4 hours ago DVT History Consult Sample Report. DATE OF CONSULTATION: MM/DD/YYYY. REFERRING PHYSICIAN: John Doe, MD. REASON FOR CONSULTATION: DVT history. HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old lady transferred from the nursing home because of left lower extremity DVT. >> Go To The Portal
Although a high Wells' score indicates a clinical probability of DVT, an objective imaging technique such as compression ultrasonography, CT venography or MRI must be used to confirm or rule out DVT. D-dimer testing can also be used to rule out DVT.
Signs of DVT on physical examination include tenderness, warmth, erythema, cyanosis, edema, palpable cord (a palpable thrombotic vein), superficial venous dilation, and signs named for the physicians who first described them.
Based on the assessment data, the major nursing diagnoses are: Ineffective tissue perfusion related to interruption of venous blood flow. Impaired comfort related to vascular inflammation and irritation. Risk for impaired physical mobility related to discomfort and safety precautions.
10 Questions to Ask Your Doctor About DVTWhat is a DVT? ... Are you sure I have a DVT? ... How did I get DVT? ... How will you treat my DVT? ... How long will I have to stay on blood thinners? ... What if I can't take blood thinners, or the clot is really big? ... Can I exercise while being treated? ... Can DVT cause a stroke or heart attack?More items...•
What should documentation and coding for DVT include? Description of DVT severity as acute, chronic, or historical. Specification of laterality (left or right). Specification of the vein (i.e., femoral, iliac, or tibial).
The affected extremity is often pale with poor or even absent distal pulses. The physical findings may suggest acute arterial occlusion, but the presence of swelling, petechiae, and distended superficial veins point to this condition.
A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.
DVT & OH. Goals include weaning the patient from the ventilator, or, long-term options, such as discharge with a ventilator, diaphragmatic pacer, etc. Nursing Interventions include: Treating an ineffective cough with assistive cough, pneumobelts, turning, increased acitivity, and chest physical therapy.
Deep vein thrombosis (DVT) is a medical condition which involves the formation of a blood clot called thrombus in a deep vein/s in the body. The legs are the most common sites of DVT. While DVT can manifest as acute pain and/or swelling, some patients do not experience any symptoms in the beginning.
Nursing care for a patient with pulmonary embolism includes: Prevent venous stasis. Encourage ambulation and active and passive leg exercises to prevent venous stasis. Monitor thrombolytic therapy.
The three factors of Virchow's triad include intravascular vessel wall damage, stasis of flow, and the presence of a hypercoagulable state.
DON'T stand or sit in one spot for a long time. DON'T wear clothing that restricts blood flow in your legs. DON'T smoke. DON'T participate in contact sports when taking blood thinners because you're at risk of bleeding from trauma.
Therefore, the patient should be advised to immediately call 911, health care provider and/or seek immediate medical attention by visiting the nearest emergency care department/hospital in the development of any ‘look out signs’. The major look out symptoms include, sharp and sudden chest pain, shortness of breath, dizziness, coughing up blood and unstoppable bleeding. The development of these signs may imply recurrent episode of DVT, development of other associated conditions such as PPS, PTS, VTE and finally may lead to death due to bleeding (Cameron et al., 2011).
These educational handout will contain the information on any symptoms to look out for as well as when to seek medical advice, among other information on DVT. A sample educational handout was prepared as shown in Appendix II, based on educational handouts given to DVT patients by RVH Victoria hospital and St.Joseph’s health care Hamilton. Moreover, another handout was prepared which contains specific information on self-care strategies, emergency situations and how to respond (Appendix III), based on other studies (Burnett, 2013; Guyatt et al., 2012)
Most common long-terms health outcomes include PTS, Venous thromboembolism and PPS (Table II). Post-thrombotic syndrome is a chronic clinical disorder characterized by pain, swelling in the leg and fatigue, that develops in 20-50% of patients within 2 year of DVT. In severe conditions, it also leads to chronic leg pain and leg ulceration. Clinical scoring systems such as Brandjes scale, Ginsberg -measure and Villalta scale can be used to assess whether there is a risk of development of PTS followed by DVT (Soosainathan et al., 2013). Using Villalta PTS scoring system, it was assessed whether Mrs. Meecham have any risk of development of PTS (Table III). Some of the clinical signs and symptoms of PTS were already visible on her. However, as the severity of these signs were not provided, calculation of accurate scoring was not possible. Yet, she may have a probability of development of PTS. Recurrent ipsilateral DVT is the most predominant risk factor for PTS , although addition factors such as gender, obesity and genetic predisposition has also been implied in other studies (Baldwin et al., 2013). Venous hypertension, following DVT is a common cause for PTS, which could lead to increased tissue permeability (Kahn et al., 2016).
