V-Sim pain assessment

The nurse is providing education to a hospitalized patient on methods to prevent peripheral vascular complications. Which would the nurse include? (Select all that apply.)

-Avoid prolonged sitting with your legs in a dependent position. -Perform active range-of-motion exercises (ROM) of your feet and ankles while in bed. -Avoid crossing your legs. -You may have to take an anticoagulant by injection. Patient education for the prevention of ineffective peripheral tissue perfusion includes the following: performing active range-of-motion exercises (ROM) of the feet and ankles while in bed; avoiding crossing the legs; avoiding prolonged sitting with the legs dependent; and education on potential anticoagulant therapy, side effects to report, and the importance of blood coagulation testing. Wearing comfortable socks and shoes while ambulating, and relaxation techniques to reduce stress and pain, are not measures to prevent impairment in peripheral tissue perfusion.

The nurse is aware that a nursing diagnosis for Mona Hernandez is Impaired Physical Mobility. The nurse would evaluate the patient for which of the following complications related to impaired mobility? (Select all that apply.)

-Deep vein thrombosis -Pressure ulcers -Atelectasis For a patient who has a nursing diagnosis of impaired physical mobility, the nurse should evaluate for pressure ulcers, deep vein thrombosis, or atelectasis. Orthostatic hypotension (not hypertension) may be seen in a patient with prolonged immobility. Candida infections may be caused by antibiotic therapy.

Components of a peripheral vascular assessment include which of the following? (Select all that apply.)

-Palpation of feet and legs for temperature -Inspection for lesions or ulcers -Palpation of the posterior tibial pulses -Inspection and palpation for edema Peripheral vascular assessment of the lower legs includes inspection for lesions and ulcers. The nurse should palpate the temperature of the feet and legs, palpate all pulses, and inspect and palpate for edema. Although the femoral pulse popliteal pulses, may be auscultated for bruits if arterial occlusion is suspected, popliteal pulses are assessed by palpation. Palpation of bones and joints is an aspect of musculoskeletal assessment.

The nurse is caring for a patient who has developed a deep vein thrombosis in the left lower extremity. Which are appropriate nursing interventions to implement for a patient with a deep vein thrombosis? (Select all that apply.)

-Perform regular assessments on the affected leg for changes in color, pulses, pain, or sensation. -Provide prescribed pain medication as needed and monitor effects. -Administer anticoagulants and oxygen therapy as prescribed, and monitor effects. Performing continued lower extremity assessment for changes in color, pain, sensation, or movement is important because a large deep vein thrombosis can cause compartment syndrome in the affected extremity. Administer anticoagulants and oxygen therapy as prescribed and monitor effects to prevent further blood clot formation and maintain oxygenation. Provide prescribed medications for pain as needed and monitor effects. Nutritional and fluid intake is encouraged, not limited. Although elastic compression stockings and sequential compression devices are important preventive measures for deep vein thrombosis, they should be removed on diagnosis of deep vein thrombosis; they may be reapplied once the pain and edema of the affected extremity have resolved. The application of cold compresses is not recommended for treatment of deep vein thromboses.

Based on the initial patient data, Mona Hernandez's report of pain, and physical assessment findings, the nurse performs a focused respiratory status on the patient. In addition to the patient's diagnosis of pneumonia, the nurse recognizes which of the following as the most important rationale for assessing the patient's respiratory status?

A serious complication of deep vein thrombosis is pulmonary embolus. Each year in the United States, approximately 900,000 people develop venous thromboembolism (VTE), a medical condition that includes pulmonary embolus (PE) and deep vein thrombosis (DVT). PE resulting from VTE accounts for about 200,000 U.S. deaths every year. According to the Agency for Healthcare Research and Quality, PE is the most common preventable cause of death in U.S. hospitals, and the prevention of VTE should be the primary strategy to improve patient safety in the hospital. The nurse's assessment of respiratory status does not determine the presence of bacterial pneumonia. This is done through diagnostic testing such as imaging or by sputa culture. Mrs. Hernandez's VS and SpO2 readings were stable in the scenario and do not indicate a worsening status. Although a history of smoking is a risk factor for peripheral arterial disease, it is not a rationale for performing a respiratory assessment on the patient.

