Terminology Sometimes called thrombophlebitis, phlebothrombosis, venous thrombosis, venous thromboembolism (VTE) Venous thrombosis refers to clot formation in a vein with inflammation –Superficial—in small vein (INT site) –Deep—usually iliac or femoral
Etiology Virchow’s triad: –Venous stasis –Damage of endothelium –Hypercoagulability
Risk Factors for Virchow’s Triad Venous stasis — incompetent valves, inactivity, obesity, heart failure, afib, orthopedic and pelvic surgeries Endothelial damage— trauma from various causes, external pressure Hypercoagulability— blood disorders, sepsis, pregnancy, hormones, smoking
Pathophysiology When vein is traumatized, inflammation occurs and platelet aggregation and fibrin attract cells to form a thrombus In venous stasis, clot forms at valve cusps or bifurcations. If clot gets big enough to occlude vein, manifestations of DVT occur; if not, body will reabsorb it.
Assessment of DVT 50% are asymptomatic unless the clot is in the ileofemoral vein. Symptomatic patients and those with ileofemoral clot have edema,redness, pain, warmth, decreased movement, +Homan’s sign (20% reliable). Dx Tests: Duplex scanning, venogram, D- dimer blood test
Prevention—Surgical Care Improvement Project Started in 1999 to identify and implement ways to decrease postop complication.s Research found that in all major surgeries, 25% of pts developed DVT and 7% developed pulmonary embolism. Recommendation: patients receive prophylaxis within 24h a or p surgery. Could be TEDS, IPCD, LMWH*, ASA.
Core Measures for Venous Thromboembolism (VTE) VTE Prophylaxis ICU VTE Prophylaxis VTE Patients with Anticoagulation Overlap Therapy VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol Anticoagulant Discharge Instructions
Elements of Performance: In other words, how does the hospital meet this NPSG? Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. –Use only oral unit-dose products, prefilled syringes, or premixed infusion bags and make sure they are age-appropriate. –Use only programmable pumps when administering continuous IV heparin –Use approved written protocols for initiation and maintenance of therapy. –Use approved written protocols for addressing baseline and ongoing labs –Assess baseline coagulation status i.e., INR, PT, PTT. –Manage potential food and drug interactions. –Provide education to prescribers, staff, patients, and families which includes follow-up, compliance, drug-food interactions, adverse reactions –Evaluate these safety practices, make improvements, and measure their effectiveness.
Acute Management Hospital or home?—depends on size of clot and presence of comorbidities BR or some degree of ambulation?—EBP has shown no difference Heat application Extremity elevation
IV Heparin—bolus followed by infusion with pump—dosage depends on established hospital protocol SQ Lovenox q12h—EBP show results as good PO Warfarin daily—dosage depends on PT, INR Analgesics—not NSAIDs Acute Pharmacologic Mgmt
Acute Management cont’d PTT, PT, INR qam—heparin and warfarin doses depend on results; not needed for Lovenox Monitor for complications—50% develop pulmonary embolism Surgery—thrombectomy, vena cava filter
Nursing Management of DVT Practice prevention for at-risk pts. For acute cases: –Monitor VS, NV status, and extremity measurements –Maintain activity orders –Discourage activities that can cause bleeding –Encourage fluids –Monitor anticoagulants meds and labs –Analgesics and heat –Monitor Vit K in diet –Monitor for complications-PE and hemorrhage
Patient Education Anticoagulant therapy Home treatment of DVT Prevention Dietary restrictions related to warfarin tx Complications How to give Lovenox at home Home INR testing How to apply TEDs
Pulmonary Embolism Usually caused from clots in the deep veins of the legs Embolizes to the lung vasculature, cutting off blood supply to a part of the lung, causing it to infarct.
Manifestations Dyspnea, tachypnea, tachycardia, hemoptysis, chest pain Can lead to right-sided heart failure and respiratory failure + Chest x-ray, VQ scan, CT, blood D-dimer
Management IV Heparin, Lovenox, or thrombolytics (severe cases only) Warfarin for long-term therapy Multiple incidences may necessitate the implantation of a vena cava filter. Nurses need to monitor anticoag tx, provide education, and practice prevention.
Peripheral Vascular Disease Affects arteries and veins Arteriosclerosis--Narrowing and sclerosis of large arteries (femoral, iliac, popliteal) especially at bifurcations due to plaque formation Chronic Venous Insufficiency—inadequate venous return due to incompetent valves. Venous stasis causes problems with diminished circulation and immune response Risk factors are same as CAD
Arterial Manifestations Diminished or absent pulses Smooth, shiny, dry skin No hair No edema Round, painful ulcers on distal foot, toes or webs of toes Dependent rubor Pallor and pain when legs elevated Intermittent claudication (pain with exercise) Brittle, thick nails
Venous Manifestations Normal pulses Brown patches of discoloration on lower legs Dependent edema Irregularly shaped, usually painless ulcers on lower legs and ankles Dependent cyanosis and pain Pain relief when legs elevated No intermittent claudication Normal nails Dermatitis, pruritis
Diagnostics Doppler ultrasound (853) Duplex ultrasound (855) Ankle-brachial index (ABI) (853) Exercise testing (854) CT and MRI Angiography and venography Contrast dye needs to be carefully considered in patients with renal dz
Management: Arterial Insufficiency Control modifiable risk factors—smoking is #1! Keep legs and feet in dependent position Use warmth carefully, avoid cold Encourage walking—to point of pain, rest, then resume No leg crossing, constrictive clothing Good foot care Good nutrition
Pharmacologic Management Vasodilators Adrenergic blocking agents Narcotics Trental or Pletal Aspirin or Plavix Statins
Surgical/Radiologic Management Bypass grafting Percutaneous transluminal angioplasty— balloon with stent placement Endardarectomy With all of these interventions, postop assessment of neurovascular status (6 Ps) is crucial!!
Management: Venous Insufficiency Elevate legs and feet 10-30” q2h during day Elevate legs and feet at night Compression stockings Encourage walking Avoid trauma, constriction, leg crossing Good foot care
Management of Leg Ulcers Goals of care : –Promote skin integrity –Increase mobility –Provide good nutrition
Management cont’d Promoting skin integrity includes good foot care, avoiding trauma, avoiding pressure and standing for long periods. It also includes proper tx of existing ulcers. Increase mobility as allowed and tolerated. Good nutrition includes protein, Vits A & C, Fe, Zn, and weight control.
Wound Care Management of Leg Ulcers Compression tx—stockings, Unna boots, etc. Amount of compression depends on ABI index. Keep wound moist—irrigate with saline, apply moisture-retentive dressings Prevent infection using good technique; wound culture if indicated. For persistent and unresponsive ulcers, surgical or pharmacologic debridement, growth factor stimulants, wound vacs, hyperbaric O2 chambers, or skin grafts may be indicated.
Education Good skin and foot care Teach pt and family to check feet and skin regularly Proper diet—Vits A & C, Fe, Zn, weight control Appropriate activity Avoidance of trauma S/S infection May need to teach patient and family dressing changes