Bodily evaluation | Nursing homework assist
Subjective Findings: Ms. J is a 65-year-old feminine who presents with complaints of ache and cramping in her left leg. She stories that the ache is worse with strolling and improves with relaxation. She denies any numbness or tingling in her leg or foot. She stories a historical past of smoking however give up 10 years in the past. She has a household historical past of peripheral artery illness (PAD).
Goal Findings:
- Important indicators: Blood stress 132/82 mmHg, coronary heart price 78 bpm, respiratory price 16 bpm, oxygen saturation 96% on room air.
- Inspection: Pores and skin shade is pale and funky to the contact within the left decrease leg in comparison with the precise leg. No seen indicators of edema or varicosities.
- Palpation: Left dorsalis pedis and posterior tibial pulses are weak and troublesome to palpate in comparison with the precise. Capillary refill time is delayed within the left foot. Left calf is tender to palpation.
- Auscultation: No bruits or different irregular sounds heard over the femoral, popliteal, or dorsalis pedis arteries bilaterally.
Precise or Potential Dangers:
- Ms. J is in danger for peripheral artery illness (PAD) because of her smoking historical past, household historical past, and signs of claudication.
- She can also be in danger for issues reminiscent of tissue injury or gangrene if blood circulation to the affected limb isn’t restored.
Suggestions:
- Ms. J must be referred for additional diagnostic testing reminiscent of an ankle-brachial index (ABI) or doppler ultrasound to substantiate the presence of PAD.
- Smoking cessation counseling must be offered to cut back her danger of additional vascular injury.
- Medicines reminiscent of antiplatelet brokers or statins could also be beneficial to handle her situation.
- Ms. J must be suggested to have interaction in common train and keep a nutritious diet to enhance blood circulation and scale back her danger of issues.
Documentation: The above findings and suggestions have been documented in Ms. J’s medical document for reference by different healthcare suppliers concerned in her care.