Nursing 211

N211: Health Differences Across the Lifespan I edema and warmth of the extremity, asymmetry of legs, tender areas on the affected extremity with very gentle palpation. Risk Factors Include prolonged bed rest, general surgery, leg trauma, previous venous insufficiency, obesity, oral contraceptives, pregnancy and malignancy. Diagnostic Testing Venogram, Doppler ultrasound and fibrinogen scanning. Nursing Diagnosis • Acute pain related to… • Ineffective tissue perfusion related to… Nursing Interven ons Administer anticoagulant therapy, observe for bleeding, teach client side effects of medications, monitor laboratory data to determine efficacy of medications, maintain pressure on venipuncture sites to minimize hematoma formation, advise client to use soft toothbrush, floss with waxed floss, advise client to wear a Medic Alert bracelet. Notify physician of any unusual bleeding such as abnormal vaginal bleeding, nosebleeds, melena, hematuria, gums or hemoptysis. Advise client to avoid aspirin and aspirin products and NSAIDS. Advise client to wear antiembolic stockings and to elevate extremity and use shock blocks at foot of bed. Monitor client for decreasing symptomatology (pain and edema). Monitor for pulmonary embolus (chest pain, shortness of breath). Teach client that there is an increased risk of DVT formation in the future. Heparin prevents conversion of fibrinogen and Prothrombin to thrombin, thereby inhibiting clot formation. The clotting mechanism is prolonged so tissue trauma should be avoided because it can lead to serious bleeding when giving heparin subcutaneously. Do not massage area or aspirate. SQ injection is given in the abdomen between the two pelvic bones, two inches from the umbilicus; always rotate sites. Heparin’s antagonist is protamine sulfate. Lab values to review are PTT or APTT to determine efficacy. The level should be 1.5 to 2.5 times the normal control. Coumadin’s antagonist is vitamin K. Lab values to review are the PT to determine efficacy. The level should be 1.5 to 2.5 times the normal control. Desirable therapeutic level is usually 2 to 3 seconds; this reflects how long it takes a blood sample to clot. 1.13 Valvular heart disease


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