12.6 Inspection and Palpation of Hands and Arms

Peripheral vascular issues usually affect the lower limbs (feet and legs) more than the upper limbs, but you should begin a complete peripheral vascular assessment with the hands and arms because most clients feel comfortable exposing these areas. However, you might focus on a particular area such as the legs if the assessment is related to a physical trauma and you are concerned about perfusion to that limb. Assessment of the hands and arms can be done while the client is sitting on the side of the exam table or in a high Fowler’s or supine position.

Steps for inspecting and palpating hands and arms include:

Step 1: Inspect the skin of the hands and arms for symmetry, color (including nails), edema, limb circumference discrepancy, lesions, presence of ulcers, venous patterns, and hair distribution. Ask the client to place their hands and arms in front of them with their palms facing downwards, and then turn their palms upwards. Next, palpate skin temperature using the dorsa of your hands from the shoulders down the arms to the fingertips (see Video 3).

• Normally, the skin color is consistent and skin temperature is warm to touch and equal bilaterally from shoulders to fingertips, although the fingertips can be slightly cool to touch. Normally, there are no signs of cyanosis or pallor in the nails or fingertips. Nails are translucent in color with a slight pinkish tone underneath. Remember that the palms of hands are a lighter skin color, particularly among people with darker skin tones. Normally, there are no ulcers and no lesions, and circumference is equal bilaterally.
• Describe the location, size, and quality of any abnormal findings such as skin discoloration, signs of cyanosis, pallor, venous pattern, presence of ulcers or lesions, and hair distribution. With regard to quality, for example, you should note what the discoloration and the ulcers look like. Describe the location and quality of abnormal skin temperatures, particularly if asymmetrical. If you notice any discrepancy in terms of unequal limb circumference, measure with a flexible tape measure at the same location on both limbs to ensure accuracy. Note the location of any edema.
• Assessing hair distribution is important when evaluating for peripheral vascular disorders. Changes in hair growth on the limbs can indicate alterations in blood circulation. A reduction or absence of hair, especially on the lower legs, can be a sign of decreased arterial supply, which is often seen in conditions like peripheral artery disease (PAD). Observing these changes can help in the early detection and management of vascular issues.

Video 3: Palpation of skin temperature [0:17]

Step 2: Test capillary refill on two or three fingernails of each hand at heart level (see Video 4). Start by applying pressure with your own finger to the client’s nail; this causes the nail to blanch (become paler in color). Apply the pressure for 5 seconds and then release and observe the return in color. 

• A normal finding when assessing capillary refill is color return that is equal to or less than 3 seconds. 
• Color return that is greater than 3 seconds is described as sluggish return for capillary refill (or slow capillary refill time), and this finding suggests that there may be issues with oxygenated blood perfusion (this may be related to peripheral vascular and/or cardiac and/or respiratory issues). Capillary refill time can be slower if the client’s hands are cold; if the client’s hands are cold from being outside or from washing in cold water, ask them to warm their hands to ensure an accurate reading. 

Video 4: Testing capillary refill [0:45]

Step 3: Palpate the radial and ulnar pulses bilaterally and simultaneously, and then palpate the brachial pulses (see Figure 12.10). Assessing the pulses simultaneously allows you to compare the strength of pulsation; recall the 4-point scale for force. Assessing pulses for the presence, force, and symmetry of force provides information about perfusion (flow of blood) to the limbs. If these pulses are not palpable, you can use a Doppler ultrasound device to assess pulsatile blood flow. 

• Normally, pulses are present, 2+ force and equal bilaterally.
• Decreased pulse force or absent pulses can be associated with arterial insufficiency. A decreased pulse force (1+) can be described as “thready,” which refers to a weak pulse that is difficult to feel.

Figure 12.10: Palpation of radial and brachial pulses. Photo by James Heilman, MD, Creative Commons Attribution-Share Alike 3.0 from Wikimedia Commons.

Step 4: The Modified Allen Test is conducted to ensure collateral circulation before potential arterial cannulation. Both radial and ulnar pulses are palpated for rate, rhythm, and quality. This assessment is crucial for determining vascular health and planning for invasive procedures.

Step 5: Palpate for edema in the hands and upper arms: position the patient’s arms at heart level and gently press the skin at various points from the back of the hands to the upper arms. Observe for pitting, where the skin retains an indentation. Compare both arms for asymmetry and note the severity and location of any edema. Document these findings concisely, indicating whether the edema is pitting or non-pitting and any associated symptoms.

Step 5: Note the findings.

• Normal findings might be documented as: “From shoulders to fingertips: equal limb circumference with no edema or ulcers, skin color consistent and hair evenly distributed. Good capillary refill. Radial, ulnar and brachial pulses 2+ force and equal bilaterally. Skin temperature warm to touch and equal bilaterally from shoulders to fingertips.”
• Abnormal findings might be documented as: “Pallor in fingernails, cool to touch in fingers bilaterally, sluggish capillary refill 4–5 seconds, 1+ radial pulses equal bilaterally.”

Activity: Check Your Understanding