• Noninvasive fl ow studies (Doppler ultrasound; compression ultrasonography duplex venous ultrasound): Detect and mea sure blood fl ow.
Ultrasound imagery can reveal a thrombus in a deep vein, especially above the knee. The Doppler ultrasound mea sures the blood fl ow velocity in veins and can detect fl ow abnormali- ties. Note: In most circumstances, compression ultrasonogra- phy is the test of choice for patients with suspected DVT. When a blood clot is pres ent in a vein, it is relatively diffi cult to collapse, making compression ultrasound a reliable indicator of DVT, especially in veins of the groin and thigh (Fogoros, 2016;
Pai & Douketis, 2016). Duplex venous ultrasonography appears to be the most accurate noninvasive method for diagnosing multiple proximal VTE in iliac, femoral, and popliteal veins but is less reliable in detecting isolated calf vein thrombi.
• Contrast venography: A special x- ray of the veins that is performed by fi rst injecting a radiopaque contrast into the vein in question and then taking a conventional x- ray.
Used to demonstrate a vein blockage. Radiographically confi rms diagnosis through changes in blood fl ow and size of channels.
Note: Although considered the gold standard for diagnosing DVT, this study carries a risk of inducing VTE and therefore is reserved for the client with negative or diffi cult to interpret noninvasive studies.
• CT scan with or without contrast: A series of x- ray images taken from dif fer ent angles using computer pro cessing to create cross- sectional images of body.
Contrast- enhanced CT scanning is increasingly used as the initial radiologic study in the diagnosis of PE, especially in patient with abnormal chest x- ray.
• Computed tomography angiography (CTA): Uses an injection of iodine- rich contrast material and CT scanning to help diagnose and evaluate blood vessel disease or blockages.
Considered by the American College of Radiology to be standard of care for detection of PE.
• Ventilation- perfusion (V/Q) scanning: Imaging test that uses special x- ray scanners to create pictures of air and blood fl ow patterns in the lungs.
May be used to establish PE when CT scanning not available or contraindicated.
• Magnetic resonance imaging (MRI): Technique that uses the properties of magnetic fi elds to provide images of the body.
May be done for diagnosis of both proximal and distal VTE and is believed to be superior to other diagnostic tests for detection of pelvic VTE or suspected VTE of the inferior vena cava or pelvic veins. MRI is highly sensitive for detection of central, lobar, or segmental PE.
D I A G N O S T I C S T U D I E S (contd.)
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Peripheral NIC In de pen dent
Inspect legs from groin to foot for skin color and temperature changes as well as edema. Note symmetry of calves;
mea sure and rec ord calf circumference. Report proximal progression of inflammatory pro cess and traveling pain.
Symptoms help distinguish between thrombophlebitis and VTE. Redness, heat, tenderness, and localized edema are characteristic of superficial involvement. Calf vein involvement is associated with the absence of edema;
femoral vein involvement is associated with mild to moderate edema, and iliofemoral vein thrombosis is characterized by severe edema. Note: Unilateral edema is one of the most reliable physical findings in DVT.
Examine extremity for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along the course of the vein.
Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebi- tis in superficial veins may be vis i ble or palpable.
Evaluate client for Homans’ sign (pain in the calf of the leg upon dorsiflexion of the foot with the leg extended) per protocol.
Homans’ sign is easily applied at point of care and is an assessment that clinicians often perform. However, its use is considered unreliable because Homans’ sign is absent in many clients with VTE and can be positive in several other conditions beside DVT. A negative Homans’ sign, on the other hand, doesn’t automatically exclude DVT (Patel et al, 2016).
Promote early ambulation. Short, frequent walks are better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, engage in range- of- motion exercises.
Elevate legs when in bed or chair, as indicated. Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistention and thereby increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity.
Initiate active or passive exercises while in bed or chair; for example, flex, extend, and rotate feet periodically. Assist with ambulation as needed as soon as client is out of bed.
These mea sures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength.
