Fundamentals of Nursing Q 521
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A. Impaired gas exchanges related to increased blood flow.
B. Fluid volume excess related to peripheral vascular disease.
C. Risk for injury related to edema.
D. Altered peripheral tissue perfusion related to venous congestion.
Correct Answer: D. Altered peripheral tissue perfusion related to venous congestion.
Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke.
Option A: Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is commonest in the lower limb below the knee and starts at low-flow sites, such as the soleal sinuses, behind venous valve pockets.
Option B: Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Nurses need to educate the patients on the importance of ambulation, being compliant with compression stockings, and taking the prescribed anticoagulation medications.
Option C: Option C may be warranted but is secondary to altered tissue perfusion. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.