CHAPTER 22
Assessing Peripheral
Vascular System
Case Study
Henry Lee is a 46-year-old man who is
relatively healthy, but obese (weight:
250 lb; height: 5 feet, 9 inches). He
comes to the clinic to see the nurse prac-
titioner with the following statement: “I
must have pulled something in my right
leg. I was walking when I felt some soreness in my lower
right leg, and now there is some swelling. It really hurts
to walk.” He states that he is a self-employed developer
of computer software programs. Mr. Lee’s case will be
discussed throughout the chapter.
Structure and Function
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. The information provided in this chapter can
help you compile subjective and objective data related to the
peripheral vascular system and differentiate normal vascular
findings from normal variations and abnormalities.
ARTERIES
Arteries are the blood vessels that carry oxygenated, nutrient-
rich blood from the heart to the capillaries. The arterial net-
work is a high-pressure system. Blood is propelled under pres-
sure 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 that they can stretch. Figure
22-1 illustrates the layers and the relative thickness of arterial
walls. 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. The other major arteries
accessible to examination—temporal, carotid, and aorta—are
discussed in Chapters 15, 21, and 23, respectively.
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). Both of these arteries
provide blood to the hand. The radial pulse can be palpated on
the lateral aspect of the wrist. The ulnar pulse, located on the
medial aspect of the wrist, is a deeper pulse and may not be
easily palpated. The radial and ulnar arteries join to form two
arches just below their pulse sites. The superficial and deep pal-
mar arches provide extra protection against arterial occlusion
to the hands and fingers (Fig. 22-2, p. 449).
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. This
artery travels down the front of the thigh then crosses to the
back of the thigh, where it is termed the popliteal artery. The pop-
liteal pulse can be palpated behind the knee. 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. Its pulse can be palpated on
the great-toe side of the top of the foot. The posterior branch is
called the posterior tibial artery. The posterior tibial pulse can be
palpated behind the medial malleolus of the ankle. The dorsa-
lis pedis artery and posterior tibial artery form the dorsal arch,
which, like the superficial and deep palmar arches of the hands,
provides the feet and toes with extra protection from arterial
occlusion (see Fig. 22-2, p. 449). For a discussion of pulse
strength measurement, see Box 22-2 on page 468.
VEINS
Veins are the blood vessels that 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
447
448 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Artery
Elastic tissue
Inner tunic
(endothelium)
Middle tunic
(smooth muscle)
Outer tunic
(connective tissue)
Blood flow
Arteriole
Capillary
FIGURE 22-1 Blood vessel walls. Arterial walls are constructed to accommodate the high pulsing pressure
of blood transported by the pumping heart, whereas venous walls are designed with valves that promote
the return of blood and prevent backflow.
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 car-
ried under much lower pressure than in the arteries, the vein
walls are much thinner (see Fig. 22-1). In addition, veins are
larger in diameter than arteries and can expand if blood vol-
ume increases. This helps to reduce the workload on the heart.
This chapter focuses on those veins that are most suscep-
tible to dysfunction: the three types of veins in the legs. Two
other major veins that are important to assess—the internal
and external jugular veins—are discussed in Chapter 21.
There are three types of veins: deep veins, superficial veins,
and perforator (or communicator) veins. The two deep veins in
the leg are the femoral vein in the upper thigh and the popliteal
vein located behind the knee. These veins account for about
90% of venous return from the lower extremities. The super-
ficial veins are the great and small saphenous veins. The great
saphenous vein is the longest of all veins and extends from the
medial dorsal aspect of the foot, crosses over the medial malle-
olus, and continues across the thigh to the medial aspect of the
groin, where it joins the femoral vein. The small saphenous
vein 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. The perforator veins connect the superficial
veins with the deep veins (Fig. 22-3, p. 450).
Veins differ from arteries in that there is no force that pro-
pels forward blood flow; the venous system is a low-pressure
system. This fact is of special concern in the veins of the leg.
Vein
Valve
Venule
Blood from the legs and lower trunk must flow upward with
no help from the pumping action of the heart. Three mecha-
nisms of venous function help to propel blood back to the
heart. The first mechanism has to do with the structure of the
veins. Deep, superficial, and perforator veins all contain one-
way valves. These valves permit blood to pass through them on
the way to the heart and prevent blood from returning through
them in the opposite direction. The second mechanism is
muscular contraction. Skeletal muscles contract with move-
ment and, in effect, squeeze blood toward the heart through
the one-way valves. The third mechanism is the creation of
a pressure gradient through the act of breathing. Inspiration
decreases intrathoracic pressure while increasing abdominal
pressure, thus producing a pressure gradient.
If there is a problem with any of these mechanisms, venous
return is impeded and venous stasis results. Risk factors for
venous stasis include long periods of standing still, sitting, or
lying down. Lack of muscular activity causes blood to pool in
the legs, which, in turn, increases pressure in the veins. Other
causes of venous stasis include varicose (tortuous and dilated)
veins, which increase venous pressure. Damage to the vein
wall can also contribute to venous stasis.
CAPILLARIES AND FLUID EXCHANGE
Capillaries are small blood vessels that form the connection
between the arterioles and venules and allow the circulatory sys-
tem to maintain the vital equilibrium between the vascular and
interstitial spaces. Oxygen, water, and nutrients in the interstitial
 22 • • • ASSESSING PERIPHERAL VASCULAR SYSTEM 449

