Question

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

1. Palpate for pedal pulses.
2. Ask the client about pain in the calf area.
3. Assess for the presence of vaginal hematoma.
4. Ask the client to ambulate and assess for the presence of pain.

Answer 1

In assessing for thrombophlebitis in a postpartum patient, a nurse should palpate for pedal pulses, enquire about calf pain, and assess pain during ambulation; however, asking about calf pain is a common direct method for detecting possible thrombophlebitis.

Step-by-step explanation:

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. In assessing for thrombophlebitis, which is an inflammation of the veins that could lead to clot formation, several actions can be taken. Thrombophlebitis is a concern postpartum due to increased clotting factors during pregnancy and the pressure the fetus places on veins in the legs, which can hinder venous return. In a practical setting, to assess for thrombophlebitis, the nurse should:

1. Palpate for pedal pulses to ensure good blood flow in the feet, although this alone does not confirm or rule out thrombophlebitis.
2. Ask the client about pain in the calf area, which is a common symptom associated with thrombophlebitis.
3. Have the client ambulate and assess for the presence of pain to see if pain increases with activity, which can be an indicator of a clot.

However, it is important to note that while all of these actions can be part of a thorough assessment, the most direct assessment technique for thrombophlebitis in the calf would generally center on looking for signs of DVT, such as calf pain, tenderness, swelling, and warmth.