ASSESSMENT OF THE

PERIPHERAL VASCULAR SYSTEM

Prepared by:
Mrs. Robeanna M. Diesto, MN
To perform a thorough peripheral
vascular assessment, the nurse needs to
understand the structure and function of
the arteries and veins of the arms and
legs, the lymphatic system, and the
capillaries.
ARTERIES – blood vessels that carry
oxygenated, nutrient-rich blood from the
heart to the capillaries.

Each heartbeat forces blood through the

arterial vessels under high pressure,
creating a surge. This surge of blood is the
ARTERIAL PULSE.

Peripheral Arteries – major arteries of the

arms and legs.
Major Arteries of the Arm
1. Brachial artery- major artery that supplies the arm.
= Brachial pulse can be palpated medial to the
biceps tendon in and above the bend of the elbow.
2. Radial artery – extends down to the thumb side of
the arm
= Radial pulse- palpated on the lateral aspect of the
wrist.
3. Ulnar artery – extends down the little finger side of
the arm.
= Ulnar pulse-located on the medial aspect of the
wrist, is a deeper pulse and may not be easily
palpated.
Major Arteries of the leg:
1. Femoral artery-major supplier of blood to the legs.
= Femoral Pulse palpated just under the inguinal
ligament; it travels down the front of the thigh then
crosses to the back of the thigh and is referred to as
2. POPLITEAL ARTERY - divides below the knee into
anterior and posterior branches.
= Popliteal pulse can be palpated behind the knee.
3. Dorsalis pedis artery - The anterior branch of the
popliteal artery that descends down the top of the foot
 Dorsalis Pedis Pulse can
be palpated on the great
toe side of the top of the
foot.
4. Posterior tibial artery -
The posterior branch and
the Pulse can be palpated
behind the medial malleolus
of the ankle.
VEINS
 the blood vessels that carry

deoxygenated, nutrient depleted, waste-

laden blood from the tissues back to the
heart.
 The veins of the arms, upper trunk, head,

and neck carry blood to the superior vena

cava, where it passes into the right atrium.
 Blood from the lower trunk and legs drains

upward into the inferior vena cava.

 The venous system is a low-pressure system
 Blood in the veins is carried under much

lower pressure than in the arteries, thus the

walls are much thinner.
 Three types of veins:

1. Deep veins
2. Superficial veins
3. Perforator ( communicator) veins
= Two other major veins that are important to
assess—the internal and external jugular
veins
 The two deep veins in the leg:
 femoral vein in the upper thigh
 popliteal vein located behind

the knee
 The superficial veins: Great

and Small saphenous veins.

 Great saphenous vein - the

longest of all veins

 The perforator veins connect

the superficial veins with the

deep veins
 Three mechanisms of
venous function help to
propel blood back to the
heart.
1. Structure of the veins
Deep, superficial, and
perforator veins all contain
one way valves - permit
blood to pass through them
on the way to the heart and
prevent blood from
returning through them in
the opposite direction.
2. Muscular contraction
= Skeletal muscles contract with movement
and squeeze blood toward the heart through
the one-way valves.
3. The creation of a pressure gradient
through the act of breathing.
= Inspiration decreases intrathoracic
pressure while increasing abdominal
pressure, thus producing a pressure gradient.
VENOUS STASIS - if with problem with any of
the mechanism
RISK FACTORS:
1. Long periods of standing still, sitting, or
lying down.
= Lack of muscular activity causes blood to
pool in the legs, which, in turn, increases
pressure in the veins.
2. Varicose (tortuous and dilated) veins, which
increase venous pressure.
3. Damage to the vein wall
 CAPILLARIES
 Capillaries are 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.
 it ensures removal of excess fluid from the

interstitial spaces, delivery of O2 and removal

of CO2
LYMPHATIC SYSTEM
 an integral and complementary component

of the circulatory system,

 a complex vascular system composed of

lymphatic capillaries, lymphatic vessels, and

lymph nodes.
 LYMPHS - fluids and proteins absorbed

into the lymphatic vessels by the

microscopic lymphatic capillaries;
filtered in the
lymph nodes
Functions of the lymphatic system:
 Primary function: to drain excess fluid

and plasma proteins from bodily tissues

and return them to the venous system.
 a major part of the immune system

defending the body against

microorganisms.
 to absorb fats (lipids) from the small

intestine into the bloodstream.