Common
carotid artery
External Common
iliac artery iliac artery Subclavian Brachiocephalic
Abdominal artery artery
aorta

Anterior
superior Axillary
iliac spine Internal artery
iliac artery
Inguinal
ligament Femoral
pulse site

Brachial
Femoral artery
artery

Radial
artery Brachial
pulse site

Popliteal
artery Radial Ulnar artery
pulse site

Popliteal Deep
pulse site palmar arch
Ulnar pulse site

Superficial
palmar arch
Anterior
tibial artery

Posterior
tibial artery

Dorsalis
pedis artery Posterior tibial
pulse site
Dorsal arch
Dorsalis
pedis pulse site

FIGURE 22-2 Major arteries of the arms and legs.

fluid are delivered by the arterial vessels to the microscopic cap-
illaries (Fig. 22-4, p. 450). Hydrostatic force, generated by 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. As men-
tioned previously, the lymphatic capillaries function to remove
any excess fluid left behind in the interstitial spaces. Therefore,
the capillary bed is very important in maintaining the equilib-
rium of interstitial fluid and preventing edema.
LYMPHATIC SYSTEM
The lymphatic system, an integral and complementary compo-
nent 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. During circulation, more fluid leaves the capil-
laries than the veins can absorb. Draining excess fluid action
prevents edema, which is a buildup of fluid in the interstitial
spaces. 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. After the lymph is filtered, it travels to
either the right lymphatic duct, which drains the upper right side
of the body, or the thoracic duct, which drains the rest of the
body, then back into the venous system circulation through
the subclavian veins (Fig. 22-5, p. 451).
This unique filtering feature of the lymph nodes allows the
lymphatic system to perform a second function as a major part
450 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

Right common of the immune system defending the body against microor-
iliac vein ganisms. A third function of the lymphatic system is to absorb
Inferior
External vena cava fats (lipids) from the small intestine into the bloodstream.
iliac vein
Lymph nodes are somewhat circular or oval. Normally they
vary from very small and nonpalpable to 1 to 2 cm in diam-
Internal eter. Lymph nodes tend to be grouped together. They are both
iliac vein deep and superficial, and many are located near major joints.
The superficial lymph nodes are the only lymph nodes accessi-
ble to examination. The cervical and axillary superficial lymph
nodes are discussed in Chapters 15 and 20, respectively. The
Femoral superficial lymph nodes of the arms and legs assessed in this
vein
chapter include the epitrochlear nodes and the superficial
Great inguinal nodes.
sapheonous The epitrochlear nodes are located approximately 3 cm above
vein the elbow on the inner (medial) aspect of the arm. These
Popliteal lymph nodes drain the lower arm and hand. Lymph from the
vein remainder of the arm and hand drains to the axillary lymph
nodes. The superficial inguinal nodes consist of two groups: a
Perforator horizontal and a vertical chain of nodes. The horizontal chain
vein is located on the anterior thigh just under the inguinal liga-
Small ment, and the vertical chain is located close to the great saphe-
sapheonous nous vein. These nodes drain the legs, external genitalia, and
vein
lower abdomen and buttocks (Fig. 22-6).

