UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING NU 301: NURSING PLAN OF CARE

ASSESSEMENTS (Subjective/Objective Data pertinent to this nursing diagnosis) Subjective: pain in RT leg c/o of pain, rated 2, RT foot Dr. said possible blood clot NURSING DIAGNOSIS NANDA diagnosis? Related factors noted? Evidence if an actual problem? Ineffective peripheral tissue perfusion R/T interruption in blood flow, venous stasis A.E.B. edema, changes in skin color and temperature in RT lower leg/foot, delayed peripheral wound healing, diminished peripheral pulses, and pain in RT foot. NURSING INTERVENTIONS Administering, demonstrating and performing treatments, & teachings pertinent to diagnosis) EVIDENCE SUPPORTING PRACTICE (Rationale) (Cite source: Author & Page #) List full reference separately.

Student Name: MONICA COX Date: January 26, 2012

IMPLEMENTATION Explain how interventions were met or explain why they were not. EVALUATION State outcome achievement in behavioral terms. Note: Continue , Change (specify), Discontinue POC Goals were met. Patient had palpable peripheral pulses, decreased edema, and showed no signs of respiratory distress. Patient verbalized level of pain at 0 the entire shift. Patient correctly demonstrated the foot/ankle exercises. Patient verbalized clear understanding of the signs/symptoms of DVT.

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Palpate and document peripheral pulses every 4 hours. (#1a) Elevate edematous legs as ordered every shift. (#1b) Ensure no pressure under the knee and heels to prevent pressure ulcers every 2 hours. (#1b) Give anticoagulant therapy as prescribed. (#1) Observe for symptoms of pulmonary embolism, including dyspnea, tachypnea, and tachycardia every 4 hours. (#1c) Assess pain management strategies and their effectiveness every 4 hours. (#2) Encourage patient to perform foot/ankle exercises to increase venous return every 4 hours while on bedrest. (#3) Teach patient the importance of recognizing the signs and symptoms that should be reported to a physician (change in skin temperature, color, or sensation or the presence of a new lesion on the foot). (#4)

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Determines level of perfusion to distal body parts. (Perry; p. 1014) Elevate the affected limb 20 degrees or more above the level of the heart to improve venous return, as appropriate.(Ignatavicius; p. 678) Prevent pressure under the popliteal space (e.g., with a pillow). (Ignatavicius; p. 678) Heparin is a preferred anticoagulant for usein situations that require rapid onset of anticoagulant effects, including pulmonary embolism (PE), evolving stroke, and massive deep vein thrombosis (DVT). (Lehne; p. 599) Pulmonary embolism is a lifethreatening complication of DVT. (Copstead-Kirkhorn; p. 370-371) Edema, venous stasis ulcers, and pain usually accompany chronic venous obstruction. (Copstead-Kirkhorn; p. 370371) Start passive and active rangeof-motion exercises for the extremities of immobilized and postoperative patients. (Ignatavicius; p. 678) Inspection of the feet is critically important in the presence of impaired circulation (Perry; p. 120)

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Peripheral pulses were palpated and documented as +1 every 4 hours. Legs were elevated at beginning of shift. Changed patient position every 2 hours as follows: back, left, right with pillows under the knees and feet. Enoxaparin (Lovenox) given as scheduled. Auscultated bilateral lung sounds every 4 hours and noted clear breath sounds and a slightly increased respiratory rate. Asked patients pain level on a scale from 0-10 every 4 hours. Patient reported level 0 pain. Discussed foot/ankle exercises with patient at beginning of shift. Patient demonstrated exercises every 4 hours. Provided verbal and written information on signs and symptoms of DVT to patient. Patient verbalized understanding.

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OUTCOME STATEMENTS Measurable? Realistic? Time element noted? Pertinent to diagnosis? Objective: reddened skin on RT foot edema in RT lower leg cool skin on lower extremities lower peripheral pulses diminished (graded +1) ulcer w/eschar on RT great toe respiratory rate is 24 bedrest order 2. b. Goals: By 1300 on Friday, January 27, 2012, the patient will: 1. Demonstrate increased perfusion as evidenced by: a. Palpable peripheral pulses Decreased edema in lower extremities And absence of respiratory distress.

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Continue with POC as described to prevent further venous stasis, blood clotting, and pressure ulcer development. Reinforce teaching rather than repeating it.

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Verbalize decreased pain level. Demonstrate appropriate exercises to increase tissue perfusion while on bedrest. Learn signs/symptoms of DVT that should be reported to a physician.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING NU 301: NURSING PLAN OF CARE

Student Name: MONICA COX Date: January 26, 2012

List a minimum of three references to indicate interventions are derived from and supported by evidence-based practice. References are to be documented in APA format. References: 1. 2. (Perry, Anne Griffin. Clinical Nursing Skills & Techniques, 7th Edition. Mosby, 032009. p. 1014). (Ignatavicius, Donna D.. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 6th Edition. W.B. Saunders Company, 022009. p. 678).

3. (Ignatavicius, Donna D.. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 6th Edition. W.B. Saunders Company, 022009. p. 678). 4. (Lehne, Richard A.. Pharmacology for Nursing Care, 7th Edition. W.B. Saunders Company, 082009. p. 599). 5. (Copstead-Kirkhorn, Lee-Ellen C.. Pathophysiology, 4th Edition. W.B. Saunders Company, 022009. pp. 370 371). 6. (Copstead-Kirkhorn, Lee-Ellen C.. Pathophysiology, 4th Edition. W.B. Saunders Company, 022009. pp. 370 371). 7. (Ignatavicius, Donna D.. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 6th Edition. W.B. Saunders Company, 022009. p. 678). 8. (Perry, Anne Griffin. Clinical Nursing Skills & Techniques, 7th Edition. Mosby, 032009. p. 120).