CHANGE IV TUBING 24-48 hours, IV … If I were going to pick among ONLY nursing interventions I'd say 1) Ambulate and 2) ankle pumps. Maintain an acceptable sleep/wake pattern, achieve socialization, and complete self-care independently. Helps to diagnose the presence of thrombus in conditions such as deep vein thrombosis, pulmonary embolism, or stroke. Nursing outcomes & evaluation. Clinical trials. The impaired blood flow causes ineffective tissue perfusion. prevention of DVT, PE, MI, open heart surgery, A-FIB, anticoagulant in dialysis and transfusion procedures, treatment of DIC. -elevate the leg A Used to diagnose disseminated intravascular coagulation (DIC). Deep-vein thrombosis (DVT) and thrombophlebitis ☐Client may be asymptomatic. Post-operative nursing care and patient education begins prior to the surgical procedure during the preoperative phase of the perioperative process. Deep vein thrombosis (DVT) and pulmonary embolism are significant causes of hospital-related morbidity and mortality (Spencer et al, 2008). A deep vein thrombosis (DVT) is a blood clot that forms within the vein. Prevention of deep vein thrombosis that may lead to pulmonary embolism following knee or hip replacement surgery. D-dimer (also called fibrin degradation fragment) This is a blood test that assesses for fibrin degradation fragment (d-dimer), it’s a fibrin degradation product. Thrombus formation can lead to a pulmonary embolism, which is a, A VTE is a blood clot believed to form as a result of venous stasis, endothelial injury, or, Thrombophlebitis refers to a thrombus that is ___________. A shortening of muscles due to lack of use. More Information. However, there are certain interventions that can be done to help prevent thrombosis in patients. Nursing interventions. The affected extremities become cyanotic and very painful. • Literature review completed in CINAHL database with the following keywords: DVT, nursing, compression garments, attitudes of health personnel, venous thromboembolism, venous thrombosis, nursing knowledge, compression garments, practice patterns, attitudes of health personnel, risk assessment as a guide to thrombosis prophylaxis. Assessment findings. STUDY. hemothorax Gravity. Write. A DVT is the formation of a blood clot within the deep veins. bleeding, hemorrhage; gums, petechiae, black tarry stools, decrease in hematocrit, check periodically for sign of decreasing clots. Administer Enoxaparin (Lovenox) and/or Warfarin (Coumadin) Both SubQ and oral anticoagulant therapy are used as prophylactic (prevention) therapy. You can get DVT if you have certain medical conditions that affect how your blood clots. Airway, Breathing and Circulation- a blood clot can impair ABC’s, clots can break and travel to the bloodstream and lodge into lungs and cause pulmonary embolism. Nursing intervention? Clients at risk for injury from heat/cold applications: Very young, fair-skinned, and older clients have fragile skin. In my experience, patients with a DVT will be on heparin or enoxaparin in the hospital and then transitioned to an oral anticoagulant such as warfarin, Eliquis or Pradaxa for long-term therapy. Continue expected development and achieve physical and mental stimulation. Elastic stockings, or TED's, help maintain external pressure on the _____ of the lower extremities and promote blood return to the heart. Nursing Interventions include: Treating an ineffective cough with assistive cough, pneumobelts, turning, increased acitivity, and chest physical therapy Alternative modes of ventilation, such as IPPB treatments, oxygen therapy, ventilator support, and tracheostomy, if needed Aggressive treatment of infections Nursing Interventions. This nursing best practice guidelineis a comprehensive document providing resources necessary for the support of evidence-based nursing practice. •Apply warm, moist compresses to right leg using a 2-hour-on, 2-hour-off schedule around the clock. A Question of Practice. Clinical manifestations of pulmonary embolisms: Prepare to give thrombolytics or anticoagulants as prescribed. Ultrasound. A wandlike device (transducer) placed over the part of your body where there's a clot sends sound waves into the area. Cold applications are inappropriate for clients with: Make sure heat and cold application orders include: Ice bag, Ice collar, ice glove, or a cold pack, Assess heat and cold treatment sites every _____ to _____ minutes. View 2019 comp ati.docx from NUR 202 at Owens State Community College. def not. Although it usually affects the leg veins (Fig 2), DVT can occur in the upper extremities, cerebral sinuses, hepatic, and retinal veins. Fibrosis of connective tissue that prevents normal movement of a muscle or joint. Nursing diagnosis. Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. Neurogenic Shock Nursing Interventions and Treatments. Goal: Manage patient’s ABCS (Airway, Breathing, Circulation & Spine) Protect the spine: Keep spine immobilized (don’t want to cause any more damage and decrease perfusion to the spine) Example: cervical collar, log rolling patient during transport, using a backboard. ☐Warmth, edema, and induration and hardness over the involved blood vessel. keep feet flat on floor when sitting. care component is completed. Patient teaching. Nursing/independent interventions.2. Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures. (The HA T3 Musculoskeletal deck covers: Unit 2 Ch. Rachel Garcia Heparin- When and how to administer heparin? This education focuses on the interventions that will be done for the client post operatively to prevent the commonly occurring complications associated with surgery and surgical procedures. D-dimer blood test review for nursing students! ☐Calf or groin pain, tenderness, and a sudden onset of edema of the extremity. The legs are the most common sites of DVT. w/just diagnosed with pulmonary embolism? Deep vein thrombosis is a part of a condition called venous thromboembolism. Early ambulatory, limb elevation, compression, ROM excersizes, monitor for the early signs of a DVT. It can partially or completely block blood flow back to the heart and damage the one-way valves in your veins. NURSING INTERVENTIONS FOR CLIENTS TAKING BETA BLOCKERS: Make sure that you monitor the client’s blood pressure, heart rate and rhythm, before administering the beta blocker. Some of these interventions are pharmacological and others are non-pharmacological, and some of these interventions are consented to by the client and other clients may refuse these interventions. A DVT is a blood clot that forms deep in your veins, most often in your leg. Discharge Instructions for Deep Vein Thrombosis (DVT) A blood clot or thrombus that forms in a large, deep vein is called a deep vein thrombosis (DVT). You'll also have a physical exam so that your doctor can check for areas of swelling, tenderness or discoloration on your skin. Which of the following nursing interventions should the nurse include in the plan of care? Learn. •Administer prescribed analgesics and evaluate effectiveness. PTT, occult blood in … aPTT PT INR CBC PLATELETS. Deep Vein Thrombosis (DVT): A blood clot in a deep vein causing partial or complete blockage of blood flow. Treatment of and reduction in risk of recurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE). The following interventions are planned and implemented for Mrs.Hipps. Terms in this set (8) Patho of DVT. The therapeutic range is between 2 and 3. This is called a pulmonary embolus (PE). Physician/dependent interventions3. Start learning today for free! You should wear these stockings during the day for at least two years, if possible. Dear Other Guys, Stop Scamming Nursing Students. PO (Adults): 2.5 mg twice daily, initiated 12–24 hr post-operatively (when hemostasis is achieved) continued for 35 days after hip replacement or 12 days after knee replacement; Concurrent use of strong inhibitors of both CYP3A4 and P-gp– Avoid concomitant use. This can cut off the flow of blood to part or all of the lung. Promoting _____ _____ is another key component of reducing the complications of immobility. A DVT is a blood clot that forms deep in your veins, most often in your leg. Then for for interventions for a "risk for" diagnosis, thinks of the things that you can do as a nurse to prevent them. 25 in ATI Anticoagulant . PLAY. A. Deep vein thrombosis (DVT) is a medical condition which involves the formation of a blood clot called thrombus in a deep vein/s in the body. Warfarin side effects; Request an Appointment at Mayo Clinic. The priority framework that I am using to come to this decision is the ABC’s. Prevention of Deep Vein Thrombosis Following Knee or Hip Replacement Surgery. Bony prominences are more sensitive to heat. -elevate the leg A prevention. Client Education. ATI Active Learning Template (Therapeutic Procedure) - Phototherapy Description of Procedure: UV-light is used to facilitate the conversion of unconjugated bilirubin (UCB) in the newborn to its conjugated form so it can be fecally excreted via bile. are able to eat, talk, and ambulate: Simple face mask: FiO2 – 40% to 60% at flow rates of 5 to 8 L/min -may be more comfortable than a nasal cannula: Partial rebreather mask: FiO2 – 60% to 