NURSING CARE PLAN: CARING FOR THE PATIENT WITH DVT
LVN
PART – 1: NURSING HEALTH HISTORY
Student Name: _Shawna Galbreath,
... [Show More] LVN______
BIOGRAPHIC DATA
Client initials: F. R. Age: 41 years old Gender: Male
Source of History: Patient
Admit Date: July 6th, 2017 Occupation: Bobtail Truck Driver
Date of Care: July 11th, 2017
Spiritual belief: Mexican American Practice: Yes No
Ethnicity/Race: Hispanic Cultural Affiliation: Catholic
CHIEF COMPLAINT/ REASON FOR HOSPITALIZATION
Record the answer given to the question “What brought you to the hospital or the E.R.?”
“My left leg, the pain from the blood clot.” -Mr. F. R.
HISTORY OF PRESENT ILLNESS
Obtain and document a relevant, clear, chronological narrative account of the problem(s) for which the client sought care prior to this hospital admission. (Write complete sentences.)
1. When did the problem/symptoms start? Was the onset sudden or gradual?
The problem of the deep vein thrombosis or DVT, began on Mr. F. R.’s last hospital admission which he was admitted on June 6th, 2017 with a urinary tract infection or UTI due to an abscess of his prostate gland which caused him to have a transurethral resection of the prostate gland also known as TURP. During his hospital stay he developed this blood clot in his left popliteal region. He was then released from the hospital on June 28th, 2017 and readmitted on July 6th, 2017 due to a sudden pulling pain he experienced during walking.
2. How did the problem manifest/present itself? What phenomena or symptoms were associated with the chief complaint? Principal symptoms need to be described in terms of their exact location of distress, duration, frequency/ interval of the problem or symptoms, character, quality, quantity, or severity/ intensity of the complaint.
After being released from the first hospital stay in June, Mr. F. R. was ambulating when he experienced the sudden onset of pain and swelling in his left knee causing difficulty to walk or to perform tasks of daily living. He tried to allow his leg to rest as he said the swelling would go down after a nights rest in bed, however, the swelling was never fully resolved and the pain in which he described as a pulling sensation from the lower leg up to the knee with an 8 out of 10 on the pain scale continued which caused him to return to the emergency department at Presbyterian Intercommunity Hospital in Whittier on July 6th, 2017.
3. Describe the activity in which the client was involved when the problem occurred.
Mr. F.R. was walking around the block with one of his three sons when he experienced the pain and difficulty during ambulation.
4. Document factors or activities that have aggravated or relieved these symptoms.
Currently Mr. F.R. states that activities that exacerbate the symptoms are ambulation, sitting or standing. The only relief he is able to obtain is after consuming pain medication (Tylenol with codeine) and resting of the affected limb.
5. What treatments were attempted to manage the problem prior to admission?
Mr. F.R. was taking Warfarin upon discharge from the last hospitalization where he had knowingly developed a DVT which is currently discontinued in his medication regimen. Minimizing activities such as walking helped to not aggravate the symptoms.
6. List any other relevant data from the client’s chart which are important to the
client’s chief complaint (i.e. lab, x-ray, diagnostic reports, medication history,
outpatient treatments, etc.)
The client had a complete blood count upon admission to the emergency department, followed by a serum blood level exam. He also obtained a vascular exam called a venous doppler of his left lower leg to obtain information and size of the blood clot in order to prevent a pulmonary embolism.
7. Describe the impact the present illness has had upon the client’s life or lifestyle.
Include the degree of the impact as well as areas of the client’s life which have
been affected.
Mr. F.R. is currently out of work due to the first hospitalization back on June 6th, 2017, causing a large amount of stress for him as he is the main provider of income for his family consisting of three boys aged eighteen, twelve and ten. He is currently experiencing feelings of depression due to his lack of ability to care for his family, to go to work and the impact this diagnosis has on his ability to ambulate and maintain function for activities of daily living. Mr. F.R. also expresses concern of his future health as he is afraid he will never feel the same as before or will never function the same as before due to the current pain and restrictions he is experiencing.
PART 2: PATIENT PROFILE DATABASE
ADMISSION INFORMATION
Date of Care: 7/11/17
Patient Initials:
F.R. Age:
41 Sex:
M Admission Date
7/6/17 Occupation:
BOBTAIL TRUCK DRIVER
Reason for Hospitalization:
DVT-DEEP VEIN THROMBOSIS Medical Diagnoses (Present diagnoses, past diagnoses, Physician’s History and Physical notes in chart, nursing intake assessment): DM, DVT, MAY-THURNER SYNDROME, HEPRIN-INDUCED THROMBOCYTOPENIA, PULMONARY EMBOLISM, LIVER ABCESS, PROSTATE ABCESS, TURP
Surgical Procedures/Date:
6/8/17 TURP
ADVANCE DIRECTIVES (NURSE’S ADMISSION ASSESSMENTS)
Living Will: 0 Yes 0 No
Power of attorney: 0 Yes 0 No
Do not resuscitate (DNR): 0 Yes 0 No
PATIENT DIAGNOSIS
Primary Medical Dx:
May-Thurner Syndrome
Potential complications: Deep vein thrombosis of the left iliofemoral vein.
