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Course: Health Assessment�Unit Title: Peripheral Circulation Assessment�Population:

Connie Jones, RN, MSN

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Module Goals

Learner Outcome:

At the completion of these modules the learner will demonstrate knowledge and skills to perform a complete health assessment of an individual.

Module Objectives

Describe the components and function of the peripheral vascular system.
Describe assessment of the peripheral vascular system
Discuss documentation of assessment findings
Interpret assessment in terms of normal vs. abnormal and emergent findings.

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Content Outline

Components and purpose of the peripheral vascular system
Normal age-related changes
Medical/surgical history (recent leg pain, cramps, swelling, skin changes, medications, smoking habits, presence of stents, aneurysms, etc.); family history (hypertension, PAD/PVD, blood clotting disorders, etc.)
Assessment of the peripheral vascular system (inspection: skin color, presence of lesions, presence of clubbing; palpation: skin temperature, texture, cap refill, pulses and grading of pulses for presence-rate-rhythm-amplitude-equality, Allen’s test, Homan’s sign, pitting edema and grading scale, Ankle-Brachial Index)
Abnormal signs vs. signs of clinical emergencies

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Blood supply to the upper extremities

Radial artery---------

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Blood supply to the lower extremities

Popliteal pulse site--------------

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Whole body blood supply

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Family History

Question patients about close family members who have

Peripheral vascular disease
Hypertension
Diabetes
Amputation other than trauma
Clotting disorders

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Patient history

Smoking? Strongest risk factor for peripheral artery disease
Swelling of extremities?
Previous blood clot?
Lesions or skin changes of the extremities?
Color changes in extremities?
Change in temperature of extremities?

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Patient history

Leg pain

Type of pain?
Worsened by activity (Claudication)?
How much activity? (Claudication distance)
Absence of claudication doesn’t rule out peripheral artery disease
What relieves it?
Is it worse with elevation or cold temperatures?
Does it occur at night?

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Patient history

Medications?

Hormone therapy can increase risk of deep vein thrombosis

Males: change in sexual function?

(often occurs along with peripheral artery disease)

Females: pregnant?

Lower extremity swelling is common in pregnancy

Recent surgery or prolonged inactivity?
Recent travel requiring sitting for long periods?

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History

Lymph node enlargement?

Where?
What size?
Recent change?

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Peripheral artery disease risk factors

Some of the risk factors for PAD are:
Age over 50 years old
Smoking
Diabetes
Family history of heart or vascular disease

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Peripheral artery risk factors

Hypertension
High levels of cholesterol and triglycerides
Lack of exercise or physical activity
Obesity (overweight)
Stress

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Peripheral artery disease (PAD)

http://www.medtronic.com/us-en/patients/conditions/peripheral-arterial-disease.html

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Peripheral artery disease (PAD)

http://www.medtronic.com/us-en/patients/conditions/peripheral-arterial-disease.html

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Peripheral artery disease symptoms

These symptoms may include:

Pain or tiredness in the lower extremities
Buttock pain
Burning or tingling in the feet
Sores or breaks in the skin of the legs and feet

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Peripheral artery disease symptoms

Loss of hair on the feet or toes
Aching in the feet or toes when at rest
Changes in skin color (reddish, bluish, or pale discoloration)
Decrease in skin temperature
Impotence (inability to get or maintain an erection)

Peripheral artery disease is caused by atherosclerosis, a hardening of the arteries which can affect many areas of the body. Presence of it in one body system (heart attack, stroke) obliges looking for it in other areas, such as the peripheral blood supply and vice versa.

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Assessment of the peripheral circulation across the life cycle

In babies and children, blood pressure should be checked in the right arm and a leg to screen for a narrowing of the aorta called coarctation.
Babies can have acrocyanosis for a short time after birth
In children, multiple bruises can be an indicator of child abuse, or along with petechiae, a sign of leukemia
Older adults can develop peripheral vascular disease as a result of the age-related changes in the blood vessels.
Patients of all ages are at risk for deep venous thrombosis due to trauma, surgery, cancer, medication, or genetics.

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Inspection of peripheral circulation

Systematically assess extremities for

Color–where skin is pale enough to assess (nailbeds, palms, soles of feet)

Pink (normal)
Pale or blanched (can indicate cold temperature or arterial insufficiency)
Ruddy or reddish (can indicate venous insufficiency)
Cyanotic (usually related to more central problems such as hypoxemia or cyanotic heart disease)
Is there a line of demarcation where the color abruptly changes?

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Inspection (continued)

Note the pale color of the legs and dusky color of the feet as well as the line of demarcation (where the color abruptly changes) on the left leg in this patient with peripheral vascular disease.

There is also marked swelling bilaterally.

Note the blanching of the fingers in Raynaud’s disease, a problem with vasospasm of the peripheral arteries of the hand

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Inspection (continued)

Clubbing (indicates prolonged hypoxemia).

