4 Resumes daily activities free of pain I DEEP VEIN THROMBOSIS THROMBOPHLEBITIS

4 resumes daily activities free of pain i deep vein

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4. Resumes daily activities; free of pain . I. DEEP VEIN THROMBOSIS (THROMBOPHLEBITIS ): formation of a blood clot in an inflamed vein, secondary to phlebitis or partial obstruction; may lead to venous insufficiency and pulmonary embolism . Deep vein thrombosis (DVT ) is most serious form. A. Pathophysiology: endothelial inflammation formation of platelet plug (blood clot) slowing of blood flow increase in procoagulants 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. Hypercoagulability of 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 blood flow), ultrasonography. A. Analysis/nursing diagnosis: 1. Altered peripheral tissue perfusion related to venous stasis. 2. Pain related to inflammation . 3. Activity intolerance related to leg pain .
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9/25/18, 4*49 PM DAVIS'S NCLEX-RN® SUCCESS | R2 Digital Library Page 40 of 41 4. 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 heparin reached (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 (pain at site of embolism ); allergic reaction (anaphylactic shock ) with streptokinase. b. Precautions: no rubbing or massage of limb. c. Medications: anticoagulants (sodium heparin , enoxaparin, warfarin [Coumadin]); streptokinase (Varidase), tissue plasminogen 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).
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