To assess a client’s dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
A.
Reduce the amount of pressure being applied on the top of the foot.
B.
Document in the nurse’s notes that the dorsalis pedis pulse is not palpable.
C.
Obtain a Doppler stethoscope to auscultate the pulse at the same site.
D.
Palpate the site on the inner side of the ankle below the medial malleolus.
The Correct Answer and Explanation is:
The correct answer is A. Reduce the amount of pressure being applied on the top of the foot.
Explanation:
When assessing a client’s dorsalis pedis pulse, it is essential to apply the appropriate amount of pressure. The dorsalis pedis pulse is located on the dorsal (top) part of the foot, between the extension tendons of the great toe and the first toe. This pulse can be subtle, especially in individuals with reduced circulation, edema, or smaller vessels. If too much pressure is applied, it can occlude the artery, making the pulse difficult or impossible to feel.
Here’s why the nurse should reduce the pressure:
- Occlusion of the artery: Applying too much pressure can compress the artery and block the pulse, leading to the false assumption that the pulse is absent. By reducing the pressure slightly, the nurse can potentially detect a weaker pulse that was being suppressed by the forceful palpation.
- Importance of palpation technique: Correct palpation technique is critical in pulse assessment. A light to moderate touch is typically more effective, especially for peripheral pulses like the dorsalis pedis. If a pulse is faint or difficult to locate, adjusting the pressure or position of the fingers can help locate it.
- Step-by-step assessment: Before documenting that the pulse is not palpable or using advanced techniques like a Doppler stethoscope, the nurse should first ensure that the technique being used is correct. If reducing the pressure still does not result in a palpable pulse, further actions (such as using a Doppler or checking another pulse site) may be warranted.
- Peripheral pulses and circulation: In clients with conditions like peripheral artery disease, the dorsalis pedis pulse can be weaker. Therefore, accurate palpation is crucial for an accurate assessment of blood flow to the extremities. By first ensuring that technique is optimal, the nurse avoids false documentation of absent pulses.
Why the other options are not correct:
- B. Documenting that the dorsalis pedis pulse is not palpable: It is premature to document an absent pulse without first ensuring proper palpation technique and possibly using a Doppler stethoscope for confirmation.
- C. Obtaining a Doppler stethoscope: While a Doppler is useful for detecting faint pulses, the nurse should first try reducing the pressure to see if a pulse becomes palpable before escalating the assessment to a Doppler.
- D. Palpating the site on the inner side of the ankle below the medial malleolus: This would assess the posterior tibial pulse, not the dorsalis pedis pulse. It’s important to check the intended site (dorsalis pedis) before moving to another pulse location.
In conclusion, reducing the pressure being applied is the next logical step to ensure proper technique before moving to more advanced methods or documenting absent findings.