Early clubbing is the loss of the angle at the base of the fingernail or toenail.

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Inspection (continued)

Compare size of extremities

Should be roughly equal right to left

Swelling

Note whether it is on only one side as in this example of a patient with deep venous thrombosis.
*Swelling of the feet, even pitting edema, is normal in the later stages of pregnancy

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Inspection

Pitting edema

Shows the presence of fluid in the interstitial space

Graded by how deep it is or by how long it takes to resolve
Checked by pressing finger into the pre-tibial space (above)
Ankle circumference is considered a more accurate day-to-day comparison
In babies or supine patients in bed the edema may be more noticeable over the sacral area.

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Pitting edema (continued)

1+ Mild pitting, slight indentation, no perceptible swelling
2+ Moderate pitting, indentation subsides rapidly
3+Deep pitting, indentation remains for a short time, marked swelling
4+ Very deep pitting, indentation remains for a long time, leg is grossly swollen

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Inspection (continued)

By DocHealer - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=64120555

Examples of unilateral swelling in these patients with lymphedema of the left side.

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Palpation

Feel skin in each extremity to assess temperature

Feel both hands at the same time and both feet for comparison
Note temperature (hot, warm, cool, cold)
Note differences in skin temperature. It is abnormal for there to be a difference between the temperature of the hands or the feet. Unless there is an easy explanation (holding coffee for example) it indicates pathology.

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Inspection (continued)�

Inspect the skin for lesions
Lesions can come from many sources including trauma or infection, but two types are associated directly with peripheral vascular disease
Arterial insufficiency (right)
Venous insufficiency

Stasis ulcers (below)

Lesions of arterial insufficiency have more blanched edges and those of venous insufficiency are typically more supplied with blood

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Inspection (continued)

Looks for varicosities

Occur when the valves in the veins break down and allow backflow and pooling of blood

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Palpation

Capillary refill

Valuable test of the quality of circulation
Press on the fingernail (or toenail, or palm) about 5 seconds. The color should blanch out, but return to pink in 2 seconds or less.
Prolonged times mean decreased circulation which can be due to many factors from being cold or spiking a temperature to peripheral vascular disease or shock.
Please view the brief video here:

https://www.youtube.com/watch?v=3KGiVw9sOcA

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Palpation: pulses

Pulses in both upper extremities and both lower extremities are used to evaluate peripheral circulation

Upper extremity pulses

Radial
Ulnar
Brachial

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Palpation (continued)

Lower extremity pulses

Femoral
Posterior tibialis
Dorsalis pedis
Popliteal

Patient positioning:

Supine for palpating the femoral and pedal pulse

Prone for palpating the popliteal pulse

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Palpation (continued)

Pulse volume should be graded

Bounding 3+
Normal 2+
Weak 1+
Absent 0

In infants, the primary pulse sites are the brachial, femoral, dorsalis pedis, and posterior tibialis

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Additional assessments

Modified Allen’s test for hand circulation

Have the patient clench his fist for 30 seconds
Occlude both radial and ulnar arteries with your thumbs
Release the ulnar artery and watch for the return of pink color to the hand

A normal result, showing circulation from both the radial and ulnar arteries to the hand shows return of the blood flow in <7 seconds
Prior to performing a radial artery stick for arterial blood gases, a modified Allen’s test should be done to show normal hand circulation

D’Amico & Barbarito (2007). P490.

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Additional assessments

Homan’s sign

Patient in supine position
Flex the knee about 5 degrees
Sharply dorsiflex the foot
A positive test may indicate a clot in one of the deep veins of the leg
Vein or tendon inflammation may also produce a positive test
Should be performed if deep venous thrombosis is suspected

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Additional assessments

Peripheral arterial circulation assessment

Place patient supine and elevate the feet 12 inches above the heart
Have the patient move their feet up and down for 60 seconds
The skin should be blanched (pale) at this point.
Sit the patient on the bedside with the feet dangling.
In normal circulation, the color should return to both feet at the same time in less than 10 seconds.
An abnormal test may indicate compromised circulation to the foot with delayed return of color.

D’Amico and Barbarito

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Additional assessments

Ankle-brachial index (ABI)

Highly specific for peripheral arterial disease
Support the patient’s head and heels. Have them lie comfortably for about 10 minutes. No smoking within two hours before the test.
Position an appropriately sized blood pressure cuff on the first extremity
Using a Doppler check the systolic pressure in the extremity. Notice where the sound stops, then increase the pressure by 20 mmHg and deflate slowly to note disappearance of the sound.
Move counterclockwise and check right arm, right posterior tibial, left posterior tibial, and left arm.

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Additional assessments

Ankle-brachial index (ABI) (continued)

Right-sided Highest ankle pressure =

Highest arm (right or left) pressure

Left-sided Highest ankle pressure =

Highest arm pressure

Normal range is an index 0.90 - 1.30.

