Running head: VENOUS THROMBOEMBOLISM: A CASE STUDY
Care of the Post-Operative Surgical Patient at Risk for Venous Thromboembolism
Laura L. Jimenez
California State University at Stanislaus
VENOUS THROMBOEMBOLISM: A CASE STUDY
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Care of the Post-Operative Patient at Risk for Venous Thromboembolism
In caring for the post-operative patient, there is certainly more for the nurse to assess and
monitor aside from the surgical site itself. Through review of the literature, the nurse knows that
the post-operative patient is at risk for the development of venous thromboembolism (VTE) and
this risk can be heightened by the presence of several predisposing risk factors. Through
application of knowledge, assessment skills, implementation of appropriate interventions, and reassessment, the nurse can play an integral role in the prevention of such complications as venous
thromboembolism and pulmonary embolism.
The nurse recognizes an array of assessment data converging to indicate the
aforementioned pathology. First, there are several pre-disposing risk factors that Mrs. D. displays
including: obesity, recent femoral neck repair, immobility, and age. Mrs. D. is 74 years of age,
and her body is susceptible to the normal physiologic changes that occur due to the aging
process. These normative changes include a loss of elasticity in the vasculature of the body
leading to venous walls and valves that are not as compliant or effective (Lewis, Ruff Dirksen,
McLean Heitkemper, Bucher, & Camera, 2011, p. 720). The nurse recognizes that Mrs. D. is
positive for two of three conditions, termed Virchow’s triad, which significantly promote the risk
of DVT development. The first is venous stasis. Her obese state, the recent prolonged surgical
procedure, and post-surgical immobility all contribute to venous stasis (Lewis et al., 2011, p.
882).
The nurse also knows that Mrs. D.’s normal physiological response to the trauma that she
has endured from the fracture, in combination with invasive surgery, has produced localized
endothelial damage. This damage engages the physiological responses of inflammation,
VENOUS THROMBOEMBOLISM: A CASE STUDY
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release of clotting factors, and platelet activation to the affected area (Potter & Perry, 2009, p.
1286). Lewis (2011, p. 884) states that normal and healthy physiological responses can later
contribute to thromboembolitic complications by decreasing fibrinolytic capabilities.
The disparity between her right and left pedal pulses indicates impaired circulation in the
left lower extremity (Potter et al., 2009, p. 605). This asymmetry of pulses could be the result of
either a mechanical obstruction of blood flow as in a clot, or of local trauma to the area as in a
fracture (Potter et al., 2009, p. 605). Another quantifiable disparity that the nurse notices is the
difference in calf circumference. Mrs. D.’s left calf is two centimeters larger in diameter than her
right, indicating edema in the left lower extremity. Edema in the lower leg significantly alters
venous return and promotes fluid stasis in the veins and surrounding tissues. The nurse also notes
slight erythema in the left lower extremity, which like local edema, is indicative of localized
venous congestion (Lewis et al., 2011, p.882).
The highest priority for the nurse at this time is to notify the provider of the assessment
data collected, followed by documentation of both the data and the notification to the provider.
While awaiting the doctor’s orders regarding bedrest or activity, the nurse can elevate Mrs. D.’s
leg to reduce edema and promote venous return. Mrs. D. should be assessed for any pain in her
lower left extremity and subsequently administered analgesics as needed.
In anticipation of anticoagulant therapy, the nurse will need to assess Mrs. D.’s use of
over-the-counter (OTC) medications and herbal supplements. Knowing whether an OTC
medication or an herbal may still be in circulation is essential information for the provider and
nurse alike in providing appropriate anticoagulant therapy dosing and administration.
VENOUS THROMBOEMBOLISM: A CASE STUDY
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To further prepare for the expected anticoagulant therapy treatment, the nurses can obtain
vital signs and review recent diagnostic laboratory data. Mrs. D.’s hematocrit, hemoglobin, and
complete blood count should be reviewed to determine her hematologic function. Her creatinine
clearance, glomerular filtration rate, and blood-urea-nitrogen lab values should be reviewed. Her
liver function diagnostics should also be reviewed, including aspartate aminotransferase and
alanine aminotransferase. Most anticoagulants, such as heparin and warfarin, are metabolized
and inactivated in the liver and excreted by the kidneys (Lehne, 2010, p.598, 603). Function of
these two important organs can effect dosing and administration of anticoagulant therapy. Any
abnormal diagnostic lab results or vital signs should be immediately reported to the provider.
