Documentation Of Problem-Based Assessment Of The Peripheral

Documentation of problem based assessment of the peripheral vascular system

Develop a comprehensive documentation report for a problem-based assessment of the peripheral vascular system. The report should be organized into three sections: Subjective, Objective, and Actual or potential risk factors for the client based on the assessment findings. Do not include explanations or reasons for the selection of these risk factors.

Paper For Above instruction

The assessment of the peripheral vascular system is a critical component of cardiovascular health evaluation. Proper documentation ensures accurate communication among healthcare providers, facilitates appropriate management plans, and aids in the identification of abnormalities or risk factors that may predispose a patient to vascular diseases.

Subjective

The subjective section captures the patient's personal experiences, concerns, and health history related to peripheral vascular health. For example, the patient reports experiencing intermittent claudication during walking, which is pain in the legs that subsides with rest. They also mention a history of hypertension and hyperlipidemia. The patient reports no recent swelling, redness, or warmth in the extremities. No known allergies or previous vascular surgeries are noted. The patient describes a dull ache in the calves after exertion and occasional numbness in the toes.

Objective

The objective assessment involves a physical examination and observation. Inspection reveals cool temperature in the lower extremities bilaterally, with hair loss and shiny skin on the calves and feet. Palpation of the dorsalis pedis and posterior tibial arteries shows decreased or absent pulses on the right side, with palpable pulses on the left. Capillary refill time exceeds 3 seconds in the toes. There is no visible swelling, erythema, or ulceration. Auscultation over the femoral, popliteal, and distal arteries reveals decreased or absent bruits. The skin appears thin, and there are trophic changes consistent with chronic ischemia.

Actual or potential risk factors

Based on the assessment findings, risk factors include a history of hypertension, hyperlipidemia, smoking, and obesity. The physical examination findings such as diminished pulses, cool skin temperature, and trophic skin changes further suggest peripheral arterial disease. The patient's sedentary lifestyle and prior episodes of intermittent claudication also pose potential risks for progression of vascular impairment. No current signs of infection or acute deep vein thrombosis are present, but the findings indicate a need for ongoing monitoring and management to prevent complications such as ischemic ulceration or limb loss.

References

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• National Institute for Health and Care Excellence (NICE). (2012). Diagnosis and Management of Peripheral Arterial Disease (Update). NICE Clinical Guideline [CG147].
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• Walker, H. K., & Hall, W. D. (2020). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd Edition. Butterworth-Heinemann.