Venous thromboembolism VTE

● What is it? Formation of a thrombus (blood clot) with vein inflammation

● Two classification:
pt may be asymptomatic
○ Superficial vein thrombosis: serious
■ Cord like veins
■ Firm palpable nodule
■ Red
■ Painful
■ Extremity edema
■ Slight leukocytosis (increased wbc) and fever
○ Deep venous thrombosis DVT
■ Effects lower extremities
● Most often in iliac or femoral veins
■ Unilateral
■ Warm
■ Redness, tenderness
■ Positive homan sign= pain when dorsiflexion
■
■ Dont use compression socks , dont massage

● PE: monitor!! Very serious

○ Is formed when a piece of DVT clot breaks off and is brought back to heart and
lungs
■ Very dangerous!
■ Can stop oxygen= difficult breathing
○ S/S
■ SOB = call hcp, immediately give oxygen
■ Coughing
■ Chest Pain
■ Decreased o2
■ Increase hr
■ Anxiety
Risk factors
● Smoking
● Inactivity
● Hypertension

Patho:
Virchow triad : 3 things that results in thrombus formation
1. Venous stasis
● Occurs when pt has not moved for a while
○ Being seated, immobilized, post op
 ■ Traveling for long hours
○ Ppl who are obese, pregnant, a. Fib, CHF, varicose veins

2. Damage of the endothelium/ inner lining of vein

● Caused by direct (surgery, trauma) or indirect (chemotherapy, diabetes)
○ Htn, birthcontrol, smoking, IV usage, etc.
● This creates little cuts in blood vessels which release platelets to form a scab.
However scab can get big and form blood clot. Clot can break off and float
towards lungs-> Pulmonary embolism
● Causes vasoconstriction
3. Hypercoagulability
● Occurs with anemias, cancer, nephrotic syndrome, antithrombin deficiency
● Smoking
● Predispose factors: corticosteroids, estrogen, sepsis
● Tobacco use, oral contraceptives

And then thrombus is formed, which causes clinical manifestations

Pharm
● Low molecular weight heparin LMWH : anticoagulant/ antithrombotic does not break
up existing clot. Only helps prevent existing clot from getting bigger and new clots from
forming

Lovenox (fast ‘short acting’ 20min or less)

● Route: subcu
● Monitor Anti factor Xa
○ Therapeutic value: 0.2-1.5 units/ml
● Do not inject IM, do not rub site after injection, rotate sites
● Caution: renal or HIT patient
● Can be use in combination with warfarin until warfarin INR is
therapeutic. Then stop use of heparin lovenox. (bc warfarin is long
acting, so heparin will start faster)
○ INR therapeutic value: 2-3
● Antidote: Protamine

● Unfractionated Heparin

Heparin sodium
● Route: continuous and intermittent IV, subq
● Monitor aPTT
○ Therapeutic value: 46-70sec (if higher than 70, decrease
dose)
○ Normal: 30-40sec
 ● Monitor ACT
○ Therapeutic value: >300 sec
■ Normal: 70-120sec
● IV given as a supplement for existing blood clots
● SQ given to prevent development of clots
● Can be use in combination with warfarin until warfarin INR is
therapeutic. Then stop use of heparin lovenox. (bc warfarin is long
acting, so heparin will start faster)
○ INR therapeutic value: 2-3
● Antidote: protamine
●
For pt with DVT of significant size, put on Heparin drip, first do bolus and then drip.
Adjust every 6 hr based on PTT
Heparin bolus: 80units/kg one time dose
*double check heparin by another RN

● Factor Xa Inhibitors

Apixaban (eliquis)
Rivaroxaban (xarelto)
● Route: PO
● VTE prevention and treatment
● Do not expel air bubble before giving fondaparinux
● Antidote: andexanet alfa
● Therapeutic value
○ 0.6-1.0 units/ml

● Vitamin K Antagonists (VKA) anticoagulant/ antithrombotic does not break up existing

clot. Only helps prevent existing clot from getting bigger and new clots from forming

