{"id":1194,"date":"2022-11-05T14:17:29","date_gmt":"2022-11-05T18:17:29","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/inspection-and-palpation-of-hands-and-arms\/"},"modified":"2024-05-03T15:46:15","modified_gmt":"2024-05-03T19:46:15","slug":"inspection-and-palpation-of-hands-and-arms","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/inspection-and-palpation-of-hands-and-arms\/","title":{"raw":"Inspection and Palpation of Hands and Arms","rendered":"Inspection and Palpation of Hands and Arms"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">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\u2019s or supine position.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Steps for <strong>inspecting and palpating hands and arms<\/strong> include:<\/span><\/p>\r\n\r\n<ol>\r\n \t<li style=\"text-align: left\"><strong style=\"color: #000000;font-size: 1em\">Inspect the skin<\/strong><span style=\"color: #000000;font-size: 1em\"> of the hands and arms for colour (including nails), edema, limb circumference discrepancy, lesions, presence of ulcers, and venous patterns<\/span><span style=\"color: #000000;font-size: 1em\">. 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, <\/span><strong style=\"color: #000000;font-size: 1em\">palpate skin temperature<\/strong><span style=\"color: #000000;font-size: 1em\"> using the dorsa of your hands from the shoulders down the arms to the fingertips (see <\/span><strong>Video 3<\/strong><span style=\"color: #000000;font-size: 1em\">).<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\"><span style=\"color: #000000\">Normally, the skin colour 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 colour with a slight pinkish tone underneath. Remember that the palms of hands are a lighter skin colour, particularly among people with darker skin tones. Normally, there is no edema, no ulcers, no lesions and circumference is equal bilaterally.<\/span><\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Describe the location, size, and quality of any abnormal findings such as skin discolouration, signs of cyanosis, pallor, venous pattern, and presence of ulcers or lesions. With regard to quality, for example, you should note what the discolouration and the ulcers look like. <\/span><span style=\"color: #000000\">Describe the location and quality of abnormal skin temperatures, particularly if asymmetrical.\u00a0<\/span><span style=\"color: #000000\">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.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n&nbsp;\r\n\r\n[embed]https:\/\/youtu.be\/N_N8Fkg5A1Y[\/embed]\r\n\r\n<strong>Video 3<\/strong>: Palpation of skin temperature [0:17]\r\n<ol start=\"2\">\r\n \t<li><span style=\"color: #000000\"><strong>Test capillary refill<\/strong> on two or three fingernails of each hand at heart level (see <strong>Video 4<\/strong>). Start by applying pressure with your own finger to the client\u2019s nail; this causes the nail to blanch (become paler in colour). Apply the pressure for 5 seconds and then release and observe the return in colour.\u00a0<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">A normal finding when assessing capillary refill is colour return that is equal to or less than 3 seconds when assessing capillary refill.\u00a0<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Colour 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\u2019s hands are cold; if the client\u2019s hands are cold from being outside or from washing in cold water, ask them to warm their hands to ensure an accurate reading.\u00a0<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\n[embed]https:\/\/youtu.be\/CXGN89Bkl-0[\/embed]\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 4<\/strong>: Testing capillary refill [0:45]<\/span><\/p>\r\n\r\n<ol start=\"3\">\r\n \t<li><span style=\"color: #000000\"><strong>Palpate the radial pulses<\/strong> bilaterally and simultaneously, and then palpate the <strong>brachial pulses<\/strong> (see <strong>Figure 9<\/strong>). Assessing the pulses simultaneously allows you to compare the strength of pulsation; recall the<\/span> <a href=\"https:\/\/pressbooks.library.torontomu.ca\/vitalsign2nd\/chapter\/what-pulse-qualities-are-assessed\/\" target=\"_blank\" rel=\"noopener\">4-point scale for force<\/a>. <span style=\"color: #000000\">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.\u00a0<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, pulses are present, 2+ force and equal bilaterally.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Decreased pulse force or absent pulses can be associated with arterial insufficiency. A decreased pulse force (1+) can be described as \u201cthready,\u201d which refers to a weak pulse that is difficult to feel.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\n<p style=\"text-align: left\"><img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-300x169.jpg\" alt=\"A nurse with their fingerpads placed along the radial bone of both wrists of a client taking radial pulse.