A nurse is caring for a client who is 24 hr postoperative following a cesarean birth.
Exhibits
Select 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
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as evidenced by
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The Correct Answer and Explanation is:
Condition: Deep Vein Thrombosis (DVT)
Client Finding: Swelling and redness in one leg
Explanation:
Postoperative clients, especially those who have undergone a cesarean section, are at risk for developing Deep Vein Thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, usually in the legs. This risk is notably higher in clients who have had major surgery, are immobile, or have other risk factors such as obesity or a history of clotting disorders.
Deep Vein Thrombosis (DVT):
A cesarean section, being a major surgical procedure, increases the risk of DVT due to several factors. During and after surgery, clients are often immobilized for extended periods, which can lead to reduced blood flow in the lower extremities. This reduced blood flow can cause blood to pool in the veins of the legs, increasing the likelihood of clot formation. Additionally, the surgical incision and subsequent inflammation can further promote clot formation due to increased blood coagulability and vascular damage.
Swelling and Redness in One Leg:
These symptoms are significant indicators of DVT. The affected leg may exhibit swelling, redness, and warmth compared to the other leg. The swelling occurs because the clot obstructs normal blood flow, causing fluid to accumulate in the tissues. Redness and warmth are signs of inflammation and increased blood flow to the area. Pain in the leg, particularly when standing or walking, can also be associated with DVT. These findings warrant immediate attention, as a DVT can lead to serious complications if not treated promptly, including pulmonary embolism (PE), where a clot travels to the lungs.
Prevention and Monitoring:
To mitigate the risk of DVT, nurses should encourage early mobilization, perform regular assessments of the legs, and implement preventive measures such as the use of compression stockings or intermittent pneumatic compression devices. Monitoring for signs of DVT, such as swelling, redness, and pain, is crucial in the early detection and management of this condition. Early intervention can prevent complications and improve overall recovery outcomes for the postoperative client.