A nurse is caring for a client who is experiencing periphera…
A nurse is caring for a client who is experiencing peripheral venous disease. Assessments: 0810: Skin warm and dry. Awake, alert, and oriented x3. Transferred to bed from chair. Sat up in chair x3 hours with legs dependent. Reports pain in legs as 4 on a scale of 0 to 10. Dilated veins noted on bilateral lower extremities. Pitting edema 2+ noted to bilateral lower extremities with hyperpigmentation. Pedal pulses palpable at 2+. Small ulcers noted on bilateral lower legs. Vital Signs Temperature 37.1° C (98.8° F) Heart rate 86/min Respiratory rate 14/min Blood pressure 120/88 mm Hg Oxygen saturation 96% Assessment: 1020: Skin warm and dry. Awake, alert, and oriented x3. Reports pain in legs as 6 on a scale of 0 to 10. Dilated veins noted on bilateral lower extremities. Pitting edema 3+ noted to bilateral lower extremities with hyperpigmentation of the skin. Pedal pulses palpable at 2+. Small ulcers noted on bilateral lower legs. Intermittent pneumatic compression pumps intact bilaterally. Vital Signs Temperature 37° C (98.6° F) Heart rate 76/min Respiratory rate 16/min Blood pressure 138/72 mm Hg Oxygen saturation 95% Which of the following interventions would the nurse include in the plan of care for this client? Select all that apply.