# A nurse is assessing a 45-year-old client with hypertension and a family history of cardiovascular disease, suspected of peripheral arterial disease. Which of the following findings should the nurse report to the healthcare provider immediately?

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## 문제

A nurse is assessing a 45-year-old client with hypertension and a family history of cardiovascular disease, suspected of peripheral arterial disease. Which of the following findings should the nurse report to the healthcare provider immediately?

## 보기

1. Dependent rubor with pallor on elevation
2. Absent dorsalis pedis pulse with cool, pale extremities **✔ 정답**
3. Pitting edema in bilateral lower extremities with skin thickening
4. Superficial varicose veins with skin discoloration

**정답: 2**

## 해설

Absent dorsalis pedis pulse with cool, pale extremities indicates arterial insufficiency in PAD, requiring immediate intervention. Other options are more typical of venous issues or less urgent findings.

## 심화 해설

Clinical Reasoning and Prioritization

The client’s presentation of suspected peripheral arterial disease (PAD) requires the nurse to differentiate between chronic, stable findings and those indicative of a sudden, emergent threat to the limb. The correct answer is the finding that signals a progression from chronic ischemia to acute limb ischemia (ALI).

Analysis of the Correct Answer: Option 2

An absent dorsalis pedis pulse accompanied by a cool, pale extremity represents a dramatic and sudden reduction in arterial perfusion. In the context of a patient with PAD, this clinical picture is the hallmark of acute limb ischemia (ALI). As defined in the literature, ALI is a sudden decrease in lower limb arterial perfusion that poses a threat not only to limb viability but also to life and requires urgent evaluation and management [2]. The underlying etiology in a PAD patient is often acute thrombosis of a pre-existing atherosclerotic lesion or a distal embolization [2]. The sensory and motor deficits that can quickly follow this presentation signal irreversible tissue damage, making immediate reporting and intervention, such as revascularization, critical for limb salvage [2]. This is a time-sensitive emergency where a delay of hours can determine the need for amputation.

Analysis of Incorrect Options

Option 1: Dependent rubor with pallor on elevation

This finding describes chronic, severe PAD. When the limb is dependent, gravity forces blood into maximally dilated, ischemic capillary beds, causing a deep red color (rubor). Upon elevation, the arterial pressure is insufficient to overcome gravity, and the limb becomes pale. While this indicates significant arterial insufficiency, it is a stable, chronic physical exam finding, not an acute change requiring immediate reporting in the same way a new loss of a previously palpable pulse would.

Option 3: Pitting edema in bilateral lower extremities with skin thickening

This presentation is more consistent with chronic venous insufficiency (CVI) or lymphedema, not arterial disease. The bilateral nature and skin thickening (lipodermatosclerosis) point to a long-standing venous pathology, which, while requiring management, does not represent the same immediate threat to limb viability as acute arterial occlusion.

Option 4: Superficial varicose veins with skin discoloration

This is another classic manifestation of chronic venous disease. The skin discoloration is typically hemosiderin deposition from the breakdown of red blood cells that have leaked into the tissues due to venous hypertension. This is a chronic, progressive condition that is managed on a non-emergent basis and is not an immediate threat to the limb.

Pathophysiology and Clinical Application

The core of this question lies in distinguishing a chronic, compensated state from an acute decompensation. In chronic PAD, collateral circulation often develops, allowing for a baseline level of perfusion even with significant main vessel stenosis. A patient may have a diminished pulse or even a monophasic Doppler signal but still have a viable, intact limb. The sudden loss of a previously documented pulse signals that a critical occlusive event has occurred, overwhelming any collateral supply. The affected tissue shifts from a state of ischemia to one of impending infarction. The severity and treatment strategy for this event must be determined rapidly based on physical and image findings, with revascularization performed surgically or endovascularly [2]. The nurse’s role is to recognize this pivotal change in the vascular assessment and activate the emergency response system to prevent irreversible nerve and muscle necrosis.References (research sources)

- [2]Revascularization for Acute Limb Ischemia.Research articleShukuzawa K, Ozawa H, Ohki T. (2026) · DOI: 10.3400/avd.ra.26-00066

## 임상 시나리오

Acute Limb Ischemia RecognitionDifferentiating ALI from Chronic PAD Findings
The sudden onset of a cold, pale extremity with an absent previously palpable pulse is a vascular emergency. This presentation indicates Acute Limb Ischemia (ALI), a sudden drop in perfusion that threatens limb viability within 6 hours.

In contrast, dependent rubor and pallor on elevation are signs of chronic, severe PAD. While serious, they represent a stable, compensated state and do not require the same immediate, emergent reporting as ALI.

CautionImmediately report any sudden change in limb color, temperature, or pulse quality in a patient with PAD. A delay in revascularization for ALI beyond 6-8 hours can lead to irreversible nerve and muscle damage, often resulting in amputation.

## 핵심 개념

- **Acute Limb Ischemia (ALI)** — A sudden decrease in limb perfusion threatening viability, often presenting with the 6 Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia.
- **Peripheral Arterial Disease (PAD)** — Atherosclerotic narrowing of arteries, typically in the lower extremities, causing chronic, progressive reduction in blood flow.
- **Dependent Rubor** — Reddish-blue discoloration of the skin when the limb is in a dependent position, indicating severe, chronic arterial insufficiency.
- **Pallor on Elevation** — Skin blanching when the limb is raised above heart level, a classic sign of chronic PAD due to inadequate arterial flow against gravity.
- **Dorsalis Pedis Pulse** — An arterial pulse palpated on the dorsum of the foot, commonly assessed to evaluate arterial perfusion to the lower extremity.

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