πŸ•‹
Trisquel.ink/Nursing
/
πŸ•‹
Adult Health Assesment
/
πŸ“˜
Chapter 21: Peripheral Vascular System
πŸ“˜

Chapter 21: Peripheral Vascular System

πŸ“Peripheral Vascular – Physical Examination (Normal Findings)

πŸ«€ Arteries & Peripheral Arterial Disease (PAD)

πŸ”Ή General Function

  • The heart pumps freshly oxygenated blood through arteries to all body tissues.
  • Arteries supply oxygen and essential nutrients to tissues.

πŸ”Ή Arteries Accessible to Examination

  • Temporal & Carotid arteries – located in the head and neck.
  • Arteries in the Arm
    • Brachial β†’ bifurcates into ulnar & radial arteries.
  • Arteries in the Leg
    • Femoral
    • Popliteal
    • Anterior tibial β†’ dorsalis pedis
    • Posterior tibial β†’ plantar arteries

πŸ”Ή Peripheral Arterial Disease (PAD)

  • Peripheral arterial disease (PAD) isΒ a condition where the arteries that carry blood to the limbs, such as the legs and arms, become narrowed or blocked.Β This reduces blood flow and oxygen delivery to the affected areas.Β 
β€£
Extra Info

The main cause of PAD is atherosclerosis, a condition where plaqueβ€”made up of fatty depositsβ€”builds up along the inner walls of the arteries. Over time, this buildup narrows the arteries and restricts blood flow to the limbs. Several factors increase the risk of developing PAD, including smoking, high blood pressure, high cholesterol, diabetes, obesity, and a family history of vascular disease. These conditions either damage the arterial walls or accelerate plaque formation, making circulation to the extremities more difficult.

image

Symptoms of Peripheral Arterial Disease (PAD)

People with PAD often experience pain, cramping, or numbness in the legs, especially when walking or exercising. This discomfort typically improves with rest, a hallmark sign known as intermittent claudication. Other symptoms may include tiredness or weakness in the legs, coldness in the feet or toes, poor nail growth, and slow-healing wounds. These occur because reduced blood flow prevents the legs and feet from receiving enough oxygen and nutrients to function and heal properly.

  • So, it refers to noncoronary arterial disease.
  • Leads to reduced blood flow, which may cause:
    • Claudication (leg pain while walking)
    • Weak/absent pulses in legs or feet
    • Delayed wound healing (Watch out if the patient has also Diabetes)

Arteries in the Arm

image
image

Vessels in the Leg

image

🩸 Veins

The course of the veins generally parallels that of the arteries, but the body contains more veins, and they usually lie closer to the skin surface. Their main function is to drain deoxygenated blood and waste products from tissues and return them to the heart. Because veins can stretch and hold large volumes of blood, they are often called capacitance vessels.

πŸ”Ž Veins Accessible to Examination

  • Jugular veins in the neck
  • Leg veins divided into three groups:
    • Deep veins: femoral and popliteal
    • Superficial veins: great and small saphenous
    • Perforator veins: connecting channels that join superficial and deep systems

βš™οΈ Mechanisms for Venous Return

Unlike arteries, veins work under a low-pressure system. To keep blood moving toward the heart, they rely on three key mechanisms:

  • Contracting skeletal muscles compress veins and push blood upward.
  • Pressure gradient from breathing helps move blood as the chest expands and contracts.
  • Intraluminal valves act as one-way doors that stop blood from flowing backward. When these valves become incompetent, blood begins to pool in the veins. This results in dilated, twisted vessels known as varicose veins.

In the legs, these mechanisms form the calf pump, often called the peripheral heart, where calf muscle contraction and venous valves work together to overcome gravity.

image
β€£
πŸ‘Ά Infants and Children (No needed for adult health)

In infants and children, the peripheral vascular system is still developing. Vessel walls are more elastic and compliant compared to adults. Circulatory changes occur at birth as the newborn transitions from fetal to independent circulation, making assessment of pulses and circulation especially important in this age group.

