Peripheral Vascular Assessment

• Components of the peripheral vascular system

  • Arteries
  • Veins
  • Lymphatic System
• Arteries


  • Carry oxygenated blood usually, and nutrients
  • Pulmonary arteries carry the oxygenated blood
  • High pressure system
  • Walls are strong, tough and elastic
  • Contains muscle fibers that constrict and dilate artery
  • Heart beat generates a pulse wave that carries throughout artery but only felt where arteries are more superficial and pass over bone
• Arteries in the Arm


  • Ulnar a.
  • Radial a.
  • Brachial a.
• Arteries in the Leg


  • Femoral a.
  • Popliteal a.
  • Posterior tibial a.
  • Dorsalis pedis a.
• Veins


  • Parallel course of arteries
  • Body has more veins than arteries, closer to surface
  • Carry deoxygenated blood and waste back to heart
  • Low pressure system - walls thinner and larger diameter
  • More distensible - expands to hold more blood when volume ↑ - ↓ stress on heart - capacitance vessels
  • No smooth muscle in vein wall - just stretchy
  • Mechanisms needed to keep blood moving
• Superficial Veins of the Right Upper Limb


  • Subclavian Vein
  • Axillary Vein
  • Cephalic Vein
  • Brachial Vein (with Brachial Artery)
  • Basilic Vein
  • Median Cephalic Vein
  • Median Basilic Vein
  • Radial Vein
  • Ulnar Vein
  • Median Vein
• Veins of the Hand


  • Cephalic Vein
  • Basilic Vein
  • Dorsal Metacarpal Veins
• Veins in the Legs


  • Inferior vena cava
  • Right common iliac vein
  • External iliac vein
  • Femoral vein
  • Great saphenous vein
  • Popliteal vein
  • Small saphenous vein
  • Anterior tibial vein
  • Dorsal venous arch
• Vein Anatomy


  • Tunica intima - lined with specialized squamous epithelium called ENDOTHELIUM that when damaged leads to clot formation
  • Tunica media - composed of connective tissues and smooth muscles that constricts and dilates NERVE VASORUM "nerve of the vessels"
  • Tunica externa - composed of connective tissues blending with surrounding connective tissues outside the vessel to hold vessels in position
• Characteristics of Arteries vs Veins

  • Direction of Flow: Arteries - Away from the heart, Veins - Towards the Heart
  • Oxygen Concentration: Arteries - High (Low in pulmonary arteries), Veins - Low (High in pulmonary veins)
  • Pressure: Arteries - High, Veins - Low
  • Lumen: Arteries - Narrow, Veins - Wide
  • Elasticity: Arteries - Highly Elastic, Veins - Limited elasticity
  • Appearance: Arteries - Rounded, Veins - Irregular/collapsed
  • Wall: Arteries - Thick, Veins - Thin
• Capillary


  • Supplies blood to tissues through PERFUSION
  • Site for gas exchange
  • Absorb oxygen and nutrients from blood
• Functions of the Lymphatic System


  • Conserve fluid and plasma proteins that leak out of capillaries
  • To form a major part of the immune system
  • Absorb lipids from the intestinal tract
• Blood flow through the body

  1. Plasma goes out of capillaries carrying oxygen and nutrient

  2. Tissues soak up oxygen and nutrients

  3. Waste products are produced and gathered by plasma to return to the body

  4. Some plasma are left on tissues due to carried waste product

  5. Lymphatic capillaries collect plasma

  6. Lymph

  7. Lymphatic vessels

  8. Lymphatic ducts (breast area)

  9. Right lymphatic duct and thoracic duct (merge into one - subclavian vein)

  10. Blood stream
• Characteristics of Pulses


  • Rate - Beats per minute (bpm)
  • Rhythm - Regularity of spacing of beats (Regular/Irregular)
  • Volume (lakas or hina) - Strength or intensity (Strong/Weak/Thready/Bounding)
• Pulse Rating Scale


  • 0 - Absent/Unable to detect
  • +1 - Thready/Weak - Difficult to palpate, obliterated by light pressure from finger
  • +2 - Strong/Normal - Easily found and obliterated by strong pressure from fingertips
  • +3 - Bounding/Full - Difficult to obliterate with fingertips
• Peripheral Vascular Assessment Methods


  • Inspection
  • Palpation
  • Auscultation
• Peripheral Cyanosis


  • Reduced blood flow
  • Low oxygen saturation the affected tissues
  • Poor perfusion
  • Increased levels of deoxygenated hemoglobin in the blood (too much color)
• Peripheral Pallor