Anterior
tibial vein
Health Assessment
COLLECTING SUBJECTIVE DATA:
Great THE NURSING HEALTH HISTORY
sapheonous
vein Disorders of the peripheral vascular system may develop grad-
ually. Severe symptoms may not occur until there is extensive
damage. Therefore, it is important for the nurse to ask ques-
tions about symptoms that the client may consider inconse-
quential. It is also important for the nurse to ask about per-
sonal and family history of vascular disease. This information
FIGURE 22-3 Major veins of the legs.

Erythrocyte
Lymph Leukocyte
vessel
Interstitial
fluid

Valve in O2
vein wall O2
CO2

CO2

O2 O2
CO2

CO2
FIGURE 22-4 Normal capillary
circulation ensures removal of
excess fluid (edema) from the
Capillary Lymph
body cell interstitial spaces as well as deliv-
Venule Interstitial Arteriole ery of oxygen (O2) and removal of
space carbon dioxide (CO2).

Right
Thoracic
lymphatic
duct
duct
FIGURE 22-5 Lymphatic drainage.
provides insight into the client’s risk for a recurrence or devel-
opment of problems with the peripheral vascular system. It is
especially important to evaluate aspects of the client’s lifestyle
and health factors that may impair peripheral vascular health.
These questions provide the nurse with an avenue for discuss-
ing healthy lifestyles that can prevent or minimize peripheral
History of Present Health Concern
QUESTION
Have you noticed any color, temperature, or texture
changes in your skin?
Do you experience pain or cramping in your legs? If so,
describe the pain (aching, cramping, stabbing). How
often does it occur? Does it occur with activity? Is the
pain reproducible with same amount of exercise?
If you have pain with walking, how far and how fast do you
walk prior to the pain starting? Is the pain relieved by rest?
Are you able to climb stairs? If so, how many stairs can you
climb before you experience pain? Does the pain wake you
from sleep?
22 • • • ASSESSING PERIPHERAL VASCULAR SYSTEM 451
Inguinal
In
nodes
no
odes
Axillary
nodes
Epitrochlear
nodes
FIGURE 22-6 Superficial lymph nodes of the arms and legs.
vascular disease (PVD). Some of the history questions may
overlap those asked when assessing the heart and the skin
because of the close relationship between systems.
RATIONALE
Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair,
especially over the lower legs, are associated with arterial insufficiency. Warm
skin and brown pigmentation around the ankles are associated with venous
insufficiency.
Intermittent claudication is characterized by weakness, cramping, aching,
fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the
feet with activity. These symptoms are quickly relieved by rest but reproduc-
ible with same degree of exercise and may indicate peripheral arterial disease
(PAD; American College of Cardiology Foundation/American Heart Association
[ACCF/AHA], 2011). Most clients with PAD are asymptomatic until more
advanced disease is present (Mann, 2013). Heaviness and an aching sensation
aggravated by standing or sitting for long periods of time and relieved by rest
are associated with venous disease.
Continued on following page
452 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
History of Present Health Concern (Continued)
QUESTION
Do you have any leg veins that are rope-like, bulging, or
contorted?
Do you have any sores or open wounds on your legs?
Where are they located? Are they painful?
Do you have any swelling (edema) in your legs or feet? At
what time of day is swelling worst? Is there any pain with
swelling?
Do you have any swollen glands or lymph nodes? If so, do
they feel tender, soft, or hard?
For male clients: Have you experienced a change in your
usual sexual activity? Describe.
Personal Health History
QUESTION
Describe any problems you had in the past with the circula-
tion in your arms and legs (e.g., blood clots, ulcers, coldness,
hair loss, numbness, swelling, or poor healing).
Have you had any heart or blood vessel surgeries or treat-
ments such as coronary artery bypass grafting, repair of an
aneurysm, or vein stripping?
Family History
QUESTION
Do you, or does your family, have a history of diabetes,
