case study

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WELCOME
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• 
  
  Presenters
• Jenson Manjaly Jose
• Shaini Abraham
• Sharan Preet Kaur
• Silsa Beegum Saifudeen Lailabeevi
• Teena Eapen

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1. HOMANS SIGN
Homans sign is an assessment finding, which
reveals pain or cramping in the calf. The
positive Homans sign is pain in the calf on
dorsiflexion of the affected foot. (Lemone, Burke
Bauldoff, 2011).
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2. DIAGNOSTIC CUES OF DVT
Deep vein thrombosis (DVT) occurs when blood clot
(thrombus) forms in one or more deep veins in the
body especially on legs. Deep vein thrombosis
may occur without any symptoms, but sometimes it
may occur with swelling and pain on legs. DVT
can also develop in certain medical conditions
such as varicose vein, clotting disorders and
prolonged bedridden patients. (Mayo clinic,
2016). blood results show elevated serum D dimer
level (normal value is less than 250mcg/L)
(WebMD, 2016).
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3.PATHOPHYSIOLOGY OF DVT
The pathophysiology of DVT was described by
Virchow in 1846 as coming from a triad of
possible changes in the venous system. The triad
includes ? Changes in the vessel wall
(injury) ? Changes in the pattern of blood flow
(venous stasis) and ? Changes in the constituency
of blood (hypercoagulability) These
physiological changes can occur as a result of
pathology, therapies and treatments. Injury to
the vessel wall may occur from trauma, surgery or
invasive treatments. ( WebMD,2016).
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4. NON PHARMACOLOGICAL MANAGEMENTS AFTER KNEE
SURGERY
A compression dressing is required to
immobilize the knee in extension immediately
after post-operative care. Isometric quadriceps
exercise begins the first day after
surgery. Active flexion exercise or passive
flexion exercises. Hemodynamic monitoring every
15 minutes. Assess airway and breathe sounds
because there is a chance to develop airway
obstruction and respiratory complication.
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• Assess neurological status including level of
  conscious and movement of extremities. The knee
  is usually protected with a knee immobilizer such
  as splint, cast or brace.
• Assess wound site drainage tubing.
• Assess urinary status, and patency of the
  catheter.
• Assess pain level and discomfort if it is
  intolerable informs the physician and get pain
  medication for the same.
• Check IV infusion and patency of the line.
• (Heikkinen, Lenio-kilpi, Hiltunen Johan
  son,2007).

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5. PHARMACOLOGICAL MANAGEMENTS
The main goals of treating deep vein thrombosis
includes Stop the blood clot from getting
bigger Prevent the blood clot from breaking off
and moving to lungs. Reduce the chance of
having another blood clot Minimize the risk of
developing the post thrombotic syndrome
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Contd1.Anticoagulants (Blood Thinners)
Warfarin 2.Low Molecular Weight
Heparins3.Unfractionated Heparins (UFH)
4.Vitamin K antagonists5. Non-warfarin oral
anticoagulants6.INFERIOR VENECAVA FILTER
(IVCF)7.Thrombolytic (fibrinolytic) drugs
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6. POST OPERATIVE NURSING CARE PLANS OF TKR
PATIENT WITH DVT
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Risk for infection related to inadequate primary
defenses. (broken skin and exposure of joint)

