II.

OUTLINE OF PRESENTATION AND ASSIGNED STUDENTS:

I. INTRODUCTION - DelaCruz, Eau Haiana

II. REVIEW OF THE ANATOMY AND PHYSIOLOGY - Himaya, Angeli Flor

III. PREPARATION - Fernandez, Leslie

a. Preparation of the Client
b. Equipment

IV. PHYSICAL ASSESSMENT PROCEDURE - All Members

ARMS

Inspection

 Observe arm size and venous pattern; also look for edema - Floro, John Steven
 Observe Coloration Of The Hands And Arms- Floro, John Steven

Palpation

 Palpate the client’s fingers, hands, and arms, and note the temperature.- Uy,
Justin Braine

 Palpate to assess capillary refill time.- Uy, Justin Braine

 Palpate the radial pulse.- DelaCruz, Eau Haiana

 Palpate the ulnar pulses.- Bruno, Samantha

 You can also palpate the brachial pulses if you suspect arterial insufficiency.-
Floro, John Steven
 Palpate the epitrochlear lymph nodes.- Napoles, Shahany

 Perform the Allen test- Napoles, Shahany

LEGS

Inspection, Palpation, and Auscultation

 Observing skin color while inspecting both legs from the toes to the groin.-
Kamenza, Mando

 Inspect distribution of hair.- Kamenza, Mando

 Inspect for edema.- Argamosa, Jovia

 Palpate edema.- Argamosa, Jovia

 Palpate bilaterally for temperature of the feet and legs- Ramos, Jenny Rose

 Palpate the superficial inguinal lymph nodes- Ramos, Jenny Rose

 Palpate the femoral pulses- Ariola, Lyka Mie

 Auscultate the femoral pulses- Ariola, Lyka Mie

 Palpate the popliteal pulses- Fernandez, Leslie

 Palpate the dorsalis pedis pulses- Pahunar, Alexis Joy

 Palpate the posterior tibial pulses- Pahunar, Alexis Joy

 Inspect for varicosities and thrombophlebitis - Himaya, Angeli Flor

 Homans’ Sign- Saludares, Chessa Jane

SPECIAL TESTS FOR ARTERIAL OR VENOUS INSUFFICIENCY

 Perform position change test for arterial insufficiency - Himaya, Angeli Flor

 Determine ankle-brachial pressure index (ABPI), also known as AnkleBrachial

Index (ABI).- DelaCruz, Eau Haiana

 Manual compression test.- Bruno, Samantha

 Trendelenburg test.- Saludares, Chessa Jane

V. COMMON ABNORMALITIES

 Arterial Insufficiency - Floro, John Steven

 Venous Insufficiency - Uy, Justin Braine
 Edema Associated With Lymphedema - Napoles, Shahany
 Edema Associated With Chronic Venous Insufficiency - Argamosa, Jovia
III. INTRODUCTION

THE PERIPHERAL VASCULAR SYSTEM

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. Equally important is an understanding of
fluid exchange.

ARTERIES

Arteries are the blood vessels that carry oxygenated, nutrient-rich blood from
the heart to the capillaries. The arterial network is a high-pressure system. Blood is
propelled under pressure from the left ventricle of the heart. Because of this high
pressure, arterial walls must be thick and strong; the arterial walls also contain
elastic fibers so they can stretch.
Each heartbeat forces blood through the arterial vessels under high pressure,
creating a surge. This surge of blood is the arterial pulse. The pulse can be felt only
by lightly compressing a superficial artery against an underlying bone.
Many arteries are located in protected areas, far from the surface of the skin.
Therefore, the arteries discussed in this chapter include only major arteries of the
arms and legs—the peripheral arteries—that are accessible to examination.

Major Arteries of the Arm

 The brachial artery is the major artery that supplies the arm. The brachial
pulse can be palpated medial to the biceps tendon in and above the bend of
the elbow.
 The brachial artery divides near the elbow to become the radial artery
(extending down the thumb side of the arm) and the
  ulnar artery (extending down the little finger side of the arm

Major Arteries of the Leg

 The femoral artery is the major supplier of blood to the legs. Its pulse can be
palpated just under the inguinal ligament
 The popliteal artery divides below the knee into anterior and posterior
branches.
 The anterior branch descends down the top of the foot, where it becomes the
dorsalis pedis artery.
 The posterior branch is called the posterior tibial artery
VEINS

Veins are the blood vessels that carry deoxygenated, nutrientdepleted, 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 veins contain nearly 70% of the body’s blood volume. Because blood in the
veins is carried under much lower pressure than in the arteries, the vein walls are
much thinner.
Veins differ from arteries in that there is no force that propels forward blood flow;
the venous system is a low-pressure system. If there is a problem with any of these
mechanisms, venous return is impeded and venous stasis results.

