Evidenced Based Paper
Evidenced Based Paper
Evidenced Based Paper
A venous thromboembolism (VTE) is a blood clot that forms in a vein and migrates to
another location in the body. Typically the clot begins as a deep venous thrombosis (DVT) that
becomes dislodged and travels the bloodstream until it is lodged in another area of the body,
typically the lungs, and may become a pulmonary embolism (PE). The outcome of the event is
often associated with serious health consequences. According to Diseases and Disorders,
pulmonary embolisms occur more frequently than expected with the incidence of venous
thromboembolism as high as 1 per 1,000 people. Each year, approximately 650,000 cases of PE
are reported and approximately 60% of patients who die in a hospital are found to have a PE on
autopsy (Unbound Medicine, 2000). Throughout this paper will examine the methods used to
prevent the occurrences of VTEs and discuss the nursing interventions and care guidelines that
can be made to have a greater reduction of VTE occurrences in the hospital.
Deep vein thrombosis is a serious condition that may cause a sequence adverse health
effects in patients. As stated by Harrisons Manual of Medicine, DVT is particularly common in
patients with prolonged bed rest, those with chronic debilitating disease, and those with
malignancies (Unbound Medicine, 2000). The pathophysiology of a thrombosis could be best
described by Virchows Triad. Virchows triad consist of three elements which include venous
stasis, damage to the endothelium, and hypercoagulability. Blood stasis occurs with immobility,
as with patients who are in surgery, who are chronically ill, and unable to walk. Vessel
endothelial damage can occur from trauma, surgery, high blood pressure, infection and
inflammation. Lastly, hypercoagulability can occur with deficiencies in antithrombin III and
protein C and S that normally inhibit clot formation (Osborne, Wraa, Watson, & Holleran, 2014).
Virchow described the pathogenesis of pulmonary embolization as a process wherein:
New masses of coagulum deposit themselves from the blood upon the end of the
thrombus layer after layer. The thrombus is prolonged beyond the mouth of the branch
into the trunk in the direction of the current of the blood, shoots out in the form of a thick
cylinder farther and farther, and becomes continually larger and larger. It is these
prolonged plugs that constitute the source of real danger; it is in them that ensues the
crumbling away, which leads to secondary occlusions in remote vessels. Thus we see that
as a rule all the thrombi from the periphery of the body produce secondary obstructions
and metastatic deposits [emboli] in the lungs (Kumar, 2010).
It is important that health care professionals observe for signs and symptoms of a
pulmonary embolism. According to Harrisons Manual of Medicine, some physical signs may
include pain and swelling over the affected vein and erythema. Symptoms of a PE often include
dyspnea, chest pain, or severe symptoms such as extreme pain, wheezing, diaphoresis, and the
sense of impending doom. The severity of the symptoms may be directly related to the size,
number, and location of the emboli (Unbound Medicine, 2000).
Due to the nature of hospital stays, patients are at an increased risk of developing a DVT
as a result of immobility after trauma, surgery, or illness. According to the study performed by
Collins, MacLellan, Gibbs, MacLellan, and Fletcher (2010), the primary medical and nursing
intervention for preventing DVT occurrences would be screening each patient for their VTE risk
assessment during their admission to the hospital. Responsibility for VTE risk assessment and
appropriate prophylaxis to prevent the onset of DVT in patients rests on the shoulders of multiple
clinical staff members. For effective VTE prophylaxis of all patients, it is important to assess
according to their individual VTE risk, taking careful consideration of their current clinical
condition, their potential for bleeding risk, and the appropriateness of the prophylaxis for the
individual patient. The assessment for VTE prophylaxis should occur on admission to hospital
and prophylaxis should continuously be re assessed on a regular basis throughout their hospital
stay to ensure prophylaxis remains appropriate. To be effective, GCS or Intermittent Pneumatic
Compression (IPC) should be measured and fitted for the individual patient and should be worn
continuously during the period of immobility to the return of full ambulation. Patient compliance
is essential so the nurse should ensure their stockings are not rolled down to the ankle.
Incorrectly fitting stockings invariably do not provide the graduated compression required for
prophylaxis and can cause more harm than benefit to patients (Collins, MacLellan, Gibbs,
MacLellan, & Fletcher, 2010).
Graduated Compression Stockings (GCS) are stockings that are used to prevent venous
thrombolysis by using high pressure at the ankle and low pressure at the knee or thigh. GCS
exert an even and sustained regressive pressure to the legs, with gradient pressure, decreasing
from the ankle to the knee and thigh. This form of mechanical prophylaxis has the double action
of increasing the venous blood flow velocity and preventing venous stasis. A systematic review
of acquired data by Autar (2009) showed that GCS effectively decrease the overall crosssectional area of the venous system of the lower limbs and increase the linear blood velocity.
