On postoperative day 3 after hip replacement, a client develops unilateral calf swelling, tenderness, warmth, and erythema. Duplex ultrasound for suspected deep vein thrombosis is pending. Which nursing actions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Suspected DVT requires clinical assessment and objective testing; Homans sign is neither sensitive nor specific and should not be used to diagnose DVT (Choice 1). Sudden respiratory symptoms, chest pain, tachycardia, syncope, or hypoxemia can indicate pulmonary embolism and require immediate escalation, supportive care, and diagnostic evaluation (Choice 2). Give ordered anticoagulation using drug-specific dosing and monitoring that accounts for renal function, weight, bleeding risk, and local laboratory methods rather than a universal aPTT ratio (Choice 3). Do not apply compression to the symptomatic leg while acute DVT is being evaluated; prophylaxis on the unaffected leg is continued only when ordered and appropriate (Choice 4). Do not massage a leg with suspected DVT (Choice 5). After anticoagulation or other treatment begins and the client is stable, early ambulation is generally favored over routine bed rest (Choice 6).
Clinical Judgment VTE care is built on the Virchow triad — stasis, endothelial injury, and hypercoagulability. The nurse counters each: SCDs and ambulation against stasis, careful line and surgical care against injury, and anticoagulation against hypercoagulability. Suspect PE in any hospitalized client with sudden dyspnea and tachycardia.
KR vs US Korean wards historically used heat compresses and massage for leg pain, which is dangerous if DVT is present. NCLEX-RN expects the nurse to avoid massage and heat in any leg pain that could be DVT and to image first.
Clinical Practice GuideACCP and CHEST VTE guidelines: confirmed DVT or PE — anticoagulation for at least 3 months with LMWH, UFH, warfarin (INR 2 to 3), or DOACs (rivaroxaban, apixaban). High-bleeding-risk or anticoagulation contraindicated — IVC filter. Hospitalized at-risk clients — mechanical SCDs and pharmacologic prophylaxis when not contraindicated. PE workup — Wells score, D-dimer, CT pulmonary angiography (V/Q scan if CTPA contraindicated).
CautionCommon NCLEX traps: massage and heat for confirmed DVT, relying on Homans sign, withholding anticoagulation while waiting for confirmatory imaging in high pretest probability, and missing PE in a postoperative client with sudden dyspnea. Remember: a clot in the leg can become a clot in the lung — protect, anticoagulate, and watch.
Deep Vein Thrombosis (DVT) — Thrombus formation in the deep veins of the lower extremities or pelvis. Risk factors follow the Virchow triad: stasis (immobility, surgery), endothelial injury (trauma, central lines), and hypercoagulability (cancer, oral contraceptives, pregnancy, inherited thrombophilias). Classic findings: unilateral calf swelling, pain, warmth, and erythema. Diagnosis: clinical assessment plus D-dimer and duplex ultrasound. NCLEX exam tip: bilateral findings are usually systemic; unilateral findings raise DVT concern.
Pulmonary Embolism (PE) — Obstruction of pulmonary arterial flow by thrombus, most often originating from a lower extremity DVT. Presents with sudden dyspnea, pleuritic chest pain, tachycardia, hypoxia, and sometimes hemoptysis. Diagnosis: Wells score, D-dimer, CT pulmonary angiography. Treatment: anticoagulation; consider thrombolytics or thrombectomy in massive PE with hemodynamic instability. NCLEX exam tip: sudden dyspnea after immobility, surgery, or DVT is PE until proven otherwise.
VTE Prophylaxis — Layered prevention of venous thromboembolism in hospitalized clients: mechanical (sequential compression devices, early ambulation, ankle pumps, hydration) and pharmacologic (LMWH such as enoxaparin 40 mg subcutaneously daily, unfractionated heparin 5000 units subcutaneously every 8 hours, or DOAC depending on risk). Mechanical alone is used when anticoagulation is contraindicated. NCLEX exam tip: massaging or applying heat to the calves is never appropriate when DVT is suspected or confirmed.