The most serious complication resulting from venous thrombosis is pulmonary embolism
(PE). Most often a PE will occur as a result of deep vein thrombosis in the lower extremities
(Lewis et al., 2011, 578). If a thrombus travels to the pulmonary vasculature causing a PE,
pulmonary infarction and pulmonary hypertension can occur. Mrs. D. presents with many of the
common risk factors for PE including obesity, lower extremity surgery in the last three months,
and immobility (Lewis et al., 2011, p. 578).
Chronic venous insufficiency (CVI) is another potential complication arising from VTE.
CVI develops as a result of permanent valvular destruction, allowing retrograde blood flow
(Lewis et al., 2011, p.884). This causes pooling of blood in the periphery, predominately the
lower extremities, and creates a potential risk for recurrent VTE. When CVI develops as a result
of VTE, it is also referred to as post-thrombotic syndrome (University of Alabama,
Birmingham).
VENOUS THROMBOEMBOLISM: A CASE STUDY
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Mrs. D. should be assessed for pain in her lower left extremity caused by the blockage in
her vein. Although she is most likely receiving pain management for her surgical incision and
healing femur, the nurse should recognize the new painful stimulus that can result from VTE and
assess accordingly.
Upon suspicion of a venous thromboembolism, there are two simple blood tests that the
provider could order to indicate the presence of thrombosis somewhere within the vasculature.
The D-dimer test is used to identify intravascular clotting and assesses both thrombin and
plasmin activity (Pagana & Pagana, 2010, p. 215). Elevated plasma levels of D-dimerized fibrin
indicate a physiologic response to the presence of a fibrin clot and the body’s attempt at
degradation (Pagana et al., 2010, p. 215). The Fibrin Monomer Complex is also used to
determine the presence of thrombosis in the vasculature (Pagana et al., 2010, p. 492). Fibrin
monomers are released into the blood stream during the blood coagulation process and therefore,
its measurement is a direct indicator of thrombosis, or clotting, in the body (Pagana et al., 2010,
p. 492).
To better determine the location of a clot, a Venous Compression Ultrasound may be
performed. This non-invasive test can locate a thrombus by locating a vein that fails to collapse
under external compression (Lewis et al., 2011, p. 885). More commonly, a Duplex Ultrasound
is performed to indicate the precise location of a thrombus. This diagnostic study combines the
use of Venous Compression Ultrasound with spectral and color flow Doppler to examine
respiratory variation, compressibility, and intralumen filling capability to locate and determine
the extent of a thrombus (Lewis et al., 2011, p. 885).
VENOUS THROMBOEMBOLISM: A CASE STUDY
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There are additional and more invasive venous studies used to diagnose
thromboembolism. A Computed Tomography Venography uses contrast dye material to indicate
the presence and location of a thrombus (Lewis et al., 2011, p. 885). Magnetic Resonance
Venography evaluates blood flow through veins and is highly accurate in the assessment of
pelvic and proximal veins and in making a distinction between acute and chronic thrombus
(Lewis et al., 2011, p. 885). Contrast Venography uses x-ray imaging to determine the location
and extent of a blood clot (Lewis et al., 2011, p. 885).
For the patient at risk for deep vein thrombosis there are many prophylactic interventions
with which to proceed. The least invasive and simplest of these is an early and aggressive plan
for mobilization, based on the patient’s condition and tolerance for physical activity (Lewis et
al., 2011, p. 885). Mrs. D. has been recovering for three days now following repair of her femur
bone and is likely still on bedrest. For her, mobilization will be defined as changing position
every two hours (Lewis et al., 2011, p. 885). As her recovery progresses, appropriate increases in
mobilization will be indicated. The nurse will collaborate with the physical therapist, other
members of the healthcare team, and Mrs. D. herself to determine this progression.
When caring for the patient at risk for deep vein thrombosis (DVT), it is important to
reposition them in ways that minimize compression of the leg veins (Potter et al., 2009, p. 1248).
