2 TerminologySometimes called thrombophlebitis, phlebothrombosis, venous thrombosis, venous thromboembolism (VTE)Venous thrombosis refers to clot formation in a vein with inflammationSuperficial—in small vein (INT site)Deep—usually iliac or femoral
3 Etiology Virchow’s triad: Venous stasis Damage of endothelium Hypercoagulability
4 Risk Factors for Virchow’s Triad Venous stasis —incompetent valves, inactivity, obesity, heart failure, afib, orthopedic and pelvic surgeriesEndothelial damage—trauma from various causes, external pressureHypercoagulability— blood disorders, sepsis, pregnancy, hormones, smoking
5 PathophysiologyWhen vein is traumatized, inflammation occurs and platelet aggregation and fibrin attract cells to form a thrombusIn 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.
6 Assessment of DVT50% 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
8 Prevention—Surgical Care Improvement Project Started in 1999 to identify and implement ways to decrease postop complication.sResearch 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.
9 Core Measures for Venous Thromboembolism (VTE) VTE ProphylaxisICU VTE ProphylaxisVTE Patients with Anticoagulation Overlap TherapyVTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by ProtocolAnticoagulant Discharge Instructions
10 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 heparinUse approved written protocols for initiation and maintenance of therapy.Use approved written protocols for addressing baseline and ongoing labsAssess 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 reactionsEvaluate these safety practices, make improvements, and measure their effectiveness.
11 Acute ManagementHospital or home?—depends on size of clot and presence of comorbiditiesBR or some degree of ambulation?—EBP has shown no differenceHeat applicationExtremity elevation
12 Acute Pharmacologic Mgmt IV Heparin—bolus followed by infusion with pump—dosage depends on established hospital protocolSQ Lovenox q12h—EBP show results as goodPO Warfarin daily—dosage depends on PT, INRAnalgesics—not NSAIDs
13 Acute Management cont’d PTT, PT, INR qam—heparin and warfarin doses depend on results; not needed for LovenoxMonitor for complications—50% develop pulmonary embolismSurgery—thrombectomy, vena cava filter
14 Nursing Management of DVT Practice prevention for at-risk pts.For acute cases:Monitor VS, NV status, and extremity measurementsMaintain activity ordersDiscourage activities that can cause bleedingEncourage fluidsMonitor anticoagulants meds and labsAnalgesics and heatMonitor Vit K in dietMonitor for complications-PE and hemorrhage
15 Patient Education Anticoagulant therapy Home treatment of DVT PreventionDietary restrictions related to warfarin txComplicationsHow to give Lovenox at homeHome INR testingHow to apply TEDs
16 Pulmonary EmbolismUsually caused from clots in the deep veins of the legsEmbolizes to the lung vasculature, cutting off blood supply to a part of the lung, causing it to infarct.
17 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
18 Management IV Heparin, Lovenox, or thrombolytics (severe cases only) Warfarin for long-term therapyMultiple incidences may necessitate the implantation of a vena cava filter.Nurses need to monitor anticoag tx, provide education, and practice prevention.
19 Peripheral Vascular Disease Affects arteries and veinsArteriosclerosis--Narrowing and sclerosis of large arteries (femoral, iliac, popliteal) especially at bifurcations due to plaque formationChronic Venous Insufficiency—inadequate venous return due to incompetent valves. Venous stasis causes problems with diminished circulation and immune responseRisk factors are same as CAD
20 Arterial Manifestations Diminished or absent pulsesSmooth, shiny, dry skinNo hairNo edemaRound, painful ulcers on distal foot, toes or webs of toesDependent ruborPallor and pain when legs elevatedIntermittent claudication (pain with exercise)Brittle, thick nails
21 Venous Manifestations Normal pulsesBrown patches of discoloration on lower legsDependent edemaIrregularly shaped, usually painless ulcers on lower legs and anklesDependent cyanosis and painPain relief when legs elevatedNo intermittent claudicationNormal nailsDermatitis, pruritis
22 Diagnostics Doppler ultrasound (853) Duplex ultrasound (855) Ankle-brachial index (ABI) (853)Exercise testing (854)CT and MRIAngiography and venographyContrast dye needs to be carefully considered in patients with renal dz
23 Management: Arterial Insufficiency Control modifiable risk factors—smoking is #1!Keep legs and feet in dependent positionUse warmth carefully, avoid coldEncourage walking—to point of pain, rest, then resumeNo leg crossing, constrictive clothingGood foot careGood nutrition
24 Pharmacologic Management VasodilatorsAdrenergic blocking agentsNarcoticsTrental or PletalAspirin or PlavixStatins
25 Surgical/Radiologic Management Bypass graftingPercutaneous transluminal angioplasty—balloon with stent placementEndardarectomyWith all of these interventions, postop assessment of neurovascular status (6 Ps) is crucial!!
26 Management: Venous Insufficiency Elevate legs and feet 10-30” q2h during dayElevate legs and feet at nightCompression stockingsEncourage walkingAvoid trauma, constriction, leg crossingGood foot care
27 Management of Leg Ulcers Goals of care:Promote skin integrityIncrease mobilityProvide good nutrition
28 Management cont’dPromoting 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.
29 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 dressingsPrevent 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.
30 Education Good skin and foot care Teach pt and family to check feet and skin regularlyProper diet—Vits A & C, Fe, Zn, weight controlAppropriate activityAvoidance of traumaS/S infectionMay need to teach patient and family dressing changes