A postpartum nurse is assessing a client who delivered vaginally 3 days ago and reports leg pain. Which assessment finding would be most indicative of thrombophlebitis?
1Bilateral leg edema with pitting
2Cramping pain that improves with walking
3Coolness and pallor of the affected extremity
4Unilateral leg pain with positive Homans' sign✓ 정답
해설
Thrombophlebitis typically presents with unilateral leg pain, warmth, redness, and a positive Homans' sign. Bilateral edema suggests other causes, cramping pain improves with walking in muscle cramps, and coolness/pallor indicate arterial issues.
Clinical Judgment
This question assesses the ability to distinguish between dangerous complications and common discomforts when evaluating leg pain in a postpartum patient. The key is to identify the most characteristic clinical finding of thrombophlebitis. The postpartum period is a time of high risk for thrombus formation due to hypercoagulability, venous stasis, and vascular injury. The correct answer, 'unilateral leg pain and a positive Homans' sign,' is a classic sign of deep vein thrombosis (DVT) that requires Notify HCP!. The other options suggest causes other than thrombophlebitis, such as bilateral edema (common postpartum swelling), cramping pain (muscle pain), and coldness with pallor (an arterial problem).
Memory Tip:
Remember Homans' sign, Unilateral pain, Warmth, Redness, Edema. H.U.W.R.E. summarizes the key symptoms of thrombophlebitis.
KR vs US:
In Korea, Homans' sign is still used as a reference in clinical practice, but in the US NGN/NCLEX, it is not considered a definitive diagnostic tool. US clinical practice places more emphasis on standardized assessment tools like the Wells criteria and objective diagnosis via ultrasound. Also, while the term 'thrombophlebitis' is more commonly used in Korea, US nursing often specifies the exact location (superficial vs. deep) as SVT (Superficial Venous Thrombosis) or DVT.
Clinical Practice Guide
When a postpartum patient complains of leg pain, the nurse should perform a systematic assessment.
1InspectionCompare both legs to check for unilateral swelling, redness, or a visible cord along the vein (superficial thrombus).
2PalpationCheck skin temperature (warmth at the thrombus site), areas of tenderness, and firmness.
3Risk AssessmentIdentify risk factors such as delivery method (cesarean section), obesity, history of blood clots, and prolonged immobility.
4Immediate ReportingIf accompanied by unilateral symptoms, difficulty breathing, or chest pain, report immediately.
Caution:
A common trap in SATA (Select All That Apply) questions is the statement that "Homan's sign is a diagnostic test for thrombophlebitis." This is false. Homan's sign is merely a screening test with low sensitivity and specificity, and a negative result does not rule out DVT. Also, "bilateral calf pain and swelling" suggests normal pregnancy-related edema or a systemic condition rather than thrombophlebitis.
Thrombophlebitis — Inflammation of a vein with blood clot formation. It is important during the postpartum period because of the risk of progression to deep vein thrombosis (DVT).
Homans' Sign — When the patient is lying with the knee extended and the ankle is passively dorsiflexed, pain is elicited in the calf. This is a traditional clinical sign that may suggest DVT, but its diagnostic specificity is not high.
Deep Vein Thrombosis — A condition where blood clots form in deep veins, primarily in the legs. The greatest risk is that a clot can break loose and cause a pulmonary embolism (PE).
Postpartum Period — The period after childbirth, typically up to 6 weeks. During this time, physiological changes occur that increase the risk of thrombosis.
Unilateral — Affecting only one side. In the evaluation of thrombophlebitis or DVT, 'unilateral' symptoms are an important distinguishing sign.