What should a nurse do if a posterior tibial pulse Cannot be obtained on a client with edema of the feet?

Finding a pedal pulse is part of the trauma patient assessment and performed before and after lower extremity splint application as well as long backboard immobilization. Assessing a pedal pulse is part of the ongoing assessment for a patient on a backboard or a lower extremity splint. During hospital care, nurses and CNAs, might need to find and document lower extremity circulation for bed-bound patients.

Locating a foot pulse can be difficult even in healthy patients. Use these tips to find a patient's pedal pulses:

1. Radial pulse first

Assess the patient's radial pulse rate and rhythm so you know what you are seeking.

2. Bare the patient's skin

Move shoes, socks, tights, and anklets out of the way to expose the patient's skin.

3. Reposition the foot to normal

Move, if not compromised by injury, the patient's foot towards the normal anatomical position.

4. Two possible pedal pulse positions to check

Check for either the dorsalis pedis pulse (on the top of the foot) or the posterior tibial pulse (located behind the medial malleolus — the ankle bone).

5. Visualize skin for pulsation

For dorsalis pedis, first, visualize because you might see the skin pulsating above the artery. If you are unable to see anything, hold two or more fingers lightly against the skin. Move up from the toes towards the leg until you locate the pulse.

6. Use two or more fingers

For posterior tibial — on the medial side of the ankle — use two or more fingers. I find more pressure is needed to find this pulse.

7. Try the other leg

If you are unable to find the pedal pulse on one leg, switch to the patient's other leg. Knowing the location of one pulse might help you find the other.

8. Mark the location

Once you have found a pedal pulse, consider using a ballpoint or felt pen to make a light mark at the pulse location to make reassessment easier.

9. Foot temperature and color

Finally, if the patient's foot is warm with normal color, it is adequately perfused.

What else works well for finding a pedal pulse? Why might a pedal pulse be absent or diminished? Share your thoughts in the comments area.

This article, originally published December 7, 2009, has been updated

Edema: Fluid frequently collects in the feet and ankles due to the effects of gravity. This is related to some perturbation in the Startling forces. Thinking in broad strokes, it's usually the result of:

Low oncotic pressure: Either failure to synthesize albumin (as with malnutrition or liver disease) or increased loss of albumin (via the kidney or local leakage due to altered capillary permeability).
Increased hydrostatic pressure: Transmitted back from the level of the heart (right heart failure), liver (portal hypertension), local venous insufficiency (e.g. venous valvular incomepetence with impaired flow of blood back to the heart from the legs), lymphatic obstruction (e.g. retroperitoneal adenopathy secondary to malignancy), or obesity (which may impair both venous and lymphatic drainage).

Realize that all "circulation" problems are not the same. Disorders of blood inflow (arterial) and outflow (venous) have different associated signs and symptoms based on their varying pathophysiology (see above). Edema is commonly associated with venous insufficiency, a blood return problem. This disorder tends to get worse when the legs are allowed to dangle for prolonged periods below the level of the heart (e.g. towards the end of the day if the patient has been standinag for long periods of time). The fluid builds up preferentially in the most distal aspects of the leg and progress up towards the knee as the process worsens. Arterial insufficiency, on the other hand, rarely causes edema, which makes perfect sense as the problem lies in the delivery of blood to the extremity, not the return from it. On occasion, the conditions may coexist.

It may be difficult to detect small amounts of fluid. Look around the malleoli, as fluid will cause a loss of the normally distinct appearing edges of the bone. Similarly, fluid will tend to "fill in" the spaces between the extensor tendons on the top of the foot, causing them to appear less defined. If you're not sure whether fluid is present, push on the area for several seconds, release, and then gently rub your finger over that same spot, feeling for the presence of a "divot," referred to as pitting. Much is said about pitting edema being associated with some disease states and non-pitting with others; however, the actual importance of this distinction is probably over stated. Also note the proximal extent of the edema and if it is present to the same degree in both legs. Edema may either be diffuse, involving all of the surrounding tissue symmetrically, as is frequently the case in disorders of low oncotic or elevated hydrostatic pressure. If, however, there is a local inflammatory process, as might occur with cellulitis, the area of edema can be quite focal. There is a very subjective scale for rating edema which ranges from "trace at the ankles" to "4+ to the level of the knees." After examining many patients, you'll develop a sense of what is a lot and what is not.

