MS Care Plan
Room #: 513-1Age
: Full code
: 80 kg (176lbs.)
: 172.2 cm(5’6”)BMI: 27
:Lower left extremity DVT (Left knee to groin)DVT can occur as the result of several combined events, including venous stasis,injury to the vessel wall, and the coagulation rate is altered. These conditionscause the formation of a blood clot, which becomes dangerous when the clotfragments and occlude the vessel. Complications of DVT include increased venouspressure, increased distal pressure, fluid stasis, and edema. (Smeltzer 2008)
Current Medical Dx
: LLE DVT w/ IVC filter placementAn IVF filter (or umbrella filter) is inserted to prevent recurring pulmonaryembolisms. The device is inserted through the internal jugular vein and advancedinto the inferior vena cava, where it is opened and operates as a filter for thebloodstream that prevents large thrombi from passing through. (Smeltzer 2008)good explanations here and with PMH
: (Bone marrow disease that leads to an abnormal increase inthe number of blood cells. WBS and platelets are also increased. Thrombosis is acomplication of this disease.)
RLE DVT in 2008:
(Formation of a blood clot in a vein. This is the pt’s currentissue, though now in the opposite leg. PMH of past DVT and polycythemia identifypt is at higher risk for venous stasis, vessel wall injury, and hypercoagulability. )
(Total removal of prostate gland in 2006. Denies complicationsfrom surgery.)
(Total removal of appendix in 1990s. Denies complications fromsurgery. History of abdominal surgery is associated with thrombus/emboli).
Social history (ethnicity, occupation, marital status, family support, livingsituation)
:White; married w/ grown children; retired; financially independent and fully mobile.
Relevant Medical Orders
: Coumadin diet what would this be?
: No restrictions
Other relevant orders
:Continuous telemetry (baseline HR 87 & sinus rhythm with no ectopy, meaning allheart beats originate from the proper place in the heart.
Safety & Communication
Primary Language: English Translator required: NSpecial Communications Needs: None Hearing aids at BS: N