Adult Physical Assessment:

Peripheral Vascular System

MR. MIRADOR
At the end of this unit, the students are expected to:
1. Describe the structure and the function of the blood vessels,
including capillaries and lymphatic circulation.
2. Discuss risk factors associated with peripheral vascular
disease across the cultures and ways to reduce one’s risks.
3. Perform a physical assessment of the peripheral vascular
system using the correct techniques.
4. Differentiate between normal and abnormal findings of the
peripheral vascular system.
5. Analyze the data from the interview and physical assessment
of the peripheral vascular system to formulate valid nursing
diagnosis, collaborative problems, and/or referrals.
ASSESSMENT OF THE PERIPHERAL VASCULAR SYSTEM

Structure and Function

Arteries
• These are blood vessels that carry oxygenated,
nutrient rich blood from the heart to the capillaries
• A high-pressure system
• Arterial pulse o The surge of blood as a result from
a heartbeat which forces blood through the arterial
vessels under high pressure
Major Arteries of the Arm o Brachial artery ▪
Major artery that supplies the arm
▪ Palpated medial to the biceps tendon in and
above the bend of the elbow
 ▪ 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) • Both arteries provide blood to the hand
Radial artery
▪ Palpated on the lateral aspect of the wrist
o Ulnar artery ▪ Located on the medial aspect of the
wrist
▪ A deeper pulse, not easily palpated
o Femoral artery ▪ Major supplier of blood to the legs
▪ Pulse palpated under the inguinal ligament
o Popliteal artery ▪ Pulse palpated behind the knee
o Dorsalis pedis artery ▪ Pulse palpated on the great-
toe side of the top of the foot
o Posterior tibial artery ▪ Palpated behind the medial
malleolus of the ankle
Major Arteries of the Leg
Veins
• 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
• Contain nearly 70% of the body’s blood volume
• Walls are much thinner, low-pressure system
3 types o Deep veins ▪ Femoral veins
▪ Popliteal veins
o Superficial veins ▪ Great and small saphenous veins
o Perforator (or communicator) veins ▪ Connect the
superficial veins with the deep veins
3 mechanisms of venous function o 1st mechanism ▪
Structure of the veins
o 2nd mechanism ▪ Muscular contraction
o 3rd mechanism ▪ Creation of a pressure gradient
through the act of breathing
Capillaries
• 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
 Collecting Objective Data

Physical Examination
• The purpose is to identify any signs or symptoms of
PVD including arterial insufficiency, venous
insufficiency, or lymphatic involvement
• Useful in acute care, extended care, and home
health care settings
• A complete peripheral vascular examination
involves inspection, palpation, and
auscultation
When performing PE, the nurse should: o Discuss risk
factors for PVD with the client.
o Accurately inspect arms and legs for edema and venous
patterning\
o Observe carefully for signs of arterial and venous
insufficiency (skin color, venous pattern, hair distribution,
lesions or ulcers) and inadequate lymphatic drainage
o Recognize characteristic clubbing
o Palpate pulse points correctly
o Use the Doppler ultrasound instrument correctly
 Assessment Procedure

Arms
Inspection
• Observe coloration of the hands and arms

Normal findings ▪ Color varies depending on the

client’s skin tone, although color should be the same
bilaterally
Abnormal findings
▪ Raynaud disorder
• A vascular disorder caused by vasoconstriction or
vasospasm of the fingers or toes, 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 o Normal findings ▪ Skin is warm
to the touch bilaterally from fingertips to upper arms