The nurse is assessing a patient for clinical manifestations of venous insufficiency. Which of the following is a characteristic of venous insufficiency?

Aching, cramping pain Aching or cramping pain is characteristic of venous insufficiency. Dry and shiny skin, thickened nails, and cool temperature of skin are characteristics of arterial insufficiency.

The nurse is preparing to perform a peripheral vascular assessment on a patient with a ulcer on the right foot. Which general principle of physical assessment is most important for the nurse to remember in performing a peripheral vascular assessment?

Always compare arms and legs bilaterally Always compare the patient's arms and legs bilaterally. Better objective data can be gained by assessing a particular feature on one extremity and then the other. For example, evaluate the dorsalis pedis pulse on the right foot and compare the findings to those on the left foot. Auscultation of the femoral pulse for bruits may be performed if arterial occlusion is suspected, but it is not part of the basic peripheral vascular assessment of the legs. Palpation of temperature is performed by using the dorsum of the fingers and hands. The patient sits or lies on the examination table for peripheral vascular assessment.

Which of the following nonpharmacologic interventions is most important for the nurse to initiate to prevent deep vein thrombosis from developing in hospitalized patients?

Apply sequential compression stockings Prevention of deep vein thrombosis (DVT) is a core measure for acute care hospitals. Nurses should verify that the patient's risk of developing deep vein thrombosis has been assessed and the patient is receiving DVT prophylaxis as soon as possible after admission, according to facility protocols. Nonpharmacologic interventions to prevent DVT are early and frequent ambulation, intermittent pneumatic compression devices, and the use of sequential compression stockings. Applying warm compresses may be used in the treatment, not the prevention, of DVT. Range-of-motion exercises and leg elevation may be done to assist in the prevention of DVT but are not the priority intervention.

A patient reports a new onset of leg pain. Which of the following assessment would the nurse perform first?

Ask the patient specific questions about the pain The nurse begins assessment of a new health concern by collecting subjective data. The nurse should interview the patient using specific, probing questions that assess the character, onset, location, duration, severity, pattern, and associated factors related to the concern. Palpation of the legs for areas of warmth and tenderness, assessment of weight-bearing ability, and inspection of the feet and legs for the presence of sores or lesions are important aspects of the objective data collection in peripheral vascular assessment.

The nurse is performing a peripheral vascular assessment on a patient and notes cramping pain, redness, and warmth in the left lower extremity. The nurse recognizes these clinical manifestations as most likely related to which of the following?

Deep vein thrombosis Alterations in peripheral vascular perfusion associated with deep vein thrombosis include the following: altered vital signs, motion or mobility changes, pain in extremities, sensory changes in extremities, skin color changes, skin temperature changes, superficial venous dilation, and unilateral edema or swelling with a difference in calf diameters. Assessment findings with arterial occlusion would include weak or absent peripheral pulses. Fluid volume overload is associated with pitting edema. Complications from diabetes are related to peripheral artery disease and include the following: a decrease in peripheral pulses, dry and shiny skin, cool-to-cold temperature, thickened nails, acute pain, loss of hair on the feet and toes, and circular deep sores.

The nurse is caring for a patient who is experiencing physical immobility related to an acute illness. A priority nursing assessment would be to monitor the patient for which of the following?

Deep vein thrombosis Priority assessments should focus on the potentially serious complications of immobility, such as deep vein thrombosis. It is also important for the nurse to monitor for all complications of immobility (including constipation, joint contractures, and exertional dyspnea); however, these are not priority assessments.

The nurse has provided patient education to Mona Hernandez and explained the blood tests and procedures that were ordered. Which of the following would be important additional education to provide to the patient in relation to deep vein thrombosis?