Warfarin (coumadin)
● Route: PO
● Monitor INR
○ INR therapeutic value: 2-3
■ Higher inr= more risk for bleeding .. blood clots slowly
■ lower= less anticoagulated you are.. Blood clots quickly
○ Can be use in combination with heparin until warfarin INR is
therapeutic. Then stop use of heparin lovenox. (bc warfarin is
long acting, so heparin will start faster)
● Eat consistent green leafy veggies (vitamin K)
● Antidote: vitamin k
● Give at same time each day
● Onset: a couple days-> take heparin first
After a big clot, pt can go home on antiplatelets
● Aspirin, clopidogrel plavix

When given anticoagulants (warfarin, heparin, loveonox) or antiplatelet (aspirin, clopidogrel)

There is a bleed precaution.
● Do not razor shave. Electric razor okay
● No straining when poop. Give stool softner
● No brushing teeth hard
● Most at risk for bleed: liver problem
● No vitamins or herbs
Action
● Greenfield filter insertion: prevents PE, clots are trapped in filter
● Ambulate pt
● No long sitting or standing
● Tight compression socks help reduce pressure in lower legs, heals ulcers ??????

After clot is resolved: SCD

● Need to fit properly
● Wear right
● Clean

When pt has a blood clot

● Dont massage rub area
● Ensure bed rest
● Warm compress
● ELEVATE EXTREMITY
○ dVt= eleVate
■ Helps vein bring blood back to heart since blood is pooling in lower
extremity

Diagnostic
● Duplex ultrasound
● CT
● MRI
Peripheral artery disease PAD https://quizlet.com/859132040/chapter-41-peripheral-artery-
disease-flash-cards/

● What is it? It is the build up of atherosclerotic plaques (from cholesterol and lipids),
which thickens the artery walls (intima and media)

● Main problem with this? The heart is having a hard time pumping out oxygenated blood
to the extremities because the arteries are too narrow and are occluded.
○ Blood flow cut off= lack of oxygen to extremities= ischemia and necrosis/
tissue death SEVERE

● Biggest risk factor that causes PAD

○ Smoking
○ Diabetes, hypertension, high cholesterol, age over 60, obesity, hyperlipidemia

● S/s
○ Intermittent claudication
■ Lower extremity/ calf pain
■ Leg pain with exercise, resolved within 10 min of rest
○ Paresthesia (numbness tingling) in toes or feet from nerve tissue ischemia
○ Cool temp
○ No leg hair
○ Skin is shiny, taut
○ Pallor
○ Delayed capillary refill
○ Decreased pedal pulses
○ Wound on feet
○ Leg pain when sleeping
○ Pallor when legs are elevated. Red when legs dangle (bc blood is returned)
■ Dangle is good!

SEVERE S/S= O2 assessment = lead to loss limb -> atrophy of skin annd muscles->
ulcerations and gangrene
PAIN is unrelieved at rest!
Paresthesia.. No o2 getting to extremities
Critical limb ischemia-> pain occurs longer than 2 weeks->amputation

● Raynaud's S/s
○ Involves fingers and toes
 ○ Color: white blue red fingers, toes, ear, nose
■ white/ pallor= decreased perfusion
■ cyan= blue
■ Rubor red= when blood flow is restored
○ Due to vasoconstriction
○ Cool, numbing
○ Risk from use of vibrating machines or cold environment
○ Numb, Throbbing, ache, tingle, swelling
○ Avoid Triggers: cold exposure, tobacco, caffeine
■ Wear warm gloves
○ Connected to autoimmune diseases
○ Loose fitting clothes
○ Drug therapy:
■ CCB- decreases vasospasm

● Diagnosis
○ Doppler ultrasound to assess for blood flow
■ With imaging: to see where blood flow is lacking
○ Ankle brachial index. Compare ankle bp to brachial bp. Divide ankle sysbp by
brachial sbp
■ If index less than 0.9= abnormal blood flow
○ Angiography with contrasts
○ Mri
● Treatment
○ Statins: reduce cholesterol a,d reduce plaque
○ Antiplatelet: prevents clots
○ Ace: decrease vasoconstriction
○ Endarterectomy: plaque removed
○ Bypass graft
■ To reroute blood flow around occluded artery
■ After: monitor pedal pluses, cap refill, skin color, cold temp, pain, pallor-
these can indicate graft occlusion
■ Keep leg straight