hypertension, coronary heart disease, intermittent claudica-
tion, or elevated cholesterol or triglyceride levels?
RATIONALE
Jain et al. (2012) found that a lower tolerance for stair climbing predicted a
higher mortality rate in people with PAD. Leg pain that awakens a client from
sleep is often associated with advanced chronic arterial occlusive disease.
However, the lack of pain sensation may signal neuropathy in such disorders
as diabetes. Reduced sensation or an absence of pain can result in a failure to
recognize a problem or fully understand the problem’s significance.
OLDER ADULT CONSIDERATIONS
Older clients with arterial disease may not have the classic
symptoms of intermittent claudication, but may experience coldness,
color change, numbness, and abnormal sensations.
Varicose veins are hereditary but may also develop from increased venous
pressure and venous pooling (e.g., as happens during pregnancy). Standing in
one place for long periods of time also increases the risk for varicosities.
Ulcers associated with arterial disease are usually painful and are often located
on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur
on the lower leg or medial ankle.
Peripheral edema (swelling) results from an obstruction of the lymphatic flow
or from venous insufficiency from such conditions as incompetent valves or
decreased osmotic pressure in the capillaries. It may also occur with deep vein
thrombosis (DVT). Risk factors for DVT include reduced mobility, dehydration,
increased viscosity of the blood, and venous stasis (Sommers, 2012). With leg
or foot ulcers, edema can reduce tissue perfusion and wound oxygenation (see
Evidence-Based Practice 22-1, p. 454).
Enlarged lymph nodes may indicate a local or systemic infection.
OLDER ADULT CONSIDERATIONS
With aging, lymphatic tissue is lost, resulting in smaller and
fewer lymph nodes.
Erectile dysfunction (ED) may occur with decreased blood flow or an occlusion
of the blood vessels such as aortoiliac occlusion (Leriche’s syndrome). Men
may be reluctant to report or discuss difficulties achieving or maintaining an
erection.
RATIONALE
A history of prior PVD increases a person’s risk for a recurrence. Symptoms
such as an absence of a prior palpable pulse; cool, pale legs; thick and opaque
nails; shiny, dry skin; leg ulcerations; and reduced hair growth signal peripheral
arterial occlusive disease (Sommers, 2012).
Previous surgeries may alter the appearance of the skin and underlying tissues
surrounding the blood vessels. Grafts for bypass surgeries are often taken from
veins in the legs.
RATIONALE
These disorders or abnormalities tend to be hereditary and cause damage
to blood vessels. An essential aspect of treating PVD is to identify and then
modify risk factors.
 22 • • • ASSESSING PERIPHERAL VASCULAR SYSTEM 453

Lifestyle and Health Practices

QUESTION RATIONALE

Do you (or did you in the past) smoke or use any other form
of tobacco? How much and for how long?
If you use tobacco currently, are you willing to quit?
Smoking significantly increases the risk for chronic arterial insufficiency.
Furthermore, Fritschi et al. (2012) found smokers with PAD had a lower self-
reported quality of life and shorter claudication pain onset when walking than
nonsmokers with PAD. The risk increases according to the length of time a
person smokes and the amount of tobacco smoked. If willing to quit smoking,
provide resources to assist in quitting. If unwilling to quit, provide information
and help identify barriers to quitting. Smoking cessation has the following
benefits: reduced workload on the heart, improved respiratory function, and
reduced risk for lung cancer.

Do you exercise regularly? Regular exercise improves peripheral vascular circulation and decreases stress,
pulse rate, and blood pressure, decreasing the risk for developing PVD.

For female clients: Do you take oral or transdermal (patch) Oral or transdermal contraceptives increase the risk for thrombophlebitis,
contraceptives? Raynaud’s disease, hypertension, and edema.

Are you experiencing any stress in your life at this time? Stress increases the heart rate and blood pressure, and can contribute to vascu-
lar disease.

