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Clinical Nursing Skills

24.2 Peripheral Vascular System

Clinical Nursing Skills24.2 Peripheral Vascular System

Learning Objectives

By the end of this section, you will be able to:

  • Identify the structures of the peripheral vascular system
  • Explain the function of the peripheral vascular system
  • Describe abnormalities in the peripheral vascular system

The peripheral vascular system plays a vital role in maintaining homeostasis—the body’s effort to maintain a relatively stable equilibrium between interdependent systems, which is accomplished via the body’s physiological processes. As nursing professionals, understanding the complexities of this intricate network of blood vessels is essential for providing comprehensive care to patients. The peripheral vascular system (PVS), consisting of arteries, veins, and capillaries, extends beyond the heart and encompasses the circulatory pathways that reach various tissues and organs. This system is responsible for the transportation of oxygen, nutrients, and waste products throughout the body, contributing significantly to homeostasis and overall well-being.

Nurses must have a comprehensive understanding of the peripheral vascular system. Application of the knowledge is crucial for assessing, diagnosing, and managing various health conditions. Disorders affecting this system can range from peripheral artery disease (PAD) and venous insufficiency to deep vein thrombosis (DVT) and varicose veins. By gaining insight into the anatomy, physiology, and common pathologies of the peripheral vascular system, nurses are better equipped to identify early signs of vascular dysfunction, implement preventive measures, and provide optimal care to individuals at risk for or affected by these conditions.

The peripheral vascular system intersects with other areas of nursing care, such as wound healing, surgical interventions, and chronic disease management. Nurses play a pivotal role in promoting vascular health, offering patient education on lifestyle modifications, and collaborating with interdisciplinary teams to ensure holistic care. This exploration of the peripheral vascular system serves as a foundational guide for nursing professionals, empowering them to navigate the complexities of vascular health and contributing effectively to the well-being of their patients.

Structures of the Peripheral Vascular System

The peripheral vascular system (PVS) comprises the arteries and veins that are responsible for systemic circulation of blood throughout the body. Although the heart is the primary organ in the cardiovascular system, the peripheral vascular system ensures blood is distributed to the various tissues throughout the body, ensuring oxygen and nutrients are provided for optimal physiological function and overall health. The PVS can be described as the aorta and its branches including the arteries, arterioles, capillaries, venules, and veins.

Arteries of the PVS are conduits that transport oxygenated blood away from the heart to the tissues and organs throughout the body. Conversely, veins form an integral pathway for the return of deoxygenated blood from the body’s tissues back to the heart (Figure 24.11). This intricate system, with its arterial-venous interplay, functions harmoniously to maintain the vital processes essential for the sustained well-being of the individual.

The left side shows a diagram of the arterial blood flow, and the right side shows a diagram of the venous blood flow.
Figure 24.11 (a) The arterial blood flow of the peripheral vascular system supplies the body with nutrients, transporting oxygen to organs and tissues. (b) The venous blood flow of the peripheral vascular system transports deoxygenated blood back to the heart and waste for elimination. (credit a and b: modification of work from Anatomy and Physiology. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)


Tubelike vessels called arteries made of smooth muscles are responsible for transporting blood away from the heart via the aorta. This blood is referred to as arterial blood because it is fully oxygenated, giving it its bright red pigmented appearance. Arterial blood first and foremost delivers oxygen to the tissues in the body. The cells ultimately use the oxygen to drive cellular respiration in order to create adenosine triphosphate (ATP). ATP is a nucleotide that collects chemical energy produced by the breakdown of food molecules to provide the energy necessary for all cellular activities (e.g., muscle contraction, transmitting nerve signals [nerve impulse propagation], breaking down the liquid-like substances within cells [condensate dissolution], making new molecules [chemical synthesis]). It is also involved in signal transduction pathways, DNA synthesis, and cell communication.

Arteries consist of multiple layers that are strong, elastic, and capable of dilating and recoiling as they respond to cardiac systole and diastole. As the heart contracts and pumps blood out into the vessels (systole), arteries dilate to accommodate the high pressure. Recoil then occurs as the blood is pushed through the arteries, thus creating a wave, recognized as a pulse. This relaxed phase of the cardiac cycle when the chambers of the heart are refilling with blood is called diastole.