Three Types of Veins:

1. Deep veins - these veins account for about 90% of venous return from the
lower extremities.
a. Femoral
b. Popliteal
2. Superficial veins
a. Great saphenous veins – the longest of all veins and extends from the
medial dorsal aspect of the foot, crosses over the medial malleolus,
and continues across the thigh to the medial aspect of the groin, where
it joins the femoral vein
b. Small saphenous veins - begins at the lateral dorsal aspect of the foot,
travels up behind the lateral malleolus on the back of the leg, and joins
the popliteal vein.
 3. Perforator (or communicator) veins - connect the superficial veins with the
deep veins

CAPILLARIES AND VENOUS EXCHANGE

Capillaries are small blood vessels that form the connection between the
arterioles and venules and allow the circulatory system to maintain the vital
equilibrium between the vascular and interstitial spaces.
Venous Exchange
Oxygen, water, and nutrients in the interstitial fluid are delivered by the arterial
vessels to the microscopic capillaries (Fig. 21-4). Hydrostatic force (generated by the
blood pressure) is the primary mechanism by which the interstitial fluid diffuses out of
the capillaries and enters the tissue space. The interstitial fluid releases the oxygen,
water, and nutrients and picks up waste products such as carbon dioxide and other
by-products of cellular metabolism. The fluid then reenters the capillaries by osmotic
pressure and is transported away from the tissues and interstitial spaces by venous
circulation.

THE LYMPHATIC SYSTEM

The lymphatic system, an integral and complementary component of the
circulatory system, is a complex vascular system composed of lymphatic capillaries,
lymphatic vessels, and lymph nodes. Its primary function is to drain excess fluid and
plasma proteins from bodily tissues and return them to the venous system.
The fluids and proteins absorbed into the lymphatic vessels by the
microscopic lymphatic capillaries become lymph. These capillaries join to form
larger vessels that pass through filters known as lymph nodes, where
microorganisms, foreign materials, dead blood cells, and abnormal cells are trapped
and destroyed.

The epitrochlear nodes and the superficial inguinal nodes:

1. Epitrochlear nodes - are located approximately 3 cm above the elbow on the

inner (medial) aspect of the arm.
2. Superficial inguinal nodes - consist of two groups. These nodes drain the
legs, external genitalia, and lower abdomen and buttocks
a. Horizontal Chain - the horizontal chain is located on the anterior thigh
just under the inguinal ligament
b. Vertical Chain - is located close to the great saphenous vein
IV. REVIEW OF THE ANATOMY AND PHYSIOLOGY

STRUCTURE FUNCTION

Artery Arteries transport oxygenated blood

throughout the body.

Temporal Artery The superficial temporal artery is a major

blood vessel located in the neck that
branches off from the external carotid
artery. Its function is to supply
oxygenated blood to the neck and head.

Carotid The carotid arteries are responsible for

supplying oxygen-rich blood to the organs
and tissues in the head and neck,
including the brain.

Aorta Is the primary artery that carries

oxygenated blood from the heart to all
other parts of the body.

Brachial Artery The brachial artery delivers blood to the

upper limbs.

Radial Artery The radial artery is responsible for

delivering oxygenated blood to the lower
arm and hand.

Ulnar Artery The ulnar artery transports oxygen-rich

blood to the forearms, wrists, hands, and
 fingers.

Femoral Artery The superficial femoral artery is essential

for supplying oxygenated blood to the
entire lower leg.

Popliteal Artery The popliteal artery provides blood supply

to the soleus, gastrocnemius, plantaris,
and distal portions of the hamstring
muscles.

Dorsalis Pedis Artery The dorsalis pedis artery is the main

source of blood supply to the foot.

Posterior Tibial Artery The posterior tibial artery is responsible

for supplying blood to the posterior crural
compartment.

Dorsal Arch The arch aids in the removal of oxygen-

depleted blood from the foot.

Veins Veins are a network of blood vessels

found throughout the body that gather
oxygen-poor blood and transport it back
to the heart.

