University of Tabuk

Faculty of medical Applied sciences

Nursing Department
Care Plan

Client Initials: F.S.S.A Student name: ID: Date: 28-10-2024

Assessment Nursing DX/Clinical Client Goals/Desired Nursing Evaluation

Problem Outcomes/Objectives Interventions/Actions/Orders
(with time scale) and Rationale
Subjective (1p) Problem(1p) Long Term: (1p) (1p) (1p)
1. Assessment
Patient reports The patient will • Intervention: Assess Goal Met as: Over the course of one week, the patient
pain and swelling experience reduced reported a consistent reduction in pain and a visible
in the left thigh Acute pain swelling and maintain pain level,
decrease in swelling in the left lower limb. By the end of
for two weeks. effective pain characteristics, and the week, pain levels were at 2/10, and the patient
management within one location every four demonstrated understanding of DVT management
week of hospitalization. techniques, including medication adherence, leg
hours.
elevation, and mobility exercises. Scheduled for regular
• Rationale: follow-up to monitor progress and coagulation status.
Continuous
monitoring of pain
Objective (1p)
helps evaluate the
effectiveness of
interventions and
History of left
ankle fracture detects any
with cast worsening of the
(1p)
immobilization condition.
for three
R/T(0.5p) Short Term: (1p) (1p)
weeks; 2. Care Goal Met as: The patient reported a reduction in pain to
Doppler Within 24 hours, the • Intervention: 3/10 within 24 hours of admission. Effective pain
ultrasound patient will report a management interventions were implemented, including
impaired blood reduction in pain levels Administer
indicates prescribed anticoagulant therapy and leg elevation, which
flow due to deep to 3/10 or lower. prescribed contributed to improved comfort.
distended
vein thrombosis anticoagulant therapy
veins with
echogenic

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components (e.g., Enoxaparin) as
and no blood per doctor’s orders.
flow, AEB(0.5p) • Rationale:
confirming Anticoagulants
DVT. prevent clot
patient’s report of
extension and
pain and Doppler
formation, addressing
ultrasound
findings showing the root cause of pain
distended veins. by improving blood
flow
3. Care
• Intervention:
Elevate the affected
limb slightly with
pillows.
• Rationale: Elevation
reduces venous
pressure, minimizes
swelling, and may
alleviate pain in the
affected area.

4. Education

• Intervention:
Educate the patient
on signs of potential
complications (e.g.,
increased pain,
shortness of breath)
and when to seek
immediate help.

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 • Rationale:
Empowering the
patient to recognize
complications
promotes timely
intervention, which is
crucial in preventing
life-threatening
conditions such as
pulmonary embolism.

References:

1. Carpenito, L. J. (2021). Handbook of nursing diagnosis (16th ed.). Lippincott Williams & Wilkins.
2. NANDA International. (2021). NANDA International nursing diagnoses: Definitions & classification, 2021-2023. Thieme.
3. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.

University of Tabuk
Faculty of medical Applied sciences
Nursing Department
Care Plan
Clinical Worksheet

Client Initials: ___ F.S.S.A _____ Student: ______________________________ Date of Care: ______ 28-10-2024 _____

Demographic Information Health History Care Prescriptions

Age: ___ 43 years _ Gender: Chronic conditions & previous health problems: Nutrition
____ Female Type of diet: Standard, balanced diet as per hospital protocol.
Nationality: __ Saudi Arabia __ • Chronic Conditions: No significant past  NPO ( No NPO orders )
Code Status: ________ medical history; patient is medically free aside  Tube Feeds: Type ___________ Rate ________
from the current DVT and history of recent left  G tube  NG tube (None)
Weight: ____ Height: ____
leg fracture.
BMI: ____: the patient is _____

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 • Previous Health Problems: Recent left ankle  Aspiration risk ( None )  Thickened liquids: Type (None)
fracture (21 days ago), immobilized with a cast. __________

Reason for Admission [patient’s Unexpected events/complications during Activity:  Independent  Assist  Dependent
own words]: hospitalization:  Ad lib  BR only  Chair  Ambulate  Bed Rest
Left leg pain and swelling for two The case in initial admission for DVT management  Assistance of ___ (# of people)
weeks." Assistive devices:
 Gait belt  mechanical lift  walker  cane
Previous surgeries: [type/year] Fixation of left  Other : Assist with ambulation
ankle fracture with cast / 2024

