RNSG 1260

Level 2 Onsite
Clinical Homework

Student Name: Iris Barrera Date of Care: 1/26-1/27

Give a HISTORY of your patient present condition. Include pertinent information since admission.
Patient’s admitting diagnosis:
DVT

Patient’s past medical diagnosis/history:

DVT, Colon Cancer, Rectal Bleeding, HTN, Severe Constipation

Presenting clinical and/or diagnostic manifestations and history of patient’s hospital stay:

Left foot presented with +2 pitting edema with accompanying foot drop. Dx Expected DVT in distal
portion of Tibial Artery. Upon Admission patient VS were Elevated temp 100.1 BP 170/98, HR 87, RR 21
. Pain Scale 8/10.

Day of Admission: 1/22/11 Age decade: 83

Post-operative Day: none Gender: Female

MEDICAL DIAGNOSIS
Directions: Write the pathophysiology process in your own words. Include your resource for the
information. Connect your patient data with the disease process by underlining patient’s presenting risk
factors, clinical manifestations, complications, medical treatments, and nursing interventions.
Each week, you need to write up a different medical diagnosis.

PATHOPHYSIOLOGY DISEASE NAME: Deep Vein Thrombosis

The three major components of Deep Vien Thrombosis aka Thrombophlebitis are venous
stasis, vessel wall injury, and a hypercoagulable state. The degree to which each aspect
contributes to the formation of a thrombus is unknown. The formation of a thrombus is called
thrombogenisis; it’s the activation of coagulation in areas of reduced blood flow. DVT of the
lower extremity statistically begins in the deep veins of the calf around the valve cusps. When
there is an alteration in the vessel wall a substance within the wall (vWF) combines with collagen
causing platelets to adhere at the site of injury. The platelets then release granules that further
the clotting process. PAF (platelet activating factors) causes the platelet cytosol to increase its
Ca+ concentration. Increased Ca+ activates protein kinase-c which activates phospholipase A2
altering the glycoprotein membrane and increasing its affintity for binding to fibrinogen. During
the coagulation cascade extrinsic factor pathway ( primary mechanism of action) forms
prothrombinkinase , and enzyme that converts prothrombin to thrombin. Thrombin converts
fibrinogen to fibrin the main component of the clot. Thrombin is the most important substance in
terms of feedback activation roles. Clot formation causes vascular fluid to leak into the interstitial

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space decreasing peripheral venous circulation, furthering the inflammatory response of the
adjacent tissues, thereby causing the perception of pain.

Regulating factor inhibit further propagation of clot formation. Antithrombin degrades thrombin
and other factors; Heparin Sodium increases its adhesion to these factors making it a primary
method of treatment. Common complications of DVT are pulmonary embolism and chronic
venous insufficiency.

RISK FACTORS
Advanced age
Sedentary lifestyle
DM
Daily intake of Analgesic narcotics (ie. Tramadol HCL 25mg bid) increases venous stasis.
Chronic constipation increases intravascular pressure

CLINICAL MANIFESTATION
temp 100.1 BP 170/98, HR 87, RR 21
Pain Scale 8/10.
+3 pitting edema (left foot)
Foot drop
Lethargy

COMPLICATIONS
Risk for pulmonary embolism, chronic venous insufficiency, hemorrhage (anticoagulant therapy),
fluid deficit (increased renal perfusion). Actual complications: 1/26-1/27 none

DIAGNOSTIC STUDIES
(Directions: Include the purpose and expected abnormalities due to the medical diagnosis)
Labs 1/27/11. All WDL pt 5days post admin. Patient Admission 1/22/11
PT 2.2 evaluates the ability of the blood to clot
PTT 69 evaluates the function of all coagulation factors
INR 2.6 used to monitor the effectiveness of blood thinning drugs
WBC 8020 evaluates ability of body to fight infection
RBC 4.4 indicative of tissue perfusion and oxygenation
HCT 45.2 total volume of RBC in blood
HGB 14.3 bloods ability to carry oxygen
MAG 2.0 effects ATP and intracellular K+
K+ 3.6 effect fluid electrolyte balance
NA+ 142 effects fluid and electrolyte balance
BG 204 effect blood osmolarity
BUN 21.1 used to evaluate a person’s general health status

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MEDICAL TREATMENTS
IV therapy discontinued by 1/27
Heparin Sodium 7ml/hr
Warfarin Sodium 2mg po daily
NS 0.9% IV Primary
Cephalexin 500mg po bid
Morphine Sulfate 2mg PRN IVP
Tramadol HCL 50mg q6h PRN

NURSING MANAGEMENT
Directions: Include nursing implications to patient care and nursing interventions required to care
for clients with this medical diagnosis.
Padded boot (foot drop)
TED hoses
Affected limb elevated
Block support (foot drop)
Provide effective pain management/ evaluate
Encourage adequate caloric intake
Encourage adequate hydration
Reposition client /Assess affected limb q2h (skin, pedal pulses)
Ensure safe and timely admin. Of IV therapy
Assist with hygiene (ADLs)
Patient teach importance of above interventions and risk for fall.

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