To be submitted by:

Abalde, Alluna
Ballares, Ma. Therese
Batoon, John Philip

Bilagantol, Jhadale Irish

Bonghanoy, Josh Allen
Cainhog, Aiken Raphael
Castillon, Vinz Khyl
Chan, Dhanneane Marie
Clarito, Kryschelle
Cortez, Caitlynn
BSN 2 – NC

To be submitted to:
Ma’am Mildred N. Pinque, RN, MN
Clinical Instructor

September 22, 2019

CEREBROVASCULAR ACCIDENT

Description
Cerebrovascular accident (CVA) is the medical term for a stroke. A stroke is when
blood flow to a part of your brain is stopped either by a blockage or rupture of a blood
vessel.

There are two main types of cerebrovascular accident, or stroke:

 an ischemic stroke is caused by a blockage;
 a hemorrhagic stroke is caused by the rupture of a blood vessel. Both types of
stroke deprives part of the brain of blood and oxygen, causing brain cells to die.

Signs and Symptoms

The quicker you can get a diagnosis and treatment for a stroke, the better your
prognosis will be. For this reason, it’s important to understand and recognize the
symptoms of a stroke. Stroke symptoms include:

 difficulty walking
 dizziness
 loss of balance and coordination
 difficulty speaking or understanding others who are speaking
 numbness or paralysis in the face, leg, or arm, most likely on just one side of
the body
 blurred or darkened vision
 a sudden headache, especially when accompanied by nausea, vomiting, or
dizziness

The symptoms of a stroke can vary depending on the individual and where in the brain
it has happened. Symptoms usually appear suddenly, even if they’re not very severe,
and they may become worse over time.

Remembering the acronym “FAST” helps people recognize the most common
symptoms of stroke:

FACE: Does one side of the face droop?

ARM: If a person holds both arms out, does one drift downward?

SPEECH: Is their speech abnormal or slurred?

TIME: It’s time to call 911 and get to the hospital if any of these symptoms are present.

Signs of Stroke in Men and Women

  sudden numbness or weakness in the face, arm, or leg, especially on one side
of the body
 sudden confusion, trouble speaking, or difficulty understanding speech
 sudden trouble seeing in one or both eyes
 sudden trouble walking, dizziness, loss of balance, or lack of coordination
 sudden severe headache with no known cause

Medical Management

Patients who have experienced TIA or stroke should have medical management for
secondary prevention.

 Recombinant tissue plasminogen activator would be prescribed unless

contraindicated, and there should be monitoring for bleeding
 Increased ICP. Management of increased ICP includes osmotic diuretics,
maintenance of PaCO2 at 30-35 mmHg, and positioning to avoid hypoxia
through elevation of the head of the bed
 Endotracheal Tube. There is a possibility of intubation to establish patent airway
if necessary
 Hemodynamic monitoring. Continuous hemodynamic monitoring should be
implemented to avoid an increase in blood pressure
 Neurologic assessment to determine if the stroke is evolving and if other acute
complications are developing

Nursing Management
Nursing Assessment
During the acute phase, a neurologic flow sheet is maintained to provide data about
the following important measures of the patient’s clinical status:
 Change in level of consciousness or responsiveness
 Presence or absence of voluntary or involuntary movements of extremities.
 Stiffness or flaccidity of the neck
 Eye opening, comparative size of pupils, and pupillary reaction to light
 Color of the face and extremities; temperature and moisture of the skin
 Ability to speak
 Presence of bleeding
 Maintenance of blood pressure

During the postacute phase, assess the following functions:

 Mental status (memory, attention span, perception, orientation, affect,
speech/language)
 Sensation and perception (usually the patient has decreased awareness of pain
and temperature)
  Motor control (upper and lower extremity movement); swallowing ability,
nutritional and hydration status, skin integrity, activity tolerance, and bowel and
bladder function
 Continue focusing nursing assessment on impairment of function in patient’s
daily activities

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with stroke
may include the following:
 Impaired physical mobility related to hemiparesis, loss of balance and
coordination, spasticity, and brain injury
 Acute pain related to hemiplegia and disuse
 Deficient self-care related to stroke sequelae
 Disturbed sensory perception related to altered sensory reception,
transmission, and/or integration
 Impaired urinary elimination related to flaccid bladder, detrusor instability,
confusion, or difficulty in communicating
 Disturbed thought processes related to brain damage
 Impaired verbal communication related to brain damage
 Risk for impaired skin integrity related to hemiparesis or hemiplegia and
decreased mobility
 Interrupted family processes related to catastrophic illness and caregiving
burdens
 Sexual dysfunction related to neurologic deficits or fear of failure

