A client is diagnosed with deep vein thrombosis. which nursing diagnosis should

POSTACUTE PHASE NURSING: RESPIRATORY AND CARDIOVASCULAR PROBLEMS (DVT & OH)

RESPIRATORY SYSTEM

1. Goals include weaning the patient from the ventilator, or, long-term options, such as discharge with a ventilator, diaphragmatic pacer, etc.

2. Problems include respiratory fatigue, pneumonia, atelectasis, and hypoxemia

3. Causes include decreased volumes of air exchange in tidal volumes, decreased chest movement with each respiration, and decreased forced expiration volume due to weakness or nonfunction of the muscles involved in respiration: the diaphragm, intercostals, and abdominals

4. Nursing Diagnoses include ineffective airway clearance; risk of aspiration, respiratory infection and altered respiratory function; impaired gas exchange; hypoxemia, atelectasis, and pneumonia

5. Assessments include observation of respiratory effort; monitoring for signs of respiratory fatigue, such as rapid shallow breathing with exaggerated abdominal movements, diminished breath sounds, and pale and dusky skin color; monitoring for increased use of accessory neck muscles; chest auscultation; and blood gas levels, chest x-rays, and pulmonary function tests

6. Nursing Interventions include:
   • Treating an ineffective cough with assistive cough, pneumobelts, turning, increased acitivity, and chest physical therapy
   • Alternative modes of ventilation, such as IPPB treatments, oxygen therapy, ventilator support, and tracheostomy, if needed
   • Aggressive treatment of infections
   • Patient/family teaching program for respiratory care, breathing exercises, assisted coughing, suction technique, and other therapies, such as oxygen, IPPB, etc.

CARDIOVASCULAR SYSTEM

1. Problems include thrombophlebitis, Deep Venous Thrombosis (DVT), Pulmonary Embolism (PE), Orthostatic Hypotension (OH), and hyperthermia/hypothermia

2. Causes are similar to the acute phase and include bradycardia, lowered blood pressure, venous pooling, and decreased cardiac output:
   • DVT is due to venous blood stasis and damage of the vein wall as a result of prolonged immobility, bed rest, or limited mobility, and to abnormalities of the clotting mechanism, such as hypercoagulability
   • OH is due to an interruption of splanchnic control in patients with lesions at T6 and above
   • Hyperthermia/hypothermia is due to the loss of thermoregulation as a result of sympathetic nervous dysfunction
3. Nursing Diagnoses include impaired gas exchange, risk of peripheral neurovascular dysfunction, dysrhythmias, DVT, PE, hypovolemia, and OH:
   • DVT presents with:
     • Swelling of the calf, thigh, or the entire leg
     • Redness, warm and hard flesh, low-grade fever, and chills
     • Asymmetrical enlargement of one leg relative to the other
     • Increased leg spasms and cramping
     • Abdominal pain
   • OH presents with:
     • Weakness, dizziness, pale color, and blurred vision that leads to blackouts or fainting
     • Excessive sweating above the level of injury and tachycardia
4. Assessments include monitoring for signs and symptoms of DVT, PE, OH, and vital signs; chest x-rays

5. Nursing Interventions include continued use of air boots and heparin and thigh-high elastic (TED) stockings, and, for:
   • DVT
     • Bed rest to prevent clot dislodgment
     • Elevate affected or both legs
     • Turn patient every 2 hours without crossing legs
     • Range-of-motion exercises to the unaffected leg
     • Warm compresses to help reduce swelling
     • Monitor vital signs every 4-6 hours
     • Assess patient for complications of PE, such as shortness of breath, chest pain, apprehension, cough, hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever
   • OH
     • Physical therapy with a tilt table and/or reclining wheelchair
     • Apply abdominal binder and anti-embolism stockings
     • Limit the degree of head elevation and dangle legs over the side of the bed to maintain stable blood pressure
     • Monitor blood pressure before and after transfers and the hypotensive effect of medications
     • Maintain adequate hydration

The PoinTIS Spinal Cord Nursing site of the SCI Manual for Providers is based on information in Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing, 4th ed., Philadelphia: Lippincott, 1997; Chin PA, et al. Rehabilitation Nursing Practice, N.Y.: McGraw-Hill, 1998; and Wirtz KM, Managing chronic spinal cord injury: issues in critical care, Critical Care Nurse 1996 16(4):24-35 Aug., except for information where other papers are cited.

What is the nursing diagnosis for deep vein thrombosis?

What are some common nursing interventions for deep vein thrombosis?

What is deep vein thrombosis diagnosis?

What is the most important intervention to prevent deep vein thrombosis?