The superficial lymph nodes of the
arms and legs:
1. Epitrochlear nodes: are located
approximately 3 cm above the elbow on
the inner (medial) aspect of the arm.
 These lymph nodes drain the lower arm

and hand.
2. Superficial inguinal nodes
consist of two groups:
A. Horizontal chain is located
on the anterior thigh just under
the inguinal ligament
B. Vertical chain is located
close to the great saphenous
vein.
 These nodes drain the legs,

external genitalia, and lower

abdomen and buttocks
LYMPH NODES
 HEALTH ASSESSMENT
 Collecting Subjective Data: The Nursing
Health History.
 Disorders of the peripheral vascular system

may develop gradually.

 Severe symptoms may not occur until there

is extensive damage.
 It is important for the nurse to ask about

personal and family history of vascular

disease.
History of Present Health Concern:
 Color, temperature, or texture changes in the skin.
• Cold, pale, clammy skin on the extremities and

thin, shiny skin with loss of hair, especially over the

lower legs  associated with Arterial insufficiency.
• Warm skin and brown pigmentation around the

ankles  associated with Venous insufficiency.

 Pain/cramping - Peripheral Arterial Disease

Pain with walking?

 Intermittent claudication- first symptom of PAD
 is characterized by weakness, cramping, aching,

fatigue, or frank pain located in the calves, thighs, or

buttocks but rarely in the feet with activity, relieved with
rest
 Leg veins – rope like, bulging or
contorted – Varicose veins

 Sores or open wounds on the legs.

Location/painful.
• Arterial Ulcers are usually painful and are
located on the toes, foot or lateral ankle.
= Venous ulcers are usually painless and
occur on the lower leg or medial ankle.

 Any swelling (edema) of legs or

feet. Any pain with swelling.
 Swollen glands or lymph nodes
Does it feel tender, soft, or hard?
 Enlarged lymph nodes may indicate a

local or systemic infection.

= Peripheral edema results from
obstruction of the lymphatic flow from
venous insufficiency .
 For male clients: change in your
usual sexual activity
 Erectile dysfunction (ED) may occur with

decreased blood flow or an occlusion of

the blood vessels such as aortoiliac
occlusion (Leriche’s syndrome).
Past Health History:
 Problems with circulation in the arms

and legs (blood clots, ulcers, coldness, hair

loss, numbness, swelling, or poor healing)
increases risk for occurrence.
 History of any heart or blood vessel

surgeries or treatments such as coronary

bypass grafting, repair of aneurysm, or vein
stripping alter the appearance of the skin
and underlying tissue
Family History
 History of diabetes, hypertension,

coronary heart disease, elevated

cholesterol or triglyceride levels.
= These tend to be hereditary and cause
damage to blood vessels.
Lifestyle and Health Practices
 Cigarette
smoking or use of other form
of tobacco. How much/how long?
= Smoking cigarettes (using other form of
tobacco) significantly increases risk for
chronic arterial insufficiency.
 Exercise

= Regular exercise improves peripheral

vascular circulation and decreases stress,
pulse rate and BP  thereby decreasing
the risk for developing peripheral vascular
disease.
 For female clients: Do you take oral or
transdermal (patch) contraceptives?
= Oral or transdermal contraceptives
increase the risk for thrombophlebitis,
Raynaud’s disease, hypertension, and
edema.
 experiencing any stress in your life at

this time?
= Stress increases the heart rate and blood
pressure, and can contribute to vascular
disease.
How have problems with your circulation
(i.e., peripheral vascular system) affected
ability to function?
= Discomfort or pain associated with chronic
arterial disease and the aching
heaviness associated with venous disease
may limit a client’s ability to stand
or walk for long periods thus may affect job
performance and the ability to care for a
home and family or participate in social
events.
 Do leg ulcers or varicose veins affect how
you feel about yourself?
= body image or feelings of self-worth may be
negatively influenced.
 Regularly take medications prescribed to

improve your circulation?

Drugs that inhibit platelet aggregation:
 Cilostazol (Pletal) or clopidogrel (Plavix) -

to increase blood flow.

 Aspirin also prolongs blood clotting - used to

reduce the risks associated with PVD.

