Question

Complete system disorder on Deep vein Thrombosis: ASSESSMENT SAFETY CONSIDERATIONS PATIENT-CENTERED CARE Alterations in Health (Diagnosis) Pathophysiology Related to Client Problem Health Promotion and Disease Prevention Risk Factors Expected Findings Laboratory Tests Diagnostic Procedures Complications Therapeutic Procedures Interprofessional Care

Answer 1

Deep Vein Thrombosis - it's assessment, diagnosis and management:

Introduction

DVT is the formation of a thrombus in the deep veins.

• Most commonly in the leg either above (proximal) or below (distal) the knee, or less commonly in the upper extremities
• May be spontaneous without a known underlying cause (unprovoked/idiopathic) provoked after events, such as trauma, surgery or acute illness (provoked)
• In the shorter-term, may lead to potentially life-threatening PE
• Long-term complications may include chronic conditions such as PTS

Diagnosis

Signs and symptoms
Common symptoms of DVT include:

• Leg pain and tenderness
• Redness
• Oedema (swelling)

Clinical probability scoring
The Wells’ score is commonly used to evaluate the probability of DVT based on a patient’s medical history and physical examination. Clinical judgment plays a critical role because certain DVT risk factors and markers are evident early in the diagnostic process.

Diagnostic imaging
Compression ultrasonography (also called venous ultrasonography or ultrasound) is the most widely used method for evaluating suspected DVT because it is safe and non-invasive.

• Involves compressing and imaging the femoral veins down to the most proximal calf veins
• Has some limitations but is considered acceptable for confirming suspected DVT when combined with a Wells’ score ≥2 (indicating DVT is likely)

Alternatives to ultrasound are CT venography or MRI:

• CT venography detects both distal and proximal DVT but is invasive, painful and expensive, and is, therefore, usually used when ultrasound does not support the clinical suspicion of DVT but other assessments do.
• MRI employs a powerful magnetic field to generate a high-resolution image of anatomic structures. It is non-invasive, but its use can be limited by a long examination time and a lack of access to equipment

D-dimer measurements
D-dimer is a protein fragment produced by thrombus degradation and it forms when plasmin dissolves the fibrin strands that hold a thrombus together. A highly sensitive D-dimer test has high negative predictive value, meaning that it can be used to effectively rule out DVT in a patient with a negative ultrasound scan.

Management

The standard initial management of deep vein thrombosis has traditionally meant admission to hospital for continuous treatment with intravenous unfractionated heparin. Treatment then continued with a transition to long term use of oral anticoagulants (vitamin K antagonists). Recently a change has taken place, and low molecular weight heparins are being used.

Guidelines prepared by the haemostasis and thrombosis task force recommend that patients receive heparin for at least four days and treatment should not be discontinued until the international normalised ratio has been in the therapeutic range for two consecutive days.

1. Thrombolytic drugs

2. Inferior venacava filter

3. Elastic compression stockings

4. Heparin

Outpatient treatment of deep vein thrombosis

With the advent of low molecular weight heparins, outpatient treatment of deep vein thrombosis without monitoring activated partial thromboplastin time is now possible. Many trials have compared a home treatment regimen with hospital treatment for the initial phase of treatment for deep vein thrombosis. Most of the trials have been uncontrolled, and their limited evidence shows that home treatment is cost effective, preferred by patients, and no more liable to lead to complications than hospital treatment.

The major nursing interventions that the nurse should observe are:

• Provide comfort. Elevation of the affected extremity, graduated compression stockings, warm application, and ambulation are adjuncts to the therapy that can remove or reduce discomfort.
• Compression therapy. Graduated compression stockings reduce the caliber of the superficial veins in the leg and increase flow in the deep veins; external compression devices and wraps are short stretch elastic wraps that are applied from the toes to the knees in a 50% spiral overlap; intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings.
• Positioning and exercise. When patient is on bed rest, the feet and lower legs should be elevated periodically above the level of the heart, and active and passive leg exercises should be performed to increase venous flow.

The following complications should be monitored and managed:

• Bleeding. The principal complication of anticoagulant therapy is spontaneous bleeding, and it can be detected by microscopic examination of urine.
• Thrombocytopenia. A complication of heparin therapy may be heparin-induced thrombocytopenia, which is defined as a sudden decrease in platelet count by at least 30% of baseline levels.
• Drug interactions. Because oral anticoagulants interact with many other medications and herbal and nutritional supplements, close monitoring of the patient’s medication schedule is necessary.

References :

1.Tovey, C., & Wyatt, S. (2003). Diagnosis, investigation, and management of deep vein thrombosis. BMJ (Clinical research ed.), 326(7400), 1180–1184. https://doi.org/10.1136/bmj.326.7400.1180

2.Aschwanden M, Labs KH, Jeanneret C, Gehrig A, Jaeger KA. The value of rapid D-dimer testing combined with structured clinical evaluation for the diagnosis of deep vein thrombosis. J Vasc Surg 1999;30: 929-35. [PubMed] [Google Scholar]

3. Kearon C, Ginsberg JS, Douketis J, Crowther M, Brill-Edwards P, Hirsh J. Management of suspected deep venous thrombosis in outpatients by using clinical assessment and D-dimer testing. Ann Intern Med 2001;135: 108-11. [PubMed] [Google Scholar]