Caution client to avoid crossing legs or hyperflexion at knee, such as seated position with legs dangling or lying in jackknife position.
Physical restriction of circulation impairs blood flow and increases venous stasis in pelvic, popliteal, and leg vessels, thus increasing swelling and discomfort.
Instruct client to avoid rubbing or massaging the affected extremity.
This activity potentiates risk of fragmenting and dislodging thrombus, causing embolization and increasing risk of complications.
N U R S I N G D I A G N O S I S :
in effec tive peripheral tissue Perfusion
May Be Related To
Deficient knowledge of disease pro cess or aggravating factors (e.g., sedentary lifestyle/immobility, trauma, smoking, obesity)
Possibly Evidenced By Edema, extremity pain
Diminished pulses, capillary refill >3 seconds
Alteration in skin characteristics (e.g., color, temperature, sensation) Desired Outcomes/Evaluation Criteria— Client Will
Tissue Perfusion: Peripheral NOC
Demonstrate improved perfusion as evidenced by peripheral pulses pres ent, equal skin color, and temperature normal and absence of edema.
Engage in be hav iors or actions to enhance tissue perfusion (e.g., engage in regular exercise, cessation of smoking, disease management).
Display increasing tolerance to activity.
CHAPTER 2Cardiovascular: Thromboembolism: Venous & Pulmonary
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Encourage deep- breathing exercises. Increases negative pressure in thorax, which assists in emptying large veins.
Increase fluid intake to at least 1500 to 2000 mL/d, within cardiac tolerance.
Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.
Collaborative
Administer pharmacological mea sures, as indicated: Pharmacological mea sures involve vari ous types of antico- agulation to reduce blood coagulability.
Heparin sodium via continuous or intermittent IV and intermittent subcutaneous (SC) injections
Heparin prevents extension of the thrombus by preventing the conversion of prothrombin to prothrombin at low doses and preventing the conversion of fibrinogen to fibrin in higher does. It has been shown to significantly reduce (but may not eliminate) the incidence of fatal and nonfatal pulmonary embolism and recurrent
thrombosis.
Low- molecular- weight heparin (LMWH) preparations, such as enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), and fondaparinux (Arixtra) via SC injections
The efficacy and safety of LMWH for the initial treatment of deep venous thrombosis have been well established in several trials. May be used as “bridging” drugs while client starts oral anticoagulant therapy.
Oral anticlotting agents; vitamin K antagonists, e.g., warfarin (Coumadin, Jantoven)
Coumadin has a potent depressant effect on liver formation of prothrombin from vitamin K and impairs formation of factors VII, IX, and X (extrinsic pathway). Coumadin is generally used for long- term postdischarge therapy to keep international normalized ratio (INR) at 2 to 3.
However, it does have a narrow therapeutic win dow and requires frequent monitoring. Many foods, drugs, and disease pro cesses alter Coumadin’s effectiveness, sometimes making it difficult to regulate.
Factor Xa inhibitors, e.g., rivaroxaban (Xarelto), apixaban (Eliquis), and fondaparinux (Arixtra)
These drugs have been approved for treating DVT and PE and for prevention of recurrences. Benefits of these agents include no need for heparin bridging, and drugs can be given in fixed doses without routine coagulation monitoring. Note: Fondaparinux is administered SC, whereas other drugs listed here are given orally (“Antiar- rhythmic Agents,” 2017; Patel et al, 2016).
Direct thrombin inhibitors, e.g., dabigatran (Pradaxa) and bivalirudin (Angiomax)
Inhibits free and clot- bound thrombin and thrombin- induced platelet aggregation. Used in both treatment and prevention of VTE (Patel et al, 2016).
Thrombolytic agents, such as tenecteplase (TNKase), activase (Alteplase), and reteplase (Retavase)
May be used in hemodynamically unstable client with PE or massive VTE. Note: Currently accepted indications for thrombolytic therapy include hemodynamic instability (systolic BP <90 mm Hg) or a clinical risk factor assess- ment that suggests that hypotension is likely to develop (Ouellette et al, 2016).