Since they are not associated with the potential bleeding risk of pharmacological interventions,
they are an attractive method for protection. To determine the magnitude of the effectiveness of
graduated compression stockings in preventing VTE in various groups of hospitalized patients, a
Cochrane Systematic Review concluded that GCS alone lower the risk of VTE significantly. A
meta-analysis of the nine randomly controlled trials (two medical, five surgical and two
orthopedic) comprising 624 patients reported that 81 patients developed DVT (13%) in the GCS
alone group, compared with 154 patients (27%) in the control group (Autar, 2009).
A notable case from the law firm of Roselli and McNelis involved the misdiagnosis of
DVT of a patient after surgery which caused a preventable death. A woman underwent
gynecological surgery with plastic surgery abdominal repair at closure. After the surgery she
was not prescribed Heparin, or compression stockings to protect against the development of
Deep Vein Thrombosis. A few days following the procedure she reported increasing leg pain to
both the Plastic Surgeon and her Gynecologist. Neither providers evaluated her for or performed
any diagnostic studies for Deep Vein Thrombosis, which is a well-known post-operative
complication of any surgery. Instead, she was referred by her Gynecologist to see a Podiatrist
who also neglected to consider or evaluate her for Deep Vein Thrombosis. She failed to be
diagnosed and treated for the Deep Vein Thrombosis which resulted in her developing a
pulmonary emboli which caused her death (Roselli & McNelis, 2009). This information is
relevant to the topic discussed as I report that it is extremely important for patients to be
identified for risks, preventive measures met, and of course to be evaluated frequently. Without
the gap between research findings (evaluating their risk and assessing patients periodically) and
practice (missing apparent signs and symptoms leading to misdiagnosis and death) this woman
could have potentially survived with appropriate therapy.
I am pleased to know that Bayfront Medical Center does in fact follow the evidenced
based practice by completing a DVT risk assessment sheet on all patients during admission to the
hospital. I am concerned though, however, that we are not completely following all guidelines
accordingly. Bayfront has recently received all new sequential compression devices throughout
the hospital, and before completing this paper I was convinced that they were great for
preventing VTE. Now that I look back, it is hard for the health care professional to determine if
the devices are truly performing the way they are intended to. For example, the devices can
easily be removed or adjusted by the patient as they are simply attached onto the leg by velcro
straps. Second, I am curious to know if appropriate documentation is being completed on the
amount of time the devices have been continuously running to effectively reduce the patients risk
for a DVT. Lastly, how often are the health care professionals physically re-evaluating their
patient to ensure that their current prophylaxis plan is still effective if that is not what they are
here for as their primary diagnosis? I know how busy staff can be at the hospitals, and I feel like
applying the SCDs have just become a routine process and the true value and importance of these
machines is being overlooked.
Based on the evidenced based practice I have no doubt that SCD machines, GCS, and
other mechanical prophylaxis measures are useful in preventing the onset of deep vein
thrombosis, but when it comes to practice, it is the health care professionals who are responsible
for ensuring that we are doing all that we can to reduce a preventable incidence of morbidity and
mortality of our patients. Moving forward, I feel that it should be required that all clinical staff
should be educated on the importance of abiding to all proper guidelines and interventions when
it comes to preventing the occurrence of venous thrombolysis.
7
References
Autar, R. (2009). A review of the evidence for the efficacy of anti-embolism stockings (AES) in
venous thromboembolism (VTE) prevention. Journal of Orthopaedic Nursing, 13(1), 4149. Retrieved from
http://ejournals.ebsco.com.ezproxy.hsc.usf.edu/Direct.asp?AccessToken=9IIQIIJ8XUUX
KD99RJ5ZUMJ5KJKP8Q5MID&Show=Object
Collins, R., MacLellan, L., Gibbs, H., MacLellan, D., & Fletcher, J. (2010). Venous
thromboembolism prophylaxis: the role of the nurse in changing practice and saving
lives. Australian Journal of Advanced Nursing, 27. Retrieved from
http://ehis.ebscohost.com.ezproxy.hsc.usf.edu/ehost/pdfviewer/pdfviewer?vid=47&sid=c
3ad420d-ec7c-49de-b286-b38e0250fa79%40sessionmgr4002&hid=106
Kumar, D. R., Hanlin, E., Glurich, I., Mazza, J. J., & Yale, H. S. (2010). Virchows contribution
to the understanding of thrombosis and cellular biology. Clinical Medical & Research, 8,
(3-4): 168172. doi: 10.3121/cmr.2009.866
Nursing Central from Unbound Medicine. (n.d.). Nursing Central from Unbound Medicine.
Retrieved November 6, 2013, from http://nursing.unboundmedicine.com/nursingcentral
Osborne, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing:
Preparation for practice. (2nd ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Rosali, R., McNelis, L., (2009). Notable Cases. Retrieved
from http://www.rosellimcnelis.com/notable-cases/