(Peters, 2012, p.231)
Etiology: Caused by the compression of the left iliac vein lumen due to the pressure of the right common iliac artery anteriorly.
(Demir, 2016)
Usual treatment goals: Treatment includes stenting of the common iliac vein to open the vein to promote adequate blood flow to the inferior vena cava.
(Peters, 2012, p.231)
Signs and symptoms: Typically there are no signs and symptoms of having the anatomical disorder until the signs and symptoms of a Deep Vein Thrombosis arise.
(Peters, 2012, p. 231)
Nursing Implications: Patient teaching of the anatomical malformation. Monitor patient for signs and symptoms associated with deep vein thrombosis.
(Peters, 2012, p. 231)
Secondary Medical Dx: Deep Vein Thrombosis (DVT)
Potential complications: Pulmonary embolism is a potential complication of deep vein thrombosis which could be fatal.
(Thachil, 2014, p. 309)
Etiology: Cause is from a thrombus formation typically in the deep veins of the lower limbs.
(Thachil, 2014, p. 309)
Usual treatment goals: Treatment usually includes anticoagulant medication, compression stockings, more extensive treatment would include clot buster treatment, inferior vena cava filter and thrombectomy.
(Thachil, 2014, p. 309)
Signs and symptoms: Signs and symptoms of DVT are pain, swelling, warmth, redness or blue discoloration of the affected limb, if it turned into pulmonary embolism the symptoms would include shortness of breath, palpitations, and sudden collapse of the patient.
(Thachil, 2014, p. 309)
Nursing Implications: Care includes application of compression stockings to prevent the thrombosis, effective medication regimen for the prevention of further clot formation by use of anticoagulation medication, observation and attention of the signs and symptoms of DVT and patient teaching of the treatment and prevention of thrombus formation.
(Thachil, 2014, p. 309)
LABORATORY DATA
Test Norms On Admission
7/6/17 Current value
7/9/17 Test Norms On Admission
7/6/17 Current value
7/8/17
WBC
4,500-11,000/mm3
(Berman, 2016, p. 720)
6,530
7,840 Sodium 135-145mEq/L
(Berman, 2016, p. 722) 133
135
Differential
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
50-70%
25-35%
4-6%
1-3%
0.4-1.0%
(Berman, 2016, p. 720-721) Not Done
Chloride 95-105mEq/L
(Berman, 2016, p. 722) 98
101
Potassium
3.5-5.3mEq/L
(Berman, 2016, p. 722) 4.4
4.1
Calcium 8.5-10.5mEq/dL
(Berman, 2016, p. 722)
8.4
8.7
RBC
4.6-6.0 Million/mm3
(Berman, 2016, p. 720) 3.67 4.18
BUN 7-20mg/dL
21
17
Hgb
13.5-18.0 g/dL
(Berman, 2016, p. 720) 11.4
12.9
Creatinine 0.6-1.3
0.7
0.6
Hct
40-54%
(Berman, 2016, p. 720) 34.4
37.6
CO2 21-33
28
29
Platelets
150,000-450,000/mm3
(Berman, 2016, p. 721)
313,000
246,000
Blood glucose
Hgb A1C (Berman, 2016, p. 723)
70-90
4.0%-5.5%
7/7/17
7.4 212
Pro time
11-13 seconds
(Berman, 2016, p. 724) Not done
Urine analysis
Specific Gravity
(Berman, 2016, p. 735)
Protein Urine
1.010-1.025
<10mg/dL
1.026
100
INR
Not done
aPTT
ALT
10-55units/L 50
(Berman,
2016, p. 724)
AST 10-40units/L 44
(Berman,
2016, p. 724)
ALP 25-100umits/L 150
(Berman,
2016, p. 724)
Albumin 3.5-4.8g/dL 3.0
(Berman,
2016, p. 724)
DIAGNOSTIC TESTS
Chest X-Ray:
EKG:
Other abnormal reports: 7/6/17 Venous doppler of the left lower leg to evaluate the worsening DVT.
Other: 7/10/17 CT of abdomen and pelvis with contrast due to hematuria.
Other:
Other:
TREATMENT
Treatment (Kardex): 7/11/17 Urinary bladder irrigation one time to determine presence or absence of blood in the urinary bladder.
