Polish up on client care

The thrombus may occlude a vein or detach

and embolize to the lungs.

Acute pain
Activity intolerance
Ineffective tissue perfusion: Peripheral

Assess cardiovascular status. Tachycardia

and chest pain may indicate pulmonary
embolism.
Assess for bleeding resulting from anticoagulant therapy.
Monitor and record vital signs, such as
hypotension, tachycardia, tachypnea, and
restlessness. Observe for bruising, epistaxis,
blood in stool, bleeding gums, and painful
joints. Tachypnea and tachycardia may suggest
pulmonary embolism or hemorrhage.
Perform neurovascular checks to detect
nerve or vascular damage.
Monitor laboratory values. Partial thromboplastin time in a client receiving heparin
and prothrombin time in a client receiving
warfarin should be 11/2 to 2 times the control.
International normalized ratio should be 2 to 3
for the client receiving warfarin. A falling Hb
level and hematocrit indicate blood loss.
Maintain bed rest and elevate the affected
extremity to promote venous return and reduce
swelling.
Administer medications, as prescribed, to
control or dissolve blood clots.
Apply warm, moist compresses to improve
circulation to the affected area and relieve pain
and inflammation.
Measure and record the circumference
of thighs and calves. Compare the measurements to assess for worsening inflammation in
the affected leg.

TREATMENT

Teaching topics

Activity changes: maintaining bed rest and

elevating the affected extremity
Antiembolism stockings
Embolectomy and insertion of a vena cava
umbrella or filter
Warm, moist compresses

Explanation of the disorder and treatment

plan
Medications and possible adverse effects
Recognizing signs and symptoms of
bleeding and clot formation
Avoiding prolonged sitting or standing,
constrictive clothing, and crossing the legs
when seated
Avoiding hormonal contraceptives

CAUSES
Hypercoagulability (from cancer, blood
dyscrasias, hormonal contraceptives)
Injury to the venous wall (from I.V. injections, fractures, antibiotics)
Venous stasis (from varicose veins, pregnancy, heart failure, prolonged bed rest)

ASSESSMENT FINDINGS
Deep vein thrombophlebitis
Cramping calf pain (may be painless)
Edema
Tenderness to touch

Superficial vein thrombophlebitis

Redness along the vein
Warmth and tenderness along the vein

DIAGNOSTIC TEST RESULTS

Hematology reveals increased WBC count.
Photoplethysmography shows venousfilling defects.
Ultrasound reveals decreased blood flow.
Venography shows venous-filling defects.

NURSING DIAGNOSES

Drug therapy
Anticoagulants: warfarin (Coumadin), heparin, enoxaparin (Lovenox)
Anti-inflammatory agents: aspirin,
dalteparin (Fragmin)
Fibrinolytic agents: streptokinase (Streptase)

INTERVENTIONS AND RATIONALES

Assess pulmonary status. Crackles, dyspnea, tachypnea, hemoptysis, and chest pain
suggest pulmonary embolism.

313419NCLEX-RN_Chap03.indd 63

63

A clot is typically
caused by venous
stasis, endothelial
damage, and
hypercoagulability.
This is called
Virchows triad.

Valvular heart disease

In valvular heart disease, three types of
mechanical disruption can occur: stenosis,
or narrowing, of the valve opening; incomplete closure of the valve; or prolapse of the
valve. These conditions can result from such

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