Checking pulses with a lower leg cast???

[NurseScholar]

my class had a question on a recent exam.

the stem read: when assessing a patient with a lower leg cast the nurse should assess? check all that apply. the answer choices were: pulse, pallor, paresis, parathesia, and pain (also known as the 5 p's)

i checked all of the answers, as i recognized that she was asking for all five of the p's and received full credit for the question, but a fellow student did not check pulse and missed the question. the student articulated that you could not check a pulse through a cast while on a lower leg as all lower leg casts wrap around the foot for support. the instructor refused to give her credit.

the instructor said that she did not tell in the stem whether or not the foot was enclosed, but it is my understanding that all lower leg casts enclose the foot and maintain the foot at a 90 degree angle.

what do you think? can you check a pulse with a lower leg cast? thanks in advance.

[Roy Fokker, BSN, RN]

Checking for pedal pulses is important.

When I work the ortho end of my floor, I have some patients come up with bulky ACE dressings post TKAs. Often times, I'll snip away the bottom inch or so off their foot to make my assessments possible.

I've pointed it out to the MD when he rounds (only one Doc is careless enough to do this. The other surgeons give us lee way) and he says it's ok with him (but he still doesn't stop wrapping that ACE all the way down with his next case! ARRRGH! )

If not, the cast will need to be cut away by the Md.

We've done this atleast twice on our floor - including for ORIF's of ankle Fx's. All we had to do was tell the MD that we needed space for our nursing assessments and the doc's were more than happy to slice away some of the cast material to make it possible.

I mean, look at it from their perspective - early detections helps avoid costly problems!

cheers,

PS to OP: Never forget to ask for "numbness, tingling, heaviness, cramping or tenderness" (especially in the calf). Patients with busted bones lie in bed for long periods - remember DVTs!

[msdobson]

You palpate for this pulse on the top of the foot, about an inch and a half (approx.) above the toes. Sometimes it is difficult to find,

The dorsal most prominence of the navicular bone provides a bony landmark to readily locate the dorsalis pedis artery.

[Psqrd]

I have heard of Nurses requesting small windows cut into the cast to get access to pulses. I am sure you need the Doctors approval but I can see no reason why they wouldn't allow it.

[jaacosmom]

I agree with above also with the pulse oximeter they give oxygen saturation and the pulse rate. The questions on your tests are N-Clex like. Only like - that is in the style of - the real ones are even more vague. If you can't feel the pedal pulse by slipping your fingers under the cast the cast is probavly to tight. I don't recall ever seeing a cast that covers the toes, except for maybe in the cartoons!!

[TraumaICURN]

I wouldn't give your friend credit for the question either. Pedal pulses should be the first thing you check for. Even if the cast does extend to the foot, there should be an opening for you to dopple or feel for the pulses. Tell your friend to quit thinking so deep into a simple question. Knowing the P's of a full neurovascular assessment are important....and pulses should definitely NOT be left out!

[P_RN, ADN, RN]

There is such a thing as a cylindar cast that doesn't go on the foot. It's pretty much been replaced with knee immobilizers.

10% of the population doesn't have a dorsalis pedis pulse per se BUT you can get a teeny weeny little pulse right where the great toe and the long toe meet. It takes practice. Try it on yourself. You can also get a pulse lateral to the ring toe. Again you gotta really try to find it. Cap refill is fine but if you don't at least TRY for a pulse then you haven't assessed. Compartment sx is a nasty way to lose a leg.

WIKI has a nice image:

http://en.wikipedia.org/wiki/Dorsalis_pedis_artery

BTW IF you suspect compartment sx it's an emergency. Don't elevate the leg. Call the doc STAT, see if you can get the cast split and the batting/soft roll too, cause bloody soft roll can get stiff as plaster. Keep bugging the doc please.

[tx2007, RN]

I'm not sure but I just did Kaplan review and we had the same type question when we asked the instructor (former NS instructor with her MSN) she said you assume it has a window left to assess the pulse. @@ Who knows.

[suzanne4, RN]

Foot casts do not always include the entire foot, many times they do not include the toes, and only cover about 1/3 of the foot. And some are actually more like splints that can be removed and the foot checked.

Not all lower leg casts include a foot, depends on why the cast was placed in the first place.

And if you think about a cast to the arm, the cast usually covers around the inner wrist area so you may have problems with the radial artery, but many times you can still feel the ulnar pulse on the lateral side.

Always include pulse when assessing. If you can reach it, great. If you cannot, then you must document that you cannot. So it is still included even if you cannot reach it. That is what the instructors are trying to impress upon you.

[jill48, ASN, RN]

The dorsal most prominence of the navicular bone provides a bony landmark to readily locate the dorsalis pedis artery.

Yes, I am aware. But since the OP is a student she may not be familiar with all those big fancy words yet; which is why I spelled it out in plain english for her.