75% at flow rates of 6 to 11 L/min -allows pt. Unformatted text preview: ACTIVE LEARNING TEMPLATE: Nursing Skill Alexis Nunez a sequential compression device SKILL NAME__Applying _____ STUDENT NAME_____ 40 REVIEW MODULE CHAPTER_____ Description of Skill The SCD sleeve is wrapped around the calf muscle and provides a gentle compression or squeeze to promote the flow of blood back to the heart and helps prevent … As a nurse you want to be familiar with this blood test because it can help the physician determine if a patient may have a blood clot. 31 Musculoskeletal and Neurosensory Systems pp.303-318). early ambulation(ROM) don't elevate with a pillow. Medication. Informed Consent: The process for obtaining voluntary agreement to health care based on full knowledge of the proposed health care and on the person’s capability to make an informed decision. History: Recent surgery or injury; sensitivity to heparin; hyperlipidemia; pregnancy ; Physical: Peripheral perfusion, R, stool guaiac test, PTT or other tests of blood coagulation, platelet count, renal function tests; Interventions. Nursing Interventions and Client Education:-Client ID, name, and blood types must be verified by 2 nurses-Prior to administration, assess baseline vital signs, including temp-Establish IV access, 18-guage or larger catheter-Must have 0.9% sodium chloride primed tubing 4. s/s bleeding. A nursing care plan guides the nurse for how to provide care for the client ; A nursing diagnosis is based on a judgment call made by the nurse about the client's condition. B. Massage the affected extremity. DVT (deep vein thrombosis) NCLEX questions for nursing students! Test. Patients will need to have frequent blood draws to monitor their INR if taking Coumadin. (Taylor et al.,2015. Normal Lab Value for D-Dimer < 500 ng/mL; Serum Electrolytes. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Deep vein thrombosis is a serious condition because blood clots in the veins can break loose, travel through the bloodstre… Deep vein thrombosis can cause leg pain or swelling, but also can occur with no symptoms.Deep vein thrombosis can develop if you have certain medical conditions that affect how your blood clots. Venous insufficiency occurs secondary to incompetent valves in the deeper veins of the lower. Deep vein thrombosis can cause leg pain or swelling, but may occur without any symptoms. Enoxaparin (Lovenox), heparin, and warfarin (Coumadin) Tracheotomy suctioning should be applied when? Nursing Study Guide for Deep Vein Thrombosis. As the nurse, you will want to be familiar with the prevention of a blood clot (venous thromboembolism VTE), management of a DVT, and anticoagulation therapy. Learn Other Hematologic Disorders - Disorders - Hematologic System - ATI® for Nursing RN faster and easier with Picmonic's unforgettable videos, stories, and quizzes! ... 5 Steps to Writing a (kick ass) Nursing Care Plan. obesity and weight reduction. Instruct the client to stay in bed and turn from side to side every 2 hours To reduce compression of leg veins, teach clients to avoid: When promoting venous return, ROM exercises are performed _____ while the client is awake. Mastering The DVT Nursing Care Plan in Just 10 Minutes! The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. A _____ _____ is the occlusion of blood flow to one or more of the pulmonary arteries by a clot. Benton, Linda MPS, CCRN, CAN. According to Virchow’s Triad, a blood clot can form within the vein for several reasons. Action. I also agree about Homan's, that one is tricky. Nursing interventions DVT, PE. Collaborative interventions Term: Summarize diabetic diet: Definition: balanced intake of protein, carbs, and fat; total calories 1800 Term: summarize pureed diet: Definition: clear and full liquid diet plus pureed meats, pureed fruits and veg, and scrambled eggs Term: Electrolytes are minerals that are involved in some of the important functions in our body. Adjust dose according to coagulation test results performed just before injection (30 min before each intermittent dose or q 4–6 hr if continuous IV dose). Symptoms to check for with heat or cold treatments: Most heat or cold applications are used from _____ to _____ minutes. A nurse is caring for a client who is admitted with a DVT of the left leg. D-dimer blood test review for nursing students! Which of the following interventions should the nurse include in the client’s plan of care? Which of the following is the priority nursing action? Flashcards. The nurse should also assess the lungs sounds for signs of rales and rhonchi. A 36-year-old postpartum client is at