Monitor laboratory studies, as indicated:
Platelet counts (if on heparin); prothrombin time (PT), partial thromboplastin time (PTT), activated pro- thrombin time (aPTT), international normalized ratio (INR) (if on warfarin), hemoglobin/hematocrit (Hgb/
Hct), as indicated
Monitors response to therapy, identifies presence of risk factors, such as hemoconcentration and dehydration, which potentiate clot formation. Note: Xa factor and thrombin inhibitors do not require serial monitoring because PT and aPTT are not affected.
Apply and regulate graduated compression stockings and intermittent pneumatic compression if indicated.
Sequential compression devices may be used to improve blood flow velocity and empty vessels by providing artificial muscle- pumping action.
Apply elastic support hose following acute phase. Take care to avoid tourniquet effect.
Properly fitted support hose are useful, once ambulation has begun, to minimize risk of postphlebotic syndrome.
They must exert a sustained, evenly distributed pressure over entire surface of calves and thighs to reduce the caliber of superficial veins and increase blood flow to deep veins.
ACTIONS/INTERVENTIONS RATIONALE Pain Management: Acute NIC
In de pen dent
Assess degree and characteristics of discomfort and pain, using standardized pain checklist.
Degree of pain is directly related to extent of circulatory deficit, inflammatory pro cess, degree of tissue ischemia, and extent of edema associated with thrombus develop- ment. Changes in characteristics of pain may indicate development of complications.
Maintain bedrest (if indicated) during acute phase. Studies suggest that individuals with DVT or PE who are receiving appropriate anticoagulant therapy do better (both immediately and later on) with early ambulation (Pai & Douketis, 2016; Thompson & Kabrhel, 2016).
Elevate affected extremity above heart level, as indicated. May be done to reduce symptoms such as swelling and pain.
Monitor vital signs, noting elevated temperature. Elevations in heart rate may indicate increased discomfort or may occur in response to fever and inflammatory pro cess.
Fever can also increase client’s discomfort.
Investigate reports of sudden or sharp chest pain, accompa- nied by dyspnea, tachycardia, and apprehension.
These signs and symptoms suggest the presence of PE as a complication of VTE.
Collaborative
Administer medi cations, as indicated; for example, analge- sics (opioid and nonopioid).
Relieves pain and decreases muscle tension. Note: NSAIDs should not be used when patient is on anticoagulants because of increased risk of bleeding.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Prepare for and assist with procedures, such as the following:
Surgical intervention, such as thrombectomy and vena cava screen, when indicated
Thrombectomy (excision of thrombus) may be done in very rare cases when condition does not respond to typical treatments or circulation is severely restricted. Multiple or recurrent thrombotic episodes unresponsive to medical treatment (or when anticoagulant therapy is contraindi- cated) may require insertion of a vena cava filter (Siskin &
Kwan, 2015).
N U R S I N G D I A G N O S I S :
acute Pain
May Be Related To
Biological injury agent (e.g., ischemia) Possibly Evidenced By
Reports of pain (e.g., extremity or chest); evidence of pain using standard pain be hav ior checklist Changes in physiological par ameters (e.g., blood pressure, heart/respiratory rate, oxygen saturation) Guarding/protective be hav ior
Expressive be hav iors— restlessness, moaning Desired Outcomes/Evaluation Criteria— Client Will Pain Control NOC
Report that pain or discomfort is alleviated or controlled.
Verbalize methods that provide relief.
Display relaxed manner; can sleep or rest and engage in desired activity.
CHAPTER 2Cardiovascular: Thromboembolism: Venous & Pulmonary
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Pulmonary NIC In de pen dent
Note respiratory rate and depth and work of breathing, such as use of accessory muscles or nasal flaring and pursed- lip breathing.
Tachypnea and dyspnea accompany pulmonary obstruction.
Dyspnea and increased work of breathing may be first or only sign of subacute PE. Severe respiratory distress and failure accompany moderate to severe loss of functional lung units.
Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds, such as crackles or wheezing.
Nonventilated areas may be identified by the absence of breath sounds. Crackles occur in fluid- filled tissues and airways or may reflect cardiac decompensation. Wheezing can occur because of airway restriction. Note: A PE is a lung injury and results in postacute reactive airways that resemble asthma and may require long- term
medi cations.
Observe for generalized duskiness and cyanosis in “warm tissues,” such as earlobes, lips, tongue, and buccal membranes.
Indicative of systemic hypoxemia.
Monitor vital signs. Note changes in cardiac rhythm. Tachycardia, tachypnea, and changes in BP are associated with advancing hypoxemia and acidosis. Rhythm alterations and extra heart sounds may reflect increased cardiac workload related to worsening ventilation imbalance.
Assess level of consciousness and evaluate mentation changes.
Systemic hypoxemia may be demonstrated initially by restlessness and irritability, then by progressively decreased mentation.
Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to client tolerance.
These par ameters assist in determining client response to resumed activities and ability to participate in self- care.
Airway Management NIC
Institute mea sures to restore or maintain patent airways, such as deep- breathing exercises, coughing, and suctioning.
Plugged or collapsed airways reduce number of functional alveoli, negatively affecting gas exchange.
Elevate head of bed as client tolerates. Promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort.
Assist with frequent changes of position, and get client out of bed to ambulate as tolerated.
Turning and ambulation enhance aeration of dif fer ent lung segments, thereby improving oxygen diffusion.
N U R S I N G D I A G N O S I S :
impaired Gas Exchange (in presence of Pulmonary Embolus)
May Be Related To
Ventilation- perfusion imbalance [altered blood flow to portions of the lung]
Alveolar- capillary membrane changes Possibly Evidenced By
Abnormal breathing pattern (e.g., rate, rhythm, depth) Restlessness, irritability, somnolence
Abnormal arterial blood gases, hypoxemia, hypercapnia Desired Outcomes/Evaluation Criteria— Client Will Respiratory Status: Gas Exchange NOC
Demonstrate adequate ventilation and oxygenation by ABGs within client’s normal range.
Report or display resolution or absence of symptoms of respiratory distress.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Assist client to deal with fear and anxiety that may be pres ent:
Feelings of fear and severe anxiety are associated with difficulty breathing and may cause increased oxygen consumption.
Encourage expression of feelings and inform client and SOs of normalcy of anxious feelings and sense of impending doom.
Understanding basis of feelings may help client regain some sense of control over emotions.
Provide brief explanations of what is happening and expected effects of interventions.
May allay anxiety related to unknown and help reduce fears concerning personal safety.
Monitor frequently, and arrange for someone to stay with client, as indicated.
Provides assurance that changes in condition will be noted and that assistance is readily available.
Embolus Care: Pulmonary NIC Collaborative
Prepare for CT or VQ lung scan. Reveals pattern of abnormal perfusion in areas of ventilation, reflecting ventilation and perfusion mismatch, confirming diagnosis of PE and degree of obstruction. Absence of both ventilation and perfusion reflects alveolar conges- tion or airway obstruction.
Monitor constant pulse oximetry and/or serial ABGs. Hypoxemia may be (but is not always) pres ent, depending on the amount of airway obstruction, usual cardiopulmo- nary function, and presence and degree of shock.
Respiratory alkalosis and metabolic acidosis may also be pres ent.
Airway Management NIC
Administer supplemental oxygen by appropriate method, if indicated.
Maximizes available oxygen for gas exchange, reducing work of breathing. When pulse oximeter shows O2 saturation 89% or higher, it is not likely that oxygen will help/is needed. Note: If obstruction is large or hypoxemia does not respond to supplemental oxygenation, it may be necessary to move client to critical care area for intubation and mechanical ventilation.
Administer fluids, IV or by mouth (PO), as indicated. Increased fluids may be given to reduce hyperviscosity of blood, which can potentiate thrombus formation, or to support circulating volume and tissue perfusion.
