Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient states he was recently diagnosed by DVT. Pt says the nurses are having a hard time getting a pulse in the left leg. Patient states he has never seen his left leg this leg. Says he has a family and personal history of DVT. Pt states he feels like he has a constant charlie horse in left leg.

Objective

Pedal and Popliteal pulses diminished in left let. Left leg cool and red/Right leg warn and pink in color. Left leg 2+ edema. Right leg no edema preseent. Unable to perform ROM in left leg. Cap refill >3sec in left and <3sec right. Pain is 6/10. Could not feel light touch or dull sensation in left leg.

Problem

Peripheral neurovascular dysfunction

Long Term:

Explain signs of neurovascular compromise and ways to prevent venous stasis

Teach the client and family to recognize signs of neurovascular dysfunction and report signs immediately to the appropriate person.

Emphasize proper nutrition to promote healing.

Client was able to explian signs and s/sx of DVT and peripheral vascular disorders.  Patient also understands that living a healthy lifestyle is imperative in preventing PVD.

Goal met.

Taught client s/sx of DVT such as unilateral edema, diminished pulses, parastheiss, and cool extremity.

Also taught patient about how important proper nutrition is and explained pt the food guide pyramid.

R/T

A vascular obstruction

Short Term:

Maintain circulation, sensation, and movement of an extremity within client's own normal limits by end of shift on [date] at 1300.

Assess severity (on a scale of 1 to 10), quality, radiation, and relief by medications. Diffuse pain that is aggravated by passive movement and is unrelieved by medication can be an early symptom of compartment syndrome or a symptom of limb ischemia Kasirajan & Ouriel, 2002 ().

Pulses: Check the pulses distal to the injury. Check the uninjured side first to establish a baseline for a bilateral comparison. An intact pulse generally indicates a good blood supply to the extremity, although compartment syndrome may be present even if the pulse is intact (Walls,2002)(Pallor/Poikilothermia: Check color and temperature changes below the injury site. Check capillary refill. If pallor is present, record the level of coldness carefully. A cold, pale, or bluish extremity indicates arterial insufficiency or arterial damage, and a physician should be notified(Bickley & Szilagyi, 2007;Kasirajan & Ouriel, 2002). A reddened, warm extremity may indicate infection (Kasper et al, 2005). Normal capillary refill time is 3 seconds or less(McConnell, 2002).

Paresthesia (change in sensation): Check by lightly touching the skin proximal and distal to the injury. Ask if the client has any unusual sensations such as hypersensitivity, tingling, prickling, decreased feeling, or numbness. Changes in sensation are indicative of nerve compression and damage and can also indicate compartment syndrome (Kasirajan & Ouriel, 2002; Walls, 2002).

Paralysis: Ask the client to perform appropriate range-of-motion exercises in the unaffected and then the affected extremity. Paralysis is a late and ominous symptom of compartment syndrome or limb ischemia (Kasirajan & Ouriel, 2002; Walls, 2002).

Client was unable to maintain circulation and sensation. Client was unable to perform active ROM. Goal not met.

Assessed the severity of pain, checked pulese bilaterally, color and temperature, paralysis and decresed sensation in lower extermities.

AEB

Diagnosed with DVT