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 complaints of pain, increased r
...
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 complaints 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
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