Nursing Care Planning & Goals

The major nursing care planning goals for the patient and family may include:
 Improve mobility
 Avoidance of shoulder pain
 Achievement of self-care
 Relief of sensory and perceptual deprivation
 Prevention of aspiration
 Continence of bowel and bladder
 Improved thought processes
 Achieving a form of communication
 Maintaining skin integrity
 Restore family functioning
 Improve sexual function
 Absence of complications

Nursing Interventions
Nursing care has a significant impact on the patient’s recovery. In summary, here are
some nursing interventions for patients with stroke:
  Positioning. Position to prevent contractures, relieve pressure, attain good body
alignment, and prevent compressive neuropathies.
 Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
 Prevent adduction. Prevent adduction of the affected shoulder with a pillow
placed in the axilla.
 Prevent edema. Elevate affected arm to prevent edema and fibrosis.
 Full range of motion. Provide full range of motion four or five times a day to
maintain joint mobility.
 Prevent venous stasis. Exercise is helpful in preventing venous stasis, which
may predispose the patient to thrombosis and pulmonary embolus.
 Regain balance. Teach patient to maintain balance in a sitting position, then to
balance while standing and begin walking as soon as standing balance is
achieved.
 Personal hygiene. Encourage personal hygiene activities as soon as the patient
can sit up.
 Manage sensory difficulties. Approach patient with a decreased field of vision
on the side where visual perception is intact.
 Visit a speech therapist. Consult with a speech therapist to evaluate gag
reflexes and assist in teaching alternate swallowing techniques.
 Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s
voiding schedule.
 Be consistent in patient’s activities. Be consistent in the schedule, routines, and
repetitions; a written schedule, checklists, and audiotapes may help with
memory and concentration, and a communication board may be used.
 Assess skin. Frequently assess skin for signs of breakdown, with emphasis on
bony areas and dependent body parts.

Improving Mobility and Preventing Deformities

 Position to prevent contractures; use measures to relieve pressure, assist in
maintaining good body alignment, and prevent compressive neuropathies.
 Apply a splint at night to prevent flexion of affected extremity.
 Prevent adduction of the affected shoulder with a pillow placed in the axilla.
 Elevate affected arm to prevent edema and fibrosis.
 Position fingers so that they are barely flexed; place hand in slight supination.
If upper extremity spasticity is noted, do not use a hand roll; dorsal wrist splint
may be used.
 Change position every 2 hours; place patient in a prone position for 15 to 30
minutes several times a day.

Establishing an Exercise Program

 Provide full range of motion four or five times a day to maintain joint mobility,
regain motor control, prevent contractures in the paralyzed extremity, prevent
further deterioration of the neuromuscular system, and enhance circulation. If
 tightness occurs in any area, perform a range of motion exercises more
frequently.
 Exercise is helpful in preventing venous stasis, which may predispose the
patient to thrombosis and pulmonary embolus.
 Observe for signs of pulmonary embolus or excessive cardiac workload during
exercise period (e.g., shortness of breath, chest pain, cyanosis, and increasing
pulse rate).
 Supervise and support the patient during exercises; plan frequent short periods
of exercise, no longer periods; encourage the patient to exercise unaffected
side at intervals throughout the day.

Preparing for Ambulation

 Start an active rehabilitation program when consciousness returns (and all
evidence of bleeding is gone, when indicated).
 Teach patient to maintain balance in a sitting position, then to balance while
standing (use a tilt table if needed).
 Begin walking as soon as standing balance is achieved (use parallel bars and
have a wheelchair available in anticipation of possible dizziness).
 Keep training periods for ambulation short and frequent.

Preventing Shoulder Pain

 Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
 Use proper patient movement and positioning (e.g., flaccid arm on a table or
pillows when patient is seated, use of sling when ambulating).
 Range of motion exercises are beneficial, but avoid over strenuous arm
movements.
 Elevate arm and hand to prevent dependent edema of the hand; administer
analgesic agents as indicated.

