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Patient Care Process for Venous Thromboembolism (VTE)

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  • 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)


  • 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)


  • 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)


  • 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




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




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 ...

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