St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

COLLEGE OF NURSING

Peripheral Vascular Assessment

Learning Objectives
1. Discuss risk factors for PVD with the client.
2. Accurately inspect arms and legs for edema and venous patterning.
3. Observe carefully for signs of arterial and venous insufficiency.
4. Recognize characteristic clubbing.
5. Palpate pulse points correctly.
6. Use the Doppler ultrasound instrument correctly.

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

Procedure
ASSESSING THE PERIPHERAL VASCULAR
EVIDENCED TO BE PRODUCED RATIONALE
1. Introduce self to the patient Enhanced cooperation
2. Explain what you are going to do, why
it is necessary and how he/she can
cooperate
3. Identify client using the patient To identify correct patient
identifiers
4. Wash hands and observe appropriate To prevent transfer of microorganisms
infection control measures
5. Provide client privacy To provide comfort and safety
6. Inspect for clinical signs suggestive of
underlying pathology (e.g. missing
limbs/digits, scars)
7. Inspect and compare the upper limbs
8. Assess and compare the temperature A cool extremity may be a sign of arterial
of the upper limbs insufficiency. Cold fingers and hands are
common findings with Raynaud’s
9. Assess the capillary refill time of the Capillary refill time exceeding 2 seconds may
upper limbs indicate vasoconstriction, decreased cardiac
output, shock, arterial occlusion or
hypothermia
10. Palpate the radial pulse Increased radial pulse volume indicates a
hyper kinetic state (3+or bounding pulse).
Diminished (1+) or absent (0) pulse suggest
partial or complete arterial occlusion.
11. Assess for radio-radial delay
12. Palpate the brachial pulse Brachial pulses are increased, diminished or
absent
13. Perform the Allen test With arterial insufficiency or occlusion of the
ulnar artery, pallor persist.
14. Offer to measure the patient’s blood
pressure
15. Auscultate the carotid artery
16. Palpate the carotid pulse
17. Inspect the abdomen for visible
pulsations
18. Palpate the aorta
19. Auscultate the aorta and renal arteries
20. Inspect and compare the lower limbs
21. Assess and compare the temperature Generalized coolness in one leg or change in
of the lower limbs temperature from warm to cool as you move
down the leg suggest arterial insufficiency
22. Assess the capillary refill time of the
lower limbs
23. Palpate the femoral pulse Weak or absent femoral pulse indicate partial
or complete arterial occlusion
24. Assess for radio-femoral delay
25. Auscultate over the femoral pulse
26. Palpate the popliteal pulse
27. Palpate the posterior tibial pulse
28. Palpate the dorsalis pedis pulse A weak or absent pulse may indicate impaired
arterial circulation
29. Assess gross peripheral sensation
30. Observe the color of the limbs Marked pallor with legs elevated is an
indication of arterial insufiiency
 31. Sit the patient up and ask them to hang
their legs down over the side of the
bed
32. Explain that the examination is now
finish to the patient
33. Thank the patient for their time
34. Dispose of PPE appropriately and
wash your hands
35. Summarize your findings
Suggest further assessments and
investigations (e.g. blood pressure
measurement, cardiovascular examination,