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Question

Difficulty: EasyReduction of Risk Potential

A nurse is caring for a client who is 1 day postoperative following a total abdominal hysterectomy. Which of the following interventions should the nurse implement to reduce the risk of developing a deep vein thrombosis (DVT)? Select all that apply.

  1. Apply sequential compression devices (SCDs) to the lower extremities while the client is in bed.Answer
  2. Encourage the client to perform active range-of-motion exercises of the legs and feet hourly.Answer
  3. C
    Place a firm pillow directly under the client's knees to provide comfort and support.
  4. D
    Maintain the client on strict bed rest for the first 48 hours to promote incisional healing.
  5. Administer the prescribed prophylactic subcutaneous enoxaparin.Answer
  6. F
    Delegate the initial assessment of the client's calves for warmth and redness to the unlicensed assistive personnel (UAP).

Answer

The correct interventions are to apply sequential compression devices, encourage hourly active range-of-motion leg exercises, and administer the prescribed prophylactic subcutaneous enoxaparin.
Interventions to prevent deep vein thrombosis focus on mitigating Virchow's triad. Sequential compression devices and active leg exercises mechanically promote venous blood return to the heart, preventing stasis. Enoxaparin provides pharmacological prophylaxis by interrupting the coagulation cascade.

Step-by-Step Solution

1
Identify the clinical risk presented in the scenario.
The client is 1 day postoperative. Surgical trauma and subsequent immobility place the client at a high risk for developing a deep vein thrombosis (DVT) due to venous stasis and hypercoagulability.
Recognizing the components of Virchow's triad (venous stasis, endothelial injury, and hypercoagulability) is essential for implementing appropriate preventative measures.
2
Select interventions that actively promote venous return and prevent coagulation.
Applying SCDs, performing active leg exercises, and administering prophylactic anticoagulants (enoxaparin) directly counteract blood pooling and clot formation.
Mechanical and pharmacological prophylaxis are the standard of care for risk reduction of venous thromboembolism in postoperative clients.
3
Eliminate actions that increase DVT risk or violate nursing scope of practice.
Placing pillows under the knees, maintaining strict bed rest, and delegating initial assessments to a UAP are incorrect and potentially harmful actions.
Knee pillows and bed rest exacerbate venous stasis. Furthermore, the registered nurse must retain responsibility for all initial assessments and clinical judgments.

Key Concept

Postoperative Deep Vein Thrombosis (DVT) Prevention
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Topics

Reduction of Risk Potential

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