How to document circulation assessment

  1. 0
    What do I include in a client assessment for circulation?
    So far I have color, temperature, edema, pedal pulse.
    When assessing pedal pulse do I use a number like +3 or do I use words like weak or strong?


    Get the hottest topics every week!

    Subscribe to our free Nursing Insights: Student Edition newsletter.

  2. 3 Comments...

  3. 1
    Capillary refill as well.

    I chart the pulses as +2 or +1, but you can also chart as weak, thready, bounding. It's up to you and what your teacher wants.
    natrgrrl likes this.
  4. 1
    I would probably start with the heart. It's the primary organ of circulation and no evaluation of the entire circulatory system should take place without it (or at least that's what I think).
    natrgrrl likes this.
  5. 2
    Assessment of the circulation includes observation and documentation of/for the following:
    • general
      • fatigue
      • syncope
      • symmetry of extremities
    • chest
      • chest pain
      • palpitations
      • dyspnea
    • skin and appendages (also note the nail beds and conjunctiva)
      • temperature
      • capillary refill
      • color changes (pallor, cyanosis, redness, brownishness)
      • shiny skin
      • presence of any ulcers
      • condition of the nails
      • presence or loss of hair
      • (dependent) edema (nonpitting or pitting)
    • numbness
    • tingling
    • blood pressure (lying, sitting and standing)
      • by palpation
      • by auscultation
    • pulses
      • rate and rhythm
      • pulsus alternans - alternating pattern of a weak and a strong pulse that occurs at regular intervals
      • pulsus bigeminus - same as pulsus alternans but occurs at irregular intervals
      • pulsus paradoxus - increased and decreased amplitude in pulse associated with respirations
      • thrills - vibrations you can feel over turbulence
      • bruits
    • heart sounds
      • normal
      • S3 ventricular gallop
      • S4 atrial gallop
      • friction rub
      • murmur
      • clicks
      • snaps
    Pules are graded on a four-point scale as follows:
    4+ = bounding
    3+ = increased
    2+ = normal
    1+ = weak, diminished
    0 = absent
    You should also check the links on this sticky thread:
    cherylshepherd and natrgrrl like this.

Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

A Big Thank You To Our Sponsors