Deep Vein Thrombosis (DVT) is a result of blood clots or thrombus formation of in deep veins and frequently occurs in limbs (Boyd, 2015). When the thrombus development occurs in lungs, it is referred to as pulmonary embolism (PE), which is one of the most serious complications of associated with ~40% DVT patients. Disability and chronic pain caused by recurrent DVT may lead to long-term health effects. These health conditions include, recurrent episodes of DVT (Cowell et al., 2016), post-phlebitic syndrome (PPS) (Nayak & Vedantham, 2012), post-thrombotic syndrome (PTS) (Prandoni et al., 2016), venous thromboembolism (VTE) (Nordstrom et al., 2015) as well as bleeding and high mortality in many patients (Verso et al., 2012).
2.3 Bleeding. The major drugs used for the prevention and treatment of DVT and VTE are anticoagulants (blood thinners) and examples include Heparin, fondaparinux, vitamin K antagonists (VKAs) and Xa inhibitors. However, they pose a greater risk of severe bleeding.
The nurse should assess the patient and the caregivers about the readiness/motivation to educate themselves, complaint or request assistance when necessary, in order to provide the best care plans and ensure the safety of the patient post-discharge. A patient/caregiver education leaflet will also be provided during this meeting. Examples of such leaflets are shown in Appendix II-III.
The priority of a discharge plan is to ensure the patient and the caregivers are given required information on the management of the patient’s conditions, education of the patients/caregivers about the disease and risk factors, and medication reconciliation. In order to assure the aforementioned, a discharge plan checklist (Appendix I) was developed based on care coordination publications of the patients with DVT/ PE from (Janssen Pharmaceuticals, 2013) and (Agency for Healthcare Research and Quality, June 2013).
SUBJECTIVE: The patient is a (XX)-year-old man referred for an opinion regarding left leg DVT. He has been in good health, but developed a stress fracture of the left foot six months ago, resulting in placement of a cast. The cast was on for three months or so, and around that time, the cast was removed. He had some problems with swelling of the left leg. A subsequent left leg ultrasound demonstrated evidence of acute thrombosis of the left popliteal veins as well as thrombus in one of the tibial veins in the calf. The patient was then placed on anticoagulation, first with Lovenox and eventually warfarin. He has remained on warfarin up to the present time. He initially had some swelling in the leg, but his swelling has gotten better. He still has some problems with the foot, particularly some discomfort with weightbearing and some decrease in mobility in the foot, most likely referable to his forefoot stress fracture.
The cast was on for three months or so, and around that time, the cast was removed. He had some problems with swelling of the left leg. A subsequent left leg ultrasound demonstrated evidence of acute thrombosis of the left popliteal veins as well as thrombus in one of the tibial veins in the calf.
Several hours later, Nathan called my office to thank me. The hospital physician had diagnosed a thrombus in the popliteal vein and in the posterior tibial vein, and he was admitted to the hospital for anticoagulant therapy.
Interestingly, after the fact, the patient learned of a family history of DVT. His father and uncles had also experienced thrombus formation but had not informed him of that family history. Genetic variants causing either an excess of a prothrombotic factor or a deficiency in an antithrombotic factor can lead to a greater risk of developing DVT and should be included in the family history inquiry.