Interventions :
1. Monitor blood pressure, measure in both arms/thighs three times, use correct cuff size and accurate technique.
Rationale : Comparison of pressures provides a more complete picture of vascular involvement/scope of problem. Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.
2. Note dependent/general edema.
Rationale : May indicate heart failure, renal or vascular impairment.
3. Note presence, quality of central and peripheral pulses.
Rationale : Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.
4. Observe skin color, moisture, temperature, and capillary refill time.
Rationale : Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output.