Exhibits

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for correct choices

• Deep vein thrombosis: The client presents with unilateral right lower extremity swelling, warmth, and pain below the knee, all of which are hallmark signs of deep vein thrombosis (DVT). Postoperative immobility, recent hysterectomy, obesity, age, and history of smoking significantly increase the risk of venous thromboembolism.

• Check for pedal pulses and signs of ischemia: Assessing pedal pulses and ischemic changes ensures that arterial circulation remains intact while monitoring for potential complications. This evaluation is essential prior to initiating interventions, including anticoagulation or mechanical therapies, to prevent tissue damage or further vascular compromise.

• Request a prescription for a lower-extremity Doppler flow study: A Doppler ultrasound is the standard diagnostic test to confirm DVT. Timely imaging guides the initiation of anticoagulation therapy and helps prevent clot propagation or embolization. Confirming the diagnosis is crucial for implementing safe and effective treatment strategies.

• Signs of bleeding after anticoagulation initiation: Monitoring for bleeding is essential because anticoagulants are the mainstay of DVT treatment. The client is at risk for hemorrhage due to medication or underlying surgical recovery, and early recognition of bleeding complications prevents serious morbidity.

• PT/INR and platelet count: These laboratory parameters are critical to monitor coagulation status and platelet function, particularly if anticoagulation therapy (e.g., heparin or warfarin) is prescribed. Tracking these values ensures therapeutic effectiveness while minimizing the risk of bleeding complications.

Rationale for incorrect choices

• Cellulitis: Cellulitis typically presents with diffuse erythema, tenderness, and possible fever. While the client has warmth and swelling, the unilateral presentation and postoperative risk factors point toward a thrombotic event rather than a bacterial infection. WBC is only slightly elevated, and systemic signs of infection are minimal.

• Muscle strain: Muscle strains usually occur after acute trauma or overuse and often involve localized pain without significant swelling or warmth. The client’s symptoms developed postoperatively without recent exertion, making a strain unlikely.

• Heart failure: Heart failure often presents with bilateral edema, pulmonary congestion, dyspnea, and elevated BNP. The client’s edema is unilateral and below the knee, with clear lungs and normal oxygen saturation, which does not support a diagnosis of heart failure.

• Implement rest, ice, elevation, compression (RICE): RICE is appropriate for musculoskeletal injuries such as strains or sprains but is not recommended for DVT, as compression and manipulation of the affected extremity could dislodge the clot and precipitate a pulmonary embolism.

• Assess for Homan's sign: Homan’s sign (pain on dorsiflexion of the foot) is not a reliable or specific indicator of DVT and is generally discouraged as a primary assessment tool. Clinical observation and Doppler imaging are preferred.

• Request a prescription for IV furosemide: Furosemide is used to treat fluid overload in conditions like heart failure, not DVT. The client’s symptoms are localized, and there is no evidence of systemic fluid retention requiring diuretics.

• Brain natriuretic peptide (BNP) levels: BNP is used to assess for heart failure. This client has no signs of pulmonary congestion or systemic fluid overload, so BNP monitoring is not indicated in this scenario.

• ECG changes: While ECG is useful for detecting cardiac arrhythmias, it does not provide information regarding lower-extremity venous thrombosis. The client’s cardiac history does not suggest arrhythmia as the primary concern at this time.

• Temperature: The client’s temperature is normal, and there is no indication of systemic infection, so monitoring temperature does not directly assess the progression of DVT.

Rationale:

A. Increased hemoglobin: A rise in hemoglobin is not expected after surgery but also does not suggest a postoperative complication. It may reflect hemoconcentration from mild dehydration or fluid shifts. This finding does not indicate infection, thrombosis, or impaired healing, so it is not a priority concern at this stage.

B. Increased urinary output: Higher urinary output may occur if the client is well-hydrated or receiving IV fluids. This finding does not suggest renal impairment or postoperative complications. As long as urine is clear and the client is stable, increased output is not concerning and requires only routine monitoring.

C. Unilateral leg swelling: One-sided leg swelling is a hallmark sign of deep vein thrombosis, a serious complication after pelvic surgery due to venous stasis and immobilization. A DVT can progress to pulmonary embolism, posing immediate danger. The finding requires prompt evaluation and intervention to prevent life-threatening complications.

D. Mild pain at the surgical site: Mild incisional pain is expected on postoperative day three as tissues heal and inflammation decreases. This finding is typical and manageable with analgesics. As long as pain is not severe or accompanied by fever, redness, or purulent drainage, it does not indicate a complication.