Question

2. Your assessment of your patient's peripheral vascular system reveals the following picture below. How would you document this finding in your nursin note? Provide an example of your objective nursing note.

Answer 1

PERIPHERAL VASCULAR SYSTEM – it is part of vascular system or circulatory system, its includes arteries and veins of arms, legs, hands, feet etc.

EXAMINATION

1. LEGS/ARM PAIN – indicate PVD

2. INTERMITTENT CLAUDICATION

3. SKIN CHANGES- such as coolness, numbness, pallor in skin. Hair lose, leg ulcer, varicose vein.

4. SWELLING – Unilateral or bilateral edema in calves, legs and feet.

5. COLOUR CHANGES IN FINFERTIP AND TOE DUE TO COLD WEATHER.

6. LYMPH NOTE ENLARGEMET – occurs in immunological, infectious, or malignant disease and swelling with redness and tenderness.

NURSES NOTE

Patient name-                          Sex-                                                 Diagnosis-

Age -                                           Admission no-

Vitals: temp-

            Pulse-

            Respiration-

BP-

Remarks

1. Subjective assessment – client is complaining for legs swelling since X days or after exposure of any risk situation. (hypervolemia, kidney disease, heart disease)

2. Objective assessment - +2 moderate pitting edema. 4mm depression that disappear in 10-15seconds and leg swelling due to circulatory dysfunction

NURSING DIAGNOSIS

Fluid overload related to decrease cardiac output as evidence by bilateral leg pitting edema

NURSING INTERVEN