DATE CUES NSG.

DX SCIENTIFIC GOAL OF CARE NSG INTERVENTION RATIONALE EVALUATION

BASIS

09/30/20 ASSESSMENT Thromboem DEFINITION After 8 hours of INDEPENDENT INDEPENDENT After 8 hours of
21 bolism r/t d OF THE NSG. nurse-patient nursing
OBJECTIVE ehydration, DX interaction, the 1. Monitor patient every 1. To ensure that there interventions, goal
- Unilateral limb immobility, Inflammation patient will be 15 minutes and check is no pressure partially met and
swelling vascular of a vein that able to do the V/S. impeding venous patient was able to
- Tenderness manipulatio occurs when a following: flow through the do the following:
around the site n, or injury blood clot popliteal space.
upon palpation develops in a. maintain 2. Assess lower 2. To determine a. have adequate
- Extremity distal to the vein. optimal extremities for redness, signs/symptoms of peripheral and
thrombus is cool, peripheral swelling, and pain; venous cardiac
pale, edematous tissue increased warmth thromboembolism perfusion as
RATIONALE perfusion in along path of vein; or pulmonary evidenced by
DX STUDIES A blood clot the affected edema or pain in embolism. normal
Hemoglobin: 100 (thrombus) in extremity, as extremity; chest pain; temperature,
g/L a deep vein in evidenced by hemoptysis; but there is still
Hematocrit: 0.25% the thigh or strong tachypnea; dyspnea; redness in the
RDW: 0.109 leg. The clot palpable and restlessness. extremity, and
can break off pulses, 3. Teach or perform 3. The muscular presence of
Plt Count as an embolus reduction in range-of-motion contraction pain sensation
(thrombocyte and make its and/or exercises such as leg produced by these
count): way to the absence of exercises 10-12 times exercises facilitates b.
160,000/mm³ lung, where it pain, warm, every 1-2 hours while venous return from
can cause and dry awake. the lower
Duplex imaging: respiratory extremities, extremities.
presence of blood distress and and adequate 4. Encourage early 4. To maintain muscle
clots in leg veins respiratory capillary refill. ambulation. contractions and
failure. b. Client will adequate vascular
Impedance report that flow.
plethysmography: pain/discomfor 5. Avoid pressure under 5. To avoid pressure
positive t is alleviated knees from bed or on veins,
or controlled. pillows and extreme constriction of
Plasma markers (D- elevation of the knees. circulation, or
dimer test): positive pooling and stasis
of blood.
6. Ensure skin care and 6. The skin of the
inspection on the site heels and post-tibial
where compression areas is particularly
devices are located. susceptible to

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 increased pressure
and breakdown.

DEPENDENT DEPENDENT
1. Administer 1. To decrease clot
anticoagulants (e.g., formation.
heparin, enoxaparin
(Lovenox) as ordered.

COLLABORATIVE COLLABORATIVE
1. Apply sequential 1. To stimulate and
compression devices, if enhance the
ordered and remove for massaging and
1 hr q8-10hr. milking actions that
are transmitted to
the veins when leg
muscles contract.

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