Mrs. Dorothy (Dotty) Beecham has a history of deep vein thrombosis (DVT) and will continue to be at risk on discharge. Using the current literature and pathophysiology explain the risk that recurrent DVT may pose to her future health. Using evidence, develop a discharge plan in relation to her educational needs and support requirements. Outline how you would explain the symptoms to look out for and when to seek medical advice to Mrs Beecham.
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).
Raising the awareness of DVT and associated conditions in patients and caregivers, development of prevention approaches, enhancement of methods for patient education and improvement of patient information materials such as handouts are essential to facilitate the proper care of the DVT patients and prevention of future health threats. Using a case study on a 74-yearold patient, Mrs. Dorothy Beecham, who was admitted to the hospital with DVT and many other complications, a patient care plan executed by a nurse is described in this review.
Recurrent DVT may pose risk in development recurrent episodes of DVT, PPS, PTS, VTE and bleeding.
Literature- and pathophysiology-based prediction: DVT can be caused by synergistic effects of genetic-, acquired- and environmental- risk factors (Figure 1A) (Streiff et al., 2016). As no information was provided on genetic factors of the patient, they could not be used to predict the recurrent DVT risk for her. On the contrary, information on both acquired and environmental risk factors were used systematically to predict her risk of DVT recurrence. Mrs. Meecham meets several of these criteria for recurrent DVT, previous history of DVT being a major reason. Additionally, her older age (74 years), cardiac conditions such as myocardial infarction, vascular conditions of hypertension, hypercholesterolemia, immobilization due to osteoarthritis may also pose higher likelihood of recurrent DVT. Moreover, based on the reports on high correlation between chronic obstructive pulmonary disease (COPD) exacerbation and DVT (Lankeit & Held, 2016), Mrs. Meecham is at high risk of developing DVT again. A major factor highlighted in her health chart was smoking (5 cigarettes/day since 2012) and daily alcohol consumption. Smoking independently cause ~25% higher risk of DVT (Cheng et al., 2013), and combined with her history of myocardial infarction and hypertension, smoking elevates her risk of recurrent DVT. Additionally, her diabetic condition also adds up the risk of DVT recurrence as shown by other studies (Chung et al., 2015). Moreover, she is scheduled to have a total knee replacement surgery in the near future. Studies suggest possibilities of increased risk of DVT after knee replacement arthroplasty (Zhao et al., 2014). Collectively, the risk factors found in Mrs. Meecham which may contribute recurrence of DVT and/or associated conditions include history of DVT, advanced age, heart failure, diabetes, smoking, COPD and immobilization (Figure 1B).
Geneva and Wells clinical prediction rules-based prediction: Guidelines provided by (Hogg et al., 2012) for clinical prediction rules of DVT were used to predict the likelihood of recurrent DVT in Mrs. Beecham (Table I). Based on the revised Geneva rules, she had a risk rate of 12, while Well’s rules placed her in the risk class of 7. Both these clinical predication rules predicted ‘high’ chance of DVT recurrence in Mrs. Meecham.
Many DVT patients develop both short-term and long term health outcomes of DVT. 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).
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. Case-fatalities from major bleeding due to anticoagulant treatment in VTE patients have been reported to be as high as 13.4% (Linkins et al., 2003). Warfarin-associated intracranial hemorrhage has been linked to 50% mortality rate (Shoeb & Fang, 2013).
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).
Medication reconciliation will be a priority discussion point with Mrs. Meecham and her caregivers during the discharge meeting. She is currently on Heparin infusion as the initial anticoagulation therapy. Two types of anticoagulants are used to treat DVT; 1) Injectable or intravenously delivered medications (Eg. Fondaparinux Heparin and low molecular weight heparin) and 2) oral anticoagulants (Eg. Warfarin). If the doctor recommends Heparin usage after discharge, the patient may have to visit the nearest health care provider to receive this or set up a home care system. Heparin administration can also be done by a caregiver and/or through self-administration. Appropriate safety measures should be taken during self-administration. As she is also diabetic, the heparin administration can be arranged during the time of insulin injections. Warfarin may be prescribed as a life-long treatment plan for recurrent DVT patients such as Mrs. Meecham. Her medical history does not indicate Warfarin as a medication being currently taken. If Mrs. Meecham is prescribed Warfarin post-discharge, specific instructions should be provided with regard to complications and dietary restrictions (Witt et al., 2016) (discussed in next section below). She should also continue wearing compression stockings.
Other discussions that should be carried out during the discharge meeting are outlined in Appendix I. 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.
3.2 Post-discharge recommendations
The major points discussed and emphasized to follow post-discharge are keeping a tightly controlled medication regime, education of the patient and the caregiver what actions to be taken if a dose is missed (Appendix III), what signs to look for in case of an emergency (will be discussed in section 4), dietary or lifestyle changes to follow while taking anticoagulants and cessation of smoking.
Dietary considerations and lifestyle changes: Patients who take Warfarin as an anticoagulant treatment for DVT should be provided with dietary restriction plans (Witt et al., 2016). It is important to maintain a regular intake on vitamin (adult men 120 µg; adult women 90 µg) and avoid taking foods containing extra vitamin K such as kale, parsley, spinach, Brussels sprouts, mustard greens and green tea. Intake of Cranberry juice and alcohol while taking Warfarin may lead to excessive bleeding. Many of the blood thinners should be taken with care and the lifestyle should be managed to avoid opportunities of bleeding. Instructions for such lifestyle changes are outlined in Appendix III.
Smoking cessation recommendations: She has reduced her smoking habits from 20 cigarettes/day up to 5 cigarettes/day. However, she still may have higher risk or exacerbation of many chronic illnesses associated with smoking such as diabetes, heart failure, hypertension and COPD. Therefore, it is advisable to recommend an efficient smoke cessation therapy. In a meta-analysis of 42 trials summarized that advice and encouragement given by nurses or other healthcare professionals at a hospital setting are much effective in smoking cessation and/or quitting by patients (Rice et al., 2013). The nurse can practice the five A system, ‘Ask, Advise, Assess, Assist, and Arrange’ (Okuyemi et al., 2006) to facilitate the smoking cessation in Mrs. Meecham (Figure 2). Possible smoking/nicotine replacement therapies include non-nicotine therapy by use pharmacologic agents and nicotine replacement therapies such as nasal spray, lozenge, gum, patch and inhaler usage (Ferguson et al., 2011). In some cases, electronic cigarette use can also be suggested (Antolin & Barkley Jr, 2015).
As described in section 2, Mrs. Meecham’s current and history of medical conditions, there are many future health risks. 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).
Educational leaflet/handouts will be provided and discussed in detail with her and the caregiver. 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)