\" width=\"357\" height=\"201\" class=\"alignnone wp-image-1192\" \/>\u00a0\u00a0<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-300x194.jpg\" alt=\"A nurse with fingerpads placed along the brachial arteries of the client.\" width=\"320\" height=\"206\" class=\"alignnone wp-image-1193\" \/><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 9<\/strong>: Palpation of radial and brachial pulses.<\/span><\/p>\r\n\r\n<ol start=\"4\">\r\n \t<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normal findings might be documented as: \u201cFrom shoulders to fingertips: equal limb circumference with no edema or ulcers, and skin colour consistent. Good capillary refill. Radial and brachial pulses 2+ force and equal bilaterally. Skin temperature warm to touch and equal bilaterally from shoulders to fingertips.\u201d<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cPallor in fingernails, cool to touch in fingers bilaterally, sluggish capillary refill 4\u20135 seconds, 1+ radial pulses equal bilaterally.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<h3><span style=\"color: #000000\"><strong>Activity: Check your Understanding<\/strong><\/span><\/h3>\r\n<p style=\"text-align: left\">[h5p id=\"93\"]<\/p>\r\n<span style=\"color: #000000\">(Photo by<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>, <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\">Creative Commons Attribution-Share Alike 3.0<\/a> <span style=\"color: #000000\">from<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Cynosis.JPG\">Wikimedia Commons<\/a><span style=\"color: #000000\">.)<\/span>","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">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\u2019s or supine position.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Steps for <strong>inspecting and palpating hands and arms<\/strong> include:<\/span><\/p>\n<ol>\n<li style=\"text-align: left\"><strong style=\"color: #000000;font-size: 1em\">Inspect the skin<\/strong><span style=\"color: #000000;font-size: 1em\"> of the hands and arms for colour (including nails), edema, limb circumference discrepancy, lesions, presence of ulcers, and venous patterns<\/span><span style=\"color: #000000;font-size: 1em\">. 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, <\/span><strong style=\"color: #000000;font-size: 1em\">palpate skin temperature<\/strong><span style=\"color: #000000;font-size: 1em\"> using the dorsa of your hands from the shoulders down the arms to the fingertips (see <\/span><strong>Video 3<\/strong><span style=\"color: #000000;font-size: 1em\">).<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\"><span style=\"color: #000000\">Normally, the skin colour 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 colour with a slight pinkish tone underneath. Remember that the palms of hands are a lighter skin colour, particularly among people with darker skin tones. Normally, there is no edema, no ulcers, no lesions and circumference is equal bilaterally.<\/span><\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Describe the location, size, and quality of any abnormal findings such as skin discolouration, signs of cyanosis, pallor, venous pattern, and presence of ulcers or lesions. With regard to quality, for example, you should note what the discolouration and the ulcers look like. <\/span><span style=\"color: #000000\">Describe the location and quality of abnormal skin temperatures, particularly if asymmetrical.\u00a0<\/span><span style=\"color: #000000\">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.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Skin Temperature Palpation 2\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/N_N8Fkg5A1Y?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><strong>Video 3<\/strong>: Palpation of skin temperature [0:17]<\/p>\n<ol start=\"2\">\n<li><span style=\"color: #000000\"><strong>Test capillary refill<\/strong> on two or three fingernails of each hand at heart level (see <strong>Video 4<\/strong>). Start by applying pressure with your own finger to the client\u2019s nail; this causes the nail to blanch (become paler in colour). Apply the pressure for 5 seconds and then release and observe the return in colour.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">A normal finding when assessing capillary refill is colour return that is equal to or less than 3 seconds when assessing capillary refill.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Colour 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\u2019s hands are cold; if the client\u2019s hands are cold from being outside or from washing in cold water, ask them to warm their hands to ensure an accurate reading.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p><iframe loading=\"lazy\" id=\"oembed-2\" title=\"Capillary Refill Test Video - Peripheral Vascular Chapter\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/CXGN89Bkl-0?