 Pentoxifylline (Trental) - reduce blood
viscosity, improving blood flow to the tissues,
thus reducing tissue hypoxia and improving
symptoms
 Failure to take their medications regularly

are at risk for developing more extensive

peripheral vascular problems.
 Does the patient wear support hose to
treat varicose veins?
= Support stockings help to reduce venous
pooling and increase blood return to
the heart.
Collecting Objective Data:
Physical Examination
 To identify any signs or symptoms of

peripheral vascular disease including arterial

insufficiency, venous insufficiency or
lymphatic involvement.
 This is accomplished by performing an

assessment first of the arms then legs,

concentrating on skin color and temperature,
major pulse sites, and major groups of lymHP
nodes.
Preparing the Client
 Put on an examination gown and to sit upright

on an examination table.
 Make sure that the room is a comfortable

temperature and free from drafts - prevent

vasodilation or vasoconstriction
 Inform the client that it will be necessary to

inspect and palpate all four extremities and

groin will be exposed for palpation of the
inguinal lymph nodes as well as palpation and
auscultation of the femoral arteries.
 Explain that the client can sit for
examination of the arms but will need to lie
down for examination of the legs and groin,
and will need to follow your directions for
several special assessment techniques
toward the end of the examination.
 explain in detail what you are doing and

answer any questions the client may have-

ease anxiety
Equipment
• Centimeter tape
• Stethoscope
• Doppler ultrasound device
• Conductivity gel
• Tourniquet
• Gauze or tissue
• Waterproof pen
• Blood pressure cuff
 PHYSICAL ASSESSMENT
 Arms:
 Inspection
 Observe arm size and venous pattern; also look

for edema. Measure bilaterally the circumference of

the arms at the same locations.
 Normal : bilaterally symmetric with minimal variations

in size and shape.

No edema or prominent venous patterning.
 Abnormal : Lymphedema – results

blocked lymphatic circulation  as a

result of breast surgery
such as Mastectomy
CLINICAL TIP
 Mark locations on arms with a permanent

marker to ensure the exact same locations

are used with each reassessment.
 Observe coloration of the hands and arms.
 Normal: color varies depending on the

client’s skin tone, although color should be the

same bilaterally.
 Abnormal: Raynaud’s disease -

a vascular disorder caused by

vasoconstriction or vasospasm of the fingers
or toes
RAYNAUD’S DISEASE:
 characterized by: rapid changes of color
( pallor, cyanosis, and redness), swelling,
pain, numbness, tingling, burning,
throbbing, and coldness.
Palpation
 Palpate the client’s fingers, hands, and

arms, and note the temperature.

 Normal: skin is warm to touch bilaterally

from fingertips to upper arms.

 Abnormal: a cool extremity may be a

sign of arterial insufficiency.

Palpate to assess capillary refill time.
 Normal: capillary beds refill ( and color

returns) in 2 seconds or less.

 Abnormal: capillary refill time exceeding

2 seconds may indicate

vasoconstriction, decreased cardiac
output, shock, arterial occlusion, or
hypothermia.
 Palpate the radial pulse. Gently press the
radial artery against the radius.
 Normal: radial pulses are bilaterally strong

(3+).
 artery walls have a resilient quality

(bounce).
 Abnormal: increased radial pulse volume

indicates a hyperkinetic (4+ or bounding

pulse ).
 Palpate the ulnar pulses.
 Apply pressure with your first 3 fingertips to
the medial aspects of the inner wrists.
 Ulnar pulses- not routinely assessed-located

deeper than radial pulse – difficult to assess.

 Normal: NOT detectable
 Abnormal: lack of resilience or inelasticity

of artery wall indicate arteriosclerosis.

= Obliteration of the pulse -
result from compression by
external sources e.g
compartment syndrome.
 Palpate the brachial pulse for arterial
insufficiency.
 Normal: brachial pulses have equal

strength bilaterally.
 Abnormal: brachial pulses are

increased, diminished, or absent.

 Palpate the epitrochlear lymph nodes.
Take the client’s left hand in your right hand
as if you were shaking hands. Flex the client’s
elbow about 90 degrees. Use your left hand to
palpate behind the elbow in the groove
between the biceps and triceps muscles
Normal: NOT palpable
Abnormal: Enlarged epitrochlear lymph
nodes - infection in the hand or forearm, or
they may occur with generalized
lymphadenopathy.
 Enlarged lymph nodes may also occur

because of a lesion in the area

Perform the Allen test.
 To evaluates patency of the radial or ulnar

arteries.
 It is implemented when patency is

questionable or before such procedures

as a radial artery puncture.
 The test begins by assessing ulnar patency.
Have the client rest the hand palm side up
on the examination table and make a fist.
 Then use your thumbs to occlude the radial

and ulnar arteries

 Continue pressure to keep both arteries occluded
and have the client release the fist
 Note that the palm remains pale.
 Release the pressure on the ulnar artery and watch

for color to return to the hand.

