Patients continue to have poor outcomes after suffering blood clots in the legs or arms, despite physician orders for therapy with sequential compression devices (SCDs). As a nurse, you can play a pivotal role in improving outcomes by evaluating patients at risk for deep vein thrombosis (DVT) and by using SCD properly and safely to prevent complications of thrombi and pulmonary embolism (PE). The Joint Commission now uses the term venous thromboembolism (VTE) to encompass both DVT and PE. (See Understanding venous thromboembolism.)
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Understanding venous thromboembolism
More than 2.5 million people are diagnosed with deep vein thrombosis (DVT) each year. DVT results from clot formation in a deep vein, usually in the leg. It can lead to pulmonary embolism (PE), in which the clot breaks loose, travels through the bloodstream to the lungs, and lodges there. In the lung, the clot inhibits blood flow and can damage part of the lung or even lead to death. Venous thromboembolism (VTE) is the umbrella term for DVT and PE.
Incidence of upper-extremity DVT has risen from increasing use of indwelling venous access catheters, permanent pacemakers, and internal cardiac defibrillators. With today's shorter hospital stays and more same-day surgeries, patients with DVT may lack symptoms while hospitalized or may not develop symptoms until after discharge. Mortality for lower-extremity DVT ranges from 13% to 21%; for upper-extremity DVT, it may be as high as 48%. With PE, mortality can be as high as 25%; the condition causes roughly 10% to 25% of hospital deaths.
The deep veins in the legs return venous blood to the right atrium and lungs. Contractions of leg muscles and one-way venous valves push blood forward from the feet to the heart's right atrium. This occurs because the venous system is a low-pressure system; muscles act as pumps to increase the velocity of returning blood, forcing blood upward to the heart. One-way venous valves open in response to pressure of the blood to prevent backward flow and blood pooling in the venous system. DVT risk increases with damage or trauma to the venous system or the lungs and with patient immobility.
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Promoting better outcomes
To enhance patient outcomes, clinicians should focus on VTE prevention. This is best achieved through risk stratification, identification of at-risk patients, and use of VTE prophylaxis (pharmacologic, mechanical, or a combination). Hospital patients are at higher risk for VTE because of their limited mobility, active disease processes, and comorbidities. Those with cancer, trauma, surgery, and obstetric diagnoses have the highest risk for VTE complications.
Mechanical devices, such as SCDs, are the first choice for VTE prophylaxis. These methods are as efficacious and reduce risk as much as pharmacologic methods, without causing bleeding complications. (Be aware, though, that SCD therapy is contraindicated in DVT, compartment syndrome, extremity deformity, and an open infected wound of the extremity.)
Traditionally, physicians' orders for SCD or other types of mechanical compression therapy have lacked all the components needed to provide adequate therapy. These orders should specify:
* whether to use bilateral or single sleeves
* whether to use sleeves on the lower or upper extremities
* whether to use knee-length or thigh-length sleeves
* duration of continuous SCD therapy
* criteria for discontinuing SCD
* instructions for sleeve removal every 8 hours to assess skin integrity and neurovascular status of the extremity. Neurovascular assessment should include checking for the "5 Ps" of ischemia--pain, pulse, pallor, paresthesia, and paralysis.
VTE risk assessment
On arrival at the hospital, adult medical and surgical patients should undergo VTE risk assessment by a physician or a licensed independent practitioner (LIP). …