Preventing_Deep_Venous_Thromboembolism

Preventing Deep Venous Thromboembolism in hospitalized patients Abstract Medical and surgical hospitalized patients are at high risk of developing deep venous thrombosis (DVT) especially with they are not ambulating during the cause of their hospitalization. Mechanical prophylaxis such as sequential compression device (SCDs) initiation as soon as possible for the patients at risk of developing DVT and educating both the nurses and the patient how important the use of SCDs can prevent DVT and PE is very important. This paper focused on the implications of not using intermittent compression devices such as sequential compression pump and other pharmacology anticoagulant in an immobilized hospitalized patients in compare to the patients who used sequential compression pump. Preventing deep venous Thromboembolism in hospitalized patients Many immobilized patients admitted to general medical floor who are at risk of developing deep venous thromboembolism (DVT) refused both mechanical prophylactic and pharmacological prophylactic anticoagulant measures. Evidence shows that risk of developing DVT is high in immobile hospitalized patients, providing early adequate DVT prophylaxis may minimize risk DVT. The purpose of this study is to show the difference the use of sequential compression device (SCDs) can have in preventing deep vein thrombosis in immobilize hospitalized patients compared to patients who refused both mechanical prophylactic measures and pharmacological prophylactic measures. The patients’ compliance to the use of both mechanical prophylactic and pharmacological prophylactic is very low, and this put the patients in higher risk of developing DVT and eventually pulmonary embolism. The best intervention to get higher compliance with the use of anticoagulant on my floor is through education. Educating both the patients and the nursing staffs is the best solution to the problem of high risk of DVT on my unit. The way I can prevent my patients from developing DVT is to educate my self on the importance of the early initiation of anticoagulant prophylaxis on patients at risk, and educating the patients on the benefit of using anticoagulant and the implication that could occur if they refused it. The best way to empower the patients in complying with the use of mechanical anticoagulant such, as sequential compression pump is to get them involve in their health care decision making. Risk of developing DVT can be easily assessed during hospital admission process. The admission nurse can get the information from the patient as well from the patient’s past history; however, DVT can also be diagnosis. As Wendy Kehl-Pruitt identified “Hospitalized patient are at increased risk of developing DVT due to immobility, advanced age, acute medical illness and central venous catheters’’ (Kehl-Pruitt, W, 2009, pg. 54). Some patients who are diagnosed with DVT without early treatment are at high risk of severe problems such as pulmonary embolism and death. PICO format question used for this research was, Does immobile hospitalized adults without history of venous thromboembolism (VTE) (P) who are not on sequential compression device,  (I) at increased risk for deep venous thrombosis (O) compared with immobilized hospitalized adult without the history of venous thromboembolism who are on sequential compression device (C). In addition to PICO format question, PS format question for this study was, what is the lived experience of adult patients (P) who developed deep venous thromboembolism during hospitalization (S). The research information used for this paper was collected through CINAHL, midline, Google, Mayo web site, and Domitila 6B unit web page. Number of research paper used for this research was six and ranged between years 1998 to 2012. The key terms used for this research finding were DVT prevention, compression devices, anticoagulants, hospital immobilized patients, deep vein thrombosis, and sequential compression devices (SCDs). This paper focused on use of SCDs outcome immobilized inpatient compared to patients that refused SCDs. High risk of the deep vein thrombosis resulting to pulmonary embolism have cause the healthcare team to pay more attention to the study of how to prevent DVT at the first place. Kehl-Pruett’s research article published in 2006 looked at how to prevent deep vein thrombosis in hospitalized patients. Kehl-Pruett (2006) pointed out, patient with DVT are at the risk of compilation such as pulmonary embolism, increased length of hospital stay and even death if not treated on time. Kehl-Pruett identified that “general medical and surgical patient have a 10% to 40% risk of developing DVT while hospitalized whereas orthopedic surgery patients have a 40% to 60% risk” (Kehl-Pruett, W. 2006, pg. 54). As indicated by Kehl Pruett, (2006), out of 5,651 hospitalized