Pharmacologic Highlights

Panic Away

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Medication or Drug Class

Dosage

Description

Rationale

Fibrinolytic agents

Anticoagulants

Varies with drug

Varies with drug and patient weight; standard heparin dose is 80 units/kg bolus IV followed by an infusion of 18 units/kg per hour titrated according to coagulation studies; starting dosage of warfarin is 5 mg/day for 2 days PO with changes depending on prothrombin time

Reteplase (r-PA, Retavase), Alteplase (t-PA, Activase)

Sodium heparin; sodium warfarin (Coumadin)

Breakdown of the blood clot for deep vein (but usually not superficial vein) thrombosis

Standard treatment is to initiate IV heparin to reduce further formation of clots.

Other Drugs: Analgesics; low-molecular-welght heparin (enoxaparin or dalteparln, 100 units/kg) is a safe and effective alternative and leads to early discharge for some patients; antibiotics if infection is suspected.

Independent

The most important nursing interventions focus on prevention. Decrease the risk of venous stasis in a bedridden patient by performing early ambulation and active or passive range-of-motion exercises several times a day. Avoid using the knee gatch because of the risk of popliteal pressure and venous stasis; encourage patients not to cross their legs, especially when sitting. If pillows are needed to elevate extremities, position them along the entire length of the extremity to prevent additional pressure on veins and to allow for adequate venous drainage. If the patient is immobile and not on fluid restriction, encourage the patient to drink at least 3 L of fluid a day to prevent dehydration and venous stasis.

To prevent injury to vessel walls, monitor IV cannulas to prevent infiltration. If IV medications are irritating to the vein, IV cannulas should be changed and rotated to new sites more often than the standard procedure.

Discuss activity restrictions with the patient and family. The patient usually feels confined and may become resentful because of the need for absolute bedrest. To increase mobility in bed, install an orthoframe and trapeze system to the bed. A sheepskin, air mattress, foam pad, foot cradle, or heel pads can reduce the risk of skin breakdown while the person is on bedrest. Provide diversional activities to reduce anxiety.

• Physical findings of affected extremity: Presence of redness, tenderness, swelling

• Response to pain medications, heat application, elevation, rest

• Reaction to immobility and bedrest

• Presence of complications: Bleeding tendencies, respiratory distress, unrelieved discomfort

Teach the patient preventive strategies. Demonstrate how to apply compression stockings correctly, if they have been prescribed. Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and need for routine laboratory monitoring for anticoagulants. If the patient is being discharged on subcutaneous heparin, the patient or family needs to demonstrate the injection technique. The patient also needs to know to avoid over-the-counter medications, particularly those that contain aspirin. Explain the need to avoid activities that could cause bumping or injury and predispose the patient to excessive bleeding. Instruct the patient to notify the physician if abdominal or flank pain, heavy bleeding during menstruation, and bloody urine or stool occurs.

Recommend using a soft toothbrush and an electric razor to limit injury. Remind the patient to notify the physician or dentist of anticoagulant use before any invasive procedure. Instruct the patient to report leg pain or swelling, skin discoloration, or decreases in peripheral skin temperature to the physician. In addition, if the patient experiences signs of possible pulmonary embolism (anxiety, shortness of breath, pleuritic pain, hemoptysis), he or she should go to the emergency department immediately.

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