Enhancing Self Care

 Encourage personal hygiene activities as soon as the patient can sit up; select
suitable self-care activities that can be carried out with one hand.
 Help patient to set realistic goals; add a new task daily.
 As a first step, encourage patient to carry out all self-care activities on the
unaffected side.
 Make sure patient does not neglect affected side; provide assistive devices as
indicated.
 Improve morale by making sure patient is fully dressed during ambulatory
activities.
 Assist with dressing activities (e.g., clothing with Velcro closures; put garment
on the affected side first); keep environment uncluttered and organized.
 Provide emotional support and encouragement to prevent fatigue and
discouragement.
Managing Sensory-Perceptual Difficulties
 Approach patient with a decreased field of vision on the side where visual
perception is intact; place all visual stimuli on this side.
 Teach patient to turn and look in the direction of the defective visual field to
compensate for the loss; make eye contact with patient, and draw attention to
affected side.
 Increase natural or artificial lighting in the room; provide eyeglasses to improve
vision.
 Remind patient with hemianopia of the other side of the body; place extremities
so that patient can see them.

Assisting with Nutrition

 Observe patient for paroxysms of coughing, food dribbling out or pooling in one
side of the mouth, food retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids.
 Consult with speech therapist to evaluate gag reflexes; assist in teaching
alternate swallowing techniques, advice patient to take smaller boluses of food,
and inform patient of foods that are easier to swallow; provide thicker liquids or
pureed diet as indicated.
 Have patient sit upright, preferably on chair, when eating and drinking; advance
diet as tolerated.
 Prepare for GI feedings through a tube if indicated; elevate the head of bed
during feedings, check tube position before feeding, administer feeding slowly,
and ensure that cuff of tracheostomy tube is inflated (if applicable); monitor and
report excessive retained or residual feeding.

Attaining Bowel and Bladder Control

 Perform intermittent sterile catheterization during the period of loss of sphincter
control.
 Analyze voiding pattern and offer urinal or bedpan on patient’s voiding
schedule.
 Assist the male patient to an upright posture for voiding.
 Provide high-fiber diet and adequate fluid intake (2 to 3 L/day), unless
contraindicated.
 Establish a regular time (after breakfast) for toileting.

Improving Thought Processes

 Reinforce structured training program using cognitive, perceptual retraining,
visual imagery, reality orientation, and cueing procedures to compensate for
losses.
 Support patient: Observe performance and progress, give positive feedback,
convey an attitude of confidence and hopefulness; provide other interventions
as used for improving cognitive function after a head injury.
Improving Communication
 Reinforce the individually tailored program.
 Jointly establish goals, with the patient taking an active part.
 Make the atmosphere conducive to communication, remaining sensitive to
patient’s reactions and needs and responding to them in an appropriate
manner; treat the patient as an adult.
 Provide strong emotional support and understanding to allay anxiety; avoid
completing patient’s sentences.
 Be consistent in schedule, routines, and repetitions. A written schedule,
checklists, and audiotapes may help with memory and concentration; a
communication board may be used.
 Maintain patient’s attention when talking with the patient, speak slowly, and give
one instruction at a time; allow the patient time to process.
 Talk to aphasic patients when providing care activities to provide social contact.

Maintaining Skin Integrity

 Frequently assess skin for signs of breakdown, with emphasis on bony areas
and dependent body parts.
 Employ pressure relieving devices; continue regular turning and positioning
(every 2 hours minimally); minimize shear and friction when positioning.
 Keep skin clean and dry, gently massage the healthy dry skin and maintain
adequate nutrition.

Improving Family Coping

 Provide counseling and support to the family.
 Involve others in patient’s care; teach stress management techniques and
maintenance of personal health for family coping.
 Give family information about the expected outcome of the stroke, and counsel
them to avoid doing things for the patient that he or she can do.
 Develop attainable goals for the patient at home by involving the total health
care team, patient, and family.
 Encourage everyone to approach the patient with a supportive and optimistic
attitude, focusing on abilities that remain; explain to the family that emotional
lability usually improves with time.