This includes refraining from placing pillows under the knees or elevating the knee gatch on the
bed. Alternatively, pillows can be placed at the level of the thighs for comfort or repositioning
(ATI Nursing Education, 2010, p. 470).
VENOUS THROMBOEMBOLISM: A CASE STUDY
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Although it may not be feasible for Mrs. D. to flex and extend her left foot and hip in the
days directly following surgery, this should be encouraged for her right foot and hip and also
for her left as recovery warrants. According to Lewis et al. (2011, p. 885), flexing and extending
the feet and hips every two to four hours is an appropriate intervention for the patient at risk for
DVT. These simple but effective movements enhance venous return and can prevent the static
pooling of blood in the veins, which is how a venous thromboembolism manifests.
As soon as recovery allows, Mrs. D should take her meals sitting up in a chair (Lewis et
al., 2011, p. 885). With teaching on the proper use of crutches, Mrs. D. should begin ambulation
between four and six times a day (Lewis, et al., 2011, p. 885). She should be encouraged to
ambulate as much as she can tolerate, even if it is just a few feet from the bed and back.
Although difficult and painful, postural changes and ambulation are essential in preventing
venous stasis and subsequent clot formation, and in accelerating the healing process. The nurse
can facilitate ambulation by educating Mrs. D. on its importance, pre-administering analgesic
therapy, and providing patience and support. Properly fitting Mrs. D. for antiembolism stockings
is another important prophylactic measure as long as proper protocol for use is adhered to. This
includes frequent assessment for cleanliness, dryness and fittingness of the stockings, and
removal of the stockings once per shift in order to assess the integrity of the underlying skin.
(Potter et al., 2009, p. 1248).
Knowing the treatment protocol for a DVT diagnosis will allow the nurse to effectively
plan appropriate assessments, interventions, and expected outcomes. The nurse can expect that
the provider will form a treatment plan centered about the goals of preventing propagation and
embolization of the clot and the development of any new thrombi (Lewis et al., 2011, p. 888).
VENOUS THROMBOEMBOLISM: A CASE STUDY
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Anticoagulant drug therapy is expected with one or a combination of the following drug classes;
Vitamin K Antagonists (warfarin), Indirect Thrombin Inhibitors (heparin), Direct Thrombin
Inhibitors (lepirudin), and Factor Xa Inhibitors (fondaparinux) (Lewis et al., 2011, p. 886-887).
Anticoagulant therapeutic drugs all carry with them a high alert and a narrow therapeutic
window, and therefore require vigilant assessment and monitoring in order to avoid
complications.
Before and during therapy there are several diagnostic tests that are valuable in
determining whether anticoagulation therapy is causing benefit, or alternatively harm, to the
patient. The nurse can expect to assess daily diagnostic values of the following labs to determine
treatment efficacy. Because coumarin interferes with the production of vitamin K clotting
factors, the International Normalized Ratio (INR) successfully reveals the adequacy of coumarin
therapy by quantifying clotting ability. If Mrs. D.’s INR is between 2.0 and 3.0, the nurse will
know that the coumarin therapy is working within its narrow therapeutic window (Pagana et al.,
2010, p. 448). The Activated Partial Thromboplastin Time (aPPT) test is invaluable in
determining a patient’s response to heparin therapy and indicates in seconds the time it takes for
whole blood to clot. A value between 46 and 70 seconds indicates a therapeutic value (Pagana et
al., 2010, p. 27). A nomogram is often used to graph the patient’s baseline and subsequent values
during therapy in order to obtain desired levels of anticoagulation factors specific to the patient
throughout therapy (Pagana et al., 2010, p. 27). The capability of the aPPT allows the nurse to
confidently hold or administer heparin therapy depending on daily diagnostic values, and to
collaborate with the provider if values are outside the therapeutic range. The Activated Clotting
Time (ACT) test is similar to the aPPT in function, and results yielding a value below 300
VENOUS THROMBOEMBOLISM: A CASE STUDY
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seconds indicates to the healthcare team that anticoagulant therapy remains within its therapeutic
window (Pagana et al., 2010, p. 27). The Anti-factor Xa is yet another diagnostic test used to
monitor heparin therapy, and is the only test to date that can successfully monitor low-molecularweight heparin (University of Alabama, Birmingham). If a patient is receiving enoxaparin or
fodaparinux, the nurse will expect to see and monitor daily results of the Anti-factor Xa test.