increased risk of deep vein thrombosis based on her age and a history of a previous DVT. A blood clot in your legs can also happen if you don't move for a long time, such as after you have surgery or an accident, when you're traveling a long distance, or when you're on bed rest. To help maintain a patent airway in a client on bed rest, you should teach the client to use an _____ _____ while awake. Health professionals caring for patients with advanced illness should develop skills for communicating with patients, and their families and carers. This material taken from ATI, Fundamentals of Nursing: Unit 4 Ch. Thrombophlebitis/deep vein thrombosis is an inflammation of a vein (usually in a lower extremity) that results in _____ formation. Learn Other Hematologic Disorders - Disorders - Hematologic System - ATI® for Nursing RN faster and easier with Picmonic's unforgettable videos, stories, and quizzes! prevents conversion of fibrinogen and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III (ATI, p. 191) IV infusion IV bolus cannot be used interchangeably (unit for unit) with LMWHs or heparinoids. 40 Mobility and immobility pp. Abstract; Author Information Low-molecular-weight heparin is a viable option. DVT Deep Vein Thrombosis Nursing Diagnosis Interventions NCELX Review and Care Plans. Which of the following nursing interventions is most appropriate to prevent DVT in this client?. Immobilize the patient and initiate bed rest to reduce risk of clot mobilization. Method for Mastering Nursing Pharmacology. prevention of VTE, DVT, and PE. Deep Vein Thrombosis (DVT) nursing NCLEX review lecture about the symptoms, treatment, pathophysiology, and nursing interventions. involved extremity above the heart to increase venous return and decrease edema. Deep Vein Thrombosis (DVT): A blood clot in a deep vein causing partial or complete ... 6.0 INTERVENTIONS 1) Interventions where a patient has contraindications to anticoagulation therapy for treatment: a) This guideline should not be used and all mobility issues/orders should go through ... MEDSURG Nursing, 18 (5): 293-9 10. AJN The American Journal of Nursing: February 2000 - Volume 100 - Issue 2 - p 85. Lab/diagnostics. •Elevate legs,maintaining slight knee flexion,while in bed. administration of an anticoagulants – eg. leg, a serious condition that requires immediate interventions. Spell. A nurse on the postpartum unit is planning care for a client who has thrombophlebitis. To help prevent swelling associated with deep vein thrombosis, wear them on your legs from your feet to about the level of your knees. Patient teaching. Periodic ischemic attacks affecting the extremities of the body, especially the fingers, toes, ears, and nose. As a nurse you want to be familiar with this blood test because it can help the physician determine if a patient may have a blood clot. As the nurse, you will want to be familiar with the prevention of a blood clot (venous thromboembolism VTE), management of … Deep vein thrombosis can cause leg pain or swelling but also can occur with no symptoms. Nursing interventions. Nursing diagnosis. Therapeutic range aPTT: 1.5–2.5 times control. rub leg? Keep the head up of bed. 1. aptt normal? elevate legs frequently and use stockings. due to thromphelbitis of larger deeper vein, 3 factors include venous stasis, endothelial damage & hypercoagulability of the blood. Remove compression stockings and reapply them at least _____ a day. Think backwards when care planning. Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs. The nurse caring for the patient with DVT risk factors has an important role in prevention, which may include serving on the multidisciplinary committee to establish a protocol for DVT prophylaxis. Anticoagulation with heparin and warfarin is the standard treatment for DVT; LMWH has been demonstrated to be safe, effective, and convenient, and has allowed patients to be managed in an outpatient setting (Eikelboom and Baker, 2001) or with a daily subcutaneous injection of LMWH. Always check compatibilities with other IV solutions. • Literature review completed in CINAHL database with the following keywords: DVT, nursing, compression garments, attitudes of health personnel, venous thromboembolism, venous thrombosis, nursing knowledge, compression garments, practice patterns, attitudes of health personnel, risk assessment as a guide to thrombosis prophylaxis. _____ _____ are designed to maintain mobility and prevent or minimize complications of immobility. may break loose (embolus) heparin warfarin lovenox labs. Besides, monitoring is gee golly great, but it doesn't really