Peripheral Vascular System 1
ALLENTOWN COLLEGE OF ST. FRANCIS DE SALES
DEPARTMENT OF NURSING AND HEALTH
Nursing 201
Nursing Skills Laboratory Procedure: Assessment of the Peripheral Vascular System

ACTION
Inspect the arms, from the shoulders to the fingertips, by observing the client’s
arms from all angles
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NORMAL FINDINGS
Symmetry in size
Skin similar in color to
the rest of the body
Skin thin, smooth,
firm, and even
Nail surfaces normal
thickness and
unridged
Presence of a flat,
barely visible venous
pattern
Absence of edema
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Symmetry
Generalized warmth
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Return of normal color
to the nail bed in  1-2
seconds when
compression on the
nail bed is released
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Symmetry
Normal rate (60-100
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Palpate the arms, wrists, and hands for temperature, by 1) placing the dorsal
(back) surface of your fingers and hands against the client’s fingers, and 2)
moving the dorsal (back) surface of your fingers and hands up the skin of the
client’s fingers toward his/her shoulders
Test capillary refill of the fingernail beds of the right hand, by 1) squeezing each of
the client’s nail beds of his/her fingers between the pads of the thumb and index
finger of your right hand for 5 seconds, 2) observing the color of each of the
client’s nail beds of his/her fingers, 3) releasing the pressure on each of the
client’s nail beds of his/her fingers by the pads of the thumb and index finger of
your right hand, and 4) noting the time it takes for the color of the nail beds of the
client’s fingers to return to normal (Reverse to test capillary refill of the
fingernail beds of the left hand)
Palpate the radial pulse of the right arm, by 1) placing the pads of your index and
middle fingers on the flexor surface of the client’s right wrist laterally, and 2)
ABNORMAL FINDINGS
 Bilateral or unilateral
swelling or atrophy
 Skin pale upon
elevation
 Skin dusky red (rubor)
or cyanosic upon
dependency
 Skin very thin, shiny,
atrophic
 Nail surfaces
thickened and ridged
 Presence of
varicosities
 Presence of edema
 Asymmetry
 Generalized coolness
 Localized areas of
warmth or coolness
 Delay ( 2 seconds) or
absence of return of
normal color to the nail
bed when
compression on the
nail bed is released
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
Asymmetry
Bradycardia ( 60
Peripheral Vascular System 2
pressing the pads of your index and middle fingers lightly on the flexor surface of
the client’s right wrist laterally (Reverse to palpate the radial pulse of the left
arm)
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beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Palpate the ulnar pulse of the right arm, by 1) placing the pads of your index and
middle fingers on the flexor surface of the client’s right wrist medially, and 2)
pressing the pads of your index and middle fingers lightly on the flexor surface of
the client’s right wrist medially (Reverse to palpate the ulnar pulse of the left
arm)
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Symmetry
Normal rate (60-100
beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Palpate the brachial pulse of the right arm, by 1) standing directly in front of the
client, 2) placing the pads of your index and middle fingers just medial to the
biceps tendon in the client’s right antecubital space, and 3) pressing the pads of
your index and middle fingers just medial to the biceps tendon in the client’s right
antecubital space (Reverse to palpate the brachial pulse of the left arm)
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Symmetry
Normal rate (60-100
beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Perform the Allen test on the right arm, by 1) having the client rest his/her right
hand in his/her lap with the palm up, 2) placing the pad of the thumb of your left

Immediate return of
normal color to the

beats per minute
Tachycardia ( 100
beats per minute
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (O), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Asymmetry
Bradycardia ( 60
beats per minute)
Tachycardia ( 100
beats per minute)
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Asymmetry
Bradycardia ( 60
beats per minute)
Tachycardia ( 100
beats per minute)
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Delay or absence of
return of normal color
Peripheral Vascular System 3
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hand lightly over the radial artery of the client’s right hand, 3) placing the pad of
the thumb of your right hand lightly over the ulnar artery of the client’s right hand,
