1. Vascular Disorders: Deep Vein Thrombosis, Pulmonary Embolism, Peripheral Vascular Disease
Brunner ch 31, pp ,

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