Blood Vessels - Examination and Findings

Assessment of the peripheral vascular system should be completed as part of a comprehensive client assessment, or as part of a focused exam if the client is experiencing issues that might be related to the function of the peripheral vascular system, like arterial or venous ulcers. Let's review the process of completing an assessment of the peripheral vascular system.

Okay, the supplies you'll need for your assessment include a stethoscope with a diaphragm and bell, a skin marker, a doppler ultrasound device, drapes, and a good source of light.

Then, prepare for the exam by ensuring your client is in a comfortable position, that your hands and stethoscope are warm, and that the temperature in the room is comfortable. Provide privacy by closing the door and curtains, properly draping your client, and only exposing areas of their body as needed to perform your examination.

Before getting started, explain the procedure to your client and be sure to answer any questions they might have before obtaining verbal consent. Then, perform hand hygiene and collect your supplies.

Now, locating the anatomical landmarks of the peripheral vascular system will help guide your assessment. Peripheral pulses that can be palpated include the carotid pulse, located on the neck behind the sternocleidomastoid muscle, or scm, just below the angle of the jaw; the brachial pulse, located in the center of the cubital fossa, medially to the biceps tendon; the radial pulse, found in the wrist along the lateral aspect of the forearm, just below the base of the thumb; the femoral pulse, located below the inguinal ligament, between the pubic and hip bones; the popliteal pulse, located behind the knees; the dorsalis pedis pulse, found on the dorsal aspect of the foot; and the posterior tibial pulse, located just behind the medial malleolus.

Alright, methods of assessment for the peripheral vascular system include inspection, palpation, and auscultation.

Let's start with inspection. During your assessment, remember to look for symmetry between the right and left sides, since an abnormal finding might be present in one side and not the other.

Look for signs of adequate perfusion by observing the color of your client's extremities. Pallor, which may indicate poor arterial perfusion, will present as a pale color in clients with light skin; in clients with dark skin, pallor may present as a more ashen or gray color; while in clients with brown skin, pallor may have yellowish undertones. Another method to assess for pallor in darker skin tones is to inspect the palmar surfaces which might appear more pale.

A dark, ruddy discoloration might indicate a vascular disorder like venous insufficiency; and an erythematous or red appearance could indicate a localized infection.

Next, look for obvious signs of peripheral vascular dysfunction like varicose veins, which are enlarged, tortuous veins most often found in the lower extremities; venous ulcerations, which typically present at the medial malleolus; or arterial ulcers, that are commonly found on the toes.

Finally, inspect the jugular veins on the neck for any signs of jugular venous distention, or JVD, as this could indicate fluid volume overload, associated with problems like heart or liver failure.

Next, move on to palpation. Assess the temperature of the upper and lower extremities, by using the back of your hands. Normally, the temperature of the skin should be warm and relatively consistent in the upper and lower extremities.

If there are localized areas where the skin is cool to the touch, this can be an indication of impaired perfusion. On the other hand, if the skin feels unusually warm, an infection might be present.

Then, use the pads of two fingers to locate each of the peripheral pulse points. Remember to assess each pulse point bilaterally and, if possible, palpate them simultaneously, so you can confirm that the pulses are equal on both sides.

An exception is the carotid pulse. The carotid pulse shouldn't be taken simultaneously, since compression of both carotids simultaneously will restrict blood flow to the brain and may cause fainting. Also be sure not to apply too much pressure to the carotid pulse point, since this can cause vagal stimulation.

Each pulse should have a regular rhythm. An irregular pulse is associated with a cardiac arrhythmia like atrial fibrillation. Then, grade the pulse intensity.

A pulse that is absent or not palpable is graded as 0. A +1 pulse is diminished and is often described as weak and thready; a +2 pulse is considered normal; a +3 pulse is a strong, full, and increased; And grade the pulse as +4 if you feel a bounding pulse against your fingertips.

Now, a pulse can be difficult to palpate in cases where there's poor perfusion or if your client is obese; so you can use a doppler ultrasound to locate the pulse by placing the probe over the pulse point. When you locate the pulse, you will hear a whooshing sound. It's a good idea to mark the location of the pulse with a skin marker so you are able to find it easily later. If you are unable to locate a pulse, grade it as a zero.

Okay, next, evaluate capillary refill. To do this, compress the bed of one of your client's fingernails until it blanches, or turns white. Then, release the pressure and count how long it takes for the color to return to the nail bed. Normally, it should take less than 2 seconds.

If it takes longer, it could mean there is poor peripheral circulation, due to problems that cause decreased cardiac output or because of localized issues with blood flow, like in Raynaud's phenomenon.

Finally, check your client's lower legs for edema, which is a collection of fluid in the tissues, that can be caused by conditions like venous insufficiency or heart failure.

To do this, press the skin over the tibia or over the top of each foot with one finger. Remove your finger and look for an indentation in the skin. You can grade edema as 0+ if there is no edema present.

When pressure is applied, and a "pit" or indentation, remains, grade the edema 1+ if the indentation is about 2mm deep and it rebounds almost immediately; 2+ if the indentation is 3 to 4mm deep and rebounds in 15 seconds or less; 3+ if there's a 5 to 6mm indentation that rebounds in 60 seconds; and 4+ if there's a pit of 8 mm or more that rebounds in 2-3 minutes.

Edema is not an expected finding, and is typically caused by problems like heart failure or venous insufficiency.

Alright, next is auscultation. Use the bell of the stethoscope to auscultate over the carotid and femoral arteries for a bruit, which is caused by turbulent blood flow moving through the vessel.

A bruit is an abnormal finding, and can indicate an arterial obstruction or an aneurysm.

As the nurse, it's your responsibility to correctly assess, interpret, report, and document your assessment findings. If your assessment reveals signs or symptoms that are potentially abnormal or emergent, such as loss of a peripheral pulse or a carotid bruit, you should report this immediately to the healthcare provider, while monitoring your client's progress and changes from baseline.

Alright, as a quick recap… Assessment of the peripheral vascular system gives the nurse information about the client's perfusion status. Supplies you'll need include a stethoscope with a diaphragm and bell, a skin marker, a doppler ultrasound device, drapes, and a good source of light. Methods of assessment for the peripheral vascular system include inspection, palpation, and auscultation. As the nurse, it's your responsibility to correctly assess, interpret, report, and document findings.