NR 304 Annie Laduke week 4 PDF

Preview

Summary

Download NR 304 Annie Laduke week 4 PDF

Description

Student Instructions for Standardized Simulation NR 304 Annie Laduke Jessica Paczesny DVT 1) Based on what you’ve learned about the nursing process, describe one applicable nursing diagnosis, treatments, and nursing considerations for this diagnosis. Nursing Dx:  Ineffective tissue perfusion: Peripheral related to decreased venous circulation in the right leg.  Pain related to inflammatory response in affected vein.  Warmth of the right lower leg.  At risk for Pulmonary embolism.  At risk for impaired skin integrity related to pooling of venous blood in the right leg. Nursing treatment:  Prevent any further complications from arising Help relieve her pain with medications.  Control the thrombus development and the potential of the turning into a pulmonary embolism.  Perform range of motion if the patient is on bed rest.  Measure the circumference of the right calf daily and compare the sizes.  Treatments for a DVT include:  Anticoagulants to prevent clots.  Prevent any other clots from forming. Nursing considerations:  Prevent the patient from being completely immobile  If on bed rest: perform ROM in bed.  A threat because a thrombus may break away with movement or massage, resulting in a pulmonary embolus, which has serious consequences for respiratory and cardiovascular function.  Watch out for signs and symptoms of a pulmonary embolus such as: sharp chest pain, tachycardia, tachypnea, elevated blood pressure, and dyspnea.  Assess the patient’s respirations.  Not getting blood to the tissue, therefore blood isn’t getting to the capillary bed; not enough oxygen, resulting in decreased respiration (difficulties breathing). 2) What are some non-pharmacological measures that can be used for pain relief in care for this patient?  Elevate legs, maintaining slight knee flexion, while in bed.  Apply warm, moist compresses using a 2-hour-on, 2-hour-off schedule.  Heat or cold therapy: o Helps with pain, tenderness, and swelling.  Apply compression stockings and remove for 30 minutes every 8 hours, monitor distal pulses.  Assist with progressive ambulation when allowed.

 

Physical therapy to keep the patient active and relieve the pain. Range of motion

3) Describe the components of a peripheral vascular nursing assessment: During a peripheral vascular nursing assessment inspect the skin for the color, size, and if there may be any trophic skin changes present such as varicose veins, sores or ulcers. Note if there is redness and what type of edema is present (1+-4+). Assess if there is pain present to the touch. Grade and palpate the femoral, popliteal, posterior tibial, dorsalis pedis pulses. Assess if the pulses are palpable or non-palpable. Assess the rate, rhythm, symmetrical, and amplitude of each pulse. Inspect the legs for symmetry, temperature, and the color of the skin such as redness, cyanosis, pallor or brown flaky discoloration. Verify the patient’s history and family history for heart disease, hypertension, and diabetes. Ask where the pain is present and what makes the pain better or worse. If the pain is gradual or sudden; if it burns, or is a stabbing pain. It’s important to also assess the patient’s respiration rate. Clots can lead to a pulmonary embolus, if the clot becomes dislodged it can cause the artery to become blocked to the point where it’s not allowing blood to get through to be oxygenated resulting in tissue damage or death. Ask the patient about any medications she may be taking or have taken in the past....