o Abnormal findings ▪ A cool extremity may be a sign

of arterial insufficiency.
▪ Cold fingers and hands, for example, are common
findings with Raynaud’s
• Palpate to assess capillary refill time.
Compress the 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. o Normal findings ▪ Capillary
beds refill (and, therefore, color returns) in 2 seconds
or less
o Abnormal findings ▪ 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.
Note elasticity and strength.
Normal findings ▪ Radial pulses are bilaterally strong
(2+). Artery walls have a resilient quality (bounce).
o Abnormal findings ▪ Increased radial pulse volume
indicates a hyperkinetic state (3+ or bounding
pulse). Diminished (1+) or absent (0) pulse suggests
partial or complete arterial occlusion (which is more
common in the legs than the arms). The pulse could
also be decreased from Buerger’s disease or
scleroderma.
Palpate the ulnar pulses.
✓ Apply pressure with your first three fingertips to
the medial aspects of the inner wrists. 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.
o Normal findings ▪ The ulnar pulses may not be
detectable

o Abnormal findings ▪ Obliteration of the pulse may

result from compression by external sources, as in
compartment syndrome. Lack of resilience or
inelasticity of the artery wall may indicate
arteriosclerosis.
Palpate the brachial pulses.
✓ 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.
o Normal findings ▪ Brachial pulses have equal
strength
bilaterally

o Abnormal findings ▪ Brachial pulses are increased,

diminished, or absent
• Perform the Allen test.
✓ Evaluates patency of the radial or ulnar arteries. It
is done 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 findings ▪ 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.

o Abnormal findings ▪ With arterial insufficiency or

occlusion of the ulnar artery, pallor persists. With
arterial insufficiency or occlusion of the radial artery,
pallor persists.
Legs
Inspection, Palpation, and Auscultation
✓ Ask the client to lie supine. Then drape the groin
area and place a pillow under the client’s head for
comfort. Observe skin color while inspecting both
legs from the toes to the groin.
• Observe skin color while inspecting both legs from
the toes to the groin
o Normal findings ▪ Pink color for lighter-skinned clients
and pink or red tones visible under darker-pigmented skin.
There should be no changes in pigmentation.

o Abnormal findings ▪ Pallor, especially when elevated, and

rubor, when dependent, suggests arterial insufficiency.
▪ Cyanosis when dependent suggests venous insufficiency.
▪ A rusty or brownish pigmentation around the ankles
indicates venous insufficiency
Inspect distribution of hair on legs o Normal
findings ▪ Hair covers the skin on the legs and
appears on the dorsal surface of the toes.

o Abnormal findings ▪ Loss of hair on the legs

suggests arterial insufficiency. Often thin, shiny skin
is noted as well.
Inspect for lesions or ulcers. o Normal findings ▪
Legs are free of lesions or ulcerations.
Abnormal findings ▪ Ulcers with smooth, even
margins that 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.
✓ Inspect the legs for unilateral or bilateral edema.
Note veins, tendons, and bony prominences. If the
legs appear asymmetric, use a centimeter tape to
measure in four different areas: circumference at
mid-thigh, largest circumference at the calf, smallest
circumference above the ankle, and across the
forefoot. Compare both extremities at the same
locations.
o Normal findings ▪ Identical size and shape bilaterally; no
swelling or atrophy.
o Abnormal findings ▪ May be detected by the absence of
visible veins, tendons, or bony prominences.
▪ Bilateral edema usually indicates a systemic problem
▪ Unilateral edema is characterized by a 1-cm difference in
measurement at the ankles or a 2-cm difference at the calf,
and a swollen extremity.
▪ A difference in measurement between legs may also be
due to muscular atrophy.
o Normal findings ▪ No edema (pitting or nonpitting) present in
the legs.
o Abnormal findings ▪ Pitting edema is associated with systemic
problems
▪ A 1+ to 4+ scale is used to grade the severity of pitting edema,
with 4+ being most severe.
Palpate edema.
✓ 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.
• Palpate bilaterally for temperature of the feet and legs.
✓ Use the backs of your fingers. Compare your findings in the
same areas bilaterally. Note location of any changes in
temperature. o Normal findings ▪ Toes, feet, and legs are
equally warm bilaterally.
o Abnormal findings ▪ Generalized coolness in one leg or
change in temperature from warm to cool as you move down
the leg suggests arterial insufficiency.
▪ Increased warmth in the leg may be caused by superficial
thrombophlebitis resulting from a secondary inflammation in
the tissue around the vein.
• Palpate the femoral pulses.
✓ Ask the client to bend the knee and move it out to
the side. Press deeply and 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 is suspected in the femoral
pulse, position the stethoscope over the femoral artery
and listen for bruits. Repeat for other artery.
o Normal findings ▪ No sounds auscultated over the
femoral arteries.
o Abnormal findings ▪ Bruits over one or both
femoral arteries
suggest partial obstruction of the vessel and
diminished blood flow to the lower extremities.
• Palpate the 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.
o Normal findings ▪ It is not unusual for the popliteal
pulse to be difficult or impossible to detect, and yet
for circulation to be normal.
o Abnormal findings ▪ Although normal popliteal
arteries may be nonpalpable, an absent pulse may
also be the result of an occluded artery.
• Palpate the 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. The pulses of both feet may be assessed at
the same time to aid in making comparisons. Assess
amplitude bilaterally.
o Normal findings ▪ Dorsalis pedis pulses are
bilaterally strong.

