
volume - Creation of a pressure gradient
- Walls are much thinner, low-pressure system through the act of breathing

Three Types of Veins

● Deep veins
➔ Femoral veins
➔ Popliteal veins

● Superficial veins
➔ Great and small saphenous veins

● Perforator (or communicator) veins

➔ Connect the superficial veins with the
deep veins
 Collecting Objective Data ➔ Use the Doppler ultrasound instrument
correctly
Physical Examination
- The purpose is to identify any signs or symptoms Capillaries
of PVD including arterial insufficiency, venous - Small blood vessels that form the connection
insufficiency, or lymphatic involvement between the arterioles and venules
- Useful in acute care, extended care, and - Allow the circulatory system to maintain the
home healthcare settings vital equilibrium between the vascular and
- A complete peripheral vascular examination interstitial spaces
involves inspection, palpation, and
auscultation Assessment Procedure (ARMS)
- When performing PE, the nurse should: Inspection
➔ Discuss risk factors for PVD with the ● Observe coloration of the hands and arms
client.
➔ Accurately inspect arms and legs for Normal Findings
edema and venous patterning ➔ Color varies depending on the client's skin
➔ Observe carefully for signs of arterial tone, although color should be the same
and venous insufficiency (skin color, bilaterally
venous pattern, hair distribution, lesions Abnormal findings
or ulcers) and inadequate lymphatic ➔ Raynaud disorder
drainage - A vascular disorder caused by
➔ Recognize characteristic clubbing vasoconstriction or vasospasm of the
➔ Palpate pulse points correctly fingers or toes, characterized by rapid
 changes of color (pallor, cyanosis, and ➔ A cool extremity may be a sign of arterial
redness), swelling, pain, numbness, insufficiency.
tingling, burning, throbbing, and ➔ Cold fingers and hands, for example, are
coldness common findings with Raynaud's

● Palpate to assess capillary refill time.

➔ Compress the nailbed until it blanches.
Release the pressure and calculate the
time it takes for color to return. This test
indicates peripheral perfusion and
reflects cardiac output.

Normal findings
Palpation ➔ Capillary beds refill (and, therefore, color
● Palpate the client's fingers, hands, and arms, returns) in 2 seconds or less
and note the temperature
Abnormal findings
Normal findings ➔ Capillary refill time exceeding 2 seconds may
➔ Skin is warm to the touch bilaterally from indicate vasoconstriction, decreased cardiac
fingertips to upper arms output, shock, arterial occlusion, or
hypothermia

Abnormal findings
 ● Palpate the radial pulse. ➔ Do this by placing the first three
➔ Gently press the radial artery against fingertips of each hand at the client's
the radius. Note elasticity and strength. right and left medial antecubital
creases. Alternatively, palpate the
brachial pulse in the groove between
the biceps and triceps.

Normal findings
➔ Radial pulses are bilaterally strong (2+). Artery
walls have a resilient quality (bounce).

Abnormal findings Normal findings

➔ Increased radial pulse volume indicates a ➔ Brachial pulses have equal strength bilaterally
hyperkinetic state (3+ or bounding pulse). Abnormal findings
Diminished (1+) or absent (0) pulse suggests ➔ Brachial pulses are increased, diminished, or
partial or complete arterial occlusion (which is absent.
more common in the legs than the arms). The
pulse could also be decreased from Buerger's ● Perform the Allen test.
disease or scleroderma. ➔ Evaluates patency of the radial or ulnar
arteries. It is done when patency is
● Palpate the brachial pulse.
 questionable or before such procedures as a ➔ Note that the palm remains pale. Release the
radial artery puncture. pressure on the ulnar artery and watch for color
➔ The test begins by assessing ulnar patency. to return to the hand. To assess radial patency,
Have the client rest the hand palm side up on repeat the procedure as before, but at the last
the examination table and make a fist. Then step, release pressure on the radial artery.
use your thumbs to occlude the radial and
ulnar arteries.

➔ Evaluates patency of the radial or ulnar

arteries. It is done when patency is
➔ Continue pressure to keep both arteries
questionable or before such procedures as a
occluded and have the client release the fist.
radial artery puncture.

