Assess Periphery

• Progress to patient‘s periphery looking for abnormalities in general
• Assess general circulation by checking temperature and capillary refill
• Depress the tip of the fingernail until it blanches. Quickly release the pressure… normally the finger will become pink again almost instantaneously
• More sluggish reperfusion can indicate a slower peripheral circulation as can occur in heart failure
• Observe and compare the size, temperature, symmetry and swelling of the limbs
• Assess for edema
• Palpate dorsalis pedis and posterior tibial pulses
• Refer to the Blood Pressure and Pulse Assessment pop-up
• Because edema varies dependent on the position of the body, daily weights are the best measure of changes
• Applying pressure to the edematous area and observing the indentation left by that pressure is the best way to assess pitting edema
• The severity is described on a scale from 0-4 (none to very marked)
• Refer to the ‘Abnormal Findings’ module for a detailed description of other abnormalities that may occur