Femoral Vein This vein gathers deoxygenated blood

from the lower leg's tissues and aids in its
transportation to the heart.

Popliteal Vein It directs blood flow away from the leg

and towards the femoral vein, which
 transports blood to the inferior vena cava
and back to the right atrium of the heart.

Saphenous Vein Similar to most other veins in the body,

saphenous veins carry deoxygenated
blood back to the heart.

Capillary They transport blood, nutrients and

oxygen to cells in your organs and body
systems.

Lymph Nodes Lymph nodes function by filtering

substances that pass through the
lymphatic fluid. These nodes contain
lymphocytes, which are white blood cells
that aid in the body's fight against
infection and disease.

Right Lymphatic Duct The right lymphatic duct collects lymph

from the right thorax, upper limb, head,
and neck.

Their function is to transport lymphatic

Thoracic Duct
fluid back into the circulatory system.

Subclavian Veins The subclavian vein is a type of deep vein

that transports oxygen-poor blood from
the upper body to the heart.

Epitrochlear Node The epitrochlear station is responsible for

collecting lymph from the medial part of
the hand and the last two or three fingers.
Superficial Inguinal Node The inguinal lymph nodes, including the
superficial inguinal node, play a vital role
in aiding the body's fight against
infections.

V..PREPARATION OF THE CLIENT

1) Request that the patient sit upright on an examination table while donning an
examination gown. - Ensure there are no drafts and that the room is a pleasant
72°F. Vasodilation or vasoconstriction is avoided as an outcome of this.

2) Before beginning the assessment, tell the client that you will need to inspect and
palpate all four limbs, as well as expose the groin for examining of the inguinal
lymph nodes and palpation and auscultation of the femoral arteries.

3) Explain that the client can sit for arm examinations but must lie down for leg and
groin examinations and must follow your directions throughout numerous special
evaluation procedures near the end of the examination.

4) As you conduct the examination, explain what you're doing in detail and answer
any questions the client may have. This alleviates any client anxiousness.

EQUIPMENT :
 Centimeter tape
 Stethoscope
 Doppler ultrasound device
 Conductivity gel
 Tourniquet
 Gauze or tissue
 Waterproof pen
 Blood pressure cuf
VI..PHYSICAL ASSESSMENT PROCEDURE

ARMS

Assessment Procedure Normal Findings Abnormal Findings

(Inspection) ● Arms are bilaterally ● Lymphedema

symmetric with results from
OBSERVE ARM SIZE minimal variation in blocked lymphatic
AND VENOUS PATTERN; size and shape. No circulation, which
ALSO LOOK FOR edema or prominent may be caused by
EDEMA. If there is an venous patterning. breast surgery. It
observable difference, usually affects one
measure bilaterally the extremity, causing
circumference of the arms induration and
at the same locations with nonpitting edema.
each re-measurement and Prominent venous
record findings in patterning with
centimeters. edema may
indicate venous
➤ Clinical Tip • Mark obstruction. See
locations on arms with a Assessment Tool
permanent marker to 21.2.
ensure the exact same
locations are used with
each reassessment.
(Inspection) ● Color varies ● Raynaud’s disease,
depending on the a vascular disorder
OBSERVE COLORATION client’s skin tone, caused by
OF THE HANDS AND although color vasoconstriction or
ARMS should be the same vasospasm of the
bilaterally fingers or toes, is
characterized by
rapid changes of
color (pallor,
cyanosis, and
redness), swelling,
pain, numbness,
tingling, burning,
throbbing, and
coldness. The
disorder commonly
occurs bilaterally;
symptoms last
 minutes to hours

Assessment Procedure Normal Findings Abnormal Findings

(Palpation) ● Skin is warm to the ● A cool extremity

touch bilaterally from may be a sign of
PALPATE THE CLIENT’S fingertips to upper arterial
FINGERS, HANDS, AND arms. insufficiency. Cold
ARMS, AND NOTE THE fingers and hands,
TEMPERATURE for example, are
common findings
with Raynaud’s
disease.

PALPATE TO ASSESS ● Capillary beds refill ● Capillary refill time

CAPILLARY REFILL (and, therefore, color exceeding 2
TIME. Compress the returns) in 2 seconds may
nailbed until it seconds or less. indicate
blanches.Release the vasoconstriction,
pressure and calculate the decreased cardiac
time it takes for the color to output, shock,
return. This test indicates arterial occlusion,
peripheral perfusion and or hypothermia.
reflects cardiac output

➤ Clinical Tip: Inaccurate

findings may result if the
room is cool, if the client
has edema, anemia, or if
the client recently smoked
a cigarette.

