The nursing process is a systematic method used by nurses to provide effective patient care. It consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. For a patient with known Diffuse Proliferative Glomerulonephritis (DPGN) who is experiencing lower left leg swelling suggestive of Acute Deep Vein Thrombosis (DVT), here’s how the nursing process may be applied:
1. Assessment
Objective Data:
- Measure and compare circumferences of both legs.
- Check for edema, warmth, erythema, or tenderness in the left leg.
- Assess for any history of recent immobilization, surgery, or use of oral contraceptives.
- Review laboratory results (e.g., kidney function tests, coagulation profile).
Subjective Data:
- Obtain the patient’s description of pain, if any, in the affected leg.
- Gather history regarding onset, duration, and any precipitating factors related to the swelling.
2. Nursing Diagnosis
Based on the assessment data, potential nursing diagnoses may include:
- Impaired Tissue Perfusion related to obstruction of venous flow due to DVT.
- Ineffective Peripheral Tissue Perfusion related to thrombus formation.
- Excess Fluid Volume related to nephrotic syndrome secondary to DPGN.
3. Planning
Goals:
- The patient will report a decrease in leg swelling within 48-72 hours.
- The patient's peripheral circulation will improve, as evidenced by normalized leg circumference and warmth to the touch.
- The patient will verbalize understanding of condition and treatment options.
4. Implementation
Nursing Interventions:
- Monitor Vital Signs: Observe for signs of pulmonary embolism (sudden dyspnea, tachycardia, chest pain).
- Assess Extremities: Continue to monitor and document changes in swelling, color, temperature, and pain.
- Educate the Patient: Teach the patient about DVT, its potential complications, and importance of early detection and treatment.
- Administer Medications: Administer anticoagulant therapy as ordered (e.g., heparin, warfarin) and monitor for side effects.
- Promote Mobility: Encourage ambulation as tolerated to enhance venous return unless contraindicated.
- Facilitate Compression Therapy: Use graduated compression stockings if ordered to help reduce swelling.
- Maintain Adequate Hydration: Encourage fluid intake to prevent dehydration unless contraindicated.
5. Evaluation
Assess Outcomes:
- Reassess for reduction in edema and improvement in leg symptoms.
- Evaluate the patient’s understanding of preventive measures and treatment plan.
- Monitor lab results for effectiveness of anticoagulant therapy and adjust nursing care accordingly.
Considerations
- Risk Assessment: Consider the patient's risk factors for DVT, including any immobility due to medical condition or previous surgeries.
- Collaboration with Healthcare Team: Engage with other healthcare providers (physicians, pharmacists, physical therapists) to ensure comprehensive care.
- Patient Education on Self-Management: Discuss lifestyle changes that may decrease the risk of DVT, including regular activity, hydration, and recognizing warning signs.
Conclusion
The nursing process is a dynamic tool that can greatly aid in the management of patients with DPGN and DVT. Individualized care based on thorough assessment and continuous evaluation is essential for achieving positive patient outcomes.