VASCULAR ASSESSMENT
The vascular assessment will answer the question “Does the wound have enough blood supply to heal?”
Healthy tissue is bright, beefy red, shiny, and granular with a velvety appearance. Tissue with poor
vascular supply is pale pink or blanched to dull, dusky red color.
Physical vascular assessment includes: peripheral pulses, temperature, presence or absence of hair,
mild to severe pain, rest pain, edema, and gangrene. The vascular assessment should also include:
Pallor: White, pale, blanched color of a limb when in the upright position.
Rubor: Dark purple to bright red color of a limb when in a dependent position.
Intermittent claudication: Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance. This suggests intermittent claudication and is caused by muscle ischemia.
Mottling or mottled skin: Irregular patchy skin coloring. Refers specifically related to blood
vessel changes in the skin which cause the patchy appearance. This may indicate
vascular insufficiency.
Capillary refill: The measurement of the rate of blood refill in empty capillaries . Measured
by pressing a nail bed or area of tissue until it turns white and then timing until the
return of color once the pressure is released. Normal refill time is less than 2 seconds.
Diagnostic studies for vascular assessment:
Transcutaneous oxygen measurement (TCOM)
Ankle brachial index (ABI)
Arterial duplex scan
Arteriogram
Magnetic Resonance Arteriogram (MRA)
Matthew Livingston R.N. C.W.S.