PALPATE THE RADIAL ● Radial pulses are ● Increased radial

PULSE bilaterally strong (3). pulse volume
Artery walls have a indicates a
Palpate the radial pulse. resilient quality hyperkinetic state
Gently press the radial (bounce). (4 or bounding
artery against the radius pulse). Diminished
(Fig. 21-9). Note elasticity (1 or 2) or absent
and strength. (0) pulse suggests
➤ Clinical Tip • For partial or complete
difficult-to-palpate arterial occlusion
pulses, use a Doppler (which is more
ultrasound device. common in the legs
(Spotlight Equipment ). than the arms). The
pulse could also be
decreased from
Buerger’s disease
or scleroderma.
See Assessment
Tool 21-1.

● Obliteration of the
 pulse may result
from compression
by external
sources, as in
compartment
syndrome.

PALPATE THE ULNAR ● The ulnar pulses ● Lack of resilience

PULSES . Apply pressure may not be or inelasticity of the
with your first three detectable. artery wall may
fingertips to the medial indicate
aspects of the inner wrists. arteriosclerosis.
The ulnar pulses are not
routinely assessed
because they are located
deeper than the radial
pulses and are difficult to
detect. Palpate the ulnar
arteries if you suspect
arterial insufficiency (Fig.
21-10).

PALPATE THE ● Brachial pulses have ● Brachial pulses are

BRACHIAL equal strength increased,
PULSES IF YOU bilaterally diminished, or
SUSPECT ARTERIAL absent.
INSUFFICIENCY. Do this
by placing the first three
fingertips of each hand at
the client’s right and left
medial antecubital
creases. Alternatively,
palpate the brachial pulse
in the groove between the
biceps and triceps

PALPATE THE ● Normally

● Enlarged lymph
EPITROCHLEAR LYMPH epitrochlear lymph
nodes: If the lymph
NODES. nodes are not
nodes in the elbow
Palpate the epitrochlear palpable
area are larger than
lymph nodes. Take the ● .Non-palpable lymph
normal, this may
client's left hand in your nodes: In some
indicate an infection
right hand as if you were people, the
or other
shaking hands. Flex the epitrochlear lymph
inflammatory
client's elbow about 90 nodes may not be
condition in the arm
degrees. Use your left palpable at all. This
or hand. Enlarged
hand to palpate behind the is considered a
lymph nodes may
elbow in the groove normal finding, and it
feel firm or rubbery,
between the biceps and does not indicate
and they may be
triceps muscles. IT nodes any health problems.
tender to the touch.
are detected, evaluate for ● Small, soft lymph
● Fixed lymph nodes:
size, tenderness, and nodes: In most
In some cases, the
consistency. Repeat people, the
lymph nodes in the
palpation on the opposite epitrochlear lymph
arm. nodes are small, elbow area may
soft, and movable. feel fixed or
They may be slightly immobile. This may
tender to the touch, indicate a more
but this is usually not serious condition,
a cause for concern. such as lymphoma
or metastatic
cancer.

● Pus or drainage: If
the lymph nodes in
the elbow area are
red, swollen, and
tender, and they
are draining pus or
other fluid, this may
indicate an infection
or abscess in the
arm or hand.

PERFORM THE ALLEN ● Pink coloration ● With arterial

TEST returns to the palms insufficiency or
The Allen test evaluates within 3 to 5 occlusion of the
patency of the radial or seconds if the ulnar ulnar artery, pallor
ulnar arteries. It is artery is patent. persists. With
implemented when arterial insufficiency
patency is questionable or ● Pink coloration or occlusion of the
before such procedures as returns within 3 to 5 radial artery, pallor
a radial artery puncture. seconds if the radial persists.
The test begins by artery is patent.
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 re-
mains pale. Release the
pressure on the ulnar
artery and watch for color
to return to the hand. To
assess radial patency, re-
peat the procedure as
before, but at the last step,
release pressure on the
radial artery.