  NURSING INTERVENTIONS RATIONALE
  a. Use strict aseptic techniques as indicated to reinforce or change dressing when handling drains.  b. Investigate reports of increased incisional pain, changes in characteristics of pain.   a. Prevents contamination and risk of wound infection, which could require removal of prosthetics.  b. Deep, dull, aching pain in operative area may indicate developing infection in joint.
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2. Impaired physical mobility related to pain and
surgery. (Gulanick, Klopp, Galanes, Myers,
Gradishar, Puzas, 2003, p. 645).
  NURSING INTERVENTION   RATIONALE
 a. Promote participation in rehabilitative exercise program. (Quadriceps gluteal muscle setting, isometrics, leg lifts, dorsiflextion.) .   b.Investigate sudden increase in pain and shortening of limb as well as changes in skin colour, temperature and sensation.  a. Strengthen the muscle groups, increasing muscle tone and mass stimulate circulation.  b.Indicative of slippage of prosthesis, chances of developing DVT. (Requiring medical evaluation/ intervention.)      
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3. Risk for peripheral neurovascular dysfunction
related to vascular obstruction (Doenges,
Moorhouse, Murr, 2010, p. 658).
  NURSING INTERVENTION   RATIONALE
 a. Palpate pulses on both sides. Evaluate capillary refill, skin colour and temperature. b. Evaluate for calf tenderness, positive Homans sign and inflammation.  a. Diminished / absent pulses, delayed capillary refill time, cyanosis and coldness of skin. b. Early identification of thrombus development and intervention may prevent embolus formation.
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4. Acute pain related to surgical procedure,
infection and DVT. (Doenges, Moorhouse, Murr,
2010, p.657).
  NURSING INTERVENTION   RATIONALE
 a. Investigate reports of sudden, severe joint pain with muscle spasms and changes in joint mobility sudden severe chest pain with dyspnoea and restlessness.   b.Maintain proper position of operated extremity.  a. Early recognition of developing problems such as dislocation of prosthesis or pulmonary emboli provides opportunity for prompt intervention and prevention of more serious complications. b. Reduces muscle spasm and undue tension on new prosthesis and surrounding tissues.
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5. Knowledge deficient related to surgical
interventions and future expectations
(Swearingen, 2012, p. 485).
  NURSING INTERVENTION   RATIONALE
 a. Review activity limitations depending on joint replaced for hi/knee sitting for long periods or in low chair/ toilet seat, jogging, jumping, excessive bending, lifting, twisting or crossing legs. b. Review and have patient or care giver demonstrate incisional / wound care  a. Prevent undue stress on implant. Long term restriction depends on individual situation or physicians protocol.  b. Promotes independence in self care , reducing risk of complication.
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7. INCIDENCE, CAUSE, SYMPTOM AND PREVENTION OF
POST PHLEBITIC SYNDROME
Post-thrombotic syndrome or PTS is a potential
long term complication. Incidence is that PTS
develops in 20 to 50 of patients after a first
episode of lower extremity DVT. Cause is unclear,
inflammation may play a role, damage to vessel
from thrombus, chronic DVT and manifests chronic
symptoms. (Nayak Vendantham, 2012)
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According to Nayak Vendantham (2012), symptoms
are mainly related to lower extremity which
includes Chronic aching (pain) Swelling Ulc
eration Fatigue, heaviness Edema Severe
manifestations may include venous claudication
and venous leg ulcers, which can limit patients
activity and ability to work.
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According to Nayak Vendantham (2012),
prevention focuses on Risk factor modification
like to encourage patients to stop smoking or
help them to access smoking cessation programs
and counsel them to reduce weight if possible as
smoking and obesity are risk factors which
worsens the disease process. Encourage to wear
elastic compression stockings daily. Exercise
therapy only for mild and moderate level
patients not for severe cases. Encourage
compliance with DVT therapy (which includes
anticoagulant therapy like warfarin). Wound
care for venous leg ulcers (including compression
wraps, topical antibiotics and ointments.
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References
Doenges, M.E., Moorhouse, M.F., Murr,
A.C.(2006).Nursing Care Plans /Guidelines for
Individualizing Client Care .(8th ed.).F.A Davis
Company Philadelphia. Douketis, J.D. (2016).
Deep Vein Thrombosis Treatments. Merck Manuals.
Retrieved on 18 August, 2016 from
http//www.merckmanuals.com/professional/cardiovas
cular-disorders/peripheral-venous-disorders/deep-v
enous-thrombosis-dvt Heikkinen, K., L enio-Kilpi,
H., Hiltunen, A., Johansson, K., (2007).
Ambulatory orthopedic surgery patients
expectations and perceptions of received
knowledge. Journal of Advanced Nursing, 60(3),
270-278. Lemone, P., Burke, K., Bauldoff, G.
(n.d.). Medical Surgical Nursing Critical
Thinking in Patient Care (5th ed., Vol. 1).
United States Pearson Education
Publishing. Mayoclinic.(2016). Diseases and
Conditions Deep Vein Thrombosis Retrieved from
http//www.mayoclinic.org/diseases-conditions/dee
p-vein-thrombosis/basics/tests-diagnosis/con-20031
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Lemone, P., Burke, K., Bauldoff, G. (n.d.).
Medical Surgical Nursing Critical Thinking in
Patient Care (5th ed., Vol. 1). United States
Pearson Education Publishing. Nayak, L.,
Vendanthan, S. (2012, March). Post - Thrombotic
Syndrome. Seminar Interventional Radiology,
1(29), 16-22. doi10.1055/5-0032-1302447 Swearinge
n, P.L. (2012). All in One Care Planning Resource
(3rd ed.). Elsevier, MO St. Louis. Gulanick.
Klopp, A., Galanes, S., Myers, J.L., Gradishar,
D., Puzas, M.K. (2003). Nursing diagnosis and
interventions (5th ed.).Elsevier, MO St.
Louis. Wong, E. Chaudhry, s. (2016).Pathophysiol
ogy. org, Venous Thrombo Embolism, Retrieved
from http//www.pathophys.org/vte/ Web
MD.(2016).D- DIMER Test Retrieved from
http//www.webmd.com/dvt/d-dimer-test
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