Clinical nursing assessment for a patient with microangiopathy who has manifested impaired peripheral arterial circulation includes all of the following, except:
A. Integumentary inspection for the presence of brown spots on the lower extremities
B. Observation for paleness of the lower extremities
C. Observation for blanching of the feet after the legs are elevated for 60 seconds
D. Palpation for increased pulse volume in the arteries of the lower extremities
Correct Answer: D. Palpation for increased pulse volume in the arteries of the lower extremities
One of the signs and symptoms of impaired peripheral arterial circulation is the absence of a pulse or a weak pulse in the legs or feet. A general concept to bear in mind is that anything impinging the vessel can decrease peripheral pulses.
Option A: This happens when high pressure in the veins pushes blood into the skin tissue causing reddish-brown staining in the skin tissue. When skin is stained like this, it is very fragile and may break down or, if knocked, fail to heal as usual.
Option B: Severe vasoconstriction reduces blood flow to the skin of the affected areas, causing the skin surface to feel cold to touch and to have a white color. The pale white color is due to virtually no blood flow to the skin.
Option C: When a person develops impaired peripheral arterial circulation, the extremities — usually the legs — don’t receive enough blood flow and oxygen to keep up with demand leading to a change in the color of the legs.
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