PERIPHERAL VASCULAR SYSTEM

Purpose and Interview

Purpose
Gather subjective and objective data.
Use collected data to help assess client's general health.
Differentiate expected from unexpected findings in physical assessment.
Interview Assessment Begin your assessment with a focused interview with the client.
Among the questions you might ask:
Describe your circulation.
Have you felt cold or hot?
Have you had numbness anywhere?
Have you noticed any redness, paleness, blueness, or brown discolorations of your arms or
legs?
Has it changed in the last 2 months or 2 years?
Do you have arm or leg pain?
What relieves the pain or makes it better or worse: Dangling? Rubbing? Walking?
Does the pain wake you up at night?
Describe the pain: is it cramping, burning, aching, and stabbing?
Was the pain sudden or gradual onset?
Any leg cramps? If yes, describe severity, characteristics, and duration. What makes the
cramps better or worse?
Any skin changes on your arms or legs? Discoloration, redness, or pale appearance?
Do you have any swelling in the arms or legs?
One arm or leg, or both arms or legs?
Does the swelling come and go or is it constant?
What makes it better or worse?
How long has this been going on?
Do you have any problems with swollen lymph nodes? Have there been recent changes?
Describe.
If there has been lymph node problems ask: Have there been any infections or pain with
your enlarged lymph nodes?
Have you or any member of your family ever had any vascular problems, heart or
respiratory problems, diabetes, or a history of smoking?
Equipment and Preparation
Equipment
Examination gown or dressed if peripheral vascular system is easily accessed
Stethoscope
Sphygmomanometer
Tourniquet
Preparation
Perform hand hygiene and adhere to standard precautions.
Knowledge of norms or expected findings is essential in determining the meaning of the
data as one proceeds.
Identify client and introduce self.
Explain each step of the procedure, including specific instructions about what is expected
of the client.

 Explain the purposes of each procedure and when and if discomfort will accompany any
procedure. Tell the client to inform you of any discomfort or difficulty at any point during the
assessment.
Providing an environment that is comfortable and private will reduce the client's anxiety.
Have the client don an examination gown for the assessment. The client may keep
undergarments on.
Ask the client to remove jewelry, such as watches or bracelets, if they interfere with
assessment. Socks or stockings should be removed.
Provide for client privacy.
Expected Findings
Blood Pressure normal: systolic less than 120 and diastolic less than 80.
The skin is warm and dry with a uniform oxygenated skin tone throughout.
The angle of the fingernail base at 160 degrees and without clubbing.
Capillary refill is brisk and less than 2 seconds.
All pulses are equal in rate, strength, and amplitude.
Axillary and distal lymph nodes are not palpable.
All distal extremities are without edema.
There is no evidence of stasis or circulatory compromise of the lower extremities.
The lower extremities are without varicosities.
Blood pressure normally does not vary more than 5 to 10 mm Hg in each arm. Pressures
are lower when taken in the supine position. The blood pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than that in the brachial artery.
When inspecting the neck for carotid pulsations, bilateral pulsations will be seen between
the trachea and sternocleidomastoid muscle.
While auscultating the carotid pulses, you should hear a very quiet sound. Expected heart
sounds could be transmitted to the neck, but there should be no swishing sounds.
The angle of the fingernail base should be about 160 degrees.
When observing for capillary refill in both hands, the area under pressure should turn pale.
Once pressure is released, the color should return in less than 2 seconds.
Arms should be nearly equal in size.
During the Allen test, when the client opens his hands while you are still compressing the
radial arteries, the palms should become pink immediately, indicating patent ulnar arteries.
Normally the epitrochlear lymph node in each arm is not palpable or is barely palpable.
On the legs, skin color should match the skin tone of the rest of the body.
Hair is normally present on the legs. If the hair has been removed, there is still usually hair
on the dorsal surface of the great toes. Hair growth should be symmetric. The skin should be
intact with no lesions.
Legs should be symmetric in size. If the legs are unequal in size, measure the
circumference of each leg at the widest point. It is important to measure each leg at the same
point.
The skin should be the same temperature on both legs.
Veins in the legs may appear as nodular bulges when the legs are in the dependent
position, but any bulges should disappear when the legs are elevated.
When performing the manual compression test, you will not feel any pulsation beneath
your lower fingers if the valves of the varicose vein are still competent.
When performing the Trendelenburg test, once a tourniquet has been placed around the
upper thigh and the client is standing, the saphenous vein should fill from below in about 30
to 35 seconds. Once the tourniquet is removed, note whether the varicose veins fill from
above. Competent valves prevent sudden retrograde filling.