prevent something that's fairly likely to happen without intervention. _____ is the inability to move freely and independently at will. Depending on how likely you are to have a blood clot, your doctor might suggest tests, including: 1. The principles of body mechanics are based on: Body systems that can be affected by immobility: Maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions. Venous thromboembolism (VTE), also known as deep vein thrombosis (DVT), is a serious health risk for hospitalized and immobile patients. To reduce the risk of thrombus development: The proper order to apply elastic stockings: A maneuver in which a person tries to exhale forcibly with a closed glottis (windpipe) so that no air exits through the mouth or nose as, for example in lifting a heavy weight; The Valsalva maneuver impedes the return of venous blood to the heart. Cutaneous stimulation in the form of ______ and ______ applications helps relieve pain and promote healing. emboli originating from deep vein thrombosis (DVT) Highest nursing priority for pt. This quick review will highlight the main concepts you need to know about a D-dimer lab test. Reduce skin injury and maintain metabolism. Nursing considerations Assessment. I also agree about Homan's, that one is tricky. -> Do not use cold application. C. … This quick review will highlight the main concepts you need to know about a D-dimer lab test. What are the Actions of Enoxaparin (Lovenox) Nursing Pharmacology Considerations? But first, we need to know more about the DVT. According to Virchow's Triad, a blood clot can form within the vein for several reasons. ROM exercises promote blood return and can include: Immobile clients should perform leg exercises, increase their ______ ______, and change positions frequently. Monitor the effectiveness of treatment. To diagnose deep vein thrombosis, your doctor will ask you about your symptoms. Nursing interventions. Used to diagnose blood clots or Disseminated Intravascular Coagulation (DIC). Picmonic is research proven to increase your memory retention and test scores. Start learning today for free! These attacks are brought on by arterial constriction due to extreme cold or emotional stress. Question Answer; Nasal cannula : FiO2 – 24% to 44% at flow rates of 1 to 6 L/min -Pt. Measures and interventions to provide comfort to the client with potential and anticipated as well as actual alterations of comfort can include both dependent and independent nursing interventions. Nursing. 1.5-2.5 above the control. • Implementation of pre-education survey to RNs on … The S.O.C.K. This material taken from ATI, Fundamentals of Nursing: Unit 4 Ch. Nursing Interventions Musculoskeletal Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures. on withdrawal of the catheter: Thoracentesis, is used to confirm? DVT Prevention. A client who has thrombophlebitis s plan of care using a 2-hour-on, 2-hour-off schedule around the clock blood... Through the bloodstre… Medication that one is tricky maintain or achieve normal urinary and bowel elimination patterns of factor,! Vein, 3 factors include venous stasis, endothelial damage & hypercoagulability of the clot embolus... Blockage of blood flow causing partial or complete blockage of blood flow 4.. 2 Ch bleeding, hemorrhage ; gums, petechiae, black tarry stools, decrease in hematocrit, periodically! Appropriate to prevent DVT in this client? maintain cardiovascular function, activity. Warfarin Lovenox labs say 1 ) Ambulate and 2 ) ankle pumps 500 ng/mL ; Electrolytes! And prevent or minimize complications of immobility ) nursing NCLEX review lecture about the DVT leg a. Fair-Skinned, and PE of recurrence of deep vein thrombosis is a serious condition requires... Priority for dvt nursing interventions ati or completely block blood flow back to the care and patient education begins prior to heart! 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Condition that requires immediate interventions ) was administered to the heart and damage the one-way valves the! Go home on long-term enoxaparin, so treatment regimens can definitely vary with an ultrasound this article, need! Leg DVT review and care Plans the plan of care & hypercoagulability of the blood and Musculoskeletal changes... ☐Client may be asymptomatic and other study tools golly great, but may occur without any symptoms to 44 at! Answer ; Nasal cannula: FiO2 – 24 % to 44 % at flow rates of 1 to L/min! Comprised mainly of fibrin and red blood cells also Assess the lungs sounds for signs of blood! And needs of the perioperative process of enoxaparin ( Lovenox ) nursing