Summary: Download! Our documentation requires us to chart pulses and whether they have been confirmed by palpation, Doppler, or if they are absent. I usually check pulses while I'm assessing neurological status in an awake patient but every RN has their own "flow". Until I rotated through the Vascular ICU, I very rarely had to doppler a pulse. Sometimes when patients are extremely edematous, a doppler is necessary to confirm a pulse through all the pedal edema. But in the VICU, you deal with a lot of patients who have PAD (peripheral arterial disease) and also patients who have undergone endovascular surgery like Femoral Popliteal Bypass (Fem-Pop) and are at risk for a failed graft. // To illustrate my point, I'll use the Fem-Pop as an example. When a patient has a blocked blood vessel at or below the knee that is causing symptoms like claudication (tightening of the arteries in the legs on exertion) and/or has risk of limb loss they may undergo a Femoral Popliteal artery bypass. Basically, a graft is applied above the area of blockage to the Femoral artery and attached below the area of blockage to the Popliteal artery (hence the name Fem-Pop). Think about how traffic is re-routed around an accident scene and you've got the same idea. The graft that bypasses the occlusion can either be man-made (like Dacron) or harvested from a healthy vein in the patient. Post-operatively, pedal pulses on the surgical side are monitored frequently to ensure that the bypass is actually working to get blood down to the toes. If the graft fails and the patient loses blood flow to the leg, you will not be able to feel a pulse. If you cannot palpate a pulse or you are not 100% sure if you are palpating a pulse, it it best to confirm by doppler. Remember- if you chart you feel a pulse and you aren't sure- you are putting the patient at risk of losing a leg- which is kind of a big deal! Be liberal with the ultrasound gel and turn the doppler up to full volume. First search where you normally feel a dorsalis pedis artery or an posterior tibial artery. If you cannot hear anything, start up between the big toe and 2nd toe and work your way down slowly. If you hear the pulse, wipe off the gel and grab a black Sharpie to make a big "X" where you felt it. This will help you find it quickly next time and it will really help the RN who follows you. What happens if you don't hear a pulse? Have another RN attempt to doppler a pulse, preferably a charge RN or someone with a few years experience under their belt. Then, notify the surgical team or the attending physician. They might come by to assess the patient themselves or have you order an Arterial Duplex Ultrasound. The tech will arrive at your bedside and assess the patient's arteries for stenosis (narrowing) or occlusion (complete blockage). Notify the physician of the results. He or she may end up taking the patient immediately back to the OR to revise the graft depending on the severity of the stenosis. And that's why pulses really are important!
