LOG
Objectives:
At the end of 2 weeks in the medical ward, I'll able to:
Demonstrate the different type of psychomotor skills. (Vital signs \ blood sampling \ canula insertion \ medications administration).
Take case of deep vein thrombosis and COPD and promote my knowledge about (definition \ etiology \ risk factors \ diagnostic evaluation \ medical and nursing managements).
Use the nursing processes to treat patient with DVT.
Identify the policy of hospital when admitting and discharge patient.
Improve my communication skills with pt. and nurses.
Activities:
Help nurses (malik) in give pt. medication.
Collaborate with instructor in achieve some skills.
Make discussion with my instructor about disease to increase my knowledge.
Find cases of DVT and COPD and take information from pt.
Read from nurses' books about DVT & COPD case.
Prepare care plan for the patient with DVT case.
Ask patient about his need and what need to know about his disease (nutrition, activity, medication, complication of disease) and give pt. education.
Introduce my self to the pt. and his family members in the unit.
Evaluation:
Activity met:
I make good communication with pt. and his family.
I found case of DVT & COPD and read about this disease.
I make good education for pt.
Prepare log for the pt. with deep vein thrombosis.
I collected information about disease from book and instructor.
Activity partial met:
Improve some skills and practice by collaborate with instructor and help the nurse (malik) in the word medical male.
Activity not met:
Make some skills ex. (blood sampling \ cannula insertion) and ECG make.
Facility:
Teacher and patients are very cooperative.
I find case of DVT & COPD.
I find time to read about some disease and the instructor help me.
Nurse (malik) cooperative with me in give pt. medication.
Barriers:
The nurse in the word of female not cooperative with student (male) in make skills.
Decrease my knowledge about some cases and medication affect on my effectiveness.
Increase number of student in word prevents me to achieve some skills and take information from pt.
Nursing process
Nursing Assessment
Obtain history of risk factors for thrombophlebitis.
Note symmetry or asymmetry of legs.
Observe for evidence of venous distention or edema, puffiness, stretched skin, hardness to touch.
Examine for signs of obstruction due to occluding thrombus—swelling, particularly in loose connective tissue or popliteal space, ankle, or suprapubic area.
Hand-test extremities for temperature variations—use dorsum (back) of same hand; first compare ankles, then move to the calf and up to the knee.
Assess for calf pain, which may be aggravated when foot is dorsiflexed with the knee flexed (Homan's sign). Unfortunately, this sign is nonspecific and has a low sensitivity for detecting thrombophlebitis
CASE STUDY
Medical Diagnosis: DVT (deep vein thrombosis) Allergy: non
Vital signs:
Temp: 37.2 ْ C Pulse: 80 Bp: 120/70 RR: 18
Past History (Reason for admission):
Abraham Falah 58 year old male patient married and father for 8 son Jordanian Islamic religion admission to K.A.U.H. to emergency room complaining of sever pain in his leg and can't stand on his leg since 4 hours and then transfer to medical word as cases of DVT.
Patient conscious and oriented for time, person and place pt. on supine position and have blue cannula in right hand.
Present complain:
Subjective Data:
Pt said "I feel painful located in right leg the pain is localized in femoral and not radiation 5 degree in pain scale".
Pt said "my pain is increase with move my leg and decrease with rest".
Pt said "I feel worm in my leg".
Pt said "no smoking or alcohol drinking".
Pt said "I don’t have information about disease and I hope increase my knowledg".
Pt said "no any problems during urinary elimination he eliminate 2-4 times\day".
Pt said "no any inherited disease in my family"
Objective Data:
H.R:80 - Temp:37.2 ْ C - B.P:120/70 - RR:18
Bed rest and limited activity.
Pt. in hospital since 5 days.
Physical examination:
1. Humans’ sign (pain in the calf after the foot is sharply dorsiflexed).
2. Pale skin and worm temperature.
3. Pitting edema in right leg.
§ Regular pulse and blood pressure.
§ Pt. weight:72kg high: 167cm
Fluid intake:
§ Drink about 2 litters.
