Peripheral Vascular Disorders Venous Thrombosis

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Peripheral Vascular DisordersVenous Thrombosis
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Peripheral Vascular DisordersVenous 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

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Venous ThrombosisEtiology

• Etiology - Virchows 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

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Venous ThrombosisPathophysiology

• 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

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Peripheral Vascular DisordersVenous Thrombosis

• Clinical Manifestations
• Unilateral leg edema, extremity pain, warm skin,
  erythema, fever, tenderness on palpation
• Homans 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

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Venous ThrombosisComplications

• 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

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Venous ThrombosisDiagnosis

• Venous Doppler Evaluation
• Duplex Scanning
• Combination of ultrasound imaging doppler
• Venogram

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Venous ThrombosisMedical 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

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Venous ThrombosisMedical 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

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Venous ThrombosisMedical Management

• Anticoagulation
• Heparin intravenous infusion
• APTT Activated partial thromboplastin time 24-36
  sec
• Therapeutic 46 70 sec Antidote Protamine
  Sulfate
• Coumadin -- oral
• PT Prothrombin Time compared with
• INR International normalized ratio 0.75 1.25
• Therapeutic 2-3 Antidote Vitamin K
• Overlapping Heparin Coumadin Therapies
• Coumadin takes 2-3 days to achieve therapeutic
  level

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Venous ThrombosisNursing Diagnoses

• Top Priority Nursing Diagnosis
• and
• the rationale

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Venous ThrombosisNursing 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

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Venous ThrombosisTreatment Goals

• Relief of pain
• Decreased edema
• Intact skin
• No complications from anticoagulation therapy
• No evidence of pulmonary edema

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Venous ThrombosisNursing 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

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Venous Thrombosis

• Heparin antidote?
• Coumadin antidote?

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Pulmonary EmbolismDefinition / Demographics

• Definition
• 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

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Pulmonary EmbolismEtiology

• 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

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Pulmonary EmbolismClinical Manifestations

• Severity depends on the size
• Sudden onset of
• dyspnea
• tachypnea
• tachycardia
• Other SS cough, pleuritic chest pain, rales,
  fever, hemoptysis, change in mental status

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Pulmonary EmbolismDefinition / Demographics

• Definition
• 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

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Pulmonary EmbolismDiagnostic 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

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Pulmonary EmbolismDiagnostic 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 pts signs
  and symptoms medications- (Warfarincauses
  decrease)
• lt250ng/mL within normal range

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Pulmonary EmbolismTreatment 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

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Pulmonary EmbolismDrug 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

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Pulmonary EmbolismSurgical Treatment

• Pulmonary embolectomy rarely done
• Intracaval Filter
• Greenfield stainless steel filter

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Pulmonary EmbolismSurgical TreatmentGreenfield
Filter
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Pulmonary EmbolismNursing Diagnosis

• Impaired tissue perfusion
• Pain
• Anxiety
• Knowledge Deficit
• Potential for Injury related to anticoagulation

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Pulmonary Embolism Nursing Process

• Assess
• observe effects of anticoagulation monitor
  anticoagulation level
• hemodynamic status VS, PO, cardiac monitoring,
  hemodynamic monitoringarterial PAWP
• Nsg Action HOB elevated Administer oxygen
  energy conservation
• Pt Education Rationale for all treatments
  anticoagulation therapy long term

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Pulmonary Embolism

• Heparin Type of Blood Monitoring?
• Coumadin Type of Blood Monitoring?

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Heparin TherapyBolus 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

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Heparin TherapyFlow 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

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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