Normal findings
➔ Pink coloration returns to the palms within 3-5
seconds if the ulnar artery is patent.
 ➔ Pink coloration returns within 3-5 seconds if the Abnormal findings
radial artery is patent. ➔ Pallor, especially when elevated, and rubor,
Abnormal findings when dependent, suggests arterial
➔ With arterial insufficiency or occlusion of the insufficiency.
ulnar artery, pallor persists. With arterial ➔ Cyanosis when dependent suggests venous
insufficiency or occlusion of the radial artery, insufficiency.
pallor persists. ➔ A rusty or brownish pigmentation around the
ankles indicates venous insufficiency
Assessment Procedure (LEGS)
● Inspect distribution of hair on legs
Inspection, Palpation, and Auscultation Normal findings
➔ Ask the client to lie supine. Then drape the ➔ Hair covers the skin on the legs and appears on
groin area and place a pillow under the client's the dorsal surface of the toes.
head for comfort. Observe skin color while Abnormal findings
inspecting both legs from the toes to the groin. ➔ Loss of hair on the legs suggests arterial
insufficiency. Often thin, shiny skin is noted as
● Observe skin color while inspecting both legs well.
from the toes to the groin
● Inspect for lesions or ulcers.
Normal findings Normal findings
➔ Pink color for lighter-skinned clients and pink or ➔ Legs are free of lesions or ulcerations.
red tones visible under darker-pigmented skin.
There should be no changes in pigmentation.
 Abnormal findings Normal findings:
➔ Ulcers with smooth, even margins that occur at ➔ Identical size and shape bilaterally; no swelling
pressure areas, such as the toes and lateral or atrophy.
ankle, result from arterial insufficiency. Abnormal findings:
➔ Ulcers with irregular edges, bleeding, and ➔ May be detected by the absence of visible
possible bacterial infection that occur on the veins, tendons, or bony prominences.
medial ankle result from venous insufficiency. ➔ Bilateral edema usually indicates a systemic
problem
● Inspect for edema. ➔ Unilateral edema is characterized by a 1-cm
➔ Inspect the legs for unilateral or bilateral difference in measurement at the ankles or a
edema. Note veins, tendons, and bony 2-cm difference at the calf, and a swollen
prominences. If the legs appear asymmetric, extremity.
use a centimeter tape to measure in four ➔ A difference in measurement between legs
different areas: circumference at mid-thigh, may also be due to muscular atrophy.
largest circumference at the calf, smallest
circumference above the ankle, and across ● Palpate edema.
the forefoot. Compare both extremities at the ➔ Determine if it is pitting or nonpitting. Press the
same locations. edematous area with the tips of your fingers,
hold for a few seconds, then release. If the
depression does not rapidly refill and the skin
remains indented on release, pitting edema is
present.
Normal findings Normal findings:
➔ No edema (pitting or nonpitting) present in the ➔ Toes, feet, and legs are equally warm
legs bilaterally.
Abnormal findings Abnormal findings:
➔ Pitting edema is associated with systemic ➔ Generalized coolness in one leg or change in
problems temperature from warm to cool as you move
➔ A 1+ to 4+ scale is used to grade the severity of down the leg suggests arterial insufficiency.
pitting edema, with 4+ being most severe. ➔ Increased warmth in the leg may be caused by
superficial thrombophlebitis resulting from a
secondary inflammation in the tissue around
the vein.

● Palpate the femoral pulses.

➔ Ask the client to bend the knee and move it
● Palpate bilaterally for temperature of the feet and out to the side. Press deeply and slowly below
legs. and medial to the inguinal ligament. Use two
➔ Use the backs of your fingers. Compare hands if necessary. Release pressure until you
your findings in the same areas bilaterally. feel the pulse. Repeat palpation on the
Note location of any changes in opposite leg. Compare amplitude bilaterally
temperature.
Normal findings
➔ Femoral pulses strong and equal bilaterally. Abnormal findings
Abnormal findings ➔ Bruits over one or both femoral arteries suggest
➔ Weak or absent femoral pulses indicate partial partial obstruction of the vessel and diminished
or complete arterial occlusion. Blood flow to the lower extremities.
➔ Although normal popliteal arteries may be
● Auscultate the femoral pulses. nonpalpable, an absent pulse may also be the
➔ If arterial occlusion is suspected in the result of an occluded artery.
femoral pulse, position the stethoscope
over the femoral artery and listen for ● Palpate the dorsalis pedis pulses.
bruits. Repeat for other artery. ➔ Dorsiflex the client's foot and apply light
pressure lateral to and along the side of the
extensor tendon of the big toe.
➔ The pulses of both feet may be assessed at the
same time to aid in making comparisons. Assess
amplitude bilaterally.

