4/26/2023

PERIPHERAL VASCULAR SYSTEM

ASSESSMENT

Temporal
• Branching network of
Right Subclavian Carotid
Left Subclavian
vessels that transports
Aortic arch

Coronary
oxygenated blood to all
Celiac
Abdominal aorta
body organs and
Superior mesenteric
Brachial

Inferior mesenteric
Renal tissues and then
Radial Common iliac returns it to the heart
Internal iliac External iliac
Ulnar
Femoral
• Measured by pulse and
pressure
Popliteal
• Disruption in the PV
system can cause
significant pain, loss of
Posterior tibial limb, or even death.
Dorsalis pedis

Peripheral-Vascular System

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Developmental Variations
Peripheral Vascular

Fetal Life: Children: Pregnant women Older Age

- Fetal Circulation - Arterial pressure rises Decrease systemic Elastic fibers of the
compensate very slowly until the vascular resistance become thin and
- Right ventricle adult pressure of Peripheral calcified(decrease the
pumping blood 120/80 mm Hg is vasodilatation flexibility and elasticity
through the patent reached at of the vessels and
1. Palmar erythema, a increase PV resistance)
ductus arteriosus adolescence. redness of the palms
2. Spider
At birth: telangiectasis, a Decreased venous
- Assumes total spider-like image on Elasticity-
the skin caused VARICOSITIES
responsibility for the
systemic circulation by a branched group of Increased Perivascular
dilated capillary blood resistance- Increase
-Arterial Ciculation vessels. blood pressure
70/40 mmHg
-Second semester- ATHEROSCLEROSIS-
decrease BP damage
ENDOTHELIUM

People of Different Cultures or Ethnic

Groups

 Hypertension (HTN) is a major health problem for

African Americans.
 Affects 12%–14% of the general population
 Prevalence increases with age affecting up to
20% of patients over the age of 75 (Hiatt et al
1995).

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Approach
You may be able to combine the
Peripheral Vascular and cardiovascular
physical assessments.

The techniques used include:

1. Inspection (Skin for edema, ulcerations,
and color or temperature changes),
2. Palpation (Major pulse points of the
body)
3. Auscultation (Blood Pressure)

Approach
 The patient should be sitting for
most of the assessment and be supine
only for palpation of the pulses of the
lower extremities.

 Use the pads of your index and middle

fingers.
 Always palpate gently, beginning with
light pressure and gradually increasing.

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Tools:
 Stethoscope
 Flashlight
 Non-stretchable tape
measure

INSPECTING THE ARTERIES AND VEINS

Upper Extremities

Inspecting the hands Checking capillary refill Positive capillary refill

 Inspect color, lesions, edema.

 Test capillary refill: press nail till it blanches; release and note time for
color return.
 Skin color uniform.
 Fingernails of equal thickness.
 Positive brisk capillary refill less than 2 to 3 seconds.
 No edema, erythema, red streaks, or skin lesions.

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ABNORMAL FINDINGS
1. Delayed capillary refill time
Causes: Arterial occlusion / Hypovolemic shock / Hypothermia

2. Edema
Causes:

Cellulitis Lymphedema Venous obstruction

(thrombophlebitis)

ABNORMAL FINDINGS
3. Intermittent pallor and cyanosis of hands and fingers

 Condition in which digital arteries respond

excessively to vasospastic stimuli).
 Constriction causes:
Hyperemia – increase amount of blood
Rubor (redness).

Raynaud’s phenomenon or Raynaud’s disease

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ABNORMAL FINDINGS
3. Ischemic changes and gangrene of hands and fingers

Buerger’s disease (thromboangitis obliterans).

INSPECTING ARTERIES AND VEINS

Lower Extremities
 Leg hair distributed evenly.

Note: Older patients may have

thinner, drier skin with less leg hair
and altered pigmentation.
 No varicosities or only superficial
ones.
 No swelling or edema.
 No lesions or ulcers.

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INSPECTING ARTERIES AND VEINS

Lower Extremities
ABNORMAL FINDINGS

Lymphedema Venous stasis ulcer Arterial insufficiency

 Hair loss, thin shiny skin, and thick nails: Arterial insufficiency.
 Eczema, stasis dermatitis: Chronic venous insufficiency.
 Edema: Injury, cellulitis, venous/lymph obstruction, thrombophlebitis, varicosities.
 Skin ulcers: Trauma or venous/arterial insufficiency.

PALPATING THE PULSES

Head and Neck Pulses

Palpating the temporal artery Palpating the carotid artery

Temporal pulse: Gently palpate Carotid pulse: Gently palpate along

next to eyes over temporal area.
 Note rate, rhythm, amplitude,
contour, symmetry, thrills.
ABNORMALFINDINGS
 Alterations in pulse rate/rhythm (Cardiac arrhythmia)
 Absent pulse (Arterial occlusion)
sternocleidomastoid
muscle; always palpate carotids
separately.
 Temporal and carotid arteries are
regular, smooth, and 2 bilaterally

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PALPATING THE PULSES AND LYMPH NODES

Upper Extremity

Brachial pulse: Radial pulse: Ulnar pulse:

Gently palpate in the Run your fingers from the Run your fingers from
anticubital space along thumb to the wrist on the the little finger to the
the medial side of the arm. radial side and gently wrist on the ulnar side
palpate pulse. and gently palpate
pulse.
 Ulnar artery may
be difficult to
palpate.
Normal:
 Skin temperature is warm bilaterally
 Brachial, radial, ulnar pulses are easily palpated and equal in strength and
amplitude bilaterally +2.