 To assess radial patency, repeat the procedure as

before, but at the last step, release pressure on the

radial artery
Normal: Pink coloration returns to the
palms within 3–5 seconds if the ulnar artery
is patent., Pink coloration returns within 3–5
seconds
if the radial artery is patent.
Abnormal:
 With arterial insufficiency or occlusion of

the ulnar artery, pallor persists.

 With arterial insufficiency or occlusion of

the radial artery, pallor persists.

CLINICAL TIP
Opening the hand into exaggerated
extension may cause persistent pallor
(false-positive Allen’s test).
 Legs
 Inspection. Ask the client to lie supine and
drape the groin area place pillow under the head
for comfort. Observe skin color while inspecting
both legs from the toes to groin.
 Normal: pink color for lighter-skinned .pink or

red tones under darker-pigmented skin. No

changes in pigmentation.
 Abnormal: pallor when elevated and rubor when

dependent suggests arterial insufficiency.

 Dark-colored toes and blisters – arterial
insufficiency
Gangrene – evident with ulcerations that are
slow to heal, dry and shrivelled skin; color
changes from brown to black and eventually
sloughs off, cold and numb skin; pain may or
may not be present
Cyanosis – when legs are in
dependent position 
indicates venous insufficiency
 Inspect distribution of hair.
 Normal: hair covers the skin on the legs and

appears on the dorsal surface of the toes.

 Abnormal: loss of hair on the legs

suggests arterial insufficiency and withThin

shiny skin is noted.
 Inspect for lesions or ulcers .
 Normal: legs are free of lesions/ ulcerations.
 Abnormal: ulcers with smooth, even margins

that occur at pressure areas (toes and lateral

ankle) result from arterial insufficiency.
Inspect the legs for unilateral or bilateral
edema.
If the legs appear asymmetric, use a
centimeter tape to measure in four different
areas:
1. circumference at mid-thigh
2. largest circumference at the calf
3. smallest circumference above the ankle
4. across the forefoot.
 Compare both

extremities at the same

locations
 Normal: identical size and shape bilaterally;
no swelling or atrophy.
 Abnormal: bilateral edema may be detected

by the absence of visible veins, tendons, or

bony prominences.
 Palpate edema.
 If edema is noted during inspection, palpate

the area to 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: no edema (pitting or nonpitting)
present in the legs.
 Abnormal: Pitting edema- congestive heart

failure or hepatic cirrhosis, venous stasis

due to insufficiency or obstruction or
prolonged standing or sitting
(orthostatic edema).
Grading of Edema
 Palpate bilaterally for temperature of the
feet and legs. Use the backs of your
fingers.
 Normal: toes, feet, and legs are equally

warm bilaterally.
 Abnormal: Generalized coolness of leg

suggests arterial insufficiency.

• Increased warmth caused by superficial

thrombophlebitis.
Palpate the superficial inguinal lymph
nodes. First, expose the client’s inguinal
area, keeping the genitals draped. Feel over
the upper medial thigh for the vertical and
horizontal groups of superficial inguinal lymph
nodes.
 If detected, determine size, mobility, or

tenderness.
 Repeat on the opposite thigh.
Normal:
Nontender, movable lymph nodes up to 1 or
even 2 cm are commonly palpated.
Abnormal:
 Lymph nodes larger than 2 cm with or

without tenderness (lymphadenopathy)

may be from a local infection or generalized
lymphadenopathy.
 Fixed nodes may indicate malignancy
 Palpate femoral pulses.
 Normal: femoral pulses strong and equal

bilaterally.
 Abnormal: weak or absent femoral pulses

– partial or complete arterial occlusion.

 Auscultate femoral pulses . If arterial
occlusion is suspected in the femoral pulse
position stet over femoral artery and listen
for bruits.
 Normal: no sounds auscultated over

femoral arteries.
 Abnormal: Bruits- suggest partial

obstruction of the vessel and diminished

blood flow to
lower extremities.
 Palpate 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
 Palpate popliteal pulses.
 Normal: it is not unusual for the

popliteal pulse to be difficult to detect.

