The document presents a seminar on peripheral vascular assessment, highlighting the structure and function of the peripheral vascular system, including arteries, veins, and the lymphatic system. It explores clinical assessments, signs and symptoms of peripheral vascular diseases, diagnostic methods, and risk factors such as age, occupation, and medical history. Additionally, it addresses diagnostic techniques and concludes with a reference to a study on sarcopenia in peripheral arterial disease.

1. SEMINAR ON
PERIPHERAL VASCULAR ASSESSMENT
By
Krishna Priya C V
M.Sc Nursing 1st year

2. ANATOMY
The peripheral vascular system (PVS) includes all the blood
vessels that exist outside the heart. The peripheral vascular
system is classified as follows:
 The aorta and its branches:
 The arterioles
 The capillaries
 The venules and
 veins returning blood to the heart
 Lymphatic system

3. LAYERS OF BLOOD VESSELS

5. ARTERIES
 Arteries are thick-walled structures that carry
blood from the heart to the tissues
 The intact endothelium synthesis regular of
thrombosis such as prostacyclin, plasminogen, and
heparin molecules.

6. VEINS
The walls of veins are thinner than arterioles, less muscular
structure of the vein wall allows these vessels to distend more than
arteries. Greater distensibility permits a large volume of blood to
remain in the vein under lower pressure, for this reason, veins are
referred to as capacitance vessels
Because of their weaker wall structure, they are susceptible to
irregular dilation

12. LYMPHATICS SYSTEM
The lymphatic system is a series of vessels and nodes that
collect and filter excess tissue fluid (lymph), before
returning it to the venous circulation

13. The drainage of lymph begins in lymph channels, which start as
blind-ended capillaries
Gradually develop into vessels. These vessels travel proximally,
draining through several lymph nodes.
Eventually the vessels empty into lymphatic trunks (also known
as collecting vessels)
These eventually converge to form the right lymphatic duct and the
thoracic duct.
The right lymphatic duct is responsible for draining the lymph from the
upper right quadrant of the body

14. The thoracic duct is much larger and drains lymph from the
rest of the body
These two ducts then empty into the venous circulation at the
subclavian veins, via the right and left venous angles.

15.  Lymph is a transudative fluid that is transparent and
yellow. It is formed when fluid leaves the capillary bed in
tissues due to hydrostatic pressure. Roughly 10% of blood
volume becomes lymph.

17. HISTORY COLLECTION (SUBJECTIVE DATA)

18.  Demographical data: including age as Arteriosclerosis
(hardening of arteries) is more prevalent among aged persons,
greater than 55 years.
 Occupation – clarify whether the occupation increases the risk
for vascular disease including hours spent, position in
occupation standing,sitting.
 Present medical history :
Pain in arterial insufficiency of the lower
extremities, the client may complain of cramping leg pain in the
calf muscles that occurs during ambulation but disappears with 1
to 2 minutes of rest.
This pain is called intermittent claudication.

19. As an artery becomes more stenosed, the pain may become
more severe, even at rest, or pain that awakens them during
the night (Rest pain).It is exacerbated by decreased cardiac
output during sleep.
Pain in chronic venous disease has a slow onset and is not
associated with exercise or rest. The client who have venous
disease may report chronic aching pain in the legs when they
are in a dependent position usually a standing position. It is a
throbbing and burning type of pain.

20. Ask for pain over the abdomen which can radiate to the back
due to the rupture of the abdominal aortic aneurysm
Ask the patient whether they feel any visible pulsation in
their abdomen.

22. Edema is a more severe form of chronic venous disorder
Are edema worsen at the end of day and is diminished at night by
leg elevation?
Any lower extremity ulcer
Past medical history
History of hypertension, and diabetes as they lead to increased
risk of atherosclerosis that eventually leads to peripheral vascular
disease.
If diabetes and hypertension are present ask about their
medication compliance.

