The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?A. Apply TED hose to bilateral legsB. Assess the need for smoking cessationC. Physical therapy consultD. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler
Question
The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?A. Apply TED hose to bilateral legsB. Assess the need for smoking cessationC. Physical therapy consultD. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler
Solution
The intervention that is contraindicated in this case is A. Apply TED hose to bilateral legs.
Here's why:
A. Apply TED hose to bilateral legs - This is contraindicated because the client has a full-thickness wound on the right lateral malleolus. Applying TED hose could potentially cause further damage to the wound and restrict blood flow, which is already compromised due to the weak pedal pulses.
B. Assess the need for smoking cessation - This is not contraindicated. Smoking can impair circulation and delay wound healing, so it would be beneficial to assess the client's need for smoking cessation.
C. Physical therapy consult - This is not contraindicated. Physical therapy could potentially help improve the client's circulation and mobility, which could aid in wound healing.
D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler - This is not contraindicated. The ABI is a test that can help determine the severity of peripheral arterial disease, which the client may have given the weak pedal pulses and absent hair on the legs. This test could provide valuable information for managing the client's care.
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