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.
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.
Peripheral neurovascular dysfunction
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.
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.
A vascular obstruction
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
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).
(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).
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.