NUR 5203 Module 4 Model System Assessment Example

Normal Written Out in Full: A Model Cardiovascular and Peripheral Vascular Assessment of a 68-Year-Old With Calf Pain on Walking, Annotated for Students

Student Name

American College of Education

NUR5203: Advanced Pathophysiology and Health Assessment

Module 4 Assignment

Instructor Name

February 1, 2028

Purpose and Patient

Students in the author's clinical group document cardiovascular assessments in a sentence, often heart regular, pulses present, and cannot say afterward which pulses they felt or how strongly. This model assessment is written to show what complete documentation looks like and why each element matters. The patient, a composite, is a man of 68 admitted for a urinary tract infection who mentioned, when asked about activity, that he stops walking after about a block because of an aching pain in his right calf, which eases within a few minutes of rest. He has a 40 pack-year smoking history, ending five years ago, and he has hypertension, type 2 diabetes and high cholesterol. Those are the major risk factors for atherosclerosis, and the history of calf pain that comes on with walking and resolves with rest is classic intermittent claudication, the most common symptom of lower extremity peripheral artery disease (Gerhard-Herman et al., 2017).

Cardiovascular Assessment

Inspection: Alert, sitting comfortably at rest, no distress. Skin of face and trunk pink and warm. No visible pulsations on the precordium other than a faint apical impulse. Jugular veins observed with the patient reclined to 45 degrees: pulsation visible 2 cm above the sternal angle, falling with inspiration, consistent with normal central venous pressure.

Palpation: Apical impulse at the fifth intercostal space in the midclavicular line, about 1.5 cm in diameter, brief and not sustained, which places the left ventricle in its normal position and size. No heaves or thrills. Radial pulses 72 per minute, regular, equal and 2+ bilaterally. Carotid pulses 2+ and equal, with a brisk upstroke; palpated one side at a time.

Auscultation: S1 and S2 clear at all five areas, S1 loudest at the apex and S2 at the base, physiological splitting of S2 heard at the pulmonic area on inspiration. No S3, S4, murmurs, rubs or clicks, listened for with the diaphragm and bell in the supine and left lateral positions. No carotid bruits. Blood pressure 146/84 mm Hg in the right arm and 142/82 mm Hg in the left, a difference of 4 mm Hg, within the range expected between arms.

Peripheral Vascular Assessment

Inspection: Left leg with normal hair distribution and skin color. Right lower leg with sparse hair below the knee, thin shiny skin and thickened toenails. No ulcers or wounds on either foot, including between the toes and on the heels. On elevation of both legs to 60 degrees for one minute, the right foot became noticeably paler than the left; on dependency, color returned in the left foot within 10 seconds and in the right in about 25 seconds, with a dusky red color.

Palpation: Left foot warm; right foot cool from mid-foot to toes. Capillary refill 2 seconds in left toes and 4 seconds in right toes. Pulses graded on a 0 to 3+ scale: femoral 2+ bilaterally; popliteal 2+ left, 1+ right; dorsalis pedis 2+ left, not palpable on the right; posterior tibial 2+ left, 1+ right. The absent right dorsalis pedis was confirmed with a Doppler, which found a monophasic signal. No edema in either leg.

Auscultation: Bruit heard over the right femoral artery at the groin; none on the left. Ankle-brachial index, measured with a Doppler after 10 minutes of rest: 0.96 on the left and 0.68 on the right, the right value consistent with moderate peripheral artery disease under current guideline thresholds (Gerhard-Herman et al., 2017).