patients enrolled for the data collection, 2,726 of them developed DVT while hospitalized. The patients both come from medical and surgical unit and do not have history of previous DVT, and they did not receive DVT prophylaxis 30 days before diagnosis. As indicated by Kehl-pruett (2006), most factors contributing to development of DVT are immobility, obesity, esmogen therapy, age, patient with central venous catheters and patient with history of DVT. Kahl-pruett added that some patient with medical condition such as heart failure, stroke, inflammatory diseases and chronic lung disease are also at higher risk. However, decreased mobility is the major risk factor predisposed hospitalized patient to DVT. Not all patients who are at risk for DVT due to hospitalization can be on pharmacological anticoagulant due to high risk of bleeding, in such case, the patient might benefit more from sequential compression device (SCDs) while in the hospital. Mechanical prophylactic measure such as SCDs are usually used for patient without history of DVT and who are at low risk of developing DVT in the hospital, likewise, this device is also mostly used for the patient who cannot tolerate pharmacological prevention. According to Kehl-Ptuett (2006) evidence showed that sequential compression device reduced DVT rate to 6.9% from 15%. Kehl-Ptuett also added that “Early ambulation is another useful technique for decreasing venous thromboembolism that is encourage in patients with low risk of developing DVT” (Kehl-preutt. A. 2006. p.56) Out of many researchers who have looked at the occurrence and causes of deep vein thromboembolisms (DVT) in patients during hospitalization is Gay Victoria and al. Looking at Gay. V & al research articles published 2009; the research showed that immobilized hospitalized patients are at higher risk for DVT, for this reason critical nurses need to be familiar with the risk of DVT in hospitalized patient and they also need to understand the various ways to prevent DVT from happening at the first place. According to (Gay. V & el), deep vein thrombosis affects as many as 350,000 people yearly nationwide. Gay. V & el indicated that “combined use of anticoagulation, compression stockings and early ambulation produce better patients’ outcome than anticoagulation and bed rest alone” (Gay. V and al, 2009, pg. 296) There study was categorized into two. (1) The effects of not using SCDs or other anticoagulants on hospitalized patients whom are at risk for DVT. (2) The outcome of using SCDs or pharmacology anticoagulants on hospitalized patients at risk of DVT or PE. The research sample involved 268 patients. To study the first case, 139 hospitalized patients were selected, 53 men and 86 women were allowed to ambulate as much as possible, but they were not given any anticoagulant prophylaxis for four days of hospitalizations. For the second case, 129 hospitalized patients (72males and 57 females) were given mechanical anticoagulant prophylaxis such as sequential compression pump and pharmacology anticoagulant such as subcutaneous heparin while on bed rest for two days. Outcome of the patients with ambulation but not on any anticoagulant prophylaxis was compared with those patients with ambulation and mechanical anticoagulant, and the result was remarkable. Gary. V & el (2011) concluded that the use of anticoagulant and SCDs decrease the risk on DVT and PE even in patients who are able to ambulate. “With combined intervention of exercise, compression, and administration of low molecular weight heparin (LMWH), no significant increased of PE was found” (Gary. V & el 2011, pg. 234). Rhys J. Morris and el 2004 are another researchers who focused their evidence-based research on types of mechanical device and its effects in preventing stasis and deep vein Thrombosis. One essential way of preventing DVT they identified is intermittent pneumatic compression. They emphasized that the most important thing to consider when choosing mechanical prophylactic system is patients’ compliance, and the suitability of the compression site. Sequential compression pump works by periodically inflating and deflating air bladder when it is wrapped around the lamb, the feet, the calf or the whole leg. Sequential compression pump can be set to inflate and deflate in different ways, some inflate uniformly, while some are set to inflate sequentially with graded pressures and some have rapid or moderate inflation rate. Morris et al (2004) amplified that the main objective behind the use of all intermittent compression device is to squeeze blood proximally from underlying deep veins. Morris identified that “all intermittent compression system produce change in femora vein velocity” (Morris R. J. and et al, 2004, pg. 163). They identified five different lower limp compression cuffs, which are: foot compression, foot and calf compression, calf