Skip to Main Content

++

PATIENT CARE PROCESS

++

Patient Care Process for Venous Thromboembolism (VTE)

Image not available.

Collect

  • Patient characteristics (e.g., age, sex, pregnant)

  • Patient medical history (personal and family)

  • Social history (e.g., tobacco/ethanol use) and dietary habits including intake of vitamin K containing foods (see Table 19-14)

  • Current medications including OTC aspirin/NSAID use, herbal products, dietary supplements, and prior anticoagulant medication use

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Labs including hemoglobin (Hgb), platelets, serum creatinine (SCr), activated partial thromboplastin time (aPTT), prothrombin time (PT)

    • Do NOT order hypercoagulability tests

    • Objective confirmation of VTE (see Fig 19-6 and 19-7)

Assess

  • Hemodynamic stability (e.g., systolic BP <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 19-11)

  • Presence of VTE provoking factors (e.g., recent surgery, plaster casting of lower extremity, indwelling catheter, cancer, pregnancy, estrogen use, prolonged immobility, recent hospitalization) (see Table 19-1)

  • Ability/willingness to self-inject low-molecular weight heparin/fondaparinux

  • Ability/willingness to pay for anticoagulation treatment options

  • Ability/willingness to obtain laboratory monitoring tests (e.g., PT/INR [warfarin], SCr [DOACs])

  • 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, 19-5, 19-8, 19-9)

  • Monitoring parameters including efficacy (e.g., PT/INR [warfarin], pain, limb swelling, shortness of breath) and safety (e.g., sign and symptoms of bleeding, SCr); frequency and timing of follow-up

  • Patient education (e.g., purpose of treatment, dietary and lifestyle modification, invasive procedures, drug-specific information, medication administration/injection technique; see Table 19-6)

  • Self-monitoring for resolution of VTE symptoms, occurrence of bleeding, when to seek emergency medical attention

  • Referrals 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., PT/INR [warfarin], SCr [DOACs], adherence assessment [all], bleeding risk assessment [all])

Follow-up: Monitor and Evaluate

  • Resolution of VTE symptoms (e.g., shortness of breath, chest pain, limb swelling, redness, pain)

  • Presence of adverse effects (e.g., bleeding [all], dyspepsia [dabigatran])

  • INR results [warfarin only] (adjust warfarin dose as needed to keep between INR goal range 2 to 3)

  • Patient adherence to treatment plan using multiple sources of information

  • Re-evaluate duration of therapy every 3 months

*Collaborate with patient, caregivers, and other health professionals

++

CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

++

For the chapter in the Wells Handbook, please go to Chapter 14. Venous Thromboembolism.

++

CONTENT UPDATE

++

Content Update

October 10, 2017

Pharmacokinetic Considerations for Apixaban Use in End-Stage Renal Disease: There is little data about use of the direct-acting oral anticoagulant (DOAC) apixaban in patients with nonvalvular atrial fibrillation and end-stage renal disease (ESRD). Recommended apixaban dosing in patients with normal kidney function is 5 mg twice daily; 2.5 mg twice daily is recommended in ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.