Transcript Thrombophlebitis (DVT) 842

Deep Vein Thrombosis
Lewis, pp. 882-890
Concept 22.4 pp. 1389-1397
Terminology
• Sometimes called thrombophlebitis,
phlebothrombosis, venous thrombosis,
venous thromboembolism
• Venous thrombosis refers to clot formation
in a vein with inflammation
– Superficial—in small vein (INT site)
– Deep—AKA: DVT—located in deep veins,
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, Ddimer blood test
Preventative Management
• Antiembolism stockings (TEDs)
• Intermittent compression device (DVT
boots, Venodynes)
• Antiembolism exercises (AEEs)
• SQLMWH (Lovenox)
• Early ambulation
• Encourage fluids
• Avoid popliteal pressure, crossing legs
Prevention—Surgical Care
Improvement Project
• Started in 1999 to identify and implement
ways to decrease postoperative
complications
• Research found that in all major surgical
procedures that 25% of pts developed DVT
and 7% developed pulmonary embolism
• Recommendation was that patients receive
prophylaxis within 24h before or after
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 t
– 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
Acute Pharmacologic Mgmt
• 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 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.
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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
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Anticoagulant therapy (890)
Home treatment of DVT (Concept p. 1395)
Prevention
Dietary restrictions related to warfarin tx
Complications
How to give Lovenox at home
Home INR testing
How to apply TEDs
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
Manifestations of PVD
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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
Brittle, thick nails
• Venous:
– 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
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 debridement, 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