For Additional Information See: Digitial DDx: Edema

Edema can also be quantified by estimating of the depth in millimeters of the “divot” left after applying steady pressure to the skin, best done over the tibial region. A comparison of the different ways of quantifying edema are demonstrated here:

Quantifying Edema

Normal

2+ edema - extending to above ankle

4+ edema – extending to upper tibia

1+	Minimal	Barely detectable impression	2mm
2+	Mild	Slight indentation	4mm
3+	Moderate	Deeper indentation	6mm
4+	Severe	Very deep indentation	8mm
*Changes in Weight Very Helpful Clinically for Assessing Total Body Volume and impact of Diuretics*

Lymphedema, Left Leg

Pain: Cellulitic skin, for example, is often tender when touched. Remember that certain disease states (diabetes in particular) cause a peripheral neuropathy that predisposes these patients to the development of skin breakdown and subsequent infection precisely because they have abnormal sensation in their distal extremities. In these cases, then, infection may occur in the absence of pain.

Paronychia: Infection of the skin medial and inferior to nail of great toe. Image on the right is post I&D.

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Information obtained should be documented in a structured format (see Toolkit item #8 for assessment form) for a patient presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.

• Medical history including history of arterial/venous insufficiency
• Family history of venous, arterial or mixed ulcers
• History of deep vein thrombosis (DVT) and/or lower leg injury
• History of episodes of chest pain, hemoptysis or pulmonary embolus
• History of heart disease, stroke or transient ischemic attack (TIA)
• Comorbidities (diabetes, peripheral vascular disease, intermittent claudication, rheumatoid arthritis or Ischemic rest pain)
• Pain (in calves, buttocks or thighs especially with walking and/or with elevation of leg above level of heart)
• Where patient sleeps at night (e.g. if patient sleeps upright in chair at night, could indicate pain if leg elevated in bed)
• Smoking history
• History of ulcer and past treatments
• Current and past medications
• Nutritional status
• Allergies
• Psychosocial status including quality of life
• Functional, cognitive, emotional status and ability for self-care
• Lifestyle (activity level, interests, employment, dependents, support system)

• Blood Pressure, height, weight, pulses in foot and ankle
• Review bloodwork that should include the following:

Perform a BILATERAL lower leg assessment including ABPI/TPBI

All clinicians involved in the management of patients with lower limb ulcers should have direct access to an 8 MHz hand held Doppler device. This should not be considered a special investigation limited to vascular laboratory1.

Assess for the following:

• ABPI/TPBI completed within last 3 months and results documented
• If unable to obtain ABPI/TPBI, referral to vascular surgeon is recommended
• Assess pulses (popliteal – behind knee, dorsalis pedis – top of foot, posterior tibial – medial ankle)
• Measurement of edema
• Assess capillary refill (normal less than 3 seconds)
• Ankle range of motion (ROM)
• Foot deformities
• Ankle flare
• Skin temperature (compare both legs)
• Skin colour (dependent and on elevation)
• Presence of pain
• Nail changes
• Presence of hair on lower leg, feet and toes
• Presence of varicosities (varicose veins)
• Dermatological changes due to impaired blood flow
• Repeat ABPI/TPBI assessment every 3 months if healing is not progressing

Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention

Signs and symptoms that may become severe may be associated with the following:

• Pale or blue skin
• Skin cold to the touch
• Sudden decrease in mobility
• No pulse where one was present prior to this
• Sudden and severe pain

Wound and Peri-wound Assessment is best performed using a validated and reliable wound assessment tool. (See Toolkit item #10a for Bates-Jensen Wound Assessment Tool and #10b Leg Ulcer Measurement Tool (LUMT))

4 P’s of Arterial Ulcers

• Pale wound base
• Punched-out appearance
• Painful
• Parched (low to no exudate)

A comprehensive wound assessment should include observation and documentation of the following:2 3

• Location: Arterial leg ulcers are usually situated on the lateral malleolus, mid tibia, phalangeal heads, toe tips or web spaces
• Odour
• Sinus Tracts (including undermining and tunneling): Measurement can be obtained by gently inserting small probe into sinus tract, marking probe with end of finger and measuring length from end of probe to finger end
• Exudate: Comment on amount and colour of exudate present. Arterial wounds usually have low to no exudate
• Pain: Usually more painful than expected
• Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough. Arterial ulcers generally have a pale wound base and a ‘punched-out’ appearance
• Condition of peri-wound (surrounding skin) and wound edges
• Document percentage of healing since last visit
• Obtain photos following best practice