Example: Pressures in the extremities right arm 120/, right leg 128/, left leg 100/, left arm 118/.

Right-sided ABI = 128 = 1.07 Left-sided ABI = 100 = 0.83

120 120

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Additional assessment techniques

Peripheral arterial circulation test

Place patient supine and elevate the feet 12 inches above the heart
Have the patient move their feet up and down for 60 seconds
The skin should be blanched (pale) at this point.
Sit the patient on the bedside with the feet dangling.
In normal circulation, the color should return to both feet at the same time in less than 10 seconds.
An abnormal test may indicate compromised circulation to the foot with delayed return of color.

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Additional assessment techniques

Ultrasound can be used to evaluate venous blood flow
Angiograms can be done to evaluate arterial supply (invasive testing)

Catheter-based balloon dilatation can open arteries that are blocked, with stents placed to hold the arteries open
Catheter-based atherectomy can remove plaque that occludes arteries
Inferior vena cava filters can be placed by catheter to prevent emboli from the deep veins traveling to the pulmonary artery

Surgery can be done to bypass arterial blockages in some cases

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Urgent/emergent situations related to peripheral circulation

Loss of blood flow to one or both legs (or arms, though far less likely) should be treated as an emergency. Like any tissue deprived of oxygen the extremities will die if blood flow isn’t restored. In the case of the extremities, this means amputation.

A deep venous thrombosis (DVT) is an urgent diagnosis, but much less so than arterial obstruction described above. It is the risk of DVT resulting in pulmonary embolism which makes this diagnosis a dangerous one. Of 350,000 to 500,000 cases of pulmonary embolism in the United States each year, approximately 100,000 die, mostly suddenly.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584727/

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In summary

“The feasibility and reproducibility of the clinical assessment of peripheral circulation are substantial, and reliance on capillary refill time, skin temperature, and mottling score must be emphasized and exploited.“

https://www.ncbi.nlm.nih.gov/pubmed/25827585

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What would the nurse do?

A 35 year old patient presents in clinic with a diagnosis of right calf pain which she credits to a pulled muscle from exercise. She has been taking acetaminophen for pain, but it has worsened over the past week. Her family history is positive for heart disease and hypertension. She is normally active, does not smoke, and is not on any medication other than the acetaminophen for pain. She reports that she visited some distant family members two weeks ago and while on the trip had severe diarrhea and had to lay down in the car for the trip home. Her legs are asymmetrical with the right being 4 cm larger. The right leg is somewhat reddened. There is 2+ pitting edema on that side, but none on the other leg. Her pedal pulses are excellent and there is brisk capillary refill.

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What would the nurse do?

What would you do for your next assessment?

What is your nursing diagnosis?

What in the history contributed to this problem?

What nursing actions would you take?

Is this an emergency?

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What would the nurse do?

Mr. M, and African-American 70 year old gentleman presents with the complaint that his arthritis in his left knee has worsened to the point he can barely stand it. It worsened abruptly after a gradual increase in pain during walking over the past year. He can’t tolerate walking or even touch on his left lower leg without 8/10 level pain. His family history is positive for heart disease, stroke, and hypertension. He has had a previous myocardial infarction and has smoked 2 packs/day for 55 years. On inspection, his legs are similar in size and color, but the sole of his left foot is pale. There is no swelling. Pulses are not palpable on that side, but are 2+ on the right. Capillary refill is sluggish but difficult to evaluate due to the pallor. The right foot is noticeably colder than the left.

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What would the nurse do?

What is the most likely cause of Mr. M’s “arthritis” pain?

What other assessments would you like to do next?

What in the description led you to that?

What in his history were contributing factors?

What are your nursing actions?

Is this an emergent or non-emergent situation?

What therapies are available for this problem?

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What would the nurse do?

Mr. G, a 28 year old construction worker, fell from a ladder and fractured his arm. He had a closed reduction of the fracture and a cast was applied from his axilla to his fingertips. He returns to clinic complaining of increasing pain and some tingling in his hand. The nurse in clinic is concerned that swelling under his cast is causing pressure on the blood supply to his hand. Describe the steps she would take to evaluate his circulation. Describe the nursing actions if the circulation is impaired. Is this an emergent situation?

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References

D’Amico, D. and Barbarito, C. (2007). Health and physical assessment in nursing. New Jersey: Pearson.

Jarvis, C. (2015). Physical examination and health assessment (7^th ed.). Illinois: Elsevier. Retrieved July 2018 from https://drive.google.com/file/d/1S99RAJRLvarQEzyzcnRC2DdVaUQKSDSV/view.

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Graphic and/or Photo Citations

All graphics used were “labeled for reuse” from Google Images.

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Glossary

Acrocyanosis: blue color of the hands and feet

Claudication: cramping pain of the leg caused by exercise

Lymphedema: localized fluid retention and swelling caused by obstruction of the lymphatic system

Petechiae: small red or purple spots under the skin caused by bleeding

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