o Abnormal findings ▪ A weak or absent pulse may

indicate impaired arterial 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 in making comparisons. Assess
amplitude bilaterally.
o Normal findings ▪ The posterior tibial pulses
should be strong bilaterally.

o Abnormal findings ▪ A weak or absent pulse

indicates partial or complete arterial occlusion.
• Inspect for varicosities and thrombophlebitis.
✓ Ask the client to stand because 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.
o Normal findings ▪ Veins are flat and barely seen under the
surface of the skin.
o Abnormal findings ▪ Varicose veins may appear as distended,
nodular, bulging, and tortuous, depending on severity.
▪ Varicosities are common in the anterior lateral thigh and
lower leg, the posterior lateral calf, or anus (known as
hemorrhoids).
▪ Superficial vein thrombophlebitis is marked by redness,
thickening, and tenderness along the vein.
▪ Aching or cramping may occur with walking.
Characteristics of Arterial and Venous Insufficiency

Arterial Insufficiency
• Pain: Intermittent claudication to sharp, unrelenting,
constant
• Pulses: Diminished or absent
• Skin Characteristics: Dependent rubor
o Elevation pallor of foot
o Dry, shiny skin
o Cool-to-cold temperature
o Loss of hair over toes and dorsum of foot
o Nails thickened and ridged
o Location: Tips of toes, toe webs, heel or other
pressure areas if confined to bed
o Pain: Very painful
o Depth of ulcer: Deep, often involving joint space
o Shape: Circular
o Ulcer base: Pale black to dry and gangrene
o Leg edema: Minimal unless extremity kept in
dependent position constantly to relieve pain
Ulcer Characteristics:
Ulcer
Venous Insufficiency
• Pain: Aching, cramping
• Pulses: Present but may be difficult to palpate
through edema
• Skin Characteristics: o Pigmentation in gaiter area
(area of medial and lateral malleolus)
o Skin thickened and tough
o May be reddish-blue in color
o Frequently associated with dermatitis
Ulcer Characteristics: o Location: Medial malleolus
or anterior tibial area
o Pain: If superficial, minimal pain; but may be very
painful
o Depth of ulcer: Superficial
o Shape: Irregular border
o Ulcer base: Granulation tissue—beefy red to yellow
fibrinous in chronic long-term ulcer
o Leg edema: Moderate to severe
Insufficiency
 Types of Peripheral Edema

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: o 1+ = slight pitting
o 2+ = deeper than 1+
o 3+ = noticeably deep pit; extremity looks larger
o 4+ = very deep pit; gross edema in extremity

• Usually unilateral; may be bilateral

• Skin ulceration and pigmentation may be present
Abnormal Arterial Findings
• Necrotic great toes with blisters on toes and foot
• Raynaud Disease o Blanching of fingers on both
hands
Abnormal Venous Findings
• Superficial thrombophlebitis o Often seen with
unilateral localized pain, achiness, edema, redness,
and warmth to touch
• Lymphedema
• Varicose veins