Case Study - Venous Thromboembolism SP20 PDF

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Venous Thromboembolism Setting: Hospital HESI Concepts: Assessment, Care Coordination, Clotting, Pain, Patient Education, Perfusion

Objectives: ● Prioritize evidence-based care for patients with vascular problems affecting perfusion and clotting. ● Apply knowledge of A&P to perform an evidence-based assessment for the patient with a venous thromboembolism. ● Teach patient about lifestyle modifications to prevent the formation of VTE. ● Safely administer medications to a patient with VTE. ● Use clinical judgment to assess laboratory data and signs and symptoms and prioritize care for patient. 1.

Scenario You are assigned to care for L.J., a 70-year-old retired bus driver who has just been admitted to your medical floor with right leg deep vein thrombosis (DVT). L.J. has a 48– pack-year smoking history, although he states he quit 2 years ago. He has had pneumonia several times and frequent episodes of atrial flutter or fibrillation. He has had 2 previous episodes of DVT and was diagnosed with rheumatoid arthritis 3 years ago. Two months ago he began experiencing shortness of breath on exertion and noticed increasing swelling of his right lower leg that became progressively worse until it extended up to his groin. His wife brought him to the hospital when the pain in his leg became increasingly severe. After a Doppler study showed a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted for bed rest and to initiate heparin therapy. His basic metabolic panel was normal; other laboratory results were as follows. Chart View Laboratory Testing PT 12.4 seconds INR 1.11 aPTT 25 seconds Hgb 13.3 g/dL (133 g/L) Hct 38.9% Cholesterol 206 mg/dL (5.34 mmol/L) 1. List 6 risk factors for DVT. Most risk factors fall within the three categories of the Virchow triad:  History of clots, immobilization, smoking, Hypertension, pregnancy, obesity, major surgery, long plane rides

2.

Something is missing from the scenario. Based on his history, L.J. should have been taking an important medication. What is it, and why should he be taking it?  Warfarin because it is a anticoagulant and will prevent him from clotting again

3.

Keeping in mind L.J.’s health history and admitting diagnosis, outline the most important assessments you will make during your physical examination.  A pain assessment (chest pain), respiratory assessment (SOB), watch for tachycardia. watch for possibility of PE

4.

What is the most serious complication of DVT?  Pulmonary Embolism (PE)

6. List at least 8 assessment findings you should monitor closely for in the development of the complication identified in Question 5. ● Tachycardia ● Dyspnea ● Chest Pain ● Tachypnea ● Cough ● Crackles or friction rub ● Diaphoresis ● Anxiety 7. You review the literature for DVT and see the abbreviation VTE. What does VTE mean?  VTE is a venous thromboembolism which is caused by a blood clot becoming a DVT and turning into a PE. CASE STUDY PROGRESS Your assessment of L.J. reveals bibasilar crackles with moist cough, normal heart sounds, BP 138/88, pulse 104, 4+ pitting edema of right lower extremity, mild erythema of right foot and calf, and severe right calf pain. He is awake, alert, and oriented but a little restless. His SpO2 is 92% on room air. He denies chest pain but does have shortness of breath with exertion. He states he is anxious about missing his grandson's wedding. He denies any voiding problems.

8. Your institution uses electronic charting. Based on the assessment noted previously, which of the following systems would you mark as “abnormal” as you document your findings? For abnormal findings provide a brief narrative note. ◻ Neurologic: NO ◻ Respiratory: YES ◻ Cardiovascular: YES ◻ Genitourinary: NO ◻ Skin: YES ◻ Psychosocial: YES ◻ Pain: YES CASE STUDY PROGRESS L.J. is placed on 72-hour bed rest with bathroom privileges and given acetaminophen (Tylenol) for pain. The physician writes orders for enoxaparin (Lovenox) injections. 9. L.J. asks, “Why do I have to get these shots? Why can’t I just get a Coumadin pill to thin my blood?” What would be your response?” Explain your answer. a. “Your physician prefers the injections over the pills.” b. “The enoxaparin will work to dissolve the blood clot in your leg.” c. “It would take the Coumadin pills several days to become effective. d. “Good idea! I will call and ask your physician to switch medications.” Bridge Therapy. Patients will have to transition to coumadin; they have to be kept on a different blood thinner because it takes a few days to become therapeutic. 10. The order for the enoxaparin reads: Enoxaparin 70 mg every 12 hours subQ. L.J. is 5 ft, 6 in tall and weighs 156 lb. Is this dose appropriate? The appropriate dose for enoxaparin is 1 mg/kg. Yes. Patient weighs 70.76kg.

