In the plan of care for a client treated with an Unna's paste boot, what assessment should be included?

• A. Check capillary refill of toes on lower extremity with Unna's paste boot
• B. Measure heart rate and rhythm
• C. Assess gag reflex
• D. Inspect for peripheral edema of the hands

Answer: (A)

Distal perfusion checks are essential when an Unna's paste boot is applied because the rigid dressing can compress tissues and potentially reduce blood flow to the toes. Assessing capillary refill in the toes provides a quick, practical measure of distal perfusion. A normal refill is usually under 2 seconds; if it’s delayed, it suggests compromised circulation and requires prompt attention—loosen or adjust the boot, check for swelling, and notify the clinician as needed. The other assessments don’t directly address how the boot affects the leg’s blood flow: heart rate and rhythm reflect overall cardiac status, gag reflex is unrelated to lower-extremity care, and edema of the hands doesn’t inform the condition of the limb under the boot.