Question

The nurse is caring for a client at risk for thrombosis. what is an appropriate nursing action when evaluating this client?

Answer 1

Examine the legs for color, capillary refill time, and tissue integrity when evaluating a client at risk for thrombosis.

Deep vein thrombosis is a condition when a blood clot (a thrombus) develops in a vein (DVT). This can dislodge and go into the bloodstream prior to reaching the lungs, where it can cause a pulmonary embolism (PE), a blockage in the pulmonary circulation that can be fatal.

In both primary and secondary care, nurses will be required to recognize and screen for deep vein thrombosis, therefore they must have the ability to evaluate the patient's clinical risk.

To utilize the Wells screening equipment properly, the leg must be extensively checked. Nurses ought to:

• Find any asymmetry or unilateral swelling, skin changes, wounds, oedema, erythema, or varicosities on both legs by keeping an eye out for them.
• Before palpating both legs, feel for heat with your hand over the suspected DVT location. Also feel for pain and any cracks in the skin.
• DVT symptoms can include deep venous system-specific pain.
• The difference in the calves' circumference is measured 10 cm below the tibial tuberosity.
• A DVT is the likely diagnosis if there is a discrepancy of more than 3 cm from the asymptomatic side.
• Check capillary refill time is between two and three seconds; this is a sign of peripheral perfusion by palpating the foot pulses.

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