5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

• Diminished or absent pulses (peripheral arterial disease or acute occlusion); prolonged capillary refill.
• A cool, pale, cyanotic, or mottled extremity; dependent rubor; pallor on elevation.
• New or worsening edema (note location, grade, and symmetry).
• Claudication (distance to onset), rest pain, or acute severe extremity pain.
• Arterial ulcers (toes or pressure points, punched-out, painful) or venous ulcers (medial malleolus, irregular, exudative).
• Hyperpigmentation and varicosities of new concern.
• Unilateral calf swelling, warmth, tenderness, and erythema (possible deep-vein thrombosis).
• The six P's of acute limb ischemia — pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness).