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4. Resumes daily activities; free of pain.I. DEEP VEIN THROMBOSIS(THROMBOPHLEBITIS): formation of a bloodclot in an inflamed vein, secondary to phlebitisorpartial obstruction; may leadto venous insufficiencyand pulmonary embolism. Deep vein thrombosis(DVT) is most serious form.A. Pathophysiology: endothelial inflammation→formation of platelet plug (bloodclot) →slowing of bloodflow →increase inprocoagulants in local area →initiation of clotting mechanisms.B. Risk factors:1. Immobility/stasis—prolonged sitting, bedrest, obesity, pregnancy.2. Venous disease; history DVT.3. Age—increased incidence in elderly.4. Gender—more often women.5. Hypercoagulabilityof blood.6. Intimal damage—IVs, drug abuse.7. Fractures.8. Oral contraceptives (related to estrogen content).A. Assessment:1. Subjective data:a. Calf stiffness, soreness.b. Severe pain: walking, dorsiflexion of foot (Homans’ sign—may be unreliable).1. Objective data:a. Vein: redness, heat, hardness, threadiness.b. Limb: swollen, pale, cold.c. Vital signs: low-grade fever.d. Diagnostic tests: venogram, impedance plethysmography (electrical resistance to bloodflow), ultrasonography.A. Analysis/nursing diagnosis:1. Altered peripheral tissue perfusion related to venous stasis.2. Painrelated to inflammation.3. Activity intolerance related to leg pain.
9/25/18, 4*49 PMDAVIS'S NCLEX-RN® SUCCESS | R2 Digital LibraryPage 40 of 414. Risk for injury related to potential pulmonary emboli.A. Nursing care plan/implementation:1. Goal: provide rest, comfort, and relief from pain.a. Bedrest until therapeutic level of heparinreached (5 to 7 days with traditional heparin; after 24 hours with low-molecular-weight heparin).b. Position: as ordered; usually extremity elevated; watch for pressure points.c. Apply warm, moist heat to affected area as prescribed (cold may also be ordered).d. Assess progress of affected area: swelling, pain, soreness, temperature, color.e. Administer analgesics as ordered.1. Goal: prevent complications.a. Observe for signs of embolism(painat site of embolism); allergic reaction(anaphylactic shock) with streptokinase.b. Precautions: no rubbing or massage of limb.c. Medications: anticoagulants (sodiumheparin, enoxaparin, warfarin [Coumadin]); streptokinase (Varidase), tissueplasminogen activator (Table 6.23).d. Bleeding: hematuria, epistaxis, ecchymosis. Check INR levels.e. Skin care, to relieve increased redness/ maceration from hot or cold applications.f. ROM: unaffected limb.1. Goal: health teaching.a. Precautions: tight garters, girdles; sitting with legs crossed; oral contraceptives.b. Preventive measures: walking daily, swimming several times weekly if possible, wading, rest periods with legs elevated,elastic stockings (may remove at bedtime).