Clinical Tip •
Opening the hand
into exaggerated
extension may
cause persistent
pallor (false-positive
Allen's test).
 LEGS

Assessment Procedure Normal Findings Abnormal Findings

(Inspection, Palpation, ● Pink color for ● Pallor, especially

and Auscultation) lighter-skinned when elevated, and
clients and pink or rubor, when
Ask the client to lie supine. red tones visible dependent,
Then drape the groin area under darker- suggests arterial
and place a pillow under pigmented skin. insufficiency.
the client’s head for There should be no ● Cyanosis when
comfort. OBSERVING changes in dependent
SKIN COLOR WHILE pigmentation. suggests venous
INSPECTING BOTH insufficiency.
LEGS FROM THE TOES ● A rusty or
TO THE GROIN brownish
pigmentation
around the ankles
indicates venous
 insufficiency.

INSPECT DISTRIBUTION ● Hair covers the ● Loss of hair on the

OF HAIR skin on the legs and legs suggests
appears on the arterial
dorsal surface of the insufficiency.
toes. ● Often thin, shiny
● Hair loss on the skin is noted as
lower extremities well.
occurs with aging
and is, therefore, not
an absolute sign of
arterial insufficiency
in the older client.

INSPECT FOR LESIONS ● Legs are free of  Ulcers with smooth,

OR ULCERS. lesions or even margins that
ulcerations. occur at pressure
areas, such as the
toes and lateral ankle,
result from arterial
insufficiency. Ulcers
with irregular edges,
bleeding, and possible
bacterial infection that
occur on the medial
ankle, result from
venous insufficiency

INSPECT FOR EDEMA ● Identical size and ● Bilateral edema

shape bilaterally; no may be detected by
● Inspect the legs for
swelling or atrophy the absence of
unilateral or bilateral
 edema. Note veins, visible veins,
tendons, and bony tendons, or bony
prominences. extremities. It
● If the legs appear usually indicates:
asymmetric, use a
centimetre tape to
 systemic problem-
measure in four
congestive heart
different areas:
failure
1) circumference at
 local problem -
midthigh
lymphedema -
2) largest
orthostatic edema
circumference at the
 Unilateral edema is
calf
characterized by a
3) smallest
1cm difference in
circumference above
measurement at the
the ankle
ankles, and 2cm
4) across the forefoot
difference at the calf,
and a swollen
● Compare both
extremity. It is usually
extremities at the
caused by venous
same locations.
stasis and
lymphedema.
 A difference in
measurement
between legs may
also be due to
muscular atrophy.

PALPATE EDEMA ● No edema (pitting or Pitting edema is

 nonpitting) present associated with:
● Palpate the area to
in the legs.
determine if it is > systemic problems
pitting or nonpitting.
- congestive heart
● Press the
failure
edematous area
with the tips of your - hepatic cirrhosis
fingers, hold for a
few seconds, then > local causes

release.
- venous stasis
● If the depression
does not rapidly - orthostatic edema
refill and the skin
● A 1+ to 4+ scale is
remains indented
used to grade the
on release, pitting
seerity of pitting
edema is present.
edema with 4+
being the most
severe.

PALPATE ● Toes, feet, and legs ● Generalized

BILATERALLY FOR are equally warm coolness in one leg
TEMPERATURE OF bilaterally. or change in
THE FEET AND LEGS.- temperature from
warm to cool as
● Use the backs of
you move down the
your fingers.
leg suggests
 ● Compare your arterial
findings in the same insufficiency.
areas bilaterally. ● Increased warmth
● Note location of any in the leg may be
changes in caused by
temperature. superficial
thrombophlebitis
resulting from a
secondary
inflammation in the
tissue around the
vein.

➤ Clinical Tip. Bilateral

coolness of the feet and
legs suggests one of the
following: The room is too
cool, the client may have
recently smoked a
cigarette, be anemic, or
the client is anxious. All of
these factors cause
vasoconstriction, resulting
in cool skin.

PALPATE THE ● Nontender

● Lymph nodes larger
SUPERFICIAL INGUINAL
than 2 cm with or
LYMPH ● Movable lymph
without tenderness
NODES - nodes up to 1 or
(lymphadenopathy)
even 2 cm are
may be from a local
● First, expose the commonly palpated.
infection or
client’s inguinal
generalized
area, keeping the
 genitals draped. lymphadenopathy.
● Fixed nodes may
● Feel over the upper indicate
medial thigh for the malignancy.
vertical and
horizontal groups of
superficial inguinal
lymph nodes. If
detected, determine
size, mobility, or
tenderness.

● Repeat palpation
on the opposite
thigh.