• Measure and document the surface areas of ulcers at regular intervals to monitor progress
• Measure depth of wound
• Measure size of wound: Area of wound measured by multiplying length (longest measurement) and width (shortest measurement) of wound

	Venous Disease	Arterial Disease and Ischemia	Mixed Venous/Arterial
Wound Appearance	Base: ruddy red; yellow adherent or loose slough; granulation tissue may be present Depth: usually shallow Margins: irregular Undermining: is rare. If present, further assessment should be undertaken to rule out other etiologies (i.e. arterial) Exudate: moderate to heavy Surrounding Skin: Venous dermatitis; hemosiderin; lipodermatosclerosis; atrophy blanche Edema: pitting or non-pitting; may worsen with prolonged standing or sitting from legs being in a dependent position Scarring: from previous ulcers, ankle flare, tinea pedis (athlete’s foot) Nails: Usually normal unless infection present Temperature: normal; warm to touch Infection: less common but chronic venous ulcers are prone to biofilms, induration, cellulitis, inflamed, tender blisters	Base: pale; granulation rarely present; necrosis, eschar, gangrene (wet or dry) may be present Depth: may be deep Margins: edges rolled; “punched out” appearance, smooth Undermining: may be present Exudate: minimal Surrounding Skin: Pale or blue feet, pallor on elevation, dependant rubor; Shiny, taut, thin, dry; Hair loss over lower extremities; Atrophy of subcutaneous tissue Edema: atypical Nails: Dystrophic Temperature: decreased/cold Infection: frequent (signs may be subtle); cellulitis, necrosis, eschar, gangrene may be present	Ulcers may have elements of both kinds of disease: Venous shape Yellow/black fibrous base Wound bed may be dry (if no edema or infection) Surrounding Skin: Possible cool skin, edema, pallor on elevation, dependant rubor Edema: variable Nails: Thickened toenails Infection: Can have signs and symptoms of both venous and arterial disease
Location	Ulceration is usually on the medial lower leg superior to malleolus in gaiter region but can be on lateral aspect as well or may encircle the entire ankle or leg Ulcers occurring above the mid-calf or on the foot likely have other origins, but may be caused by trauma in a leg with existing venous insufficiency	Areas exposed to pressure or repetitive trauma, or rubbing of footwear: Lateral malleolus Mid tibial Phalangeal heads Toe tips or web spaces	Same as venous or ulcer may be circumferential
Pain	Described as throbbing, sharp, itchy, sore, tender, heaviness Worsens with prolonged dependency. Some relief on elevation of limb.	Pain is increased with elevation of limb. Pain may also be incurred with walking. This is usually due to the presence of intermittent claudication which will be relieved with 10 minutes of rest	Pain with elevation Intermittent claudication (early) Night time rest pain (late disease)

Perform ABPI/TBPI to rule out the arterial disease. If patient is a diabetic, toe pressures should be obtained.

An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy. ABPI measurement offers valuable information as a screening tool for lower extremity peripheral arterial disease8.

An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. People with abnormally low or abnormally high ABPI should be further investigated for peripheral arterial disease. For example, an ABPI >1.3 is considered indicative of non-compressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age. In these cases, compression therapy may not be recommended11.

Referrals to vascular lab may be required for the following investigations12:

Transcutaneous oxygen (TcPO2)

• Measures partial pressure in adjacent areas of the wound
• Considered reliable method to measure the viability of tissue except where acute edema or inflammation is present
• Tissue hypoxia results TcPO2 <40 mmHg
• Critical ischemia TcPO2 <30 mmHg

Laser Doppler Flowmetry

• Useful in cases where false readings obtained in TcPO2 (where acute edema or inflammation is present)

Doppler Arterial Waveforms

• Non-invasive
• Demonstrates the normal tri-phasic signal of the pulse

Segmental Doppler Pressures

• Determines location of vascular lesion
• Pressures measured at thigh, above knee, calf and ankles
• Results compared with each other and with other leg

Imaging Studies (Angiography)

• Determines location and extent of disease
• Used by surgeon to provide roadmap in deciding and planning revascularization of the limb

• Healable: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized
• Maintenance: have healing potential, but various patient factors are compromising wound healing at this time
• Non-healable/Palliative wound: has no ability to heal due to untreatable causes such as terminal disease or end-of-life13

The following assessments and blood work should be considered when investigating nutritional status of a person with a wound:

In addition to inquiring about recent weight loss, signs of dehydration, and assessing the Braden Scale Nutritional sub-scale, which helps to capture protein intake, there are several signs of micronutrient deficiencies that are easy to detect when you know what to look for.