πŸ§β€β™€οΈ Pregnant Woman

  • During pregnancy, hormonal changes lead to vasodilation, which lowers blood pressure.
  • There could be dependent edema, varicosities in the legs and vulva, and the development of hemorrhoids. This is because the enlarging uterus compresses the iliac veins and the inferior vena cava. This obstruction of venous return can

πŸ‘΅ Aging Adult

-arteriosclerosis

-intermittent claudication

-risk of DVT and pulmonary embolism

-loss of lymphatic tissue

β€£
Explanation:

With aging, peripheral blood vessels become more rigid, leading to arteriosclerosis and increasing the risk of Peripheral Arterial Disease (PAD). It is important to assess for intermittent claudication (IC), a common symptom in older adults with PAD. The aging process also causes progressive enlargement of intramuscular calf veins, raising the risk for deep vein thrombosis (DVT) and subsequent pulmonary embolism, especially in individuals with prolonged bed rest, immobility, or heart failure. Additionally, there is a loss of lymphatic tissue with age, resulting in fewer lymph nodes and a reduction in the size of remaining nodes. This may decrease the efficiency of lymphatic drainage in older adults.

Notes: Intermittent claudication isΒ a condition where leg pain occurs during exercise and subsides with rest.Β It is caused by a narrowing or blockage of the arteries in the legs, reducing blood flow to the muscles.Β 

β€£
🌍 Culture and Genetics in PAD

The American Heart Association (AHA) considers Peripheral Arterial Disease (PAD) a coronary artery disease (CAD) risk equivalent, meaning that patients with PAD are at the same cardiovascular risk level as those with CAD. Because of this, early screening and treatment are essential to reduce morbidity and mortality.

PAD is influenced by multiple genes interacting with environmental factors which include smoking, diabetes, hypertension, elevated cholesterol, and obesity (the most IMPORTANT).

From a cultural and genetic perspective, PAD is seen to disproportionately affect Black populations, with non-Hispanic Blacks showing the highest prevalence of PAD risk factors compared to other ethnic groups. This highlights the need for prevention and education in high-risk communities.

One of the most valuable diagnostic tools for PAD is the Ankle-Brachial Index (ABI), a simple, noninvasive screening test. Expanding access to comprehensive screening programs remains essential for early detection and effective management.

πŸ“Œ Quick Summary

  • AHA: PAD is considered a CAD risk equivalent β†’ screening & treatment required.
  • Genetics: Multiple genes + environment; no single biomarker.
  • Environmental factors: Smoking, diabetes, HTN, high cholesterol, obesity.
  • Disparities: PAD disproportionately affects non-Hispanic Blacks.
  • Screening: Ankle-Brachial Index (ABI) is the main noninvasive tool; wider access is needed.

Extra Notes:

Dependent edema isΒ a condition where excess fluid accumulates in the lower extremities, such as the ankles, feet, and calves, due to gravity.Β 

πŸ“ Subjective Data in Peripheral Vascular Assessment

When assessing subjective data, it is essential to explore patient-reported symptoms and histories that may indicate peripheral vascular disease.

🦡 Leg Pain or Cramps

β€£
Text:

Patients should be asked whether they experience leg pain or cramping, and if so, the location of the discomfort. The description and onset of pain are important, as well as any precipitating activities that bring it on, such as walking or exercise. The clinician should determine whether variablesβ€”such as rest, position, or environmental conditionsβ€”affect the pain. Questions should also cover recent changes in activity level, alleviating factors, and the impact of pain on activities of daily living (ADLs). Finally, a history of comorbidities such as diabetes, hypertension, or vascular disease should be explored.

Quick Summary – Questions.

  • Leg pain or cramps?
  • PQRSTU (Questions)
  • Precipitating activity (walking, exercise)
  • Recent activity changes
  • Effect on Activities of Daily Living (ADLs)
  • Comorbid conditions

🩹 Skin Changes (Arms and Legs)

β€£
Text:

Skin assessment begins with questions about changes in color or temperature, such as pallor, redness, or coolness. Patients should be asked about visible changes in appearance, such as dryness or thin, shiny skin. Inquire about the use of support hose or prior treatments. Important details include the presence of sores or ulcers, their location, and whether they are painful. Swelling should also be assessed, along with any associated symptoms. Patients should describe what factors relieve or worsen these changes.

Quick Summary – Questions.

  • Color or temperature changes
  • Appearance (dryness, thinness, shiny skin)
  • Support hose use or prior treatment
  • Presence and location of sores/ulcers (painful or not)
  • Swelling and associated symptoms
  • Factors that relieve or worsen symptoms

πŸ’Š Ask the patient about Medications they consume:

  • Prescription (Rx) medications
  • Over-the-counter (OTC) therapies
  • Supplements

🚬 Smoking History

Smoking is one of the most significant risk factors for peripheral vascular disease. Patients should be asked about their pack-per-day (PPD) history, duration of smoking, and whether they have attempted or are currently undergoing cessation therapy.

