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46 Cards in this Set
- Front
- Back
Venous Thrombosis
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The formation of a thrombus (clot) in association with inflammation of the vein.
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Two Classifications
Superficial Thrombophlebitis Deep Vein Thrombosis (DVT) |
Superficial Thrombophlebitis
-inflammation of a vein -occurs in about 65 percent of patients receiving IV therapy |
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Two Classifications cont.
Deep Vein Thrombosis (DVT) |
-Disorder involving a thrombus in a deep vein, most commonly the iliac and femoral veins
-Occurs in 5% of all Med-Surg patients |
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Deep Vein Thrombosis
Etiology |
Vichrow's Triad
-Venous Stasis -Damaged Endothelium -Hypercoagulability |
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Venous Stasis (pooling of blood)
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-Occurs when valves are dysfunctional or the muscles of the extremities are inactive
-*Causes: bed rest, immobility, obesity, CHF, AF, pregnancy (30% increase in blood volume during pregnancy), and post partum |
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Damaged Endothelium
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-Occurs as a result of trauma or external pressure on the vessel itself
-Everytime a venipuncture is performed *causes: IV agents irritating to veins-antibiotics, K+, chemo, or hypertonic solutions; burns, DM, pooling blood, sepsis (bacteria damage endothelium of vessel wall), IV drug abuse |
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Hypercoagulability
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-Occurs as the result of hematologic disorders
*Causes: Polycythemia (increased RBC's), severe anemia, oral contraceptives, smoking, and various malignancies (breast, brain, pancreas, GI tract), sepsis |
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Pathophysiology
Thrombus=clot |
-A change in blood flow, vessel wall, and coagulability of blood leading RBC's, WBC's, platelets, and fibrin to adhere and form a thrombus.
-This frequently occurs at valve custps of veins where venous stasis allows accumulation of blood clots |
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Pathophysiology (cont)
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-As the thrombus enlarges, increases amounts of blood cells and fibrin collect behind it producing a larger clot that eventually occludes the lumen of the vein.
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Pathophysiology (cont)
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-If a thrombus only partially occludes the vein, the thrombus becomes covered by endothelial cells and the thrombotic process stops.
-If it does not detach, it undergoes lysis or becomes firmly organized and adherent within 5 to 7 days |
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Clinical Manifestations
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-Pain or heaviness of the limb
-Edema, Redness (dark red) -+Homan's Sign (10% of patients) -Malaise, fever, and chills |
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Diagnostic Tests
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*Non Invasive Doppler - determines venous flow
*Duplex Scan - combination of ultrasound and doppler; determines flow, location and extent of thrombus *Venogram - x-ray with contrast-determines location and extent of thrombus and development of collateral circulation (most definitive test) |
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Laboratory Values
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PT (Prothrombin Time), PTT (Partial Thromboplastin Time), INR (International Normalized Ratio), Bleeding Time
*Increase - more prone to bleeding, decreased risk for clots *Decrease - polycythemia, increased risk for clots **Also need to consider the platelet count |
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Treatment
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Medical
-Bed rest -Elevation (decreases swelling) -Warm Compresses (promotes venous return) **Anticoagulation (will not dissolve clot) -Heparin -Lovenox -Coumadin |
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Anticoagulation
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Goal: Prevent enlargement of the clot, development of new thrombus, and embolization.
**Anticoagulation does not dissolve the clot. Lysis of the clot happens through the bodies intrinsic fibrinolytic system. |
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IV Heparin
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-Class-fast/short acting anticoagulant
-Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin (major clotting factors) -Inhibits thrombin and prevents conversion of fibrinogen to fibrin **Antidote - Protamine Sulfate (given IV) |
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IV Heparin (cont) Acute DVT
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-Treatment of a large DVT requires continuous IV heparin for 5-7 days. oral anticoagulation for 3-6 months
*Heparin must be continued until the patient is therapeutic on Coumadin* -Heparin is administered as an IV bolus, followed by a continuous drip-wt based in units/hr **Must be on an infusion pump** -Monitor PTT 6 hours after starting - and every 6 hours after a change in dose -Normal PTT 24-36 seconds *Therapeutic PTT is 1.5-2X normal (*Heparin Protocol*) |
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Prophylactic Heparin
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-Prevention of DVT
-Heparin SC Given deep SC into the fatty layer of the abdomen, 2 inches away from the umbilicus, rotate sites, do not aspirate, hold skin fold during injection, do not rub *Dose - 5,000 units SC Q 8-12 hours *No monitoring of PTT |
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Lovenox SC (Low molecular weight heparin)
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-Classification: low molecular weight heparin
-Action: potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin -No PTT monitoring -Do not expel air bubble -First line therapy for prevention and treatment of small DVT -Prevention Dose - 30-80mg/day SC (weight based) -Small uncomplicated DVT can be treated outpatient with Lovenox 1mg/kg Q 12 hours -Patient is given Coumadin concurrently-Lovenox is discontinued when patient is therapeutic on Coumadin *Antidote: Protamine Sulfate |
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Coumadin
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-Classification - Anticoagulant/long acting
-Action - Interferes with hepatic synthesis of vitamin K (four clotting factors require vitamin K for their synthesis) -Prevention of thrombus formation -Recurrent DVT's require lifelong anticoagulation **Antidote: Vitamin K |
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Coumadin (cont)
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-Peak effects take several days to a week
-Starting dose 10-15mg/day po daily -Monitor INR -INR = International Normalized Ratio -Normal INR 0.75-1.25 seconds -Therapeutic INR 2-3 seconds **Continue heparin until INR is therapeutic -If discontinued can take >3days for INR to return to normal **Must know INR before you give Coumadin** |
