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46 Cards in this Set

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Venous Thrombosis
The formation of a thrombus (clot) in association with inflammation of the vein.
Two Classifications
Superficial Thrombophlebitis
Deep Vein Thrombosis (DVT)
Superficial Thrombophlebitis
-inflammation of a vein
-occurs in about 65 percent of patients receiving IV therapy
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
Deep Vein Thrombosis
Etiology
Vichrow's Triad
-Venous Stasis
-Damaged Endothelium
-Hypercoagulability
Venous Stasis (pooling of blood)
-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
Damaged Endothelium
-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
Hypercoagulability
-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
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
Pathophysiology (cont)
-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.
Pathophysiology (cont)
-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
Clinical Manifestations
-Pain or heaviness of the limb
-Edema, Redness (dark red)
-+Homan's Sign (10% of patients)
-Malaise, fever, and chills
Diagnostic Tests
*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)
Laboratory Values
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
Treatment
Medical
-Bed rest
-Elevation (decreases swelling)
-Warm Compresses (promotes venous return)
**Anticoagulation (will not dissolve clot)
-Heparin
-Lovenox
-Coumadin
Anticoagulation
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.
IV Heparin
-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)
IV Heparin (cont) Acute DVT
-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*)
Prophylactic Heparin
-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
Lovenox SC (Low molecular weight heparin)
-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
Coumadin
-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
Coumadin (cont)
-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**
Adverse Effects of Anticoagulants
-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
Medications that interact with oral anticoagulants
-See Table 37-11 in Lewis page 932
***Caution with ASA and NSAIDS with heparin and lovenox
Surgical
Venous Thrombectomy
-remove DVT through incision in vein
Vena Cava Interruption Devices (IVC Filters)
Venous Thrombectomy
-Removal of DVT through an incision in the vein
-Done to prevent PE or decrease the risk of chronic venous insufficiency
Vena Cava Interruption Devices/Intracaval Filter Devices
-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
Complications of DVT
-Pulmonary Embolism
-Chronic Venous Insufficiency (CVI)
-Phlegmasis Cerulea Dolens
Painful blue swollen foot
Chronic Venous Insufficiency (CVI)
-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
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
Core Components and Competencies of Nursing Practice
1. Care Manager
2. Care Provider
3. Clinical Decision Maker
4. Collaborator
5. Communicator
6. Learner
7. Professional Behaviors
8. Teacher
Nursing Process
Assessment: Physiological Integrity
Risk Factors for DVT--Table 37-7 Lewis page 928
Analysis/Diagnosis
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
Analysis/Diagnosis (cont)
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.
Plan/Outcomes
-Relief of pain
-Decreased edema
-Absence of skin ulceration
-Absence of complications from anticoagulation therapy
-Absence of pulmonary emboli
Implementation: Prevention
-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
Implementation: Acute
-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
Implementation: Post Hospital
-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
Herbs
-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
Current Trends & Research
-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
Thrombocytopenia
An abnormal decrease in the number of platelets
Hematemesis
The vomiting of blood
Hemoptysis
The coughing up of blood
Hematuria
Blood in the urine
Epistaxis
Nosebleed
Petechiae
Small, purplish, hemorrhagic spots on the skin that appear in patients with platelet deficiencies (thrombocytopenias) and in many febrile illnesses.
Phlegmasis Cerulea Dolens
A complication of Deep Vein Thrombosis of the iliofemoral veins, in which the entire limb distal to the clot becomes swollen, purple, and painful.