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Vocabulary
Thrombophlebitis =
Inflammation of a vein associated with thrombus formation or a clot in a
vein.
SCD's =
Sequential compression device
Stasis =
1. A stoppage or diminution of the flow of blood or other body fluid in any
part.
2. A state of equilibrium among opposing forces.
Stent =
1. A mold for keeping a skin graft in place, made of stent's mass or some
acrylic or dental component.
2. A device or mold for keeping a skin graft in place.
3. A slender rod - or thread - like device used to provide support for
tubular structures that are being anastomosed or to induce or maintain
patency within these tubular structures.
Viscosity =
1. A physical property of fluids that determines the internal resistance to
shear forces.
Anticoagulant =
1. preventing blood clotting
2. any substance that prevents
Atrial fibrillation =
An arrhythmia in which minute areas of the atrial myocardium are in various
uncoordinated stages of depolarization and repolarization due to multiple
re-entry circuits within the atrial myocardium, instead of intermittently
contracting, the atria quiver continuously in a chaotic pattern, causing a
totally irregular, often rapid ventricular rate.
International normalized ratio (INR) =
2.0 - 3.0 for therapeutic range
Partial Thromboplastin Time (PTT or APTT) =
Used to evaluate the adequacy of the extrinsic system and common pathway in
the clotting mechanism. (page 366 of lab book)
Polycythemia =
An increase in the total red cell mass of the blood
Prothrombin time =
Factor II (coagulation factor)
Pulmonary embolus =
A mass of clotted blood or other formed elements (bubbles of air, calcium
fragments, etc.) Brought by the blood from another vessel and forced into a
smaller one, thus obstructing the circulation.
Thromboembolism =
Obstruction of a blood vessel with thrombotic material carried by the blood
stream from the site of origin to plug another vessel.
Thrombolytic =
1. dissolving or splitting up a thrombus
2. a thrombolytic agent
Types of thrombophlebitis
1. Superficial - small vein, can be from IV
2. Deep - post of 5 % complication, can be due to immobility
CAUSES OF THROMBOPHLEBITIS
1. Venous stasis
- dysfunctional venous valve
- immobilized and non use of skeletal muscles
- Other factors
- Virchow's triad
- Geriatrics
- Spinal cord injury
- Diabetes
- Post partum
- Pregnancy
- CHF
- A fib
- Steroid use
2. Hyper-coagulation ability
- antiprothrombin
- hematological dysfunction
- anemia
- septicemia
- elderly dehydration (not a lot of fluid)
- smoking
- estrogen usage
3. Vein wall trauma
- DVT
- Fracture with compression of blood vessels
- Diabetic
- Extensive burns second degree or worse
PATHOPHYSIOLOGY
Different element are in the blood, they include…
RBC, WBC, platelets, fibrin
DVT common place they clot is valve cusps *****test******
More accumulation of RBC, WBC, Platelets, and fibrin = clot enlargement in
diameter and forms a tail. It is the tail that causes the occlusion.
Clot dislodges and moves now it is called an embolism. It usually gets stuck
in the pulmonary circulation.
SUPERFICIAL THROMBOPHLEBITIS
Symptoms
- Red
- Swollen
- Indurated
- Warmer temp at site
- Don't typically see edema.
Can see this with IV drug abusers
Varicose veins = very superficial
Signs and symptoms of DVT (usually in leg)
1. Pain
2. Swelling
3. Positive Homan's sign in affected leg
4. Red or warm leg
5. Dilated veins by the inclusion
6. Low grade fever 99.4 or higher
7. Unequal leg measurements
- calf 6" below knee
- Knee
- Thigh 8 " above knee
- Measure in centimeters, worry if there
is a 2" or more difference in one area
8. Cyanosis (later sign) Sites
Veins
- femoral
- iliac
- inferior vena cave
- superior vena cave
- axillary veins
- subclavian vein
Treatment
SCD, Ted hose, leg exercises, adequate hydration (2-3 l/per day), low dose
anticoagulation.