The primary functions of the arteries are not only transportation of oxygen but also transporting nutrients and hormones throughout the body and aiding in thermoregulation. Arteries also provide oxygen and nutrients to the uterus during pregnancy, allowing for proper fetal growth. These highly adaptable vessels respond to signals and stimuli received from the central nervous system and the environment, such as temperature, chemicals, air pollution, and atmospheric pressure. A hormone neurotransmitter called catecholamines is released into the blood, triggering the nerves to signal the arteries to constrict or dilate based on the stimuli, thus causing a change in blood pressure. This reaction is important in maintaining homeostasis as well as optimal perfusion to tissue.

While arteries primarily carry oxygenated blood away from the heart to the body, the pulmonary artery moves deoxygenated blood from the heart to the lungs to engage in gas exchange in the alveoli. After oxygenation occurs, the arteries and veins of the pulmonary system switch roles. The pulmonary vein transports oxygenated blood back to the heart to be pushed out through the aorta to the body.

Branching from the arteries are arterioles, where blood is directed into the capillaries (Figure 24.12). These vessels have sympathetic nerve fibers that receive signals from the sympathetic nervous system, which helps to regulate the amount of blood flow to tissues. This regulation of the sympathetic nervous system triggers the arterioles to constrict, thus increasing the resistance of blood flow. When the system triggers the arterioles to dilate, the resistance is decreased. Hormones, including angiotensin II, travel through the bloodstream to act on tissues throughout the body. A local signaling molecule, such as prostaglandin, is released and act on a specific part of the body. Both hormones and local signaling molecules can also trigger an arteriole diameter response.

A diagram showing how arterioles connect arteries with capillaries.
Figure 24.12 Arterioles are the vessels that connect the arteries with the capillaries. As blood reaches the tissue, the arteries become smaller (arterioles) so that blood can completely saturate the tissues through capillary exchange. (credit: modification of work from Anatomy and Physiology. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Life-Stage Context

Arteries and Aging

During the aging process, health issues arise that often affect the cardiovascular system. Arteries stiffen and thicken, which is caused not only by advanced age, but also poor diet, sedentary lifestyle, and genetic factors. Hypercholesterolemia is a primary cause of this thickening of the arteries in the form of plaque buildup known as atherosclerosis. The arteries can also become hard or thick from other causes. The term arteriosclerosis encompasses the other reasons for the stiffening, which could include inflammation or smoking. Whatever the cause, thickening of the arteries increases strain on the heart that can lead to congestive heart failure. Continuous blockage of arteries leads to obstruction of blood to vital organs, such as the heart, resulting in ischemia, which increases the risk of myocardial infarction.


Thin-walled, low-pressured vessels, known as veins, are less elastic-like than arteries. This allows for high capacitance, which is defined as a greater volume of blood at a much lower pressure. Venous blood is returned to the heart from the periphery by veins through skeletal muscle contraction. Unlike arteries that rely on cardiac systole to assist in the forward movement of blood, the veins are farther away from the heart and require the muscles surrounding them to contract and squeeze blood forward. Intraluminal valves located within the veins prevent blood from flowing backward, maintaining a forward flow.

Blood flow through the lower extremities relies heavily on muscle contraction to return blood to the heart. The forward movement of blood from these extremities also relies on changes in respiration that affect the pressure gradients in both the abdominal and thoracic cavities. Deep inspiration brings a higher pressure than what is observed throughout the entire respiratory cycle. This is another example of how the cardiovascular and respiratory systems work interdependently to maintain homeostasis.

When deoxygenated blood enters the capillaries, it moves through the venules into the veins. Like arterioles, venules are tiny vessels that transition from the capillaries into the larger return vessels that carry blood back to the heart. These vessels are small, yet highly porous, and play an integral role in gas exchange in the tissue. Working in conjunction with capillaries, the postcapillary venule regulates solute exchange. This is the segment of microvasculature most reactive to inflammation. Postcapillary venules contain intercellular endothelial junctions that allow plasma proteins and circulating cells (leukocytes) to exit from the bloodstream in response to foreign agents (e.g., infection, inflammation).

