ASSESSING THE PERIPHERAL VASCULAR SYSTEM. Prior to performing the procedure, introduce yourself and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Inquire if the client has any of the following: past history of heart disorders, varicosities, arterial disease, and hypertension; lifestyle habits such as exercise patterns, activity patterns and tolerance, smoking, and use of alcohol.
5. Palpate the peripheral pulses on both sides of the client’s body individually, simultaneously (except the carotid pulse), and systematically to determine the symmetry of pulse volume. If you have difficulty palpating some of the peripheral pulses, use a Doppler ultrasound probe.
6. Inspect the peripheral veins in the arms and legs for the presence and/or appearance of superficial veins when limbs are dependent and when limbs are elevated.
7. Assess the peripheral leg veins for signs of phlebitis. Inspect the calves for redness and swelling over vein sites.
- Palpate the calves for firmness or tension of the muscles, the presence of edema over the dorsum of the foot, and areas of localized warmth. Push the calves from side to side to test for tenderness.
- Firmly dorsiflex the client’s foot while supporting the entire leg in extension (Homans’ test), or have the person stand or walk.
8. Inspect the skin of the hands and feet for color, temperature, edema, and skin changes.
9. Assess the adequacy of arterial flow if arterial insufficiency is suspected.
- Press at least one nail on each hand and foot between your thumb and index finger sufficiently to cause blanching (about5 seconds).
- Release the pressure, and observe how quickly normal color returns (less than 2 seconds).
- Inspect the fingernails for changes indicative of circulatory impairment. See the section on assessment of nails earlier in this chapter.
- See also peripheral pulse assessment earlier
10. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate.