NURSING DIAGNOSIS: Acute pain related to inflammation response in affected vein as evidenced by edematous right leg.
DEFINING CHARACTERISTICS SCIENTIFIC BASIS
Subjective:
“My left leg is in pain“ as
verbalized by the patient.
Objective:
- Erythematous leg noted
- Tender calf noted
- Warm to touch in the
affected leg noted
- -facial grimacing noted
- Guarding behavior
noted
- Restlessness noted
EXPECTED OUTCOME
Deep vein thrombosis (DVT)
occurs when a blood clot
(thrombus) forms in one or
more of the deep veins in your
body, usually in your legs. Deep
vein thrombosis can cause leg
pain or swelling but also can
occur with no symptom.
NURSING INTERVENTION
Short term goal:
After 3-4 hours of nursing
intervention, the patient will be
able to manifest alleviated pain.
Long term goal:
After 1 to 2days of nursing
intervention, the patient will be
able to manifest absence of
pain.
RATIONALE
 Establish rapport
 Obtain patient’s
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.
 Monitor vital signs,
noting increased
 To have a trusted nurse
to patient relationship
and to have therapeutic
communication.
 To rule out worsening or
underlying condition or
development of
complications.
 Observations may not
be congruent with
verbal reports or maybe
only indicator present
when client is unable to
verbalize.
 temperature.  Elevations in heart rate
Vital Sign take as may indicate increased
follows: discomfort or may occur
-BP- 90/50 in response to fever and
-T- 36.6 inflammatory process.
-PR- 84 Fever can also increase
-RR- 27 client’s discomfort.

 Provide comfort
measures
 To promote non
pharmacological pain
 Encourage diversional management.
activities.
 To divert the patient’s
attention.

 Encourage adequate
rest periods.
 To prevent fatigue.

 Encourage patient to
change position
frequently.  Reduces muscle fatigue,
helps minimize muscle
spasm and maximizes
circulation to tissues.

 Provide foot cradle.

  Cradle keeps the
pressure of bedclothes
off the affected leg,
thereby reducing
 Elevate affected pressure discomfort.
extremity.
 Encourages venous
return to facilitate
circulation, reducing
stasis and edema
formation.

 Administer medication
as Ordered by physician
and monitor  To alleviate pain.
effectiveness.

Source: https://nurseslabs.com/5-deep-vein-thrombosis-nursing-care-plans/3/

Moorhouse, M.F (2002) Nurse’s pocket guide 10 th edition

NURSING DIAGNOSIS: Ineffective tissue perfusion related to