Case study - Deep vein thrombosis: Nursing

Nurse Hakim works on a medical surgical unit and is caring for Lucille, a 72 year old who was admitted for a deep vein thrombosis or DVT in her left iliofemoral vein and is currently awaiting discharge.

In collaboration with the registered nurse, RN Owen nurse Hakim goes through the steps of the clinical judgment measurement model to make clinical decisions about Lucille's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Hakim recognizes important cues. He notes slight redness and swelling of Lucille's left leg upon light palpation.

Nurse Hakim notes Lucille's leg is tender and she rates her pain as two out of 10 and describes it as aching but tolerable.

Next. Nurse Hakim analyzes these cues.

He reviews the electronic health record or EHR and sees that Lucille recently had surgery and that an ultrasound identified the DVT.

He also notes that Lucille has been receiving continuous IV Heparin which was discontinued that she will be transitioned to oral anticoagulation therapy and then discharged with a prescription for oral dabigatran nurse Akim recognizes that immobility after surgery increased Lucille's risk for a DVT and that the thrombus lodged in her vein caused inflammation and decreased venous return to her heart, resulting in swelling and pain in her leg.

He understands that anticoagulants like heparin are often used initially to keep the clot from getting larger, to prevent the formation of new clots and to decrease the risk of a venous thromboembolism or VTE E which happens when the clot breaks free and travels to the heart and into the lungs.

Nurse akim also knows that oral anticoagulants like dabigatran can be used after a Heparin infusion is discontinued to decrease the body's ability to make clots and that these treatments can also increase Lucille's chances of bleeding.

Now, using the information he's gathered. Nurse Hakim reports his findings to RN Owen and together they choose a priority hypothesis of risk for bleeding.

Next, they generate solutions to address Lucille's risk for bleeding. And they establish the expected outcome that after intervening, Lucille will verbalize two strategies to reduce her risk of bleeding prior to discharge.

Nurse Akim, then takes action to implement these solutions. He reviews the EHR and sees that RN Owen provided Lucille teaching about her new medication.

Nurse Akim then enters Lucille's room to reinforce the plan of care and administer her scheduled dose of dabigatran. Hi, Lucille, I have your dabigatran here.

Now, I understand nurse, someone already spoke with you about this new medication. Although it will help prevent your DVT from getting worse, it can also increase the risk of bleeding.

Yeah, I remember nurse Owen saying that he also told me that there are things I can do to prevent bleeding. But II can't remember all of them.

That's ok. Let's review the strategies together.

After you take your medication. Nurse Akim then administers the dabigatran according to the principles of safe medication administration.

Next nurse Hakim reviews strategies with Lucille to reduce her risk for bleeding while taking dabigatran. He discusses the importance of implementing fall precautions in her home such as removing throw rugs, ensuring adequate lighting and placing a nonskid mat in the shower.

He also encourages her to use a soft bristle toothbrush to avoid trauma to her gums when brushing her teeth. And he reminds her to be extra careful when using a knife or scissors to avoid cutting herself.

Lastly, he reinforces the importance of calling her health care provider if she notices any unusual bleeding, like easy bruising, frequent nosebleeds, bleeding from a cut that lasts longer than normal pink or brown urine or red or tarry black stools.

One hour later, Lucille is ready for discharge and nurse Hakim evaluates the outcomes of his actions. As Lucille prepares for discharge, she tells nurse Hakim that she will implement fall precautions when she arrives home and that after her husband picks her up from the hospital, they'll go to the store to purchase a soft bristle toothbrush, night lights and a nonskid bathmat.

All right. As a quick recap, nurse Hakim recognized and analyzed cues related to Lucille's DVT and in collaboration with RN Owen prioritized hypotheses and generated solutions to address this problem.

Nurse Hakim and RN Owen then took actions by implementing measures to address Lucille's risk for bleeding and evaluated Lucille's outcomes comparing them to the expected outcome.

Since Lucille was able to verbalize two strategies to reduce her risk for bleeding. They determined that the plan of care was successful.