TAGUM DOCTORS COLLEGE, INC.

Mahogany St. Rabe Subdivision, Tagum City

Bachelor of Science in Nursing
NCP
B

Assessment Need Nursing Diagnosis Plan of Care Nursing Intervention w/ Rationale Evaluation

Subjective cues: GORDON’S Ineffective After 3hrs patient  Established Rapport GOAL MET
FUNCTIONAL peripheral tissue will demonstrate R: To gain trust and cooperation on Patient will maintain
“My calves are
providing client care and needs.
sore and little HEALTH perfusion related increased optimal peripheral tissue
swollen” As Dependent
PATTERNS to interruption peripheral tissue  Administer anticoagulants as perfusion in the affected
verbalized by the
patient of venous blood perfusion in the (heparin/warfarin [Coumadin]) as extremity, as evidenced by
flow as affected prescribed.
strong palpable pulses,
evidenced by extremities R: Treatment with anticoagulant is used
primarily to prevent the formation of new reduction in and/or
PHYSIOLOGIC slight edema and
clots by decreasing the normal activity of the absence of pain, warm,
Objective Cues:
AL NEEDS pain in the
clotting mechanism. Heparin IV or and dry extremities.
 Joint calves subcutaneous low-molecular-weight heparin
enlargeme is started initially.
nt
 With a massive DVT severely
 Limited
RDM both comprising tissue perfusion, anticipate
knees, thrombolytic therapy.
consistent R: Thrombolytic therapy is used only in
with DJD severe embolism that significantly comprises
 Bilateral blood flow to the tissues since they can cause
osteoarthri can cause sudden bleeding. For the
tis of knees
maximum effectiveness, therapy must be
8yrs.
started soon after the onset of symptoms
(within 5 days).
 Assess for contributing factors: Central
venous catheters, Dehydration, History
of varicosities, Immobility Leg trauma
and surgery Malignancy, Obesity, Oral
contraceptive use, Pregnancy, Smoking,
Venous stasis.
R: Most clients with DVT are asymptomatic.
Knowledge of high-risk situations helps in
early detection.
 -Assess for the signs and symptoms of
deep vein thrombosis (DVT).
R: The signs and symptoms occur in the leg
affected by the deep vein clot which includes
swelling, pain or tenderness, increased
warmth, and changes in skin color (redness).
 Measure the circumference of the
affected leg with a tape measure.
R: Unilateral leg and thigh swelling can be
assessed by measuring the circumference of
the affected leg 10 cm below the tibial
tuberosity and 10 cm to 15 cm above the
upper edge of the patella. Deep vein
thrombosis is suspected if there is a
difference of >3 cm between the extremities.
 Monitor the results of diagnostic tests.
R: These tests are used to document the
location of a clot and the status of the
affected vein
 Maintain adequate hydration.
R: Hydration prevents an increased viscosity
of blood, which contributes to venous stasis
and clotting.
 Encourage bedrest and keep the
affected leg elevated (depending on size
 and location of the clot) as indicated.
R: Clients usually require bed rest until
symptoms are relieved. The affected leg
should be elevated to a position above the
heart to decrease swelling.
 Provide warm, moist heat to the
affected site.
R: Heat promotes comfort and reduces
inflammation.
 Apply below-knee compression
stockings as prescribed. Ensure that the
stockings are the correct size and are
applied correctly.
R: Compression stockings enhance
circulation by providing a graduated
pressure on the affected leg to help return
the venous blood to the heart. Inaccurately
applied stockings can serve as a tourniquet
and can promote clot formation.