Functions of the Peripheral Vascular System

The function of each segment of the PVS is dependent on the organ it supplies. The PVS plays an important role in perfusion and oxygenation of tissues of the periphery, the areas away from the center of the body. When perfusion is altered or impaired, there is risk for issues to occur such as hypoxia, tissue damage, necrosis, and even shock. Perfusion occurs as oxygenated blood from the lungs is transported to the left side of the heart and pumped out through the aorta. The oxygenated blood is then pumped to the arteries, arterioles, and into capillaries where nutrients and oxygen are exchanged. Blood that is rich in carbon dioxide, or deoxygenated blood, is then transported back to the heart from the capillaries, through venules, then veins into the right side of the heart via the superior and inferior vena cavae. This deoxygenated blood is then pumped through the heart to the lungs via the pulmonary artery to be exchanged in the capillaries of the alveoli with oxygen-rich blood.

Nutrients are supplied to the tissue in the same way as oxygenated blood that has picked up oxygen in the lungs for delivery to the body. Macromolecules such as carbohydrates, fats, and proteins along with essential vitamins and minerals are absorbed through the small intestine into the capillaries. Once in the bloodstream, nutrients are carried to various tissues by veins and venules. These vessels are smaller than arteries so nutrients are absorbed more slowly, which also allows for the exchange of waste in the capillaries. Waste is then transported in the bloodstream to the organs of elimination. For example, excess water carrying waste is transported to the kidneys and processed for elimination, whereas toxins in the blood are filtered through the liver.

Capillaries and Fluid Exchange

Capillaries are the smallest vessels where fluid is exchanged throughout the body at the cellular tissue level. It is at this point where oxygen, nutrients, hormones, waste, and other molecules are exchanged. Smaller molecules (e.g., gases, lipids) can diffuse directly through endothelial cells of the capillary wall. Larger molecules (e.g., glucose, sodium, potassium, calcium) use transporters to move through the membrane by facilitated diffusion. Water moves across the membrane through osmosis. The thickness of the artery and arteriole walls limits premature exchange of oxygen-rich blood and nutrients, allowing for optimal perfusion at the tissue level. Capillaries are classified by their function as well as structure and arrangement of endothelial cells and basement membrane. This allows for the exchange of molecules needed for specific tissue function (Figure 24.13).

A diagram of the exchange of oxygenated and deoxygenated blood.
Figure 24.13 Loading and unloading of nutrients occur within the capillaries that are attached directly to tissues. Exchange of oxygenated and deoxygenated blood occurs at this level to maintain homeostasis. (credit: modification of work from Biology. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Common in muscle, connective, and nervous tissues are continuous capillaries and they have the lowest permeability capabilities of all capillaries. Molecules needed for function (e.g., water, glucose, hormones, gases) can pass through these capillaries, but large molecules (e.g., plasma proteins, platelets) are blocked. Continuous capillaries create the blood-brain barrier that prevents toxins from entering into the tissues of the brain. The brain, however, does need rapid absorption and filtration of vital nutrients, water, and glucose, which is provided through continuous capillaries that have small pores in them. These are called fenestrated capillaries, and they are located in areas that require rapid absorption or filtration (e.g., kidneys, small intestines, brain). These capillaries have many fenestrae, which are like windows or pores, and provide no resistance to fluid flow across the membranes. Found in areas where white blood cells are formed are sinusoid capillaries and they have large pores that are required to allow for movement of these cells in and out of the bloodstream. These capillaries can be found in areas such as red bone marrow and the liver. Red bone marrow produces red and white blood cells and platelets. On the other hand, yellow bone marrow produces fat, cartilage, and bone.

