Deep Vein Thrombosis Assessment Subj.

The patient states I cant feel my right leg Diagnosis P: Ineffective tissue perfusion (peripheral) related to E: interruption of venous flow as evidenced by S: DVT, edematous in RLL & Lab. values abnormal. Planning After 6-8 hrs. of nursing intervention patient will demonstrate increased perfusion. Nursing Intervention Independent: Establish rapport Rationale To have a trusted nurse to patient relationship and to have a therapeutic communication. Lab values reflect progress of the patients venous flow and peripheral tissue perfusion. HB/Hct Evaluation After 6-8 hrs. of nursing intervention patient demonstrated increased perfusion.

Obj. Lab: -UTZ: deep vein thrombosis -slight erythematous leg - calf tender to touch

Monitor lab values to assess effect of anticoagulant therapy and report lab values outside the desired range.

Leg measurement discrepancies of more than Monitor swelling in RLL and 2cm warrant further check for pedal pulses. investigation. Swelling or lack of Monitor pain associated swelling indicates whether with edema (before venous flow is efficient. treatment) Medications will help the Collaborative: patient return to baseline levels, but need to be monitored due Administer medication as to serious side effects. ordered by physician and monitor effectiveness Discuss care of RLL with regard to DVT and edema When circulation is impaired, changes in sensation place client at risk for injury.

Assessment Subj. The patient states My calf is in pain

Obj. Lab: -UTZ: deep vein thrombosis -O2 sat: 99% -slight erythematous leg - calf tender to touch VS: -BP- 90/50 -T- 36.4 -PR- 84 -RR- 27

Diagnosis P: Acute Pain related to E: interruption of venous flow as evidenced by S: DVT, edematous in RLL & Lab. values abnormal.

Planning Short Term Goal: After 3-4 hours of nursing interventions, the patient will be able to manifest alleviated pain.

Nursing Intervention Independent: Establish rapport

Rationale To have a trusted nurse to patient relationship and to have a therapeutic communication. To rule out worsening or underlying condition or development of complications.

Evaluation Short Term Goal: After 3-4 hours of nursing interventions, the patient is able to manifest alleviated pain.

Long Term Goal: After 1-2days, the patient will be able to manifest absence of pain.

Obtain patients assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity, and precipitating or aggravating factors. Observe non-verbal cues and pain behaviors.

Observations may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. To promote nonpharmacological pain management. To divert the patients attention.

Long Term Goal: After 12days, the patient is able to manifest absence of pain.

Provide comfort measures

Encourage diversional activities.

Encourage adequate rest periods. Encourage patient to assume position where he feels. Collaborative: Administer medication as ordered by physician and monitor effectiveness

To prevent fatigue.

To promote comfort for the patient.

To alleviate pain.

References Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). 23 & 31.Brunner & Suddarth'stextbook of medical-surgical nursing (11th ed., p. 666 p. 1005). Philadelphia: Lippincott Williams & Wilkins. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse's pocket guide diagnoses, prioritized interventions, and rationales (12th ed.). Philadelphia: F.A. Davis. Lippincott's nursing drug handbook 2012. (2012). Philadelphia, Pa.: Lippincott Williams &Wilkins. Pagana, K. D., & Pagana, T. J. (2010). Mosby's manual of diagnostic and laboratory tests (4th ed.). St. Louis, Mo.: Mosby Elsevier. Partial thromboplastin time (PTT): MedlinePlus Medical Encyclopedia. National Libraryof Medicine - National Institutes of Health. Retrieved November 10, 2011, fromhttp://www.nlm.nih.gov/medlineplus/ency/article/003653.htm

Polycythemia vera - PubMed Health. National Center for Biotechnology Information .Retrieved November 10, 2011, fromhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001615/