Medical Diagnosis [medical Nursing Diagnoses (5, prioritized, with related Elimination:  Continent  Incontinent
terms]: factors):  Voiding  Foley catheter  I & O
• Primary Diagnosis:  Enema  Colostomy  Other: _____________
Acute Deep Vein Skin Care:
Thrombosis (DVT) in the 1. Acute Pain related to impaired blood flow due  Intact skin  Pressure ulcer stage: __________
left lower limb. to DVT, as evidenced by patient-reported pain  Other: ________  Turn & position w/ skin care q. 2 hrs
• Secondary Issues: and Doppler findings. Wound Care: Regular inspection of the left leg for changes in
2. Risk for Impaired Physical Mobility related to color, warmth, and signs of complications.
History of left ankle
discomfort and prescribed bedrest for DVT  Dressing/drain  Drsg. Change/treatment
fracture (healed). Location & Type______________________________
management.
IV Site: Location : in a suitable site Size: _ 18
3. Risk for Bleeding related to anticoagulant
Date of admission: 28-10-2024 therapy.
 Saline Lock
4. Risk for Impaired Skin Integrity related to  IV Fluids:_None Rate: ___________
Allergies: irrelevant immobilization and swelling in the left lower
Pulmonary care:
limb.
Other notes:  O2 ___ L/min via  N/C  mask  on room air
5. Knowledge Deficit regarding DVT and self-
 Incentive Spirometer q ___ hrs.
care management to prevent recurrence.
 MDI inhaler Mini-neb Med.  albuterol  atrovent
 Other
Glucometer:  ac & hs  other ____________
 sliding scale insulin, every______hours

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Discharge Plan/Long Term Needs:

• Follow-Up Care: Regular outpatient follow-up with vascular specialist and routine blood work to monitor coagulation status.
• Home Instructions: Patient should avoid prolonged periods of immobility, maintain hydration, and report any signs of increased pain, swelling, or
difficulty breathing.
• Anticoagulant Education: Instructions on enoxaparin administration, bleeding precautions, and dietary recommendations.

Teaching Needs:
1. Understanding DVT: Explain DVT, symptoms (swelling, pain, redness), and risk of complications if untreated.

2. Anticoagulation Therapy: Describe the role of anticoagulants (e.g., Enoxaparin) to prevent clots, side effects (e.g., minor bleeding), and signs to seek
urgent help.
3. Mobility: Encourage regular movement, leg elevation, and light exercises (when approved) to improve circulation.

4. Bleeding Precautions: Advise on safe practices (soft toothbrush, avoiding sharp objects) and when to report unusual bruising or bleeding.

5. Lifestyle: Stress hydration, balanced diet, and avoiding foods high in Vitamin K; avoid alcohol and certain painkillers.

6. Warning Signs: Instruct to seek help for severe symptoms like increased pain, chest pain, or shortness of breath.

7. Follow-Up: Reinforce attending follow-ups and lab tests for effective management.

Medications (scheduled & prn)

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Name/Dose/Route Class & Major Side Nursing Patient
Action Effects Implications Education
Enoxaparin 80 mg/0.8 Anticoagulant; Bleeding, Monitor for signs
mL, Low bruising, of bleeding,
subcutaneous Molecular hematoma, assess injection
(SC), twice Weight injection site site for irritation,
daily for 1 Heparin pain, anemia check platelet
week (LMWH). counts to avoid
Prevents clot heparin-induced
formation by thrombocytopenia
inhibiting (HIT).
thrombin and
factor Xa.

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Lab Values & Diagnostic Test Results

a. Important lab tests to monitor Why? (Consider diagnosis, pre-existing conditions, medications, complications, etc.)
Anticoagulation Parameters to monitor therapeutic effects of anticoagulation.
PT/INR
D-Dimer For Indicative of clot resolution progress.
Complete Blood Count (CBC) Monitor for any signs of anemia or infection.
Electrolytes Monitor for any imbalances

b. Hematology Normal values Patient’s Values (include serial labs) Significance for this patient
Date Date Date
27-10-2024 27-10-2024
WBC 4-11 x10^3/uL 8.66 x10^3/uL Within range, no infection.
Plt 150-400 431 x10^3/uL Elevated; monitor as DVT marker.
x10^3/uL
Hgb 12-16 g/dL 13.8 g/dL Normal; no anemia.
Hct 36-54% 42.7% Normal
RBC 4.0-5.4 x10⁶/uL 5.19 x10⁶/uL Normal; indicates proper red blood cell count.
MCV 76-96 fL 82.3 fL Normal; indicates average red blood cell size.
MCH 27-32 pg 26.5 pg Slightly low; assess if any clinical relevance.
MCHC 32-35 g/dL 32.2 g/dL Normal; red blood cell concentration within range.
MPV 6.3-10.3 fL 8.98 fL Normal; average platelet size within range.

