QLexNursing

Deep vein thrombosis – due to their immobility

💠Clients who have had a stroke often experience severe functional limitations, such as the left-sided weakness noted in this client, leading to significantly reduced mobility.

💠Immobility slows venous return in the lower extremities, creating conditions for blood to stagnate, especially in the calves, which dramatically increases the risk of DVT formation.

💠The new finding of swelling and tenderness in the right calf is one of the classic early symptoms of a developing deep vein thrombosis.

💠With pedal pulses still intact, the concern is not arterial occlusion but venous clot formation due to venous stasis, which is a direct result of reduced ambulation after the stroke.

💠 This situation requires urgent evaluation because a DVT can progress to a pulmonary embolism, a life-threatening complication in immobile patients.

Incorrect Options

“Deep vein thrombosis due to their platelet level”

💠The platelet level of 165,000/mm³ is within the normal range (150,000–400,000/mm³).

💠Normal platelets do not increase the client’s risk of clot formation; they simply indicate normal clotting function.

💠DVT development is driven mainly by stasis of blood flow, not normal platelet values.

💠Using platelet count as the cause ignores the client’s immobility, which is the true risk factor.

💠Therefore, the platelet level is not the reason for the client's DVT risk.

“Deep vein thrombosis due to their prealbumin level”

💠The prealbumin level of 23 mg/dL is normal (15–36 mg/dL), indicating adequate nutritional status.

💠Prealbumin levels relate to nutritional assessment and wound-healing—not venous clot formation.

💠Normal prealbumin does not contribute to thrombosis and is not a risk factor for DVT.

💠Linking DVT with a normal nutritional marker ignores the main cause, which is immobility and venous stasis.

💠Therefore, prealbumin level is irrelevant to the risk of DVT in this scenario.

“Impaired healing due to their immobility”

💠 Immobility mainly increases the risk of pressure injury and blood clots, not impaired healing.

💠Healing is influenced by nutritional markers, such as prealbumin—and this client’s level is within normal range.

💠The scenario provides no wounds or surgical sites, so impaired healing is not applicable.

💠The new calf swelling directly suggests venous thrombosis, not a healing issue.

💠Therefore, immobility is linked with DVT, not impaired healing in this case.

“Impaired healing due to their platelet level”

💠Platelets affect clotting, not tissue repair or healing rate.

💠A normal platelet count does not impair or interfere with wound healing processes.

💠 Impaired healing would be expected if the prealbumin level were low—not the case here.

💠The scenario contains no evidence of wounds, making this option clinically irrelevant.

💠Thus, platelet level does not relate to impaired healing in this client.

“Impaired healing due to their prealbumin level”

💠 Prealbumin is normal (23 mg/dL), indicating healthy protein stores and adequate nutrition.

💠 Adequate protein supports tissue repair, immune function, and recovery.

💠There is no malnutrition, so impaired healing is not expected in this client.

💠The main clinical concern in the scenario is immobility and calf swelling, leading toward DVT risk—not healing issues.

💠Therefore, this option does not correctly match the client’s risk profile.