How have problems with your circulation (i.e., peripheral Discomfort or pain associated with chronic arterial disease and the aching
vascular system) affected your ability to function? heaviness associated with venous disease may limit a client’s ability to stand
or walk for long periods. This, in turn, may affect job performance and the
ability to care for a home and family or participate in social events.

Do leg ulcers or varicose veins affect how you feel about If clients perceive the appearance of their legs as disfiguring, their body image
yourself? or feelings of self-worth may be negatively influenced.

Do you regularly take medications prescribed by your physi-
cian to improve your circulation?
Drugs that inhibit platelet aggregation, such as cilostazol (Pletal) or clopidogrel
(Plavix), may be prescribed to increase blood flow. Aspirin also prolongs blood
clotting and is used to reduce the risks associated with PVD. Pentoxifylline
(Trental) may be prescribed to reduce blood viscosity, improving blood flow
to the tissues, thus reducing tissue hypoxia and improving symptoms. Clients
who fail to take their medications regularly are at risk for developing more
extensive peripheral vascular problems. These clients require teaching about
their medication and the importance of taking it regularly.

Do you wear support hose to treat varicose veins? Support stockings help to reduce venous pooling and increase blood return to
the heart.

Case Study
The nurse interviews Mr. Lee using specific probing questions. The client reports swelling and pain in his right
lower leg. The nurse explores this health concern using the COLDSPA mnemonic.

Mnemonic Question Data Provided

Character Describe the sign or symptom (feeling, appear- Mr. Lee states that he must have pulled some-
ance, sound, smell, or taste if applicable). In this thing in his right lower leg and that now it is
case, “Describe the pain/soreness in your leg.” very sore and it hurts to walk.
Onset When did it begin? 3 days ago.
Location Where is it? Does it radiate? Does it occur any- Right calf is swollen, red, warm, and tender to
where else? touch. Right calf measures 42 cm while left calf
is 34.5 cm.

Continued on following page

454 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

Mnemonic Question Data Provided

Duration How long does it last? Does it recur? In this case,
“Is the pain constant or intermittent?”
Severity How bad is it? or How much does it bother you?
In this case, “Rate your pain on a 0–10 point
scale.”
Pattern What makes it better or worse? In this case, “Have
you taken any medication or other treatment for
the pain? Anything else that seems to make it
worse/better?”
Associated factors/ What other symptoms occur with it? How does
How it Affects the it affect you? In this case, “Describe your activity/
client exercise currently and prior to 3 days ago. Are you
having any shortness of breath?” (May indicate a
pulmonary embolism.) Pulmonary embolism is
the primary life-threatening complication of DVT
(Sommers, 2012).
Pain is constant.
Rates pain at a 4 on a 0–10 point scale.
Reports increased level of pain when up walking
but better when the right leg is elevated. Reports
taking 1000 mg acetaminophen 2–3 times per
day to relieve pain.
Sits at desk for 4–6 hours at a time. Has only
limited exercise; walks several blocks for lunch,
then walks back to apartment. Worries that there
is something really wrong, thus has trouble con-
centrating on programming. Needing to elevate
leg makes it difficult to work at his computer,
but plans to load files on a laptop to continue
to work. Denies shortness of breath or a history
of clots, but states that he had a pulmonary
embolus 5 years ago.

After exploring Mr. Lee’s leg pain, the nurse continues with
the present history. He says that he usually sits at his com-
puter for about 4 hours, then he walks a couple of blocks to
a coffee shop for lunch (a sandwich or a salad with cheese
and fruit, and usually a piece of cake or pie). After lunch,
Mr. Lee says he goes back to his apartment and works for
another 5–6 hours. At night, he eats dinner and watches a
few hours of television. Other than walking a short distance
at noon, he gets no other planned exercise.
Mr. Lee’s medical history includes a coronary artery
bypass graft (CABG) 5 years ago for angina, complicated
postoperatively by a pulmonary embolus. However, he has
not had any further problems. He denies numbness, tin-
gling, or loss of mobility in either extremity.

