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Needs practice
Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
skill 2-10
Assessing the peripheral vascular system
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
Goal:
The assessment is completed accurately without causing
the patient to experience anxiety or discomfort, the findings
are documented and the appropriate referral is made to other
healthcare professionals, as needed, for further evaluation.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
tape measure, Doppler ultrasound device,
conductivity gel (if indicated).
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), if indicated.
8. Ensure patient privacy is maintained and that
interruptions are minimal.
9. Undertake a health history, as per Skill 2-1.
10. Help the patient to undress, if needed, and provide a
patient gown. Assist the patient to a supine position. Use
a blanket or drape to cover any exposed area other than
the one being assessed.
11. Begin with a survey of the patient’s overall hygiene and
physical appearance.
12. Inspect the upper extremities for skin colour, oedema,
venous pattern, hair distribution and the presence of
lesions, rashes or ulcers. Measure circumference of limb
and compare bilaterally. Inspect the nail beds for colour
and clubbing. Compare bilaterally.
13. Palpate the radial and brachial pulse points noting
the strength of the pulse (use ultrasound Doppler if
required), the skin temperature and texture and the
presence of masses. Compare bilaterally.
14. Assist the patient to a supine position. Examine the
lower extremities. Inspect the legs and feet for skin
colour, oedema, hair distribution, muscle mass and the
presence of lesions, ulcers and varicosities. Measure the
circumference of each limb and compare bilaterally.
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