How to Assess Distal Circulation

Instructor: Courtney Dohse
In this lesson, we will learn the definition of distal circulation as well as the five techniques most often used to assess healthy blood flow: capillary refill, color, temperature, pulses and swelling.

Case Study

Arthur is an 86-year-old man living in a nursing home. He was diagnosed with Type II Diabetes ten years ago and as a result has poor circulation to his feet. In this lesson, we will take a look at the different assessment techniques his nurses should be using to ensure that he is getting proper circulation to his lower extremities.

What is Distal Circulation?

When we refer to distal circulation, we are referring to the flow of blood occurring furthest away from the central body, which are mainly the arms, hands, legs and feet. When there is a problem with circulation, these are the areas of the body that are usually the most affected because they are furthest from the heart, and the last areas to receive blood. Arthur's diabetes has caused damage to his blood vessels, therefore making it difficult for the heart to pump enough blood through the damaged vessels. This is why it is important for us to understand how to assess his distal circulation.

Assessing Distal Circulation

Assessing distal circulation is imperative, especially in patients with a disease that affects the cardiovascular system. This would be any disease that affects the manner in which the heart pumps blood, or the pathways by which the blood must travel (arteries or veins). There are five main things we look at when assessing distal circulation: capillary refill, color, temperature, pulses, and swelling. We will look into each of these in a little more detail.

Capillary Refill

Capillary Refill is the time it take for blood to return to an area when pressure is applied. The time is always recorded in seconds and should be less than 3 seconds in a patient who has adequate circulation.

We assess the capillary refill in Arthur's feet by removing his shoes and socks, firmly applying pressure to one of his toes until it blanches, or becomes white, and count the number of seconds it takes for his skin to return to it's normal color.


The color of a patient's extremities can tell us a lot about how effectively blood is reaching these areas. In an individual with healthy circulation, all extremities should appear pink. In a patient with impaired circulation, you may notice cyanosis which is a blueish discoloration of the skin. This is an abnormal finding and indicates a lack of oxygen to these areas which has occurred because of inadequate blood flow.

When looking at Arthur's feet, the nurses notice cyanois in his feet. It is just another tell-tale sign that his distal circulation is weak.


If proper circulation is occurring, all extremities should feel warm to the touch. If the arteries in the body are not bringing enough blood to an area, that area may be cold to the touch. On the other hand, if an area is receiving enough blood flow, but the veins are failing to return the blood to the heart and the blood continues to pool in an extremity, this area will feel hot to the touch.

In the case of Arthur, the nurses observe that his feet are colder than other patients, leading them to further suspect that his distal circulation is weak.

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