A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate
The nurse should implement measures to prevent what complication?
A) Aoritis
B) Deep vein thrombosis
C) Thoracic aortic aneurysm
D) Raynaud's disease
Ans: B
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Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
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