Assessment of Peripheral Vasculature

General approach

1. Explain to the patient what you are going to do.

2. Use a drape and uncover only those areas that are necessary as the assessment is done.

3. Position the patient in a supine or sitting position.

Collection of Subjective Data

Examination Normal Findings Abnormal Findings Pathophysiology
Inspection of Jugular Venous
Pressure
 Place the patient in a A JVP reading of less A JVP reading of more An elevated JVP can be due
supine position with head than 4 cm is than 4 cm to an increased right
and upper torso at 30 considered normal ventricular pressure,
degrees angle increased blood volume or an
 Measure the vertical obstruction to right
distance in centimeters ventricular pressure.
from the patient’s sternal Document as JVP is at
angle to the top of ___cm at a ___ degree
distended neck vein this will bed angle.
give you the JVP
 Knowing that the sternal
angle is roughly 5cm above
the right atrium, take the
JVP measurement and add
5cm to get an estimate of
CVP.
Inspection of Hepatojugular
reflux Normally, this pressure A rise of more than 1 cm A rise in JVP that occurs with
 Place the patient flat in bed, should not elicit any in JVP is abnormal this technique is suggestive
or elevated at 30 degree change in the jugular of right sided congestive
angle if the jugular veins veins heart failure or fluid
are visible. Remind patient overload. The heart simply
to breathe normally cannot accept the increase in
 Using a single or bimanual venous return.
deep palpation. Press firmly
on the RUQ for 30-60
seconds. Press on another
part of the abdomen if this
area is tender,
 Observe the neck for
elevation in JVP

Inspection and palpation of
peripheral perfusion
 Inspect bilaterally for size,
presence of edema, and
venous patterning
 Inspect bilaterally for skin
color
 Inspect fingertips for
clubbing
 Palpate fingers, hands, and
arms for temperature,
using dorsal surface of your
fingers
 Palpate radial, ulnar and
brachial pulses
No ulcerations should Venous ulceration are Ulcers are due to inadequate
be noted abnormal venous flow
Location: occurs at the
sides of the ankles
Ulcers, pain and
characteristics are due to
Characteristics: uneven inadequate arterial flow such
edges and ruddy as PVD (peripheral vascular
granulation of tissue; disease) and DM
thin, shiny skin that
lacks the support of Arterial ulcers of the toes, tip
subcutaneous tissue; of fingers or nose can be
disruption of hair caused by Raynaud’s
pattern, or hairlessness. disease.
 Pain: deep muscular Arteriolar spasm leads to
pain (decrease venous pallor and pain, followed by
flow) aching and cyanosis, with numbness and
cramping relieved by tingling and burning; rubor
elevation. also develops. Over time area
may develop an ulcer
Arterial ulcerations are
abnormal

Location: occurs at toes

or points of trauma on
the feet or the legs

Characteristics: well
defined edges, black or
necrotic tissue; a deep
pale base and lack of
bleeding

Pain: exceedingly
painful; claudication
related to chronic
arterial insufficiency, is
relieved by rest; pain at
rest is relieved by
dependency.

