Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization?
1. Capillary refill is greater than 3 seconds.
2. Lower extremities are warm, with a capillary refill of less than 3 seconds.
3. Sensation is decreased with a weakened dorsalis pedis pulse.
4. Dorsalis pedis pulse is palpable but posterior tibial pulse is weak.
2
Explanation:
1. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
2. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than 3 seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.
3. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
4. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
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