22-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:

PERIPHERAL ARTERY DISEASE (PAD)

INTRODUCTION
According to Hayward (2012), peripheral artery disease is pres-
ent in approximately 20% of adults, with an expected 7 mil-
lion Americans to have the disease by 2020. The disease preva-
lence increases with age and is associated with other diseases,
such as diabetes. PAD is a major cause of impaired ambula-
tion, lower-extremity wounds, and amputations. The disease
occurs when there is a reduced blood flow to the limbs, usually
from atherosclerotic buildup in the vessels. Once the disease
becomes symptomatic, the primary symptom is intermittent
claudication (especially pain in the leg when walking, but may
be pain in arms or legs with activity). Calf pain is the most com-
mon symptom, but other symptoms may include numbness,
weakness, coldness, sores on toes, change in skin color of legs,
hair loss or slow growth on legs, shiny skin, slow-growing toe-
nails, diminished pulses in legs and feet, and erectile dysfunc-
tion in men (Mayo Clinic, 2010). As noted by the Mayo Clinic,
PAD is usually an indication of more widespread atherosclero-
sis in other parts of the vascular system.
HEALTHY PEOPLE 2020 GOAL
Not contained in the Topics and Objectives for Healthy People
2020.
SCREENING
The U.S. Preventive Services Task Force (USPSTF, 2005) recom-
mended against routine screening for peripheral vascular
disease. However, this recommendation has been highly criti-
cized by many (see American Heart Association (AHA), 2008;
Wood, 2006). These and other authors criticize the use of
only morbidity of the legs as the reason for not screening as
opposed to screening to prevent clot development leading to
stroke, heart attack, and other complications.
Mayo Clinic (2010), ACCF/AHA (2011), and Reizes (2011)
describe newer recommendations for screening for PAD
that contradict the USPSTF. These recommendations stress
that ankle-brachial index (ABI) should be performed as an
effective strategy for diagnosing at-risk people. The recom-
mended age for ABI screening is 65 years of age (previously
70 years of age). It is also recommended that people with a
history of diabetes or smoking should be screened starting
at 50 years of age. Furthermore, people under 50 years of
age with diabetes and other PAD risk factors, such as obesity
or high blood pressure, should undergo ABI screening (Mayo
Clinic, 2010).
 22 • • • ASSESSING PERIPHERAL VASCULAR SYSTEM 455

RISK ASSESSMENT (“Facts about,” 2006; Mayo Clinic,
2010; Moye, 2011)
Risk factors for lower-extremity PAD include:
• Age younger than 50 in people who have diabetes and one
additional risk factor, such as smoking, dyslipidemia, hyper-
tension, or hyperhomocysteinemia
• Ages 50 to 64 in people with a history of smoking or diabetes
• Age 65 or older—Leg symptoms with exertion (suggesting
claudication) or ischemic rest pain
• Atherosclerotic coronary, carotid, or renal artery disease
• Smoking, or history of smoking
• Diabetes
• Obesity (a body mass index over 30)
• High blood pressure (140/90 millimeters of mercury or
higher)
• High cholesterol (total blood cholesterol over 240 milligrams
per deciliter, or 6.2 millimoles per liter)
• Family history of peripheral artery disease, heart disease,
or stroke
• Excess levels of homocysteine
• African American (more than twice as like to have PAD as
Caucasians)
People who smoke or have diabetes have the greatest risk
of developing PAD due to reduced blood flow.
CLIENT EDUCATION
Teach Clients
(Mayo Clinic, 2010)
• Quit smoking if you’re a smoker.
• If you have diabetes, keep your blood sugar in good control.
• Exercise regularly. Aim for 30 minutes at least three times a
week after you’ve gotten your doctor’s OK.
• Lower your cholesterol and blood pressure levels, if necessary.
• Eat foods that are low in saturated fat.
• Maintain a healthy weight.
• Ask your health care provider about screening with an
ankle-brachial index (ABI) measurement once you reach
50 years of age.