4) asking the client to clench his/her right fist tightly, 5) firmly compressing the
radial artery of the client’s right hand with the pad of the thumb of your left hand,
6) firmly compressing the ulnar artery of the client’s right hand with the pad of the
thumb of your right hand, 7) asking the client to open the fist of his/her right hand
into a relaxed, partly flexed position, 8) observing the color of the client’s right
palm (should be pale), 9) releasing the pressure of the pad of the thumb of your
right hand from the ulnar artery of the client’s right hand, and 10) observing the
color of the client’s right palm (should be pink) (Reverse to perform the Allen
test on the left arm)
Palpate the epitrochlear node of the right arm, by 1) asking the client to shake
your right hand with his/her right hand, 2) reaching around under the elbow of the
client’s right arm, and 3) placing the pads of the index and middle fingers of your
right hand lightly in the groove between the biceps and triceps muscles of the
client’s right arm about 3 centimeters (1 1/4 inches) above the medial epicondyle
of his/her right arm (Reverse to palpate the epitrochlear node of the left arm)
Inspect both legs, from the buttocks to the feet, by observing the client’s legs from
all angles
palm when
compression on the
ulnar artery is
released
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Usually nonpalpable
If palpable: small ( 1
centimeter) with
regular borders,
round, discrete,
mobile, soft,
nontender
Symmetry in size
Skin similar in color to
the rest of the body
Skin thin, smooth,
firm, and even
Nail surfaces normal
thickness and
unridged
Even distribution of
hair over the lower
legs, feet, ankles, and
toes
Absence of lesions,
ulcers
Presence of a flat,
barely visible venous
pattern
Absence of edema
to the palm when
compression on the
ulnar artery is
released
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Enlarged ( 1
centimeter) with
irregular borders
Confluent
Immobile
Hard, firm
Tenderness
Bilateral or unilateral
swelling or atrophy
Skin pale upon
elevation
Skin dusky red (rubor)
or cyanosic upon
dependency
Presence of brown
pigmentation around
the ankle
Skin very thin, shiny,
atrophic
Nail surfaces
thickened and ridged
Loss of hair over the
lower legs, feet,
ankles, and toes
Presence of ulcers
Peripheral Vascular System 4
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Palpate the legs, ankles, and feet for temperature, by 1) having the client lie down
on an examining table, 2) placing the dorsal (back) surface of your fingers and
hands against the client’s toes, and 3) moving the dorsal (back) surface of your
fingers and hands up from the client’s toes toward his/her hips
Test capillary refill of the toenail beds of the right foot, by 1) having the client lie
down on an examining table, 2) squeezing each of the client’s nail beds of his/her
toes between the pads of the thumb and index finger of your right hand for 5
seconds, 3) observing the color of each of the client’s nail beds of his/her toes, 4)
releasing the pressure on each of the client’s nail beds of his/her toes by the pads
of the thumb and index finger of your right hand, and 5) noting the time it takes for
the color of the nail beds of the client’s toes to return to normal (Reverse to test
capillary refill of the toenail beds of the left foot)
Palpate the superficial horizontal inguinal lymph nodes of the right leg, by 1)
having the client lie down on an examining table, 2) placing the pads of your index
and middle fingers over the client’s anterior superior iliac spine of his/her right leg,
and 3) moving the pads of your index and middle fingers from the client’s anterior
superior iliac spine across to his/her symphysis pubis (Reverse to palpate the
superficial horizontal inquinal lymph nodes of the left leg)
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
Symmetry
Generalized warmth

Return of normal color
to the nail bed in  1-2
seconds when
compression on the
nail bed is released
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
Usually nonpalpable
If palpable: small ( 1
centimeter) with
regular borders,
round, discrete,
mobile, soft,
nontender
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Palpate the superficial vertical inquinal lymph nodes of the right leg, by 1) having
the client lie down on an examining table, 2) placing the pads of your index and
middle fingers over the client’s symphysis pubis, and 3) moving the pads of your
index and middle fingers from the client’s symphysis pubis down his/her inner
thigh (Reverse to palpate the superficial vertical inquinal lymph nodes of the
left leg)
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Palpate the femoral pulse of the right leg, by 1) having the client lie down on an
examining table, 2) placing the pads of the index and middle fingers of your right

