CPNE Study Guide 16th Edition page 472

JG DOB 9/14/37

DX unstable angina, DVT right leg

Information only: renal failure with kidney transplant, telemetry. Left arteriovenous shunt

Safety – siderails x2

No BP, IV, blood draws in Left arm

Mobility-

Bedrest with BRP

Reposition x 1 during PCS

Elevate legs on 1 pillow

Fluid Management-

I & O

Parenteral: 5% Dextrose in water 50 ml/hr ICD

Enteral: Fluids ad lib

Diet: regular with no added salt

Vital Signs: temporal artery temp, apical pulse, BP, Respiration, O2 Sat: report if <92% to primary RN

PVA – lower extemities

Skin assessment – lower legs

Medications:

Cellcept 250 mg po 0830

Protonix 40 mg po 0830

Lasix 40 mg po 0830

Potassium Chloride 40 meq po 0830

Comfort Management – comfort measures

K pad to right calf



Care Plan

#1 ND Ineffective Tissue Perfussion – peripheral venous r/t dx Deep venous thrombosis AEB edema, patient complaints of pain



Goal: patient will have palpable pulses during pcs.



Interventions: 1- peripheral vascular assessment

2- report any deviation form baseline to primary RN



#2 ND Impaired physical mobility r/t DVT AEB {This is a treatment and not a symptom (defining characteristic) of the nursing diagnosis.} forced bedrest



Goal: patient will assist with repositioning once during pcs



Interventions: 1- encourage patient to assist with repositioning

2- elevate legs on 1 pillow