Helping the Patient Cope with Sexual Dysfunction

 Perform in depth assessment to determine sexual history before and after the
stroke.
 Interventions for patient and partner focus on providing relevant information,
education, reassurance, adjustment of medications, counseling regarding
coping skills, suggestions for alternative sexual positions, and a means of
sexual expression and satisfaction.
Teaching points
 Teach patient to resume as much self-care as possible; provide assistive
devices as indicated.
 Have occupational therapist make a home assessment and recommendations
to help the patient become more independent.
 Coordinate care provided by numerous health care professionals; help family
plan aspects of care.
 Advise family that patient may tire easily, become irritable and upset by small
events, and show less interest in daily events.
 Make a referral for home speech therapy. Encourage family involvement.
Provide family with practical instructions to help patient between speech
therapy sessions.
 Discuss patient’s depression with the physician for possible antidepressant
therapy.
 Encourage patient to attend community-based stroke clubs to give a feeling of
belonging and fellowship to others.
 Encourage patient to continue with hobbies, recreational and leisure interests,
and contact with friends to prevent social isolation.
 Encourage family to support patient and give positive reinforcement.
 Remind spouse and family to attend to personal health and wellbeing.

Evaluation

Expected patient outcomes may include the following:

 Improved mobility.
 Absence of shoulder pain.
 Self-care achieved.
 Relief of sensory and perceptual deprivation.
 Prevention of aspiration.
 Continence of bowel and bladder.
 Improved thought processes.
 Achieved a form of communication.
 Maintained skin integrity.
 Restored family functioning.
 Improved sexual function.
 Absence of complications.

Discharge and Home Care Guidelines

Patient and family education is a fundamental component of rehabilitation.
 Consult an occupational therapist. An occupational therapist may be helpful in
assessing the home environment and recommending modifications to help the
patient become more independent.
 Physical therapy. A program of physical therapy may be beneficial, whether it
takes place in the home or in an outpatient program.
 Antidepressant therapy. Depression is a common and serious problem in the
patient who has had a stroke.
 Support groups. Community-based stroke support groups may allow the patient
and the family to learn from others with similar problems and to share their
experiences.
 Assess caregivers. Nurses should assess caregivers for signs of depression,
as depression is also common among caregivers of stroke survivors.
CLOTTING PROCESS

The multistep process of blood clot formation to stop bleeding is called coagulation.
When the entire coagulation cascade works properly, blood holds together firmly at an
injury site and bleeding stops. People who have a bleeding disorder, however, are
unable to make strong clots quickly or at all.

How a Blood Clot is made

The coagulation cascade is a complex chemical process that uses as many as 10
different proteins (called blood clotting factors or coagulation factors) found in plasma
in the blood. Put simply, the clotting process changes blood from a liquid to a solid at
the site of an injury. Here’s how the process works:

Injury
A small tear in a blood vessel wall that causes bleeding.

Vessel constriction
To control blood loss the blood vessel narrows (called constriction), thus limiting blood
flow through the vessel.

Platelet plug
In response to the injury, tiny cells in the blood called platelets are activated. The
platelets stick to one another and to the wound site to form a plug. The protein von
Willebrand factor helps the platelets stick to each other and to the blood vessel wall.

Fibrin clot
Clotting factor proteins trigger production of fibrin, a strong, strand-like substance that
forms a fibrin clot, a mesh-like net that keeps the plug firm and stable. Over the next
several days to weeks, the clot strengthens and then dissolves as the wounded blood
vessel wall heals.

What happens when a person has a bleeding disorder?

People with von Willebrand disease either don’t have enough of the VWF protein or
the VWF protein doesn’t work properly. When they have a bleed they’re not able to
form a platelet plug. In addition, VWF acts as a carrier protein for factor VIII (FVIII),
one of the clotting factors in plasma. VWF helps ensure enough FVIII is in the blood
and that it gets to where it’s needed. Without VWF, FVIII will be broken down in the
bloodstream and there may not be enough of it to stop bleeding.

When a person has hemophilia, the blood vessel narrows and the platelets form a
plug, but one of the clotting factor proteins essential to a firm fibrin clot is missing or
damaged, so the clot is not made or is not strong enough to stop the bleeding. This is
why a person with hemophilia bleeds for a longer period of time. A number of rare
platelet disorders may also disrupt the blood clotting process.

