Question

Nurse has guillian barre pt. flaccid paralysis of both legs, history of coronary artery bypass 3 wks ago, 20 yr history of HTN and high cholesterol, recently diagnosed with T2DM. nurse prepares to apply anti-embolism stockings to both legs. which priority action does nurse implement?

- bilateral pretibial edema
- palpate both calves for pain
- ask the reason for stocking application
- bilateral pedal pulse strength

Answer 1

The nurse's priority before applying anti-embolism stockings is to assess for potential contraindications and complications by checking for signs of poor circulation or deep vein thrombosis, such as by palpating for calf pain and evaluating bilateral pedal pulses.

Step-by-step explanation:

Before applying anti-embolism stockings, the nurse's priority should be to assess for any contraindications and complications associated with their use in the patient's current condition. Given this patient's history of recent coronary artery bypass surgery, long-standing hypertension (HTN), high cholesterol, and recent diagnosis of type 2 diabetes mellitus (T2DM), there is an increased risk for peripheral vascular disease and poor circulation, which might be exacerbated by the stockings.

The presence of bilateral pretibial edema may indicate issues with fluid overload or deep vein thrombosis (DVT), which needs to be assessed before applying compression. Palpating both calves for pain is essential to rule out DVT since causing additional harm to a patient with an existing clot could be dangerous. Therefore, determining bilateral pedal pulse strength is critical to ensure that there is adequate blood flow to the lower extremities. If pulses are weak or absent, the use of compression stockings may worsen perfusion to the feet. A thorough assessment and understanding of the patient's overall condition is necessary to prevent any adverse events related to the application of anti-embolism stockings.