Nursing Case Studies Worksheet

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Identifying information: 76 y/o Caucasian male Source and reliability: Friend to a family member, seems reliable Chief Compliant: Left leg pain and swelling x 3days History of present illness: He first felt some pain on the left leg from the groin down to the feet three days ago, onset sudden. Reports pain felt intense and sharp-like, localized to the left leg; rated as a 9 on a numeric scale of 1-10. Pain is worse with movement, standing and bending of knee especially calf. Reports no relief with OTC Tylenol ES. Denies any change in exercises, prolonged standing/sitting, or bed rest. Denies any cough, fever or chills. On day two, reports swelling and warmth on left leg with same intensity of pain. By day three, left leg was extremely painful…show more content…
DVT left lower extremity 2. Thrombophlebitis 3. Cellulitis PLAN Diagnostic Doppler Ultrasonography: Often the test of choice in detecting DVT. With the use of sound waves, showing the velocity of blood flow through the veins and arteries, the diagnosis of DVT can be ascertained. Impedance Plethysmography and Compression ultrasound scanning of the left leg veins also useful in aiding diagnosis of DVT and Thrombophlebitis. CT or MRI scans: Provide visual images that indicate the presence of blood clots D dimer blood test: Typically elevated in patients with DVT and Thrombophlebitis Blood test: To check for hypercoagulability to include the following: Primary coagulation studies, PT, APTT, Fibrinogen Liver Enzymes, renal function and electrolytes Urinalysis and occult blood Tx: Coumadin 5mg 1 tablet oral every evening for DVT Fragmin 12,500 units inject subcutaneously every 24hours daily x 7days for DVT Tylenol ES 1-2 tablets oral every 6hours as needed for pain D/C Aspirin 81mg, 1 tablet oral daily Blood tested 2x weekly or as needed based on INR levels to assess effect of anticoagulant therapy Elevate legs, maintaining slight knee flexion, while in…show more content…
Pt. Ed/Referral/Follow-up: Inspect legs and feet daily and report any unusual bleeding or findings Immediately seek medical help when experiencing sudden-onset dyspnea (SOB), rapid breathing, chest pain worsened by breathing, cough and hemoptysis (coughing up blood) or bleeding of any kind. Decrease use of alcohol and coffee Take medicines as prescribed and adjusted based on INR levels Take prescribed analgesics as needed for pain control and report any ineffectiveness Reduce ingestion of dark-green/leafy vegetables and other foods contradicted with anticoagulant Decrease foods with high vitamin K content and eat consistent amounts of foods low in vitamin K. Food category includes: broccoli spinach, cabbage, celery, cucumber, mustard greens, carrots, Asparagus, lettuce, okra, turnip greens Maintain good hydration and healthy, balanced diet Schedule follow-up appointments with Lab and MD to maintain therapeutic INR levels and prevent complications of DVT Teaching and FU with MD on GDS result of mild depression to prevent further severe episodes Health Maintenance: Seek medical advice before embarking on any long distance travel especially long haul

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