The clotting process Clotting factors are proteins in the blood that control bleeding.
When a blood vessel is injured, the walls of the blood vessel contract to limit the flow
of blood to the damaged area. Then, small blood cells called platelets stick to the site
of injury and spread along the surface of the blood vessel to stop the bleeding. At the
same time, chemical signals are released from small sacs inside the platelets that
attract other cells to the area and make them clump together to form what is called a
platelet plug. On the surface of these activated platelets, many different clotting factors
work together in a series of complex chemical reactions (known as the coagulation
cascade) to form a fibrin clot. The clot acts like a mesh to stop the bleeding.
Coagulation factors circulate in the blood in an inactive form. When a blood vessel is
injured, the coagulation cascade is initiated and each coagulation factor is activated in
a specific order to lead to the formation of the blood clot. Coagulation factors are
identified with Roman numerals (e.g. factor I or FI).
CORONARY ARTERY DISEASE

Coronary artery disease is the narrowing or blockage of the coronary arteries, usually
caused by atherosclerosis. Atherosclerosis (sometimes called "hardening" or
"clogging" of the arteries) is the buildup of cholesterol and fatty deposits (called
plaques) on the inner walls of the arteries. These plaques can restrict blood flow to the
heart muscle by physically clogging the artery or by causing abnormal artery tone and
function.

Without an adequate blood supply, the heart becomes starved of oxygen and the vital
nutrients it needs to work properly. This can cause chest pain called angina. If blood
supply to a portion of the heart muscle is cut off entirely, or if the energy demands of
the heart become much greater than its blood supply, a heart attack (injury to the heart
muscle) may occur.

Symptoms

If your coronary arteries narrow, they can't supply enough oxygen-rich blood to your
heart — especially when it's beating hard, such as during exercise. At first, the
decreased blood flow may not cause any coronary artery disease symptoms. As
plaque continues to build up in your coronary arteries, however, you may develop
coronary artery disease signs and symptoms, including:

Chest pain (angina). You may feel pressure or tightness in your chest, as if someone
were standing on your chest. This pain, referred to as angina, usually occurs on the
middle or left side of the chest. Angina is generally triggered by physical or emotional
stress.

The pain usually goes away within minutes after stopping the stressful activity. In some
people, especially women, this pain may be fleeting or sharp and felt in the neck, arm
or back.

Shortness of breath. If your heart can't pump enough blood to meet your body's needs,
you may develop shortness of breath or extreme fatigue with exertion.
Heart attack. A completely blocked coronary artery will cause a heart attack. The
classic signs and symptoms of a heart attack include crushing pressure in your chest
and pain in your shoulder or arm, sometimes with shortness of breath and sweating.

Women are somewhat more likely than men are to experience less typical signs and
symptoms of a heart attack, such as neck or jaw pain. Sometimes a heart attack occurs
without any apparent signs or symptoms.

Medical Management
 All patients with stable coronary artery disease require medical therapy to
prevent disease progression and recurrent cardiovascular events. Three classes of
medication are essential to therapy: lipid-lowering, antihypertensive, and antiplatelet
agents. Lipid-lowering therapy is necessary to decrease low-density lipoprotein
cholesterol to a target level of less than 100 mg per dL, and physicians should consider
a goal of less than 70 mg per dL for very high-risk patients. Statins have demonstrated
clear benefits in morbidity and mortality in the secondary prevention of coronary artery
disease; other medications that can be used in addition to statins to lower cholesterol
include ezetimibe, fibrates, and nicotinic acid. Blood pressure therapy for patients with
coronary artery disease should start with beta blockers and angiotensin-converting
enzyme inhibitors. If these medications are not tolerated, calcium channel blockers or
angiotensin receptor blockers are acceptable alternatives. Aspirin is the first-line
antiplatelet agent except in patients who have recently had a myocardial infarction or
undergone stent placement, in which case clopidogrel is recommended. Anginal
symptoms of coronary artery disease can be treated with beta blockers, calcium
channel blockers, nitrates, or any combination of these. Familiarity with these
medications and with the evidence supporting their use is essential to reducing
morbidity and mortality in patients with coronary artery disease.

Nursing Management

Assessment

Chest pain is provoked by exertion or stress and is relieved by nitroglycerin and rest.

