THE CARDIOVASCULAR SYSTEM & THE BLOOD
Client Profile Mr. Luke is a 58-year-old man who is currently a client on an outpatient rehabilitation
unit following a left total knee replacement (TKR) five days ago. This afternoon
during physical therapy he complained that his left leg was unusually painful when
walking. His left leg was noted to have increased swelling from the prior day. He
was sent to the emergency department to be examined.
Case Study Mr. Luke’s vital signs are temperature 98.1°F (36.7°C), blood pressure 110/50,
pulse 65, and respiratory rate of 19. His oxygen saturation is 98% on room air.
The result of a serum D-dimer is 7 μg/mL. Physical exam reveals that his left
calf circumference measurement is ¾ of an inch larger than his right leg calf
circumference. Mr. Luke’s left calf is warmer to the touch than his right. He will
have a noninvasive compression/doppler flow study (doppler ultrasound) to rule
out a DVT in his left leg.
Questions
1. The health care provider in the emergency department chooses not to assess Mr. Luke for a positive Homan’s sign. What is a Homan’s sign and why did the health care provider defer this assessment?
2. Discuss the diagnostic cues gathered during Mr. Luke’s examination in the emergency department that indicate a possible DVT.
3. Discuss Virchow’s triad and the physiological development of a DVT.
4. The nurse who cared for Mr. Luke immediately following his knee surgery, when writing the postoperative plan of care, included appropriate interven- tions to help prevent venous thromboembolism. Discuss five nonpharmacological interventions the nurse included in the plan.
5. Discuss the common pharmacologic therapy options for postsurgical clients to help reduce the risk of a DVT.
6. Mr. Luke’s noninvasive compression/doppler flow study (doppler ultrasound) shows a small thrombus located below the popliteal vein of his left leg. While a positive DVT is always of concern, why is the health care provider relieved that the thrombus is located there and not in the popliteal vein?
7. Mr. Luke was admitted to the hospital for observation overnight. He is being discharged back to the rehabilitation unit with the following prescribed discharge
instructions:
(a) bed rest with bathroom privileges (BRP) with elevation of left leg for 72 hours;
(b) thromboembolic devices (TEDs);
(c) continue with enoxaparin 75 mg subcutaneously (SQ) every 12 hours;
(d) warfarin sodium 5 mg by mouth (PO) per day starting tomorrow;
(e) nicotine transdermal system 21 mg per day for 6 weeks, then 14 mg per day for 2 weeks, and then 7 mg per day for 2 weeks;
(f) acetylsalicylic acid 325 mg PO once daily;
(g) prothrombin time (PT) and international normalized ratio (INR) daily;
(h) occult blood (OB) test of stools;
(i) have vitamin K available; and
(j) vital signs every four hours.
Provide a rationale for each of the prescribed discharge instructions.
9. Prioritize five nursing diagnoses to include in Mr. Luke’s plan of care when he returns to the reha- bilitation unit.
10. What is an inferior vena cava (IVC) filter and for which clients is this filter indicated?
11. Discuss the symptoms the nurse at the rehabilita- tion center should watch for that could indicate that Mr. Luke has developed a pulmonary embolism (PE).
12. Because of the DVT, Mr. Luke is at risk for post- phlebitic syndrome (also called post-thrombotic syndrome or PTS). Discuss the incidence, cause, symptoms, and prevention of this potential long-term complication.