Lovenox 30 mg SQ Q 12 hours
Heparin 5000u SQ Q 8 hours
Aspirin 80 mg Q day
Not prolonged periods of sitting or standing
Stop smoking
Oral estrogen use = once DVT has happened you no longer should use these.
Diagnosis of DVT
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Test
CBC (WBC = elevated)
Platelet
PT
APTT
Bleeding time
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Normal range
usually > 11,000
150,000 - 400,000
12 - 15 seconds
30 - 45 seconds
1 - 6 minutes
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DVT value
elevated
decreased
decreased
decreased
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PT measuring extrinsic coagulation factors are Factor I, II, V, VII, X
APTT measuring intrinsic coagulation factors are Factor I, II, V, VII,
VIIII, XXI, XII
Once patient has indicators that are present you can do further studies:
* Doppler evaluation
- to determine venous flow for occlusion
- if this indicates or inconclusive can
go on to further radiological studies
1. Duplex scanning
· Ultrasound image and doppler can detect
location and if total or partial occlusion.
2. Plethymography
· not don't that much
· looks at measurement of leg volume
caused by possible DVT
· thigh cuff/inflated (measuring speed or
volume as blood cuff decreases)
· slow outflow time if + DVT
3. Venogram (nuclear medicine)
· $$$$$
· injected with dye
· 1 -1 ˝ hours later has x-ray can find
exact location of the DVT
Affected leg
Positioned up past level of heart
Helps increase venous return
Decreases edema MD orders/ warm
compresses, heat
Decreases pain/swelling
Opens smaller capillaries TEDS
(sometimes)
Activities are BR w/ BRP
Assess first where the clot is before
letting patient walk to restroom
If in thigh area pt. may need to be bed
bound for days.
Drug management
Anticoagulant (effects fibrinolytic system)
Goals
· prevent the clot from growing in size
· prevents new clots from developing
· embolization clot movement (I have no
clue what embolization is)
Medical management of DVT
Drugs
1. Heparin (thrombin inhibitor, intrinsic factor)
· inhibits thrombin conversion from
fibrinogen to fibrin
· potentates the action of antithrombin
II
· inhibits actor factor VIIII
· neutralizes activated factor X
get a baseline PTT, CBC, PT and weight of patient.
Dose IV bolus
5,000 - 10,000 units then 750 - 1,000 units per hour IV Patient is on this
for 5-7 days then starts oral therapy Heparin doses decrease as Coumadin is
added in.
2. Coumadin (oral)
· adjust dose based on prothrombin time
· PT wanted 1.5 - 2.0 times normal value
· INR 2.0 - 3.0 therapeutic range
· Adjust dosage to bring INR to range
Coumadin competes with vitamin K
Inhibits liver synthesis of Vitamin K dependent
Coagulation factors.. II, VII, VIIII, X
Starting dose - ORAL
2 ˝ - 5 mg
As heparin in decreased down or d/c then daily take 5 - 10 mg
Side effects:
· bleeding (skin, urine, stool, emesis)
· fever
· rashes
· LFT's elevated
Do clotting studies when on IV heparin therapy
APTT Normal = 24 - 36 therapeutic level 48 - 60 seconds
ACT Normal 80 - 135 sec. therapeutic level 3 minutes (180 seconds)
LOVENOX
Antithrombin action
Inhibits factor XA
Dosage
1mg/kg body weight Q 12 hours SQ
PATIENT TEACHING
Increase vitamin K either in food or supplements (don't splurge)
Voice concerns with behavior
Brush teeth with soft toothbrush
No vigorous flossing
Stool softeners
Absolutely NO IM INJECTIONS
SQ is okay
Medications to avoid
· aspirin
· NSAIDS
· Alcohol intake because it can cause
gastritis irritant
DO NOT D/C THERAPY WITHOUT MD ORDER
If you are having any surgery type procedures let them know well in advance.
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