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Usually nonpalpable
If palpable: small ( 1
centimeter) with
regular borders,
round, discrete,
mobile, soft,
nontender
Symmetry
Normal rate (60-100
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over the tips of the
toes, metatarsal
heads, lateral malleoli,
points of trauma,
medial malleoli
Presence of
varicosities
Presence of edema
Asymmetry
Generalized coolness
Localized areas of
warmth or coolness
Delay ( 2 seconds) or
absence of return of
normal color to the nail
bed when
compression on the
nail bed is released
Enlarged ( 1
centimeter) with
irregular borders
Confluent
Immobile
Hard, firm
Tenderness
Enlarged ( 1
centimeter with
irregular borders
Confluent
Immobile
Hard, firm
Tenderness
Asymmetry
Bradycardia ( 60
Peripheral Vascular System 5
hand over the client’s inquinal ligament about midway between the anterior
superior iliac spine and the symphysis pubis, and 3) pressing the pads of the
index and middle fingers of your right hand deeply below the inquinal ligament
about midway between the anterior superior iliac spine and the symphysis pubis
(Reverse to palpate the femoral pulse of the left leg)
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beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Palpate the popliteal pulse of the right leg, by 1) having the client lie down on an
examining table, 2) asking the client to relax his/her right leg, 3) flexing the client’s
right leg 90° at his/her right knee, 4) placing the pads of the fingertips of both your
hands behind the client’s right knee so that they just meet in the midline of the
popliteal space behind the client’s right knee, and 5) pressing the pads of the
fingertips of both your hands deeply into the popliteal space behind the client’s
right knee (Reverse to palpate the popliteal pulse of the left leg)
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Symmetry
Normal rate (60-100
beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Palpate the dorsalis pedis pulse of the right leg, by 1) having the client lie down
on an examining table, 2) placing the pads of the index and middle fingers of your
right hand over the dorsum of the client’s right foot just lateral to the extensor
tendon of the client’s right great toe, and 3) pressing the pads of the index and
middle fingers of your right hand lightly over the dorsum of the client’s right foot
just lateral to the extensor tendon of the client’s right great toe (Reverse to
palpate the dorsalis pedis pulse of the left leg)
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Symmetry
Normal rate (60-100
beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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Palpate the posterior tibial pulse of the right leg, by 1) having the client lie down
on an examining table, 2) placing the pads of the index and middle fingers of your
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Symmetry
Normal rate (60-100
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beats per minute)
Tachycardia ( 100
beats per minute)
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Asymmetry
Bradycardia ( 60
beats per minute)
Tachycardia ( 100
beats per minute
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Asymmetry
Bradycardia ( 60
beats per minute)
Tachycardia ( 100
beats per minute)
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Asymmetry
Bradycardia ( 60
Peripheral Vascular System 6
right hand just behind and slightly below the medial malleolus of the client’s right
ankle, and 3) pressing the pads of the index and middle fingers of your right hand
lightly just behind and slightly below the medial malleolus of the client’s right ankle
(Reverse to palpate the posterior tibial pulse of the left leg)
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beats per minute)
Regular rhythm
Elastic arterial wall
Normal (2+) force
(amplitude)
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beats per minute)
Tachycardia ( 100
beats per minute)
Irregular rhythm
Thickened, hard, rigid,
beaded arterial wall
Absent (0), thready or
weak (1+), increased
(3+), or bounding (4+)
force (amplitude)
Mild (1+), moderate
(2+), deep (3+), very
deep (4+) pitting
edema
Palpate for pitting edema of the right foot, ankle, and leg, by 1) having the client
lie down on an examining table, 2) pressing the thumb of your right hand firmly for
5 seconds behind the medial malleolus of the client’s right ankle, over the dorsum
of the client’s right foot, and over the client’s right shin, 3) removing the thumb of
your right hand from over the dorsum of the client’s right foot, behind the medial
malleolus of the client’s right ankle, and over the client’s right shin, and 4)
observing for an indentation left in the skin over the dorsum of the client’s right
