Chapter 19: Venous Thromboembolism

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

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 risk (e.g. estrogen)

• Presence of contraindications to anticoagulation therapy

• Ability/willingness to ...