While diagnostic tests are a most definitive way of monitoring the effects of
anticoagulant therapy on a patient’s physiology, there are other assessment data to be collected
and monitored throughout therapy to prevent or indicate the development of complications. As
the nurse removes the antiembolism stockings each shift, she will need to assess and document
the site for any warmth, edema, and induration over the involved vessel. Routinely measuring
and recording the circumference of the right and left calf and thigh will show changes over time
and indicate a resolution or worsening of the affected leg (ATI Nursing Education, 2010).
Imparting education on living a healthier lifestyle will help prevent Mrs. D. from enduring
further complications regarding venous insufficiency in the future. The nurse can sit down and
talk with her about the importance of maintaining a healthy weight and frequent physical
activity. It is important to inform her that vigorous exercise is not necessary, but walking at a
moderate pace for a half-an-hour each day will reap many health benefits. The nurse can also
provide literature on healthy living for Mrs. D. to take home with her as a reminder. Advocating
and arranging for a dietary consult is yet another intervention that the nurse could implement.
The patient with a recent limb fracture, such as Mrs. D., is at risk for pulmonary
embolism. This occurs when the clot formed in the extremity dislodges and travels through the
system to the lungs, where it can easily obstruct the pulmonary artery or one of its branches
VENOUS THROMBOEMBOLISM: A CASE STUDY
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(Taber, 2005, p.746). Ten to fifteen percent of patients faced with this complication will die
(Taber, 2005, 746). The nurse can frequently assess and document respiratory rate and rhythm,
presence of dyspnea or shortness of breath, and subjective information regarding chest pain. Any
variation from baseline in these assessment data would prompt the nurse to immediately notify
the physician due to the possible threat of pulmonary embolism. Expectorated blood, or
hemoptysis, is also a tell-tale sign of PE (Lewis et al., 2011, p. 506).
While the health care team may have limited to no control over pre-existing risk factors a
patient may present with for the development of VTE while receiving clinical care, they can
certainly be proactive in the prevention of vascular complications within the hospital setting.
Today a plan of care for at-risk patients can be swiftly implemented thanks to the utilization of
evidence-based practice and methods of care whose efficacy is steeped in robust scientific data.
A nurse’s knowledge of this evidence and her subsequent implementation of the practice can
assist in the accomplishment of the four main goals of the profession; promoting health,
preventing illness, restoring health, and alleviating suffering. In Mrs. D.’s case, these four goals
can be met by promoting the healing of her femur and surgical incision, preventing thrombus
formation, teaching her how to live a more healthful lifestyle, and administering both
pharmacological and alternative methods of pain relief.
VENOUS THROMBOEMBOLISM: A CASE STUDY
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References
ATI nursing education. RN adult medcal surgical nursing. (2010)
Lehne, R. A. (2010). Pharmacology for nursing care. St. Louis: Saunders.
Lewis, S. L., Ruff Dirksen, S. , McLean Heitkemper, M. , Bucher, L. , & Camera I. M. (2011).
Medical-surgical nursing: assessment and management of clinical problems, volume 1.
St. Louis: Wiley-Blackwell Publishing
Pagana, K.D., & Pagana, T.J. (2010) Mosby’s manual of diagnostic and laboratory tests. St.
Louis: Mosby, Inc.
Potter, P.A., & Perry, A.G. Fundamentals of nursing. St. Louis: Mosby, Inc.
Taber, C.W. (2005). Taber’s cyclopedic medical dictionary. Philadelphia: F.A. Davis.
University of Alabama, Birmingham. Complicated diagnostic test names. Retrieved from
http://pier.path.uab.edu/coag/article_187.shtml
VENOUS THROMBOEMBOLISM: A CASE STUDY
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TOPICAL QUIZ QUESTIONS
1. A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor,
and coolness in the left leg. The nurse should notify the health care provider and
a)
b)
c)
d)
elevate the left leg on a pillow.
apply an elastic wrap to the leg.
assist the patient in gently exercising the leg.
keep the patient in bed in the supine position.