foot, behind the medial malleolus of the client’s right ankle, and over the client’s
right shin (Reverse to test for pitting edema of the left foot, ankle, and leg)
Test for Homan’s sign of the right calf, by 1) having the client lie down on an
examining table, 2) cupping the client’s heel and resting the sole of his/her foot on
your forearm, and 3) pressing up on the ball of the client’s right foot with your
forearm (Reverse to test for Homan’s sign of the left calf)
Palpate the right calf for signs/symptoms of deep phlebitis, by 1) having the client
lie down on an examining table, 2) asking the client to relax his/her right leg, 3)
flexing the client’s right leg 90 at his/her right knee, and 4) compressing the
client’s right calf muscles against his/her tibia with the pads of the fingertips of
your right hand (Reverse to palpate the left calf)
Inspect the saphenous system for varicosities, by 1) having the client stand, and
observing the clients legs from all angles
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Absence of edema
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Absence of pain
elicited upon
dorsiflexion of the foot
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Presence of pain
elicited upon
dorsiflexion of the foot
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Nontender
Soft
Absence of tension in
the calf muscles
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Tenderness
Firm
Presence of tension in
the calf muscles
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Perform the manual compression test, by 1) having the client stand, 2) placing
your left hand over the lower part of the client’s varicose vein in his/her leg, 3)
placing your right hand over the upper part (about 15-20 centimeters above the
lower part) of the client’s varicose vein in his/her leg, 4) firmly compressing the
upper part of the client’s varicose vein in his/her leg with your right hand, and 5)

Presence of a flat,
barely visible venous
pattern
Absence of a palpated
pulsation transmitted
beneath your lower
fingers
Presence of dilated,
tortuous veins with
thickened walls
Presence of a
palpated pulsation
transmitted beneath
your lower fingers
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Peripheral Vascular System 7
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palpating the lower part of the client’s varicose vein with your left hand for a
pulsation
Perform the retrograde filling (Trendelenburg) test of the right leg, by 1) having
the client to lie down on an examining table, 2) asking the client to elevate his/her
right leg at a 90 angle until the venous blood has drained from the great
saphenous vein in his/her right leg, 3) placing a tourniquet around the upper thigh
of the client’s right leg tightly enough to occlude the great saphenous vein but not
the femoral artery, 4) assisting the client to a standing position, 5) inspecting
venous filling of the client’s right leg, 6) releasing the tourniquet around the upper
thigh of the client’s right leg, and 7) inspecting venous filling of the client’s right
leg (Reverse to perform the retrograde filling (Trendelenburg) test of the left
leg)
Perform Buerger’s test, by 1) having the client lie down on an examining table, 2)
elevating both of the clients legs, ankles, and feet 30 centimeters (1 foot) above
the level of his/her heart for 60 seconds, 3) observing the skin color of the client’s
legs, ankles, and feet when elevated, 4) having the client sit up and dangle
his/her legs, ankles, and feet over the edge of the examining table, and 5) noting
the time it takes for the color of the client’s legs, ankles, and feet to return to
normal
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Slow filling (30-35
seconds) from below
of the superficial veins
while the tourniquet is
applied
Absence of sudden
additional filling of the
superficial veins after
the tourniquet is
released
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Pallor on elevation
Return of preelevation skin color in
 10 seconds after the
legs, ankles, and feet
are dangled
Filling of the veins of
legs, feet, and ankles
in 15 seconds after the
legs, ankles, and feet
are dangled
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GRADING PULSE FORCE (AMPLITUDE)
GRADE
O
1+
DESCRIPTION
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Absent; not discernible
Thready or weak; difficult to feel
Rapid filling ( 30-35
seconds) from below
of the superficial veins
while the tourniquet is
applied
Presence of sudden
additional filling from
above of the
superficial veins after
the tourniquet is
released
Marked pallor on
elevation
Return of preelevation skin color in
 10 seconds after the
legs, ankles, and feet
are dangled
Filling of the veins of
the legs, feet, and
ankles in  15
seconds after the legs,
ankles, and feet are
