A nurse is assessing a 55-year-old patient with diabetes and a history of smoking who presents with leg pain. Which of the following findings should the nurse report to the healthcare provider immediately?

Nursing Clinical Practice Guide Clinical Scenario You are a nurse on a medical-surgical unit. Mr. Johnson, a 62-year-old with type 2 diabetes and a 40-pack-year smoking history, is admitted for worsening leg pain. He says, "My right calf cramps up after walking just one block, and now my foot is cold and looks pale when I lift it up." Nursing Intervention Strategy 1. Assessment: Perform a comprehensive vascular assessment. Compare bilaterally. • Inspection: Note skin color (check for pallor on elevation, dependent rubor), temperature (use back of hand), hair distribution, nail thickness, and any lesions/ulcers. • Palpation: Check capillary refill (normal < 3 seconds). Palpate all lower extremity pulses (femoral, popliteal, posterior tibial, dorsalis pedis) and grade them (0=absent, 1+=diminished, 2+=normal, 3+=bounding). • Auscultation: Listen for bruits over the abdominal aorta and femoral arteries. 2. Nursing Diagnosis & Planning: Primary concerns are Ineffective Peripheral Tissue Perfusion and Risk for Impaired Skin Integrity. The plan includes monitoring for worsening ischemia, promoting circulation, and protecting extremities. 3. Implementation & Patient Education: • Positioning: Instruct to avoid elevating legs above heart level (can further reduce arterial flow). For PAD, a slightly dependent position or neutral position is better. For venous issues, elevation is key—don't confuse them! • Foot Care: Emphasize daily inspection with a mirror for heels and between toes. Use lukewarm water, dry thoroughly (especially between toes), and apply moisturizer to dry areas (but not between toes). Wear well-fitting shoes and clean, dry socks. Never go barefoot. • Lifestyle Modifications: Collaborate on a smoking cessation plan. Discuss a supervised walking program (walk to the point of pain, rest, resume) to promote collateral circulation. 4. Evaluation: Monitor for reduction in claudication distance, improvement in skin color/temperature, and absence of new ulcers or tissue breakdown. Patient Safety and Precautions • Key Point! Never apply direct heat (heating pads, hot water bottles) to ischemic limbs. The patient has reduced sensation and blood flow, creating a high risk for burns. • Caution with vasoconstrictive medications (e.g., decongestants containing pseudoephedrine). • Report immediately: Sudden onset of severe pain, pallor, coolness, pulselessness, or paralysis (the "5 P's" of acute arterial occlusion)—this is a surgical emergency. Nursing Procedure & Medication Flow • Ankle-Brachial Index (ABI) Procedure: The nurse often assists. Blood pressure cuffs are placed on both arms and ankles. The systolic pressure in each ankle is divided by the higher of the two brachial systolic pressures. Document results carefully. • Medication Administration: If administering cilostazol, note it is contraindicated in patients with heart failure. Teach the patient it may take several weeks to see improvement in walking distance. A Word from Your Senior Nurse "Vascular assessment is a core nursing skill. When you see a patient with leg pain, don't just ask 'where does it hurt?'—let your hands do the assessing. Feel for that pulse, check the temperature, and look for color changes. That moment you identify dependent rubor and a faint pulse could be the moment you save a limb. On the NCLEX and in practice, thinking through the pathophysiology—'Is this an inflow or an outflow problem?'—will always guide you to the right action. Your careful assessment is the first line of defense against amputation in these high-risk patients."