Fluid output:
§ Go to bathroom about 5 times in day output about 1.7 litters
Medication:
1- Lovenox Enoxaparin (60 mg s.c Q12h)
Drug classes
Anticoagulant
Therapeutic actions
Low molecular weight heparin that inhibits thrombus and clot formation by blocking factor Xa, factor IIa, preventing the formation of clots.
Adverse effects
Hematologic: Hemorrhage; bruising; thrombocytopenia; elevated SGOT, SGPT levels; hyperkalemia.
Hypersensitivity: Chills, fever, urticaria, asthma.
Other: Fever; pain; local irritation, hematoma, erythema at site of injection.
Nursing Considerations
Assessment
History: Recent surgery or injury; sensitivity to heparin, pork products, enoxaparin; lactation; history of GI bleed.
Physical: Peripheral perfusion, R, stool guaiac test, PTT or other tests of blood coagulation, platelet count, and kidney function tests.
Implementation
Give deep SC injections; do not give enoxaparin by IM injection.
Administer by deep SC injection; patient should be lying down.
Apply pressure to all injection sites after needle is withdrawn; inspect injection sites for signs of hematoma; do not massage injection sites.
Provide for safety measures (electric razor, soft toothbrush) to prevent injury to patient who is at risk for bleeding.
Check patient for signs of bleeding; monitor blood tests.
Discontinue and initiate appropriate therapy if thromboembolic episode occurs despite enoxaparin therapy.
Treat overdose as follows: Protamine sulfate (1% solution). Each mg of protamine neutralizes 1 mg enoxaparin. Give very slowly IV over 10 min.
2- Warfarin (10 mg p.o qd)
Drug classes
Oral anticoagulant /Coumarin derivative
Therapeutic actions
Interferes with the hepatic synthesis of vitamin K-dependent clotting factors (factors II-prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of clotting times.
Adverse effects:
GI: Nausea, vomiting, anorexia, abdominal cramping, diarrhea, retroperitoneal hematoma, hepatitis, jaundice, mouth ulcers
Hematologic: Granulocytosis, leukopenia, eosinophilia
GU: Priapism, nephropathy, red-orange urine
Dermatologic: Alopecia, urticaria, dermatitis
Bleeding: Hemorrhage; GI or urinary tract bleeding (hematuria, dark stools; paralytic ileus, intestinal obstruction from hemorrhage into GI tract); petechiae and purpura, bleeding from mucous membranes; hemorrhagic infarction, vasculitis, skin necrosis of female breast; adrenal hemorrhage and resultant adrenal insufficiency; compressive neuropathy secondary to hemorrhage near a nerve
Other: Fever, “purple toes” syndrome
Nursing Considerations
Assessment
History: Allergy to warfarin; SBE; hemorrhagic disorders; TB; hepatic diseases; GI ulcers; renal disease; indwelling catheters, spinal puncture; aneurysm; diabetes; visceral carcinoma; uncontrolled hypertension; severe trauma; threatened abortion, menometrorrhagia; pregnancy; lactation; CHF, diarrhea, fever; thyrotoxicosis; senile, psychotic or depressed patients.
Physical: Skin lesions, color, temperature; orientation, reflexes, affect; P, BP, peripheral perfusion, baseline ECG; R, adventitious sounds; liver evaluation, bowel sounds, normal output; CBC, urinalysis, guaiac stools, PT, renal and hepatic function tests.
Implementation
Monitor PT regularly to adjust dosage.
Do not change brand names once stabilized; bioavailability problems exist.
Evaluate patient regularly for signs of blood loss (petechiae, bleeding gums, bruises, dark stools, dark urine).
Do not give patient any IM injections.
Double check all drugs ordered for potential drug–drug interaction; dosage of both drugs may need to be adjusted.
Use caution when discontinuing other medications; warfarin dosage may need to be adjusted; carefully monitor PT values.
Maintain vitamin K on standby in case of overdose.
Evaluate for therapeutic effects: PT 11/2–21/2 times the control value.