c. Chemistry Normal values Patient’s Values (include serial labs) Significance for this patient
K+ 3.5-5.1 mmol/L 4.35 mmol/L Normal ;essential for heart and muscle function.
Na+ 136-145 mmol/L 141 mmol/L Normal; necessary for fluid balance and nerve function.
Ca+ 2.1-2.55 mmol/L 2.32 mmol/L Normal; necessary for muscle contraction and bone
health.
Cl-
CO2
BUN 2.5-6.7 mmol/L 3.40 mmol/L Normal kidney function
Cr 0.57-1.11 mg/dL .666 mg/dL Normal; reflects kidney function
Glucose fasting 4.1-5.6 mmol/L 4.98 mmol/L Normal; indicates blood glucose control.
Albumin 3.5-5.0 g/dL 3.9 g/dL Normal; maintains osmotic pressure.
Total Protein (TP) 6.4-8.3 g/dL 7.8 g/dL Within normal range; reflects protein status.
Alkaline 40-150 U/L 118 U/L Normal; indicative of liver and bone health
Phosphatase
GGT (Gamma 0-38 U/L 13 U/L Within range; suggests liver function is stable.
Glutamyl
Transferase)

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 Total Bilirubin 0.2-1.2 mg/dL 0.281 mg/dL Normal; no indication of liver dysfunction.
Direct Bilirubin 0-0.5 mg/dL 0.113 U/L ????????
ALT (Alanine 0-55 U/L 27 U/L Normal; liver enzyme within expected range.
Aminotransferase)
AST (Aspartate 5-34 U/L 35 U/L Slightly high
Aminotransferase)

d. Coagulation Normal values Patient’s Values (include serial labs) Significance for this patient
PT 11-13 seconds 13.9 seconds Slightly prolonged, monitor closely.
INR 0.9-1.1 Ratio 1.05 Ratio Within range; therapeutic level.
APTT 24-37 seconds 29.2 seconds Within range; anticoagulant effects expected.
D-Dimer <500 ng/mL 3530 ng/mL Elevated, confirming active clot formation; indicative of
DVT.

e. Urine Normal values Patient’s Values (include serial labs) Significance for this patient
Color Light yellow to
amber
Appearance Clear
Spec. gravity 1.005-1.030
PH 4.5-8.0
Glucose Negative
Ketones Negative
Nitrates Negative
RBCs 0-2 / HPF
WBCs 0-5 / HPF
Casts Negative
Protein Negative

f. ABGs Normal values Patient’s Values (include serial labs) Significance for this patient
pH 7.35-7.45
PaCO2 35-45 mmHg
HCO3 22-26 mEq/L
PaO2 80-100 mmHg
SaO2 95-100%

g. Other Normal values Patient’s Values (include serial labs) Significance for this patient

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h. Pertinent radiological studies:

• Study: US Doppler vein map (Left lower limb)

• Date: 27-10-2024
• Results: Distended left lower limb veins with echogenic components, non-compressible, and no detectable color flow within the veins.
• Significance for this Patient: Confirms diagnosis of acute deep vein thrombosis (DVT) in the left lower limb, indicating impaired blood flow and an
increased risk of clot-related complications. Immediate anticoagulant therapy is necessary to prevent clot extension or potential embolization.

i. Other diagnostics (e.g. ECG, EEG, echo):

Patient Assessment & Nurses Notes

VS: (P,T,RR,BP,PO2,Pain)

HR : 75 T: 37 BP: 126/85 RR: 18 PO2 : 94 Pain: left thigh pain

Neuro: (GCS, Pupil size,….)

(Glasgow Coma Scale) :

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 • Eye Opening: (spontaneous response)

• Verbal Response: (oriented to time , place and person)

• Motor Responses : (obeys command)

Total 15/15 (Best response)

Pupil Size : 3 mm (Normal)

Balance and Coordination : The patient walk steadily

Musculoskeletal: (Strength, movement, coordination,….)