When material is transferred between capillary blood and body tissues, this is capillary exchange, which is essential for delivery of nutrients and removal of waste products. Fluid exchange in the capillaries occurs through opposing forces called hydrostatic and osmotic pressures. The pressure of fluids against the walls of the capillaries that forces molecules, typically water, through the capillary wall is called hydrostatic pressure. While osmotic pressure is the minimal pressure of a solution needed to stop the movement of a solute across a semipermeable membrane. Osmotic pressure works to prevent the movement of water across a semipermeable membrane to maintain homeostasis between intracellular and extracellular fluid. It is important to note that in this process, solutes cannot pass through the capillaries, only the solvent (e.g., water) (Figure 24.14).

A diagram showing how osmosis occurs.
Figure 24.14 (a) Osmosis occurs when the solution becomes heavy with solvent or solute, causing an imbalance in the tonicity of the solution, which causes a buildup of pressure and forces the solvent to move through the semipermeable membrane. (b) The tonicity of a solution determines whether the solvent moves in or out of the cell. Isotonic solutions have equal amounts of solutes and solvent so no movement occurs; hypertonic solutions have more solutes outside the cell, causing water to move out of the cell to balance the solution and hypotonic solutions have lower solutes in the cell, causing water to move inside the cell to maintain balance. (credit a and b: modification of work from Chemistry. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Capillary exchange occurs through one of three mechanisms: diffusion, transcytosis, and bulk flow. Diffusion depends on a difference in the gradient between the blood and interstitial tissue to allow the flow of small molecules across the capillary wall. Molecules, such as glucose and oxygen, are moved from the bloodstream into the tissue, and waste products, such as carbon dioxide, move from the tissue into the bloodstream. This is the most widely used mechanism within the body that allows movement of molecules from areas of high concentration to areas of low concentration.

Transcytosis allows for larger, lipid-insoluble substances to cross the capillary membrane through processes called endocytosis and exocytosis. Endocytosis brings molecules into the cell, allowing for nutrient absorption and hormone regulation as well as maintaining fluid balance. Exocytosis is the process of moving molecules out of the cell to be eliminated or moved to another area of the body.

Net filtration pressure to modulate capillary dynamics using small, lipid-insoluble solutes in water to cross the capillary wall is called bulk flow. Movement across the wall is bidirectional based on hydrostatic or osmotic pressure (Figure 24.15). Osmotic pressure (also called oncotic or colloid osmotic pressure) is exerted by proteins, and hydrostatic pressure is generated by the pressure of fluid within or outside the capillary on the capillary wall. Net filtration pressure, the sum of forces, determines the fluid flow in or out of the capillary. Larger plasma proteins (e.g., albumin) cannot cross easily through the capillary walls, resulting in fluid leakage from the capillaries. However, when there is decreased volume of plasma proteins, or blood pressure is increased significantly, there is a change in net filtration, causing excess fluid buildup in the tissues (edema).

A diagram showing capillary microcirculation.
Figure 24.15 Capillary microcirculation involves hydrostatic and osmotic pressures that move molecules across the capillary wall. (credit: modification of work “Capillary microcirculation.svg” by “Kes47”/Wikimedia Commons, Public Domain)

Abnormalities in the Peripheral Vascular System

Common disorders of the peripheral vascular system (PVS) include peripheral artery disease (PAD) and peripheral vascular disease (PVD). Typically, abnormalities that occur in the PVS are occlusive or functional in nature, both of which involve blockage or narrowing of the blood vessels in the periphery (Figure 24.16).

A diagram showing the difference between a normal artery and an atherosclerotic artery.
Figure 24.16 Both peripheral artery disease (PAD) and peripheral vascular disease (PVD) involve narrowing of the peripheral blood vessels typically caused by a buildup of plaque. (credit: modification of work “Peripheral Arterial Disease.gif” by National Heart Lung and Blood Institute/Wikimedia Commons; Public Domain)

An obstructive or organic blockage, called an occlusive blockage, involves inflammation, plaque buildup, or trauma to tissue. A functional blockage involves changes in the vessels as a result of temperature, blood pressure, and various nervous system signals. These changes cause dilation (widening) or constriction (narrowing). Some abnormalities are cosmetic (e.g., varicose veins) but others are more severe and can lead to crisis (e.g., deep vein thrombosis (DVT)) (Table 24.2).