Support Services (Kardex):
Consultations (Kardex):
DIET
Type of Diet (Kardex):
Consistant carb diet-180grams, moderate calorie 1501-1800
Restrictions (Kardex) Gag Reflex Intact
1 yes 0 no
Appetite:
Breakfast:
100 %
Lunch:
100 %
Supper:
%
Tube feedings: Type and rate (Kardex)
INTRAVENOUS FLUIDS (IV Therapy Record)
Fluids and Rate (Maintenance IV solution):
IV Site:
Right upper arm
IV Catheter Type:
Peripherally inserted 20-gauge power glide
SUPPORTIVE MEDICAL DIAGNOSIS DATA
1. The primary diagnosis of Mr. F.R.’s hospital admission is DVT or deep vein thrombosis.
a. Deep vein thrombosis is a condition where a blood clot develops in the deep veins particularly in the legs. Clot formation begins due to lack of circulation allowing the platelets to clump together forming a thrombus. Highest risk of patients to develop a DVT are those after surgery, patients who are immobile or bed ridden or sitting for long periods of time without being able to get up and move like those on a long flight, those with blood conditions such as thrombophilia, and patients with damage to veins or anatomical predisposition of circulatory compromise. If left untreated the thrombus can become dislodged and cause a pulmonary embolism or PE which can become life threatening because the circulatory route only allows for veins to pump blood back to the heart and then out to the lungs where the clot could travel to and cause respiratory issues. (Trachil, 2014, p.309)
b. Not all signs or symptoms are noticed by the patient so it is highly important for the nurse to recognize and assess the patient for pain or cramping particularly in the leg, mainly one leg but could be both, swelling of the extremity, redness or discoloration of the skin, warmth of the affected area and a positive Homans’ sign, the nurse should also be aware of any signs or symptoms of shortness of breath, palpitations, chest pain or sudden collapse of the patient as these are signs of a pulmonary embolism. (Trachil, 2014, p.309)
c. The signs and symptoms my patient Mr. F.R. experienced were sudden onset of pain in his left lower leg he describes as a pulling sensation from his calf up to the backside of his knee or popliteal area, followed by swelling of his knee and surrounding area, redness of the skin surrounding the knee and warmth which caused him to admit himself to the emergency department. My patient exhibited all signs associated with a DVT, sudden severe pain of his leg 8 out of 10 on the pain scale, swelling of the affected area, warmth and redness of the area and surrounding tissues.
2. The secondary diagnosis that affects Mr. F.R.’s care is May-Thurner Syndrome.
a. May-Thurner syndrome is an anatomical condition in which the right common iliac artery compresses the left common iliac vein against the fifth lumbar vertebra. This compression of the vein causes stasis of venous blood return to the heart which in turn can cause other conditions such as DVT, varicosities, chronic venous stasis ulcers and pulmonary embolism (Demir, 2016).
b. Some people with May-Thurner syndrome are asymptomatic or may experience swelling of the left leg associated with the signs and symptoms of a DVT or other condition due to the anatomical condition of MTS (Demir, 2016).
c. Mr. F.R. presented with the signs and symptoms associated with a DVT, specifically pain in the left leg, swelling, redness and warmth.
SUPPORTIVE DIAGNOSTIC DATA
NAME/TYPE OF LAB TEST,
X-RAY, SCAN, PROCEDURE Explanation of lab test, x-ray, scan or procedure. Include any pre or post nursing interventions. Why was this lab test, x-ray, scan, or procedure ordered for this client??? 1. Expected normal textbook results.
2. Client’s Actual Results.
3. If abnormal, explain why you think they are abnormal in this client.
Cardiovascular Venous doppler of the left lower leg
Ultrasound of the vessels of the leg to determine the flow of blood throughout the veins of the leg. There is no preparation involved and the procedure will take about 20 minutes, upon return the patient will have no post-procedure care as the exam is noninvasive (Hopper, 2007, P.365) The patient was ordered this ultrasound in order to observe the DVT size and location. 1.The expected outcome of the patient is normal and adequate blood flow throughout the vessels.
2. Mr. F.R.’s results were abnormal as expected for DVT, reduced blood flow and diminished compressibility of the left common femoral vein and the left proximal femoral vein.
3. The results indicated that the DVT is causing abnormal blood flow through the vessels is expected because that is the etiology of a DVT to compromise adequate blood flow which is the cause of the pain and swelling in the affected area that Mr. F.R. is experiencing.
CT of abdomen and pelvis
Computerized tomography is a painless noninvasive x-ray procedure that has the ability to distinguish minor differences in the density of tissues. There is no preparation or post care as the procedure is noninvasive.