Quick Summary – Smoking

  • Pack-per-day (PPD) history
  • Duration of smoking
  • Use of cessation therapy

🧾 Objective Data – Peripheral Vascular System

πŸ›  Preparation

β€£
Text:

During a complete physical examination, the arms should be assessed first, usually at the same time as vital signs, while the patient is sitting. Both arms and legs are evaluated for peripheral vascular characteristics, musculoskeletal findings, and neurologic findings. The room should be comfortably warm to avoid vasoconstriction, and bilateral comparisons are essential for accuracy.

Equipment Needed:

  • Paper tape measure
  • Tourniquet or blood pressure cuff
  • Stethoscope
  • Doppler ultrasonic probe

βœ‹ Inspect and Palpate the Arms

The arms are examined for color, nail bed appearance, skin temperature, texture, and turgor, as well as the presence of lesions, edema, or clubbing.

  • Clubbing: detect early changes using the profile sign.
  • Capillary refill: note if it is brisk or sluggish.
  • Radial pulse: graded on a 0–3+ scale (0 = absent, 2+ = normal, 3+ = bounding).
  • Ulnar and brachial pulses: not usually assessed in routine exams.
β€£
Modified Allen test:

evaluates adequacy of collateral circulation.

Modified Allen Test for Arterial Blood Gas (ABG) Procedure Collection Blood Draw

The modified Allen test is a simple test used to determine whether collateral blood flow exists to the hand. The modified Allen test is performed before collecting an arterial blood gas from the radial artery. πŸ“šNurse Sarah's ABG Study Notes: https://nursesarah.com/ The test ensures that blood flow is adequate to the hand in case there is a problem during collection from the radial artery. The modified Allen test is performed by occluding the radial and ulnar arteries with your thumbs. The patient can make a fist and open and close the hand. This will cause the skin color to lighten or become "blanched." Next, you release pressure on the ulnar artery. if the hand returns to its normal color within 5 seconds, the result is considered normal. You can usually proceed with radial artery ABG sampling. #modifiedallentest #nursing #nurse #nursesarah Join this channel to get access to perks: https://www.youtube.com/channel/UCPyMN8DzkFl2__xnTEiGZ1w/join Article: https://www.registerednursern.com/modified-allen-test-steps/ Website: https://www.registerednursern.com/ More Videos: https://www.youtube.com/watch?v=R2XMro13dD0&list=UUPyMN8DzkFl2__xnTEiGZ1w Instagram: https://www.instagram.com/registerednursern_com/ Facebook: https://www.facebook.com/RegisteredNurseRNs Twitter: https://twitter.com/NursesRNο»Ώ Popular Playlists: NCLEX Reviews: https://www.youtube.com/playlist?list=PLQrdx7rRsKfWtwCDmLHyX2UeHofCIcgo0 Fluid & Electrolytes: https://www.youtube.com/playlist?list=PLQrdx7rRsKfWJSZ9pL8L3Q1dzdlxUzeKv Nursing Skills: https://www.youtube.com/playlist?list=PLQrdx7rRsKfUhd_qQYEbp0Eab3uUKhgKb

youtu.be

Modified Allen Test for Arterial Blood Gas (ABG) Procedure Collection Blood Draw

🦡 Inspect and Palpate the Legs

The legs should be uncovered while keeping genitalia draped.

  • If asymmetry is observed, measure the circumference at the same level on both legs.
  • Document skin discoloration, ulcers, or gangrene, noting size and location.
  • Palpate for temperature and pulses with bilateral comparison.
  • Assess neurovascular status with a monofilament test.
  • Check for presence of hair (patchy hair can be a symptom of Peripheral Artery Disease or DVT)

Key Lower Extremity Pulses:

  • Femoral artery: below inguinal ligament, midway between pubis and iliac spine.
  • Popliteal pulse: felt with fingers curled into the popliteal fossa.
  • Posterior tibial: behind the medial malleolus in the groove near the Achilles tendon.
  • Dorsalis pedis: just lateral and parallel to the tendon of the big toe.