PALPATE THE
FEMORAL PULSES-
● Ask the client to ● Femoral pulses ● Weak or absent
bend the knee and strong and equal femoral pulses
move it out to the bilaterally. indicate partial or
side. complete arterial
● Press deeply and occlusion.
slowly below and
medial to the
inguinal ligament.
Use two hands if
necessary.
● Release pressure
until you feel the
pulse.
 ● Repeat palpation on
the opposite leg.
Compare amplitude
bilaterally.

AUSCULTATE THE
FEMORAL PULSES-
● If arterial occlusion ● No sounds ● Bruits over one or
is suspected in the auscultated over the both femoral
femoral pulse, femoral arteries arteries suggest
position the partial obstruction
stethoscope over of the vessel and
the femoral artery diminished blood
and listen for bruits. flow to the lower
Repeat for other extremities.
artery.
PALPATE THE ● A regular rhythm
POPLITEAL PULSES- it is and strong pulse
located behind the knee ● A pulse rate similar ● Absence of a pulse,
and can be felt by pressing to that of other which could
your fingers deeply into the peripheral pulses in indicate a blockage
crease behind the knee. the body in the artery
● Symmetry between supplying the lower
the two popliteal leg
Palpating the popliteal
pulses ● A weak or
pulse can be a bit more
diminished pulse,
challenging than other
which could
pulse points, but here are
indicate peripheral
the steps to follow:
artery disease
1. Have the person lie (PAD)
flat on their stomach ● Irregular rhythm or
or in a prone strength of the
position pulse, which could
2. Locate the popliteal indicate an
fossa, which is the aneurysm or
small indentation at arterial disease
the back of the
If you have concerns
knee.
about the presence or
3. With your fingers,
absence of a popliteal
press gently but
pulse, or if you notice any
firmly into the
changes in the strength or
popliteal fossa,
rhythm of the pulse, you
using the pads of
should consult a
your fingers, not
healthcare provider for
your fingertips.
further evaluation and
4. Move your fingers
treatment.
around until you feel
the pulsation of the
 artery.
5. Once you have
found the pulse,
note its rate,
rhythm, and
strength.

It's important to remember

that the popliteal pulse is
deeper than other pulses,
so you may need to apply
a bit more pressure to feel
it. Also, if you have trouble
finding the pulse, it may be
helpful to have the person
flex their foot to help you
feel it more easily.

PALPATE THE Dorsalis pedis pulses are

A weak or absent pulse
DORSALIS PEDIS bilaterally strong. This
may indicate impaired
PULSES pulse is congenitally absent
arterial circulation. Further
1. Dorsiflex the client’s foot in 5% to 10% of the
circulatory assessments
and apply light pressure population.
(temperature and color)
lateral to and along the
are warranted to
side of the extensor
determine the significance
tendon of the big toe.
of an absent pulse.
2. The pulses of both feet
may be assessed at the
same time to aid in making
comparisons.
3. Assess amplitude
bilaterally.

➤ Clinical Tip • It may be

difficult or impossible to
palpate a pulse in an
edematous foot. A Doppler
ultrasound device may be
useful in this situation.

PALPATE THE The posterior tibial pulses

A weak or absent pulse
POSTERIOR TIBIAL should be strong bilaterally.
indicates partial or
PULSES However, in about 15% of
complete arterial
1. Palpate behind and just healthy clients, the
occlusion.
below the medial malleolus posterior tibial pulses are
(in the groove between the absent.
ankle and the Achilles
tendon).
2. Palpating both posterior
tibial pulses at the same
time aids in making
comparisons.
3. Assess amplitude
bilaterally.

➤ Clinical Tip • Edema in

the ankles may make it
difficult or impossible to
palpate a posterior tibial
pulse. In this case,
Doppler ultrasound may be
used to assess the pulse.

INSPECT FOR
Veins are flat and barely Varicose veins may
VARICOSITIES AND
seen under the surface of appear as distended,
THROMBOPHLEBITIS-
the skin. nodular, bulging, and
Ask the client to stand tortuous, depending on
Varicosities are common in
because varicose veins severity. Varicosities are
the older client.
may not be visible when common in the anterior
the client is supine and lateral thigh and lower leg,
notas pronounced when the posterior lateral calf, or
the client is sit ting. As the anus (known as
client is standing, inspect hemorrhoids). Varicose
for superficial vein veins result from
thrombophlebitis. To fully incompetent valves in the
assess for a suspected veins, weak vein walls, or
phlebitis, palpate for an obstruction above the
tenderness. If superficial varicosity. Despite venous
vein thrombophlebitis is dilation, blood flow is
present, note redness or decreased and venous
discoloration on the skin pressure is increased.
surface over the vein. Superficial vein
thrombophlebitis is
marked by redness,
thickening, and
tenderness along the vein.
Aching or cramping may
occur

with walking or
dorsiflexion of the foot
(positive Homans’ sign).
Swelling and inflammation
are often noted