Occlusive Disorders of the PVS
Condition Description Risk
Atherosclerosis Thickening or hardening of the arteries over time
  • Potential heart attack or stroke
Buerger disease (thromboangiitis obliterans) Chronic inflammatory condition that blocks blood flow in the minor arteries of the extremities; Almost all people who get Buerger disease smoke cigarettes or use other forms of tobacco (e.g., chewing tobacco)
  • Blood clots and blockages typically experienced in the feet first and eventually the hands
  • Infection and death of body tissue (gangrene)
  • Amputation of fingers and toes if patient does not stop all forms of tobacco consumption
Carotid artery disease Narrowing of the carotid artery that impairs oxygenation to the brain
  • Stroke
Deep vein thrombosis (DVT) Blood clots that develop in a vein within a muscle (deep vein); typically, after long periods of inactivity
  • Pulmonary embolism (blockage of the lung artery) if the clot dislodges and travels to the lungs
Lymphedema Swelling caused by buildup of lymph (fluid in the lymphatic system that travels through the body to fight disease and infection)
*Note: There is a higher incidence of lymphedema in people who have had or are undergoing cancer treatment, (e.g., surgery, radiation therapy)
  • Problems moving the affected limb
  • Skin changes and breakdown
  • Increased risk of skin infections and sepsis
Functional Disorders of the PVS
Condition Description Risk
Chronic venous insufficiency (CVI) Dysfunction of the valves in the veins that prevent the return of blood from the legs to the heart
  • Pooling of blood in the legs
  • Leg pain and swelling
  • Leg ulcers
Raynaud phenomenon Decreased blood flow to the fingers (and sometimes ears, toes, and nose) brought on by cold temperatures and stress or anxiety
  • Minimal
  • Cold fingers
  • Pain is usually not experienced
Varicose veins Enlarged, twisted, visible, often blue veins caused by venous insufficiency; typically occur in the legs as a result of pregnancy, obesity, and extended periods of standing
  • Cosmetic discoloration of the skin
  • Slight pain in some cases
Table 24.2 Occlusive and Functional Disorders of the Peripheral Vascular System

Characteristics of Arterial and Venous Insufficiency

Patients experience an insufficient supply of blood throughout the body when narrowing of the arteries and veins occurs, which is caused by systemic atherosclerosis. The most affected areas are the lower extremities because of their distance from the heart. A primary symptom of peripheral vascular disease is intermittent claudication, a cramp-like muscle pain, burning sensation, or extreme fatigue in the calf, thigh, or buttocks that is induced by exercise and relieved by rest. Acute or critical limb ischemia may occur if left untreated.

Patient Conversations

What If Your Patient Complains About Leg Pain?

Scenario: An 80-year-old female presents to the primary care provider’s office with complaints of new onset leg pain. The nurse begins to ask the patient questions before beginning a physical assessment.

Nurse: Hi, my name is Rachel, and I am going to be your nurse today. Do you mind verifying your name and date of birth for me?

Patient: I’m Elizabeth Johansen and my birthday is March 26, 1944.

Nurse: Can you tell me why you came to see us today?

Patient: I’ve been taking my dog for a walk three times a day for literally ten years. Probably a couple of months ago I started to notice that after walking a little bit, my calf starts hurting. It gets bad enough that I have to sit down till it goes away.

Nurse: Show me where it hurts and tell me what the pain is like.

Patient: The worst of the pain is right here [Patient points to her right calf]. At first, my right leg just feels real tired but then I get like a charley horse in my calf and it starts to burn.

Nurse: Does this happen to your left leg?

Patient: No, just my right leg. But it goes away after I rest a bit. That’s why I waited to come in. I thought it would just go completely away. But it isn’t—in fact I think it might be getting worse.

Nurse: Do you have a current or past history of smoking?

Patient: No, not ever.

Nurse: That’s good because some vascular conditions are caused or made worse if you smoke. I see that your weight is good for your height and your blood pressure was good this morning. According to your medical record, you’re not taking any medicine for diabetes, high blood pressure, or high cholesterol. Is that correct?

