Page 1714 - Saunders Comprehensive Review For NCLEX-RN

as tissue necrosis, infection, or
pulmonary embolus.

C. Deep vein thrombophlebitis

1. Assessment
a. Calf or groin tenderness or pain with or
without swelling
b. Positive Homans’ sign may be noted;
however, false-positive results are
common, so this is not a reliable
assessment measure.
c. Warm skin that is tender to touch
2. Interventions
a. Provide bed rest as prescribed.
b. Elevate the affected extremity above the
level of the heart as prescribed.
c. Avoid using the knee gatch or a pillow
under the knees.
d. Do not massage the extremity.
e. Provide thigh-high or knee-high
antiembolism stockings as prescribed
to reduce venous stasis and assist in
the venous return of blood to the heart;
teach how to apply and remove
stockings.
f. Administer intermittent or continuous
warm, moist compresses as prescribed.
g. Palpate the site gently, monitoring for
warmth and edema.
h. Measure and record the circumferences
of the thighs and calves.
i. Monitor for shortness of breath and
chest pain, which can indicate
pulmonary emboli.
j. Administer thrombolytic therapy (tissue
plasminogen activator) if prescribed,
which must be initiated within 5 days
after the onset of symptoms.
k. Administer heparin therapy as
prescribed to prevent enlargement of
the existing clot and prevent the
formation of new clots.
l. Monitor activated partial
thromboplastin time during heparin
therapy.
m. Administer warfarin as prescribed
following heparin therapy when the
symptoms of deep vein

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