Nursing Actions: -Monitor for bleeding -Monitor: PT and INR-Teach patient about food sources containing vitamin K (to avoid fluctuations in the amount and frequency of consumption).-Bleeding Precautions (use electric razor and soft toothbrush). Start studying Nursing interventions. (Sadovsky, 2001) A chest xray was also done to rule out the possibility of a Pulmonary Embolism (PE), a possible complication of a DVT, and the was no sign of infiltration involving the … It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. Risk for potential Pulmonary embolism r/t DVT formation. • Pain related to inflammatory response in affected vein • Anxiety related to unexpected hospitalization and uncertainty about the seriousness of her illness A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. What statement indicates understanding? August 2011, Volume :41 Number 8 , page 33 - 33 [Free] Authors . Am I at risk for DVT? Depending upon the patient's situation, underlying medical conditions, and the reason for developing a blood clot, a longer duration of anticoagulation may be required. Over 3,500 NCLEX practice questions for free (updated for 2021). The answer is A. stiffness and joint pain. On Stuvia you will find the most extensive lecture summaries written by your fellow students. Instruct the client to stay in bed and turn from side to side every 2 hours A care plan should have nursing interventions based on outcomes of assessment to help the patient in achieving the desired results. DVT, on the other hand, can be life-threatening and requires immediate medical attention. 4/21/2020 RN Comprehensive 2019 A Flashcards | Quizlet 2/35 treat a L leg DVT. If the aPTT is too high, bleeding can occur. However, the MD must further investigate if the patient has a DVT. Why are the other options wrong? The answer is B. Nursing Interventions and Teaching. Impaired Physical Mobility - Nursing Care Plan Nursing Diagnosis for Impaired Physical Mobility Musculoskeletal System: 1. 4. I will present information about the Impaired Physical Mobility - Nursing Care Plan. The unpleasant feeling of pain is highly subjective in nature that may be experienced by the patient. Pulmonary embolism (PE) Nursing Care Plan A Pulmonary Embolism PE occurs when one or more pulmonary arteries in the patients lungs have become blocked. Warfarin (Coumadin) does NOT start working immediately. Patient Education Series: Deep vein thrombosis Share This. Homan's Sign is NOT a reliable method for assessing for a DVT. Nursing diagnosis. A. Select all the nursing interventions that are appropriate for this patient: The answers are B, D, G. Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Red blood cells, fibrin and platelets bind together and create a thrombus (clot). Learn vocabulary, terms, and more with flashcards, games, and other study tools. 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. Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad: The answers are C, D, and E. Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. DVT (deep vein thrombosis) is a blood clot in a vein, usually the leg. The answer is A. Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. Or use the search field that already we provide. Urgent advice: Ask for an urgent GP appointment or call 111 if: You think you have DVT. DVT (deep vein thrombosis) NCLEX questions for nursing students! 04.09 Nursing Care and Pathophysiology for Venous Disorders (Chronic venous insufficiency, Deep venous thrombosis/DVT) Take Quiz Show More Overview. Administer heparin to prevent formation of a thrombus. Nursing outcomes & evaluation. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. Deep vein thrombosis is the most frequent cause of chronic venous insufficiency. … As the nurse, you will want to be familiar with the prevention of a blood clot (venous thromboembolism VTE), management of a DVT, and anticoagulation therapy. If client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several … According to Virchow's Triad, a blood clot can form within the vein for several reasons. 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