HOMANS’ SIGN
Calf pain and tenderness
Discomfort in the calf No pain or tenderness
elicited are a positive
muscles on forced elicited indicates a negative
Homan's sign. A positive
dorsiflexion of the foot with Homan's sign.
sifn may indicate deep
the knee straight has been
vien thrombosis (blood
a time-honored sign of
clot in deep vien) or
DVT.
 superficial
● The Homans Sign thrombophlebitis
test is performed (inflammation of a
with the patient in superficial vien). However,
supine position. further diagnostic testing
● The examiner lifts such as ultrasound of the
the affected leg and legs and referral ara
rapidly dorsiflexes indicated for a definitive
the patient’s foot diagnostic .
with the knee
extended.
● This maneuver is Notes:
repeated with the
patient’s knee Calf pain with the knee

flexed while the extended can also be

examiner caused by intervertebral

simultaneously disk disease (radicular

palpates the calf. symptoms) or muscle

contractures.

Obviously, injury to the

gastrocsoleus complex
may also be aggravated
by Homans test.

Special Tests for Arterial or Venous Insufficiency

Assessment Procedure Normal Procedure Abnormal Procedure

PERFORM POSITION
Feet pink to slightly pale in Marked pallor with legs
CHANGE TEST FOR
ARTERIAL color in the light-skinned elevated is an indication of
INSUFFICIENCY client with elevation. arterial insufficiency.
Inspect the soles in the Return of pink color that
If pulses in the legs are
dark-skinned client, takes longer than 10
weak, further assessment
although it is more difficult seconds and superficial
for arterial insufficiency is
to see subtle color changes veins that take longer than
warranted. The client
in darker skin. When the 15 seconds
should be in a supine
client sits up and dangles
position. Place both of to fill suggest arterial
the legs, a pinkish color
your hands under both of insufficiency.
returns to the tips of the
the client’s ankles. Raise
toes in 10 seconds or less. Persistent rubor (dusky
the legs about 12 inches
The superficial veins on top redness) of toes and feet
above the level of the
of the feet fill in 15 seconds with legs dependent also
heart. As you support the
or less. suggests arterial
client’s legs, ask the client
insufficiency.
to pump the feet up and Normal responses with
down for about a minute to absent pulses suggest that
drain the legs of venous an adequate collateral
blood, leaving only arterial circulation has developed
blood to color the legs. around an arterial
occlusion.
Then ask the client to sit
up and dangle legs off the
side of the examination
table.

Note the color of both feet

and the time it takes for
color to return.

➤ Clinical Tip • This

assessment maneuver
will not be accurate if the
client has peripheral
vascular disease

of the veins with

incompetent valves.

DETERMINE ANKLE- Generally the ankle ● In addition to the

BRACHIAL PRESSURE pressure in a healthy abnormal ABPI
INDEX (ABPI), ALSO person is the same findings, reduced or
KNOWN AS ANKLE or slightly higher absent pedal
BRACHIAL INDEX (ABI). than the brachial pulses, cool leg
If the client has symptoms pressure, resulting in unilaterally, lack of
of arterial occlusion, the an ABPI of hair, and shiny skin
ankle-brachial pressure approximately 1, or on the leg suggest
index should be used to no arterial peripheral arterial
compare the upper and insufficiency occlusive disease
lower limbs systolic blood (Holman, 2004). (Holman, 2004).
pressure. The Early recognition of
anklebrachial pressure cardiovascular
index (ABPI) is the ratio of disease may be
the ankle systolic blood determined using
pressure to the arm ABPI
(brachial) systolic blood measurements
pressure. See Table 21.1. (Pearson, 2007).
The ABPI is considered an
accurate objective
assessment for
determining the degree of
peripheral arterial disease.
It detects decreased
systolic pressure distal to
the area of stenosis or
arterial narrowing and
allows the nurse to
quantify this measurement.
Use the following steps to
measure ABPI: • Have the
client rest in a supine
position for at least 5
minutes. • Apply the blood
pressure (BP) cuff to first
one arm and then the
other to determine the
brachial pressure using the
Doppler. First palpate the
pulse and use the Doppler
to hear the pulse. The
“whooshing” sound
indicates the brachial
pulse. Pressures in both
arms are assessed
because asymptomatic
stenosis in the subclavian
artery can produce an
abnormally low reading
and should not be used in
the calculations. Record
the higher reading. • Apply
the BP cuff to the right
ankle, then palpate the
posterior tibial pulse at the
medial aspect of the ankle
and the dorsalis pedis
pulse on the dorsal aspect
of the foot. Using the same
Doppler technique as in
the arms, determine and
record both systolic
pressures. Repeat this
procedure on the left ankle
(Fig. 21-24). If you are
unable to assess these
pulses, use the peroneal—
artery (Fig. 21-25).

