Medsurg DVT & Pulmonary Embolus Quiz

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

a client who is on complete bed rest following extensive spinal surgery a client who has a large venous stasis ulcer on the right ankle area a client who has recently been admitted with a broken femur and is awaiting surgery a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy Rationale: Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolism, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and infection usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a pulmonary embolism.

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.

12 Rationale: The recommended dose of 18 units/kg should be obtained by multiplying the weight in kilograms by 18 units. 66 kg × 18 units = 1188 units/hr. Concentration for the medication is 25,000 units/250 mL. Use the formula Desired/Have × Volume: 1188 units/25,000 units × 250 mL = 11.88 mL/hr or 12 mL/hr.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees. Rationale: Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The HCP must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

The health care provider (HCP) prescribed knee-high sequential compression devices. The client reports new pain localized in the right calf area. The nurse notes the area is reddened and warm to touch. What should the nurse do first?

Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings. Rationale: Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the HCP; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the HCP as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus.

The nurse reviews the morning laboratory results from a client admitted with a deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do? Hgb12g/dL, Hct37g/dL, Plt 165,000, aPTT 65sec, PT 11 sec, INR 1.1, BUN 19, Cr 1.0, AST 25, ALT 30

Maintain the current rate of the heparin infusion. Rationale: An aPTT of 65 seconds is considered therapeutic with a control of 30. Therapeutic levels for heparin are 1.5 to 2.5 times the control, which would make therapeutic level between 45 seconds and 75 seconds. The nurse should continue the infusion at the current rate and continue to monitor the client. The liver enzymes (AST, ALT) are within normal range; it is not necessary to notify the HCP. The BUN and creatinine are within normal limits; the client does not need to increase fluid intake beyond 3,000 mL. The hemoglobin and hematocrit are within normal limits; it is not necessary to obtain frequent oxygen saturation levels.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate. Rationale: Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings would the nurse be alert for related to the condition?

chest pain and dyspnea Rationale: The client with deep vein thrombosis is at risk for pulmonary embolism. As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism may exhibit a cough that produces blood-tinged sputum. Hypertension, fever, bradypnea, and bradycardia aren't associated with pulmonary embolism. Calf pain and redness are associated with a deep vein thrombosis and would be expected.

A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. What should the nurse include in the plan of care for this client?

monitoring the client's activated partial thromboplastin time (aPTT) Rationale: Heparin dosage is usually determined by the health care provider (HCP) based on the client's aPTT. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

protamine sulfate Rationale: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

The client returns to the hospital 3 days after diagnosis of deep vein thrombosis, with reports of cough, hemoptysis, shortness of breath, and sharp pain under the right scapula. The client is subsequently is diagnosed with a pulmonary embolus (PE). The client asks the nurse, "How did I even get a pulmonary embolus?" What is the best response by the nurse? Select all that apply.

venous endothelial changes having any condition that produces venous stasis increased blood coagulability Rationale: The nurse should relay to the client that a pulmonary embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body. Because the clots block blood flow to the lungs, a pulmonary embolism can be life-threatening. Major risk factors for the development of PE include any condition that produces venous stasis, increased blood coagulability, or venous endothelial changes. Major risk factors do not include frequent falls or taking medications such as warfarin sodium and should not be communicated to the client.