Vascular Assessment

1. [noun] a peripheral vascular assessment is a medically based assessment to identify signs of pathology related to peripheral vascular system. This definition is specific to the "PERIPHERAL" Vascular Assessment. Assessment includes : · Signs of trauma · Previous surgery (particularly scars indicating veins used for bypass surgery) · Muscle wasting · Erythema (redness) · Ulcers Venous : typically on medial aspects of leg/superior to the medial malleolus Arterial: typically on the border or sides of the foot Neuropathic : typically on the plantar surface of the foot · Hair : May be absent with arterial disease. · Shiny skin , often thin with arterial disease · Hemosiderin may be seen with venous disease · Lipodermatosclerosis · Temperature : Compare temperature to both feet and legs. Cool suggests poor arterial supply · Pitting edema : Test multiple sites. Start on the dorsum of the foot to shins · Capillary refill : in a healthy adult it should be less than 3 seconds. Seniors is less than 4-5 seconds. NOTE: if the nail on the hallux is thickened or discolored, assess the proximal skin. Multiple sites on the dorsum of the foot is recommended · Arterial pluses : Dorsalis pedis and posterior tibial plus are the typical pulses assessed by a foot care nurse. Popliteal and femoral pulse are may be assessed in some situations Note if the pulse is normal, bounding, diminished or non-palpable · Auscultation for femoral artery bruits · Ankle-brachial pressure index (ABPI) or Toe-brachial pressure index (TBPI)may be used to aid with diagnosis · Venous refill with dependency (should be less than 30 seconds), the vein should bulge outward within 30 seconds of elevation for one minute. · Buerger’s test : to assess for arterial sufficiency When patient is supine: Note the color of the soles (should be pink) 1. Elevate both legs at 45 degrees for more than 1 minute 2. Observe the color of the soles: Pallor (whiteness) – indicates ischemia Rubor (reddish/purple) with dependency 3. Sit patient upright and observe feet. In normal patients the feet quickly turn pink. If it occurs slowly, they turn red or ischemia · Presence of varicose veins · Patient complaints of intermittent claudication · Complaints of pain · Doppler testing (assessment tool): Assess bilateral peripheral pulses and assess for: o Presence of pulse (present, diminished, or not audible) o Triphasic, biphasic or monophasic Sources: https://en.wikipedia.org/wiki/Peripheral_vascular_examination and https://www.clwk.ca/buddydrive/file/llafs-guideline-paper-only/ Accessed Oct 31st, 2019 C Color Pallor,pink, red, purple, blue, hemosiderin, black W Warmth Cold, cool, warm, hot M Movement Active and passive range of motion (ROM) is it normal or decreased S Sensation Patient complains of numbness, burning, tingling, electric shock, crawling sensation or absence of feeling. Assess if the sensation is bilateral, continuous, intermittent, or present during the day or at night

Source: https://en.wikipedia.org/wiki/Peripheral_vascular_examination