• ABPI calculation: Divide

the higher ankle pressure
for each foot by the higher
brachial pressure. For
example, you may have
measured the highest
brachial pulse as 160, the
highest pulse in the right
ankle as 80, and the
highest pulse in the left
ankle as 94. Dividing each
by 160 (80/160 and
94/160) will result in a right
ABPI of 0.5 and a left ABPI
of 0.59.
MANUAL
COMPRESSION TEST You will feel a pulsation
No pulsation is palpated if
If the client has varicose with your upper fingers if
the client has competent
veins, perform manual the valves in the veins are
valves.
compression to assess the incompetents.
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 to 8 inches above
your first hand (Fig 21-26).
Feel for a pulsation to your
fingers in the upper hand.
Repeat this test in the
other leg if varicosities are
present.

TRENDELENBURG TEST Saphenous vein fills from Filling from above with the
(tourniquet test) below in 30 second. If tourniquet in place and the
This test is used to locate valves are competent,there client standing in the
the site of the incompetent will be no rapid filling of the saphenous vein. Rapid
venous valves. If using varicose veins from above filling of the superficial
fingers, it is called the (retrograde filling after varicose veins from above
Trendelenburg test, if removal of tourniquet. after the tourniquet has
using a tourniquet instead been removed also
it’s called the tourniquet indicates retrograde filling
test. past incompetent valves in
the veins.
VII..COMMON ABNORMALITIES

RAYNAUD'S DISEASE This is a condition where the

blood vessels in the fingers and toes narrow when
exposed to cold temperatures or stress, causing the
fingers to turn white or blue and feel cold or numb. In
Raynaud's disease, the affected fingers may have a
lower temperature than the rest of the hand, and the CRT may be prolonged.

PERIPHERAL ARTERY DISEASE (PAD)- PAD is a

condition where the arteries that supply blood to the legs
and arms become narrowed or blocked, leading to
reduced blood flow. In severe cases, the affected limb
may have a lower temperature and the CRT may be prolonged.

EDEMA ASSOCIATED WITH LYMPHEDEMA -

Caused by abnormal or blocked lymph vessels
• Nonpitting
• Usually bilateral; may be unilateral
• No skin ulceration or pigmentation

ARTERIAL INSUFFICIENCY- is a condition that results

in reduced blood flow through the arteries, usually due to
atherosclerosis, where fatty material builds up on the
walls of the arteries, causing them to narrow and stiffen.
The symptoms of arterial insufficiency include pain,
diminished or absent pulses, and skin characteristics such
as dependent rubor, elevation pallor, dry and shiny skin, cool-to-cold temperature,
hair loss, and thickened nails. Ulcers that result from arterial insufficiency are usually
deep, circular, and located in pressure areas of the feet or toes, and are very painful
with a pale black to dry and gangrenous base.

VENOUS INSUFFICIENCY - is a condition in which the

veins struggle to send blood from the legs back to the
heart due to weakened vein walls and damaged valves.
Symptoms of venous insufficiency include aching and
cramping pain, present but hard to palpate pulses due to
edema, and skin characteristics such as pigmentation in
the gaitor area, thickened and tough skin, and reddish-
blue color that is frequently associated with dermatitis.

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
VIII..SUMMARY

 Blood flow is restricted to the tissue because of spasm or narrowing of the vessel.
 Peripheral vascular disease can affect all types of blood vessels.
 The most common symptom is pain, which becomes worse as the circulation
more limited.
 Restoring blood flow and preventing disease progression is the goal of treatment.

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