PERIPHERAL VASCULAR ASSESSMENT

PURPOSE: to identify any signs or symptoms of peripheral vascular disease including arterial or venous insufficiency
and or lymphatic involvement.

SEQUENCE: assessment first of the arms then the legs, concentrating on skin color and temperature, major pulse
sites, and major group of lymph nodes.

ACTIONS FINDINGS
1. Gather equipment (gloves, tape measure, Gloves, tape measure and stethoscope
stethoscope, DUS & conductivity gel (KY/water
soluble lubricant), gauze or tissue and
tourniquet, pen and BP cuff)
2. Ask client to put on a gown. And sit upright on Done
an examination table. Make sure the room is a
comfortable temperature. This helps to prevent
vasodilation or vasoconstriction. Before you
begin the assessment, inform the client that it
will be necessary to inspect and palpate all four
extremities and that the groin will also need to
be exposed for palpation of the inguinal lymph
nodes and palpation and auscultation of the
femoral arteries.
Assess Arms
1. Inspect bilaterally for size, presence of edema, Arms are symmetric bilaterally, no edema or prominent
and venous patterning. venous pattering detected
2. Inspect bilaterally for skin color. Skin color same bilaterally
3. Inspect figertips for clubbing. No clubbing present in fingertips
4. Palpate fingers, hands, and arms for Skin warm and moist bilaterally from fingertips through
temperature, using dorsal surface of your arms
fingers.
5. Determine capillary refill time. Compress the Capillary refill less than 2 seconds bilaterally
nailbed until it blanches. Release the pressure
and calculate the time it takes for color to
return.this test indicates peripheral perfusion
and reflects cardiac output.
6. Palpate radial, ulnar, and brachial pulses. Radial and brachial pulses are 2+ bilaterally
Ulnar pulses not detectable
7. Palpate epitrochlear lymph nodes behind the Epitrochlear lymph nodes not palpable
elbow in the groove between the biceps and
triceps muscles.
8. Perform Allen test by occluding the radial and Pink color returns to hand in 4 seconds after
ulnar arteries and observing for palm pallor. compressing both the radial and ulnar arteries
Then, release the ulnar artery and watch for separately
color to return to hand.
Assess Legs
1. Inspect bilaterally for skin color (client in supine Skin is brown bilaterally without changes in
position) pigmentation
2. Inspect bilaterally for distribution of hair. Hair present over legs and dorsal surface of toes
3. Inspect for lesions or ulcers (note whether No lesions or ulcers detected
 margins are smooth and even, location such as
at pressure points, size, depth, drainage, odor)
4. Inspect for edema, unilateral or bilateral (if No edema present
calves are asymmetric, measure calf
circumference).
5. If client has edema, determine whether it is No edema present
pitting or nonpitting. If client has pitting edema,
rate on a 1+ to 4+ scale.
6. Palpate skin temperature (cool, warm, hot). Skin is warm and dry bilaterally
Use dorsal surface of hands.
7. Palpate the superficial inguinal lymph nodes Nontender, movable lymph nodes
while keeping the genitals draped. If detected,
note size, mobility, or tenderness.
8. Palpate and auscultate femoral pulses over Femoral arteries strong and equal bilaterally; no bruits
artery. Listen for bruits. auscultated
9. Palpate popliteal, dorsalis pedis, and posterior Unable to detect popliteal pulses Dorsalis pedis and
tibial pulses. posterior tibial pulses strong and equal bilaterally
10. Inspect for varicosities and thrombophlebitis by Varicosities and thrombophlebitis not detected
asking client to stand
11. Perform position change test for arterial Pink skin color returns to tips of toes in 8 seconds and
insufficiency while client is in the supine to top of feet in 12 seconds
position by placing hands under both of the
client’s ankles. Raise legs 30-48 cm (12 in)
above heart level, and ask client to pump feet
up and down for 1 minute. Have client sit up
and dangle legs. Note color of the feet. Time
the interval for color to return.
12. Place patient in a comfortable position Done
13. Document and relay findings to the client Done
14. After care. Done
15. Make necessary referrals Client does not need referrals