The nurse on the medical-surgical unit is caring for a 69-ye…
The nurse on the medical-surgical unit is caring for a 69-year-old male client with pain and swelling of the right lower extremity. Nurses’ Notes Day 1. 0930 Admission note: Client admitted from the Emergency Department via stretcher and transferred to bed. Client is alert and oriented. Saline lock IV in the R antecubital vein patent. Right lower extremity noted to have 2+ pedal edema, pain 8/10 in right calf. Warmth noted to right calf. Positive Homan’s sign to R lower extremity noted. Client has positive motion and sensation to right lower extremity. Right pedal pulse weak, palpable. R lower extremity elevated on 2 pillows. VS: BP 145/82, HR 96, RR 16, Temp 36.7C (98F). Client ordered to be on complete bedrest. Client made aware. 1010: Radiology called results of right leg ultrasound: Positive for deep vein thrombosis of the right posterior tibial vein. Provider made aware. New orders pending. 1030: Patient begins to experience SOB, anxiety, O2 Sat 83%, RR 38, HR 108, BP 149/88, patient seems to be apprehensive and anxious Which of the following actions should the nurse anticipate including in the patient’s plan of care? Select all that apply