Question

SCENARIO OVERVIEW: 

Annie Laduke is a 32-year-old Native American female with no significant health history. This morning, she presented to her provider's office with complaints of pain, increased redness, and warmth of the right lower leg in the calf area. She was directly admitted to the inpatient medical unit by her provider.

 1. Based on what you've learned about the nursing process, describe one applicable nursing diagnosis, treatments, and nursing considerations for this diagnosis.

 2. What are some non-pharmacological measures that can be used for pain relief in care for this patient?

 3. Describe the components of a peripheral vascular nursing assessment.

Answer 1

Deep vein thrombosis can cause leg pain or swelling but may occur without any symptoms.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

• Ineffective tissue perfusion related to the interruption of venous blood flow.
• Impaired comfort related to vascular inflammation and irritation.
• Risk for impaired physical mobility related to discomfort and safety precautions.
• Deficient knowledge regarding the pathophysiology of condition related to lack of information and misinterpretation.

• Nursing Interventions

  The major nursing interventions that the nurse should observe are:

• Provide comfort. Elevation of the affected extremity, graduated compression stockings, warm application, and ambulation are adjuncts to the therapy that can remove or reduce discomfort.
• Compression therapy. Graduated compression stockings reduce the caliber of the superficial veins in the leg and increase flow in the deep veins; external compression devices and wraps are short-stretch elastic wraps that are applied from the toes to the knees in a 50% spiral overlap; intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings.
• Positioning and exercise. When a patient is on bed rest, the feet and lower legs should be elevated periodically above the level of the heart, and active and passive leg exercises should be performed to increase venous flow.