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Ncma219 Course Task 4

Mary has red streaks on both legs along her veins and pain when flexing her foot, indicating possible thrombophlebitis. A nursing care plan was developed to reduce her risk during labor and postpartum. The plan included keeping her legs elevated above heart level, encouraging fluid intake, and applying warm compresses to improve perfusion and reduce swelling. The plan's success would be evaluated after 4 weeks by assessing improved perfusion through equal pulses and capillary refill.

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1K views

Ncma219 Course Task 4

Mary has red streaks on both legs along her veins and pain when flexing her foot, indicating possible thrombophlebitis. A nursing care plan was developed to reduce her risk during labor and postpartum. The plan included keeping her legs elevated above heart level, encouraging fluid intake, and applying warm compresses to improve perfusion and reduce swelling. The plan's success would be evaluated after 4 weeks by assessing improved perfusion through equal pulses and capillary refill.

Uploaded by

Nikoru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NCMA219 LECTURE

COURSE TASK 4
Kiyo, Marynella
Labro, Christell Mae
Lestones, Shaine Aubrey
CASE STUDY
-When Mary returns for a postpartal checkup,
you notice red streaks on both legs along the
course of her veins, and she has pain on
dorsiflexion of her foot. You are concern that
she is developing thrombophlebitis.

-Describe a plan of care that could have


reduces this risk during labor and in the
immediate postpartal period.
NURSING CARE PLAN
BACKGROUND
ASSESSMENT DIAGNOSIS KNOWLEDGE
PLANNING INTERVENTION RATIONALE EVALUATION

• Never massage the skin over


the clotted area because this
An episiotomy • Instruct the client to could loosen the clot, causing
repair is necessary
Subjective in pregnant women
After 4 weeks avoid massaging or a pulmonary or cerebral
rubbing the affected embolism.
Data: who are at risk for of nursing
venous stasis due extremity
to blood vessel
intervention, • Implement bed rest and
elevation of the affected
• She has compression the patient • Elevate the client’s extremity for the client
After 4 weeks
pain in the •Ineffective caused by the
weight of the
will feet and lower legs diagnosed with DVT. It helps

tissue demonstrate above heart level when to reduce interstitial swelling of nursing
dorsiflexion uterus or by
sitting or lying down.
and promote venous return
of her foot. perfusion pressure behind the
improved from that leg. intervention,
knees while the
related to legs are supported perfusion as individually
by stirrups. The • Dehydration increases blood
Objective venous client's
evidenced by • Encourage viscosity and venous stasis, appropriate
Data: blood flow hypercoagulability palpable and increased fluid intake predisposing to thrombus increased
state raises her of 2500 ml/day formation.
interruption chance of
equal unless
perfusion was
• Red streaks as evidenced developing venous peripheral contraindicated.

•Be sure the compresses are demonstrated


on both legs by redness.
thrombus
pulses, good the proper temperature
along the development if she
before applying them. by the patient.
has varicose veins capillary refill, Changes in blood flow may
course of her or is in bed rest.
reduced •Apply warm, moist impair the client's ability to
veins.
compresses or detect temperature extremes.
https://nurseslabs.c edema, and heating pads to the As directed, apply warm
om/postpartum-
thrombophlebitis- erythema. affected extremity as compresses. Use a waterproof
pad to protect the linens from
nursing-care-plans/ ordered. moist heat applications if

feasible.

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