An 82-year-old man is recovering from a right hip fracture repair on the rehabilitation unit, day 3 postoperatively. He has a history of osteoarthritis and is on a scheduled oral pain-management regimen. The LPN/VN notes sequential compression devices are in place on both lower extremities per protocol. On rounds, the client reports his left calf feels "tight and warm," and the nurse notes the left calf is visibly larger than the right, with mild redness. The client's vital signs are stable, and he denies shortness of breath. The health care provider has not yet been notified of this finding. What should the LPN/VN do first?
- Document the finding in the chart and continue with the scheduled compression device routine without notifying the RN or health care provider.
- Report the unilateral calf swelling, warmth, and redness to the RN or provider promptly.
- Perform a comprehensive vascular assessment and adjust the plan of care independently.
- Gently massage the left calf to improve circulation and relieve the tightness.