1. Peripheral Vascular Disorders Venous Thrombosis

3. Peripheral Vascular Disorders Venous Thrombosis
Most common disorder of the veins
Thrombus formation associated with inflammation
Superficial – occurs in 65% of patients receiving IV therapy
Deep Vein Thrombosis
Iliac or femoral vein
5% of all postoperative patients

4. Venous Thrombosis Etiology
Etiology - Virchow’s Triad
Venous stasis
Atrial fibrillation, obesity, immobility, pregnancy
Endothelial damage
Trauma, external pressure, IV caustic substances
Hypercoagulability of the blood
Hematologic disorders – polycythemia, severe anemias, malignancies, sepsis, use of contraceptives, smoking

5. Venous Thrombosis Pathophysiology
Thrombus formation: RBCs, WBCs, platelets & fibrin
Valvular cusps of veins
Clot increased in size – develops a “tail”
Partial occlusion
Complete occlusion
May detach and become “embolus” – travels through larger vessels then lodges in pulmonary circulation

6. Peripheral Vascular Disorders Venous Thrombosis
Clinical Manifestations
Unilateral leg edema, extremity pain, warm skin, erythema, fever, tenderness on palpation
+ Homan’s Sign: pain on forced dorsiflexion of the foot when the leg is raised – unreliable sign – late and appears in only 10% of the patients
If the inferior vena cava is involved – lower extremities edematous and cyanotic
If the superior vena cava is involved – upper extremities, back, neck and face show signs

7. Venous Thrombosis Complications
Pulmonary Emboli
Life threatening
Chronic venous insufficiency
Valvular destruction, retrograde blood flow
Persistent edema, increased pigmentation, secondary varicosities, ulceration, dependent position cyanosis
Phlegmasia cerulea dolens – rare
Sudden occurrence - edematous cyanotic painful leg
May result in gangrene

8. Venous Thrombosis Diagnosis
Venous Doppler Evaluation
Duplex Scanning
Combination of ultrasound imaging & doppler
Venogram

9. Venous Thrombosis Medical Management
Prevention & Prophylaxis
At risk patients – AROM/PROM Exercise; ambulation; elastic compression hose; intermittent compression devices (venodynes); low molecular weight (LMWH) anticoagulation
Non-pharmacologic
Bedrest with leg elevated; custom fit support hose

10. Venous Thrombosis Medical Management
Drug Therapy
Anticoagulation
Prevention of clot propagation & development of new clots or embolization
Does not dissolve the present clot
Heparin
Inhibits Factor IX & potentiates the action of antithrombin III – Intrinsic Clotting Pathway
Inhibits thrombin-mediated conversion of fibrinogen to fibrin
Coumadin
Inhibits hepatic synthesis of Vitamin K-dependent coag factors II, VII, IX, & X

11. Venous Thrombosis Medical Management
Anticoagulation
Heparin – intravenous infusion
APTT Activated partial thromboplastin time sec
Therapeutic: 46 – 70 sec Antidote: Protamine Sulfate
Coumadin -- oral
PT Prothrombin Time compared with
INR International normalized ratio 0.75 – 1.25
Therapeutic: Antidote: Vitamin K
Overlapping Heparin & Coumadin Therapies
Coumadin takes 2-3 days to achieve therapeutic level

12. Venous Thrombosis Nursing Diagnoses
Top Priority Nursing Diagnosis
and
the rationale

13. Venous Thrombosis Nursing Diagnoses
Acute pain r/t venous congestion impaired venous return, and inflammation
Potential complication: bleeding r/t anticoagulant therapy
Ineffective health maintenance r/t lack of knowledge
Potential complication: pulmonary embolism r/t thrombus, dehydration, immobility

14. Venous Thrombosis Treatment Goals
Relief of pain
Decreased edema
Intact skin
No complications from anticoagulation therapy
No evidence of pulmonary edema

15. Venous Thrombosis Nursing Process
Assess: Hemodynamic status; peripheral vascular assessment; anticoagulation side effects; anticoagulant lab values; assess for interacting medications; assess for complications
Nsg Action: Administer meds & adjust according to specific times; Avoid trauma; skin protection; proper body positioning; referrals as needed
Pt/Family Education: Long-term anticoagulation therapy; DVT prevention

16. Venous Thrombosis
Heparin – antidote?
Coumadin – antidote?

17. Pulmonary Embolism Definition / Demographics
Blockage of pulmonary artery by thrombus, fat, or air emboli
Most common complication of hospitalized patients
650,000 in USA per year
50,000 deaths per year

18. Pulmonary Embolism Etiology
Presence of unsuspected DVT
Originate from femoral or iliac veins
Most common mechanism:
Jarring of the thrombus by mechanical forces – sudden standing, changes in the rate of flow, e.g., Valsalva
Fat embolism – fractured long bones / pelvis
Air embolism – improper IV therapy