  • Reduced blood flow
  • Low oxygen saturation in the affected tissues
  • Poor perfusion
  • Decreased levels of oxygenated hemoglobin in the blood
• Tar Staining


  • Smoking (tar comes from this)
  • Deposition of tar
  • Staining: fingers and nails
  • Associated with Peripheral Vascular Disease, Coronary Artery Disease, hypertension
• Gangrene


  • Inadequate perfusion
  • TISSUE DEATH!
• Raynaud's Phenomenon


  • White due to lack of blood flow
  • Blue due to lack of oxygen
  • Red when blood flow returns
• Buerger's Disease


  • Blood vessels become inflamed, swell and can become blocked with blood clots (thrombi)
• Normal Temperature


  Upper limbs should be symmetrically warm
• Abnormal Temperature


  Cool and pale limb is indicative of poor arterial perfusion
• Normal Capillary Refill Time


  Less than two seconds
• Abnormal Capillary Refill Time


  Greater than two seconds suggests poor peripheral perfusion
• Allen's Test


  1. Occlude radial and ulnar arteries while client makes a fist

  2. Continue occluding arteries while client releases fist

  3. Remove pressure on ulnar artery while observing color return to palm
• Pulse Locations


  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis
• Carotid Pulse


  • Location: between larynx and anterior border of sternocleidomastoid muscle
  • Auscultate using the BELL of the stethoscope first to rule out the presence of BRUIT (wooshing sound - airy)
  • Suggests underlying carotid stenosis (narrowing)
  • Dangerous: risk of dislodging a carotid plaque and causing an ischemic stroke
• Brachial Pulse


  • Position: upper arm is abducted, elbow is partially flexed and forearm is externally rotated
  • Support patient's right forearm with your left hand
  • Palpate then assess the volume and character
  • Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery
• Radial Pulse


  • Palpate using the tips of your index and middle fingers aligned longitudinally over the course of the artery
  • Assess rate and rhythm palpating for at least 5 cardiac cycles
• Femoral Pulse


  • Location: Midline of inguinal (gitna ng singit), halfway between the anterior superior iliac spine and the pubic symphysis
• Popliteal Pulse


  • Palpatted in the inferior region of the popliteal fossa
  • With the patient prone, ask them to relax their legs and place their thumbs on the tibial tuberosity
  • Passively flex the patient's knee to 30 degrees as you curl your fingers into the popliteal fossa
  • This will allow you to feel the pulse as you compress the popliteal artery against the tibia
  • This pulse is often difficult to palpate so don't pretend to feel it if you can't.
• Posterior Tibial Pulse


  • Located posterior to the medial malleolus of the tibia
  • Palpate the pulse to confirm its presence and then compare pulse strength between the feet
• Dorsalis Pedis Pulse


  • Located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones
  • Palpate to confirm presence and compare pulse strength between the feet
• Auscultation Locations


  • Angle of the jaw
  • Midcervical area
  • Base of neck
• Abdominal Auscultation


  • Ensure there is adequate exposure
  • Auscultation before palpation
  • If wearing shorts, waistband below pubis symphysis
  • Look for: obvious pulsation
  • Abdominal aorta: located in the midline of the epigastrium
• Aortic Bruits


  • Auscultate 1-2 cm superior to umbilicus (diaphragm of stet)
  • A bruit may be associated with an abdominal aortic aneurysm (swelling in the aorta - the artery that carries blood from the heart to the abdomen)
• Palpation of Abdomen


  1. Using both hands perform deep palpation just superior to the umbilicus in the midline

  2. Note the movement of your fingers

  3. In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta

  4. If your hands move outwards, it suggests the presence of an expansile mass (abdominal aortic aneurysm)

  5. This is a crude clinical test and further investigations would be required before a diagnosis of an abdominal aortic aneurysm was made.
• Lower Limb Assessment


  • Look for: Cyanosis, Pallor (Venous Guttering, Foot Elevated), Gangrene
  • Missing limbs, toes, fingers - Due to amputation secondary to critical ischemia
  • High-Blood Sugar - matagal magheal sugat
  • Scars - Indicate previous surgical procedure
  • Hair Loss - Associated with PVD due to chronic impairment of tissue perfusion
  • Paralysis - Critical limb ischemia can cause weakness and paralysis of limbs