PERIPHERAL
VASCULAR
ASSESSMENT
Preparing the Client
1. Have the client wear an examination gown
and sit upright on an examination table.
2. Make sure the room has a comfortable
temperature without drafts.
3. Inform the client that it will be necessary to
inspect and palpate all four extremities and
the groin area.
Preparing the Client
4. Explain that the client can sit for
examination of the arms but will need to lie
down for examination of the legs and
groin.
5. Explain in detail what you are doing and
answer any questions the client may have.
Equipment
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Centimeter ruler
Stethoscope
Doppler ultrasound device
Conductivity gel
Tourniquet
Gauze or tissue
Waterproof pen
Blood pressure cuff
Physical
Assessment of
Upper Extremities
Inspection
Observe arm size, venous pattern, and
color; also look for edema.
Abnormal findings:
• Lymphedema
• Prominent venous pattern
• Raynaud’s disease
Palpation
• Palpate the client’s fingers, hands and
arms, and note the temperature.
Abnormal findings:
• Arterial insufficiency
• Raynaud’s disease
Palpation
• Assess capillary refill time.
Abnormal findings:
• Capillary refill time exceeding 2 seconds
Palpation
• Palpate the radial pulse.
Abnormal findings:
increased volume - hyperkinetic state
decreased or absent pulse
- partial or complete arterial occlusion
Buerger’s disease or scleroderma
Compartment syndrome
Buerger’s Disease
Scleroderma
Compartment
Syndrome
Palpation
Palpate the ulnar pulses.
Abnormal finding:
- non-elastic wall - arteriosclerosis
Palpate the brachial pulses if arterial
insufficiency is suspected.
Abnormal findings:
– Increased, diminished,
or absent
Palpation
Palpate the epitrochlear lymph nodes
(size, tenderness, consistency)
Abnormal findings:
• infection on the hand
or forearm / lesion
Palpation
Perform the Allen test
Abnormal findings:
- persistence of pallor for more than 5
seconds
- arterial insufficiency or occlusion of the
ulnar / radial artery
Physical
Assessment of
Lower Extremities
Inspection
• Observe skin color while inspecting
both legs from the toes to the groin
Abnormal findings:
• arterial insufficiency (pallor)
• venous insufficiency (cyanosis & brownish
pigmentation)
Inspection
• Inspect distribution of hair
– Abnormal findings:
• arterial insufficiency (Hair Loss)
Inspection
Inspect for lesions or ulcers
– Abnormal findings:
• arterial insufficiency (smooth, even margins
that occur at pressure areas)
• venous insufficiency (irregular edges,
bleeding and possible bacterial infection
that occur in the medial ankle)
Inspection
• Inspect for edema
– Abnormal findings:
• Bilateral and Unilateral edema
Palpation
• Palpate edema
– Abnormal findings:
• CHF or hepatic cirrhosis
Palpation
Palpate bilaterally for temperature of
the feet and legs
Abnormal findings:
• generalized coolness in one leg or change
in temperature from warm to cool as you
move down the leg
• increased warmth
Palpation
• Palpate the superficial inguinal lymph
nodes
– Abnormal findings:
• local infection
• Palpate the femoral pulses
– Abnormal findings:
• partial or complete arterial
occlusion
Palpation
• Auscultate the femoral pulses
– Abnormal findings:
• Bruit
Palpation
• Palpate the popliteal pulses
Palpation
• Palpate the dorsalis pedis pulses
Palpation
• Palpate the posterior tibial pulses
– Abnormal findings:
• partial or complete arterial occlusion
Inspection
• Inspect for varicosities and
thrombophlebitis
– Abnormal findings:
• Varicose veins
Palpation
• Check for Homan’s sign
– Abnormal findings:
• CHF or hepatic cirrhosis
Special Tests for
Arterial or Venous
Insufficiency
• Perform position change
arterial insufficiency
test
for
– Abnormal findings:
• pallor with legs elevated
• return of pink color that takes longer than 10
seconds and superficial veins that take
longer than 15 seconds to fill
• persistent rubor
• Use ankle-brachial pressure index
(ABPI)
– Abnormal findings:
• an ABPI of 0.5 to 0.95 indicates mild to
moderate arterial insufficiency
• an ABPI of 0.25 or lower indicates severe
stenosis
• Manual compression test
– Abnormal findings:
• you will feel a pulsation with your upper
fingers if the valves in the veins are
incompetent
• Trendelenburg test
– Abnormal findings:
• filling from above with the tourniquet in
place and the client standing
• rapid filling of the superficial varicose veins
from above after the tourniquet has been
removed
Documentation of Objective Data
• arms are equal in size, no swelling, pinkish skin
tone
• no clubbing of fingertips, warm bilaterally
• capillary refill time less than 2 seconds
• radial and brachial pulses strong bilaterally
• no epitrochlear lymph nodes palpated
• legs are pink from toes to groin bilaterally, normal
distribution of hair, no ulcers or edema
• legs are warm bilaterally
• 1-cm nontender inguinal lymph nodes palpated
• femoral, popliteal, dorsalis pedis, and posterior
tibial pulses strongly palpated bilaterally
• no apparent varicosities or superficial
thrombophlebitis
Nursing Diagnosis
Wellness Diagnoses
– Readiness
extremities
for
enhanced
circulation
to
– Health-Seeking Behavior. Requests information
on regular monitoring of pulse, blood pressure,
cholesterol and triglyceride levels. Regular
exercise, and smoking cessation
Nursing Diagnosis
Risk Diagnoses
– Risk for Ineffective
Management
Therapeutic
Regimen
– Risk for Infection
– Risk for Injury
– Risk for Impaired Skin Integrity
– Risk for Activity Intolerance
– Risk for Peripheral Neurovascular Dysfunction
Nursing Diagnosis
Actual Diagnoses
– Ineffective Tissue Perfusion
– Impaired Skin Integrity
– Pain
– Fear of loss of extremities
– Disturbed Body Image
END