A nurse is caring for a client who is postoperative following vascular surgery.
Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
A.
Dull, aching calf pain.
B.
Positive Kernig’s sign.
C.
Soft, pliable calf muscle.
D.
Positive Homan’s sign.
The correct answer and Explanation is:
The correct answer is A. Dull, aching calf pain.
Explanation:
Following vascular surgery, it is important for nurses to be vigilant for signs of thrombus formation (blood clots) as these can lead to serious complications, including deep vein thrombosis (DVT) or pulmonary embolism.
Dull, aching calf pain is a common symptom associated with thrombus formation, particularly in the deep veins of the legs. This pain often results from the increased pressure and inflammation in the affected vein. In the postoperative period, patients may be at increased risk of developing a thrombus due to reduced mobility and other factors. Therefore, monitoring for such pain is crucial for early detection and treatment.
Positive Kernig’s sign is not typically related to thrombus formation. It is more often associated with meningitis. Kernig’s sign involves resistance to the extension of the knee while the hip is flexed, which indicates irritation of the meninges.
A soft, pliable calf muscle is generally a sign of normal muscle tone and is not indicative of a thrombus. In fact, a thrombus could lead to a hardening or tenderness of the calf muscle.
Positive Homan’s sign involves pain in the calf upon dorsiflexion of the foot and is a traditional test for DVT. However, it is important to note that Homan’s sign is not always reliable and can be inaccurate. It has been criticized for its lack of sensitivity and specificity. Modern practice tends to rely more on imaging studies (like ultrasound) and clinical assessment rather than Homan’s sign alone.
In summary, dull, aching calf pain is a more direct indicator of potential thrombus formation and should prompt further investigation and management to prevent complications.