• Reddish tongue with a smooth surface (Vitamin B deficiency)
• Magenta flank-steak appearing tongue with cracks at corners of the mouth (called angular stomatitis) (Vitamin B2 deficiency)
• Dementia, diarrhea, dermatitis (pellagra) — crepe paper skin with wrinkles in the skin and flat surfaces between the wrinkles – also associated with bullous pemphigoid and gramuloma annulare (Vitamin B3 deficiency)
• Prominent “snowflake” exfoliation of the epidermis of the lower legs (Essential Fatty Acid deficiency)
• Skin and capillary fragility with purpura, skin tears, increase risk of pressure ulcers, severe collagen deficiency so that the skin is like plastic wrap, and extensor tendons and venous plexus is easily seen through the transparent epidermis (Chronic Scurvy/Vitamin C deficiency)
• Reddish, scaly, itchy skin lesions (Vitamin A, E, and K deficiency)
• Seborrheic-like rash that is red, flaky seen along the lateral eyebrows, nasal labial folds and chin (Zinc deficiency)
• Prolonged tenting of the skin in the presence of adequate fluid intake

If the presence of any of these signs of micronutrient deficiencies is noted, a referral should be made to a Registered Dietitian who can work with the primary care provider for screening of dietary deficiencies and treatment.

The Nestle Mini-Nutritional Assessment (MNA) is a screening and assessment tool that identifies individuals age 65 and above who are malnourished or at risk of malnutrition, allowing for earlier intervention to provide adequate nutritional support. It has not been validated for use with younger individuals. The screening tool consists of 6 questions.

Complete the screen by filling in the boxes with the appropriate numbers.
Total the numbers for the screening score.

The screening score (max 14 points):

• 12 - 14 points = normal nutritional status
• 8 - 11 points = at risk of malnutrition
• 0 - 7 points = malnourished

Nutritional supplementation should be provided to a patient only after a thorough nutritional assessment has been completed and the reason for malnutrition has been identified14.

Macronutrients such as carbohydrates, proteins and lipids (fats) are required in adequate amounts to provide the body with total energy needs. Caloric intake of 30-35 kcal/kg of body weight is recommended for patients with chronic wounds. Patients that are underweight may require a caloric intake of 35-40% kcal/kg of body weight15.

These macronutrients should be consumed daily in the following amounts:

• Carbohydrates 45-60%
• Fat 25-30%
• Protein 15-20% (1.25-1.5 g/kg of body weight)16

Protein needs are increased in order for healing to occur. Diets that include inadequate amounts of protein can be blamed for “increased skin fragility, decreased immune function, poorer healing and longer recuperation after illness”17. Caution should be taken when administering protein to patients with liver or kidney failure. Consultation with a Registered Dietician is recommended with this patient population.

Arginine and Glutamine are amino acids that are needed in the production of collagen. Collagen is required for healing to occur. Although supplementation of Glutamine is controversial, it is believed to be helpful in those patients where malnutrition and chronic wound healing are being addressed. Arginine is required by the body when under metabolic stress. Supplementation of Arginine has been shown to improve healing. It is important to note that both Arginine and Glutamine require adequate protein intake to be of any value18.

Fats are an integral part of a healthy diet required for healing to occur. Omega 3 fatty acids are antithrombotic, vasodilators and anti-inflammatory. Omega 6 fatty acids are responsible for platelet aggregation, inflammation and vasoconstrictors. Further research is required before supplementation of Omega 3 or Omega 6 should be recommended19.

Zinc

• Should only be supplemented if deficiency is determined
• Recommended dose: 40mg of elemental zinc/day (176 mg zinc sulfate) for up to 10 days to enhance wound healing

Ascorbic Acid (Vitamin C)

• Recommended dose: 500 to 1000 mg daily in divided doses

Vitamin A

• Recommended in patients taking corticosteroids
• Recommended dose: 10,000-25,000 IU daily for 10-14 days
• Use with caution in patients with protein deficiencies or liver failure

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