DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN - PowerPoint PPT Presentation

1 / 43
About This Presentation

DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN


DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN Ed. Why are all those steps important???? The Joint Commission and the Centers for Medicare and Medicaid ... – PowerPoint PPT presentation

Number of Views:316
Avg rating:3.0/5.0
Slides: 44
Provided by: mcccEdum


Transcript and Presenter's Notes

Title: DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN

DVT Prophylaxis and Pulmonary Embolism
  • Karen Ruffin RN, MSN Ed.

Frequency in the US
  • Up to 2 million people are affected annually by
    Venous Thromboembolism(VTE).
  • Of those 2 million people it is estimated that
    300,000 of them will develop and die from a
    Pulmonary Embolism (PE).
  • The highest incidence of PE is with hospitalized
  • Autopsy shows that as many as 60 of patients
    dying in the hospital have had a PE, but the
    diagnosis is being missed 70 of the time.

According to Center for Disease Control (CDC),
Department of Health and Human Services, Food and
Drug Administration (FDA), The Surgeon General
Percentage if at risk for Development of a VTE
  • All hospitalized patients, depending on acuity,
    have between a 10-48 of developing a VTE
  • Med-Surg patients placed on bed rest for a week
  • Patients in the MICU (29-33).
  • Patients with Pulmonary Disease on bed rest for 3
    or more days (20-26).
  • Patients in the CCU with an MI (27-33).
  • Patients who are asymptomatic after a CABG (48).

Feied, C.F. Handler, J.A., (2008)
Mortality and Morbidity
  • Approximately 10 of the patients with an acute
    PE will die with in the first 60 minutes.
  • 1/3 of those who live, the condition is diagnosed
    and treated.
  • 2/3 of the remaining patients go undiagnosed.
  • Deaths that are a result of VTE/PE were shown to
    be the most common cause of preventable hospital

According to Center for Disease Control (CDC),
Department of Health and Human Services Food and
Drug Administration (FDA), The Surgeon General
Mortality and Morbidity
  • Race- Subtle population differences may exist,
    but the incidence is high in all racial groups.
  • Sex- Women only when they are pregnant.
  • Age- Although the frequency for developing a PE
    increases with age, age alone is not an
    independent risk factor. It has more to do with

Virchows Triad
  • Vessel Damage
  • Vascular Constriction
  • Blood Viscosity

Vessel Damage
  • Endothelial cells allow blood to flow with ease
    through vessels.
  • Factor VIII or Willibrands Factor
  • Conditions/lifestyles that damage vessel walls
  • Past VTE - Pressure Ulcers
  • Smoking - Cellulites
  • High Cholesterol
  • Varicose Veins

Vascular Constriction
  • Trauma
  • Surgery
  • Insertion of central line
  • Varicose Veins
  • Restricted Mobility
  • Sepsis
  • Induction
  • MI
  • HF
  • Stroke
  • Any external force that cause damage to the
    vascular system can cause slow blood flow

Blood Viscosity
  • Dehydrating
  • Birth Control Pills
  • High estrogen states
  • Pregnancy
  • Postpartum
  • Cancer
  • Sepsis
  • Blood transfusions
  • Obesity
  • IBS
  • Hematologic Disorders
  • Elevated Blood Sugar
  • Platelet Aggregation

Physiology of Clotting
(No Transcript)
What is the difference between a thrombus and an
  • A thrombus is a clot that is stationary and a
    emboli is a thrombus that has broken off and is

Most Common Cause of a PE
  • 90 are thrombi dislodged from deep veins in the
  • Some originate in the pelvis, particularly in
    pregnant women.
  • Fat embolus occur when long bones are broken
    (this is rare).

What is a Pulmonary Embolism (PE)?
  • Occlusion of a portion of the pulmonary vascular
    bed by an embolism. They can be a
  • Thrombus (Blood Clot)
  • Tissue Fragment
  • Lipids (Fat)
  • Air Bubble

  • Once the embolus is released into the blood
    stream they are distributed in
  • 65 of the time both lungs
  • 25 of the time right lung
  • ? 10 of the time left lung
  • ? Lower lobes are 4 times more often upper

  • Massive Occlusion- an embolus that occludes a
    major portion of the pulmonary circulation.
  • Embolus with Infarction- An embolus that is
    large enough to cause an infarction (death) of a
    portion of lung tissue
  • Embolus without Infarction- Not sever enough to
    cause permanent lung injury.
  • Multiple Pulmonary Emboli- This can be chronic
    or recurrent.