19. Pulmonary Embolism Clinical Manifestations
Severity depends on the size
Sudden onset of:
dyspnea
tachypnea
tachycardia
Other S&S: cough, pleuritic chest pain, rales, fever, hemoptysis, change in mental status

20. Pulmonary Embolism Definition / Demographics
Blockage of pulmonary artery by thrombus, fat, or air emboli
Most common complication of hospitalized patients
650,000 in USA per year
50,000 deaths per year

21. Pulmonary Embolism Diagnostic Studies
Ventilation – Perfusion Lung Scan
Perfusion scanning: IV injection of radioisotope – detects adequacy of pulmonary circulation
Ventilation scanning: inhalation of radioactive gas (xenon) – detects distribution gas through the lung fields – may not be able to be done in critically ill patients
Pulmonary Angiography – peripheral catheter advanced into pulmonary artery – contrast media allows visualization of pulmonary circulation & location of embolus
Computerized tomography – multislice spiral views
Arterial Blood Gas Analysis – respiratory alkalosis

22. Pulmonary Embolism Diagnostic Studies
D-Dimer Test:
Assists in the detection and evaluation of pulmonary embolism
Plasma study/blue top tube
Increased result: arterial or venous thrombus, DVT; DIC; Pulmonary embolism; recent surgery; secondary fibrinolysis
Evaluate test results in relation to pt’s signs and symptoms; medications- (Warfarin—causes decrease)
<250ng/mL– within normal range

23. Pulmonary Embolism Treatment Goals
Prevent further growth or multiplication of thrombi in the lower extremities
Prevent embolization from the upper or lower extremities to the pulmonary vascular system
Provide cardiovascular support

24. Pulmonary Embolism Drug Therapy
Anticoagulation Therapy**
Immediate Prevention: Heparin by infusion
Therapy adjusted according to PTT
Long Term Prevention: Coumadin (Warfarin)
Therapy adjusted according to INR
Thrombolytic Therapy – tPA – dissolves PE and the source of the thrombus
** May be contraindicated – blood dyscrasias, hepatic dysfunction, overt bleeding, hx of hemorrhagic stroke

25. Pulmonary Embolism Surgical Treatment
Pulmonary embolectomy – rarely done
Intracaval Filter –
Greenfield stainless steel filter

26. Pulmonary Embolism Surgical Treatment Greenfield Filter

27. Pulmonary Embolism Nursing Diagnosis
Impaired tissue perfusion
Pain
Anxiety
Knowledge Deficit
Potential for Injury related to anticoagulation

28. Pulmonary Embolism Nursing Process
Assess:
observe effects of anticoagulation; monitor anticoagulation level
hemodynamic status: VS, PO, cardiac monitoring, hemodynamic monitoring—arterial & PAWP
Nsg Action: HOB elevated; Administer oxygen; energy conservation
Pt Education: Rationale for all treatments; anticoagulation therapy – long term

29. Pulmonary Embolism Heparin – Type of Blood Monitoring?
Coumadin – Type of Blood Monitoring?

30. Heparin Therapy Bolus in Units and mL IV Push
A patient with deep vein thrombosis who weighs 163 pounds is ordered to have a heparin bolus of 80 units per kg followed by an infusion. Calculate the dosage of the heparin bolus to be administered.
USE HEPARIN BOTTLE 1,000 u/ mL- RN mixes
Step 1 – convert pounds to kilograms:
163 / 2.2 = 74 kgs.
Step 2 – calculate dose in units: 74 x 80 = 5920units
Step 3 – calculate mL dosage
1000U : 1ml :: 5920 u : X mL
1000U x XmL = 5920U - bolus
X mL = 5920 / 1000 = 5.9 mL bolus

31. Heparin Therapy Flow rate in mL/hr
Order: Heparin 2,500 U per hr via IV pump from Heparin 50,000U in 1,000mL D5W.
Use Heparin Bottle 25,000U/mL – mixed by Pharmacy
Calculate the flow rate. Show all math.
Step 1: U/mL: 50,000 / 1,000 = 50 U/mL
Step 2 –
50U : 1 mL :: 2,500U : XmL
50x = 2,000
X = 2,500 / 50
X = 50mL/hr

32. Heparin Therapy Amount in Units/Hour
A patient is receiving 20,000 units of heparin in 1,000 mL of D5W
by continuous infusion at 30mL/hr. What heparin dose is he receiving?
Use Heparin Bottle 25,000U/mL – mixed by Pharmacy
20,000 u : 1,000 :: XU : 30mL
1,000mL x XU = 20,000U x 30mL
1,000 x XU = 600,000
XU = 600,000 / 1,000 = 600units/hr