Risk factors may include
Orthopedic surgery, mechanical compression (eg, bandages, braces, cast), vascular obstruction, immobilization
It is obvious from
(Not, the presence of symptoms of a real diagnosis)
Desired outcomes / evaluation criteria, the client
Tissue Perfusion: Peripheral
Supports, as evidenced by the emotion and movement within the normal range for this specific situation.
Demonstrate a sufficient blood supply to tissues, as evidenced by palpable pulses, capillary filling live, hot or dry and normal skin color.
Nursing interventions on the ground:
Feel the heartbeat first. Assessment of capillary refill and skin color and temperature. Compare with unoperated limbs.
Background: Diminished or absent pulses, delayed capillary filling time, pale, white, cyanosis and coolness of the skin reflects less traffic and traffic. Compared with unoperated limbs idea or neurovascular problem is localized or general.
Assessment of the second movement and the sensation of being at work.
Background: Increased pain, numbness or tingling and / or inability to perform essential activities such as bending amount of nerve damage, danger or dislocation of the prosthesis, which requires immediate attention.
3rd Test sensation peroneal nerve pinch or a defect in the dorsal web between the first and second side, and the ability to finger dorsiflexion hip or knee replacement surgery to assess.
Justification: The location and length of the peroneal nerve increases the risk of direct injury or compression of tissue swelling or hematoma.
4th Monitor vital signs.
Background: tachycardia, and low blood pressure (BP), respond to hypovolaemia or blood loss during or suggest anaphylaxis associated with the use of methyl methacrylate into the systemic circulation. Note: This happens less often since the appearance of the prosthesis with porous coating, which promote bone ingrowth, rather than relying on general adhesives to fix interior furnishings.
5th Monitor size and type of drainage pumps and salads. Note: The swelling in the operational field.
Background: This may involve bleeding or department, which may increase the neurovascular compromise. Note: Drainage of hip joint can be reached at the beginning of 1000 ml postoperatively, and circulating volume.
6th Make sure the stabilization device, such as abduction pillow or splint device is in position and did not exert undue pressure on the skin and underlying tissues. Avoid using a pillow or bed Gatch knee on knee.
Background: Reduces the risk of pressure on the nerves or the circulation of the main threats to the extremities.
7th Evaluation of calf tenderness, a positive Homans' sign, and inflammation.
Background: Although the clinical symptoms are often unreliable in this population should control plans. Early detection and intervention of thrombus may prevent embolism.
8th also signs of continued bleeding, oozing puncture and mucous membranes, or ecchymosis after minor trauma.
Background: Depression clotting mechanisms or sensitivity to anticoagulants can cause bleeding by red blood cells (RBC), the level and distribution of the affected volume.
Promoting a ninth regular "foot pumps" during the day.
Background: When the foot, pointing fingers and pull the toes toward the ceiling allowing the body to strengthen and support the return of venous blood together to prevent and reduce the risk of deep vein thrombosis (DVT).
10th Medication administration, as indicated, for example, a low molecular weight heparin, enoxaparin (Lovenox), dalteparin (Fragmin), or tinzaparin (innohep).
Justification: anticoagulants or antiplatelet drugs can often be used to reduce the risk of thrombosis and pulmonary embolism to reduce decreased. Note: The incidence of deep venous thrombosis prophylaxis without about 50% to 80% of clients with knee and 47% to 64% in exchange for our legs. Studies show that a significant reduction in the number of contraceptives.