Vascular Disorders: Deep Vein Thrombosis, Pulmonary Embolism, Peripheral Vascular Disease

1. Vascular Disorders: Deep Vein Thrombosis, Pulmonary Embolism, Peripheral Vascular Disease Brunner ch 31, pp 848-866, 874-884

2. Terminology • Sometimes called thrombophlebitis, phlebothrombosis, venous thrombosis, venous thromboembolism (VTE) • Venous thrombosis refers to clot formation in a vein with inflammation • Superficial—in small vein (INT site) • Deep—usually iliac or femoral

3. Etiology • Virchow’s triad: • Venous stasis • Damage of endothelium • Hypercoagulability

4. 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

5. 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.

6. 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, D-dimer blood test

7. 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

8. Prevention—Surgical Care Improvement Project • Started in 1999 to identify and implement ways to decrease postop complication.s • Research found that in all major surgeries, 25% of pts developed DVT and 7% developed pulmonary embolism. • Recommendation: patients receive prophylaxis within 24h a or p surgery. Could be TEDS, IPCD, LMWH*, ASA.

9. 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

10. 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 • 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.

11. 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

12. 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

13. 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

14. Nursing Management of DVT • Practice prevention for at-risk pts. • For acute cases: • 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

15. Patient Education • Anticoagulant therapy • Home treatment of DVT • Prevention • Dietary restrictions related to warfarin tx • Complications • How to give Lovenox at home • Home INR testing • How to apply TEDs

16. Pulmonary Embolism • Usually caused from clots in the deep veins of the legs • Embolizes to the lung vasculature, cutting off blood supply to a part of the lung, causing it to infarct.

17. Manifestations • Dyspnea, tachypnea, tachycardia, hemoptysis, chest pain • Can lead to right-sided heart failure and respiratory failure • + Chest x-ray, VQ scan, CT, blood D-dimer

18. Management • IV Heparin, Lovenox, or thrombolytics (severe cases only) • Warfarin for long-term therapy • Multiple incidences may necessitate the implantation of a vena cava filter. • Nurses need to monitor anticoag tx, provide education, and practice prevention.

19. 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 • Risk factors are same as CAD

20. Arterial Manifestations • 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 (pain with exercise) • Brittle, thick nails

21. Venous Manifestations • 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

22. Diagnostics • Doppler ultrasound (853) • Duplex ultrasound (855) • Ankle-brachial index (ABI) (853) • Exercise testing (854) • CT and MRI • Angiography and venography • Contrast dye needs to be carefully considered in patients with renal dz

23. Management: Arterial Insufficiency • Control modifiable risk factors—smoking is #1! • Keep legs and feet in dependent position • Use warmth carefully, avoid cold • Encourage walking—to point of pain, rest, then resume • No leg crossing, constrictive clothing • Good foot care • Good nutrition

24. Pharmacologic Management • Vasodilators • Adrenergic blocking agents • Narcotics • Trental or Pletal • Aspirin or Plavix • Statins

25. Surgical/Radiologic Management • Bypass grafting • Percutaneous transluminal angioplasty—balloon with stent placement • Endardarectomy • With all of these interventions, postop assessment of neurovascular status (6 Ps) is crucial!!

26. Management: Venous Insufficiency • Elevate legs and feet 10-30” q2h during day • Elevate legs and feet at night • Compression stockings • Encourage walking • Avoid trauma, constriction, leg crossing • Good foot care

27. Management of Leg Ulcers • Goals of care: • Promote skin integrity • Increase mobility • Provide good nutrition

28. 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.

29. 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 or pharmacologic debridement, growth factor stimulants, wound vacs, hyperbaric O2 chambers, or skin grafts may be indicated.

30. 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