Inspection of epitrochlear node

The epitrochlear node drains Normally epitrochlear An enlarged epitrochlear An infection in the forearm or
lymph nodes from the ulnar node is not palpable node is abnormal hand can lead to a palpable
surface of the forearm and hand and tender epitrochlear node
and from the middle, ring, and
little fingers Malignancies can cause an
 Place the patient in a sitting enlarged, hard and non
position tender epitrochlear
 Support the patient’s hand
with your hand
 With the other hand, reach
behind the elbow and place
your finger pads in the
groove between the biceps
and the triceps muscles
 Palpate the epitrochlear
node for the size and
shape, consistency,
tenderness and mobility
Orthostatic Hypotension
 Check the blood Wide Orthostatic vital Orthostatic can occur
pressure in a supine discrepancies signs have been to patients who are
position. In this position,
regarding the considered positive hypovolemic, have a
the patient should be
flat for at least 5 orthostatic with a systolic or neurogenic problem,
minutes. Record the response. Many diastolic blood or are experiencing
blood pressure and the normal patients pressure decrease side effects from a
heart rate as the first set
of tilts
may have what of more than 10 prescribed medications
 Assist the patient to a has been mm/hg or a heart
sitting position with the considered as rate increase of
feet dangling. Wait 1 to positive tilts more than 20bpm
3 minutes. Retake the
blood pressure and consistent with
heart rate. This waiting hypovolemia
period allows time for even though they
the reflex mechanism to
are not
activate and ensure a
normal blood pressure. hypovolemic
Take and record the
blood pressure and
heart rate as the second
set of tilts. Also, ask the
patient about any
symptoms of weakness
or dizziness related to
position change. If the
patient becomes weak
or dizzy, assist the
patient back to a supine
position.
 Finally assist the patient
to a standing position.
Measure the blood
pressure and heart rate
again after 1 to 3
minutes. Again, ask the
patient about any
symptoms of weakness
or dizziness related to
position change. If the
patient becomes weak
or dizzy, assist the
patient back to supine
position.
Homan’s sign
A positive Homan’s sign is
present in less than 20% of all
DVT cases
 With the patient’s knee There should be no A positive Homan’s sign May indicate Deep Vein
slightly bent, sharply complaints of calf pain may be abnormal Thrombosis. Early detection
dorsiflex the patient’s when this is evaluated is essential
foot and ask the patient
if this maneuver elicit
pain in the calf
 Repeat this technique
with the other foot
Perform Color return and
venous filling time
Elevate the supine patient’s leg
approximately 12 inches above
heart level by placing hands
under both of the client’s ankle
for 1 minute

Have the client sit up and dangle

legs. Note color of feet. Time the
interval for color to return
 N: CR 10 seconds VFT 15
seconds
 A: delayed CR of 15-25
seconds or a VFT of 20-30
seconds (moderate
ischemia)
 A: delayed CR of 40 seconds
and more or VFT of 40
seconds indicate severe
ischemia

Pallor
 Instruct the patient to
raise extremities
 Note the time it takes
for pallor, or lack of
color, to develop
No pallor should Pallor that develops Pallor that develops quickly is
develop within 60 quickly in the indicative of arterial
seconds extremities when the insufficiency. The quicker the
extremities are lifted is pallor develops, the more
abnormal severe the disease

Allen’s Test
Is used to assess the patency of If the radial artery is If the color did not Atherosclerosis or thrombus
the radial and ulnar arteries. compressed, the blood return within 6 seconds, can cause either artery to be
Performed prior to radial artery flow through the ulnar obstruction may be not patent.
cannulation. artery should be present, this is a
If the radial artery becomes sufficient to maintain negative Allen’s test
occluded with a thrombus, the normal palm
continued viability depends on color,.
the collateral blood flow from This is positive
the ulnar artery
Allen’s test
 Ask the patient to make
a tight fist, if the patient
is unresponsive; raise
the arm above the heart
for several seconds to
force blood to leave the
hand.
 Apply direct pressure on
the radial and ulnar
arteries to obstruct
blood flow to the hand
as the patient opens and
closes the fist
 Instruct the patient to
open the hand, with the
radial artery remaining
compressed. If the
patient is unresponsive,
keep the arm above the
heart level
 Examine the palmar
surface of the hand for a
blush or pallor within 15
seconds
Orthostatic Hypotension- when an individual stands, blood pools in the lower part of the
body and the blood pressure falls transiently. However, in a healthy individual,
Baroreceptors located in the carotid sinus area sense the decrease in the blood pressure
and initiate reflex vasoconstriction and increase the heart rate.

These mechanisms bring the blood pressure back to normal. When this mechanism fails,
orthostatic hypotension may ensue.

When assessing for orthostatic hypotension, take the patient’s blood pressure and heart
rate with the patient in supine, sitting, and standing positions. This set of orthostatic vital
sign is commonly referred to as Tilts.