DVT and PE Flashcards by brooke posey

clot formed in a vessel

thrombus

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a thrombus that moves through the blood stream

Embolus

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inflammation associated with a clot

Thrombophlebitis

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thrombus in a deep vein with inflammation

DVT

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What is virchow’s triad?

 Vascular injury-
 Alteration of blood flow-
 Hypercoagulability

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What is a vascular injury?

Endothelial damage

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What occurs when there are alterations in blood flow?

venous stasis

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How does hypercoagulability occur?

◦ Sudden withdrawal anticoagulant meds
◦ Oral contraceptive use
◦ Clotting factor abnormalities-genetic
◦ Pregnancy

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What signs and symptoms should you look for when assessing for DVT?

◦ Dull ache
◦ Tenderness
◦ Pain
◦ Cramping
◦ Erythema
◦ Warmth
◦ Edema
◦ Measure affected extremity daily

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What are the diagnostic test done for DVT?

 D Dimer
 ESR
 Venous Duplex
 Venogram

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What are the nursing interventions?

 Activity-rest, elevate, walk after anticoagulated
 Leg exercises – elevate extremity
◦ Avoid prolonged sitting or standing
 Anti-embolism stockings
 Sequential Compression Devices (SCD)
 IV fluids
 Medications – anti coagulants
◦ Monitor: Heparin – PTT = 1.5-2.5x control
 Usually PTT=over 60-under100 per protocol
◦ Coumadin – PT/INR = 2-2.5x control
 Usually between INR 2.0-3.0
◦ Analgesics – pain relief

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What are the complications of DVT?

 Pulmonary Embolus (PE)
 Cerebrovascular Accident (CVA)
 Re-occuring DVT
 Venous stasis ulcers

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What are the priority nursing diagnosis for DVT?

 Pain
 Impaired mobility
 Ineffective tissue perfusion
Risk for embolism

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 Obstruction of the pulmonary artery or one of its branches by a thrombus
 Thrombus usually originates elsewhere in the venous system

Pulmonary Embolism

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What is the ideal location for pulmonary emboli? Why?

Lungs are ideal location for emboli to lodge because of extensive capillary network & arterial blood flow

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What part of the lungs are more frequently affected?

Lower lobes are most frequently affected because they have a higher blood flow

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What is the etiology (causes) of pulmonary embolism?

 Thrombi in the deep veins can dislodge spontaneously
 Mechanical events (ie injury, sudden standing) can break off a clot & send it into cardiovascular network
 Clot partially or completely obstructs the pulmonary artery or its branches

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What is the physiologic presentation of pulmonary embolism?

 Pulmonary alveolar space that is near the occluded vessel gets little or no O2
 Substances released from the clot cause surrounding blood vessels & bronchioles to constrict
 Gas exchange is impaired or absent
◦ Due to little or no blood flow to area

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Less common causes of pulmonary emboli besides blood clots include:

 Fat emboli
 Air emboli
 Amniotic fluid
 Tumors emboli – break off of tumor tissue

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What are the risk factors for pulmonary embolism?

 Trauma or surgery
 Heart failure
◦ Right side heart pathology
 Atrial fibrillation (irregular heart rhythm)
 Hyper-coagulable states=DVT
 Prolonged immobility
 Over age 50
 Long term use of oral contraceptives

What are the signs & symptoms of pulmonary embolism?

 Sudden onset of unexplained dyspnea
 Tachypnea
 Tachycardia
 Chest pain – sudden, sharp &amp; pleuritic
 Cough - may be dry
 Secretions - clear or blood tinged
 Crackles
 Fever
 Accentuation of pulmonic heart sound
 Change in mental status
◦ Secondary to hypoxemia
 Anxiety
 Apprehension – feeling of impending doom

What are the signs & symptoms of massive emboli?

 Sudden collapse
 Shock
 Massive emboli patients may not have chest pain
 EKG indicates right ventricular strain with acute cor pulmonale
◦ Right ventricle can no longer pump blood into the lungs
 Death occurs in > 60% of patients

 May go undetected
 Produce vague transient symptoms
 May cause cardiac compromise

small pulmonary emboli

What are the complications of a pulmonary embolism?

