Assessing Peripheral

Vascular System
 History of Present Health Concern
Have you noticed any color, Rationale: Cold, pale, clammy skin on the
temperature, or texture changes in extremities and thin, shiny skin with loss of hair,
your skin? especially over the lower legs, are associated with
arterial insufficiency. Warm skin and brown
pigmentation around the ankles are associated
with venous insufficiency.

Do you experience pain or cramping Rationale: Intermittent claudication is characterized

in your legs? If so, describe the pain by weakness, cramping, aching, fatigue, or frank pain
(aching, cramping, stabbing). How located in the calves, thighs, or buttocks but rarely
often does it occur? Does it occur in the feet with activity. These symptoms are
with activity? Is the pain quickly relieved by rest but reproducible with same
reproducible with same amount of degree of exercise and may indicate peripheral
exercise? arterial disease
Do you have any leg veins that are Rationale: Varicose veins are hereditary but may
r o p e - like, bulging, or contorted? 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.

Do you have any swelling (edema) Rationale: Peripheral edema (swelling) results
in your legs or feet? At what time of from an obstruction of the lymphatic flow or from
day is swelling worst? Is there any venous insufficiency from such conditions as
pain with swelling? incompetent valves or decreased osmotic
pressure in the capillaries.
Do you have any sores or open Rationale: Ulcers associated with arterial
wounds on your legs? Where are disease are usually painful and are often
they located? Are they painful? locate don the toes, foot, or lateral ankle.

Do you have any swollen glands or Rationale: Enlarged lymph nodes may
lymph nodes? If so, do they feel indicate a local or systemi c infection.
tender, soft, or hard?

For male clients: Have you Rationale: Erectile dysfunction (ED) may
experienced a change in your usual occur with decreased blood flow or an
sexual activity? Describe. occlusion of the blood vessels such as
aortoiliac occlusion (Leriche’s syndrome). Men
may be reluctant to report or discu ss
difficulties achieving or maintaining an
erection.
 Personal Health History
Describe any problems you had Rationale: A history of prior PVD increases a
in the past with the circulation in person’s risk for a recurrence. S y m p t o m s such
your arms and legs. 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

Have you had any heart or blood Rationale: Previous surgeries may alter the
vessel surgeries or treatments appearance of the skin and underlying tissues
such as coronary artery b y p a s s surrounding the blood vessels. Grafts for
grafting, repair of aneurysm, or b y p a s s surgeries are often taken from veins in
vein stripping? the legs.
 Family History

Do you, or does your family, have a Rationale: These disorders or abnormalities

history of diabetes, hypertension, tend to be hereditary and cause damage to
coronary heart disease, intermittent blood vessels. An essential aspect of treating
claudication, or elevated cholesterol PVD is to identify and then modify risk
or triglyceride levels?
factors.
 Lifestyle and Health Practices
Do you (or did you in the past) smoke Rationale: Smoking significantly
or use any other form of t o ba c c o? How increases the risk for chronic arterial
much and for how long? insufficiency.

Rationale: Regular exercise improves

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

Rationale: Oral or transdermal

For female clients: Do you take oral or
transdermal (patch) contraceptives? contraceptives increase the risk for
thrombophlebitis, Raynaud’s disease,
hypertension, and edema.
Are you experiencing any stress in your Rationale: Stress increases the heart rate and
life at this time? blood pressure, and can contribute to vascular
disease

How have problems with your Rationale: Discomfort or pain associated with
circulation (i.e., peripheral vascular chronic arterial disease and the
system) affected your ability to aching heaviness associated with venous
function? disease may limit a client’s ability to stand or
walk for long periods.

Rationale: If clients perceive the appearance

Do leg ulcers or varicose veins affect
how you feel about yourself? of their legs as disfiguring, their body image or
feelings of self- worth may be negatively
influenced.
Do you regularly take Rationale: Drugs that inhibit platelet
medications prescribed by your aggregation, such as cilostazol (Pletal) or
physician to improve your clopidogrel (Plavix), m a y be prescribed to
circulation? increase blood flow. Aspirin
also prolongs blood clotting and is used to
reduce the risks associ ate d with PVD.

Do you wear support hose to treat Rationale: Support stoc kings help to
varicose veins? reduce venous pooling and increase blood
return to the heart.
COLLECTING OBJECTIVE DATA:
PHYSICAL EXAMINATION
• Examination of the peripheral vascular s y s t e m is very useful in acute
care, extended care, and home health care settings.

• Early detection of P V D can prevent l o n g - term complications.

• A complete peripheral vascular examination involves inspection,

palpation, and auscultation.

• In addition, there are several special a s s e s s m e n t techniques that

are necessary to perform on clients with s u s p e c t e d peripheral
vascular problems.
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 c o mf o r t ab le temperature (about 72°F), without

drafts.

• Before you begin the assessment, inform the client that it will be n e c e s s a r y to
i n s p e c t and palpate all four extremities and that the groin will also need to be
e x p o s e d for palpation of the inguinal lymph no d e s as well as palpation and
auscultation of the femoral arteries.

• Explain that the client can sit for examination of the arms but will need to lie
down for examination of the legs and groin, and will need to follow your
directio ns for several spe c ial a s s e s s m e n t te c hn iq ue s toward the end 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.
Equipment
• Centimeter tape
• Stethosc ope
• Doppler ultrasound device
• Conduc tivity gel
• Tourniquet
• Gauze or tissue
• Waterproof pen
• Blood pressure cuff

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
LYMPHEDEMA
 Determine ankle-brachial index (ABI), also known as ankle-brachial
pressure index (ABPI).

• Even though this advanced skill is most often performed in a cardiovascular center, it
is important to know how the test is performed and the implications.

• If the client has s y m p t o m s of arterial occlusion, the ABPI should be used to

compare upper- and lower- limb systolic blood pressure.

• The ABI is the ratio of the ankle systolic blood pressure to the arm (brachial)
systolic blood pressure.
• The ABI is considered an accurate objective assess m en t 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.

• Generally, the ankle pressure in a healthy person is the same or slightly higher than the
brachial pressure, resulting in an ABI of approximately 1,or no arterial insufficiency.
 Measure ABI.
Use the following steps to measure ABI:

• 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”
sou n d indicates the brachial pulse.

• Pressures in both arms are a s s e s s e d because asymptomatic stenosis in the

subclavian artery can produce an abnormally low reading and should not be u sed
in the calculations.

• Record the higher reading.

 ABI calculation.
Use the following formula to calculate ABI:

• 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 of these ankle pressures by 160 (the highest

brachial pressure; 80/160 and 94/160) will result in a right ABI of
0.5 and a left ABI of 0.59.
 ANKLE BRACHIAL INDEX (ABI)
GUIDELINES

1.0–1.2: Normal—No arterial insufficiency

0.8–1.0: Mild insufficiency
0.5–0.8: Moderate insufficiency
<0.5: Severe insufficiency
<0.3: Limb threatening
Manual compression test.
• If the client has varicose veins, perform manual
compression to assess the 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 – 8 inches above your
first hand.
• Feel for a pulsation to your fingers in the upper
hand.
• Repeat this test in the other leg if varicosities
are present.
 Trendelenburg Test

• If the client has varicose veins, perform the Trendelenburg

test to determine the competence of the saphenous vein
valves and the retrograde (backward) filling of the
superficial veins.
• The client should lie supine.
• Elevate the client’s leg 9 0 degrees for about 15 s e c o n d s or
until the veins empty.
• With the leg elevated, apply a tourniquet to the upper thigh.
Thank you
very much!