 When testing for Homan's sign, sharply dorsiflexing the client's foot should not cause
pain.
If the inguinal lymph nodes can be palpated, they should be movable and not tender.
When testing for arterial supply to the lower extremities, once youve asked the client to
sit up and dangle the feet, the original color should return in about 10 seconds. The
superficial veins in the feet should fill in about 15 seconds. The feet of a dark-skinned person
may be difficult to evaluate, but the soles of the feet should reflect a change in color.
Toenails should be pink and not thickened. Clubbing should not be present.
Unexpected Findings
Blood Pressure pre-hypertension: systolic is 120 - 139 and diastolic is 80-89.
Allen Test
Perform the Allen test. If you suspect an obstruction or insufficiency of an artery in the arm,
the Allen test may determine the patency of the radial and ulnar arteries. The purpose of the
Allen test is to evaluate collateral circulation.
Ask the client to place the hands on the knees with palms up.
Compress the radial arteries of both wrists with your thumbs.
Ask the client to open and close the fist several times.
While you are still compressing the radial arteries, ask the client to open the hands.
Next, occlude the ulnar arteries and repeat the same procedure to test the patency
of the radial arteries.
Expected response is that the full color in the hand will return in 2 to 5 seconds.
Trendelenburg Test: When varicosities are present in the legs, use this test to evaluate
peripheral valve competence.
Assist client to a supine position.
Raise leg at 90-degree angle toward the ceiling. This permits the veins to empty.
Apply tourniquet at mid thigh position.
Assist client to stand, evaluate and compare legs for venous filling.
Expected response is slow filling of the saphenous veins (about 30 seconds). This
indicates competent valves. Rapid filling of the vein means incompetent valves and is
an unexpected finding.
Venous Status / Poor peripheral circulation
Prominent leg veins may be visualized.
Lower leg edema, possibly extending up the calf of the leg.
Skin appears shiny, atrophic, and possibly cyanotic.
Skin may appear brownish or pigmented.
The area is easily traumatized.
Stasis dermatitis and ulcer may be present.
Varicose Veins
Incompetent lower leg valves will permit venous blood reflux. This results in tortuous
dilated vessels that are commonly called varicose veins. The client often complains of leg or
foot cramps, aching, or heaviness in the calves.
Peripheral Edema
Check for edema of the legs.
Press the skin for at least 5 seconds over the tibia, behind the
malleolus, and over the dorsum of each foot.
Look for a depression in the skin caused by the pressure of your

medial
fingers.

 If edema is present, it should be graded on scale of 1+, mild, to 4+, severe.

Lymphedema
Removal of the lymph nodes secondary to a mastectomy or trauma
surgery may result in compromised lymphatic drainage of the distal
extremities. Stagnant lymphatic fluid in the forearm and hand may
lead to chronic inflammation, infection, and poor wound healing.
Arterial Deficiency
Assess for arterial supply to the lower legs and feet. If you suspect an
arterial deficiency, test for arterial supply to the lower extremities. Ask the
client to remain supine. Elevate the client's legs 12 inches above the heart.
Ask the client to move the feet up and down to drain the venous blood. The
skin will be blanched in color because only arterial blood is present. Now ask
the client to sit up and dangle the feet. Compare the color of both feet.

Considerations
Korotkoff Sounds When assessing the blood pressure, the American Heart Association
recommends using the fifth Korotkoff sound as the diastolic pressure in adults, and the fourth
Korotkoff sound as the diastolic pressure in children. In adults, if the fourth and fifth Korotkoff
are 10 mm Hg or greater apart, note all three readings.
Lifespan
Infants and Young Children
Approach
The approach and techniques used in examining the peripheral vascular system are the
same as for all other clients.
Findings
Blood pressure findings may be reviewed in the module on vital signs.
The infant may show mottling if left uncovered in a cool environment.
Pregnant Women
Approach
The approach and techniques used in examining the peripheral vascular system of the
pregnant woman are the same as for all other clients.
Findings
Blood pressure findings may be reviewed in the module on vital signs.
By the third trimester, there may some lower extremity edema. This should resolve after
resting in the supine position.
Varicose veins are also commonly seen by the third trimester.
Older Adults
Approach

 The approach and techniques used in examining the peripheral vascular system of the
older adult are the same as for all other clients.
Findings
Blood pressure findings may be reviewed in the module on vital signs.
The dorsalis pedis and posterior tibial pulses may be difficult to locate.
Arterial insufficiency resulting in thin shiny skin with loss of hair and thick ridged nails may
be an expected finding in the older adult.