Explain the importance of reporting worsening calf pain, chest pain, edema, or dyspnea For a patient with suspected deep vein thrombosis, be sure to cover the importance of reporting worsening edema, calf pain, chest pain or dyspnea, because these are all symptoms associated with this condition. Increasing vitamin K in the diet may interfere with the action of anticoagulant medications such as warfarin. Use of the incentive spirometer is appropriate for the patient's diagnosis of pneumonia, but is not an intervention related to prevention or treatment of deep vein thrombosis. Maintenance of normal blood glucose levels is an important aspect in the prevention of peripheral arterial disease.

Which of the following is a factor that increases the risk for deep vein thrombosis for Mona Hernandez?

Immobility Risk factors for deep vein thrombosis (DVT) include the following: malignancy, presence of a central venous catheter, surgery (especially orthopedic), trauma, pregnancy, oral contraceptive use, hormone replacement therapy, immobilization, heart failure, and history of previous DVT. Mona Hernandez was experiencing decreased mobility related to dyspnea during her hospitalization. Her age, history of smoking, and diagnosis of pneumonia didn't increase her risk for DVT.

Which nursing diagnoses would the nurse identify as the priority for Mona Hernandez based on her assessment findings?

Ineffective Peripheral Tissue Perfusion During the scenario, Mona Hernandez was experiencing the clinical manifestations of deep vein thrombosis. Ineffective Peripheral Tissue Perfusion is an actual problem and is the top priority based on the patient's new assessment findings. Risk for Impaired Skin Integrity and Risk for Infection are also appropriate nursing diagnoses for a patient with deep vein thrombosis, but these are not actual problems based on assessment findings, thus not the priority problem. Impaired Gas Exchange is an actual problem for Mona Hernandez based on her diagnosis of pneumonia. However, it is not the first priority because the patient's vital signs were within normal limits, her respiratory assessment was unchanged, and her pneumonia was reported as slowly improving.

The nurse is performing a peripheral vascular assessment on the lower extremities of a patient diagnosed with diabetes. Which assessment is important for the nurse to include?

Palpate dorsalis pedis pulse Physical assessment of the peripheral vascular system includes palpation of peripheral pulses, such as the dorsalis pedis pulse. Assessment of the patellar reflex and knee flexion is part of neuromuscular assessment. Although inspection for thickened nails is indicated, inspection for fungus is not indicated in peripheral vascular assessment.

The nurse is performing a peripheral vascular assessment on the lower extremities of a patient with 4+ edema of the left foot. The nurse is unable to palpate a dorsalis pedis pulse. Which is the best initial response by the nurse?

Use a Doppler ultrasound device to detect the pulse. It may be difficult or impossible to palpate a pulse in an edematous foot. A Doppler ultrasound device may be useful in this situation as it receives ultrasound waves to detect blood flow. If the pulse cannot be palpated, further circulatory assessment (such as evaluation of temperature and color) is warranted to determine the significance of the absent pulse before calling the health care provider. Taking the patient's blood pressure is not the best assessment of peripheral perfusion. Elevating the foot may decrease peripheral circulation and therefore decrease pulse strength.

The nurse is performing an assessment of the peripheral vascular system and notes edema in one of the lower extremities. Which are causes of unilateral edema of the lower extremities?

Venous stasis and obstruction Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf. It is usually caused by venous stasis due to insufficiency or obstruction. Congestive heart failure and prolonged standing may cause bilateral edema. Being in a cast for a prolonged time may cause muscular atrophy of the extremity.

The nurse is preparing to call the health care provider regarding Mona Hernandez's new onset of redness, swelling, and pain in the left lower extremity. In addition to using SBAR format in communication, which of the following is most important for the nurse to do to prevent communication errors when telephoning the health care provider about the patient's change in condition?

Write down and read back any orders received or information shared Nurses must be able to verbally share and report assessment findings to other health care professionals in an effective manner. To prevent communication errors, it is important for the nurse to do the following: use a standardized method of communication such as SBAR; communicate face-to-face if possible; allow time for the receiver to ask questions; validate what the receiver has heard by questioning or asking for a summary; and write down and read back any information received. The other answer options are not needed to prevent communication errors.