compression, calf and thigh compression, and whole limp compression. Morris et al believe that using foot compression in preventing DVT was generally effective with positive result when compared to graded-sequential calf compression. Morris et al also showed that “The combination of stocking and foot compression has proved more effective than stocking alone in both DT and pulmonary embolism incidence (Morris et al, 2004, pg.165). After synthesizing the literature result, and I got an answer to my PICO questions. I realized that to be able to do a good job in preventing DVT, the nurse should be aware of the risk factors that predisposed their hospitalized patients to developing DVT. Hospitalized patient are more prone to DVT because they are often placed on a bed rest, even those who are not on bed rest are still inactive as they used to be before hospitalization. This might be related to illness and diseases, weakness, fatigue, monitoring equipment’s, intravenous line, draining tube and so on. Through the literature, I understood that among the many problems that put patients to high risk to DVT was low compliance from hospitalized patient regarding the use of SCDs especially vascular pump on my unit. I have seen many patients refused both mechanical prophylactics such as sequential compression pump and pharmacological anticoagulant. There are many problems with patient compliance in the use of SCDs during hospitalization, among them are patients not sure how important this is for their well being and some do not know there is any evidence based study that SCDs really decrease their chance of developing DVTs. Literature research helped me understood that nurses can help with compliance in using SCDs through information collected from the patients during admission. Patient’s data’s such as the patient’s mobile ability, age, history of medication and other medical conditions that can predispose the patients to deep venous thromboembolism (DVT) can help the nurse aware of the patients risk for developing DVT. To improve patient compliance, patient’s education is very important. Most patients wants detail explanation of reasons why using mechanical prophylaxis or pharmacology prophylaxis is important in decreasing their risk of developing DVT or PE. The nurse needs to know the rational of using SCDs and be able to explain to the patients. To help health care providers prevent DVT in both medical and surgical patients, the American College of Chest Physicians establish some guidelines. “The American College of Chest Physicians (ACCP) has produced evidence-based guidelines on antithrombotic and thrombolytic therapy”(Kehl-Pruett, W. 2006, pg. 55). “The ACCP guideline currently recommend use of mechanical prophylaxis measures in all hospitalized patient with anticoagulant contraindication” (Kehl-preutt. A. 2006. Pg. 56) Most common ways to prevent DVT identified by Kehl –preutt, (2006) are mechanical prophylactic measures and pharmacological prophylactic measures. Mechanical measures include graduated stocky exercise, range of motion and pneumatic compression device. However, Pneumatic device was focused on in this paper. Jean Watson theory of caring is use on my floor by making sure of early initiation of SCDs as soon as they are ordered. Nurses plays a key role in preventing development of DVT on my unit, for instance they are more likely to know if patient is at risk of developing DVT. On my unit, we believe it is high importance to know that part of caring for our patients is to decrease their risk of developing DVT through educating and encouraging nurses to initiate the use of sequential compression pump as soon as they are ordered. One of the protocols just put in place on my unit is to make sure every patient has an order for SCDs or pharmacological anticoagulant as soon as possible after admitted to the unit. Another way to show caring is to empower our patients in complying with the use of mechanical prophylactic such as sequential compression pump is through education. For SCDs to be effective, the patient has to have it on for at least 18 hours a day. Many things predispose multiple trauma patients to deep venous thrombosis (DVT) and possibly pulmonary embolism. Risk of developing DVT is high in hospitalized patient, providing early adequate DVT prophylaxis may minimize this risk. To decrease the risk of hemorrhage in patients at high for bleeding, heparin anticoagulant may not be recommended. This type of patients can benefit from sequential pump if they can keep it on at least 18 hours a day to equivalent a 12 hours walk. There low risk in using sequential compression device, and it highly beneficial immobile hospitalized patients to be on either mechanical anticoagulant prophylaxis or pharmacology anticoagulant prophylaxis to decrease their risk to DVT or PE. 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