A2

New unilateral calf swelling — possible DVT

Skilled peripheral vascular assessment found new right calf swelling with warmth, tenderness, and erythema; the right calf measured 3 cm larger than the left; pulses remained palpable and the patient denied dyspnea or chest pain. Findings are concerning for deep-vein thrombosis. Provider notified at 11:15 with the calf measurements, warmth, and tenderness; order received to obtain a duplex ultrasound and evaluate, with instruction to activate emergency response for dyspnea, chest pain, or tachycardia suggesting pulmonary embolism. Patient educated on warning signs requiring 911 and advised against vigorous calf manipulation; the agency coordinated imaging. Reassessment and follow-up coordinated with the provider.

A3

Worsening venous ulcer with infection signs

Skilled peripheral vascular and wound assessment found the medial-malleolar venous ulcer enlarged to 2.6 cm from 1.8 cm with increased purulent exudate, surrounding erythema and warmth extending 2 cm, and a temperature of 100.8 °F. Findings indicate a deteriorating, possibly infected ulcer. Wound reassessed and the ordered dressing reinforced; provider notified at 10:40 with the wound measurements, drainage, periwound changes, and temperature. Orders received to obtain a wound culture, begin the ordered antibiotic, and modify the dressing. Patient educated on infection warning signs, elevation, and compression; the agency coordinated the culture. Reassessment of the wound and temperature planned in 48 hours.

A4

Claudication progression / new rest pain

Skilled peripheral vascular assessment found worsening claudication, with leg pain now occurring after 50 feet (previously 200 feet) and new pain at rest at night relieved by dangling the leg. Dorsalis pedis pulse diminished to 1+ from 2+; the foot is cool with dependent rubor; skin intact. Findings indicate progressing arterial insufficiency. Provider notified at 13:20 with the claudication distance, the new rest pain, and the pulse change; order received to evaluate, including vascular studies, with instruction to escalate for a sudden cold, pale, or pulseless extremity. Foot protection, the walking program, and warning signs reinforced; teach-back accurate. Reassessment of perfusion and symptoms planned next visit.

A5

New or worsening edema

Skilled peripheral vascular assessment found new 3+ pitting edema to the mid-calf bilaterally, increased from 1+ at the prior visit, with taut shiny skin; pulses remained palpable; the patient denies sudden weight gain, chest pain, or dyspnea. Findings represent worsening lower-extremity edema requiring evaluation of the cause. Legs elevated and skin integrity assessed; provider notified at 12:05 with the edema change and the absence of cardiopulmonary symptoms; order received to evaluate, including a review of medications and possible studies. Elevation, skin monitoring, and warning signs reinforced; the agency arranged the ordered evaluation. Reassessment of edema and skin planned next visit.

A6

Arterial ulcer on pressure point

Skilled peripheral vascular and wound assessment identified a new punched-out, painful ulcer on the lateral aspect of the right fifth toe with a pale base and minimal exudate; the dorsalis pedis pulse is 1+ and the foot is cool. Findings are consistent with an arterial ulcer in the setting of peripheral arterial disease. Pressure offloaded per order and the extremity positioned per the patient-specific order; provider notified at 11:50 with the ulcer characteristics and the diminished pulse; orders received to evaluate perfusion, obtain vascular studies, and apply the ordered dressing. Patient educated on offloading, foot protection, and warning signs of worsening ischemia; the agency coordinated vascular evaluation. Reassessment of the wound and perfusion planned next visit.