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Circulation and Pulses
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Assess
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Document: Assessment, interventions, outcomes.
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Pulses
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Equality and character of pulses, comparing right and left.
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6 Ps
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Pain, pallor, pulselessness, polar, paresthesia, paralysis.
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S/S
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Swelling, limb pain, change in sensation, fatigue.
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Skin
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Color, temperature, moisture, hair growth.
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Edema
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Extremities and dependent areas for edema, varicosities.
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Nails
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Capillary refill, cyanosis, angle of attachment, clubbing.
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History
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PVD, DM, HTN, CHF, DVT, surgical procedures, lymphedema, meds.
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Capillary Refill
Normal . . . . . . . . . . . . . . . <3 seconds
Delayed . . . . . . . . . . . . . . . >3 seconds
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Pulse Strength
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>0 . . . . . . . . . . . . . Absent
1 . . . . . . . . . . . . .Weak
2 . . . . . . . . . . . . . Normal
3 . . . . . . . . . . . . . Full
4
. . . . . . . . . . . . . Bounding
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Right
arm:
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Left arm:
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Right
leg:
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Left
leg:
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Edema Scale
+1 . . . Slight pitting with 2 mm of depression that disappears rapidly. No visible distortion of extremity.
+2 . . . Deeper pitting with 4 mm of depression that disappears in ~10–15 seconds. No visible distortion of extremity.
+3 . . . Depression of 6 mm that lasts >1 minute. Dependent extremity appears swollen.
+4 . . . Very deep pitting with 8 mm of depression that lasts 2–3 minutes. Dependent extremity is grossly edematous.
Common Pulse Points
Temporal . . . . . . . . Just anterior to upper third of ear
Carotid . . . . . . . . . Below angle of jaw on either side of trachea
Apical . . . . . . . . . . Left side of chest at the 5th ICS, midclavicular line
Brachial . . . . . . . . . Medial antecubital fossa
Radial . . . . . . . . . . Medial-ventral wrist below base of thumb
Femoral . . . . . . . . . Crease of groin between pubis and hip bone
Popliteal . . . . . . . . Popliteal fossa behind knee
Dorsal pedis . . . . . . Medial dorsum of foot
Posterior tibial . . . . Slightly below the posterior malleolus of the foot
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