PALPATING THE PULSES

Upper Extremity

Brachial pulse: Radial pulse: Ulnar pulse:

ABNORMALFINDINGS
 Cool extremities: Decreased circulation, vasoconstriction, Raynaud’s
disease, Buerger’s disease, response to cold external temperature.
 Absent pulse, pallor, pain, or paresthesias of distal upper extremities:
Arterial occlusion.
 Unequal pulses: Arterial narrowing or obstruction on one side.

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PALPATING THE PULSES

Lower Extremity Pulses
Femoral Pulse
■ Place patient supine and feel below the

inguinal ligament, halfway between

the symphysis pubis and the anterior-
superior iliac spine.
■ Palpate in the groin crease halfway

between the symphysis pubis and

the anterior-superior iliac spine.

Note:
If you are unable to palpate a pulse, use a
Doppler if available.
Non-invasive test that can
be used to estimate the
blood flow through your
blood vessels by bouncing
high-frequency sound
waves

PALPATING THE PULSES

Lower Extremity Pulses
Popliteal Pulse
■ Flex the patient’s knee so that his or her foot

rests on the examination table.

■Place one hand on each side of the knee with

your thumbs near the front of the patella.

■ Curl your fingers around the knee and rest

them in the popliteal fossa.

Note:
If the popliteal pulse is difficult to feel, try
Palpating the popliteal pulse slightly straightening the patient’s leg.

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PALPATING THE PULSES

Lower Extremity Pulses
Dorsalis Pedis
■ Place your fingers between the patient’s

great toe and the first toe and slowly move

away from the toes between the extensor
tendons until you feel pulse

Note:
• Plantar flexing the foot may make pedal
pulse easier to palpate.
• Pedal pulse may be congenitally absent
or branch high in the ankle.

PALPATING THE PULSES

Lower Extremity Pulses
Posterior Tibialis
■ Place your fingertips in the groove

between the medial malleolus and the

Achilles tendon, and feel for pulse.

Note:
Passive dorsiflexion of the foot makes
the posterior tibial pulse easier to
palpate.

Femoral, popliteal, posterior tibial, and

dorsalis pedis pulses are easily
palpated and bilaterally equal in strength and
amplitude +2.

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PALPATION
SKIN TEMPERATURE
Compare bilaterally, use light
palpation and the dorsal portion
of your hand to assess skin
temperature, and lightly palpate
texture.
 If edema present, grade degree
of edema.
 Temperature is cool to warm.

ALERT
Sudden loss of peripheral pulse with cold, mottled extremity suggests
arterial occlusion, (medical emergency)
Cold feet: Arterial insufficiency, especially if unilateral.

CALF CIRCUMFERENCE
 Measure leg circumference to monitor
edema at forefoot, above ankle, at calf,
and at midthigh.
 Measure in centimeters.
Leg circumferences at forefoot, above
ankle, at calf, and at midthigh are equal
bilaterally.

ABNORMALFINDINGS
Difference in leg circumference over 1 cm above ankle or 2 cm at calf:
(Edema).

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CALF PAIN
Support patient’s leg while dorsi flexing
foot.
■ Note pain with dorsiflexion of foot.

■ No calf pain is present on dorsiflexion-

(Negative Homan sign)

ABNORMALFINDINGS
 Pain on dorsiflexion (Homans’ sign): Deep vein thrombosis (in 50% of
patients).
 Negative sign does not rule out deep vein thrombosis.

AUSCULTATING THE PULSES

Head and Neck Pulses
 Auscultating bruits: Listen with the bell
portion of the stethoscope for bruits.
 Auscultating carotid arteries:
Place bell of stethoscope over each artery
and ask patient to hold her or his breath.
 Heart sounds may normally be heard in
neck.
 No other audible sounds when
auscultating temporal and carotid arteries.

ABNORMALFINDINGS

Soft, low-pitched, rushing sound during cardiac cycle:

Bruit in temporal or carotid artery signifies narrowing of artery.

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ADDITIONAL TEST FOR

PERIPHERAL BLOOD FLOW
Allen Test
• This test assesses arterial flow
in the hands.

ADDITIONAL TEST FOR PERIPHERAL BLOOD FLOW

Allen Test
• Have patient make a tight
fist.
• Compress radial and
ulnar arteries.

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ADDITIONAL TEST FOR PERIPHERAL BLOOD FLOW

Allen Test
• Tell patient to open hand
to a slightly flexed
position.
• Observe for pallor.

ADDITIONAL TEST FOR PERIPHERAL BLOOD FLOW

Allen Test
• Release ulnar artery and
watch for return of pink color
in 3 to 5 seconds.

• Repeat procedure on radial

artery.

 Persistent pallor with the Allen’s test suggests ulnar artery

occlusion.
 Perform this test before obtaining an arterial blood specimen from
the wrist.
 If both ulnar and radial arteries are not patent, the site cannot be
used to obtain an arterial specimen

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