Administer medi cations, as indicated, for example:
Thrombolytic agents, such as alteplase (Activase, t- PA), reteplase (Retavase), and tenecteplase (TNKase)
Indicated in massive pulmonary obstruction when client is seriously hemodynamically threatened. Note: These clients will prob ably be initially cared for in, or transferred to, the critical care setting.
Morphine sulfate and antianxiety agents May be necessary initially to control pain or anxiety and improve work of breathing, maximizing gas exchange.
Provide supplemental humidification, such as ultrasonic nebulizers.
Delivers moisture to mucous membranes and helps liquefy secretions to facilitate airway clearance.
Assist with respiratory therapy, such as incentive spirometer. Facilitates deeper respiratory effort.
Prepare for surgical intervention, if indicated. Vena caval ligation or insertion of an intracaval umbrella may be useful for clients who experience recurrent emboli despite adequate anticoagulation, when anticoagulation is contraindicated, or when septic emboli arising from below the renal veins do not respond to treatment. Additionally, pulmonary embolectomy may be considered in life- threatening situations.
CHAPTER 2Cardiovascular: Thromboembolism: Venous & Pulmonary
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Pro cess NIC In de pen dent
Ascertain client’s/SO’s level of knowledge about condition and ability, readiness, or barriers to learning. Note personal factors (e.g., age, functional and developmental level) that may impact ability to understand condition and treatment regimen.
Individual may not be physically, emotionally, or mentally capable of learning early in disease pro cess. Information may be presented in small units over time, relayed to family members, and repeated/reinforced.
Review pathophysiology of condition and signs and symp- toms of pos si ble complications, such as PE, chronic venous insufficiency, and venous stasis ulcers (postphle- botic syndrome).
Provides a knowledge base from which client can make informed choices and understand and identify healthcare needs. A significant number of clients experience a recurrence of DVT. Note: Ge ne tic blood testing may help identify inherited thrombotic disorders. Screening tests should be done when venous thrombosis occurs in those aged 45 years or younger; when a thrombus occurs at an unusual location such as in gastrointestinal tract, brain, or arm; and when there is an immediate family history of VTE.
Explain purpose of activity restrictions (if any) and need for balance between activity and rest.
Rest reduces oxygen and nutrient needs of compromised tissues. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.
Establish appropriate exercise and activity program. Aids in developing collateral circulation, enhances venous return, and reduces risk of recurrence.
Problem- solve solutions to predisposing factors that may be pres ent, such as employment that requires prolonged standing or sitting, wearing restrictive clothing, use of oral contraceptives, obesity, prolonged immobility, and dehydration.
Actively involves client in identifying and initiating lifestyle and be hav ior changes to promote health and prevent recurrence of condition or development of complications.
Review position recommendations, such as sitting with feet touching the floor, avoiding crossing of legs.
Prevents excess pressure on the popliteal space and enhances venous return.
Review purpose and demonstrate correct application and removal of antiembolic hose.
Understanding may enhance cooperation with prescribed therapy and prevent improper or in effec tive use.
Instruct in meticulous skin care of lower extremities, such as prevent or promptly treat breaks in skin and report development of ulcers or changes in skin color.
Chronic venous congestion and postphlebotic syndrome may develop, especially in the presence of severe vascular involvement and recurrent VTE, potentiating risk of stasis ulcers.
N U R S I N G D I A G N O S I S :
deficient Knowledge [Learning Need] regarding condition, treatment program, self- care, and discharge needs
May Be Related To
Insufficient information or insufficient interest in learning Insufficient knowledge of resources
Possibly Evidenced By Reports the prob lem
Inaccurate follow- through of instructions Development or preventable complications
Desired Outcomes/Evaluation Criteria— Client Will Knowledge: Thrombus Threat Reduction NOC
Verbalize understanding of disease pro cess, treatment regimen, and limitations.
Participate in learning pro cess.
Identify signs and symptoms requiring medical evaluation.
Correctly perform therapeutic actions and explain reasons for actions.