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 4<\/strong>: Testing capillary refill [0:45]<\/span><\/p>\n<ol start=\"3\">\n<li><span style=\"color: #000000\"><strong>Palpate the radial pulses<\/strong> bilaterally and simultaneously, and then palpate the <strong>brachial pulses<\/strong> (see <strong>Figure 9<\/strong>). Assessing the pulses simultaneously allows you to compare the strength of pulsation; recall the<\/span> <a href=\"https:\/\/pressbooks.library.torontomu.ca\/vitalsign2nd\/chapter\/what-pulse-qualities-are-assessed\/\" target=\"_blank\" rel=\"noopener\">4-point scale for force<\/a>. <span style=\"color: #000000\">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.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, pulses are present, 2+ force and equal bilaterally.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Decreased pulse force or absent pulses can be associated with arterial insufficiency. A decreased pulse force (1+) can be described as \u201cthready,\u201d which refers to a weak pulse that is difficult to feel.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p style=\"text-align: left\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-300x169.jpg\" alt=\"A nurse with their fingerpads placed along the radial bone of both wrists of a client taking radial pulse.\" width=\"357\" height=\"201\" class=\"alignnone wp-image-1192\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-300x169.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-65x37.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-225x127.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery-350x197.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/11\/Radial-artery.jpg 451w\" sizes=\"auto, (max-width: 357px) 100vw, 357px\" \/>\u00a0\u00a0<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-300x194.jpg\" alt=\"A nurse with fingerpads placed along the brachial arteries of the client.\" width=\"320\" height=\"206\" class=\"alignnone wp-image-1193\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-300x194.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-65x42.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-225x145.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery-350x226.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Brachial-artery.jpg 451w\" sizes=\"auto, (max-width: 320px) 100vw, 320px\" \/><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 9<\/strong>: Palpation of radial and brachial pulses.<\/span><\/p>\n<ol start=\"4\">\n<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normal findings might be documented as: \u201cFrom shoulders to fingertips: equal limb circumference with no edema or ulcers, and skin colour consistent. Good capillary refill. Radial and brachial pulses 2+ force and equal bilaterally. Skin temperature warm to touch and equal bilaterally from shoulders to fingertips.\u201d<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cPallor in fingernails, cool to touch in fingers bilaterally, sluggish capillary refill 4\u20135 seconds, 1+ radial pulses equal bilaterally.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3><span style=\"color: #000000\"><strong>Activity: Check your Understanding<\/strong><\/span><\/h3>\n<p style=\"text-align: left\">\n<div id=\"h5p-93\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-93\" class=\"h5p-iframe\" data-content-id=\"93\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Peripheral Vascular Chapter Inspection of Hands\"><\/iframe><\/div>\n<\/div>\n<p><span style=\"color: #000000\">(Photo by<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>, <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\">Creative Commons Attribution-Share Alike 3.0<\/a> <span style=\"color: #000000\">from<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Cynosis.JPG\">Wikimedia Commons<\/a><span style=\"color: #000000\">.)<\/span><\/p>\n","protected":false},"author":34,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[85],"license":[56],"class_list":["post-1194","chapter","type-chapter","status-publish","hentry","contributor-january-2023","license-cc-by-nc"],"part":1171,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1194","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":3,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1194\/revisions"}],"predecessor-version":[{"id":1916,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1194\/revisions\/1916"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/1171"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1194\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=1194"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=1194"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=1194"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=1194"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}