Peripheral Vascular System

• Adult Physical Assessment


  Peripheral Vascular System
• Arteries


  • Blood vessels that carry oxygenated, nutrient rich blood from the heart to the capillaries
  • High-pressure system
  • Arterial pulse - the surge of blood as a result from a heartbeat which forces blood through the arterial vessels under high pressure
• Major Arteries of the Arm

  • Brachial artery - major artery that supplies the arm, palpated medial to the biceps tendon in and above the bend of the elbow, divides near the elbow to become the radial artery and the ulnar artery
  • Radial artery - palpated on the lateral aspect of the wrist
  • Ulnar artery - located on the medial aspect of the wrist, a deeper pulse, not easily palpated
• Major Arteries of the Leg

  • Femoral artery - major supplier of blood to the legs, pulse palpated under the inguinal ligament
  • Popliteal artery - pulse palpated behind the knee
  • Dorsalis pedis artery - pulse palpated on the great-toe side of the top of the foot
  • Posterior tibial artery - palpated behind the medial malleolus of the ankle

  
• Veins


  • Carry deoxygenated, nutrient depleted, waste-laden blood from the tissues back to the heart
  • Contain nearly 70% of the body's blood volume
  • Walls are much thinner, low-pressure system
  • 3 types: deep veins, superficial veins, and perforator (or communicator) veins
  • 3 mechanisms of venous function: structure of the veins, muscular contraction, and creation of a pressure gradient through the act of breathing
• Capillaries


  • Small blood vessels that form the connection between the arterioles and venules
  • Allow the circulatory system to maintain the vital equilibrium between the vascular and interstitial spaces
• Physical Examination


  1. Identify any signs or symptoms of PVD including arterial insufficiency, venous insufficiency, or lymphatic involvement

  2. Involves inspection, palpation, and auscultation

  3. Discuss risk factors for PVD with the client

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

  5. Observe carefully for signs of arterial and venous insufficiency and inadequate lymphatic drainage

  6. Recognize characteristic clubbing

  7. Palpate pulse points correctly

  8. Use the Doppler ultrasound instrument correctly
• Inspection of Arms


  • Observe coloration of the hands and arms
  • Normal findings: color varies depending on the client's skin tone, although color should be the same bilaterally
  • Abnormal findings: Raynaud disorder - a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color, swelling, pain, numbness, tingling, burning, throbbing, and coldness
• Palpation of Arms


  • Palpate the client's fingers, hands, and arms, and note the temperature
  • Normal findings: skin is warm to the touch bilaterally from fingertips to upper arms
  • Abnormal findings: a cool extremity may be a sign of arterial insufficiency, cold fingers and hands are common with Raynaud's
  • Assess capillary refill time - normal is 2 seconds or less, abnormal is exceeding 2 seconds indicating vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia
  • Palpate the radial pulse - normal is bilaterally strong (2+) with resilient artery walls, abnormal is increased (3+ or bounding) or diminished (1+) or absent (0) pulse suggesting partial or complete arterial occlusion
  • Palpate the ulnar pulses - normal is may not be detectable, abnormal is obliteration of the pulse from compression or lack of resilience indicating arteriosclerosis
  • Palpate the brachial pulses - normal is equal strength bilaterally, abnormal is increased, diminished, or absent
  • Perform the Allen test to evaluate patency of the radial or ulnar arteries - normal is pink coloration returns to the palms within 3-5 seconds, abnormal is persistent pallor indicating arterial insufficiency or occlusion
• Inspection, Palpation, and Auscultation of Legs

  • Observe skin color - normal is pink for lighter-skinned clients and pink or red tones visible under darker-pigmented skin, abnormal is pallor suggesting arterial insufficiency or cyanosis suggesting venous insufficiency
  • Inspect distribution of hair on legs - normal is hair covers the skin on the legs and appears on the dorsal surface of the toes, abnormal is loss of hair suggesting arterial insufficiency
  • Inspect for lesions or ulcers - normal is legs are free of lesions or ulcerations, abnormal are ulcers with smooth, even margins that occur at pressure areas
• Normal skin color findings

  • Pink color for lighter-skinned clients and pink or red tones visible under darker-pigmented skin. There should be no changes in pigmentation.
• Abnormal skin color findings

  • 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
• Normal hair distribution on legs

  • Hair covers the skin on the legs and appears on the dorsal surface of the toes.
• Abnormal hair distribution on legs

  • Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well.
• Normal leg findings


  • Legs are free of lesions or ulcerations.

  
• Abnormal leg findings


  • 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
• Inspect for edema


  Inspect the legs for unilateral or bilateral edema. Note veins, tendons, and bony prominences. If the legs appear asymmetric, use a centimeter tape to measure in four different areas: circumference at mid-thigh, largest circumference at the calf, smallest circumference above the ankle, and across the forefoot. Compare both extremities at the same locations.

  
• Normal edema findings


  • Identical size and shape bilaterally; no swelling or atrophy.
• Abnormal edema findings


  • May be detected by the absence of visible veins, tendons, or bony prominences
  • Bilateral edema usually indicates a systemic problem
  • 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
  • A difference in measurement between legs may also be due to muscular atrophy
• Palpate edema


  Determine if it is pitting or nonpitting. Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.
• Normal edema palpation findings


  • No edema (pitting or nonpitting) present in the legs.
• Abnormal edema palpation findings

  • Pitting edema is associated with systemic problems
  • A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe
• Palpate bilaterally for temperature of the feet and legs

  Use the backs of your fingers. Compare your findings in the same areas bilaterally. Note location of any changes in temperature.
• Normal temperature findings


  • Toes, feet, and legs are equally warm bilaterally.
• Abnormal temperature findings


  • 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
• Palpate the femoral pulses

  Ask the client to bend the knee and move it out to the side. Press deeply and slowly below and medial to the inguinal ligament. Use two hands if necessary. Release pressure until you feel the pulse. Repeat palpation on the opposite leg. Compare amplitude bilaterally
• Normal femoral pulse findings


  • Femoral pulses strong and equal bilaterally.
• Abnormal femoral pulse findings

  • Weak or absent femoral pulses indicate partial or complete arterial occlusion.
• Auscultate the femoral pulses

  If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits. Repeat for other artery.
• Normal femoral auscultation findings


  • No sounds auscultated over the femoral arteries.
• Abnormal femoral auscultation findings

  • Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremities.
• Palpate the popliteal pulses


  Ask the client to raise (flex) the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse. It is usually detected lateral to the medial tendon.
• Normal popliteal pulse findings

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


  • Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery.
• Palpate the dorsalis pedis pulses

  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 be assessed at the same time to aid in making comparisons. Assess amplitude bilaterally.
• Normal dorsalis pedis pulse findings

  • Dorsalis pedis pulses are bilaterally strong.
• Abnormal dorsalis pedis pulse findings

  • A weak or absent pulse may indicate impaired arterial circulation.
• Palpate the posterior tibial pulses


  Palpate behind and just below the medial malleolus (in the groove between the ankle and the Achilles tendon). Palpating both posterior tibial pulses at the same time aids in making comparisons. Assess amplitude bilaterally.
• Normal posterior tibial pulse findings

  • The posterior tibial pulses should be strong bilaterally.
• Abnormal posterior tibial pulse findings

  • A weak or absent pulse indicates partial or complete arterial occlusion.