A client is admitted to the psychiatric unit for depression with suicidal ideations. The client has tried and failed multiple antidepressants. The next course of treatment recommended is electroconvulsive therapy (ECT). Which condition(s) should the nurse recognize as contraindicated for ECT? Select all that apply.

Pulmonary embolism management transitions from acute anticoagulation to long-term prevention and risk factor modification. A pulmonary embolism occurs when a thrombus, often from a deep vein, obstructs pulmonary arterial flow, leading to ventilation-perfusion mismatch and potential right heart strain. Discharge education focuses on hemorrhage prevention while on anticoagulants, enhancing peripheral venous return to prevent stasis, and addressing modifiable factors like nicotine use that promote a prothrombotic state.

Rationale:

A. Avoiding aspirin is essential because it is an antiplatelet agent that increases the risk of bleeding when combined with anticoagulants. The concurrent use of multiple blood-thinning medications significantly elevates the potential for gastrointestinal hemorrhage or intracranial bleeding. Clients must be taught to screen over-the-counter medications for hidden salicylates to maintain pharmacological safety during the recovery period.

B. Moving and stretching the lower extremities prevents venous stasis, a primary component of Virchow’s triad. Frequent movement facilitates the skeletal muscle pump, which assists in pushing venous blood back toward the heart and prevents the formation of new thrombi. This is especially critical for a client with a recent lower extremity fracture and cast who has reduced mobility.

C. Keeping legs in a dependent position is contraindicated because it promotes venous pooling and increases the risk of deep vein thrombosis. The client should be encouraged to elevate the legs above the level of the heart to facilitate venous drainage and reduce generalized edema. Dependent positioning worsens stasis and creates an environment conducive to further clot formation.

D. Smoking cessation is highly encouraged because nicotine causes vasoconstriction and hypercoagulability, increasing the risk of recurrent thromboembolic events. This client has a significant smoking history, which likely contributed to the development of the pulmonary embolism post-surgery. Quitting smoking is a vital lifestyle modification to improve vascular health and prevent future life-threatening complications.

E. Reporting shortness of breath is a priority instruction as it may indicate a recurrent embolism or worsening pulmonary function. Since the client already experienced an acute event characterized by respiratory distress, he must be vigilant in recognizing early symptoms. Prompt reporting allows for immediate clinical evaluation and prevents the progression of potential pulmonary infarction or failure.

F. Performing range of motion exercises maintains joint flexibility and promotes circulation while the client is convalescing. These exercises help prevent the complications of immobility-induced stasis, which is a high risk given his recent ankle fracture and surgery. Consistent movement ensures that blood flow remains active in the unaffected and partially affected limbs to support recovery.

G. Avoiding anal intercourse is a specific safety precaution to prevent mucosal trauma and subsequent rectal bleeding while on anticoagulation therapy. The rectal mucosa is highly vascular and easily injured, leading to significant blood loss if the client's clotting ability is pharmacologically suppressed. This instruction is a necessary component of comprehensive education regarding the prevention of internal bleeding.

H. Applying warm moist heat to fresh bruising is contraindicated as it causes vasodilation and can worsen local bleeding and hematoma expansion. Instead, clients should apply cold compresses to new bruises to promote vasoconstriction and limit the size of the hemorrhage. Heat should only be used in later stages of healing once the initial clot has stabilized.

Brief introduction:

Nociceptive pain in malignancy results from osteoclast activation and direct periosteal stretching. This somatosensory experience requires qualitative differentiation between sharp, dull, or radiating sensations. Comprehensive assessment prevents uncontrolled suffering and guides pharmacological selection for severe pathological fractures.

Rationale:

A. Subjective description is the gold standard for identifying the sensory quality of pain. The client uses specific descriptors to differentiate neuropathic burning from deep somatic aching. This information is clinically vital for determining if the pain is localized or spreading.

B. Behavioral observation is a secondary method used primarily for non-verbal patients or those with cognitive deficits. In alert clients, movement patterns may indicate guarding behaviors but fail to define the specific nature. Relying solely on physical cues often leads to the under-treatment of chronic pain.

C. The numeric scale is a quantitative tool used to measure pain intensity rather than qualitative characteristics. While a rating of 0 to 10 determines severity levels, it does not clarify if the pain is throbbing. Quantitative data is insufficient alone to develop a multi-modal analgesic plan.

D. Identifying relief measures focuses on palliative interventions rather than the initial assessment of the pain itself. Understanding what helps can indicate therapeutic efficacy but does not define the current sensation. The nurse must first define quality before evaluating the success of prior comfort strategies.