1. Character. Substernal chest pain, pressure, heaviness, or discomfort.

Other sensations include a squeezing, aching, burning, choking,
strangling, or cramping pain.
2. Severity. Pain maybe mild or severe and typically present with a gradual
buildup of discomfort and subsequent gradual fading away.
3. Location. Behind middle or upper third of sternum; the patient will generally
will make a fist over the site of pain (positive Levine sign; indicates diffuse
deep visceral pain), rather than point to it with fingers.
4. Radiation. Usually radiates to neck, jaw, shoulders, arms, hands, and
posterior intrascapular area. Pain occurs more commonly on the left side
than the right; may produce numbness or weakness in arms, wrist, or
hands.
5. Duration. Usually last 2 to 10 minutes after stopping activity; nitroglycerin
relieves pain within 1 minute.
6. Precipitating factors. Physical activity, exposure to hot or cold weather,
eating a heavy meal, and sexual intercourse increase the workload of the
heart and, therefore, increase oxygen demand.
7. Associated manifestation. Diaphoresis, nausea, indigestion, dyspnea,
tachycardia, and increase in blood pressure.
 8. Signs of unstable angina:
 A change in frequency, duration, and intensity of stable angina
symptoms.
 Angina pain last longer than 10 minutes, is unrelieved by rest
or sublingual nitroglycerin, and mimics signs and symptoms of
impending myocardial infarction.

Diagnostic Evaluation

1. Resting ECG may show left ventricular hypertrophy, ST-T changes,

arrhythmias, and possible Q waves.
2. Exercise stress testing with or without perfusion studies shows ischemia.
3. Cardiac catheterization shows blocked vessels.
4. Position emission tomography may show small perfusion defects.
5. Radionuclide ventriculography shows wall motion abnormalities and
ejection fraction.
6. Fasting blood levels of cholesterol, low density lipoprotein, high density
lipoprotein, lipoprotein A, homocysteine, and triglycerides may be
abnormal.
7. Coagulation studies, hemoglobin level, fasting blood sugar as baseline
studies.

Nursing Diagnosis

 Altered tissue perfusion (myocardial) related to narrowing of the coronary

artery(ies) associated with atherosclerosis, spasm, and/or thrombosis
 Acute pain
 Risk for decreased cardiac output
 Anxiety
 Deficient knowledge (Learning Need) regarding condition, treatment plan,
self-care, and discharge need

Nursing Intervention

1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes
during an anginal attack.
2. Maintain continuous ECG monitoring or obtain a 12-lead ECG, as directed,
monitor for arrhythmias and ST elevation.
3. Place patient in comfortable position and administer oxygen, if prescribed,
to enhance myocardial oxygen supply.
4. Identify specific activities patient may engage in that are below the level at
which anginal pain occurs.
5. Reinforce the importance of notifying nursing staff whenever angina pain
is experienced.
6. Encourage supine position for dizziness caused by antianginals.
7. Be alert to adverse reaction related to abrupt discontinuation of beta-
adrenergic blocker and calcium channel blocker therapy. These drug must
be tapered to prevent a “rebound phenomenon”; tachycardia, increase in
chest pain, and hypertension.
8. Explain to the patient the importance of anxiety reduction to assist to
control angina.
9. Teach the patient relaxation techniques.
10. Review specific factors that affect CAD development and progression;
highlight those risk factors that can be modified and controlled to reduce
the risk.
DEEP VEIN THROMBOSIS

Description
Deep vein thrombosis is a part of a condition called venous thromboembolism. Deep
vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep
veins in the body, usually in the legs. This is a serious condition because blood clots
in the veins can break loose, travel through the bloodstream, and obstruct the lungs,
blocking blood flow. It can cause leg pain or swelling, but may occur without any
symptoms.

The exact cause of deep vein thrombosis remains unknown, but there are factors that
may aggravate it further.

 Direct trauma. Direct trauma to the vessels, as with fracture or dislocation,

diseases of the veins, and chemical irritation of the veins from IV medications
and solutions, can damage the veins.
 Blood coagulability. Increased blood coagulability occurs most commonly in
patients for whom anticoagulant medications have been abruptly withdrawn.
 Oral contraceptives. Oral contraceptives use also lead to hypercoagulability.
 Pregnancy. Normal pregnancy is accompanied by an increase in clotting factors
that may not return to baseline until longer than 8 weeks postpartum, increasing
the risk of thrombosis.
 Repetitive motions. Repetitive motions may cause irritation to the vessel wall,
causing inflammation and subsequent thrombosis.

Signs and Symptoms

A major problem associated with recognizing DVT is that the signs and symptoms are
nonspecific.

