About
Blood clot in one or more extremities that can dislodge and travel causing a pulmonary embolism.
Assess
Extremity discomfort, unilateral swelling of extremity, pain, edema, warmth, compare measurements of right and left extremities, D-Dimer
Complications
- Pulmonary embolism; bleeding; chronic venous insufficiency; additional clot formation
Diagnosis
- Acute pain related to tissue edema
- Impaired tissue perfusion related to altered distal blood flow
- Risk for injury related to movement of blood clot to lungs.
Goals
- The client will remain free from injury.
- The client will be able to state rationale, side effects and adverse reactions of anticoagulant therapy.
- The client will have a pain of less than 4 on a VAS 0-10 pain scale.
- The client will have palpable distal pulses with warmth of effected extremity ( s).
Interventions
- Monitor for s/s of respiratory complications including sudden shortness of breath, chest pain, decreased pulse-oximetry, or changes in level of consciousness.
- Monitor labs, especially coagulation studies.
- Monitor for s/s of bleeding including bruising, petechiae, purpura, bleeding gums, bloody stools, hypotension.
- Assess distal pulses and signs of adequate tissue perfusion.
- Administer medications ( heparin, Coumadin, thrombolytics, etc.) as indicated.
- Teach client s/s to monitor for including bleeding, return of symptoms, shortness of breath.
- Teach client about medication therapies including rationale, side effects, dietary considerations, adverse reactions, and follow-up laboratory testing.
- Monitor for signs/ symptoms of complications.
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