A nurse is caring for a client 24 hours after total shoulder replacement surgery. Which assessment finding requires the most immediate nursing intervention?
2Serosanguineous drainage of 50 mL from the surgical drain in the past 8 hours
3Inability to perform straight leg raises due to quadriceps weakness
4Sudden onset of severe calf pain with positive Homan's sign✓ 정답
해설
Sudden severe calf pain with positive Homan's sign suggests deep vein thrombosis, a life-threatening complication post-knee replacement requiring immediate intervention to prevent pulmonary embolism. Other findings like pain or drainage are less urgent.
Core Nursing Explanation
This question tests the critical nursing skill of prioritizing assessment findings in the postoperative period, specifically after a major orthopedic surgery. The core principle is recognizing a Key Point!life-threatening complication that requires immediate action to prevent further harm, such as a pulmonary embolism (PE).
Key Concept Analysis: The scenario involves a client 24 hours after total shoulder replacement surgery. While pain management and wound drainage are important, the nurse must be hypervigilant for signs of venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and PE. Orthopedic surgeries of the lower extremities (like knee/hip) are highest risk, but any major surgery, immobility, and trauma increase VTE risk. The finding of "sudden onset of severe calf pain with a positive Homan's sign" is a classic, though not definitive, indicator of a potential DVT.
Answer Rationale: Key Point! Option ④ describes a potential DVT. A DVT is a medical emergency because a clot can dislodge and travel to the lungs, causing a PE, which can be fatal. Immediate nursing intervention includes: DO NOT massage the calf, notify the provider immediately, anticipate orders for a Doppler ultrasound, and ensure the patient remains on bedrest to prevent clot dislodgement. This finding represents an ABC (Airway, Breathing, Circulation) threat to circulation and takes absolute priority.
Distractor Analysis:
Option ① (Knee pain 7/10): While significant pain is concerning, it is in a joint not involved in the surgery (shoulder). This is unexpected and should be assessed for other causes (e.g., referred pain, pre-existing condition), but it does not indicate an immediate life threat like a DVT/PE. Pain management is important but not the most immediate priority here.
Option ② (Serosanguineous drainage 50 mL/8hrs): This is a Watch out for confusion!normal and expected finding 24 hours post-op. Serosanguineous drainage (pink-tinged, watery) is typical. The amount (approx. 6 mL/hr) is within normal limits for a major joint replacement with a drain. The nurse should monitor, but this does not require immediate intervention.
Option ③ (Inability to perform straight leg raises): This assesses lower extremity strength (quadriceps). Watch out for confusion! For shoulder surgery, the priority neurovascular assessments are on the upper extremity (hand/arm sensation, movement, color, capillary refill, pulse). This finding is irrelevant to the surgical site and may indicate a separate neurological issue, but it is not an acute surgical complication or life threat.
Related Concepts: Postoperative nursing priorities always follow the ABCs and Maslow's Hierarchy of Needs. After airway, breathing, and circulation are stable, the focus shifts to preventing complications: infection, hemorrhage, VTE, and managing pain. For orthopedic surgeries, specific assessments include CMS (Circulation, Movement, Sensation) checks of the affected extremity.Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, a 68-year-old who underwent a left total shoulder arthroplasty yesterday for severe osteoarthritis. He has a patient-controlled analgesia (PCA) pump, a surgical drain, and sequential compression devices (SCDs) on his lower legs. During your 0800 assessment, he reports, "My right calf is killing me all of a sudden. It feels tight and swollen." You inspect and find mild swelling, redness, and warmth compared to the left leg. Dorsiflexion of his right foot (Homan's sign) elicits sharp calf pain.
Nursing Intervention Strategy:
1. Immediate Action (Assessment & Safety): Say, "Mr. Johnson, please try not to move or massage your leg." Immediately assess vital signs, especially for tachycardia, tachypnea, or decreased SpO2 (signs of possible PE). Perform a focused neurovascular assessment of the upper extremity (surgical site) to ensure no other acute issues, but your primary concern is the calf.
2. Notification & Collaboration: Notify the surgeon or hospitalist immediately. Report using SBAR: Situation (post-op day 1 s/p shoulder replacement), Background (sudden onset severe calf pain), Assessment (positive Homan's sign, calf swelling/redness, vital signs), Recommendation (request stat Doppler ultrasound and possible anticoagulant orders).
3. Patient Care & Monitoring: Keep the patient on bedrest with the affected leg elevated. Do not flex the knee or massage the area. Ensure SCDs are functioning but be cautious. Monitor closely for signs of PE: sudden chest pain, dyspnea, cough, hemoptysis, anxiety.
4. Patient Education: Explain the concern for a blood clot in a calm manner. Reiterate the importance of not rubbing the leg and reporting any new chest symptoms immediately.
Patient Safety and Precautions:
Key Point!NEVER massage a painful, red, swollen calf. This could dislodge a thrombus.
Homan's sign (calf pain on dorsiflexion) is not a reliable or specific test for DVT and should not be performed routinely, as it may dislodge a clot. Its presence in this context, with other symptoms, is highly suspicious.
The priority is preventing a PE, which is a leading cause of preventable hospital death.
Nursing Procedure & Medication Flow
If a DVT is confirmed, anticipate administering anticoagulants (e.g., enoxaparin, heparin drip).