Post op: vascular check, monitor bleeds, elevate leg

● Actions
○ Don't cross legs
○ Watch for feet injury
■ Avoid prolonged sitting or kneee bending
■ No compression sock
○ Avoid extreme temp
○ Walk until in pain, stop, rest, resume
 ○ Warm environment, wear socks, well fitting shoes, encourage exercise 30-45min/
day for at least 3 days/ week for 3 months
○ Avoid nic and caffeine
○ Toenails trimmed only by provider
○ Low sodium diet
○ Arteries (away)= hAng (color should return, pain should stop)
■ Goal to push oxygenated blood to toes

Aortic Aneurysm and dissection

● What is the aorta? It is the largest blood vessel that supplies o2, nutrients, and blood to
all vital organs
● What is an aortic aneurysm? It is the permanent, localized outpouching or dilation of the
aortic vessel wall

● Two types of aortic aneurysm TAA

○ Thoracic aortic arch aneurysm TYPE A
■ More serious
■ Can be Asymptomatic
■ Occasional Symptoms include: deep diffuse chest pain
■ Ascending/ aortic arch aneurysms can cause
● Angina from decreased blood flow to coronary arteries
● TIA: from decreased blood flow to carotid arteries
● coughing , sob, hoarseness, difficulty swallowing from
pressure on laryngeal nerve
 ○ Emergency surgery
■ Dissection is: severe anterior chest or back pain, sudden onset

● Abdominal aorta aneurysm AAA TYPE B

○ Asymptomatic
○ Descending aortic; occasional epigastric
○ Occasional SE: back flank pain, epigastric discomfort, ‘blue toe’
syndrome (mottling of feet and toes, palpable pedal pulses), pulsating
abd mass, bruit
■ Do not palpate bc it can rupture
○ Lower bp
○ Diagnosis: often found during routine physical assessment for another
problem
■ Xray, ct
○ Dissection: sharp ripping tearing stabbing back or leg pain

● Risk factors
○ SMOKER
○ 65< age, male gender, HTN, CAD, family hx, high cholesterol, lower extremity
PAD, CAD, stroke, obesity, tobacco
○ larger= more at risk for rupture

● Causes
○ Atherosclerosis- hardening of arteries
○ HTN
○ Infection
○ Trauma to chest

● Diagnostic
○ Xray
■ Chest: shows abnormal widening of thoracic aorta
■ Abd: shows calcification in aortic wall
○ CT or MRI: assess location and severity
○ Ultrasound: monitor aneurysm
● Care
○ Prevent rupture
■ Stop tobacco use, decrease bp, lipids, gradually increase physical
exercise
■ Management for htn, hyperlipidemia, diabetes, cad risks factors
■ Statin and ACE meds

Aortic Dissection
● What is an aortic dissection? A serious condition that occurs when there is a tear in the
arterial wall (between intima and media), and blood rushes through the tear, causing the
aorta layers (intima and media) to split apart.
○ If it ruptures, it is fatal
○ Increase HR, and increased pressure on dissection can worsen it

● How is it classified? Aortic dissection is classified based on the location and duration of
onset

● What are the types of dissection?

○ Type A: tearing in the ascending/ upper aorta and arch-- most common and
dangerous type
■ Requires emergency surgery
■ Must get treated asap
■ SE: abrupt onset of severe anterior chest or back pain
If aortic arch is involved= neuro problems
LOC, weak carotid temporal pulse, dizzy, syncope

○ Type B: tear in the descending/ lower aorta, allowing for potential

conservative management
■ Acute 14days
■ Subacute 14-90days
■ Chronic >90days
■ SE: pain in back, abd, legs, decreased tissue perfusion
Pain described as sharp, worst ever, tearing, ripping

