Class 3: DVT and Pulmonary Embolism

Perfusion and clotting

Virchows triad

Venous stasis

Damage of vein linings

Hypercoagulability 

Virchows triad: Venous Stasis 

Blood isn’t moving. Some causes: 

Immobility/long periods of sitting 

Anaesthetic 

Pregnancy 

Varicose veins 

Virchows triad: Damage of vein lining

Some causes of damage:

IVs/Drugs/medications

Athrogenesis 

Smoking 

Diabetes 

Burns

Trauma 

Chemotherapy 

Virchows triad: Hypercoagulability 

Blood sticking together more

Birth control

Medication side effects 

Smoking

Anemia 

Other factors that increase the risk of DVT or SVT

Family history

Previous clots

Where do SVTs normally occur

Theyre not as common as DVTs.

Normally occur in legs (also in armsbut more rare)

Signs and symptoms of SVT

Palpable, cordlike vein (hard, not bouncy)

Tender, reddened, warm

Mild temperature 

How is SVT diagnosed

Ultrasound (duplex-visual and audio to listen to blood flow) 

SVT interprofessional care

Removal of IV (if thats the cause)

Elevate extremity

Warm, moist heat 

NSAIDs

Anticoagulants 

Compression stockings (if on lower extremity)

Mild exercise (walking)

Signs and symptoms of DVT

Unilateral leg edema

Pain

Tenderness

Paresthesia (tingling from pressure on nerves)

Warm skin

Erythema 

Elavted temp

Diagnosis of DVT

Clinical assessment

D-dimer levels (extremely elevated)

Duplex ultrasound 

What does D-dimer measure

Amount of fibrin in blood

Normal amount is very minimal, will be extremely elevated if DVT is present 

DVT assessment

Comparing both legs (to have a baseline). Looking for:

Pulses

Pallor 

Pain 

Bruising 

Cap refill

Complications of VTE (DVT/SVT)

Pulmonary embolism

Post thrombotic syndrome 

Phlegmasia cerulea dolens (very rare)

Post thrombotic syndrome

20-50% of patients with VTE

Will resolve over time 

Pain, aching, heaviness, cramps, persistent edema 

Home management:

compression devices

Physio

anticoagulants

mobility aids (if needed)

Phlegmasia Cerulea dolens

Very rare

Associated with advanced cancer

Have to open up vessel

Develops quickly

Swollen, blue, painful leg 

Sudden massive swelling, deep pain, intense cyanosis of extremity 

Prevention and prophylaxis of VTEs

Early mobility

Graduated compression stockings (TEDS)

Sequential compression devices (SCDs) (inflatable)

How to incorporate early mobility into VTE prevention

Get them standing/walking as early/as much as possible 

If they can’t walk/stand:

Meals in chair and ambulate 4-6x per day 

Bed mobility (turn Q2, flex and extend feet, knees and hips Q2-4)

Considerations for TEDs and SCDs

Assess skin regularly (at least Qshift)

Medication/surgical intervention for VTE

Start with anticoagulants and advnace as needed:

Anticoagulant medications

Thrombolytic medications

Surgical and interventional therapy

Anticoagulant therapy considerations:

PO can take days to come into effect, so may start with IV and oral then d/c IV when INR is therapeutic 

IV heparin/lovenox during PO warfarin  

Examples of anitcoagulant medications

Heparin

Lovenox 

Warfarin 

Argatroban 

Pradaxa 

Xarelto

Therapuetic INR (for warfarin)

2-3 (want slightly higher than normal)

Thrombolytics meds use

For complete obstruction/when its really needed

Contraidicated in some pts 

Breaks up clot 

Examples of thrombolytic medications

Urokinase 

Tissue plasminogen activator 

Surgical therapy for VTEs

Only use when needed, increases risks 

Thrombectomy (removal of clot)

IVC filter (traps large emboli and prevents PE)

Nursing Management of VTEs

Prevention

Assessment (head to toe, vitals, monitor blood work)

Avoid IM injections (increased bleeding risk)

Encourage mobility 

Eductate patient 

What to monitor in a VTE pts blood work

Platelets

What to edciate patient on regarding VTEs

No sitting for a long time

Move around 

Do not cross legs (causes compression)

S+S of a PE

Signs of bleeding

Bruising

Bloody stool

Decreased BP and increaed HR

Bleeding gums

Takes a long time to stop bleeding after a cut, IV or injections

Signs and symptoms of a PE

May have none/be unspecific 

Sudden SOB

Chest pain

Hemoptysis 

Pink tinged sputum

Mild to moderate hypoxemia (change in mental status 

Cough 

Crackles 

Fever 

PE

Blockage of a pulomary artery (from thrombus, fat, air emboli, tumour)

Risk factors for PE

Immobility/reduced mobility (move Q2)
Surgery in the last 3 months

History of DVT

Malignancy

Obesity

Pregnancy

Oral contraceptives

Hormone therapy

Cigarette smoking

Prolonged air travel

Clotting disorders

Diagnostic studies for a PE

Spiral CT scan/CT pulm-angio 

Ventilation perfusion (VQ)

D-Dimer (elevated)

Spiral CT scan

IV contrast 

Checking lung perfusion

Ventilation perfusion (VQ)

For patients who cant have contrast

Injected in IV and inhaled 

Looking at gas exchange under x ray 

ABG and PE

Supports diagnosis, doesnt confirm it

Very painful so avoid if possible

Other tests to run if pt presents with s+s of PE

EKG and troponin

May be a myocardial infarction

Prevention of a PE

SCDs/TEDs

Early ambulation

Prophylactic anticoagulants 

O2 (want >90)

Turning

Coughing 

Deep breaths 

Incentive spirometry 

Medication theraoy of a PE

Fibrinolytic meds (tPA, alteplase) to dissolve PE

Anticoagulant therapy (prevent further emboli)

Surgical therapy of a PE

Embolectomy (rare, only if not responding to other tx, lots of risks associated)

Inferior vena cava filter (temporary or permanent)

Nursing management of a PE

Prevention measures

Bedrest, semifowlers (not flat, comfortable position)

IV, O2

Physical assessment and vitals 

Lab values (aPTT, INR, ABGs)

Monitor for bleeding

Emotional support and education

Considerations for warfarin

Antidote: Vitamin K (know location)

INR should be 2-3 

Monitor lab values (CBC-platelets, check before giving)

Monitor for side effects (thromobocytopenia, anemia, hemorrhage)

Considerations for heparin

Antidote: Protamine sulfate

Dont get rid of air bubble while giving 

Heparin induced thrombocytopenia (AI response where plateletes stick together and clots form), changed meds if this occurs

Monitor lab values (CBC-platelets, check before giving)

Monitor for side effects (thromobocytopenia, anemia, hemorrhage)

Thrombolytic meds considerations

Review side effects and contraindications

FOllow hospital protocol 

Pre labs: PT, PTT, Hgb, Platelets 

Monitor for bleeding (increased risk!)

No IM/IV injections 

Monitor VS and O2 sat (continuous)

Cardiac monitor 

Why might someone on a thrombolytic med be moved to ICU

Need continous O2/cardiac moniter 

At increased risk for bleeds 

Thrombolytic meds

Clot busters:

tPA

Alteplase (Activase)