Page 483 - Saunders Comprehensive Review For NCLEX-RN

A. Description: Loss of circulatory fluid volume, which usually is
caused by hemorrhage
B. Assessment: Similar to assessment findings in hemorrhage

C. Interventions

1. If shock develops, elevate the legs.
2. Notify the surgeon.
3. Determine and treat the cause of shock.
4. Administer oxygen, as prescribed.
5. Monitor level of consciousness.
6. Monitor vital signs for increased pulse or decreased
blood pressure.
7. Monitor intake and output.
8. Assess color, temperature, turgor, and moisture of the
skin and mucous membranes.
9. Administer IV fluids, blood, and colloid solutions, as
prescribed.

If the client had spinal anesthesia, do not elevate the legs any

higher than placing them on the pillow; otherwise, the diaphragm
muscles needed for effective breathing could be impaired.
VIII. Thrombophlebitis
A. Description
1. Thrombophlebitis is an inflammation of a vein, often
accompanied by clot formation.
2. Veins in the legs are affected most commonly.

B. Assessment

1. Vein inflammation
2. Aching or cramping pain
3. Vein feels hard and cord-like and is tender to touch.
4. Elevated temperature

C. Interventions

1. Monitor legs for swelling, inflammation, pain,
tenderness, venous distention, and cyanosis; notify
the surgeon if any of these signs are present.
2. Elevate the extremity 30 degrees without allowing any
pressure on the popliteal area.
3. Encourage the use of antiembolism stockings as
prescribed; remove stockings twice a day to wash and
inspect the legs.
4. Use a sequential compression device as prescribed (see
Fig. 15-3).
5. Perform passive range-of-motion exercises every 2
hours if the client is confined to bed rest.

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