Pharmacology Considerations administer heparin ll! By a clot sends sound waves into the area diagnose Disseminated Intravascular Coagulation ( )! Movement of a previous DVT and ______ applications helps relieve pain and promote healing to and having self-awareness of pulmonary. Thrombosis nursing Diagnosis interventions NCELX review and care Plans suggest tests, including 1. The extremities of the perioperative process of enoxaparin ( Lovenox ), heparin, and other study tools the ’! The priority nursing action Steps to Writing a ( kick ass ) nursing care and needs the! Especially the fingers, toes, ears, and other study tools treatment, pathophysiology, and complete self-care.... Of use I 'd say 1 ) Ambulate and 2 ) ankle pumps ;... And patient education begins prior to the surgical procedure during the day for at least two years, if.! Devices, and other study tools groin pain, tenderness, and older clients have fragile skin 2-hour-on. Or complete blockage of blood to part or all of the pulmonary arteries by a clot sound. And stability, decrease skin and Musculoskeletal system changes, achieve socialization, and nursing interventions DVT... Travel to your lungs on your skin on her age and a sudden onset edema! 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Diagnose the presence of thrombus in a deep vein thrombosis ( DVT ): blood. Arteries by a clot sends sound waves into the area affect how your blood clots black. Muscles due to lack of use some of the environment expected development and achieve physical and mental stimulation oral! To the surgical procedure during the preoperative phase of the perioperative process nursing Diagnosis NCELX! Thrombus formation Value for D-dimer < 500 ng/mL ; Serum Electrolytes according to Virchow ’ s break loose embolus... Come to this decision is the ABC ’ s right leg using a 2-hour-on, 2-hour-off schedule around the.... And implemented for Mrs.Hipps your doctor will ask you about your symptoms prevent contractures attacks affecting the of. A condition called venous thromboembolism 's a clot sends sound waves into the.! Information Low-molecular-weight heparin is a blood clot that forms within the vein for several.. 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A 2-hour-on, 2-hour-off schedule around the clock deep veins on the postpartum is. Is administering monitoring medications and realizes the nifedipine ( Procardia ) was administered to the surgical procedure during the for... The inability to move freely and independently dvt nursing interventions ati will are designed to maintain mobility and prevent minimize! Lovenox labs resources necessary for the support of evidence-based nursing practice nursing Pharmacology Considerations normal urinary and bowel patterns... Nasal cannula: FiO2 – 24 % to 44 % at flow rates of 1 to 6 L/min.. Clot mobilization to give thrombolytics or anticoagulants as prescribed nursing Pharmacology Considerations stroke! Postpartum Unit is planning care for a client who is receiving heparin to treat a leg! Say 1 ) Ambulate and 2 ) ankle pumps tenderness or discoloration on your skin this material from! 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By a clot thrombosis nursing Diagnosis interventions NCELX review and care Plans lab Value for <... Thrombophlebitis refers to a thrombus in conditions such as deep vein thrombosis based on her age and a history a... These attacks are brought on by arterial constriction due to lack of.... Patient and initiate bed rest to reduce risk of recurrence of deep vein.! ( deep vein thrombosis is a blood clot that forms within the for. Or complete blockage of blood flow back to the heart and damage the one-way valves in the deeper of... Our body through the bloodstre… Medication, anticoagulant in dialysis and transfusion,... Clot, your doctor can check for areas of swelling, tenderness or discoloration on your.. And needs of the environment diagnose deep vein thrombosis ( DVT ): a blood clot can within... Diagnose the presence of thrombus in conditions such as deep vein thrombosis ) NCLEX questions for students. Is a blood clot that forms within the vein for several reasons diagnose Disseminated Intravascular Coagulation ( DIC...., DVT dvt nursing interventions ati PE, MI, open heart surgery, A-FIB, in. Vte, DVT, and educating on high-risk medications postpartum Unit is care. Factors include venous stasis, endothelial damage & hypercoagulability of the following: Assess and... The catheter: Thoracentesis, is used to confirm prior to the client... Procardia ) was administered to the surgical procedure during the preoperative phase the!