HA RLE

• Assessment of the PERIPHERAL VASCULAR System

  1. Gather equipment

  2. Explain procedure to client

  3. Assist client to put on a gown
• Equipment


  • Gloves
  • Centimetre tape
  • Stethoscope
  • Doppler ultrasound probe
  • Tourniquet
• Arms


  • Bilaterally symmetric with minimal variation in size and shape
  • No edema or prominent venous pattern
• Skin color


  • Varies depending on client's skin tone
  • Color should be the same bilaterally
• Nail clubbing


  Proliferation of tissue under the nail causes the angle to increase to more than 160 degrees
• Possible causes of nail clubbing

  • Symptom of disease, like heart or lung disease which cause chronically low blood levels of oxygen
  • Family history of nail clubbing
  • Digestive conditions: Crohn's disease, Celiac disease
  • Liver disease: Liver cirrhosis
  • Cancers
  • Thyroid conditions: Hyperthyroidism and Grave's disease
• Skin temperature


  • Warm to touch bilaterally from fingertips to upper arms
• Capillary refill time


  Indicates peripheral perfusion and reflects cardiac output
• Capillary beds refill in 1 to 2 seconds or less
• Causes of prolonged capillary refill time

  • Shock
  • Dehydration
  • Dengue hemorrhagic fever
  • Hypothermia
  • Decreased peripheral perfusion
  • Peripheral artery disease
• Radial pulse


  • Equal strength bilaterally (2+)
  • Artery walls have a resilient quality (bounce)
• Ulnar pulse


  • Palpate if you suspect arterial insufficiency
• Brachial pulse


  • Equal strength bilaterally
• Epitrochlear lymph nodes


  Located approximately 3 cm above the elbow on the inner (medial) aspect of the arm
• Normally, epitrochlear lymph nodes are not palpable
• Swollen lymph nodes usually occur as a result of infection from bacteria or viruses
• Allen's test


  1. Occlude the radial and ulnar arteries and observe for palm pallor

  2. Release the ulnar artery and watch for color to return to hand
• Pink coloration returns to the palms within 3 to 5 seconds if the ulnar artery is patent
• Pink coloration returns within 3 to 5 seconds if the radial artery is patent
• Skin color of legs

  • For lighter-skinned clients - PINK color
  • For dark pigmented skin - PINK or RED
  • No changes in pigmentation
• Abnormal skin color of legs

  • Pallor - when elevated
  • Rubor - when dependent (arterial insufficiency)
  • Cyanosis - when dependent (venous insufficiency)
  • Rusty or brownish pigmentation - (venous insufficiency)
• Hair distribution on legs

  • Hair covers the skin on the legs and appears on the dorsal surface of the toes
  • Hair loss on the lower extremities occurs with aging and is not an absolute sign of arterial insufficiency in the older client
• Edema


  • Pitting edema - depression does not rapidly refill and the skin remains indented on release
  • Non-pitting edema - depression rapidly refills
• No edema (pitting or non-pitting) present in the legs is normal
• Skin temperature of legs


  • Toes, feet and legs are equally warm bilaterally
• Superficial inguinal lymph nodes

  • Non-tender, movable lymph nodes up to 1 or even 2 cm are commonly palpated
• Femoral pulse


  • Strong and equal bilaterally on palpation
  • No sounds auscultated over the femoral arteries
• Popliteal pulse


  • It is not unusual for the popliteal pulse to be difficult or impossible to detect, and yet for circulation to be normal
• Dorsalis pedis pulse


  • Bilaterally strong
  • This pulse is congenitally absent in 5% to 10% of the population
• Posterior tibial pulse


  • Should be strong bilaterally
  • However, in about 15% of healthy clients, the posterior tibial pulses are absent
• Varicose veins


  Swollen or inflamed veins due to increased blood pressure inside the veins
• Thrombophlebitis


  Swollen or inflamed vein due to a blood clot (surface of the skin)
• Veins are flat and barely seen under the surface of the skin, but varicosities are common in the older client
• Homan's sign


  Elicited by flexing the knee 5 degrees, placing hands under the calf muscle, and quickly squeezing the muscle against the tibia
• No pain or tenderness elicited with this maneuver is normal (Homan's sign is negative)
• Manual compression test for varicosities

  1. Firmly compress the lower portion of the varicose vein with one hand

  2. Place other hand 6 to 8 inches above and feel for pulsation
• No pulsation is palpated if the client has competent valves
• Trendelenburg test for varicosities

  1. Elevate leg 90 degrees for 15 seconds

  2. Apply tourniquet to upper thigh

  3. Assist client to standing position and observe for venous filling

  4. Remove tourniquet after 30 seconds and watch for sudden filling of the varicose veins from above
• Saphenous vein fills from below in 30 seconds if valves are competent, with no rapid filling of the varicose veins from above (retrograde filling) after removing the tourniquet
• Analysis of data


  1. Formulate nursing diagnoses (wellness, risk potential)

  2. Formulate collaborative problems

  3. Make necessary referrals