Edema Assessment:

  • Press firmly over tibia or medial malleolus for 5 seconds.
  • Grade pitting edema:
    • 1+ mild, slight indentation
    • 2+ moderate, subsides quickly
    • 3+ deep, remains, leg swollen
    • 4+ very deep, lasts long, gross swelling
  • Note: ankle circumference is more reliable; always follow institutional standards.

Color Change Test:

  • Raise legs for 30 seconds β†’ arterial contribution only.
  • Sit with legs down β†’ note time for color return (<10 sec normal) and venous filling.
  • Assess strength and sensation in lower legs.

🎧 Doppler Ultrasonic Probe

Used to detect weak peripheral pulses, measure low blood pressure, or assess lower extremity circulation.

  • Position supine, legs rotated outward.
  • Apply coupling gel; place transducer at 90Β° with light pressure.
  • Identify pulses by swishing, whooshing sound.
β€£
πŸ“Š Ankle-Brachial Index (ABI)

A noninvasive test for peripheral vascular disease:

  • Patient lies flat with heels supported.
  • Correct cuff size required; no smoking 2 hours prior; rest 5–10 minutes before test.
  • Two measurements taken; the average is recorded.
  • ABI is calculated as ankle systolic Γ· brachial systolic.
β€£
🩸 Wells Score for DVT

A clinical model to estimate probability of Deep Vein Thrombosis.

  • Considers malignancy, immobility, swelling, varicose veins, history of DVT, and differential diagnoses.
  • Scoring:
    • 0 or less = low probability
    • 1–2 = moderate probability
    • β‰₯3 = high probability

πŸ‘ΆπŸ‘΅ Developmental Competence

β€£
Infants/Children:
  • small, firm, mobile, nontender lymph nodes common; vaccinations may cause temporary enlargement.
  • Pregnant Women: expect diffuse bilateral pitting edema, especially in third trimester; varicose veins common.
  • Older Adults: dorsalis pedis and posterior tibial pulses may be harder to find; trophic arterial changes such as thin shiny skin, thick ridged nails, and hair loss on lower legs.

πŸ‘£ Health Promotion & Foot Care

  • Inspect feet regularly for breakdown or abnormalities.
  • Exercise to improve circulation; avoid prolonged sitting.
  • Wear well-fitting shoes indoors and outdoors.
  • Lubricate feet to prevent dryness and cracking.
  • Recommend patients to use a mirror if necessary to check the the the sole or plantar surface.

🚨 Abnormal Findings

  • Pulse contours: weak (1+), bounding (3+), water-hammer, bigeminus, alternans, paradoxus, bisferiens.
  • Arms: Raynaud phenomenon, lymphedema.
  • Legs: arterial ulcers, venous (stasis) ulcers, neuropathic ulcers.
  • Peripheral vascular disease: varicose veins, DVT, aneurysms, occlusions.

Pain Profiles:

  • Arterial disease β†’ oxygen deficit symptoms.
  • Venous disease β†’ metabolic waste buildup.
  • Always note location, character, onset, duration, aggravating/relieving factors, and risk factors.

βœ… Summary Checklist

  • Inspect arms (color, size, lesions)
  • Palpate radial & brachial pulses, check epitrochlear node
  • Inspect legs (color, size, lesions, trophic changes)
  • Palpate temperature, inguinal nodes, and pulses (femoral, popliteal, posterior tibial, dorsalis pedis)
  • Test sensation with monofilament

πŸ“ Peripheral Vascular System – Professor’s Notes

  • DVT (Deep Vein Thrombosis) β†’ expect swelling, pain, edema, warmth; patient often avoids moving the extremity due to discomfort.
  • Ulcers/Lesions β†’ wounds that do not heal, commonly in arterial disease (ischemic ulcers), venous disease (stasis ulcers), or in diabetes.
  • Pitting Edema β†’ press over tibia or ankle; grade 1+ to 4+ depending on depth and duration.
  • Neurovascular Test β†’ check strength and sensation. Example: patient closes eyes and describes what is felt when you touch or apply pressure.
  • Pregnancy β†’ dependent edema common, especially in the third trimester; varicose veins may also develop.
  • Diabetic Foot Care β†’ loss of sensation (neuropathy) β†’ high risk for ulcers.
    • Wear comfortable shoes, avoid walking barefoot.
    • Inspect feet daily; use a mirror to check bottoms of feet.
  • Varicosities β†’ common in people who stand for long periods; due to incompetent valves and venous congestion.
  • Femoral artery β†’ used during CPR.