COLLECTING OBJECTIVE DATA: Equipment

PHYSICAL EXAMINATION • Centimeter tape
• Stethoscope
The purpose of the peripheral vascular assessment is to iden-
• Doppler ultrasound device
tify any signs or symptoms of PVD including arterial insuf-
• Conductivity gel
ficiency, venous insufficiency, or lymphatic involvement. This
• Tourniquet
is accomplished by performing an assessment first of the arms
• Gauze or tissue
then the legs, concentrating on skin color and temperature,
• Waterproof pen
major pulse sites, and major groups of lymph nodes.
• Blood pressure cuff
Examination of the peripheral vascular system is very use-
ful in acute care, extended care, and home health care settings.
Early detection of PVD can prevent long-term complications.
A complete peripheral vascular examination involves inspec-
tion, palpation, and auscultation. In addition, there are several
special assessment techniques that are necessary to perform on
clients with suspected peripheral vascular problems.
Compare the client’s arms and legs bilaterally. Better objec-
tive data can be gained by assessing a particular feature on
one extremity and then the other. For example, evaluate the
strength of the dorsalis pedis pulse on the right foot and com-
pare your findings with those of the left foot.

Preparing the Client

Ask the client to put on an examination gown and to sit
upright on an examination table. Make sure that the room is
a comfortable temperature (about 72°F), without drafts. This
helps to prevent vasodilation or vasoconstriction. Before you
begin the assessment, inform the client that it will be neces-
sary to inspect and palpate all four extremities and that the
groin will also need to be exposed for palpation of the ingui-
nal lymph nodes as well as palpation and auscultation of the
femoral arteries. Explain that the client can sit for examina-
tion of the arms but will need to lie down for examination
of the legs and groin, and will need to follow your directions
for several special assessment techniques toward the end of
the examination. As you perform the examination, explain in
detail what you are doing and answer any questions the client
may have. This helps to ease any client anxiety.
Physical Assessment
• Discuss risk factors for PVD with the client.
• Accurately inspect arms and legs for edema and venous
patterning.
• Observe carefully for signs of arterial and venous insuffi-
ciency (skin color, venous pattern, hair distribution, lesions
or ulcers) and inadequate lymphatic drainage.
• Recognize characteristic clubbing.
• Palpate pulse points correctly.
• Use the Doppler ultrasound instrument correctly (Assessment
Guide 22-1).
456 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

ASSESSMENT GUIDE 22-1 How to Use the Doppler Ultrasound Device

The Doppler ultrasound device transmits and receives ultrasound
waves to evaluate blood flow. It works by transmitting ultra high-
frequency sound waves that strike red blood cells (RBCs) in an artery
or vein. The rebounding ultrasound waves produce a whooshing
sound when echoing from an artery and a nonpulsating rush when
echoing from a vein. The strength of the sound is determined by the
velocity of the RBCs. In partially occluded vessels, RBCs pass more
slowly through the vessel, thus decreasing the sound. Fully occluded
vessels produce no sound. The battery-operated hand-held Doppler
device is used to:
• Assess unpalpable pulses in the extremities
• Determine the patency of arterial bypass grafts
• Assess tissue perfusion in an extremity
Operating the Device
When assessing peripheral circulation with a Doppler ultrasound
device, first inform the patient that the assessment is painless and
noninvasive. Then the test can proceed as follows:
• Apply a fingertip-sized mound of lukewarm gel over the blood
vessel to be assessed.
• At a 60- to 90-degree angle, lightly place the vascular probe at
the top of the mound of gel. Improving Results
• Listen for a whooshing (artery) or nonpulsating, rushing (vein) • A warm extremity will increase signal strength.
sound. • Place the tube or packet of gel in warm water before use because
• Clean the skin with a tissue. cold gel will promote vasoconstriction and make it more difficult
• Clean the probe as recommended by the manufacturer. to detect a signal.
• Mark the site with a permanent pen for easy reassessment. • Avoid pressing the probe too snugly against the skin, which may
• Record findings. obliterate the signal.

