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
...
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
Helps with pain, tenderness, and beginning of swelling
b. Aromatherapy
Helps psychologically with the pain.
3) Describe the components of a peripheral vascular nursing assessment.
a. Inspect and Palpate the Arms
Profile sign (checking for early clubbing of nails)
Check Capillary Refill (index of peripheral perfusion and cardiac output) Note any present of scars (needle tracks/linear scars)
Palpate both radial pulses (note rate, rhythm, equal force) Palpate both radial pulses if arterial insufficiency is suspected Check Epitrochlear lymph nodes in the depression
Modified Allen Test to see adequate collateral circulation before cannulating the radial artery if needed.
b. Inspect and Palpate the Legs
Inspect both legs (skin color, hair distribution, venous return, size and any skin lesions/ulcers)
Palpate both legs for temperature working from legs down to feet.
Palpate the femoral, popliteal, dorsalis pedis, and posterior tibial on both legs Check for pretibial edema
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