 Edema. With obstruction of the deep veins comes edema and swelling of the
extremity because the outflow of venous blood is inhibited
 Phlegmasia cerulea dolens. Also called massive iliofemoral venous thrombosis,
the entire extremity becomes massively swollen, tense, painful , and cool to the
touch.
 Tenderness. Tenderness, which usually occurs later, is produced by
inflammation of the vein wall and can be detected by gently palpating the
affected extremity.
 Pulmonary embolus. In some cases, signs and symptoms of a pulmonary
embolus are the first indication of DVT.

Prevention
Deep vein thrombosis can be prevented, especially if patients who are considered high
risk are identified and preventive measures are instituted without delay.

 Graduated compression stockings. Compression stockings prevent

dislodgement of the thrombus.
 Pneumatic compression device. Intermittent pneumatic compression devices
increase blood velocity beyond that produced by the stockings.
 Leg exercises. Encourage early mobilization and leg exercises to keep the
blood circulating adequately.

Medical Management

The objectives for treatment of DVT are to prevent thrombus from growing and
fragmenting, recurrent thromboemboli, and postthrombotic syndrome.

 Endovascular management. Endovascular management is necessary for DVT

when anticoagulant or thrombolytic therapy is contraindicated, the danger of
pulmonary embolism is extreme, or venous drainage is so severely
compromised that permanent damage to the extremity is likely.
 Vena cava filter. A vena cava filter may be placed at the time of thrombectomy;
this filter traps late emboli and prevents pulmonary emboli.

Pharmacologic Therapy
Measures for preventing or reducing blood clotting within the vascular system are
indicated in patients with deep vein thrombosis.

 Unfractionated heparin. Unfractionated heparin is administered subcutaneously

to prevent development of DVT, or by intermittent or continuous IV infusion for
5 days to prevent the extension of a thrombus and the development of new
thrombi.
 Low-molecular-weight heparin (LMWHs). Subcutaneous LMWHs that may
include medications such as dalteparin and enoxaparin are effective treatments
for some cases of DVT; they prevent the extension of a thrombus and
development of new thrombi.
 Oral anticoagulants. Warfarin is a vitamin K antagonist that is indicated for
extended coagulant therapy.
 Factor Xa inhibitor. Fondaparinux selectively inhibits factor Xa.
 Thrombolytic therapy. Unlike heparins, catheter-directed thrombolytic therapy
lyses and dissolves thrombi in at least 50% of patients.

Nursing Management
Nursing Assessment

 Presenting signs and symptoms. If a patient presents with signs and symptoms
of DVT, carry out an assessment of general medical history and a physical
examination to exclude other causes.
 Well’s diagnostic algorithm. Because of the unreliability of clinical features,
Well’s diagnostic algorithm has been validated whereby patients are classified
as having a high, intermediate, or low probability of developing DVT.

Nursing Diagnosis

 Ineffective tissue perfusion related to interruption of venous blood flow.

 Impaired comfort related to vascular inflammation and irritation.
 Risk for impaired physical mobility related to discomfort and safety
precautions.
 Deficient knowledge regarding pathophysiology of condition related to lack of
information and misinterpretation.

Nursing Care Planning & Goals

 Demonstrate increased perfusion as individually appropriate.

 Verbalize understanding of condition, therapy, regimen, side effects of
medications, and when to contact the healthcare provider.
 Engage in behaviors or lifestyle changes to increase level of ease.
 Verbalize sense of comfort or contentment.
 Maintain position of function and skin integrity as evidenced by absence of
contractures, foot drop, decubitus, and so forth.
 Maintain or increase strength and function of affected and/or compensatory
body part.

Nursing Interventions

 Provide comfort. Elevation of the affected extremity, graduated compression

stockings, warm application, and ambulation are adjuncts to the therapy that
can remove or reduce discomfort.
 Compression therapy. Graduated compression stockings reduce the
caliber of the superficial veins in the leg and increase flow in the deep veins;
external compression devices and wraps are short stretch elastic wraps that
are applied from the toes to the knees in a 50% spiral overlap; intermittent
pneumatic compression devices increase blood velocity beyond that
produced by the stockings.
 Positioning and exercise. When patient is on bed rest, the feet and lower legs
should be elevated periodically above the level of the heart, and active and
passive leg exercises should be performed to increase venous flow.
Evaluation

 Demonstrated increased perfusion as individually appropriate.