Patient: Yes, I may be old [Patient laughs] but I am actually in good health.

Nurse: Yes, I can see that and you have a great sense of humor too! May I examine your legs? [Patient nods yes] I feel the pulses in your left foot very well but the pulses in your right foot seem less in comparison. And your right foot feels a little cooler.

Patient: Is that bad?

Nurse: Not necessarily but it does indicate that something is going on. It could be intermittent claudication, which is pain caused by too little blood flow to muscles during exercise, such as walking. Intermittent means the pain usually isn’t constant; it begins during exercise and ends with rest.

Patient: That sounds exactly what I’ve been feeling. Can it be fixed?

Nurse: Yes, but first we need you to see your doctor and probably get some tests down. Do you have time to wait a bit while I have the doctor come in to talk to you?

Patient: Yes, I do. That’s great; I’d hate to have to wait weeks to figure this all out.

Nurse: Good. Do you need a magazine to read while you wait or a bottle of water?

Patient: No, I always carry a book with me and I have a bottle of water right here in my purse so I’m good for now.

Nurse: Okay, the doctor should be in to see you soon.

Vascular insufficiency in the extremities manifests as delayed venous filling time, cool skin, and abnormal skin color. An abnormal pedal pulse may be palpated and femoral artery bruit may be heard on auscultation. Findings may be subtle or there may be no symptoms, making diagnosis difficult. Diagnostic testing is critical in determining proper treatment. The ankle-brachial index (ABI) is the most common test used for patients in the outpatient setting. Blood pressure from the brachial artery in the arm is taken and compared with blood pressure from the posterior tibial and dorsalis pedis arteries in the ankle (Figure 24.17). Accurate results of the ABI depend on the provider’s ability to perform the test correctly.

A diagram explaining the ankle-brachial index (ABI) test).
Figure 24.17 The ankle-brachial index (ABI) test is used to determine blood flow to the heart. (credit: modification of work “Pad abi.jpg” by National Heart Lung and Blood by (NIH)/Wikimedia Commons; Public Domain)

Both venous and arterial insufficiencies are the result of systemic atherosclerosis, but in different types of vessels. Blockage in the veins between the extremities and heart is venous insufficiency and can result in thick, tough skin that is brownish in color Figure 24.18).

An image of a leg with venous insufficiency.
Figure 24.18 Venous insufficiency is a decrease in blood flow back to the heart from the legs. The skin of the lower leg will be thick and brownish in color. (credit: modification of work “Venoplasty and Venous Stenting in Patients with Chronic Venous Insufficiency in the Lower Extremities” by National Library of Medicine, CC BY 3.0)

In contrast, arterial insufficiency is blockage in the arteries, limiting blood flow to the extremities and resulting in thin, shiny, dry skin that is cool to the touch.


Edema is the collection of excess tissue fluid in the interstitial space outside of the cell that results in swelling. This occurs most often in the lower extremities throughout the day caused by gravitational pull and is seen in people who stand or sit for long periods of time (e.g., long-distance airplane flights and car trips). The problem is immobility secondary to the lack of muscle contractions. However, clinical edema is the accumulation of fluids that is in excess of normal daily occurrences and requires medical intervention. Table 24.3 describes the various types of edema.

Type of Edema Description
Peripheral edema Swelling of the feet, ankles, legs, hands, and arms
Pulmonary edema Collection of excess fluid in the lungs, making breathing difficult
Cerebral edema Excess accumulation of water in the intracellular and/or extracellular spaces of the brain
Macular edema Swelling of the macula (part of the retina) caused by fluid leakage and accumulation; a serious complication of diabetic retinopathy
Periorbital edema Swelling around the eyes, most often temporary
Table 24.3 Types of Edema

Venous blood is forced toward the heart by the skeletal muscle pump or muscle contractions, which include one-way valves to prevent blood from backing up in the vessels. A lack of use of these muscles and pumps, or dysfunction in the cardiovascular system, contributes to lower extremity edema. Often, this is a result of patients being non ambulatory or relying primarily on a wheelchair. Blood flow to the legs becomes congested because of increased hydrostatic pressure caused by decreased function.