11. What special techniques do you use when giving the subcutaneous injection of enoxaparin? Select all that apply.

a. Rotate injection sites. b. Give the injection near the umbilicus. c. Massage the injection site gently after the injection is given. d. After inserting the needle, do not aspirate before giving the injection. e. Expel the bubble from the prefilled syringe before giving the injection.

12. True or False? Enoxaparin dosage is directed by monitoring aPTT levels. Explain your answer. True, PTT levels measures body’s ability to clot.

13. L.J. asks you how long it will take for the Lovenox injections to dissolve his blood clot. What is your response to him? Most people need shots for 5 to 10 days, but in some cases it can be longer. Your doctor will tell you how long you need to have the shots as well as bridge therapy. 14. After providing teaching about anticoagulant therapy, you ask L.J. to teach back to you what he has learned. Which statements indicate a need for further education? Select all that apply. a. “I will not blow my nose really hard.” b. “I will brush my teeth gently with a soft toothbrush.” c. “I will take aspirin or ibuprofen if I have a headache.” d. “I will shave very carefully with my disposable razor.” e. “I will put lotion on my skin to keep it from getting too dry.” f. “I will purchase and wear a medical alert necklace for blood thinners.” g. “I will get help right away if I notice bleeding in my stools or urine or if I have a bad headache or stomach pain.”

15. You identify pain as a key issue in the care of L.J. List 4 interventions you will choose for L.J. to address his pain. ● Elevate legs ● Cold/hot compress to relieve pain ● Distraction from pain ● encourage rest ● administer Tylenol as ordered

16. What pertinent laboratory values and measurements would you expect the physician to order and the results of which you will monitor? Explain the reason for each test. ● PTT - anticoagulant test; check if in therapeutic range ● PT/INR - anticoagulant test; check if in therapeutic change ● Cholesterol – should be below 200 ● CBC – checking blood and platelet count ● Input/output - edema and fluid retention ● ABG’s - hypoxia, O2 levels ● Urinalysis - specific gravity/protein ● BUN/Cr - kidney function ● Chest X-ray – Checking abnormality

17. You evaluate L.J.’s electrocardiogram (ECG) strip. Name this rhythm and explain what consequences it could have for L.J.

Atrial Fibrillation. It can cause pooling of blood in the heart which can lead to blood clots and poor perfusion.

(Modified from Lilley LL, Rainforth Collins S, Harrington S, et al: Pharmacology and the Nursing Process, ed. 8, St. Louis, MO: Mosby; 2017.)

CASE STUDY PROGRESS A week has passed. L.J. responded to heparin therapy and was bridged to oral warfarin therapy. His heart dysrhythmia converted to sinus rhythm after he started taking cardiac medications, and he is being discharged to home with home care follow-up. “Good,” he says, “just in time to fly out west for my grandson’s wedding. His wife, who has come to pick him up, rolls her eyes and looks at the ceiling. 18. Although you are surprised at his comment, you realize he is serious about going to the wedding. What are you going to tell him? ● Do not sit for long periods of time, be mobile ● Give compression socks with suit ● Take medication on a schedule ● No alcohol when taking medication

19. What discharge instructions about activity will you give L.J.?

● Take medication as prescribed ● No alcohol ● Encourage rest when in pain ● Compression socks to help the circulation in your legs ● Do not massage and painful areas ● Go to ER if you have chest pain ● Avoid excessive sitting. Elevate legs or walk around.

CASE STUDY OUTCOME L.J. listens to you, and his wife is quite relieved. They were able to watch the wedding ceremony via a live-stream connection, and he watches the recording daily and points out his favorite parts to the home care nurse every time the nurse visits.

Reference: Harding, M. & Snyder, J. (2020). Clinical Reasoning Cases in Nursing 7th Edition. Elsevier: MO....