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Deep Vein Thrombosis: Nursing Care Plan
Student’s Name
Institutional Affiliation
Course
Instructor
Date
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Patient’s Problems and Diagnosis List
Problem
Maslow’s hierarchy
needs
Pain in left lower limb
Physiological
Low levels of hemoglobin (8.3
Physiological
g/dl), hematocrit (24 %), and red
blood cells (3,300,000/µL)
Abdominal distention with
Physiological
hypoactive bowel sounds
The patient is obese, has
elevated cholesterol levels, and
has a BMI of 32.70
She lives alone and works as a
cashier
Slight erythema and an open
wound on the lower extremity
Priority
nursing
diagnosis
1
Nursing diagnosis
2
Activity intolerance related to impaired limb function and reduced
oxygen capacity of the blood, as evidenced by increased rest
requirements (NANDA International, 2018)
3
Constipation related to immobility, as evidenced by
hypoactive bowel sounds and difficulty opening bowels four
days post-surgery (NANDA International, 2018).
Sedentary lifestyle related to insufficient knowledge about
nutritional requirements and health benefits associated with
exercise, as evidenced by a body BMI of 32.70 (NANDA
International, 2018)
Self5
actualization/knowledge
Physiological
4
Acute pain related to edema secondary to ankle fracture as
evidenced by pain of 5/10 on a pain scale (NANDA
International, 2018)
Risk for infection as evidenced by a break of skin integrity
on the left lower limb (NANDA International, 2018)
Maslow’s Hierarchy of Needs: A= Physiological, B=Safety & Security, C=Love & Belonging, D=Self-Esteem, E=SelfActualization/Knowledge (Montag et al., 2020).
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Assessment data
Nursing
diagnosis
Subjective: patient reports
hives and pain of 3-5/10
on the pain scale on the
left ankle. She also
verbalizes a pain of 3/10
on a pain scale on the left
calf area
Objective: On assessment,
the calf circumference of
the right lower limb is 8
cm while the left limb is
10cm.
Acute pain related
to edema
secondary to ankle
fracture as
evidenced by the
pain of 5/10 on a
pain scale
(NANDA
The patient encouraged to
take total rest and avoid
strenuous activities
Laboratory values show
low levels of hemoglobin
(8.3 g/dl), hematocrit (24
%), and red blood cells
(3,300,000/µL)
Activity
intolerance related
to impaired limb
function and
reduced oxygen
capacity of the
blood, as
evidenced by
increased rest
requirements
(NANDA
International,
2018)
Goals
Nursing Care Plan for D.R
Interventions
1. Short term goal
 The patient will verbalize
reduced pain from 5/10 to 1/10
on a pain scale at the end of
four hours of nursing
intervention.
2. Long term goal
 The patient will identify ways
of managing pain in the future
1. Short term goal
 The patient will demonstrate
increased engagement in
activities of daily living within
48 hours
2. Long term goal
 The patient will have normal
hematological values by the
end of the hospitalization
period
International,
2018)
Subjective: The patient
reports that she has not
passed stool for the past
four days
Constipation
related to
immobility as
1. Short term goal
 The patient will be able to pass
stool and demonstrate
1. Interventions for short term goals
 Identify a non-pharmacological pain management
approach suitable for the patient to prevent her
from focusing on the pain.
 Encourage the patient to take a tolerable position
and keep the affected limb in straight alignment
to relieve pain from unnecessary movements.
 Administer analgesics as prescribed to prevent
transmission of pain impulses. (Mwanza et al.,
2019)
2. Intervention for long term goal
 Provide compression stockings as indicated to
relieve edema and educate the patient about their
benefit (Dahm et al., 2019)
1. Interventions for short term goals
 Encourage the patient to perform activities
progressively with rest, from sitting up in bed to
walking a few steps, to offer the body enough
time to adjust.
 Offer a bedside commode as indicated to lessen
energy expenditure.
 Assist the patient in performing activities when
necessary to conserve energy and avoid patient
dependency
2. Intervention for long term goal
 Monitor the patient’s vital signs and laboratory
values closely for abnormalities and refer her to a
specialized consult in case of abnormalities.
(Scheerman et al., 2020)
1. Interventions for short term goals
Evaluation
Goal met.
After two hours of
intervention, the
patient reports pain of
1/10 on a pain scale.
Goal partially met.
At the end of two
days, the
the patient can only
sit in bed for a short
while due to fatigue
and pain.
Goal met.
At the end of 10
hours of intervention,
the patient reports
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Objective: On
examination, the patient
has a distended abdomen
and hypoactive bowel
sounds from all quadrants.
evidenced by
hypoactive
bowel sounds
and difficulty in
opening bowels
four days postsurgery
(NANDA
International,
2018)
improved bowel movements
within 24 hours of nursing
intervention
2. Long term goals
 The patient will be able to
identify activities to prevent
constipation in the future
 Provide the patient with assistive equipment such
as a wheelchair to ease her pain burden when
moving around.
 Perform a gentle abdomen massage to ease
symptoms of constipation by decreasing colon
transit time and increasing gastric motility.
 Administer laxatives as prescribed to enhance
bowel movements.
2. Intervention for a long-term goal
 Involve a dietician for nutritional intervention and
refer her to the physiotherapist to provide
appropriate education about exercise postdischarge.
(Forootan et al., 2019)
opening bowels,
which are
voluminous, without
straining.
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References
Dahm, K. T., Myrhaug, H. T., Strømme, H., Fure, B., & Brurberg, K. G. (2019). Effects of
preventive use of compression stockings for elderly with chronic venous insufficiency
and swollen legs: a systematic review and meta-analysis. BMC geriatrics, 19(1), 76.
https://doi.org/10.1186/s12877-019-1087-1
Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation: A review of
literature. Medicine, 97(20), e10631. https://doi.org/10.1097/MD.0000000000010631
Montag, C., Sindermann, C., Lester, D., & Davis, K. L. (2020). Linking individual differences in
satisfaction with each of Maslow's needs to the Big Five personality traits and Panksepp's
primary emotional systems. Heliyon, 6(7), e04325.
https://doi.org/10.1016/j.heliyon.2020.e04325
Mwanza, E., Gwisai, R. D., & Munemo, C. (2019). Knowledge on Non-pharmacological
Methods of Pain Management among Nurses at Bindura Hospital, Zimbabwe. Pain
research and treatment, 2019, 2703579. https://doi.org/10.1155/2019/2703579
NANDA International. (2018). Nursing Diagnoses: Definitions & classification 2018-2020. New
York: Thieme.
Scheerman, K., Mesters, J. W., Borger, J. N., Meskers, C., & Maier, A. B. (2020). Tasks and
responsibilities in physical activity promotion of older patients during hospitalization: A
nurse perspective. Nursing open, 7(6), 1966–1977. https://doi.org/10.1002/nop2.588