(Berman, 2015, p. 738) The patient was ordered this CT in order to determine the source of blood in the urine. 1. The expected outcome is a clear CT with no abnormal findings.
2. Mr. F.R.’s results were the prostatic abscess has essentially resolved with few foci of air adjacent to the foley cath.
SUPPORTIVE TREATMENT DATA
MD/ Nursing Order for Tx Reason why client Receiving this Tx Nursing Interventions/
Modifications for this
client General/ Special Precautions
Glucose checks
Diabetes Teach patient why and when to test for blood glucose levels, clean and rotate sites to obtain accurate reading, monitor pt. on blood thinners/anticoagulants monitor for prolonged bleeding (Berman, 2015 p.723) If the blood sugar is below 70, follow hospital protocol for hypoglycemia.
180 gram consistent carb diet
Diabetes Educate the patient of the type of diet and the selections of good carbs vs. bad carb choices, assist with meal planning. Do not exceed the daily amount of allotted carbohydrates as it will increase blood sugar level, monitor tray prior to delivery to ensure the correct diet is obtained.
Urinary bladder irrigation
Check for presence of blood in urine in order to determine whether to continue holding anticoagulant or continue anticoagulant therapy for DVT. When performing bladder irrigations on a patient with a foley catheter the main concern is to maintain sterility to avoid infection. Educate the patient on the discomfort they may feel while irrigating the bladder and the reason for the irrigation.
(Berman, 2015, p. 1199) Check the fluids upon return of the irrigation and after completion check the foley catheter for patency, color and consistency of the urine.
Medication Administration Tool
Routine
Medication
Generic
&
Trade Name Classification
Medication
Action Route
Dose
Frequency
&
Time
Side
Effects Contraindications Nursing
Implication
Pt. Teaching
piperacillian
Zosyn
(Vallerand, 2014, p.1008) Anti-infectives Binds to bacterial cell wall causing cell death IVPG 3.375g Q6H
0000
0600
1200
1800
Seizures, pseudomembranous colitis, anaphylaxis, Hypersensitivity to penicillins, beta-lactums, cepalosporins, or tazobactam. Obtain allergy info prior to administration, observe s/s of anyphalaxsis. Teach pt. to notify nurse of fever or diarrhea
Clopidogrel
Plavix
(Vallerand, 2014, p.327) Antiplatelet agent Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors PO 75mg Daily
0800 Depression,GI bleeding, bleeding, throbotic thrombocytopenic purpura Hypersensitivity, pathologic bleeding, concurrent use of omeprazole or esomeprazole Monitor pt. for signs of TTP, monitor pt. lab bleeding time therapy, CBC w/ Diff and platelet count Teach pt. to notify nurse if bleeding, fever, chills, sore throat, rash, or bruising occurs.
Insulin Aspart
Novalog
(Vallerand, 2014, p.691) Antidiabetics, hormone Lowers blood glucose, stimulates glucose uptake of the skeletal muscle and fat, inhibits hepatic glucose production, lipolysis and proteolysis SQ 12units 3X day
Breakfast
Lunch
dinner Hypoglycemia and anaphylaxis Hypoglycemia, stress and infection may temporarily increase insulin requirement. Assess for signs and symptoms of hypoglycemia; anxiety, restlessness, tingling in extremities, lips or tongue, chills cold sweats, confusion, excessive hunger Instruct pt. to notify you of any signs or symptoms of hypoglycemia or hyperglycemia
Insulin Aspart
Novalog
Short Acting
(Vallerand, 2014, p.691) Antidiabetics, hormone Lowers blood glucose, stimulates glucose uptake of the skeletal muscle and fat, inhibits hepatic glucose production, lipolysis and proteolysis SQ Refer to sliding scale 3X day
Breakfast
Lunch
dinner Hypoglycemia and anaphylaxis Hypoglycemia, stress and infection may temporarily increase insulin requirement. Assess for signs and symptoms of hypoglycemia; anxiety, restlessness, tingling in extremities, lips or tongue, chills cold sweats etc. Instruct pt. to notify you of any signs or symptoms of hypoglycemia or hyperglycemia
Insulin detemir
Levemir
Long Acting
(Vallerand, 2014, p.689)
Antidiabetics, hormone Lowers blood glucose, stimulates glucose uptake of the skeletal muscle and fat, inhibits hepatic glucose production, lipolysis and proteolysis SQ 26units Daily
HS Hypoglycemia and anaphylaxis Hypoglycemia, stress and infection may temporarily increase insulin requirement. Assess for signs and symptoms of hypoglycemia; anxiety, restlessness, tingling in extremities, lips or tongue, chills cold sweats, confusion, excessive hunger Instruct pt. to notify you of any signs or symptoms of hypoglycemia or hyperglycemia [Show Less]