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Questions and Answers
Why do elastic (antiembolic) stockings cause external pressure on the muscles of the lower extremities?
Why do elastic (antiembolic) stockings cause external pressure on the muscles of the lower extremities?
What should clients avoid doing to prevent thrombophlebitis?
What should clients avoid doing to prevent thrombophlebitis?
How often should clients who are immobile change their positions?
How often should clients who are immobile change their positions?
What is the purpose of SCDs and IPCs?
What is the purpose of SCDs and IPCs?
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What should be done to the elastic stockings every 8 hours?
What should be done to the elastic stockings every 8 hours?
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What type of exercises help prevent thrombophlebitis?
What type of exercises help prevent thrombophlebitis?
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What should be documented by healthcare professionals?
What should be documented by healthcare professionals?
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Why are positioning techniques important?
Why are positioning techniques important?
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What is the result of the Valsalva maneuver on the heart?
What is the result of the Valsalva maneuver on the heart?
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What is the purpose of elastic stockings?
What is the purpose of elastic stockings?
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Why is it important to review the client's total protein level?
Why is it important to review the client's total protein level?
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What is the consequence of placing pillows under the knees and lower extremities?
What is the consequence of placing pillows under the knees and lower extremities?
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How often should the client perform antiembolic exercises?
How often should the client perform antiembolic exercises?
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What is the benefit of frequent position changes?
What is the benefit of frequent position changes?
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How often should the skin under the sequential pressure device be assessed?
How often should the skin under the sequential pressure device be assessed?
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Why is it important to increase the client's intake of fluids?
Why is it important to increase the client's intake of fluids?
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What should you avoid doing when a client has thrombophlebitis or deep-vein thrombosis?
What should you avoid doing when a client has thrombophlebitis or deep-vein thrombosis?
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What is a key assessment method for clients prone to thrombosis?
What is a key assessment method for clients prone to thrombosis?
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Why should you turn the antiembolic stockings inside out to the heel?
Why should you turn the antiembolic stockings inside out to the heel?
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What should you do every 8 hours when using antiembolic stockings?
What should you do every 8 hours when using antiembolic stockings?
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Why is it important to avoid pressure at the site of inflammation?
Why is it important to avoid pressure at the site of inflammation?
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What should you do when applying antiembolic stockings?
What should you do when applying antiembolic stockings?
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What is a key positioning technique for clients with thrombophlebitis or deep-vein thrombosis?
What is a key positioning technique for clients with thrombophlebitis or deep-vein thrombosis?
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What should you anticipate giving to clients with thrombophlebitis or deep-vein thrombosis?
What should you anticipate giving to clients with thrombophlebitis or deep-vein thrombosis?
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What is the primary purpose of palpating the apical and peripheral pulses in clients at risk of deep-vein thrombosis?
What is the primary purpose of palpating the apical and peripheral pulses in clients at risk of deep-vein thrombosis?
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Which of the following is a key assessment technique for maintaining urinary and bowel elimination in clients?
Which of the following is a key assessment technique for maintaining urinary and bowel elimination in clients?
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What is the primary benefit of consuming at least 2,000 mL fluid per day, unless intake is restricted, in clients at risk of deep-vein thrombosis?
What is the primary benefit of consuming at least 2,000 mL fluid per day, unless intake is restricted, in clients at risk of deep-vein thrombosis?
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What is the purpose of auscultating the heart at the apex for S3 in clients at risk of deep-vein thrombosis?
What is the purpose of auscultating the heart at the apex for S3 in clients at risk of deep-vein thrombosis?
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What is the primary reason for teaching clients to turn, cough, and breathe deeply every 1 to 2 hours while awake?
What is the primary reason for teaching clients to turn, cough, and breathe deeply every 1 to 2 hours while awake?
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Study Notes
Antiembolic Stockings and Sequential Compression Devices
- Antiembolic stockings promote venous return and prevent thrombus formation by applying external pressure to the muscles of the lower extremities.
- Sequential compression devices (SCDs) have plastic or fabric sleeves that wrap around the leg and secure with hook-and-loop closures, attached to an electric pump that alternately inflates and deflates the sleeve around the leg.