Risk Factors for DVT and PE
  • Previous episode of thromboembolism
  • Prolonged immobility
  • Cancer
  • Obesity
  • Pregnancy
  • Oral estrogen
  • Fever
  • Atrial fibrillation
  • CHF, Shock
  • Varicose veins
  • Over 60 y/o
  • Hematologic disorders
  • Trauma
  • Central Lines
  • Dehydration
  • Hypovolemia
  • Surgical Patients

Prophylaxis Strategies
  • The evidence based practice guidelines published
    by the ACCP in June 2008 incorporated data
    obtained from a comprehensive literature review
    of the most recent studies available.
  • The recommendations are broken up in to different
    categories from general patient populations to
    specific groups and conditions.

American College of Chest Physicians, (2008)
Understanding the Different Recommendation
  • Grade 1 Benefits outweigh risk
  • Grade 2 Less certain about the magnitude of
    benefits versus risk
  • Grade A High quality evidence
  • Grade B Moderate quality evidence
  • Grade C Low quality evidence

American College of Chest Physicians, (2008)
General Patient Population
  • Every hospital should have a formal strategy for
    addressing VTE prophylaxis (Grade 1A)
  • Mechanical methods of thromboprophylaxis should
    be used primarily in patients who have a high
    risk of bleeding (Grade 1A)
  • It is recommended against the use of aspirin
    alone as thromboprophylaxis for VTE for any group
    of patients (Grade 1A)

American College of Chest Physicians, (2008)
What about patients w/ a PICC line??????
  • We are a seeing and increased incidence of DVT in
    patients with PICC lines.
  • How can we assess for it?

Clinical Manifestation of PE
  • Massive Occlusion- Profound shock, hypotension,
    tachycardia, pulmonary hypertension, and chest
  • Embolus with Infarction- Pleural pain, pleural
    friction rub, pleural effusion, hemoptysis,
    fever, and leukocytosis.
  • Recurrent PE- Occur in individuals who have had
    a history of previous emboli.

Applying the Nursing Process
  • Assessment
  • Diagnosis
  • Planning
  • Intervention
  • Evaluation

Assessment and Symptoms
  • Homons sign
  • HP
  • Cough
  • Sudden onset of SOB
  • Agitation
  • Lightheadness
  • Fainting
  • Dizziness
  • Sweating
  • Anxiety
  • Rapid Breathing
  • Tachycardia
  • Air Hunger

What are your nursing diagnosis going to be???
  • Tell me your long and short term goals.

  • Arterial Blood Gases
  • EKG
  • Echocardiogram
  • Chest x-ray
  • VQ scan
  • Spiral CT scan
  • Pulmonary Angiogram
  • Pt, ptt, INR
  • D-DImer
  • Split Fibrinogen
  • MRA

What are your Interventions for your stated goals?
  • Remember to always have
  • Assessment
  • Action
  • Psychosocial
  • Education
  • For every goal!

  • Supportive
  • Filters
  • Anticoagulants/Thrombolytics
  • Heparin
  • Coumadin
  • Streptokinase
  • Retavase
  • TPA

So what will we evaluate and why?
Cost of Prevention vs. Treatment????
  • V/Q scan- 1500
  • ICU bed 9000 day
  • Arterial Angiogram- 3200
  • Many other realted cost?????
  • Sequential stockings- 10 day
  • Heparin subq- pennies a day
  • Lovenox subq 15 a day

Prevention is KEY
  • Intermittent Pneumatic Stockings
  • SCD
  • Teds
  • Early Ambulation
  • Low Dose Anticoagulation
  • Heprin
  • Lovenox
  • Arixtra

So, what does all of this mean to us?
Assessment and Documentation
  • We must assess if a patient is at risk for the
    development of a VTE
  • Document that assessment
  • Communicate with the health care team that the
    patient is at risk for a VTE.
  • Document that communication
  • Education, Education, Education

Why are all those steps important????
  • The Joint Commission and the Centers for Medicare
    and Medicaid have implemented VTE quality
    measures for surgical patients which include the
    Surgical Care Improvement Project (SCIP 1 SCIP
  • SCIP 1 evaluates if patients were identified as
    being at risk, was prophylaxis ordered
  • SCIP 2 examines if prophylaxis was actually
    received by patient. Surgical types include
    ortho, gyn, urological, elective spine,
    intracraneal . Appropriate prophylaxis includes
    LDUFH, Fundaparinux, LMWH, warfarin

Why are all those steps important????
  • The CMS has created guidelines on payment for
    service for healthcare providers that use
    evidence based practice to promote the best
    possible outcomes for its customers.

