| Measure the capillary filling time |
Carry out comprehensive evaluation of peripheral circulation (eg check peripheral pulses, oedema, capillary filling, color and temperature) |
Circulatory care: arterial insufficiency (4062) |
| Palpate the pulses to determine their presence and characteristics |
| Monitor/measure oedema and capillary filling and pulse periodically |
| Measure the circumference of the limbs |
Check the ankle-brachial index as appropriate |
| Evaluate tibial pulse |
Evaluate peripheral oedema and pulses |
| Determine the pain’s history and characteristics |
Monitor the degree of discomfort or pain with exercise, at night, or while resting |
| Keep right lower limb hanging |
Position end in dependent position, as appropriate |
| Elevation of the heated lower limb |
| Helping to carry out active and passive mobilization exercises |
Encourage the patient to exercise, as tolerated |
| Encourage early ambulation when possible |
| Keep lower limb warm |
Provide heat (eg, extra bedding, increased room temperature), as appropriate |
| Perform limb coverage with orthopedic cotton in order to raise site temperature and improve venous return as well as area protection) |
| Keep loose clothing |
Orient the patient on factors that interfere with circulation (eg, smoking, restrictive clothing, exposure to cold temperatures, and crossing of legs and feet) |
| Guide patient to avoid crossing legs |
| Guide non-stay for long periods in seated or standing position |
Change patient position at least every 2 hours, as appropriate |
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Inspect the skin for ulcers or tissue rupture
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Circulatory care: arterial insufficiency (4062) |
| Implement wound treatment
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| Guidance on the importance of the treatment of the underlying disease to improve the general |
Guide the patient about measures to prevent/minimize symptoms, as appropriate |
Teaching: disease process (5602) |
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Discuss therapy/treatment options
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| Properly moisturize affected limb skin with moisturizing lotions |
Moisturize dry skin, still intact |
Prevention of pressure ulcer (3540) |
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Apply protectors to the heels and elbows when appropriate
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| Record evolution of wound healing |
Describe the characteristics of the ulcer at regular intervals, including size (length × width × depth), stage (I-IV), location, exudate, granular or necrotic tissue and epithelization |
Pressure ulcer care (3520) |
| Daily bandage appliance on the lesion of the right lower limb |
Apply bandages when appropriate |
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Monitor for signs and symptoms of wound infection
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