23.  Past surgical history
Detail of any previous operations that the
client has endured, particularly vascular bypass surgery.
Note if there has been any previous angiography,
endovascular graft or stent placement, or harvesting of
arteries or veins from the lower extremities.
Any history of fracture or any condition that
leads to prolonged bed rest (due to increased risk of deep
vein thrombosis )

24. Dietary habits:
 Ask about sodium, cholesterol and
fat intake
 Ask about the usual intake of protein
and calories
 Any allergic to seafoods

25. FAMILY HISTORY
Family history of diabetes, hypertension, and peripheral
vascular disease.
Personal history:
History of cigarette smoking
Sleep pattern whether it is disturbed due to rest
pain
Assess client activity level and whether it is
reduced due to claudication pain.
Any history of dyspnea due to
pulmonarymbolism

26.  Ask for any history of pain and paraesthesia in fingers
and toes when exposed to cold environment.
 It indicate Raynaud syndrome

27. Female patients
Oral contraceptive pills leads to an
increased risk of atherosclerosis
due to changes in lipid
metabolism, and DVT risk due to
increased fibrinogen levels

28. Multiple pregnancies as it compresses arteries and veins
to the leg leads to an increased risk of peripheral vascular
disease

29. PHYSICAL EXAMINATION

30. • Introduce yourself to the patient
• Get patient consent
• Provide privacy
• Wash your hands
• Briefly explain to the patient what the examination
involves
• Position the patient supine
 Always start with the upper limb and proceed as below

31. Articles
 Inch tape
 Sphygmomanometer
 Stethoscope


32.  Inspection
 Palpation
 Auscultation

33. INSPECTION
UPPER EXTREMITIES:
The Arms
• Inspect for signs of
• Peripheral cyanosis
• Tar staining
As peripheral cyanosis
present in arterial
insufficiency or in
Raynaud syndrome

35. The Legs
• Expose the legs and observe from the end of the bed
• Scars
• Spider vein
• Varicose vein
• Dry flaky skin or hair loss seen in peripheral vascular
disease due to arterial insufficiency
• Skin changes
• Ulcers
• Dry Gangrene (seen in arterial insufficiency)
• Wet gangrene (seen in venous insufficiency)

36. Arterial ulcers are deep, painful wounds that occur when
there is inadequate blood supply, resulting in tissue damage
and slow healing.
Venous ulcers are larger, shallower sores that develop as a
consequence of impaired circulation in the veins.

37. ARTERIAL ULCER

38. VENOUS ULCER

42. Haemosiderin Staining
Hemosiderin is an iron storage complex. Hemosiderin, a
protein that stores iron in your body, can accumulate under your
skin and in major organs. It is due to leakage, of venous blood as in
chronic venous stasis, which also occurs when the smallest blood
vessels, known as capillaries, begin to leak.

43. looks like a patch of skin that is a darker color than the surrounding
skin

44. ATROPHIE BLANCHE :
Atrophie blanche describes the result of healed ulcers.
These characteristically present as a white, atrophic stellate
scar with peripheral telangiectasias. Atrophie blanche is also
known as livedoid vasculopathy

46.  VARICOSE ECZEMA
Skin inflammation in the lower legs is caused
by fluid build-up. Stasis dermatitis is caused by fluid build-
up due to varicose veins, circulation issues or heart disease.
It is also called as Stasis dermatitis

49. THE ABDOMEN
 Look at the abdomen for obvious scars or pulsations

51. Assess for muscle atrophy ( sarcopenia )progressive loss of
muscle mass due to arterial insufficiency
Patients with PAD have lower exercise capacity due to
exercise‐induced pain/discomfort in the lower extremities,
leading to muscle wasting by reduction in daily physical
activity

54. CAPILLARY REFILL TIME
Squeeze the nail bed until it blanches, release, and observe the time
for the color to return. It is used to assess arterial blood flow to extremities.
Normal refill is less than 1-2 seconds

55. PALPATION
Palpate the upper and lower extremities for temperature,
moisture, pulses and edema bilaterally to assess for
symmetry.

56. TEMPERATURE
Palpate for temperature normally it is cold in peripheral
vascular disease, arterial insufficiency
Warmth in venous stasis, DVT, varicose vein

57. PULSE

59. The distal finger is kept hard pressed to stop the rebound pulse
coming from the palm[due to radial and ulnar arch, commonly
called as palmar arch]

60. ASSESS THE PULSE FOR
 Rate
 Rhythm
 Amplitude
 Force
 Symmetry

61. Rate:
It is the number of heart beat per minute, normal is 70-
80 beats/minute
RHYTHM
Regular at regular interval
Irregular at regular interval
irregular at irregular interval

62. AMPLITUDE
When a pulse wave passes below the middle finger,
expansion of the artery pushes the middle finger upward
which is called lifting of the middle finger
where stroke volume is more amplitude is high (or) vice
versa

