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Patient Care Process for the Treatment of Venous Thromboembolism
Collect
Patient characteristics (e.g., age, sex, pregnant)
Patient history (past medical, family, social — dietary habits including intake of vitamin K containing foods (see Table 19-13), tobacco/ethanol use)
Current medications including aspirin/OTC NSAID use and prior anticoagulant medication use
Objective data
BP, heart rate (HR), respiratory rate (RR), O2-sat, height, weight
Labs (e.g. Hgb, Scr, platelets, aPTT, PT)
Do NOT order hypercoagulability tests
Objective confirmation of VTE (see Fig 19-6 and 19-7)
Assess
Hemodynamic stability (e.g. SBP <90 mm Hg, HR >110 bpm, O2-sat <90%, RR), evidence of limb ischemia
Presence of active bleeding and/or bleeding risk factors (see Figure 19-8, Table 19-10)
Presence of VTE provoking factors (e.g. recent surgery, plaster casting of lower extremity, indwelling catheter, cancer, pregnancy, estrogen use, prolonged immobility, recent hospitalization)
Ability/willingness to self-inject LMWH/fondaparinux
Ability/willingness to pay for various anticoagulation therapy options
Ability/willingness to obtain appropriate laboratory monitoring (e.g. INR for warfarin)
Emotional status (e.g. presence of anxiety, depression)
Plan
Drug therapy regimen including specific anticoagulant(s), dose, route, frequency, and duration; (see Figs 19-8, 19-9, Tables 19-3, 19-4, 19-6, 19-8, 19-9)
Monitoring parameters including efficacy (e.g. INR results, pain control, limb swelling, shortness of breath), safety (bleeding, VTE recurrence), and timing of assessments
Patient education (e.g. purpose of treatment, dietary and lifestyle modification, invasive procedures, drug therapy; see Table 19-5)
Self-monitoring for resolution of VTE symptoms, occurrence of bleeding, when to seek emergency medical attention
Referals to other providers when appropriate (e.g. thrombosis specialist, behavioral health, dietician)
Implement
Provide patient education regarding all elements of treatment plan
Use motivational interviewing and coaching strategies to maximize adherence
Schedule follow-up (e.g. INR tests [warfarin], Scr [DOACs], adherence assessment, bleeding risk assessment, duration of therapy assessment)
Follow-up: Monitor and Evaluate
Resolution of VTE symptoms (e.g. shortness of breath, chest pain, swelling, redness, pain)
Presence of adverse effects (e.g. bleeding, GI upset [dabigatran])
INR results (adjust warfarin dose as needed to keep between 2-3)
Patient adherence to treatment plan using multiple sources of information
Duration of therapy after 90 days
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Patient Care Process for the Prevention of Venous Thromboembolism
Collect
Patient characteristics (e.g., age, sex, active cancer, pregnant, etc.)
Patient history (past medical [e.g. bleeding history], family, social — dietary habits including intake of vitamin K containing foods (see Table 19-13), tobacco/ethanol use)
Current medications including aspirin/OTC NSAID use and prior anticoagulant medication use
Objective data
BP, heart rate (HR), respiratory rate (RR), O2-sat, height, weight
Labs (e.g. Hgb, Scr, platelets, aPTT, PT)
Assess
Presence of VTE risk factors (see Tables 19-1, 19-2); consider use of Padua Prediction Score for medical patients or the Caprini Score for surgery patients (excludes orthopedic surgery)
Presence of active bleeding and/or bleeding risk factors (see Table 19-10)
Presence of medications that increase VTE ...