Presentation as a requirement for the Graduate Nurse Program - Canberra Hospital, April 2003

1. New Graduate Nurse Program / Acute Care Nursing Program: Clinical Case Study Jamie Ranse 16 April 2003 1

2. Background You are currently employed as a Registered Nurse at the Canberra Hospital. You have completed nine months of the New Graduate Nurse Program and are currently on a clinical rotation on the Orthopaedic Trauma Ward. You are allocated a group of patients with a high acuity. You take particular interest in one of the patient’s clinical history and current condition. You sit down to read through his notes. 2

4. Medications Morphine Maxalon Keflin Endone 7.5mg 10mg 1g 240mg 10 - 15mg 1g IV/PO SC/IM PO IV IV IV PO q30mins PRN TDS PRN QID q4-6hrly PRN QID Daily q30mins PRN Ampicillin Gentamicin Paracetamol 1g 08/12 08/12 08/12 08/12 08/12 08/12 08/12 4

5. Time: 0900 You are attending to your patients antibiotics - he tells you that he has been experiencing cramping and burning sensations in his legs. What are you thinking? Is it muscle spasm? Is it a DVT? Has he had this cramping before? What alleviated it? When did he last have pain relief? Morning Shift 10 December 5

6. Deep Vein The term venous thrombosis, sometimes called thrombophlebitis, describes the presence of thrombus within a vein and the accompanying inflammatory response in the vessel wall. Thrombi can be superficial or in the deep veins. Deep Vein Thrombosis [DVT] most commonly occur in the lower extremities. DVT is a serious condition, complicated by Pulmonary Embolism. Thrombosis Porth (1998): 355 Definition 6

7. Triad Virchows Virchows Triad Blood Flow Endothelium Coagulability 7

8. Triad Virchows Endothelium Endothelial Injury Normal Blood Flow Laminar Flow Clear Plasma Zone Site of Injury 8

9. Blood Flow Virchows Triad Clear Plasma Zone Laminar Flow 9

10. Triad Virchows Abnormal Blood Flow - Turbulance - Venous Stasis Red Blood Cells White Cells and Platelets Blood Flow 10

11. Triad Virchows Coagulability 11 Coagulation Cascade:

12. Triad Virchows Vitamin K dependent Thrombin Intrinsic Common / Final Extrinsic Pathways Coagulability 11

13. DVT Diagnosis Clinical History: Significant history. Clinical Hx 12

14. DVT Diagnosis Clinical History: Doppler ultrasound is a highly sensitive and specific test for deep-vein thrombosis. It combines the ability Doppler Ultrasound: Significant history. to detect changes in venous flow and venous collapse under the ultrasound probe pressure using colour doppler visual display. 12 Ultrasound

15. Time: 1000 Morning Shift 10 December Your patient has gone to the medical imaging department for a Doppler ultrasound. Time: 1130 Time: 1530 Your patient returns to the ward and the results of the ultrasound are with him: You finish your shift and go home. You are able to sleep during the night knowing that your patient does not have a DVT. You have 2 days off. Ultrasound Results - No Abnormalities Detected 13

16. Time: 1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery . 14

17. Post Op 13 December 1. ORIF Pelvis 2. Anterior transverse incision along abdomen and repair of bladder Orders: 1. Continue IV antibiotics 2. Jordan Frame lift or roll to Right side 3. X-ray / FBC / UEC tomorrow 15

18. Time: 1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery . - PCA of morphine [1mg/1ml, 1.5mg bolus, 5 minute lock- out] - IVT [over 6/24] - 4 exu-drains He has the following attached: 16

19. Time: 1000 Morning Shift Your enter your patients room to find him short of breath and holding his chest …… What are you immediate actions? 12 lead ECG Give O 2 Calm and reassure the patient Set of General Observation: - Pulse, Respirations, BP, Oxygen Saturation Notify the RMO ?Call a MET Get some assistance Blood work-up Mobile CXR Cardio-pulmonary assessment 21 December 17

20. 19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A 06

21. 19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 83% R/A 10 06

22. 19/12 20/12 21/12 06 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A 10 SpO 2 83% R/A 10 SpO 2 95% 15LPM via NRB

23. ECG This ECG shows slight PR depression You attend to a 12 lead ECG: 21 December 21

24. Blood Results 21 December FiO 2 21 pH 7.46 pCO 2 40 HCO 3 - 27.8 pO 2 24 FBC / UEC / Coagulation: All within normal limits ABG: The ABG shows a slight Metabolic Alkalosis with inadequate Oxygenation    22

25. CXR 21 December The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of clot in those arteries 23

26. What are you thinking? 24

27. Pulmonary Embolus Pulmonary embolism [PE] develops when a bloodborne substance lodges in a branch of the pulmonary artery and obstructs blood flow. Almost all PEs result from deep vein thrombosis in the lower extremities. Porth (1998): 550 Definition 25

