Cu10-April 9
Cu10-April 9
George is a 75 year-old patient with urosepsis being treated in the Intensive care unit (ICU). The
nurse assesses George and finds that he has blood in his urine and stool, and is oozing blood
from his central line site and his gums.
Fred, a 43 year-old construction worker, has a history of hypertension. He smokes two packs of
cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping
with stress. His current concern is calf pain during minimal exercise, which decreases with rest.
1. What does the nurse is the hallmark symptom of peripheral arterial occlusion disease?
The hallmark of peripheral arterial disease is the symptom of claudication which
is an intermittent cramping pain in the leg that is induced by exercise and relieved
by rest.
2. The patient is having ankle-brachial index (ABI) determined. The right posterior tibial
reading is 75 mm Hg, and the brachial systolic pressure is 150mm Hg. What would the
ABI be for this patient?
The ABI for this patient is 0.5 ratios.
3. The nurse is educating Fred about managing his condition. What methods can the nurse
suggest to increase arterial blood supply?
Systemic lowering of the extremity below heart level
Buerger Allen exercise- specific exercises intended to improve circulation to the
feet and legs. The lower extremities are elevated to a 45 to 90 degree angle and
supported in this position until the skin blanches (appears dead white).
Stress management.
4. What is the best method for the nurse to assess Fred’s peripheral pulses to obtain
consistent results with other health care practitioners?
Use light touch
Avoid using only the index finger for palpation because this finger has the
strongest arterial pulsation of all fingers
The thumb should not be used for the same reason
Georgia, a 30 year-old woman, is diagnosed as having secondary hypertension when serial blood
pressure recordings 170/100 mm Hg. Her hypertension is the result of renal dysfunction.