1

Adventist University of the Philippines

College of Nursing
MNHA 510 – Advanced Health Assessment

Blood Vessels
Equipment’s: a marking pencil, centimeter ruler, tape measure, and stethoscope.

Physiological Examination Findings

Blood Vessels Inspection, Palpation and Auscultation
Measure, the jugular venous pressure (or JVP), using
tangential lighting and following five steps.

- Place the patient supine until the jugular veins - Patient was in supine position.
are engorged.

- Gradually raise the head of the bed until you - The head of the bead was
can see jugular vein pulsations between the raised. JVP was located.
angle of the jaw and the clavicle. If you have
trouble telling the jugular and carotid pulse
waves apart, apply gentle pressure over the
vein at the base of the neck above the clavicle.
This action easily eliminates the jugular pulse
wave but has no effect on the carotid.
- Did this step.
- Hold a ruler vertically at the midaxillary line at
nipple level.
- Did this step.
- Fourth, hold a second ruler horizontally at the
level of the jugular venous pulsation.
- The JVP is around 7cm H2O
- Note the point on the vertical ruler where the upon measurement.
horizontal ruler crosses it. This represents JVP
in centimeters of water.

Physiological Examination Findings

To help confirm the JVP, assess the hepatojugular
reflux in three steps.

- Press firmly on the abdomen in the mid - Performed this one.

epigastric region.

- Maintain your hand pressure while having the - Performed this step.
patient breathe normally.

- Observe the JVP throughout this procedure. - Had performed this step.
The JVP should rise for a few seconds when
your hand pressure is applied, and then fall to
the previous level when the pressure is
 2

released.

Using the bell of the stethoscope, auscultate for bruits No bruits noted on these areas.
over the temporal, carotid, subclavian, renal, iliac and
femoral arteries, as well as the abdominal aorta.

Using the pads of your second and third fingers,

palpate seven arterial pulses (carotid, brachial, radial,
femoral, popliteal, dorsalis pedis and posterior
tibialis). Note the following:

- Rate and rhythm - Rate was normal with 88bpm.

With regular rhythm.
- Amplitude (grade on a 0 to 4 scale) - 4 grade scale, bounding pulse

- Symmetry - Symmetrical pulse.

Physiological Examination Findings

If the patient has claudication, characterize the pain
and assess for seven other signs of arterial disease.
- Note pulse alterations, such as a weak, thread,
or absent pulse.
- Auscultate over the arteries for bruits.
The patient has no claudication.
All pulses are strong and bounding.
No bruits heard over arteries.
Absent of pallor or cyanosis on skin.
No any abnormalities or irregularities
on the skin.

- Feel for coolness in the affected area.

- Look for localized pallor and cyanosis.

- Assess for collapsed superficial veins, with

delayed venous filling.

- Check for thin, atrophied skin; muscle atrophy;

and hair loss.

- Inspect the skin for mottling, possibly with

ulceration, localized anesthesia, and
tenderness.

To determine the severity of arterial stenosis, measure No arterial stenosis noted. Capillary
the capillary refill time. Also, perform this three-step refill time 0-1sec.
procedure.

- Raise the supine patient’s leg and note the

degree of blanching.

- Have the patient sit up with the legs in a

dependent position.

- Note how long it takes for the color to return.

 3

Normally slight pallor occurs on elevation and

full color returns as soon as the leg becomes
dependent. If it takes much longer for the color
to return, suspect arterial insufficiency.

Physiological Examination Findings

If you suspect venous obstruction and insufficiency,
assess the extremities for four signs.

- Note any signs of thrombosis, such as redness, - No signs of thrombosis noted.

thickening, swelling, pain, or tenderness along
a vein.

- Check for Homan’s sign by flexing the - Negative Homan’s sign.

patient’s knee slightly and dorsiflexing the
foot.
- No presence of edema noted on
- Inspect and palpate the extremities for edema.
extremities.
Grade he severity of any edema from 1 to 4-
plus.
- No varicose veins assessed.
- Observe for varicose veins. If they are
suspected, have the patient stand on the toes
ten times in succession. If the venous system is
competent, the pressure in the veins will
disappear in a few seconds.