NR 304 Annie Laduke [complete solution]
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NR 304 Annie Laduke SCENARIO OVERVIEW: Annie Laduke is a 32-year-old Native American female with no significant health history. This morning, she presented to her provider’s office with complaint... s of pain, increased redness, and warmth of the right lower leg in the calf area. She was directly admitted to the inpatient medical unit by her provider. 1) Based on what you’ve learned about the nursing process, describe one applicable nursing diagnosis, treatments, and nursing considerations for this diagnosis. Applicable Nursing Diagnosis Ineffective peripheral tissue perfusion Applicable Treatment Anticoagulants or Thrombolytic agents Nursing Considerations Pulmonary embolism 2) What are some non-pharmacological measures that can be used for pain relief in care for this patient? a. Heat or Cold Therapy i. Helps with pain, tenderness, and possible beginning of swelling b. Aromatherapy i. Helps psychological with the pain and what is currently occuring 3) Describe the components of a peripheral vascular nursing assessment. a. Inspect and Palpate the Arms i. Profile sign (checking for early clubbing of nails) ii. Check Capillary Refill (index of peripheral perfusion and cardiac output) iii. Note any present of scars (needle tracks/linear scars) iv. Palpate both radial pulses (note rate, rhythm, equal force) v. Palpate both radial pulses if arterial insufficiency is suspected vi. Check Epitrochlear lymph nodes in the depression vii. Modified Allen Test to see adequate collateral circulation before cannulating the radial artery if needed. b. Inspect and Palpate the Legs i. Inspect both legs (skin color, hair distribution, venous return, size and any skin lesions/ulcers) ii. Palpate both legs for temperature working from legs down to feet. iii. Palpate the femoral, popliteal, dorsalis pedis, and posterior tibial on both legs iv. Check for pretibial edema [Show More]
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