How to document circulation assessment

[natrgrrl]

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?

Thanks.

[cardiacRN2006, ADN, RN]

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.

[TakeTwoAspirin, MSN, RN, APRN]

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).

[Daytonite, BSN, RN]

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:

• https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html and http://connection.lww.com/Products/bickley9e/documents/PDFs/ch08.pdf - assessment of the cardiovascular system which is on post #14 of that thread.