Lap Results / Diagnostic tests:
Type Results Normal range Nursing consideration
WBC
RBC
HB
PT
PTT
PT(INR) 7.1*10^3\mm3
4.5*10^6\mm3
13.3 gm/dl
22.5 sec
36.3 sec
1.0 5-10*10^3
3.8-5.8*10^6
13-18
9.5-12 sec
20-45 sec
20 Normal
Normal
Normal
Increase because pt. take warfarin
Normal
Increase because pt. take anticoagulant therapy
Diagnosis:
Pain related to impaired venous return as manifested by pt. verbalized that.
Risk for Injury related to anticoagulant therapy as manifested by medication sheet and increase PT.
Impaired Physical Mobility related to pain and imposed treatment as manifested by pt. on bed rest and limited activity.
Knowledge deficit about disease and treatment related to new disease as manifested by pt. verbalized that.
Planning and interventions
1- Goal: relief of pain.
Objectives: the patient will able to:
Verbalized the pain decrease from 5 to 2 degree during my shift.
Become comfortable and without problem.
Interventions:
1. Elevate legs as directed to promote venous drainage and reduce swelling.
2. Warm, moist packs applied to the affected extremity to promote circulation and reduce pain.
· Ensure that water temperature is not too hot.
· Cover plastic water bottle or heating pad with towel before applying to skin.
3. Bed rest to improve circulation and increase comfort.
2- Goal: prevent bleeding.
Objectives: the patient will able to:
Take anticoagulant therapy without sign of bleeding during pt. founding in hospital.
Normal range of PT & PTT during pt. takes therapy.
Intervention:
1. Monitored by the partial thromboplastin time and prothrombin time or INR to prevent inadvertent infusion of large volumes of heparin, which could cause hemorrhage.
2. The use of low molecular weight heparin because is less frequently associated with heparininduced thrombocytopenia.
3. Monitoring of platelet counts to Prevention of thrombocytopenia (decrease in platelets).
4. Monitor sign and symptoms of bleeding include (Bruises, nosebleeds, and bleeding gums and other) to make early treatment.
3- Goal: Preventing Other Hazards of Immobility.
Objectives: the patient will able to:
1. Prevent complication of immobility during pt. founding in hospital.
Intervention:
2. Encourage adequate fluid intake, frequent changes of position, and effective coughing and deep-breathing exercises to prevent constipation and ulceration.
3. Encourage pt. to make exercise in the bed and move extremity to promote the muscle pumping effect on the deep veins, improving venous return.
4. After the acute phase (5–7 days), apply elastic stockings. Remove twice daily and check for skin changes and calf tenderness to reducing the caliber of the superficial veins in the legs and resulting in increased flow in the deeper veins.
5. Encourage ambulation when allowed (usually after 5–7 days, when clot has fully adhered to vessel wall) to prevent constipation and ulceration.
6. Prevent bony prominence of one leg from pressing on soft tissue of other leg (in side-lying position, place a soft pillow between legs) to Prevent venous stasis.
4- Goal: increase pt. knowledge.
Objectives: the patient will able to:
Knowing the pathology of deep venous thrombosis and preventive measures.
Retain information about the disease and treatment at the end of my shift.
Intervention:
Teach the pathophysiology of deep venous thrombosis, including (Effect of thrombosis on valves, Hydrostatic pressure in venous system, Pressure transmitted to capillary system, and Pressure in subcutaneous tissue) to pt. understand treatment process.
Teach pt. about anticoagulant therapy; refer to the information about douse and side effect.
Teach pt. maintain a fluid intake of 2,500 mL a day unless contraindicated because adequate hydration prevents increased blood viscosity.
Encourage pt. maintain ideal weight Obesity because increases compression of vessels and causes hypercoagulability.
Instruct client and family to advise health care providers of the history of deep vein thrombosis (DVT), to Persons with previous DVT are at four times greater risk for developing new DVT.
Teach pt. about complication of DVT disease and how prevent it to prevent complication.
Evaluation
Goal met:
Pt. becomes more comfortable.
Pt. not has signs and symptoms of bleeding.
Pt. becomes able to retain information about the disease and treatment.
Goal partial met:
Pt. can make some activity in bed with pain.
Pt. pain decrease to 3 degree.
Goal not met:
· PT still increases because pt. takes anticoagulant medication.
موضوع: CASE STUDY / D.V.T 
17/11/2009, 02:25
