Medical Surgical Peripheral Vascular Disease #6

Question

The nurse is caring for a client with complaints of claudication. An ankle-brachial index (ABI) is ordered and the client asks what the test measures and why it is important. Which statement by the nurse best describes the ABI?

Answers

  1. “The ankle-brachial index (ABI) is a noninvasive procedure to check your risk of peripheral artery disease.”
    • Rationale:

      This answer is correct because a symptom associated with PAD includes pain in the leg when walking (claudication). A way to help check a client’s risk of peripheral artery disease is by means of the ankle brachial index (ABI). This test is a noninvasive test that compares the blood pressure of the upper extremities to the lower extremities. The ABI is determined by dividing the blood pressure reading in an artery of the ankle (post-tibial) compared to the blood pressure reading in the arm (brachial).

  2. “The ankle-brachial index (ABI) produces a ratio of SBP with retrograde wave reflection from resistant distal arterioles.”
    • Rationale:

      This answer is not correct because the ankle-brachial index (ABI) does not produce a ratio of SBP with retrograde wave reflection from resistant distal arterioles. Instead, the ABI is determined by dividing the blood pressure reading in an artery of the ankle (post-tibial) compared to the blood pressure reading in the arm (brachial).

  3. “The test is a physician ordered exam, but nothing compares to old fashion palpation of your pulses.”
    • Rationale:

      This answer is not correct because palpation of pulses only does not help predict the client’s risk of PAD. A way to help check a client’s risk of peripheral artery disease is by means of the ankle brachial index (ABI). This test is a noninvasive test that compares the blood pressure of the upper extremities to the lower extremities. The ABI is determined by dividing the blood pressure reading in an artery of the ankle (post-tibial) compared to the blood pressure reading in the arm (brachial). Also, the response by the nurse is not appropriate since it reflects disagreement with a prescribed test.

  4. “The test is no big deal. Don’t worry about anything as results can be misleading.”
    • Rationale:

      This answer is not correct because the ABI test, although simple and noninvasive, is very accurate. Accuracy levels are as much as 90% when performed on clients. Also, the response by the nurse is not appropriate since it reflects doubt of accuracy of the prescribed test.

Overview

Peripheral arterial occlusive disease (PAD) is a condition where circulation is compromised due to occluded peripheral arteries. Assessment of the ankle-brachial index helps check a client’s risk of peripheral artery disease.

Explanation

Learning Outcomes

Peripheral arterial occlusive disease (PAD) is a condition where circulation is compromised due to occlusion of peripheral arteries, often associated with atherosclerosis (fatty deposits that build up on the walls of the arteries). Symptoms associated with PAD include pain in the leg when walking (claudication), decreased or absent pulse, mottled pallor which worsens when elevated and rubor when dependent, dry scaly skin, paresthesia, coolness, hairlessness, and sores that will not heal on the affected extremity. Assessment of the affected extremity, including comparison of pulses, temperature, skin, pain from the affected extremity to the unaffected is important. A way to help check a client’s risk of peripheral artery disease is by means of the ankle brachial index (ABI). This test is a noninvasive test that compares the blood pressure of the upper extremities to the lower extremities. The ABI is determined by dividing the blood pressure reading in an artery of the ankle (post-tibial) compared to the blood pressure reading in the arm (brachial).

Test Taking Tip

When choosing answers, consider completing the least invasive action first, then move to more invasive actions secondly, unless the situation is emergent and least invasive is not an appropriate option.

Video Rationale