Chapter 22

Assessing Peripheral Vascular

System
Structure and Function #1

 Structures
o Arteries and veins in arms and legs
o Lymphatic system
o Capillaries
 Function
o Fluid exchange

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Structure and Function #2

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Arteries #1

 Carry oxygenated, nutrient-rich blood from the heart

to the capillaries
 Blood is moved by pressure from left ventricle
through the arteries.
 Major arteries of arm:
o Brachial, radial, ulnar
 Major arteries of the leg:
o Femoral, popliteal, dorsalis pedis, posterior tibial

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Arteries #2

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Veins #1

 Carry deoxygenated, nutrient-depleted, waste-laden

blood from the tissues back to the heart
 Three types:
o Deep veins
o Superficial veins
o Perforator veins
 Major veins of legs:
o Femoral, popliteal, saphenous veins

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Veins #2

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Capillaries and Fluid Exchange

 Small vessels that form connection between

arterioles and venules
 Allow circulatory system to maintain vital
equilibrium between vascular and interstitial space

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Lymphatic System #1

 Complex vascular system composed of lymphatic

capillaries, lymphatic vessels, and lymph nodes
 Primary function: drain excess fluid and plasma
proteins from bodily tissues and return them to
venous system
 Helps prevent edema
 Lymph nodes: filters through which lymph fluid
passes to trap and destroy microorganisms, foreign
materials, dead blood cells, and abnormal cells
 Fluid then travels to either right lymphatic duct or
thoracic duct to re-enter venous system.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Lymphatic System #2

Reprinted with permission from Cohen, B. J., & DePetris, A. [2014]. Medical terminology: An illustrated guide.
Lippincott Williams & Wilkins.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Lymphatic System #3

 Filtering function allows lymphatic system to be

part of immune system
 Also helps absorb lipids from small intestine into
bloodstream

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Biologic (Genetic) and Cultural Behavior
Variations

 Highest rate of venous insufficiency in the United States

in White women; significant differences in incidence and
prevalence when comparing racial groups and increasing
age.
 Incidence appeared to decrease with age for African
Americans and Hispanics.
 African Americans have more lower leg veins than
Whites, which may be a contributing factor.
 Lower prevalence rates of varicose veins in people of
African descent when compared with White.
 Peripheral arterial disease more prevalent in African
Americans and lower in Asian Americans as compared
with Whites.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Older Adult Considerations

 If older client with arterial disease may not have

classic symptoms of intermittent claudication but
may experience coldness, color change, numbness,
and abnormal sensations.
 With aging, lymphatic tissue is lost, resulting in
smaller and fewer lymph nodes.
 Hair loss on lower extremities occurs with aging and
is not an absolute sign of arterial insufficiency in the
older client.
 Varicosities are common in older client.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Question #1

Is the following statement true or false?

Arteries carry deoxygenated, nutrient-depleted, waste-

laden blood from the tissues back to the heart.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Answer to Question #1

False

All veins (with the exception of the pulmonary vein)

carry deoxygenated, nutrient-depleted, waste-laden
blood from the tissues back to the heart. All arteries
(with the exception of the pulmonary artery) carry
oxygenated, nutrient-rich blood from the heart to the
capillaries.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Subjective Data: The Nursing
Health History

 History of present health concern

 Personal health history
 Family history
 Lifestyle and health practices

Copyright © 2022 Wolters Kluwer · All Rights Reserved

General Routine Screening

 Observe arm size, venous pattern, and for edema.

 Inspect color and palpate client’s fingers, hands, and arms,
noting temperature.
 Palpate to assess nail bed capillary refill time.
 Palpate the radial and ulnar pulses.
 Inspect legs for distribution of hair, temperature, lesions,
ulcers, or edema.
 Inspect for varicosities and thrombophlebitis.
 Palpate the popliteal and femoral pulses.
 Palpate the dorsalis pedis and posterior tibial pulses.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Focused Specialty Assessment

 Palpate the brachial pulses if suspect arterial insufficiency.

 Perform the Allen test.
 Palpate the epitrochlear lymph nodes.
 Palpate the superficial inguinal lymph nodes.
 Auscultate the femoral pulses.
 Perform position change test for arterial insufficiency.
 Determine ankle–brachial index (ABI).
 Perform manual compression test if have varicose veins.
 Perform Trendelenburg test if have varicose veins.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #1

 Preparing the client

o Ask client to put on examination gown and sit
upright.
o Ensure room at comfortable temperature.
o Inform client will be examining both arms and
legs and groin area.
o Will need to lie down for examination of legs and
groin.
o Explain in detail while performing the
assessment.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #2

 Equipment
o Centimeter tape
o Stethoscope
o Doppler ultrasound device
o Conductivity gel
o Tourniquet
o Gauze or tissue
o Waterproof pen
o BP cuff
o Gown

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #3

 Physical assessment
o Discuss risk factors for PVD.
o Accurately inspect arms and legs for edema and venous
patterning.
o Observe carefully for signs of arterial and venous
insufficiency and inadequate lymphatic drainage.
o Recognized characteristic clubbing.
o Palpate pulse points correctly.
o Use the Doppler ultrasound instrument correctly:
 See Assessment Guide 22-1

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #4

 Arms
o Inspection
 Observe arm size and venous pattern; look for
edema.
 Observe coloration of hands and arms .
o Palpation
 Palpate fingers, hands, and arms, note
temperature.
 Assess capillary refill time.
 Palpate radial pulse.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #5

 Arms, palpation—(cont.)
o Palpate ulnar pulse.
o Palpate brachial pulses if suspect arterial insufficiency.
o Palpate epitrochlear lymph nodes.
o Perform Allen test.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #6

 Legs
o Inspection, palpation, auscultation
 Observe skin color.
 Inspect distribution of hair on legs.
 Inspect legs for lesions or ulcers.
 Inspect top and bottom of feet for lesions or
ulcers
 Palpate for sensation.
 Inspect for edema.
 Palpate edema (see Table 22-1).