- SCDs and IPCs require a prescription.
Positioning Techniques
- Positioning techniques reduce compression of leg veins and promote blood return to the heart.
- ROM exercises cause skeletal muscle contractions, which promote blood return.
- Specific exercises that help prevent thrombophlebitis include ankle pumps, foot circles, and knee flexion.
Client Education
- Avoid crossing legs, sitting for long periods, wearing restrictive clothing on the lower extremities, putting pillows behind the knees, and massaging legs.
- Perform ankle pumps, foot circles, and knee flexion hourly while awake.
- Increase fluid intake, and change positions frequently.
Complications
- Thrombophlebitis and deep-vein thrombosis are inflammation of a vein (usually in the lower extremities) that result in clot formation.
- Manifestations of thrombophlebitis include pain, edema, warmth, and erythema at the site.
- Complications can lead to pulmonary embolism.
Assessment and Nursing Actions
- Assess skin, circulation, and presence of edema in the legs.
- Measure calf and/or thigh circumference and length of the leg to select the correct size stocking.
- Remove stockings every 8 hours to assess for redness, warmth, or tenderness.
- Avoid pressure at the site of inflammation and anticipate giving anticoagulants.
- Keep stockings clean and dry.
Social Isolation
- Alterations in every physiological system in adults
- Alterations in family and social systems, job identity, and self-esteem
Respiratory System
- Maintain airway patency, achieve optimal lung expansion, and gas exchange
- Mobilize airway secretions
- Assess every 2 hours
- Observe chest wall movement for symmetry
- Auscultate lungs for diminished breath sounds, crackles, or wheezes
- Observe for productive cough, and note the color, amount, and consistency of secretions
Older Adults
- Alterations in balance resulting in a major risk for falls and injuries
- Steady loss of bone mass resulting in weakened bones
- Slower walk with smaller steps
- Decreased coordination
- Increased dependence on staff and family, which can become long-term
- Alterations in functional status
SCDs (Sequential Compression Devices)
- Use tape measure and sequential stockings
- Document the application and removal of the stockings
Pulmonary Embolism
- Potentially life-threatening occlusion of blood flow to one or more pulmonary arteries by a clot
- Clot or embolus often originates in the venous system of the lower extremities
- Manifestations: shortness of breath, chest pain, hemoptysis, decreased blood pressure, and rapid pulse
Nursing Actions
- Reposition every 1 to 2 hours
- Remove abdominal binders every 2 hours and replace correctly
- Use chest physiotherapy
- Auscultate lungs to determine the effectiveness of chest physiotherapy or other respiratory therapy
- Monitor the ability to expectorate secretions
- Use suction if unable to expectorate secretions
- Prepare to give thrombolytics or anticoagulants
- Position client in a high-Fowler's position
- Obtain pulse oximetry
- Administer oxygen
- Prepare to obtain blood gas analysis
- Monitor vital signs frequently
Client Education
- Turn, cough, and breathe deeply every 1 to 2 hours while awake
- Yawn every hour while awake
- Use an incentive spirometer while awake
- Consume at least 2,000 mL fluid per day, unless intake is restricted
Cardiovascular System
- Maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation
- Assess orthostatic blood pressure and pulse (lying to sitting to standing), and assess for dizziness
- Palpate the apical and peripheral pulses
- Auscultate the heart at the apex for S3 (an early indication of heart failure)
Elimination
- Maintain urinary and bowel elimination
- Assess I&O
- Measure orthostatic blood pressure and pulse (lying to sitting to standing), and assess for dizziness
- Observe urine for color, amount, clarity, and frequency
- Palpate the apical and peripheral pulses
- Auscultate bowel sounds
- Observe feces for color, amount, frequency, and consistency
- Palpate for edema in the sacrum, legs, and feet
- Maintain hydration (at least 2,000 mL/day unless fluid is restricted)
- Give a stool softener, laxative, or enema as needed
- Teach bladder and bowel training
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Description
Learn about the proper application and removal of elastic antiembolic stockings, including monitoring circulation and skin, promoting venous return, and documenting the process.
