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Ineffective Tissue Perfusion

The patient presented with complaints of a heavy and pale right leg. Examination revealed a thrombus in the right femoral vein, weak pulse, edema, and pale skin in the right leg. The nursing diagnosis was ineffective tissue perfusion in the right leg due to decreased venous circulation secondary to the thrombus. The goals were for the patient to understand health teaching, comply with treatment, and participate in care within 8 hours. Interventions included administering thrombolytics and anticoagulants as ordered, advising regular exercise, leg elevation, and use of compression stockings to relieve symptoms and prevent long term complications of DVT.

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Diane Rey
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2K views

Ineffective Tissue Perfusion

The patient presented with complaints of a heavy and pale right leg. Examination revealed a thrombus in the right femoral vein, weak pulse, edema, and pale skin in the right leg. The nursing diagnosis was ineffective tissue perfusion in the right leg due to decreased venous circulation secondary to the thrombus. The goals were for the patient to understand health teaching, comply with treatment, and participate in care within 8 hours. Interventions included administering thrombolytics and anticoagulants as ordered, advising regular exercise, leg elevation, and use of compression stockings to relieve symptoms and prevent long term complications of DVT.

Uploaded by

Diane Rey
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Diane Mari C.

Rey BSN III CA3 Cues/Data Subjective: Feeling ko ngalay yung paa ko tapos parang maputla yung kulay nya. As verbalized by the patient. Objective: -Presence of thrombus in the right femoral proximal to popliteal vein -Weak peripheral pulse -Edema on the right leg -Pale colored skin -Obesity http://www.eho w.com/facts_67 49826_ineffecti ve-tissueperfusion_.html #ixzz1YY1Hh2 Uy Nursing Diagnosis Ineffective tissue perfusion related to decrease venous circulation on the right leg secondary to a thrombus. Rationale Inadequate tissue perfusion can be a diagnosis, a sign and a symptom that one or more organs of the body are beginning to fail due to a lack of oxygenated blood either reaching an organ or fully circulating through an organ or body system. Goals/ Objectives Within 8 hours of nursing intervention the client will be able to: Verbalize understandi ng about the health teaching and its benefits. Comply with the therapeutic regimen. Show willingness to participate in the nursing plan of action to decrease and stop the return of the problem. Intervention/s Rationale Evaluation Within 8 hours of nursing intervention the client was able to: Verbalize understan ding about the health teaching and its benefits. Comply with the therapeut ic regimen. Show willingnes s to participat e in the nursing plan of action to decrease and stop the return of the problem.

-Administer thrombolytics and anti-coagulants as ordered by the physician.

-Use of thrombolysis or clot dissolving drugs could reduce the long-term complications of postthrombotic syndrome (pain, swelling, skin discolouration, or venous ulceration) in the affected leg.

-Advise the patient about ways to prevent or reduce recurrence by:

Having a regular low intensity exercise, such as walking

http://www.inate.org/en/ 1/2/6/956/default.aspx

Mobility can help prevent persistent calf symptoms after DVT, and reduce the risk of further DVT, by improving circulation in the affected limb.

Elevate the legs and maintaining a slight knee flexion while

Leg elevations relieves the pressure in the veins and alleviates the pain and

in bed.

swelling in the affected leg. http://www.loungedoc tor.com/

Use tightfitting stockings as ordered and remove for 30 minutes every 8 hours.

http://www.inate.org/en/ 1/2/6/956/default.aspx

The use of knee-high elastic compression stockings (pressure 30 40 mm) on the affected leg may also relieve discomfort and prevent postthrombotic syndrome (the long term effects of DVT). Stockings are worn except when bathing or sleeping.

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