An early indicator of venous dysfunction is dependent edema, which is measured by placing slight pressure with a finger in the area of swelling to determine the degree of pitting. A pitting edema is rated based on the depth of indentation and the time it takes to recover. This rating is on a scale of 0 (absent, no clinical findings) to 4+ (very deep pit that lasts up to two to five minutes) (Figure 24.19) (Swenty & Hall, 2020).

A diagram showing the different grades of edema.
Figure 24.19 Edema is measured by placing slight pressure on the area of swelling, releasing, and then determining the lapse in recovery. (credit: modification of work “Grading of Edema” by Chippewa Valley Technical College; CC BY 4.0)

Heart failure, liver disease, pregnancy, dietary intake, kidney disease, and some medications all contribute to the onset of edema as well as the severity of the condition. It is important to understand that edema is not a discrete disorder but a sign of an underlying disorder that must be addressed. Although edema can occur in any area of the body, the lower extremities are most often affected in peripheral vascular disease. Heart failure, hypertension, and deep vein thrombosis (DVT) are all disorders that must be accurately diagnosed to properly treat and alleviate edema.

Hypoalbuminemia contributes to the reduced oncotic pressure that manifests as hair loss in some chronic illnesses such as nephrotic syndrome, lupus nephropathy, and chronic glomerulonephritis. Cirrhosis and chronic liver disease (e.g., hepatitis C, alcohol abuse) also contribute to inadequate albumin absorption leading to edema. When swelling is unilateral, or asymmetrical, the cause is most often due to venous thrombosis. Accurate assessment and testing is needed to determine the exact location of edema and create a comprehensive nursing care plan. Cardiomyopathies that produce equal involvement of both left and right ventricles will manifest as both pulmonary and peripheral edema. However, right-sided heart failure (also called cor pulmonale) will manifest with edema in the extremities (Lent-Schochet & Jialal, 2023).

Signs of edema are determined by the underlying contributing factor but most often begin with swelling of the ankles. Swelling that begins to rise into the legs should warrant a thorough assessment. Signs and symptoms that may accompany swelling include shortness of breath and pitting edema.

Real RN Stories

Frequent Hospital Visitors

Nurse: Natasha, BSN
Clinical setting: Preoperative area of a busy operating room
Years in practice: 7
Facility location: A suburb of a large metropolitan area in Colorado

We serve a diverse, lower-to-middle class, large retirement-age population. I was working the 7 a.m. to 3:30 p.m. shift. One of my patients arrived with her husband and adult daughter around 9:15 a.m. in preparation for corneal transplant surgery early that afternoon.

After having the patient change into a hospital gown and slippers, I took vital signs including weight (171 lbs. [78 kg]), height (5′ 2″ [157 cm]), and pain level (3/10). I completed the ophthalmic portion of the assessment, and then began to perform the rest of the admission assessment. I noted that the patient had lower extremity edema and swelling that encompassed both feet and rose to the midcalf. I noted that it was pitting edema and I rated it as moderate, with pitting approximately 5 mm in depth that took almost thirty seconds to resolve.

I realized that edema is not a discrete disorder—it’s a sign of an underlying condition. So, I needed to get more information from the patient to determine the cause. First, I asked the patient about the edema—how long ago it started, does anything help it (such as elevation), does anything make it worse (such as sitting with feet dependent on the floor), whether she had any unexplained abdominal fullness or sudden weight gain, or any shortness of breath.

I also looked at the patient’s medical record and noted that she was a smoker, had high blood pressure, and that her mother had died of congestive heart failure. So, based on her history and the assessment, I was concerned that the edema was a sign of heart failure. I documented my findings in her chart and notified the surgeon.

