Winningham Case

1. List 6 risk factors for DVT.
Inheriting a blood clot disorder
Prolonged bed rest, such as long hospital stay
Injury or surgery
Pregnancy
Birth control pills or hormone replacement
Being overweight or obese

2. Identify at least 5 problems from L.J.’s history that represent his personal risk factors. Smoking history
Personal history of DVT
Prolonged bed rest
Age of above 60 years old
Sitting for long period of times (Bus Driving)

3. Something is missing from the scenario. Based on his history, L.J. should have been taking an important medication. What is it, and why should he be taking it? He should have been taking a blood thinner. This will decrease the blood’s ability to clot. This keeps the existing clots from getting larger and new clots from forming.

4. Keeping in mind L.J.’s health history and admitting diagnoses, what are the most important assessments you will make during your physical examination and assessment? I will continually assess for peripheral circulation and monitor for pain associated with his right leg DVT. I would also monitor for swelling, redness, excess warmth, and discoloration in comparison with unaffected limb. 5. What is the most serious complication of DVT?

Most serious complication is that a thrombus becomes mobile changing its status as an embolus. An embolus has a high likelihood of reaching the lungs and which can potentially become fatal as a pulmonary embolism.

6. List at least 8 assessment findings you should monitor closely for in the development of the complication identified in Question 5. Monitor for shortness of breath.
Skin cool to touch
Assess for chest pain
Auscultate heart sounds for accentuated (stressed) sounds
Auscultate for wheezing and crackled breathing sounds in the lungs. Monitor heart rate for tachycardia
Observe for neck vein distension
Observe patient for cyanosis

7. L.J. asks, “Why do I have to get these shots? Why can’t I just get a Coumadin pill to thin mu blood?” What should be your response? a. “Good idea! I will ask the physician to switch medications.” b. “It would take the Coumadin pills several days to become effective.” c. “Your physician prefers the injections over the pills.” d. “The enoxaparin will work to dissolve the blood clot in your leg.” 8. The order for the enoxaparin reads: Enoxaparin 70mg every 12 hours subcutaneous. L.J. is 5ft, 6in. and weighs 156lb. Is this dose appropriate?

The dose is appropriate because enoxaparin may be given at rate of 1mg/kg every 12 hours for acute impatient DVT treatment. Pt is 156lb which is approx. 70kg making this his appropriate dose.

9. What special techniques do you use when giving the subcutaneous injection of enoxaparin?
a. Rotate injection sites
b. Give the injection near the umbilicus
c. Expel the bubble from the prefilled syringe before giving the injection
d. After inserting the needle, do not aspirate before giving the injection.
e. Massage the injection site gently after the injection is given.

10. True or False: Enoxaparin dosage is directed by monitoring activated partial thromboplastin time (aPTT) levels. Explain your answer. While aPTT may be monitored in obese or patients with renal insufficiency, it is not typically necessary for deciding dosages. Instead patient weight typically is used to decide appropriate drug dosing for Enoxaparin.

11. What instructions will you give L.J. about his activity? He is to be on bed rest with low mobility due to need for elevation of extremities to prevent thrombus from developing into an embolus. Tell him to change positions periodically to prevent skin breakdown and formation of pressure ulcers.

12. What pertinent laboratory values or test results would you expect the physician to order and you to monitor? aPTT- to monitor effectiveness of heparin on thinning blood PT- to monitor the effectiveness of Coumadin on thinning blood after discontinuing heparin

13. You identify pain as a key issue in the care of L.J. List 4 interventions you will choose for L.J. to address his pain. I will request the use of a prn analgesic for pain
Immobilize the effected extremity to prevent agitation and pain from ambulation Provide distraction such as television to distract patient from pain Elevate the leg to reduce swelling that may cause greater pain

14. You evaluate L.J.’s ECG strip. Name this rhythm, and explain what consequences it could have for L.J. Atrial Fibrillation- due to lack of synchronized atrial contraction blood movement is reduced creating stagnant blood. This stagnant blood may blood and form new thrombi in L.J.’s venous system. 15. What are you going to tell him?

I am going to remind him that long periods of sitting are not preferred following DVT diagnoses as they may cause a new formation of clots in his extremities. Also the sudden changes in altitude may cause problems in venous return form the legs increasing risk of clotting. It is not advised that you fly for quite some time. Are you sure there isn’t anyone who would tape the ceremony? I’m sure your grandson will understand your absence following your recent hospital stay.