question about my pt for future reference

[ACNP 2B S1S2RRR]

Hi, I have a question about my pt. I had a 55 year old post-MI pt who was readmitted 6 months post-op. This hospitalization, he was admitted for SOB but all Dx tests came back normal- no pleural effusion, no consolidation, clean cultures, no PE, no MI, etc. He was admitted six months ago for cardiac stent placement following an MI. he'd been discharged and had follow-up exam as ordered, and no abnormalities were found. However, several years before (2000), he'd been admitted for an inguinal hernia repair. They repaired his inguinal hernia, but they went in to put the stent in where he'd had his hernia.

He showed me the area where he'd had the stent put in 6 months ago because it was swollen and blue. He said that it was painful as well. He'd also been c/o pain in that same leg all day, but I didn't think anything of it. His leg didn't look swollen, so I didn't really think that it was a DVT. plus, the area around the localized swelling in his inguinal area was blue, so I didn't think about a DVT because they tell us in school that the area will be red and swollen, positive homan's, etc. I asked him if the pain was similar to when he'd had the hernia, and he said that it was a different kind of pain. He also said that the affected leg from his knee up was hurting.

I just wanted to get everyone else's thoughts on this. Could this have been a DVT? Could he have re-herniated? the man was a truck driver (long periods of sitting), but he also told me that he hauls motorcycles and unloads them himself (this was considered his exercise). he said he unloads around 20-50 each time he unloads.

Should I have done something? I kept this area elevated, but there was nothing in the chart about this! Any thoughts on this, for future reference?

Thanks!! God bless!!

[ACNP 2B S1S2RRR]

also, for future reference, when you suspect a dvt, do you tell the pt to try to keep the area elevated and minimize activity to prevent the clot from breaking off and moving to the lungs/heart/brain? can you do this without an order? i know that if you suspect a dvt, you call the md, but do you minimize their activity without an order until you call the md and they r/o dvt?

thanks.

[pinkfluffybunny]

I'm curious as to what your clinical instructor said.

[LongLiveCairo]

I'm just a level one nursing student, doing bed baths and what not. But I googled your question of the bluish potential DVT site.

Diagnosis:

Clinical: The clinical features - swelling, tenderness and warmth will be recognised in less than 50% of cases with calf DVT and in about 80-90% of patients with ilio-femoral DVT. The severe forms - phlegmasia cerulea (blue leg) and alba (white leg) dolens should he recognised, as more aggressive therapy may be appropriate.

Now the definition of phlegmasia cerula from Websters Dictionar(2007) states:

severe thrombophlebitis with extreme pain, edema, cyanosis, and possible ischemic necrosis

I don't really know if this helps, but from what i've read..I wouldn't let your DVT Dx slip away, because it's still a possibility. I think a more exp. person should elaborate on this.

[pinkfluffybunny]

http://books.google.com/books?id=yujV5S_TP_UC&pg=PA34&lpg=PA34&dq=swollen+blue+dvt&source=bl&ots=E3Ox57gfPP&sig=ES38xRsgSii67oGf5sg-_C_Ck9g&hl=en&ei=xYfLTJ7kGsKBlAfiqvyYBg&sa=X&oi=book_result&ct=result&resnum=2&ved=0CBoQ6AEwAQ#v=onepage&q=swollen%20blue%20dvt&f=false

I found this link to a book. Look at #11.

[ACNP 2B S1S2RRR]

Thanks, guys. That helped a lot!! I told the nurse about my finding, but I don't know what happened after that. My teacher told me to tell the nurse, and I told the nurse but I don't know what happened after that because we left early that day, but I was just curious as to what may have happened. I wish I could have done more, but we really can't do more as students. I guess I wanted to know what we'd do when we've graduated because as a student when we find something out of the ordinary, we tell the nurse or our instructor.

[BluegrassRN]

I guess I wanted to know what we'd do when we've graduated because as a student when we find something out of the ordinary, we tell the nurse or our instructor.

As a nurse, here is what I would have done:

Upon learning of this, I would have asked the patient the history of the pain: how long had he had it, how long had the area been swollen and tender, etc. I would have done a complete vascular assessment on the lower extremities, including cap refill, warmth, palpate pulses, ask about sensation (tingling, numbness, etc). I would have asked the pt if he had discussed this with a physician, or if the area had been evaluated by a practitioner.

Then I would have looked at the H&P from his admission. Did the doc document anything regarding this? Have the physician's progress notes addressed it at all? If they have, explore it further. Does it seem changed from what the physicians describe? Have they done any sort of testing or have they made any sort of plan (will monitor for change in symptoms, well continue fragmin therapy, etc) regarding this?

If it had been addressed and did not appear much changed, I would simply have documented it in my notes and mentioned it to the oncoming shift, as an issue to actively monitor. If no one had addressed it at all, or there was a significant change, I would have contacted the physician.

Hope that helps.

And FYI, from what you describe, I don't know if I would have been thinking DVT so much as hematoma and/or infection, and I'd worry that there was some damage being done by the swelling, specifically that his vascular status was compromised due to the compression of the hematoma/infection on the vessels to and from the leg. It's also possible that the hernia had recurred, or there was some sort of combination of issues (bruising, infection, herniation) going on there.