1.Based on what you’ve learned about the nursing process, describe one applicable nursing
diagnosis, treatments, and nursing considerations for this diagnosis.
Based on the ADPIE and NANDA, the patient displays signs and symptoms of (DVT).
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Nursing Dx: Infective tissue perfusion in right lower leg
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At risk Deep vein thrombosis (DVT).
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Claudication (redness) due to interference with venous blood flow
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Pain due to inadequate blood flow, and inflammation
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Warmth due to ineffective peripheral tissue
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Risk for immobility
Nursing Tx: Prevent Clots
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Anticoagulants to alleviate pain and thin blood
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Compression therapy via stockings
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Prevent immobility, ROM exercise
Nursing Considerations:
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Risk of Pulmonary Embolus
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Assessing respirations
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Re-Eval daily ROM exercise
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Re-Assess signs and symptoms for DVT and Pulmonary embolus.
2. What are some non-pharmacological measures that can be used for pain relief in care for this
patient?
Some non-pharmacological measure can include:
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Elevate affected leg
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Apply therapeutic compressions
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Apply temperature therapy (warm or cold compressions)
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Physical therapy can assist with ROM and ambulating
3. Describe the components of a peripheral vascular nursing assessment.
According to the ADPIE, first, the SN will inspect the affected right lower calf and leg.
The inspection will consist of skin color, size, and temperature. The SN will continue to closely
look over the skin for varicose veins, open wounds, lesions, ulcers, or any topical issues. The SN
will palpate the affected area and will note the redness and pitting edema. The SN will assess the
pain and follow the PQRST for pain assessment. The SN will assess and monitor the patient
respiration rate. Second, the SN will verify the patient history, medication history, and family
history while planning treatment and goals. Next, the SN will implement said goals. Lastly, the
SN will re-evaluate to see if goals are met.