Peripheral Vascular Assessment

NUR216 FINAL

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Study Tools For Peripheral Vascular Assessment

Peripheral Artery Disease Pathochart (Cheatsheet)

Cardiovascular Circulation (Image)

Vascular System (Image)

Cardiac Anatomy (Image)

Circulatory System (Image)

Nursing Assessment (Book)

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Outline

Overview

Peripheral vascular assessment includes portions of a skin assessment as well as pulses and other indicators of perfusion

Nursing Points

General

Start with upper extremities, then move to lowers

Assessment

Upper extremities
1. Inspect
  1. Color of skin and nail beds
  2. Lesions
  3. Edema
  4. Size of arms
    1. Any difference bilaterally?
  5. Presence of hair
2. Palpate
  1. Temperature
  2. Texture
  3. Turgor
  4. Edema (pitting?)
    1. See Integumentary assessment
3. Pulses
  1. Brachial – medial aspect of elbow
  2. Radial – medial, anterior aspect of wrist, proximal to thumb joint
  3. Rating:
    1. 0 = absent
    2. +1 = weak
    3. +2 = normal
    4. +3 = strong
    5. +4 = bounding
  4. Compare bilaterally
4. Capillary refill – press nail bed, see how long it takes for color to return
  1. Should be less than 3 seconds
5. If patient has an AV graft or fistula
  1. Palpate for a thrill
  2. Auscultate for a bruit
Lower extremities
1. Inspect
  1. Color of skin and nail beds
  2. Lesions
  3. Edema
  4. Size of legs
    1. Any difference bilaterally?
  5. Presence or absence of hair
  6. Venous pattern
    1. Tortuous or varicose veins
2. Palpate
  1. Temperature
  2. Texture
  3. Edema (pitting?)
    1. See Integumentary assessment
3. Pulses
  1. Popliteal – medial aspect of posterior knee joint
  2. Dorsalis pedis – dorsal aspect of foot between 1st and 2nd metatarsal
  3. Posterior tibial – along the medial malleolus
  4. Rating:
    1. 0 = absent
    2. +1 = weak
    3. +2 = normal
    4. +3 = strong
    5. +4 = bounding
  5. Compare bilaterally
4. Capillary refill on toenails
  1. Press nail bed, see how long it takes for color to return
    1. Should be less than 3 seconds
Abnormal findings
1. Venous insufficiency
  1. Dark discoloration of skin
  2. Absence of hair
  3. warm to touch
  4. Edema
  5. Varicose veins
  6. “Tiredness” in legs
  7. Flaky skin
2. Arterial insufficiency
  1. Erythematous skin
  2. Bright red ulcerations
  3. Edema
  4. Pain
  5. Weakness
  6. Cool to touch
3. Absent pulses
  1. Use doppler to confirm if truly absent
  2. Report to provider, especially if NEW finding

Nursing Concepts

Common to see peripheral vascular issues in patients with hyperlipidemia, diabetes, and peripheral vascular disease

Patient Education

Importance of checking feet/legs, good foot care, and good shoes
Symptoms to report to provider

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Transcript

In this video we’re going to review the peripheral vascular assessment. Not only are we looking at actual blood vessels and pulses, but we’re looking at other signs of perfusion as well, like skin and nail color and condition. We always recommend starting with the upper extremities and moving to the lowers.

Start by inspecting the arms and compare them bilaterally. Is one more swollen than the other? Is there any edema? What color is the skin and nailbeds and are there any lesions? Is there hair where there should be hair?
Next, we’ll palpate. Feel for the temperature, texture, and turgor of the skin. If there’s edema, is it pitting? Press one finger into it to find out.
We’ll also press down on the nailbeds to check capillary refill. You should see the color return to the nails in less than 3 seconds.
Once we’ve done that, we can check our pulses. There are two main pulses you’ll check in the upper extremities – the brachial pulse – found in the medial aspect of the elbow.
And the radial pulse found on the wrist in the groove just below the thumb. Make sure you compare these pulses bilaterally and give them a score from 0 to 4, with 0 being absent, 2 being normal, and 4 being bounding. An absent pulse is never normal, so if you need to, get a doppler and verify whether it’s truly absent before you call the provider.
Now we’ll move on to the lower extremities and basically look at all of the same things. Inspect the skin color and nail beds, look for lesions or ulcerations and look for edema. If there is edema, is it the same bilaterally? Is it pitting? And, make note of the hair distribution – any kind of venous insufficiency can cause a lack of hair growth and dark discolorations.
We also want to look at vasculature – are there any tortuous or varicose veins – a really common place is behind the knees.
You also want to palpate the temperature, texture, and turgor as well. Then you can move on to pulses.
There are 3 main pulses we check in the legs, the popliteal – which is located behind the knee, the dorsalis pedis on the top of the foot, and the posterior tibial, which is along the medial malleolus. Again, check that they’re the same on both sides and give them a score.
Then finally check the capillary refill on the toes, should also be less than 3. You’ll notice the nurse took off the socks – you cannot properly assess the peripheral vascular system without actually visualizing the feet – that’s so important.

If you note any abnormalities, make sure you assess the details and report them to the provider, especially if they’re new. Poor perfusion is nothing to mess with!

Peripheral Vascular Assessment

You're watching a preview. 300,000+ students are watching the full lesson.

Included In This Lesson

Study Tools For Peripheral Vascular Assessment

300,000+ Students Use These Cheatsheets To Pass NCLEX

NURSING.com students have a 99.25% NCLEX pass rate.

Outline

Overview

Nursing Points

General

Assessment

Nursing Concepts

Patient Education

Unlock the Complete Study System

Used by 300,000+ nursing students. 99.25% NCLEX pass rate.

Transcript

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