Physical assessment | Nursing homework help
Subjective Findings: Ms. J is a 65-year-old female who presents with complaints of pain and cramping in her left leg. She reports that the pain is worse with walking and improves with rest. She denies any numbness or tingling in her leg or foot. She reports a history of smoking but quit 10 years ago. She has a family history of peripheral artery disease (PAD).
- Vital signs: Blood pressure 132/82 mmHg, heart rate 78 bpm, respiratory rate 16 bpm, oxygen saturation 96% on room air.
- Inspection: Skin color is pale and cool to the touch in the left lower leg compared to the right leg. No visible signs of edema or varicosities.
- Palpation: Left dorsalis pedis and posterior tibial pulses are weak and difficult to palpate compared to the right. Capillary refill time is delayed in the left foot. Left calf is tender to palpation.
- Auscultation: No bruits or other abnormal sounds heard over the femoral, popliteal, or dorsalis pedis arteries bilaterally.
Actual or Potential Risks:
- Ms. J is at risk for peripheral artery disease (PAD) due to her smoking history, family history, and symptoms of claudication.
- She is also at risk for complications such as tissue damage or gangrene if blood flow to the affected limb is not restored.
- Ms. J should be referred for further diagnostic testing such as an ankle-brachial index (ABI) or doppler ultrasound to confirm the presence of PAD.
- Smoking cessation counseling should be provided to reduce her risk of further vascular damage.
- Medications such as antiplatelet agents or statins may be recommended to manage her condition.
- Ms. J should be advised to engage in regular exercise and maintain a healthy diet to improve blood flow and reduce her risk of complications.
Documentation: The above findings and recommendations were documented in Ms. J’s medical record for reference by other healthcare providers involved in her care.