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Arms
INSPECTION

Observe arm size and venous pattern;
also look for edema. If there is an observ-
able difference, measure bilaterally the
circumference of the arms at the same loca-
tions with each re-measurement and record
findings in centimeters.
CLINICAL TIP
Mark locations on arms with a per-
manent marker to ensure the exact same
locations are used with each reassessment.
Arms are bilaterally symmetric with mini-
mal variation in size and shape. No edema
or prominent venous patterning.
Lymphedema results from blocked lymphatic
circulation, which may be caused by breast
surgery. It usually affects one extremity,
causing induration and nonpitting edema.
Prominent venous patterning with edema
may indicate venous obstruction (see Box
22-1 on page 468).

Observe coloration of the hands and arms
(Fig. 22-7).
Color varies depending on the client’s
skin tone, although color should be the
same bilaterally (see Chapter 14 for more
information).
Raynaud’s disorder is sometimes referred
to as a disease, syndrome, or phenomenon
(National Heart, Lung, Blood Institute,
2011). It is 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. The disorder commonly occurs
bilaterally; symptoms last minutes to hours.
Raynaud’s affects about 5% of the popula-
tion and can often be controlled with minor
lifestyle changes (National Heart, Lung,
Blood Institute, 2011; Fig. 22-8).

ASSESSMENT PROCEDURE
FIGURE 22-7 Inspecting color related to circulation.
PALPATION
Palpate the client’s fingers, hands, and
arms, and note the temperature.
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.
CLINICAL TIP
Inaccurate findings may result if
the room is cool, if the client has edema,
has anemia, or if the client recently
smoked a cigarette.
Palpate the radial pulse. Gently press the
radial artery against the radius (Fig. 22-9,
p. 458). Note elasticity and strength.
CLINICAL TIP
For difficult-to-palpate pulses,
use a Doppler ultrasound device (see
Evidence-Based Practice 22-1, p. 454).
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 (Fig. 22-10,
p. 458).
22 • • • ASSESSING PERIPHERAL VASCULAR SYSTEM 457
NORMAL FINDINGS ABNORMAL FINDINGS
FIGURE 22-8 Hallmarks of Raynaud’s disease are color changes.
(Used with permission from Effeney, D. J., & Stoney, R. J. [1993]. Wylie’s
atlas of vascular surgery: Disorders of the extremities. Philadelphia: J. B.
Lippincott.)
Skin is warm to the touch bilaterally from A cool extremity may be a sign of arte-
fingertips to upper arms. rial insufficiency. Cold fingers and hands,
for example, are common findings with
Raynaud’s.
Capillary beds refill (and, therefore, color Capillary refill time exceeding 2 seconds
returns) in 2 seconds or less. may indicate vasoconstriction, decreased
cardiac output, shock, arterial occlusion, or
hypothermia.
Radial pulses are bilaterally strong (2+). Increased radial pulse volume indicates a
Artery walls have a resilient quality hyperkinetic state (3+ or bounding pulse).
(bounce). 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 (see
Box 22-2, p. 468).
The ulnar pulses may not be detectable. 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.
Continued on following page
458 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Arms (Continued)

FIGURE 22-9 Palpating the radial pulse. FIGURE 22-10 Palpating the ulnar pulse.

You can also palpate the brachial pulses Brachial pulses have equal strength Brachial pulses are increased, diminished, or
if you suspect arterial insufficiency. Do bilaterally. absent.
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 (Fig. 22-11).

Palpate the epitrochlear lymph nodes. Normally, epitrochlear lymph nodes are not Enlarged epitrochlear lymph nodes may
Take the client’s left hand in your right hand palpable. indicate an infection in the hand or forearm,
as if you were shaking hands. Flex the client’s or they may occur with generalized lymph-
elbow about 90 degrees. Use your left hand adenopathy. Enlarged lymph nodes may also
to palpate behind the elbow in the groove occur because of a lesion in the area.
between the biceps and triceps muscles (Fig.
22-12). If nodes are detected, evaluate for
size, tenderness, and consistency. Repeat
palpation on the opposite arm.

FIGURE 22-11 Palpating the brachial pulse. FIGURE 22-12 Palpating the epitrochlear lymph nodes located
in the upper inside of the arm.