NURS 258 Lecture Notes - Lecture 12: Varicose Veins, Capillary Refill, Palpation
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South Dakota State University
College of Nursing, Department of Undergraduate Nursing
NURS 258: Nursing Principles and Application I: Assessment and Interventions
Peripheral Vascular Assessment
Overall fluid (lymph, blood) system
I. Subjective Data
A. Leg pain or cramps
- Constant, quality, how do you relieve the pain
B. Changes in skin on arms or legs
- Ulcers, thin skin, shiny skin, varicose veins (blood clots)
1. Color and temperature
- Difference in right and left*
C. Swelling (edema) of arms or legs
- Sock ring marks, shoes feel tighter, jewelry on fingers feels tighter
D. Exercise regularly
D. Smoking history
- Packs/day, how long
F. Family History: cardiac or respiratory disease, diabetes, varicose veins or blood clots
II. Objective Data
A. Inspect and palpate – adequacy of circulation, compare right and left sides
1. Arms/Hands
• Color, temperature – warm, pink
• Capillary refill – nail beds, count how many seconds it turns back to normal (less than 2 or 3
seconds)
• Nail beds or skin - color
• Epitrochlear lymph node – shake hands with the patient and then bring other hand up (may
indicate infection)
• Radial & brachial pulse – brachial is easier to feel on children and not adults
▪ Note rate(beats/min), rhythm(regular/irregular), symmetry (rt. vs. lft. sides)
▪ Grading pulses (amplitude) – force you feel
o 4+ (bounding)
o 3+ (full/strong)
o 2+ (normal/expected)
o 1+ (weak, thready)
o 0 (absent)
2. Legs – common for blood clots
• Symmetry (right and left sides)
• Calf circumference – done if there is a suspected blood clot
• Color, temperature – warm/cool
• Homan’s sign – OB, checking for blood clot, dorsiflex the patient’s foot – push toes up to tibia if
there is pain present may indicate blood clot
