Care Plan by: Venezuela, Carmel Marie C.

Date: September 3, 2021

Patient: Mr. L

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Diagnosis: Short term: Independent: After 4 hours of
Ineffective tissue After 4 hours of nursing - Maintain - Hydration nursing intervention:
- “sakit ako tiil perfusion related to intervention, patient will: adequate prevents an
dili ko hapit increased coagulability hydration. increased - Patient pain
maka lakaw of blood as evidenced - Patient verbalizes viscosity of scale was
kay ni hubag” by increased leg or demonstrates blood, which decreased to 6
- “ngut ngut e warmth and swelling normal sensations contributes to on a scale of 0-
lihok sa tiil” on (L) leg and movement as venous stasis 10
appropriate. and clotting. - Patient
Objective: Scientific basis: - Patient identifies - Encourage - Clients usually showed signs
Thrombophlebitis is factors that bedrest and require bed of slightly
- Patient’s vital the inflammation of improve circulation. keep the rest until increased
signs: the vein wall resulting - Patient engages in affected leg symptoms are comfort when
T: 36.7 in the formation of a behaviors or actions elevated as relieved. The moving or
BP: 110/50 thrombosis (blood to improve tissue indicated. affected leg standing up
P: 65bpm clot) that may perfusion. should be
RR: 19bpm interfere the normal Long term: elevated to a After 8 hours of
- Patient’s D- blood flow through the After 8 hours of nursing position above nursing intervention:
dimer is vessel. Typically, intervention: the heart to
7μg/mL venous decrease - Patient was
- Patient’s (L) leg thrombophlebitis - Client will use swelling. able to engage
appears occurs in the lower pharmacological - Provide warm, - Heat promotes in his desired
swollen and and moist heat to comfort and activities
extremities. It may
warm to touch nonpharmacological the affected reduces - Patient
also occur in
- Skin on (L) leg pain relief site. inflammation. maintained
appears superficial veins such strategies. - Apply below- - Compression optimal
darkened as cephalic, basilic, - Client will engage in knee stockings peripheral
- using the and greater desired activities compression enhance tissue
universal pain saphenous veins. without an increase stockings as circulation by perfusion on
assessment in pain level. prescribed. providing a affected leg.
tool, patient’s - Client will report Ensure that the graduated
pain scale is at satisfactory pain stockings are pressure on the
8 when trying control at a level the correct size affected leg to
to walk less than 3 to 4 on a and are applied help return the
scale of 0 to 10. correctly. venous blood
- Client will maintain - Asses vital signs to the heart.
optimal peripheral every 4 hours
tissue perfusion in Dependent:
the affected - Administer
extremity, as prescribed
evidenced by strong medications by
palpable pulses, the physician: - Helps prevent
reduction in and/or - Enoxaparin the formation
absence of pain, 75mg q12H of blood clots.
warm, and dry - This medication
extremities, and - Warfarin is used to treat
adequate capillary sodium 5mg PO blood clots and
refill. q.d to prevent new
- clots from
forming in the
body.
- Used for the
- Acetylsalicylic treatment of
acid 325mg PO pain and fever
q.d due to various
causes.
- Helps with
- Administer blood clots and
vitamin K healing
wounds.

Collaborative: - To help
- Assess in detecting
prothrombin bleeding
time and disorders or
international excessive
normalized clotting
ratio with the disorder.
physician - Prevents
- Promote venous stasis
active/passive and further
ROM exercises circulatory
with pt s/o compromise.
1. Three nursing diagnosis:
- Impaired physical mobility
- Ineffective tissue perfusion related to increased coagulability of blood
- Risk for bleeding r/t thrombolytic therapy