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Zorluk: ZorData Collection Techniques

A practical nurse (PN) is performing a focused circulatory data collection on a client with a history of severe peripheral arterial disease (PAD). During palpation, the PN is unable to locate the dorsalis pedis pulse on the client's right foot. The PN observes that the right foot is warm to the touch, and capillary refill is 2 seconds. Which action should the PN take next to complete this data collection?

  1. Obtain a Doppler ultrasound device to auscultate for the presence of arterial blood flow in the area.Cevap
  2. B
    Document the pulse as absent and reassess at the next scheduled interval, as the warm skin indicates adequate perfusion.
  3. C
    Elevate the client's right leg above heart level to decrease tissue swelling and attempt to palpate the pulse again.
  4. D
    Stop the physical assessment and prioritize administering a prescribed analgesic for the client's chronic leg pain.

Cevap

The correct action is to obtain a Doppler ultrasound device to auscultate for the presence of arterial blood flow in the area.
When a peripheral pulse is non-palpable, especially in a client with known peripheral arterial disease, the standard data collection technique is to utilize a Doppler ultrasound device. The Doppler amplifies the sound of blood moving through the vessel, allowing the practical nurse to determine if perfusion is present but simply too weak to feel manually. Because the foot remains warm with a normal capillary refill, it indicates some perfusion exists, making Doppler verification the immediate and necessary next step to complete the data collection accurately.

Adım Adım Çözüm

1
Analyze the clinical findings presented in the scenario.
The client has a history of PAD, a non-palpable dorsalis pedis pulse, but compensatory signs of perfusion (warm foot, normal capillary refill).
Synthesizing these assessment findings determines the current physiological status of the limb.
2
Identify the appropriate nursing standard for a non-palpable pulse.
A Doppler ultrasound device is the standard tool required to detect blood flow when manual palpation is unsuccessful.
To confirm whether arterial blood flow is truly absent or simply too weak to feel due to the client's arterial disease.
3
Evaluate the remaining options against safety protocols and the LPN scope of practice.
Elevating the leg worsens arterial flow, waiting delays necessary care, and focusing on pain ignores the primary circulatory priority.
Ensures the selected action safely and effectively completes the focused data collection without causing harm.

Anahtar Kavram

Peripheral Pulse Assessment utilizing Doppler Ultrasound
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Konular

Data Collection Techniques

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