Peripheral Vascular Disorders
Venous Thrombosis
Peripheral Vascular Disorders
Venous Thrombosis
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Most common disorder of the veins
Thrombus formation associated with
inflammation
Superficial – occurs in 65% of patients
receiving IV therapy
Deep Vein Thrombosis
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Iliac or femoral vein
5% of all postoperative patients
Venous Thrombosis
Etiology
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Etiology - Virchow’s Triad
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Venous stasis
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Endothelial damage
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Atrial fibrillation, obesity, immobility, pregnancy
Trauma, external pressure, IV caustic substances
Hypercoagulability of the blood
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Hematologic disorders – polycythemia, severe anemias,
malignancies, sepsis, use of contraceptives, smoking
Venous Thrombosis
Pathophysiology
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Thrombus formation: RBCs, WBCs, platelets
& fibrin
Valvular cusps of veins
Clot increased in size – develops a “tail”
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Partial occlusion
Complete occlusion
May detach and become “embolus” – travels
through larger vessels then lodges in
pulmonary circulation
Peripheral Vascular Disorders
Venous Thrombosis
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Clinical Manifestations
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Unilateral leg edema, extremity pain, warm skin,
erythema, fever, tenderness on palpation
+ Homan’s 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
Venous Thrombosis
Complications
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Pulmonary Emboli
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Life threatening
Chronic venous insufficiency
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Valvular destruction, retrograde blood flow
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Persistent edema, increased pigmentation, secondary
varicosities, ulceration, dependent position cyanosis
Phlegmasia cerulea dolens – rare
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Sudden occurrence - edematous cyanotic painful leg
May result in gangrene
Venous Thrombosis
Diagnosis
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Venous Doppler Evaluation
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Duplex Scanning
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Combination of ultrasound imaging & doppler
Venogram
Venous Thrombosis
Medical Management
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Prevention & Prophylaxis
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At risk patients – AROM/PROM Exercise;
ambulation; elastic compression hose; intermittent
compression devices (venodynes); low molecular
weight (LMWH) anticoagulation
Non-pharmacologic
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Bedrest with leg elevated; custom fit support hose
Venous Thrombosis
Medical Management
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Drug Therapy
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Anticoagulation
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Prevention of clot propagation & development of new
clots or embolization
Does not dissolve the present clot
Heparin
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Inhibits Factor IX & potentiates the action of
antithrombin III – Intrinsic Clotting Pathway
Inhibits thrombin-mediated conversion of fibrinogen to
fibrin
Coumadin
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Inhibits hepatic synthesis of Vitamin K-dependent coag
factors II, VII, IX, & X
Venous Thrombosis
Medical Management
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Anticoagulation
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Heparin – intravenous infusion
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Coumadin -- oral
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APTT Activated partial thromboplastin time 24-36 sec
Therapeutic: 46 – 70 sec Antidote: Protamine Sulfate
PT Prothrombin Time compared with
INR International normalized ratio 0.75 – 1.25
Therapeutic: 2-3 Antidote: Vitamin K
Overlapping Heparin & Coumadin Therapies
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Coumadin takes 2-3 days to achieve therapeutic level
Venous Thrombosis
Nursing Diagnoses
Top Priority Nursing Diagnosis
and
the rationale
Venous Thrombosis
Nursing Diagnoses
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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
Venous Thrombosis
Treatment Goals
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Relief of pain
Decreased edema
Intact skin
No complications from anticoagulation therapy
No evidence of pulmonary edema
Venous Thrombosis
Nursing Process
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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
Venous Thrombosis
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Heparin – antidote?
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Coumadin – antidote?
Pulmonary Embolism
Definition / Demographics
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Definition:
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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 Embolism
Etiology
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Presence of unsuspected DVT
Originate from femoral or iliac veins
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Most common mechanism:
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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
Pulmonary Embolism
Clinical Manifestations
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Severity depends on the size
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Sudden onset of:
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dyspnea
tachypnea
tachycardia
Other S&S: cough, pleuritic chest pain,
rales, fever, hemoptysis, change in mental
status
Pulmonary Embolism
Definition / Demographics
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Definition:
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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 Embolism
Diagnostic Studies
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Ventilation – Perfusion Lung Scan
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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
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Computerized tomography – multislice spiral views
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Arterial Blood Gas Analysis – respiratory alkalosis
Pulmonary Embolism
Diagnostic Studies
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D-Dimer Test:
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Assists in the detection and evaluation of pulmonary embolism
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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 pt’s signs and symptoms;
medications- (Warfarin—causes decrease)
<250ng/mL– within normal range
Pulmonary Embolism
Treatment Goals
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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
Pulmonary Embolism
Drug Therapy
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Anticoagulation Therapy**
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Immediate Prevention: Heparin by infusion
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Long Term Prevention: Coumadin (Warfarin)
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Therapy adjusted according to PTT
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
Pulmonary Embolism
Surgical Treatment
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Pulmonary embolectomy – rarely
done
Intracaval Filter –
Greenfield stainless steel filter
Pulmonary Embolism
Surgical Treatment
Greenfield Filter
Pulmonary Embolism
Nursing Diagnosis
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Impaired tissue perfusion
Pain
Anxiety
Knowledge Deficit
Potential for Injury related to
anticoagulation
Pulmonary Embolism
Nursing Process
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Assess:
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observe effects of anticoagulation;
monitor anticoagulation level
hemodynamic status: VS, PO, cardiac
monitoring, hemodynamic monitoring—arterial &
PAWP
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Nsg Action: HOB elevated; Administer
oxygen; energy conservation
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Pt Education: Rationale for all treatments;
anticoagulation therapy – long term
Pulmonary Embolism
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Heparin – Type of Blood Monitoring?
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Coumadin – Type of Blood Monitoring?
Heparin Therapy
Bolus in Units and mL IV Push
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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.
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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
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X mL = 5920 / 1000 = 5.9 mL bolus
Heparin Therapy
Flow rate in mL/hr
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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
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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
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