  • In 2005, section 5001(c) of the Deficit Reduction
    Act of 2005 (DRA) authorized the Secretary of the
    Department of Health and Human Services to select
    conditions that 
  • (1) are high cost, high volume, or both (2) are
    identified through ICD-9-CM coding as
    complicating conditions (CCs) or major
    complicating conditions (MCCs) that, when present
    as secondary diagnoses on claims, result in a
    higher-paying MS-DRG and (3) are reasonably
    preventable through the application of
    evidence-based guidelines.

So what does that mean to the bedside nurse?
  • We must encourage all healthcare members to
    follow best practices as outline by creditable
    bodies such as the ACCP.
  • Our role in assisting with reimbursement for care
    provided is to appropriately assess our patients
    and determine who is at risk for VTE/PE.
  • Next we must communicate this information with
    the physicians.
  • Once orders are receive for thromboprophylaxis we
    should ensure that treatment is delivered as soon
    as possible or within 2 to 3 hours of receiving
    the orders.

The Power of Suggestion!! Dont ever
underestimate it!!!!!!!
Case Studies
  • 37y/o women presented to the ER 18 days s/p
    laparotomy for lyses of adhesions.
  • Symptoms- CP, SOB, lightheadness, tachycardia.
  • She was seen by an NP and not by an MD. CBC,
    Cardiac Enzymes, and Chem 7 ordered and were
    normal. Pt was sent home and told to follow up
    with her primary in two days.
  • Pt. suffered a nonfatal PE that night. She was
    awarded 1,000,000.00

Case Study
  • Nurse was to D/C a pt. home. She noted a large
    reddened, raised, warm area on the pt. right
    ankle. The nurse documented it, but did not
    notify the physician.
  • The pt. suffered a fatal PE two days later. A
    claim was filed against the nurse and was settled
    for 4,000,000.00.

Case Study
  • Pt. was admitted with a fractured right hip on
    Sat morning. Patient was started on Lovenox 30mg
    subq daily. That order was renew on Monday after
    the patient had an ORIF of the right hip. The
    order was missed for 2 days. The patient
    suffered a non-fatal PE was transferred to the
    ICU. The hospital stay was extended by 3 weeks.
    A claim was filed against several nurses and was
    settled for 1,500,000.00 and medical expenses.

-American College of Chest Physicians, (2008).
Antithrombotic and Thrombolytic Therapy American
College Of Chest Physicians Evidence Based
Clinical Practice Guidelines. 8th Edition. Volume
133/number 6 (Suppl) pages 67s-968s.-Center for
Disease Control, (2008). Are you at risk for deep
vein thrombosis? Retrieved from
http//www.cdc.gov/Features/Thrombosis on
December 12, 2008.-Center for Medicare and
Medicaid Services, (2008). CMS improves patient
safety for Medicare and Medicaid by addressing
never events., CMS Manual System.-Feied, C.F.
Handler, J.A., (2008). Pulmonary Embolism.
Retrieved from eMedicine.com on December 12,
2008.-Galson, S.K., (2008) The Surgeon General
calls to action to prevent deep vein thrombosis.
US Department of Health and Human Services Office
of the Surgeon General. Retrieved from
http//www.surgeongeneral.gov on December 12,
2008.-National Institute for Health, (2007).
What is a Deep Vein Thrombosis? Retrieved from
on December 12, 2008.-Sanofi-Aventis, (2008).
The Coalition to Prevent Deep-Vein Thrombosis.
Retrieve from, http//www.preventdvt.org on
December 12, 2008.-Sumpio, B.E., Riley, J.T,
Dardik, A. (2002). Cells in focus endothelial
cell. Department of Surgery, Yale University
School of Medicine. Retrieve from
http//www.ncbi.nlm.nih.gov on December 12, 2008.
Now we will do an Evolve case study!
Write a Comment
User Comments (0)
About PowerShow.com