An older adult client is receiving a continuous intravenous heparin infusion for a newly diagnosed left lower extremity deep vein thrombosis (DVT). The nurse is developing a plan of care focusing on the client's basic comfort, mobility, and safety. Which intervention is the most appropriate to include in the plan of care?
- APlace a rolled towel directly under the client's left knee to provide joint support and relieve discomfort
- BInstruct the unlicensed assistive personnel (UAP) to apply sequential compression devices (SCDs) to both legs to prevent further stasis
- CReassure the family that sudden, mild confusion is a normal physiological response to the stress of hospitalization in older adults
- Assist the client with supervised ambulation once therapeutic anticoagulation levels have been confirmedAnswer
Answer
The correct answer is to assist the client with supervised ambulation once therapeutic anticoagulation levels have been confirmed.
Current evidence-based practice guidelines recommend early ambulation for clients with an acute deep vein thrombosis (DVT) once therapeutic anticoagulation levels have been achieved. Ambulation promotes venous return, decreases edema, and alleviates pain without increasing the incidence of pulmonary embolism. Strict bedrest is no longer routinely recommended as it can contribute to further venous stasis and functional decline.
Step-by-Step Solution
Key Concept
Evidence-based mobility and comfort interventions for acute deep vein thrombosis