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Adverse Effects of Anticoagulants
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-Heparin Induced thrombocytopenia (HIT)
-Black tarry stools or blood in stools -Hematemesis or hemoptysis -Hematuria -Epitaxis -Petechiae and bleeding of lips and gums -Heavy menstrual bleeding -Handout Table 37-12 **Treat significant bleeding with FFP, Plts, and PRBCS |
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Medications that interact with oral anticoagulants
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-See Table 37-11 in Lewis page 932
***Caution with ASA and NSAIDS with heparin and lovenox |
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Surgical
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Venous Thrombectomy
-remove DVT through incision in vein Vena Cava Interruption Devices (IVC Filters) |
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Venous Thrombectomy
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-Removal of DVT through an incision in the vein
-Done to prevent PE or decrease the risk of chronic venous insufficiency |
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Vena Cava Interruption Devices/Intracaval Filter Devices
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-Greenfield or Simon-Nitinol filters
-Inserted percutaneously through superficial femoral or internal jugular veins -Filter is opened and the spokes penetrate the vessel walls -This permits filtration of clots without interruption of blood flow |
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Complications of DVT
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-Pulmonary Embolism
-Chronic Venous Insufficiency (CVI) -Phlegmasis Cerulea Dolens Painful blue swollen foot |
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Chronic Venous Insufficiency (CVI)
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-Results from valvular destruction allowing retrograde flow of venous blood
-Persistent edema, increased pigmentation, secondary varicosities, ulceration, cyanosis of the limb in the dependent position |
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Phlegmasia Cerulea Dolens
(Swollen Blue Painful Leg) |
-Rare, may develop with severe lower extremity DVT
-Causes sudden massive swelling and intense cyanosis of the extremity -Gangrene occurs due to arterial occlusion secondary to venous obstruction |
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Core Components and Competencies of Nursing Practice
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1. Care Manager
2. Care Provider 3. Clinical Decision Maker 4. Collaborator 5. Communicator 6. Learner 7. Professional Behaviors 8. Teacher |
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Nursing Process
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Assessment: Physiological Integrity
Risk Factors for DVT--Table 37-7 Lewis page 928 |
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Analysis/Diagnosis
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Actual: Acute pain related to venous inflammation and venous congestion
Risk For: -Altered peripheral tissue perfusion related to impaired venous return. -Impaired skin integrity related to immobility and edema. -Ineffective management of therapeutic regime related to insufficient knowledge of prevention of treatment |
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Analysis/Diagnosis (cont)
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Potential Complications (PC):
-Bleeding related to anticoagulation therapy -Pulmonary emboli related to embolization of thrombus and immobility. -Chronic leg edema related to venous congestion. -Chronic stasis ulcers related to venous congestion. |
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Plan/Outcomes
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-Relief of pain
-Decreased edema -Absence of skin ulceration -Absence of complications from anticoagulation therapy -Absence of pulmonary emboli |
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Implementation: Prevention
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-Adequate hydration (increases blood volume)
-Early ambulation/OOB three times a day -Exercises: ROM change position every 2 hours Dorsiflex feet every 2 hours Rotate ankles every 2 hours -Intermittent Compression Devices -Elastic Compression Stockings -Anticoagulation |
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Implementation: Acute
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-Bed rest with limb elevation
-Decrease risks of immobility TCDB -Anticoagulants -Warm packs for comfort and inflammation -Analgesics -Anti-inflammatories (caution with NSAIDS) -No ICDS on leg with +DVT -Teds only when patient resumes ambulation |
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Implementation: Post Hospital
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-Prevention
-Medical Alert Bracelet: on Coumadin -Bleeding Precautions - Table 37-12 Lewis -Drug Interactions - Table 37-11 Lewis -Anticoagulation teaching guide - Table 37-14 Lewis -Follow up lab studies for INR -Maintain a consistent level of vitamin K rich foods-broccoli, spinach, kale, greens -Smoking cessation -Nutrition/Weight Control -Stop oral contraceptives/hormonal therapy -Avoid/limit alcohol |
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Herbs
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-Can interfere with clotting in various ways
-A common mechanism is to inhibit platelet aggregation ***garlic, ginger, ginkgo, ginseng, goldenseal, feverfew, chamomile, angelica, bilberry, and evening primrose |
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Current Trends & Research
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-Lovenox as first line therapy for prevention and treatment of small DVT's
-Three times a day dosing of SC Heparin for prophylaxis instead of twice a day -Arixta SC once daily for treatment of DVT (synthetic drug as effective as lovenox) -Home self-monitoring of INR |
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Thrombocytopenia
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An abnormal decrease in the number of platelets
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Hematemesis
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The vomiting of blood
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Hemoptysis
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The coughing up of blood
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Hematuria
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Blood in the urine
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Epistaxis
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Nosebleed
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Petechiae
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Small, purplish, hemorrhagic spots on the skin that appear in patients with platelet deficiencies (thrombocytopenias) and in many febrile illnesses.
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Phlegmasis Cerulea Dolens
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A complication of Deep Vein Thrombosis of the iliofemoral veins, in which the entire limb distal to the clot becomes swollen, purple, and painful.
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