Question

Read Chapter 37 from your Text Book

II. NCLEX Review Questions Chapter 37 from Evolve Resources

III. Case Study:  Deep Vein Thrombosis

Patient Profile

D.R. is a 74-year-old obese Hispanic woman who is in the third postoperative day after an open reduction internal fixation (ORIF), for repair of a left femoral neck fracture after a fall at home.

Subjective Data

States pain in her left hip is a 4 to 5 on a 1-to-10 scale

States pain in her left calf area is a 3 on a 1-to-10 scale

Discussion Questions

1. What do you suspect is occurring with D.R.? What data were used to make this determination?

2. What are the priority nursing interventions at this time?

3. Using SBAR, what would you report to the provider?

4. What diagnostic studies would be used to determine the existence, location, and extent of a DVT?

5. What risk factors for development of a DVT does D. R. have?

6. What measures can be taken to prevent a DVT in an at-risk patient?

Answer 1

1. What do you suspect is occurring with D.R.? What data were used to make this determination?

● LLE: diminished pedal pulse (+1), +2 unilateral LLE edema, pain, & increased

circumference relative to RLE, erythematous, risk due to 3 day post operation

○ Indicates DVT of LLE calf

■ Difference in calf circumference and unilateral edema + pain indicate

DVT

2. What are the priority nursing interventions at this time?

● Oxygen with the goal of reaching at least 96% SPO2

● Perform a full neuro exam, obtain an EKG, assess vital signs (specifically pulse

oximetry), ask if patient is experiencing cough, chest pain, or dyspnea: If patient is

positive for a DVT, monitor for blood clot moving to the lungs which can result in a PE,

the heart which can result in a myocardial infarction, or the brain which can result in a

cerebrovascular accident.

3. Using SBAR, what would you report to the provider?

Situation: 74-year-old obese Hispanic woman who is in the third postoperative day after

an open reduction internal fixation (ORIF), for repair of a left femoral neck fracture after

a fall at home.

Background:

Assessment:

● General: A&O x4

● Respirations - 20

○ Oxygen 93%

● Cardiac:

○ Apical pulse: 64

● Peripheral

○ LLE: diminished pedal pulse (+1), +2 unilateral LLE edema, pain, &

increased circumference relative to RLE (8 to 10), erythematous

●

Recommendation:

 Provide and monitor O2

 safety and comfort

4. What diagnostic studies would be used to determine the existence, location, and extent of a

DVT?

● Blood Lab studies

○ ACT, apTT, INR, bleeding time, Hgb, Hct, platelet count

○ D-dimer: fragment of fibrin formed from fibrin degradation. Elevated suggests

VTE

○ Fibrin monomer complex

● Noninvasive Venous Studies

○ Venous compression ultrasound: assesses location

■ Abnormal finding: vein fails to collapse with application of external

pressure

○ Duplex ultrasound: combination of compression u/s with spectral and color flow

■ Determines location and extent of thrombus

● Invasive venous studies

○ Computed tomography venography (CTV)

○ Magnetic resonance venography: evaluates blood flow accurate for pelvic and

proximal veins, less for calf veins

■ Distinguishes from acute and chronic thrombus

○ Contrast venography (phlebogram): x-ray determines extent of clot

5. What risk factors for development of a DVT does D. R. have?

● Venous stasis

○ Age: 74 y/o

○ Irregular heart rate

○ Fractured hip

○ Obesity

○ Hip reduction surgery

○ Limited mobility

● Endothelial damage

○ Hip fracture

● Hypercoagulability of blood

● Hypertension

6.What measures can be taken to prevent a DVT in an at-risk patient?

● Ambulation: Early mobilization post surgery, position change if bed rest, teach pt flex

body extremities q 2-4 hours

- Graduated compression stockings: fitted properly, worn consistently from admission until

discharge or full mobility

● Intermittent pneumatic compression devices (IPCS)

● Drug therapy

○ Anticoagulants

■ Vitamin K antagonist : Coumadin

■ Thrombin inhibitors (direct and indirect): heparin, bivalirudin, desirudin,

argatroban, dabigatran

■ Factor Xa inhibitors: fondaparinux, rivaroxaban, apixaban, edoxaban