64. FORCE:
 It is corresponding to systolic pressure
 Continue palpating the use by middle finger now you
have to give pressure to the proximal finger on the artery
and increase it gradually
 At one point pressure will be sufficient to stop
pressure coming to the middle finger
 The degree of pressure exerted by the proximal
finger is your observation

65.  If systolic blood pressure is more heavy over the proximal
finger
 Normotensive situation will require moderate
pressure over proximal pressure
 Light pressure is required in hypotensive patients

67. SYMMETRY
Normally pulse should be symmetrical on both side of the
extremities
Radio Radial delay
It is usually seen in subclavian artery stenosis,
Radio femoral delay
It is usually seen in aortic coarctation,

70.  Apex-pulse deficit has been described as a clinical sign in
patients with AF. This is the difference between the heart
rate counted from heart sounds (in terms of apex beat)
and the peripheral pulse palpated at the radial artery.
More than two beats per minutes is abnormal

72. ALLENS TEST

73. EDEMA

74. LYMPHEDEMA
Lymphedema is edema from impaired lymph node drainage. Surgical
removal or damage from surgery or radiation to lymph nodes and vessels
impedes lymph drainage. Lymph builds up causing lymphedema. It is
common after breast cancer treatment. Lymphedema is chronic and
progressive, so needs to be recognized and treated, such as with
compression bandages. Obesity causes lymphedema because the sheer
additional weight puts too much pressure on the lymph nodes in the groin
area, compromising the system.

75. This causes a fluid backup like a clogged drain. Skin can thicken, harden,
and become red, dry, and warm to the touch. It is nonpitting and feels hard
to touch unilaterally, compare the size to the other extremity:
Mild lymphedema causes an asymmetry of 1 to 3 Moderate lymphedema
causes an asymmetry of 3 to 5 Severe lymphedema is an asymmetry of
more than 5 cm

78. AUSCULTATION
Auscultate for abdominal bruit in case of abdominal
aneurysm
The abdominal aorta can be palpated at or slightly above the
umbilicus in the epigastrium in the supine position with the
knees bent.

81. BLOOD PRESSURE
 Blood pressure (BP) is the pressure of circulating blood
against the walls of blood vessels.
 It depends upon cardiac output and systemic vascular
resistance.

83. PULSE PRESSURE
 Pulse pressure is the difference between systolic and
diastolic blood pressure. It is measured in millimeters of
mercury (mmHg). It represents the force that the heart
generates each time it contracts. Healthy pulse pressure
is around 40 mmHg
 It is higher(wider) in hypertension, arrhythmia, aortic
regurgitation, anemia, arteriosclerosis
 It is lower(Narrower) in congestive heart failure, blood
loss

85. ANKLE BRACHIAL INDEX
 Measurement of blood flow in your leg arteries. Compares systolic blood
pressure in the arm with the ankle.
 Measured by Ankle systolic pressure divided by highest
brachial systolic pressure

86. ABI – interpretation
 >1.2 – suggests calcification of vessels (age)
 1.2-1.0 – Normal Range
 0.9 – 1.0 – Acceptable (borderline abnormal) No
referral needed
 0.8-0.9 – mild disease (manage risk factors)
 0.5 – 0.8 - moderate disease (routine referral) (mixed
ulcers )
 <0.5 – severe disease (URGENT referral) (no
compression bandaging!!!)

87. PULSE PARODOXUS
 Pulsus paradoxus, also paradoxic pulse or paradoxical
pulse, is an abnormally large decrease in stroke volume,
systolic blood pressure (a drop of more than 10 mmHg),
and pulse wave amplitude during inspiration
 Seen in cardiac tamponade and decreased blood to the
left heart due to lung hyperinflation (e.g. asthma, COPD)
and anaphylactic shock.

93. DISEASE SPECIFIC EXAMINATION

94. PERIPHERAL VASCULAR DISEASES
Check for 5 p’s

95. BUERGER TEST
 Buerger's test is performed in an assessment of arterial
sufficiency
 The vascular angle, which is also called Buerger's angle, is the
angle to which the leg has to be raised before it becomes pale,
whilst lying down
 In a limb with normal circulation the toes and sole of the foot,
stay pink, even when the limb is raised by 90 degrees. In an
ischaemic leg, elevation to 15 degrees or 30 degrees for 30 to 60
seconds may cause pallor. (This part of the test checks for
elevation pallor.) A vascular angle of less than 20 degrees
indicates severe ischemia

