A client hospitalized with an open reduction and internal fixation of a fractured femur reports right calf pain. The nurse notes that the right calf is 3.5 cm larger than the left calf with generalized posterior erythema
The right calf is tender to touch. Dorsalis pedis pulse is 3/4+ bilaterally. Which is the priority action by the nurse?
A) Use a Doppler stethoscope to confirm pedal pulses.
B) Notify the healthcare provider of the findings.
C) Prepare to apply a cast to the right leg.
D) Prepare to administer intravenous heparin.
Answer: B
These findings indicate a possible deep vein thrombosis. Notifying the healthcare provider immediately is the first action after assessing these signs and symptoms. If pedal pulse can be palpated, then a Doppler stethoscope is not needed. A Doppler ultrasound test may be ordered by the provider. A cast is not indicated with internal fixation. Intravenous heparin will likely be ordered after the condition is confirmed.
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