 Abnormal: an absent pulse result of

an occluded artery.
Palpate 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.
assessed at the same time to aid in
making comparisons.
Assess amplitude
bilaterally
 Palpate dorsalis pedis pulses.
 Normal: dorsalis pedis pulses are

bilaterally strong.
 Abnormal: weak or absent pulse indicate

impaired 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
Assess amplitude bilaterally
Normal: strong bilaterally.
However, in about 15% of healthy clients, the
posterior tibial pulses are absent.
Abnormal: A weak or absent pulse indicates
partial or complete arterial occlusion.

IF with edema - Doppler UTZ to assess for

pulse
Pulses checked according to ranking

1. Radial
2. Carotid
3. Dorsalis pedis
4. Femoral
5. Posterior tibial
6. Popliteal
Inspect for varicosities and
thrombophlebitis. Ask the client to stand -
varicose veins may not be visible when the
client is supine and not as pronounced when
the client is sitting.
As the client is standing, inspect for superficial
vein thrombophlebitis.
To fully assess for a suspected phlebitis, lightly
palpate for tenderness.
If superficial vein thrombophlebitis is present,
note redness or discoloration on the skin
surface over the vein
Normal: Veins are flat and bar
 Varicosities are common in the older client.

Abnormal:
 Varicose veins may appear as distended,

nodular, bulging, and tortuous, depending on

severity - result from incompetent valves in the
veins, weak vein walls, or an obstruction above
the varicosity.
common in the anterior lateral thigh and lower leg,
the posterior lateral calf, or anus
 Superficial vein thrombophlebitis is marked

by redness, thickening, and tenderness along

the vein
Manual compression test. to assess the
competence of the vein’s valves.
Ask the client to stand. Firmly compress the
lower portion of the varicose vein with one
hand. Place your other hand 6–8 inches
above your first hand. Feel for a
pulsation to your fingers in the upper hand.
Repeat this test in the
other leg if varicosities
are present.
Normal: No pulsation is palpated if the
client has competent valves.
Abnormal: a pulsation is palpated with
fingers if the valves in the veins are
incompetent.
TRENDELENBURG TEST- FOR CLIENT
WITH VARICOSE VEINS
 to determine the competence of the

saphenous vein valves and the retrograde

(backward) filling of the superficial veins.
 The client should
lie supine - Elevate
the client’s leg 90
degrees for about
15 seconds or until
the veins empty.
 With the leg

elevated, apply a
tourniquet to the
upper thigh.
 Assist the client to
a standing position
and observe for
venous filling.
 Remove the

tourniquet after 30
seconds, and
watch for sudden
filling of the
varicose veins
from above.
NORMAL: Saphenous vein fills from below
within 30 seconds
 If valves are competent - no rapid filling of the

varicose veins from above (retrograde filling)

after removal of tourniquet.
• ABNORMAL: Filling from above with the

tourniquet in place and the client standing --

incompetent valves in the saphenous vein.
 Rapid filling of the superficial varicose veins

from above after the tourniquet has been

removed also indicates retrograde filling past
incompetent valves
ARTERIAL INSUFFICIENCY
Pain: Intermittent claudication to sharp, unrelenting,
constant
Pulses: Diminished or absent
Skin Characteristics: Dependent rubor
• Elevation pallor of foot
• Dry, shiny skin
• Cool-to-cold temperature
• Loss of hair over toes and
dorsum of foot
• Nails thickened and ridged
VENOUS INSUFFICIENCY
Pain: Aching, cramping
Pulses: Present but may be difficult to palpate
through edema
Skin Characteristics:
• Pigmentation in gaiter area (area of medial and
lateral malleolus)
• Skin thickened and tough
• May be reddish-blue in
color
• Frequently associated
with dermatitis
EDEMA ASSOCIATED WITH LYMPHEDEMA
• Caused by abnormal or blocked lymph vessels
• Nonpitting
• Usually bilateral; may be unilateral
• No skin ulceration or pigmentation
EDEMA ASSOCIATED WITH CHRONIC
VENOUS INSUFFICIENCY
• Caused by obstruction or insufficiency of deep
veins
• Pitting, documented as:
1+ = slight pitting
2+ = deeper than 1+
3+ = noticeably deep pit; extremity looks larger
4+ = very deep pit; gross edema
in extremity
• Usually unilateral; may be bilateral
• Skin ulceration and
pigmentation may be present
 Validation & Documentation
 Analysis of Data/Nursing diagnoses
 Health promotion diagnoses
 Risk diagnoses
 Actual diagnoses
 Collaborative problems