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Question:

Discuss about the Nursing: Deep Vein Thrombosis. 

 

Answer:

Introduction:

John Grant’s case is discussed in this essay. It is evident that he is at risk of deep vein thrombosis (DVT) because he has to undergo knee replacement surgery for bilateral knee surgery. In addition to the bilateral knee injury, he is associated with metabolic, cardiovascular and psychological   disorders. John’s current state is described by taking into consideration of his medical history and family background. As John is susceptible for deep vein thrombosis, its pathophysiology is discussed. Tests for the assessment of John condition are discussed. Planned interventions for the problems detected in the assessment are discussed. Discussion about the different professionals for providing care to John is also discussed in the essay.   

John Grant is 63 year old and he having age related disease like bilateral knee osteoarthritis. He is consuming Endone for pain management. However, due to less improvement with medicatiosn, he is advised to have knee replacement surgery for both the legs. He is having different disease like angina, hypertension (HTN), hyperlipidemia, type 2 diabetes (T2DM), and depression. Previouslu, he used to work for 6 days per week, however now he is working for 2 days per week because of knee pain. He is capable of doing his daily activities on own. Occasinaly, his family members are visiting him to assist him in daily activities.    

Main reason for the occurrence of deep vein thrombosis is reduced flow. In case of John, it may occur due to blood clotting post surgery. Decreased blood flow, vein dilatation and less contraction of skeletal muscle can lead to venous stasis. As a result intimal lining of the blood vessels get damaged. This damaged site is susceptible for clot and thrombus formation. After thrombus formation inflammation occurs and it is called as phlebitis.  Aggregation of the platelets at the vein wall is responsible for the venous thrombi. Venous thrombi is having tail like structure consisting of fibrin, white and red blood cells (Houshmand et al., 2015).

 

Assessment:

Musculoskeletal system should be assessed for John as he is having osteoarthritis. Strength, balance and joint range of motion necessary for performing his daily activities should be assessed using functional assessment. Movement of John and his body posture along with body symmetry should be assessed by observation. It would be helpful in the evaluating power of muscles and joint. Visual observation of spine should be done to understand spine contour and tenderness. Gait assessment should be done in John by asking him to walk few steps like heel-to-toe walking and steps on tiptoe walking in the room. Romberg testing should be used for assessment of balance in John (Almoallim and Gelidan, 2012). 

Assessment of diabetes in John should be done by monitoring body weight changes, sweating, weakness, polydipsia, polyphagia and polyuria. Blood pressure and heart beat should also be assessed in John because in diabetes cardiovascular parameters can change significantly. Ophthalmoscopy should be used to evaluate vision problem in John. In neuropathic assessment, tendon hammer should be used to assess ankle and knee reflexes.  

Blood glucose level test using glucose oxidase method and HBA1C test using ELISA kit should be performed in John for assessment of diabetes. Clinical laboratory scientist and pathologist should be incorporated in the assessment of John for carrying gout required tests. His family members should take him to pathology lab for assessment (Pagana and Pagana, 2014).

 

Risk Assessment:

John is susceptible to risks like fall due to osteoarthritis and infection due to surgery. Evidence of fall for John in last 3 months would be helpful is assessing fall in John. Evidence should include information about number of falls per week and reason behind fall. Number of visits to toilet for urination and defecation also would be helpful in fall assessment because elderly patient’s fall in bathroom is very common. Gait and vision or hearing impairment would also be helpful in assessment of fall in John (Suman et al., 2013). John is more susceptible to infection due to surgery. Risk of infection can be assessed by observing secretions form the surgery site and carrying out culturing  of  fluid or tissue from surgery site. Physical characters like  pain, swelling and redness are also useful in the assessment of infection (Cheng et al., 2015). 

Strategies to Meet the John’s Needs:

Nurse should provide intervention for the improvement in mobilization for John. Warm water treatment and gentle massage can be useful in reducing stiffness of joints. Mobilization can be improved with this treatment. Mobility exercise like range of movement (ROM) and stretching exercise would be helpful in improving mobility  (Musumeci et al., 2014). 

For control of blood glucose level in John, he should be administered with gliclazide and acarbose. Gliclazide and acarbose produce its action by acting on sulfonylurea receptors (SUR-1) on the pancreatic beta-cells and alpha-glucosidase in small intestine and alpha amylase in the pancreas respectively. Acarbose reduces HBAIC level by carrying out carbohydrate digestion (Singla et al., 2016; Singh and Singh, 2016).  