Pain and Cramping

Symptoms of peripheral vascular disease (PVD) depend on the affected artery and the severity of blood flow restriction. A condition in which oxygen-rich blood flow is restricted or reduced in a part of the body is called ischemia. Indications of PVD can include pain and cramping that is dull, numbing, or tingling. Intermittent claudication is pain in the calves, thighs, and buttocks that occurs when walking distances and is relieved with rest. However, as the disease progresses, pain occurs when walking shorter distances and can cause a limp. Over time, the pain may become severe, prohibiting walking completely. While most often experienced in the calves and upper legs, the feet and hips may be affected as well. Intermittent claudication is most often experienced in men older than age 55 and women aged 60 and older (Lent-Schochet & Jialal, 2023).

During a peripheral vascular assessment, it is important to ask if pain is intermittent, relieved with rest, or continuous. Asking these questions can help determine the potential for secondary conditions, which can manifest as leg pain on exertion but is relieved when at rest, or exertional leg pain that continues on, even when at rest. The location of pain along with how the patient describes the quality of pain can also indicate the site of potential ischemia:

  • Thigh: common femoral, aortoiliac
  • Upper calf: superficial femoral
  • Lower calf: popliteal
  • Buttock, hip: aortoiliac
  • Foot: tibial, peroneal
  • Genitalia: aortoiliac-pudendal

Based on the patient’s description and location of the pain, the nurse should notify the provider and then provide pain relief measures and continue to monitor for tissue perfusion. Other interventions may include observing for deep vein thrombosis (DVT), assessing popliteal and pedal pulses, assisting with position changes, and administering anticoagulants and pain medication as ordered. Nurses also should provide patient and family education to include instructions on how to safely apply warmth to the area, encourage range-of-motion (ROM) exercises, exercise therapy, and ambulation as tolerated. It is also important to provide education to the patient on at-home care, which should include dietary recommendations.

Temperature Changes

The temperature of the skin is affected by insufficient blood flow to and from the tissues. Interrupted blood flow to the tissue results in arterial insufficiency, and interrupted blood flow away from the tissue is venous insufficiency. Chronic, or advanced, insufficiency can result in damage to the tissue of the extremities, including ulceration and gangrene. Skin that is cold and clammy, especially over the lower legs, is attributed with arterial insufficiency. Skin that is warm with edema around the ankles are attributed to venous insufficiency (Table 24.4).

Arterial Ulcers Venous Ulcers
Intermittent claudication pain Dull, achy pain
No edema Lower leg edema
No pulse or weakened pulse Pulse present
No drainage Drainage
Round, smooth sores Sores with irregular borders
Black eschar Yellow slough or ruddy skin
Sores on feet or toes Sores on ankles
Table 24.4 Arterial versus Venous Ulcers The differences in arterial and venous insufficiency can be recognized by the type of pain and edema present, ability to palpate pulses, and the location of sores. For example, arterial insufficiency will have intermittent claudication pain, no edema, and sores on the toes and feet; venous insufficiency will have pain that is described as dull and achy, lower leg edema, and sores located on the ankles.

Skin Changes

Just as there are changes in skin temperature with blood flow insufficiency, there are skin changes as well. Skin on the lower legs that appears thin and shiny with hair loss is attributed to arterial insufficiency. Skin also may be pale on elevation and reddened on dependency. Nails appear thickened and ridged. Ulcerations can occur at points of trauma on the toes or feet. In contrast, skin around the ankles that appears thickened and brown is attributed to venous insufficiency. Skin may be cyanotic on dependency with petechiae occurring prior to brown pigmentation. Stasis dermatitis, also called venous eczema, may also be seen around the ankles. If ulcerations occur, they are typically found over the medial side of the ankle (Patel & Surowiec, 2023).

Clinical Safety and Procedures (QSEN)

QSEN Competency: Assessment of Support System

Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Competency: Examine common barriers to active involvement of patients in their own healthcare process.

Exemplar: Patient A is an inpatient receiving wound care related to peripheral artery disease (PAD). The patient lives alone and has not been adhering to recommendations for diet, smoking cessation, and compression stockings. When asked, the patient states the closest family member is a daughter who lives about two hours away.

Solution: Ensure patient is supported at home, has transportation to and from appointments, and fully understands what is being requested of them.


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