Assessment before administration: Check baseline coagulation labs (PT/INR, aPTT, platelets), assess for other bleeding risks (e.g., active surgical site bleeding, history of ulcers).
Administration: For subcutaneous enoxaparin, use proper technique (pinch skin fold, inject at 90-degree angle into abdomen, do not rub site). For IV heparin, use an infusion pump and double-check the dose and rate per protocol.
Monitoring after administration: Monitor for signs of bleeding (surgical drain output, hematoma, gums, urine, stool). Monitor coagulation labs per order (e.g., aPTT for heparin, anti-Xa levels for enoxaparin).
A Word from Your Senior Nurse
"Orthopedic post-op patients are like ticking time bombs for DVTs—their veins are injured from surgery, they're immobile, and they're in a hypercoagulable state. Your eyes need to be on their calves and their lungs, not just their surgical dressing. That sudden complaint of calf pain or new shortness of breath is a five-alarm fire. In this question, they tried to trick you with knee pain and leg raises for a shoulder patient. Always ask yourself: 'What is the threat to life RIGHT NOW?' That's how you find the priority. This mindset saves lives on the floor and will help you ace priority questions on the NCLEX."
Concept Summary
Concept
Key Points
Postoperative Priority
ABCs > Life-threatening complications (Hemorrhage, PE) > Surgical site complications > Pain > Other needs.
Deep Vein Thrombosis (DVT)
Clot in deep vein (often calf). Signs: Unilateral calf pain, swelling, redness, warmth, positive Homan's sign (not reliable).
Serosanguineous (pink) is normal. Amount varies; 50-100 mL in first 24 hrs for a joint replacement can be expected.
Neurovascular Assessment (CMS)
For extremity surgery: Circulation (pulse, color, cap refill, warmth), Movement (strength, ROM), Sensation (feeling, numbness).
Side-by-Side Comparison!
Assessment Finding
Indicates
Priority & Action
Sudden calf pain, +Homan's sign
Possible Deep Vein Thrombosis (DVT)
HIGHEST PRIORITY. Immediate notification. Risk of PE. Do not massage.
Serosanguineous drainage, 50 mL/8hrs
Normal post-op drainage
Low priority. Continue to monitor amount and character.
Severe pain at non-operative site (knee)
Unexpected finding; requires assessment
Moderate priority. Investigate cause (injury, gout, referred pain) but not an immediate life threat.
Inability to move non-operative extremity
Possible neurological issue (e.g., stroke, nerve compression)
High priority, but for a shoulder patient, a potential DVT in the calf is a more direct and common life threat in the immediate post-op period.
Anatomy, Physiology & Pharmacology Points
Virchow's Triad: The three factors contributing to thrombosis: 1) Venous Stasis (immobility), 2) Endothelial Injury (surgery/trauma), 3) Hypercoagulability (post-op state). Orthopedic surgery hits all three.
Calf Veins: The deep veins of the calf (e.g., posterior tibial, peroneal) are common sites for DVT initiation.
Anticoagulant Mechanism: Drugs like heparin/enoxaparin enhance antithrombin III to inactivate clotting factors (Xa, IIa), preventing clot extension but not dissolving existing clots.
Memory Tips
DVT Red Flags: Think "HOT and "RED": Homan's sign (cautiously), Oedema (swelling), Tenderness. And Redness, Elevated warmth, Diameter increase.
Prioritization (Delegation, "First", "Immediate"): NCLEX loves to test which patient you see first or which finding requires immediate action. Always choose the option that indicates a threat to Airway, Breathing, or Circulation (ABCs).
Postoperative Complications: DVT/PE, hemorrhage, infection, and atelectasis are classic high-yield topics.
Orthopedic Nursing: Neurovascular assessments (CMS), proper use of devices (immobilizers, traction), and complication prevention (VTE, compartment syndrome) are frequently tested.
Watch Out for Question Variations!
From Symptom to Intervention: "The nurse assesses a positive Homan's sign. Which action should the nurse take first?" (Answer: Notify the provider and have the patient remain on bedrest; do not massage).
Changing the Surgery: The same DVT finding after a total knee replacement would still be the highest priority, but the distractors might include expected findings like knee pain or drainage, making the contrast less obvious.
Focus on Teaching: "Which statement by a client 1 day post-total hip replacement indicates a need for immediate teaching?" (Answer: "My calf is sore; I'll rub it to help the cramp go away.").
Deep Vein Thrombosis — A blood clot that forms in a deep vein, usually in the leg. It is a serious postoperative complication due to risk of dislodgement causing a pulmonary embolism (PE).
Homan's Sign — Calf pain elicited by passive dorsiflexion of the foot. While a classic sign associated with DVT, it is neither sensitive nor specific and its routine use is discouraged due to potential risk of dislodging a clot.
Pulmonary Embolism — A life-threatening condition where a blood clot (often from a DVT) travels to and blocks an artery in the lungs, impairing gas exchange and cardiac output.
Serosanguineous Drainage — A pale pink, watery drainage composed of serum and a small amount of blood. It is a normal and expected type of exudate in the early postoperative period for many surgeries.
Neurovascular Assessment (CMS Checks) — A systematic assessment of an extremity focusing on Circulation (pulse, color, temperature, capillary refill), Movement (motor function, strength), and Sensation (feeling, numbness). Critical after orthopedic or vascular surgery.