● Risks
○ Weaken aortic wall
■ Can be from high BP, major trauma to chest, abnormalities of aortic valve
○ Male gender, htn, aortic diseases, atherosclerosis, trauma, tobacco, pregnancy

● Diagnostics
○ MRI
○ CT
○ TEE

● Care
○ Lower HR and BP
■ IV bblocker to target hr under 60 and sbp 100-110
■ Ccb lower hr if bblocker is contraindicated
○ Surgery: artificial graft
■ Graft occlusion: absent pulses, cool, mottled extremity= emergency
 ■ Should not have blood stool after surgery

Bronchiectasis
● What is it? It is when the bronchioles are permanent abnormally dilated, which
makes it harder to clear secretions
○ Caused by: untreated lung infections, immune system problems or genetic
factors

● Patho
○ Permanent dilation occurs from inflammatory changes that destroy the elastic
and muscular structures supporting the bronchial wall.
■ Cycle of inflammation, airway damage, remodeling-> accumulation of
neutrophils in airways
■ Airways can become colonized with microorganisms-> bronchial walls
weaken and infections form
■ Bacteria and mucus accumulate -> increase neutrophils and
inflammation-> edema
■ Decreased ability to clear mucus from lungs-> decreased expiratory
airflow

Cannot effectively clear mucous, which can lead to bacteria-> infection and inflammation-> can
leas to respiratory failure

● Cause/ risk factors

○ Bacterial infection of lungs
○ Mucus plugs, impaired pulmonary defenses, repeated aspiration
○ Diabetes, inflammatory bowel disease, RA, immune disorders
● Sig complications
○ Pulmonary htn
○ neovascularization-> hemoptysis: emergency!
○ Pneumonia
○ Heart failure
● S/s
○ Persistent cough
 ○ Thick purulent sputum
○ SOB
○ Recurrent infections injure blood vessels
○ bleeding/ hemoptysis= life threatening
○ Pleuritic chest pain, dyspnea, wheezing, clubbing, weight loss, anemia
When to see doc: when more serve cough, increase sob, fever,
● Diagnostic
○ CT scan!
○ Chest xray
○
● Care
○ Outpatient basis
○ Antibiotics to treat innfections
■ IV or nebulizer
○ Bronnchodilator therapy and ICS
■ SABA
■ LABA
■ Anticholinergics
■ ICS

Maintain airway, stable vitals

Slow steady unlabored breathing
Lots of blood= notify hcp
If pt not in immediate distress= obtain family hx

Chronic Venous Insufficiency CVI

 ● What is it? It describes abnormalities of the venous system that results in advanced
signs and symptoms: edema, skin changes, venous leg ulcers
○ Leads to venous leg ulcers: painful, slow to heal

● Patho
○ Causes? Varicose veins and PTS
○ Ambulatory venous htn causes serous fluid and rbc to leak from capillaries and
venules into tissue-> edema and chronic inflammatory changes
○ Breakdown of rbc-> hemosiderin (brown skin color)
○ Fibrous tissue replacement -> thick hardened contracted skin

● S/s
○ Lower leg is leathery, brownish brawny
○ Edema
○ Eczema, itchy
○ Venous ulcer- untreated can be at risk for infection

● Care
○ Avoid sitting or standing for long periods
■ Elevate above heart to reduce edema
○ Proper leg foot care
○ Compression
■ Socks
■ Bandages
■ Velcro wrap
■ Ipc
○ Moist dressings
○ Proper nutrition

Do not use antibiotics

Cystic fibrosis
● It is thick, sticky, mucus that is hard to clear
○ In airways, pancreas, intestines
○ Frequent infections
● S/s
○ Thick cough
○ Thick sticky tar poop- in baby’s poop
 ○ Steatorrhea-oil poops
● Interventions
○ Chest physiotherapy
■ OT or PT does this
○ Bronchodilators
○ Fluids
○ exercise
○ Pancreatic enzyme supplements
■ Before meals
○ High protein high cal diet, unrestricted fat
○ vaccinated
● Diagnosis
○ Sweat chloride test (should be <30mmol/L if negative for CF)
○ Salty skin