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Nursing Diagnosis for DVT Management

The patient presented with acute pain in the right leg due to inflammation from a deep vein thrombosis. Nursing interventions included establishing rapport, assessing the patient's pain, providing comfort measures like elevation and medication, encouraging rest and activity, and monitoring vital signs to alleviate pain and prevent complications over the short and long term. The goal was for the patient to experience relief from pain within a few hours and be pain-free after 1-2 days of nursing care.

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Marie Ashley Casia
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330 views4 pages

Nursing Diagnosis for DVT Management

The patient presented with acute pain in the right leg due to inflammation from a deep vein thrombosis. Nursing interventions included establishing rapport, assessing the patient's pain, providing comfort measures like elevation and medication, encouraging rest and activity, and monitoring vital signs to alleviate pain and prevent complications over the short and long term. The goal was for the patient to experience relief from pain within a few hours and be pain-free after 1-2 days of nursing care.

Uploaded by

Marie Ashley Casia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING DIAGNOSIS: Acute pain related to inflammation response in affected vein as evidenced by edematous right leg.

DEFINING CHARACTERISTICS SCIENTIFIC BASIS EXPECTED OUTCOME NURSING INTERVENTION RATIONALE


Subjective: Deep vein thrombosis (DVT) Short term goal:  Establish rapport  To have a trusted nurse
“My left leg is in pain“ as occurs when a blood clot to patient relationship
verbalized by the patient. (thrombus) forms in one or After 3-4 hours of nursing and to have therapeutic
more of the deep veins in your intervention, the patient will be communication.
body, usually in your legs. Deep able to manifest alleviated pain.
vein thrombosis can cause leg
pain or swelling but also can  Obtain patient’s  To rule out worsening or
occur with no symptom. assessment of pain to underlying condition or
include location, development of
characteristics, onset complications.
and duration, frequency,
quality, intensity, and
precipitating or
aggravating factors.

 Observe non-verbal cues  Observations may not


Objective: Long term goal: and pain behaviors. be congruent with
After 1 to 2days of nursing verbal reports or maybe
- Erythematous leg noted intervention, the patient will be only indicator present
- Tender calf noted able to manifest absence of when client is unable to
- Warm to touch in the pain. verbalize.
affected leg noted
- -facial grimacing noted
- Guarding behavior
noted
- Restlessness noted  Monitor vital signs,
noting increased
temperature.  Elevations in heart rate
Vital Sign take as may indicate increased
follows: discomfort or may occur
-BP- 90/50 in response to fever and
-T- 36.6 inflammatory process.
-PR- 84 Fever can also increase
-RR- 27 client’s discomfort.

 Provide comfort
measures
 To promote non
pharmacological pain
 Encourage diversional management.
activities.
 To divert the patient’s
attention.

 Encourage adequate
rest periods.
 To prevent fatigue.

 Encourage patient to
change position
frequently.  Reduces muscle fatigue,
helps minimize muscle
spasm and maximizes
circulation to tissues.

 Provide foot cradle.


 Cradle keeps the
pressure of bedclothes
off the affected leg,
thereby reducing
 Elevate affected pressure discomfort.
extremity.
 Encourages venous
return to facilitate
circulation, reducing
stasis and edema
formation.

 Administer medication
as Ordered by physician
and monitor  To alleviate pain.
effectiveness.

Source: [Link]

Moorhouse, M.F (2002) Nurse’s pocket guide 10 th edition


NURSING DIAGNOSIS: Ineffective tissue perfusion related to

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