Case Study: Deep Vein Thrombosis Patient Profile

In: Nursing

Case Study: Deep Vein Thrombosis Patient Profile D.R. is a 74-year-old obese Hispanic woman who is…

Case Study: Deep Vein Thrombosis
Patient Profile
D.R. is a 74-year-old obese Hispanic woman who is in the third postoperative day after an open reduction internal fixation (ORIF), for repair of a left femoral neck fracture after a fall at home.
Subjective Data
States pain in her left hip is a 4 to 5 on a 1-to-10 scale
States pain in her left calf area is a 3 on a 1-to-10 scale
Objective Data
Physical Examination
Vital signs: blood pressure 140/68, pulse 64, temperature 98.7° F, respirations 20
Oxygen saturation 93% on room air
Lungs clear all lobes
Bowel sounds arepresent in all four quadrants
Apical pulse: 64, irregular
Alert and oriented to person, place, and time
Skin warm to touch bilateral lower extremities, slight erythema left lower extremity
No edema right lower extremity, 2+ left lower extremity
Pedal pulses 3+ right lower extremity, 1+ left lower extremity
Calf circumference: right, 8 cm; left, 10 cm
Left hip wound has staples; no signs or symptoms of infection
Last bowel movement was four days ago
Interprofessional Care
Medication Administration Record
Morphine sulfate 2 mg IVP every two hours as needed for pain scale 6-10
Lisinopril 20 mg PO daily
Bisacodyl 10 mg PO daily
Discussion Questions
What do you suspect is occurring with D.R.? What data were used to make this determination?
What are the priority nursing interventions at this time?
Using SBAR, what would you report to the provider?
What diagnostic studies would be used to determine the existence, location, and extent of a DVT?
What risk factors for development of a DVT does D. R. have?
What measures can be taken to prevent a DVT in an at-risk patient?

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