Explaining the Abnormal Findings

Every abnormal finding on the right follows from a narrowed artery supplying the leg. An atherosclerotic plaque in the right femoral or popliteal artery reduces the lumen, so that blood flow at rest is barely adequate and cannot rise to meet the muscle's demand during walking. The calf muscles then work without enough oxygen, anaerobic metabolism produces lactate and other metabolites, and the result is the cramping pain of claudication, relieved when rest lowers demand. The femoral bruit is the sound of turbulent flow across the narrowing. Distal pulses are weak or absent because pressure falls across the obstruction. The cool foot, slow capillary refill, pallor on elevation and delayed dusky return of color on dependency reflect reduced perfusion pressure, which gravity makes worse when the leg is raised. The sparse hair, thin skin and thick nails reflect chronic undernourishment of the skin and its appendages. The ankle-brachial index quantifies all of this as the ratio of pressure at the ankle to pressure in the arm.

Physical signs vary in how much they tell a clinician. Pooling studies of the bedside examination, Khan et al. (2006) found that among patients with leg symptoms, cool skin, the presence of a bruit and any palpable pulse abnormality each substantially increased the likelihood of disease, while the absence of any bruit or pulse abnormality reduced it. No single sign settles the question, which is why the model documents every pulse and every comparison rather than stopping at the first abnormal one.

How the Ankle-Brachial Index Was Measured

Because the ankle-brachial index is the one number in this assessment, it is modeled step by step. The patient rested supine for 10 minutes. A cuff sized to the limb was placed on each upper arm and each ankle just above the malleoli. Using a handheld Doppler, the systolic pressure was recorded in both brachial arteries and in the dorsalis pedis and posterior tibial arteries of each leg. Following the method recommended in the American Heart Association's scientific statement on the index, each leg's value was calculated by dividing the higher of its two ankle pressures by the higher of the two arm pressures (Aboyans et al., 2012). The right leg's pressures were 100 mm Hg at the posterior tibial and 88 mm Hg at the dorsalis pedis, giving 100 divided by 146, or 0.68. The same statement notes that values above 1.40 suggest arteries too stiff to compress, common in long-standing diabetes, in which case the index is not reliable and a toe pressure should be measured instead. This patient's values were well below that range, so the index could be interpreted. Students should learn to record every pressure used, not only the final ratio, so that a colleague can check the calculation.

Common Student Errors This Model Addresses

Four errors are common in student documentation, and the model is written to prevent each. First, pulses charted as present without a grade or site; the model grades each pulse by name and side. Second, no comparison between legs; the model documents both legs for every finding, because in peripheral disease the difference between sides is often the most important information. Third, an absent pulse accepted without confirmation; the model confirms it with a Doppler, since a pulse can be missed by palpation alone. Fourth, normal findings written as within normal limits; the model states what was normal, which shows the reader that it was actually checked. When the author's students rewrote their assessments against this model, the number of peripheral pulse entries that named the site and grade rose from about one in four to nearly all in the following week's charts.

References

Aboyans, V., Criqui, M. H., Abraham, P., Allison, M. A., Creager, M. A., Diehm, C., Fowkes, F. G. R., Hiatt, W. R., Jönsson, B., Lacroix, P., Marin, B., McDermott, M. M., Norgren, L., Pande, R. L., Preux, P.-M., Stoffers, H. E., & Treat-Jacobson, D. (2012). Measurement and interpretation of the ankle-brachial index: A scientific statement from the American Heart Association. Circulation, 126(24), 2890-2909. https://doi.org/10.1161/CIR.0b013e318276fbcb

Gerhard-Herman, M. D., Gornik, H. L., Barrett, C., Barshes, N. R., Corriere, M. A., Drachman, D. E., Fleisher, L. A., Fowkes, F. G. R., Hamburg, N. M., Kinlay, S., Lookstein, R., Misra, S., Mureebe, L., Olin, J. W., Patel, R. A. G., Regensteiner, J. G., Schanzer, A., Shishehbor, M. H., Stewart, K. J., ... Walsh, M. E. (2017). 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 135(12), e726-e779. https://doi.org/10.1161/CIR.0000000000000471

Khan, N. A., Rahim, S. A., Anand, S. S., Simel, D. L., & Panju, A. (2006). Does the clinical examination predict lower extremity peripheral arterial disease? JAMA, 295(5), 536-546. https://doi.org/10.1001/jama.295.5.536