Pulmonary infarction

* Pulmonary hypertension

occurs death of lung tissue occurs with medium or large sized pulmonary vessels are occluded

pulmonary infarction

occurs when there is insufficient collateral blood flow as well as pre-existing lung disease is present

pulmonary infarction

Occurs when more than 50% of area of normal pulmonary bed compromised

pulmonary hypertension

occurs when there is dilation & hypertrophy of the right | ventricle from multiple Pulmonary Emboli

pulmonary hypertension

What are the diagnostic test for pulmonary emboli?

* Spiral CT (also called helical) * Ventilation/Perfusion lung scan * Coagulation studies * Platelets * Venous doppler * Duplex scanning * Venogram * Pulmonary angiogram * EKG * CBC * ABGs

 Supplies definitive diagnosis  Most recently developed  Most accurate method  beam remains on continuously & rotates around patient  More efficient technique ◦ Reduces scanning time of entire chest to 20- 30 seconds  3 dimensional images

spiral CT

◦ Injection of a radioisotope | ◦ Scanning device detects ability of the body to pick up the isotope

perfusion scanning

◦ Inhalation of a radioactive gas (xenon) ◦ Patient is then scanned for the lung pick-up of the gas ◦ Must be cooperative for this test ◦ May be omitted for intubated patients

ventilation scanning

◦APTT, PT, INR: | ◦Use to monitor the anticoagulation medication used for treatment of PE

Coagulation studies

 Although not a diagnostic for PE |  This test may R/O blood dyscrasia which may be causative factor for PE

platelets

◦ Assesses blood flow in veins

venous doppler

◦ Ultrasound imaging & Doppler to determine location & extent of thrombus within the veins

duplex scanning

X-ray determination of location & extent of clot using contrast media to outline filling defects Development of collateral circulation is defined

venogram

A contrast is injected  Patient is then x-rayed to determine location & size of pulmonary emboli

pulmonary arteriogram

What type of conservative care should be done for mild pulmonary embolism?

``` Elevate HOB when SOB = High Fowlers  Patients receive oxygen based on ABGs  IV site maintenance  Activity-rest, elevate, walk after anticoagulated  Pain relief - analgesics  EKG  Anti-coagulation ```

◦ Initial treatment = Heparin ◦ May be omitted in the following patients:  Blood dyscrasias, history of hemorrhagic CVA, neurologic conditions or hepatic dysfunction

Anti-coagulation

What should be included in the discharge plan for anti-coagulation: heparin administration?

 SQ Heparin ◦ Injection instructions may be part of the nurse’s role  Bleeding precautions  Avoidance of drugs that increase risk of bleeding

What are the treatments for pulmonary embolism?

* low molecular weight heparin * warfarin * dabigatran * rivaroxaban * Thrombolytic Therapy

 Interfers with liver synthesis of the vitamin K dependent clotting factors  Depress synthesis of factor X, IX, VII, & II prothrombin  Agent does not affect established clots  Prevents further extension of formed clots  Taken 1X a day, after maintenance dose established  Coumadin cannot be given to pregnant patients

warfarin (Coumadin)

Side effects:  Hemorrhage – bleeding precautions  Antidote = Vitamin K  Coagulations Studies: must be routinely monitored to avoid excessive anti coagulation  PT / INR – must be in therapeutic range, monitored in “Coumadin Clinic”

warfarin (Coumadin)

Patient Teaching:  Bleeding precautions  Recommend pt limit-avoid green/leafy veggies & any food high in vitamin K – decreases effectiveness

warfarin (Coumadin)

Actions:  Inhibits thrombin, blocks last step in clot formation  Approved prevent clots in Afib - drug of choice

dabigatran (Pradaxa)

Side Effects:  Hemorrhage – bleeding precautions  Used with caution due to lack of antidote  No dietary restrictions

dabigatran (Pradaxa) and rivaroxaban (Xarelto)

Actions:  Blocks an earlier step in clot formation  Approved to prevent DVT that might lead to PE in pts with knee or hip replacement

rivaroxaban (Xarelto)

```  Actions: ◦ Used for severely compromised pts ◦ Helps restore hemodynamic stability  Side effects: Severe bleeding  Contraindications: ◦ Less than 2 months since CVA ◦ Less than 10 days post op ◦ Recent child birth, trauma, or severe HTN ```

Thrombolytic Therapy:  Medications: ◦ Urokinase, Streptkinase, Reteplase