Blood flow in the DVT patient like John can be increased by providing suitable position,  increasing motion of the leg and by providing compression therapy. Elevated position of leg and knee flexion in John can increase blood glow in the leg. Warm and moist compresses can also increase blood flow to leg in John. Superficial veins caliber can be reduced by using graduated compression stockings which increases blood flow. Short stretch elastic wraps and intermittent pneumatic compression devices should be used in John for increasing blood flow. It is evident from the literature that use of compression devices are helpful in blood clot formation and moreover possibility of bleeding is less in using these devices as compared to the medications use for preventing clot formation. However, it should considered that medications are more effective in preventing blood clot as compared to these devices (Blann, 2015).

 

Evaluation of Care:

Nurse should incorporate different professional like doctor, pharmacist, clinical pharmacologist, clinical laboratory scientist, physical trainer, dietician, psychologist and family members in providing intervention to John. Nurse should consult with doctor to maintain optimal perfusion in John. This would be helpful in reducing thickness of blood and decreasing chances of clot formation. Pharmacist and clinical pharmacologist should be incorporated in providing education about medication consumption to John. These professionals should educate him about accurate dose and timings of anticoagulant consumption because high dose of anticoagulant can result in bleeding. Clinical laboratory scientist should help John in carrying out tests. Family members should be educated about the medications and tests for John because they can help in completing these things in time. Physical trainer can assist John in performing stretching exercise for John to increase blood flow in the leg. It is evident that, john is associated with metabolic, diabetic and cardiovascular complications. In these disease conditions proper diet should be consumed. Dietician can help John in taking suitable diet for his health conditions. John becomes depressive due to his age and disease condition. Hence, psychologist should be incorporated in his care to improve his moral boost (Blann, 2015).     

I illustrated current status of John keeping in mind his medical history. I understood that John is having very complex health condition comprising of osteoarthritis, diabetes, cardiovascular complications and depression. I performed health assessment of John to know his significant health problems. I identified problems like immobilization for osteoarthritis and increased blood glucose level for diabetes. I provided nursing intervention to improve mobility and to reduce blood glucose level in John (Papathanasiou et al., 2014).

 

Conclusion:

John is having painful bilateral knee osteoarthritis and medications are not relieving him. Hence, knee replacement surgery is suggested for him. Patients with knee replacement surgery are more susceptible for DVT. As John is having diabetes, risk of DVT is more in John. Assessment should be performed in John for providing correct intervention to John. Assessment for osteoarthritis and diabetes should be performed in John. Diabetes and long duration bed rest are identified as the risk factors for DVT in John. Professionals from different disciplines should be incorporated for John for mediation administration, diet plan, physical exercise and tests for assessment. In summary, assessment of John by using specific tests for his complications and relevant intervention would be helpful in providing holistic care to John.

 

References:

Almoallim, Hani., and  Gelidan, A. (2012).  Musculoskeletal Examination Skills: Are We Still Interested? International Journal of Clinical Medicine, 3, 335-340. 

Blann, A.  (2015). Deep Vein Thrombosis and Pulmonary Embolism: A guide for practitioners.M&K Update Ltd.  

Cheng, K., Jiawei, L., Qingfang, K., Changxian, W., Nanyuan, Y., and Guohua, X. (2015). Risk factors for surgical site infection in a teaching hospital: a prospective study of 1,138 patients. Patient Preference and Adherence, 9, 1171–1177. 

Houshmand, S., Salavati, A., Hess, S., Ravina, M., Alavi, A. (2014). The role of molecular imaging in diagnosis of deep vein thrombosis. American Journal of Nuclear Medicine and Molecular Imaging, 4(5), 406–425. 

Musumeci, G., Mobasheri, A., Trovato, F.M., Szychlinska, M.A., Imbesi, R., and Castrogiovanni, P. (2014).  Post-operative rehabilitation and nutrition in osteoarthritis. doi: 10.12688/f1000research.4178.3. 

Pagana, K.D., and Paganam T.J.  (2014). Blood studies. In: Pagana KD, Pagana TJ, eds. Mosby's Manual of Diagnostic and Laboratory Tests. 5th ed. St Louis, MO: Elsevier Mosby; 2014:chap 2. 

Papathanasiou, I.V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., Kourkouta, L. (2014). Critical Thinking: The Development of an Essential Skill for Nursing Students. Acta Informatica Medica, 22(4), 283–286. 

Singla, R.K., Singh, R., and Dubey, A.K. (2016). Important Aspects of Post-Prandial Antidiabetic Drug, Acarbose. Current Topics in Medicinal Chemistry, 16(23), 2625-33. 

Singh, A.K., and Singh, R. (2016). Is gliclazide a sulfonylurea with difference? A review in 2016. Expert Review of Clinical Pharmacology, 9(6), 839-51. 

Suman, V.B., Khalid, P., Jeganathan, P.S., Subbalakshmi, N.K., Sheila, R. P., Shaila, M.D. (2013). Risk factors associated with Osteoporosis- A population based study using p-Dexa technique. International Journal of Scientific and Research Publications, 3(2), 1 – 5.

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