96.  From a sitting position, in normal circulation, the foot will
quickly return to pink color. Where there is peripheral
artery disease the leg will revert to the pink color more
slowly than normal and also pass through the normal
pinkness to a red-range coloring (rubor-redness) often
known as sunset foot. This is due to the dilatation of the
arterioles (post hypoxic vasodilation)

98. Deep Vein Thrombophlebitis (DVT)
Evaluation
Homan’s Sign
 Discomfort in the calf muscles on forced dorsiflexion
of the foot with the knee straight has been a time-
honored sign of DVT.
 Calf Circumference Measure at the widest point of the
calf and compare to other calf. Acute, unilateral,
painful swelling with asymmetry of the calves of 1 cm
or more is abnormal, refer for DVT.
 Consider this with other findings like edema,
redness, the warmth of leg (blood flow can’t return to
the heart)Calf circumference

101. VARICOSE VEIN
 The Trendelenburg Test or Brodie–Trendelenburg test is a
test that can be carried out as part of a physical
examination to determine the competency of the valves in
the superficial and deep veins of the legs in patients with
varicose veins
 With the patient in the supine position, the leg is flexed
at the hip and raised above heart level. The veins will
empty due to gravity or with the assistance of the
examiner's hand squeezing blood towards the heart

102.  A tourniquet is then applied around the upper thigh to
compress the superficial veins but not too tight as to
occlude the deeper veins. The leg is then lowered by
asking the patient to stand.
 Normally the superficial saphenous vein will fill from
below within 30–35 seconds as blood from the capillary
beds reaches the veins; if the superficial veins fill more
rapidly with the tourniquet in place there is valvular
incompetence below the level of the tourniquet in the
"deep" or "communicating" veins.

103.  After 20 seconds, if there has been no rapid
filling, the tourniquet is released. If there is
sudden filling at this point, it indicates that the
deep and communicating veins are competent but
the superficial veins are incompetent
 The test is reported in two parts, the initial
standing up of the patient (positive or negative
based on rapid filling) and the second phase once
the tourniquet is removed (positive or negative
based upon rapid filling).

105. DIAGNOSIS IN PERIPHERAL VASCULAR DISEASE

108. Nailfold capillaroscopy

109. LYMPHOSCINTIGRAPHY

110. LYMPH NODE ASSESSMENT
Pre auricular lymph node – palpated anterior to the tragus of
ear
Post auricular lymph node- behind the ear to mastoid
process
Submental lymph node-
Inguinal lymph node

111. JOURNAL REFERENCE
Sarcopenia in peripheral arterial disease: Establishing and
validating a predictive nomogram based on clinical and
computed tomography angiography indicators
Nie et al. Heliyon. 2024.
Methods: Clinical data and CTA imaging features from 281
PAD patients treated between January 1, 2019, and May 1,
2023, at two hospitals were retrospectively analyzed using
binary logistic regression to identify the independent risk
factors for sarcopenia

112. Conclusions:
A simple nomogram based on five independent factors,
namely age, BMI, history of CHD, WBC count, and the
severity of luminal stenosis, was developed to assist
clinicians in estimating sarcopenia risk among PAD patients.

113. APPLICATION OF ALLIED HEALTH
SCIENCES
 Nutrition therapist for dietary modification
 Physiotherapy

115. BIBLIOGRAPHY
1. Suddharth &Brunner. Textbook of Medical Surgical Nursing, 13th edition: Wolter
Kluwer publication; 2014.pgno 1450-1460.
2.Black JM, Hawks JH. Medical Surgical Nursing, 1st edition : Elseiver
publication;2019. pgno 1458-1489.
3. Woods LS, FroelicherE , Cardiac Nursing.6th edition :Wolters Kluwer
publication;2009.pgno 936-939
4.Kaur L, Kaur p. Adult Medical Surgical Nursing ,3rd edition :Lotus
publication;2008 .pgno [1080-98]
5. Workman, Ignatavicus. Medical Surgical Nursing,7th edition :Evolve
publication;2009 .pgno [1080-98]

116. JOURNAL REFERENCE
 Nie L, Yang Q, Song Q, Zhou Y, Zheng W, Xu Q. Sarcopenia in
peripheral arterial disease: Establishing and validating a predictive
nomogram based on clinical and computed tomography angiography
indicators. Heliyon. 2024 Mar 26;10(7):e28732. doi:
10.1016/j.heliyon.2024.e28732.