1. Preparing for Discharge Pain Management and Anticoagulation Therapy Justina Lehman- Lane, FNP, DNP

2. Pain Management The major goal in the management of pain is minimizing the dose of medication to lessen the side effects while still providing adequate pain relief.

3. Effective Pain Management Early ambulation Decrease risk for complications Sleep Improved Mood

4. Ineffective Pain Management Impairs sleeping Ability to perform deep respirations and coughing Ambulation Mood Performing general activities

5. Alternative Pain Management Interventions Music Therapy Massage Therapy Guided Imagery and Relaxation Techniques Ice Therapy

6. Pain Management: What patients need to know Reviewing the prescribed medication Dosing their pain medication Uncontrolled pain Pain medication and constipation Pain medication and rehabilitation

7. Anti-coagulation Therapy Lovenox Coumadin Aspirin combined with mechanical devices

8. Anti-coagulation Patient Education Encourage moderation and consistency in eating foods high in Vitamin K. Limit intake of herbs than interfere with warfarin, such as Vitamin C, green tea, cranberry juice, garlic, ginger, ginseng, and goldenseal (Crowther & McCourt, 2005). Be moderate in consuming alcohol. Large amounts add to Coumadin’s anticoagulant effect (Lippincott, Williams, and Wilkens, 2012). Contact their medical provider prior to any invasive dental or surgical procedure. Exercise extreme caution to avoid bruising and injuries that may cause bleeding. Keep routine laboratory appointments related to Coumadin management. Avoid concurrent use with aspirin or NSAIDs as they increase the risk for bleeding.

9. Complications Deep Vein Thrombosis (DVT) Pulmonary Embolus (PE)

10. DVT The formation of a blood clot (thrombus) inside a deep vein. Most commonly seen in the thigh or calf. Usually caused by sluggish or disturbed blood flow, secondary to a recent surgery or restricted mobility. If left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung (PE).

11. Statistics DVT is one of the most prevalent medical problems today, with an annual incidence of 80 cases per 100,000 patients (Patel & Brenner, 2011). Each year in the U.S., more than 200,000 people develop a DVT; of those 50,000 cases are complicate by a PE (Patel & Brenner, 2011).

12. Clinical Presentation DVTs are often asymptomatic, and thus often challenging to recognize. When a DVT does produce symptoms, the following are signs and symptoms that may be present: – Redness, warmth, and swelling in the affected extremity. – Unilateral pitting edema with collateral venous engorgement, localized warmth and erythema. – Dilated superficial veins in the affected extremity. – Pain, tenderness, or a dull ache, particularly in the calf of the affected extremity. (Matharu & Porter, 2010) Image provided courtesy of Wikimedia Commons and made available under the Free Documentation License, Retrieved October 1 st, 2012 from http://en.wikipedia.org/wiki/File:DVT2012.JPGhttp://en.wikipedia.org/wiki/File

13. Strategizing Risk Low level: A 10% risk for DVT -Minor surgery in patients younger than 40 years of age, immobilization lasting less than 30 minutes. Moderate level: A 30% risk for DVT -Minor surgery for patients aged 40-60 years and major surgery in patients younger than 40 years of age. High level: A 60% risk for DVT - Minor surgery in patients older than 60 years of age or major surgery in patients older than 40 years of age. This category includes patients who have multiple risk factors, such as THA, TKA, or major orthopedic trauma, especially a spinal cord injury. ( National Clearinghouse, 2006)

14. Diagnosis & Management of DVT Diagnosis -Diagnostic Imaging- ultrasound Pharmacological Management -Anticoagulants -Thrombolytics

15. PE PE’s are a life-threatening complication caused by emboli obstructing pulmonary arteries and thereby increasing the workload of the heart. The heart may be unable to maintain sufficient circulation to support blood pressure, resulting in hypovolemic shock. Over 90% of PE’s are caused by a DVT, usually in the legs (Goldsmith, 2006).

16. Signs and Symptoms of a PE Dyspnea Tachypnea Tachycardia Chest Pain Anxiety Cough Hemoptysis Fever Arrhythmias Hypertension Syncope Diaphoresis Image provided courtesy of Wikimedia Commons and made available under the Free Documentation License, Retrieved October 1 st, 2012 from http://en.wikipedia.org/wiki/File:DVT2012.JPGhttp://en.wikipedia.org/wiki/File

17. Diagnosis and Management of a PE Diagnosis - Diagnostic Imaging - Blood Test Pharmacological Management -Anticoagulants -Thrombolytics

18. Questions ?

20. CONFLICT OF INTEREST I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.