28. V/Q Scan: V/Q scans visualise the ventilation and perfusion [gas exchange] within the lungs by using radiopaque gases. perfusion without ventilation = shunt normal ventilation and perfusion venous blood arterial blood airway alveolus ventilation without perfusion = dead space Diagnosis Embolus Pulmonary 26

29. Time: 1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. 27

30. V/Q Scan Ventilation 28

31. V/Q Scan Perfusion 29

32. Time: 1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. The radiologist is unhappy with the results and suggests an additional diagnostic test. 30

33. V/Q Scan: CTPA [ CT Pulmonary Angiogram]: V/Q scans visualise the ventilation and perfusion [gas exchange] in the lungs by using radiopaque gases. The pulmonary angiogram is the "gold standard" test for diagnosing pulmonary embolism. A contrast is used for the diagnosis. The aim of the CTPA is to look for cut-offs in the vascular tree. Embolus Pulmonary Diagnosis 31

34. CTPA Diagnosis 32

35. Morning Shift 21 December Time: 1200 Your patient returns to the ward and the results from Medical Imaging are with him: V/Q Scan - Decreased ventilation and perfusion in right lung CTPA - Large PE in right main pulmonary artery Time: 1030 Your patient has gone to the medical imaging department for a V/Q scan. 33

36. Treatment is generally targeted at preventing further clot formation and allowing the normal coagulation process to lyse the clot. Under certain clinical situations, it may be appropriate to accelerate clot lysis by using fibrinolytic agents. Treatment Pulmonary Embolus 34

37. Anticoagulation Therapy: Anticoagulation Heparin is the primary anticoagulant used. Heparin binds to and activates antithrombin III and deactivates thrombin to inhibit further clot formation. Heparin works here, it keeps platelets from aggregating on an embolus. Treatment 35 The usual treatment dose for Heparin is a loading dose of 5,000 units followed by an infusion of approximately 1,000 units per hour.

38. Treatment 08/12 N/Saline 500ml var 25,000 IU Heparin Sodium Anticoagulation 36

39. Treatment Warfarin Therapy: Warfarin is a compound that competes with vitamin K and depletes vitamin K-dependent clotting factors. Warfarin therapy can begin on day one of heparin therapy and is monitored using the International Normalised Ratio (INR). An INR of 2.0 - 3.0 is considered therapeutic. Warfarin Warfarin works here by inhibiting Vitamin K. 37

40. Treatment If PEs ocurr despite therapeutic anticoagulation therapy, then an inferior vena cava filter should be considered. Filter 38

41. Outcome Due to your increased knowledge and evidence base regarding: - Physiology of DVT and PE, - Diagnostic test for DVT and PE - Treatment options for DVT and PE Your patient receives the most appropriate management and is on the way to a full recovery. 39

42. References Bonno, N. B., (1999) Deep Vein Thrombosis (DVT) . Clinical Reference System . United States. Dahlback, B., (2000) Blood Coagulation . The Lancet 9215(355), 1627-1632. Marieb, E. N., (1998) Human Anatomy and Physiology (4 th ed.) . Benjamin Cummings Science Publishing. California. Milto, L. D., (1999) Deep Vein Thrombosis . Gale Encyclopaedia of Medicine (1 st ed.) . United States. Proctor M. C. and, Greenfield L. J., (1997) Justifying inferior vena caval filter placement . Internal Medicine, May:85-89 Porth, C. M. (1998) Pathophysiology: Concepts of Altered Heath States (5 th ed.). Lippincott.

43. Images Govan, D. T., Macfarlane, P. S., and Callander, R., (1995) Pathology Illustrated (4 th ed.) . Churchill Livingston. New York. [Abnormal Blood Flow, and Endothelial Injury] Grrenfield Vena Cava Filter http://www.greenfieldfilter.com/ [Filter] Porth, C. M. (1998) Pathophysiology: Concepts of Altered Heath States (5 th ed.). Lippincott. [V/Q Scan, Normal Blood Flow] Miller, I. (2003) ImpactED Nurse. http://www.impactednurse.com [Background] The Canberra Hospital - Emergency Department Education http://www.canberrahospital.act.gov.au/ [ECG - PR Depression] The Canberra Hospital - Intranet http://tchi/ [Header] Virtual Hospital: The diagnosis of Pulmonary Embolus http://www.vh.org/adult/provider/radiology/electricpe/electricpe.html [Dolplar Ultrasound, Ventilation Scan, Perfusion Scan, Pulmonary Angiogram]

44. The End

45. New Graduate Nurse Program / Acute Care Nursing Program: DVT / PE Clinical Case Study Jamie Ranse 16 April 2003