dangled
Dusky red (rubor) or
cyanosis of the feet
after the legs, ankles
and feet are dangled
Peripheral Vascular System 8
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2+
3+
4+
Normal; detected readily, obliterated by strong pressure
Increased
Bounding; difficult to obliterate
GRADING PITTING EDEMA
GRADE
1+
2+
3+
4+
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DESCRIPTION
Mild; 2 millimeter indentation, no perceptible swelling of the leg
Moderate; 4 millimeter indentation that subsides rapidly
Deep; 6 millimeter indentation that remains for a short time, leg looks swollen
Very deep; 8 millimeter indentation that lasts for a long time, leg looks very swollen
CHRONIC INSUFFICIENCY OF ARTERIES AND VEINS
Pain
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CHRONIC ARTERIAL INSUFFICIENCY
Intermittent claudication
Cramping
Worsens with elevation
Aggravated by walking
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CHRONIC VENOUS INSUFFICIENCY
Slow onset
Aching pain
Exercise improves pain
Better with elevation
Peripheral Vascular System 9
Pulses
Color
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Decreased or absent
Pale (especially upon elevation)
Dusky red (rubor) or cyanosis upon dependency
Temperature
Edema
Skin
Changes
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Cool
Absent or mild
Absence of hair over the lower legs, feet, ankles, and toes
Very thin, shiny, atrophic skin
Nails thickened and ridged
Ulceration
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Tips of the toes
Metatarsal heads
Lateral malleoli
Points of trauma
May develop
Reduced, tissue atrophy
Gangrene
Muscle Mass
NAME OF
PULSE
Normal
Absent
CHARACTERISTICS
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Regular, even in intensity
No palpable pulse, no waveform
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Nocturnal cramping
Pruritis
Paresthesias
Heaviness in the legs at the end of the day
Normal, through may be difficult to feel through edema
Normal
Dusky red (rubor) or cyanosis upon dependency
Often brown pigmentation around the ankles
Normal
Present, often marked
Often brown pigmentation around the ankles
Stasis dermatitis
Possible thickening of the skin
Possible narrowing of the leg as scarring develops
Medial malleoli
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
Does not develop
Unaffected
ARTERIAL WAVEFORM
PATTERN
CONTRIBUTING CONDITIONS
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Normal
Cardiac Arrest
Arterial line disconnected
Peripheral Vascular System 10
Weak/thready
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Force (amplitude) is 1+
Difficult to palpate
Need to search for it
May wax and wane
Force (amplitude) is 4+
Very easy to observe in arterial
locations near the surface of the skin
Very easy to palpate
Difficult to obliterate with pressure from
the fingertips
Has two strong systolic peaks with a
dip in between
Best detected in the carotid artery
Pulsus
alternans
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Alternating strong and weak pulses
Equal interval between each pulse
Pulsus
bigeminus
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Alternating strong and weak pulses
Weak pulse (premature beat) comes in
early after the strong pulse (normal
beat)
Force of premature beat is decreased
due to shortened cardiac filling time
Pulse beats have weaker amplitude
with inspiration and a stronger
amplitude with expiration
Bounding
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Biferiens
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Pulsus
parodoxus
Water-Hammer,
Corrigan’s
pulse
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Shock
Severe peripheral vascular disease

Hyperdynamic states such as seen
with hyperthyroidism, exercise, anxiety,
vasodilation seen in high cardiac output
syndromes
May be due to normal aging secondary
to arterial wall stiffening
Aortic regurgitation
Combination of aortic regurgitation and
stenosis
Hypertrophic obstructive
cardiomyopathy
Aortic regurgitation
Terminal left ventricular heart failure
Systemic hypertension
Regular bigeminal dysrhythmias such
as PVCs and PACs
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Pulse beats have greater than normal
force then collapses suddenly
Rapid systolic upstroke and no dicrotic
notch secondary to rapid
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Cardiac tamponade
Acute pulmonary embolus
Pericarditis
May be present in clients with chronic
lung disease
Hypovolemic shock
Pregnancy
Aortic regurgitation
Peripheral Vascular System 11
Unequal

Difference in the force (amplitude)
between right and left pulses
==========================
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Dissecting aneurysm (location of
aneurysm determines where the
difference in amplitude is felt