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PATIENT CARE PROCESS

Patient Care Process for the Treatment of Venous Thromboembolism

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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

Image not available.

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 ...

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