Video Case Study - Caring for Patients With Venous Thromboembolism

Nurse Hakeem 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 Hakeem 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 Hakeem recognizes important cues. He notes slight redness and swelling of Lucille’s left leg.

Upon light palpation, Nurse Hakeem notes Lucille’s leg is tender, and she rates her pain as 2 out of 10 and describes it as aching, but tolerable.

Next, Nurse Hakeem 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 yesterday, that she will be transitioned to oral anticoagulation therapy, and then discharged with a prescription for oral dabigatran.

Nurse Hakeem 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, which happens when the clot breaks free and travels to the heart and into the lungs.

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

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

Now, I understand Nurse Owen 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.

Lucille: Yeah, I remember Nurse Owen saying that. He also told me that there are things I can do to prevent bleeding, but I can’t remember all of them.

Nurse Hakeem: That’s okay, let’s review the strategies together after you take your medication. Nurse Hakeem then administers the dabigatran according to the principles of safe medication administration.

Next, Nurse Hakeem 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 Hakeem evaluates the outcomes of his actions. As Lucille prepares for discharge, she tells Nurse Hakeem that she will implement fall precautions once 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, nightlights, and a non-skid bathmat.

Alright, as a quick recap…. Nurse Hakeem 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 Hakeem 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.