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.

Module 5 Case Study(s):

 

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: BP 140/68, pulse 64, temperature 98.7°F, respirations 20

 

Oxygen saturation 93% on room air

 

Lungs clear all lobes

 

Bowel sounds are present in all 4 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 2+ 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 to 10

 

Lisinopril 20 mg PO daily

 

Bisacodyl 10 mg PO daily

 

 

 

Use the Sample Venous Thromboembolism Protocol PDF for the following questions.

 

 

 

. Include any references used to research your answer in APA format, with proper citations and references. Please number your answers.

 

1.What do you suspect is occurring with D.R.? What data were used to make this determination?

2.What are the priority nursing interventions at this time?

3.Using SBAR, what would you report to the provider?

4.What diagnostic studies would be used to determine the existence, location, and extent of a DVT?

5.What risk factors for development of a DVT does D. R. have?

6.What measures can be taken to prevent a DVT in an at-risk patient?

 

Case Study Progression

 

D.R. is diagnosed with a deep vein thrombosis (DVT) in the left lower extremity.

 

7.What treatment do you anticipate for D.R.?

8.What is the most serious complication of a DVT, and how would you monitor D.R. for this complication?

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