Cardiovascular
From your syllabus
Unilateral warm, swollen, tender calf after surgery is a DVT.
Do not massage it, do not walk it off, do not test Homans sign — keep it still and call.
In the exam
A client on day four after abdominal surgery reports a dull ache in the left calf. The calf is warm, slightly swollen and tender. What should the nurse do?
- Keep the limb still, notify the provider, and do not massage the calf(correct answer)
- Massage the calf to relieve the ache and improve circulation
- Apply a heating pad and encourage the client to walk it off
- Check Homans sign by dorsiflexing the foot to confirm the diagnosis
What it was testing
deep vein thrombosis
These findings suggest deep vein thrombosis. Manipulating the calf risks dislodging clot into the pulmonary circulation.