Running header: VENOUS THROMBOEMBOLISM

Venous Thromboembolism, Deep Vein Thrombosis, & Pulmonary Embolism: Prophylaxis and Proactive Prevention

Running header: VENOUS THROMBOEMBOLISM

Deep vein thrombosis is a common disorder frequently seen in both the inpatient and outpatient settings, which increases the risk of pulmonary embolism, a potentially fatal complication. Pulmonary embolism is an important healthcare disorder because of not only its association with significant morbidity and mortality but also its significant cost factor to the US healthcare economy. Together, deep vein thrombosis and pulmonary embolism are known as venous thromboembolism (Mason, 2009). The bodys veins are labeled as superficial or deep, respective to their depth below the skins surface. Superficial veins run near the surface of the skin and the deep veins are located underneath muscles and run parallel to the arteries. Deep vein thrombosis is a blood clot that forms most commonly within the deep veins of the legs, but it can also occur in the pelvis or arms. A clot is formed due to platelet activation resulting from damage to the vessel wall. Damage can be mechanical in nature, such as trauma, or it can be damage caused by the pathophysiology of a disease like high blood pressure. The activated platelets clump together, forming a thrombus. If the thrombus detaches from the vessel wall and becomes free floating, it is known as an embolus, which can occlude a blood vessel. A pulmonary embolism occurs when the embolus travels to the lungs, blocking its main blood vessel or one of its branches (Stockman, 2009). Patients who are most at risk for deep vein thrombosis are those undergoing major surgery, especially orthopedic surgery. Other at-risk patients include those who smoke or have lung disease, diabetes, blood disorders, or peripheral vascular disease and women who use oral contraceptives; but the formation of blood clots is really a significant threat to anyone wholl be immobile for an extended period of time.

Running header: VENOUS THROMBOEMBOLISM Signs and symptoms of a deep vein thrombosis include edemic swelling of the affected extremity, pain, tenderness, or redness, a temperature increase of the affected extremity compared with the rest of the body, and cyanosis and mottling of skin distal to the clot due to

stagnation of blood flow. A deep vein thrombosis, however, can be difficult to confirm clinically because it may not immediately exhibit signs or symptoms. To confirm a deep vein thrombosis diagnostically, a healthcare provider may order a venous ultrasound of the patients legs, an MRI, or a D-dimer test (Stockman, 2009). Almost all hospitalized patients have some risk of developing DVT; therefore thromboprophylaxis is supported and encouraged by clinical practice guidelines. Prevention of deep vein thrombosis and pulmonary embolism has been found to be cost-effective when compared with treating an existing thrombosis. Despite the presence of sufficient evidence to recommend routine thromboprophylaxis, compliance with the clinical practice guidelines is less than ideal (Long, 2009). Reasons for this low adherence rate include variability in knowledge of risk assessment and appropriate prophylaxis strategies, and a lack of belief and acceptance that the evidence presented in the guidelines for VTE prophylaxis is appropriate in all clinical situations (Mason, 2009). Whether preventing the formation of a venous thrombus or treating an VTE, clinical practice guidelines recommend pharmacological interventions (such as heparin, low molecular weight heparin, selective factor Xa inhibitors, and vitamin K antagonists) and/or nonpharmacological interventions, including mechanical measures, such as inferior vena cava filters, compression stockings, intermittent pneumatic compression devices, continuous passive mobilization, and early patient mobilization (Long, 2009). A study done in Australia of patients who underwent a total knee replacement demonstrated a decreased incidence of DVT the greater the distance the patient mobilized 24 hours after surgery. The odds of developing a DVT was

Running header: VENOUS THROMBOEMBOLISM reduced by a third for patients who mobilized greater than 1 meter and no DVTs were found in patients who mobilized more than 5 meters (Chandrasekaran, Ariaretnam, Tsung, Dickison, 2009). A potential problem with use of prophylaxis is patient compliance. Pharmacological prophylaxis compliance after hospital discharge reported that 55% of the patients had complete

compliance established by the protocol. Compliance using a compression device was reported at 56% for patients developing DVT and 80% for patients not developing DVT (Hardwick, Pulido, Colwell, 2011). An additional problem is accurate documentation by nurses of the use of mechanical compression. As nurses, we are in a position to enhance the awareness of VTE prophylaxis. Nurses are often the initiators for thrombosis prophylaxis; and clinical application of prophylaxis guidelines is imperative in protecting patients. Improvements in patient education concerning awareness and risks of VTE as well as the importance of compliance with treatment are essential elements to preventing VTE. Education and awareness of the problem is the first step in shifting the paradigm of noncompliance among healthcare professionals as well as patients. As nurses, when we provide that type of education were providing our patients with a superior level of patient care (Long, 2009).

Running header: VENOUS THROMBOEMBOLISM REFERENCES Chandrasekaran, S., Ariaretnam, S., Tsung, J., & Dickison, D. (2009). Early mobilization after

total knee replacement reduces the incidence of deep venous thrombosis. ANZ Journal Of Surgery, 79(7-8), 526-529. Hardwick, M. E., Pulido, P. A., & Colwell, C. W. (2011). A Mobile Compression Device Compared With Low-Molecular-Weight Heparin for Prevention of Venous Thromboembolism in Total Hip Arthroplasty. Orthopaedic Nursing, 30(5). Kaur, M., Yadav, K., Yadav, V., Gupta, B., & Misra, ,. (2012). Deep vein thrombosis (DVT) prophylaxis: awareness or ignorance amongst staff personnel. International Journal Of Nursing Education, 4(1), 32-34. Long, J. B. (2009). Venous Thromboembolism: Pharmacological and Nonpharmacological Interventions. Journal of Cardiovascular Nursing, 24(6S), S8-S13. Mason, C. (2009). Venous Thromboembolism: A Chronic Illness. Journal of Cardiovascular Nursing, 24(6S), S4-S7. Stockman, J. (2009). In Too Deep: Understanding Deep Vein Thrombosis. LPN, 5(6), 10-16.