Key Problem/Nursing Dx: Key Problem/Nursing Dx: Key Problem/Nursing Dx:

Priority #1 Priority #2 Priority#3

Risk for Ineffective tissue Risk for fall related to Risk for deficient fluid
perfusion related to deep deep vein thrombosis volume related to
vein thrombosis decreased fluid intake
Supporting Data: Supporting Data: Supporting Data:

 DVT prophylaxis  DVT  Dry mucous

 SCD to help  1-person assistant membrane
circulation  bed rest until DVT  Dry skin and dry lips
 Patient in bed rest resolved  Total oral intake is
with Foley catheter  swelling knee 250ml which is less
until DVT resolve. than recommended
 History of heart fluid intake 2000 mL
failure daily.
 Output greater than
input.

Reason for needing Health Care (Medical Dx/Surgical Procedure):

Deep vein thrombosis and pulmonary embolism

Plan of Care
Complete this section for the highest priority problem
The patient will maintain maximum tissue perfusion to vital organs as evidenced by
present and strong peripheral pulses and vitals within patient’s normal range during
hospitalized.
Nursing Interventions (List 4 specific)

 Assist with position changes and ROM exercises.

 Monitor arterial blood gas levels, pulse oximetry and oxygenation panels, as
ordered.
 Check for optimal fluid balance. Administer IV fluids as ordered.
 Check respiratory and absence of work of breathing.
Intervention Rationale

 Assessing ABG will help the nurse ensure that if patient has hypoxia, cyanosis
or other risk of complications related to ineffective tissue perfusion. Maintain
a baseline vital signs can help nurse to compare the changes of vitals (Hinkle &
Cheever, 2013).
 Sufficient fluid intake maintains adequate filling pressures and optimizes
cardiac output needed for tissue perfusion (Hinkle & Cheever, 2013).
 Repositioning patient and help patient do ROM exercise can prevent venous
stasis and further circulatory compromise (Hinkle & Cheever, 2013).
 Cardiac pump malfunction and ischemic pain may result in respiratory
distress. Nevertheless, abrupt or continuous dyspnea may signify
thromboembolic complications (Hinkle & Cheever, 2013).

References

Hinkle, J. L., & Cheever, K. H. (2013). Brunner & Suddarth’s textbook of medical-surgical nursing. 13th

ed. Philadelphia, PA, United States: Lippincott Williams and Wilkins.