Your assessment of L.J. reveals bibasilar crackles with moist ...

[NClaborn]

Your assessment of L.J. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3+ pitting edema of right lower extremity; mild erythema of right foot and calf; and severe right calf pain.
 
  He is awake, alert, and oriented but a little restless. His Spo2
  is 92 on room air. He denies chest pain but does have shortness of breath with exertion. He states he is
  anxious about missing his grandson's wedding. He denies any voiding problems.
 
  Your institution uses electronic charting. Based on the assessment noted previously which of
  the following systems would you mark as abnormal as you document your findings? For
  abnormal findings provide a brief narrative note.

Question 2

Keeping in mind L.J.'s health history and admitting diagnosis, what are the most important assessments you will make during your physical examination and assessment?
 
  What is the most serious complication of DVT? and List at least eight assessment findings you should monitor closely for in the development of Pulmonary Embolism.

[allisonblackmore]

Answer to Question 1

 Neurologic: Awake, alert, and oriented, but restless.
 Respiratory: Bibasilar crackles with moist cough. Spo2 92 on room air. States he is short of breath
on exertion.
 Cardiovascular: BP 138/88 mm Hg; pulse 104 beats/min.
 Genitourinary:
 Skin: 3+ pitting edema of right lower extremity; mild erythema of right foot and calf.
 Psychosocial: States he is anxious about missing his grandson's wedding.
 Pain: Complains of severe right calf pain.

Answer to Question 2

Cardiovascular: Obtain baseline vital signs (VS); assess heart sounds; compare perfusion of the extremities.

Venous compromise of affected leg: Assess warmth, redness, pain, edema, Homans sign, distal pulses, capillary refill, and baseline calf and thigh girth. Don't forget to compare both legs.

Lungs: Assess breath sounds; assess for dyspnea and chest pain.
Mental status: Assess for confusion, restlessness, and lethargy.

Pulmonary embolism

 Crackles
 Cough
 Tachycardia
 Restlessness
 Dyspnea and tachypnea (occur in 85 of cases)
 Sudden pleuritic chest pain (occurs in 74 of cases)
 Apprehension
 Hemoptysis
 Fever
 Nausea and vomiting
 Cyanosis

[NClaborn]

Thank you

[allisonblackmore]

No problemo