PERIPHE

• Peripheral vascular assessment


  Evaluation of the blood vessels and circulation in the arms and legs
• Equipment for peripheral vascular assessment


  • Centimeter tape
  • Stethoscope
  • Doppler ultrasound device
  • Conductivity gel
  • Tourniquet
  • Gauze or tissue
  • Waterproof pen
  • Blood pressure cuff
• Physical examination


  1. Discuss risk factors for PVD with the client

  2. Accurately inspect arms and legs for edema and venous patterning

  3. Observe for signs of arterial and venous insufficiency

  4. Recognize characteristic clubbing

  5. Palpate pulse points correctly

  6. Use the Doppler ultrasound instrument correctly
• Arms


  • Observe arm size and venous pattern; also look for edema
  • Measure bilaterally the circumference of the arms at the same locations
  • Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning
  • Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and non-pitting edema. Prominent venous patterning with edema may indicate venous obstruction
• Hands and arms


  • Observe coloration of the hands and arms
  • Palpate the client's fingers, hands, and arms, and note the temperature
  • Skin is warm to the touch bilaterally from fingertips to upper arms
  • Capillary refill time exceeding 2 seconds may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia
• Radial pulse


  • Note elasticity and strength
  • Increased radial pulse volume indicates a hyperkinetic state (3+ or bounding pulse). Diminished (1+) or absent (0) pulse suggests partial or complete arterial occlusion (which is more common in the legs than the arms). The pulse could also be decreased from Buerger's disease or scleroderma
• Ulnar pulse


  • The ulnar pulses may not be detectable
  • Obliteration of the pulse may result from compression by external sources, as in compartment syndrome
  • Lack of resilience or inelasticity of the artery wall may indicate arteriosclerosis
• Allen test


  1. Assess ulnar patency

  2. Assess radial patency

  3. Pink coloration returns to the palms within 3–5 seconds if the ulnar artery is patent

  4. Pink coloration returns within 3–5 seconds if the radial artery is patent

  5. With arterial insufficiency or occlusion of the ulnar artery, pallor persists

  6. With arterial insufficiency or occlusion of the radial artery, pallor persists
• Legs


  • Inspect skin color
  • Inspect distribution of hair
  • Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency. Cyanosis when dependent suggests venous insufficiency. A rusty or brownish pigmentation around the ankles indicates venous insufficiency
  • Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well
• Leg lesions and ulcers


  • Legs are free of lesions or ulcerations
  • Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle result from venous insufficiency
• Leg edema


  • Identical size and shape bilaterally; no swelling or atrophy
  • Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as congestive heart failure, or a local problem, such as lymphedema (abnormal or blocked lymph vessels) or prolonged standing or sitting (orthostatic edema). Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema
• Palpating edema

  • No edema (pitting or non-pitting) present in the legs
  • Pitting edema is associated with systemic problems, such as congestive heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema). A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe
• Leg temperature


  • Toes, feet, and legs are equally warm bilaterally
  • Generalized coolness in one leg or change in temperature from warm to cool as you move down the leg suggests arterial insufficiency. Increased warmth in the leg may be caused by superficial thrombophlebitis resulting from a secondary inflammation in the tissue around the vein
• Femoral pulse

  • Femoral pulses strong and equal bilaterally
  • Weak or absent femoral pulses indicate partial or complete arterial occlusion
• Femoral artery auscultation


  • No sounds auscultated over the femoral arteries
  • Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremities
• Popliteal pulse


  • It is not unusual for the popliteal pulse to be difficult or impossible to detect, and yet for circulation to be normal
  • Although normal popliteal arteries may be non-palpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. Cyanosis may be present yet more subtle in darker-skinned clients
• Dorsalis pedis pulse


  • 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
• Partial obstruction of the vessel and diminished blood flow to the lower extremities


  • Suggested by abnormal palpation of femoral arteries
• Palpating popliteal pulses

  1. Raise (flex) the knee partially

  2. Place thumbs on knee, fingers in bend of knee

  3. Apply pressure to locate pulse

  4. Pulse usually detected lateral to medial tendon
• It is not unusual for the popliteal pulse to be difficult or impossible to detect, and yet for circulation to be normal
• Assessing significance of absent popliteal pulse


  1. Check for temperature changes

  2. Skin-color differences

  3. Edema

  4. Hair distribution variations

  5. Dependent rubor (dusky redness) distal to popliteal artery
• Cyanosis may be present yet more subtle in darker-skinned clients
• Palpating dorsalis pedis pulses


  1. Dorsiflex the client's foot

  2. Apply light pressure lateral to and along the side of the extensor tendon of the big toe
• Dorsalis pedis pulses are bilaterally strong. This pulse is congenitally absent in 5%–10% of the population
• Palpating posterior tibial pulses

  Palpate behind and just below the medial malleolus (in the groove between the ankle and the Achilles tendon)
• The posterior tibial pulses should be strong bilaterally. However, in about 15% of healthy clients, the posterior tibial pulses are absent
• Weak or absent pulse


  May indicate impaired arterial circulation
• Inspecting for varicosities and thrombophlebitis


  1. Ask client to stand

  2. Inspect for superficial vein thrombophlebitis

  3. Lightly palpate for tenderness
• Veins are flat and barely seen under the surface of the skin
• Varicose veins

  • Distended, nodular, bulging, and tortuous, depending on severity
  • Common in anterior lateral thigh and lower leg, posterior lateral calf, or anus (known as hemorrhoids)
  • Result from incompetent valves in the veins, weak vein walls, or an obstruction above the varicosity
  • Despite venous dilation, blood flow is decreased and venous pressure is increased
• Superficial vein thrombophlebitis

  • Marked by redness, thickening, and tenderness along the vein
  • Aching or cramping may occur with walking
  • Swelling and inflammation are often noted
• Performing position change test for arterial insufficiency


  1. Client supine, raise legs 12 inches above heart level

  2. Client pumps feet up and down for 1 minute to drain venous blood
• Feet pink to slightly pale in color in the light-skinned client with elevation. Inspect the soles in the dark-skinned client, although it is more difficult to see subtle color changes in darker skin
• When the client sits up and dangles the legs, a pinkish color returns to the tips of the toes in 10 seconds or less. The superficial veins on top of the feet fill in 15 seconds or less
• Marked pallor with legs elevated

  • Indication of arterial insufficiency
• Return of pink color that takes longer than 10 seconds and superficial veins that take longer than 15 seconds to fill

  • Suggest arterial insufficiency
• Persistent rubor (dusky redness) of toes and feet with legs dependent


  • Also suggests arterial insufficiency
• Normal responses with absent pulses suggest that an adequate collateral circulation has developed around an arterial occlusion
• Ankle-brachial index (ABI)


  • Also known as ankle-brachial pressure index (ABPI)
  • Calculated as SYSTOLIC ANKLE PRESSURE / SYSTOLIC BRACHIAL PRESSURE
  • Generally the ankle pressure in a healthy person is the same or slightly higher than the brachial pressure resulting in an ABI of approximately 1 or no arterial insufficiency
• Normal resting ABI


  • 1.0-1.4, meaning the client's ankle BP is equal or greater than the brachial arm pressure & there is no significant narrowing or blockage of blood flow