2. A patient at the clinic says, “I have always taken an evening walk, but lately my leg cramps
and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.”
The nurse should
a)
b)
c)
d)
attempt to palpate the dorsalis pedis and posterior tibial pulses.
check for the presence of tortuous veins bilaterally on the legs.
ask about any skin color changes that occur in response to cold.
assess for unilateral swelling, redness, and tenderness of either leg.
3. After teaching a patient with newly diagnosed Raynaud’s phenomenon about how to manage
the condition, which behavior by the patient indicates that the teaching has been effective?
a) The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
b) The patient exercises indoors during the winter months.
c) The patient places the hands in hot water when they turn pale.
d) The patient takes pseudoephedrine (Sudafed) for cold symptoms.
4. The health care provider has prescribed bed rest with the feet elevated for a patient admitted
to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the
patient’s feet is to
a) place the patient in the Trendelenburg position.
b) place two pillows under the calf of the affected leg.
c) elevate the bed at the knee and put pillows under the feet.
d) put one pillow under the thighs and two pillows under the lower legs.
VENOUS THROMBOEMBOLISM: A CASE STUDY
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5. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin
(Coumadin). The patient asks the nurse why two medications are necessary. Which response by
the nurse is accurate?
a) “Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.”
b) “Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from
occurring.”
c) “The Lovenox will work immediately, but the Coumadin takes several days to have an
effect on coagulation.”
d) “Because of the potential for a pulmonary embolism, it is important for you to have more
than one anticoagulant.”
6. The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin
(Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse
determines that additional teaching is needed when the patient says,
a) “I should reduce the amount of green, leafy vegetables that I eat.”
b) “I should wear a Medic Alert bracelet stating that I take Coumadin.”
c) “I will need to have blood tests routinely to monitor the effects of the Coumadin.”
d) “I will check with my health care provider before I begin or stop any medication.”
7. Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer
on the right lower leg?
a) Adequate carbohydrate intake
b) Prophylactic antibiotic therapy
c) Application of compression to the leg
d) Methods of keeping the wound area dry
8. A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which
of these statements by the patient is most consistent with the diagnosis?
a) “I can’t get my shoes on at the end of the day.”
b) “I can never seem to get my feet warm enough.”
c) “I wake up during the night because my legs hurt.”
d) “I have burning leg pains after I walk three blocks.”
9. A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on
the surgical unit. Which action by an LVN caring for the patient requires the RN to intervene?
VENOUS THROMBOEMBOLISM: A CASE STUDY
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a) The LVN places the patient in a Fowler’s position for meals.
b) The LVN has the patient sit in a bedside chair for 90 minutes.
c) The LVN assists the patient to ambulate 40 feet in the hallway.
d) The LVN administers the ordered aspirin 160 mg after breakfast.
10. A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger’s disease). When the
nurse is planning expected outcomes for the patient, which outcome has the highest priority for
this patient?
a) Cessation of smoking
b) Control of serum lipid levels
c) Maintenance of appropriate weight
d) Demonstration of meticulous foot care
15
VENOUS THROMBOEMBOLISM: A CASE STUDY
Quality
Relevance
Contribution
Global Picture
Appropriate
comments:
thoughtful,
reflective, and
respectful of other
student's postings.
Clear reference to
assignment or prior
posting being
discussed
Furthers the discussion
with questions, or
statements that encourage
others to respond.
Participates beyond the
required number of
postings.
Clearly connects the
posting to text or
reference points
from previous
readings, activities,
and discussions.
Optimal Points
Optimal Points
Optimal Points
Optimal Points
Appropriate
comments and
responds
respectfully to
other student's
postings,
Some reference
but taken out of
context, the reader
would not
understand.
Participates, but does
not post anything that
encourages others to
respond to the posting.
Participates with the
required number of
postings.
Vague or possible
connection to
reference points
from previous
readings, activities,
and discussions.
Average Points
Average Points
Average Points
Average Points
Responds, but
with minimum
effort. (i.e. "I
agree with Bob")
Posting is attached
to the right
discussion board,
but does not
clearly reflect the
assignment.
Less than required
number of postings.
Does not further any
discussions
Mentions the text
or previous activity
without logical link
to topic.
Least points
Least points
Least points
Least points