Basic Care and Comfort

The nurse is caring for a client with deep vein thrombosis (DVT). Which should be included in the plan of care?

Posted on by NCLEX.ME Nurse
  • bed rest with the affected extremity elevated
  • bed rest with the bed in reverse Trendelenburg
  • walking slowly in the hall with assistance to prevent pneumonia
  • sitting up in the chair for all meals and during visitation time
Number 1 is correct.
Clients with DVT should be on bed rest to prevent movement of the DVT and pressure changes that occur with walking and other weight-bearing activities. The affected extremity should be elevated. Placing the bed in reverse Trendelenburg will increase pressure on the affected extremity. Walking is contraindicated for clients with DVT; while preventing hospital-acquired pneumonia is important, client safety takes priority over pneumonia prevention at this time. The client may still use an incentive spirometer and practice coughing and deep breathing to clear the lungs without ambulating. Sitting up in a chair is also contraindicated until the DVT has resolved and the health care provider has prescribed activity for the client.
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NCLEX.ME Nurse