Upper extremities: Normal strength and movement

Lower limb extremities: left limb swelling, redness and tenderness.

Coordination : Normal coordination.

Skin: (Color, warmth, texture, abnormalities,…)

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 Skin Color : normal skin color (light complexion), no pallor or cyanosis except in left thigh due to fracture and DVT in which there is redness

Temperature : Skin is warm to the touch, no signs of hypothermia or hyperthermia except in left thigh that is hot

Texture : Skin is smooth and elastic, no dryness or flaking.

Abnormalities Signs : no cuts or bruises present.

Sensitivity Response : no signs of allergic reactions or inflammation.

Cardiac: (Cardiac & peripheral pulses for rhythm, sounds, strength,…)

Cardiac Pulses

Rhythm :Pulse is regular during the examination.

Strength :Pulse is strong and palpable, with no signs of weakness.

Site :Pulses were measured at the radial and carotid arteries, both being normal.

Heart Sounds : Heart sounds are normal, with no abnormal sounds such as murmurs or irregular beats.

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 Peripheral Pulses :

Pulses in the arms and legs were normal and consistent in strength.

No signs of ischemia (such as pallor or coldness).

Pulmonary: (auscultation, airway clearance, breathing pattern, respiratory therapy,…etc)

Auscultation : Lung sounds are normal, with no wheezes or crackles.

Airway Clearance : No signs of obstruction, and coughing is effective.

Breathing Pattern :

Respiratory rate is normal (18 breaths per minute).

Breathing appears normal, with no clear signs of pulmonary embolism

GI/Nutritional Status: (appetite, food consumption, bowel sound, bowel motion, NPO status, type of diet, disorders,..)

Appetite : Appetite is normal; there are no complaints of loss of appetite.

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 Food Consumption :

She consumes 3 meals a day, with snacks in between.

The diet is balanced, including fruits, vegetables, and proteins.

Bowel Sounds : are normal, audible, and there are no signs of obstruction.

Bowel Motion :

Bowl movements are normal, occurring once daily.

There are no complaints of constipation or diarrhea.

NPO Status : The patient is not NPO and is able to eat normally.

Type of Diet She follows a balanced diet, comprising all food groups.

Disorders : No known gastrointestinal disorders, and no symptoms such as nausea or vomiting are reported.

GU/Reproductive: (Continence, abnormalities,…)

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 Continence : The patient demonstrates good continence, with no complaints of urinary or fecal incontinence.

Abnormalities :

No signs of any abnormalities in the genitourinary system

No reported pain during urination or changes in the color or odor of urine.

Menstrual History :The patient reports a normal menstrual cycle.

Psychosocial: (anxiety level, social interaction, family support, body image, psychological disorders,…)

Anxiety Level :The patient experiences a moderate level of anxiety.

Social Interaction: The patient has normal social interactions.

Family Support : She has strong support from her family, who provide emotional support and encourage her.

Body Image :The patient does not have concerns about her body image and feels that it is normal.

Psychological Disorders : No known psychological disorders.

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Page 15 of 17 15
Date/Time Nurses Notes
28-10- Patient admitted to Female Surgical Ward with diagnosis of acute DVT in the left lower
2024 limb. Reports left thigh pain and swelling for two weeks. Initial assessment completed.
08:00 AM
28-10- Pain level assessed; patient rates pain as 6/10. Administered Enoxaparin (80 mg
2024 subcutaneously) as per doctor’s order. Patient educated on the purpose and side effects
10:00 AM of medication.
28-10- Patient instructed to elevate the affected leg slightly to reduce swelling. Reinforced
2024 importance of not remaining immobile for prolonged periods and performing light
02:00 PM exercises as tolerated.
28-10- Monitored injection site for signs of bruising or bleeding. Educated patient on bleeding
2024 precautions due to anticoagulant therapy, including avoiding sharp objects and reporting
06:00 PM any unusual bruising.
28-10- Pain reassessed; patient reports mild improvement with pain level at 4/10. Encouraged
2024 continued compliance with medication and leg elevation. No complications observed.
10:00 PM

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Note: Nurses Notes are for additional information not included in the assessment or worksheet, such as events or procedures done during the shift.
Do not just repeat assessment information or list routine care included in the worksheet or that would be charted on flow-sheets.

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