A nurse is caring for a 75-year-old client who is admitted to the medical- surgical unit. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation & Rationale
Potential Condition: Deep Venous Thrombosis (DVT) Actions to Take: Request a prescription for a lower extremity Doppler flow study Check for pedal pulses and signs of ischemia Parameters to Monitor: PT/INR and platelet count Signs of bleeding after anticoagulation initiation Rationale: DVT: The client presents with classic signs of DVT, including: unilateral leg swelling, pain and warmth in the affected limb, recent immobility (limited ambulation after surgery). DVT is a serious complication that can lead to pulmonary embolism (PE) if the clot dislodges. Actions to Take: Request a prescription for a lower extremity Doppler flow study: A Doppler ultrasound is the gold standard for diagnosing DVT by assessing blood flow and detecting clots. Check for pedal pulses and signs of ischemia: Ensuring adequate circulation is crucial to monitor for complications like arterial occlusion. Parameters to Monitor: PT/INR and platelet count: If anticoagulation therapy is initiated, monitoring PT/INR (for warfarin) or platelet count (for heparin-induced thrombocytopenia) is essential. Signs of bleeding after anticoagulation initiation: Anticoagulants increase the risk of bleeding, so assessing for bruising, hematuria, or GI bleeding is critical.