An older client recovering from a total hip replacement is demonstrating edema and pain in the operative limb. Which intervention does the nurse perform first?
1. Assess the client's lower extremity pulses.
2. Situate the client comfortably with pillows.
3. Evaluate the client's respiratory status.
4. Determine if anticoagulant medication is prescribed.
1. Assess the client's lower extremity pulses.
Explanation: 1. Problems that can develop in the operative limb after surgery include hematoma, pinched circulation, and deep vein thrombosis. The nurse first ensures that the client has a pulse in the affected limb.
2. The client should be assisted to a comfortable and safe position to rest while interventions are prescribed. Once a possible DVT is identified, the client should not ambulate until the healthcare provider has cleared it.
3. The client does not have any current symptoms of respiratory issues indicating a pulmonary embolism. The nurse does a respiratory assessment at this time to establish a firm baseline for comparison should the client develop a PE.
4. A post-orthopedic surgery client should usually have an anticoagulant prescribed. If the client does, it is perhaps not being effective, if DVT symptoms are clear. The nurse needs this information when calling the doctor with the assessment findings.
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