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #7

 Legs, inspection, palpation, auscultation—(cont.)

o Palpate bilaterally for temperature of legs and feet.
o Palpate superficial inguinal lymph nodes.
o Palpate femoral pulses.
o Auscultate femoral pulses.
o Palpate popliteal pulses.
o Palpate dorsalis pedis pulses.
o Palpate posterior tibial pulses.
o Inspect for varicosities and thrombophlebitis.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Collecting Objective Data: Physical
Examination #8

 Special tests for arterial or venous insufficiency

o Perform position change test for arterial
insufficiency
o Determine ABI
o Measure ABI
o Manual compression test
o Trendelenburg test

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Validating and Documenting Findings

 Validate all assessment data collected.

 Verify data are reliable and accurate.
 Document both normal and abnormal findings to
form baseline.
 Follow policy of health care facility or agency when
documenting:
 COLDSPA
 SBAR

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Analyzing Data to Make Informed Clinical
Judgments

 Selected client concerns

o Opportunity to improve health
o Risk for client concerns
o Client concerns
 Selected collaborative problems
o RC: Risk for Complications
 Medical problems

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Question #2

Is the following statement true or false?

Hair loss on the lower legs in an older adult is a sign of

arterial insufficiency and should be investigated
further.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Answer to Question #2

False

Hair loss on the lower legs of an older adult is a

normal expectation and does not automatically
indicate an arterial insufficiency.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Peripheral Artery Disease (PAD) #1

 Also referred to as peripheral vascular disease,

atherosclerosis, or hardening of the arteries
 Arteries slowly become narrowed or blocked when
plaque gradually forms inside artery walls, reduces
or stops blood flow to tissue.
 Symptoms: intermittent claudication; leg numbness
or weakness; coldness in lower leg or foot; sores on
toes, feet, or legs that will not heal; change in color
of legs; hair loss or slower hair growth on feet and
legs; slower growth of toenail; shiny skin on legs; no
pulse or weak pulse in legs or feet; erectile
dysfunction in men

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Peripheral Artery Disease (PAD) #2

 If PAD progresses: pain occurs even at rest or when

lying down (ischemic rest pain); pain may be
intense enough to disrupt sleep; hanging legs over
edge of bed or walking around may or may not
temporarily relieve pain
 Usually an indication of more widespread
atherosclerosis in other parts of vascular system

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Peripheral Artery Disease (PAD) #3

 Risk assessment
o Smoking, diabetes, history of CAD, or stroke
o Obesity: BMI over 30
o High blood pressure
o High cholesterol
o Increasing age, especially after reaching 50 years
o Family history of PAD, heart disease, or stroke
o High levels of homocysteine
o African American

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Peripheral Artery Disease (PAD) #4
 Client education
o Quit smoking.
o If diabetic, keep blood sugar in good control.
o Exercise regularly.
o Maintain normal cholesterol and blood pressure
levels.
o Eat well-rounded diet, foods low in saturated fat.
o Maintain healthy weight.
o Ask about screening with ABI measurements after 50.
o Control Reynaud, if have.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Abnormal Arterial Findings
 Necrotic great toe with Raynaud disease
blisters on toes and foot

Reprinted with permission from Craft, N., Fox, L. P.,

Goldsmith, L. A., Papier, A., Birnbaum, R., Mercurio, M.
G., Miller, D., Rajendran, P., Rosenblum, M., Taylor, E.,
& Tumeh, P. C. (2015). VisualDx: Essential adult
Reprinted with permission from Baranoski, S., &
dermatology. Wolters Kluwer.
Ayello, E. (2015). Wound care essentials. Wolters
Kluwer.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Characteristics of Arterial and Venous
Insufficiency

Arterial insufficiency Venous insufficiency

Reprinted with permission from Berg, D., & Worzala, K.

(2006). Atlas of adult physical diagnosis. Lippincott
Williams & WilkinsUse

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Neuropathic Ulcer

 Neuropathic ulcer

Reprinted with permission from Pellico, L. H. (2013). Focus on adult health. Wolters Kluwer.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Abnormal Venous Findings #1

 Superficial thrombophlebitis Lymphedema

Reprinted with permission from Baranoski, S., &

Reprinted with permission from Jensen, S. (2015). Ayello, E. (2015). Wound care essentials. Wolters
Nursing health assessment: A best practice approach. Kluwer Heath.
Wolters Kluwer.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Abnormal Venous Findings #2

 Varicose veins

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Types of Peripheral Edema #1
 Edema associated Edema associated with
with lymphedema chronic venous
insufficiency

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Types of Peripheral Edema #2

 Pitting edema

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Question #3

Is the following statement true or false?

Enlarged epitrochlear lymph nodes may suggest an

infection in the hand or forearm.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Answer to Question #3

True

Enlarged epitrochlear lymph nodes may suggest an

infection in the hand or forearm, or they may occur
with generalized lymphadenopathy.

Copyright © 2022 Wolters Kluwer · All Rights Reserved