Normal findings
➔ No sounds auscultated over the femoral
arteries.
Normal findings ➔ Varicose veins may appear as distended,
➔ Dorsalis pedis pulses are bilaterally strong. nodular, bulging, and tortuous, depending on
Abnormal findings severity.
➔ A weak or absent pulse may indicate impaired ➔ Varicosities are common in the anterior lateral
arterial circulation. thigh and lower leg, the posterior lateral calf, or
anus (known as hemorrhoids).
● Inspect for varicosities and thrombophlebitis. ➔ Superficial vein thrombophlebitis is marked by
➔ Ask the client to stand because varicose veins redness, thickening, and tenderness along the
may not be visible when the client is supine vein.
and not as pronounced when the client is ➔ Aching or cramping may occur with walking.
sitting. As the client is standing, inspect for
superficial vein thrombophlebitis. Characteristics of Arterial and Venous Insufficiency
➔ To fully assess for a suspected phlebitis, lightly
palpate for tenderness. If superficial vein Arterial Insufficiency
thrombophlebitis is present, note redness or ● Pain:
discoloration on the skin surface over the vein. ➔ Intermittent claudication to sharp,
unrelenting,
Normal findings constant
➔ Veins are flat and barely seen under the ● Pulses:
surface of the skin. ➔ Diminished or
Abnormal findings absent
● Skin Characteristics:
➔ Dependent rubor
 ➔ Elevation pallor of foot ➔ Leg edema:
➔ Dry, shiny skin - Minimal unless extremity kept
➔ Cool-to-cold temperature in dependent position
➔ Loss of hair over toes and dorsum of constantly to relieve pain
foot
➔ Nails thickened and ridged Venous Insufficiency
● Pain:
● Ulcer Characteristics: ➔ Aching, cramping
➔ Location: ● Pulses:
- Tips of toes, toe webs, heel or ➔ Present but may be difficult to palpate
other pressure areas if through edema
confined to bed ● Skin Characteristics:
➔ Pain: ➔ Pigmentation in
- Very painful gaiter area (area
➔ Depth of ulcer: of medial and
- Deep, often involving joint lateral malleolus)
space ➔ Skin thickened and
➔ Shape: tough
- Circular ➔ May be
➔ Ulcer base: reddish-blue in
- Pale black to dry and color
gangrene ➔ Frequently associated with dermatitis
 ● Ulcer Characteristics: ● No skin ulceration
➔ Location: or pigmentation
- Medial malleolus or anterior
tibial area -
➔ Pain:
- If superficial, minimal pain; but
may be very painful
➔ Depth of ulcer:
- Superficial Shape: Irregular
border
➔ Ulcer base:
- Granulation tissue-beefy red to
yellow fibrinous in chronic Edema Associated with Chronic Venous Insufficiency
long-term ulcer ● Caused by obstruction or insufficiency of deep
➔ Leg edema: veins Pitting, documented as:
- Moderate to severe ➔ 1+= slight pitting
➔ 2+= deeper than 1+
Types of Peripheral Edema ➔ 3+ = noticeably deep pit; extremity
looks larger
Edema Associated with Lymphedema ➔ 4+= very deep pit; gross edema in
● Caused by abnormal or blocked lymph vessels extremity Usually unilateral; may be
● Nonpitting bilateral
● Usually bilateral; may be unilateral
 ➔ Skin ulceration and pigmentation may ➔ Often seen with unilateral localized
be present pain, achiness, edema, redness, and
warmth to touch
● Lymphedema
● Varicose veins

Abnormal Arterial Findings

● Necrotic great toes with blisters on toes and
foot
● Raynaud Disease
➔ Blanching of fingers on both hands

Abnormal Venous Findings

● Superficial thrombophlebitis