 Verbalized understanding of condition, therapy, regimen, side effects of
medications, and when to contact the healthcare provider.
 Engaged in behaviors or lifestyle changes to increase level of ease.
 Verbalized sense of comfort or contentment.
 Maintained position of function and skin integrity as evidenced by absence of
contractures, footdrop, decubitus, and so forth.
 Maintained or increased strength and function of affected and/or compensatory
body part.

Discharge and Home Care Guidelines

The nurse must also promote discharge and home care to the patient.

 Drug education. The nurse should teach about the prescribed anticoagulant,
its purpose, and the need to take the correct amount at the specific times
prescribed.
 Blood tests. The patient should be aware that periodic blood tests are
necessary to determine if a change in medication or dosage is required.
 Avoid alcohol. A person who refuses to discontinue the use of alcohol should
not receive anticoagulants because chronic alcohol intake decreases their
effectiveness.
 Activity. Explain the importance of elevating the legs and exercising
adequately.
HEMOPHILIA

Description
Hemophilia is a rare condition in which the blood does not clot properly. It mostly
affects men. Proteins called clotting factors work with platelets to stop bleeding at the
site of an injury. People with hemophilia produce lower amounts of either Factor VIII
or Factor IX than those without the condition. This means the person tends to bleed
for a longer time after an injury, and they are more susceptible to internal bleeding.
This bleeding can be fatal if it occurs within a vital organ such as the brain.

Hemophilia is caused by a mutation or change, in one of the genes, that provides

instructions for making the clotting factor proteins needed to form a blood clot. This
change or mutation can prevent the clotting protein from working properly or to be
missing altogether. These genes are located on the X chromosome. Males have one
X and one Y chromosome (XY) and females have two X chromosomes (XX). Males
inherit the X chromosome from their mothers and the Y chromosome from their
fathers. Females inherit one X chromosome from each parent. The X chromosome
contains many genes that are not present on the Y chromosome. This means that
males only have one copy of most of the genes on the X chromosome, whereas
females have 2 copies. Thus, males can have a disease like hemophilia if they inherit
an affected X chromosome that has a mutation in either the factor VIII or factor IX
gene. Females can also have hemophilia, but this is much rarer. In such cases both X
chromosomes are affected or one is affected and the other is missing or inactive. In
these females, bleeding symptoms may be similar to males with hemophilia. A female
with one affected X chromosome is a “carrier” of hemophilia. Sometimes a female who
is a carrier can have symptoms of hemophilia. In addition, she can pass the affected
X chromosome with the clotting factor gene mutation on to her children.

Hemophilia can result in:

 Bleeding within joints that can lead to chronic joint disease and pain
 Bleeding in the head and sometimes in the brain which can cause long term
problems, such as seizures and paralysis
 Death can occur if the bleeding cannot be stopped or if it occurs in a vital organ
such as the brain.

There are several different types of hemophilia. The following two are the most
common:
 Hemophilia A (Classic Hemophilia)
 This type is caused by a lack or decrease of clotting factor VIII.
 Hemophilia B (Christmas Disease)
 This type is caused by a lack or decrease of clotting factor IX

Signs and Symptoms

Common signs of hemophilia include:
  Bleeding into the joints. This can cause swelling and pain or tightness in the
joints; it often affects the knees, elbows, and ankles
 Bleeding into the skin (which is bruising) or muscle and soft tissue causing a
build-up of blood in the area (called a hematoma)
 Bleeding of the mouth and gums, and bleeding that is hard to stop after losing
a tooth
 Bleeding after circumcision (surgery performed on male babies to remove the
hood of skin called the foreskin, covering the head of the penis)
 Bleeding after having shots, such as vaccinations
 Bleeding in the head of an infant after a difficult delivery
 Blood in the urine or stool
 Frequent and hard-to-stop nosebleeds

Medical Treatment
The best way to treat hemophilia is to replace the missing blood clotting factor so that
the blood can clot properly. This is done by infusing (administering through a vein)
commercially prepared factor concentrates. People with hemophilia can learn how to
perform these infusions themselves so that they can stop bleeding episodes and, by
performing the infusions on a regular basis (called prophylaxis), can even prevent
most bleeding episodes.
Good quality medical care from doctors and nurses who know a lot about the disorder
can help prevent some serious problems. Often the best choice for care is to visit a
comprehensive Hemophilia Treatment Center (HTC). An HTC not only provides care
to address all issues related to the disorder, but also provides health education that
helps people with hemophilia stay healthy.

Nursing Management

Assessment
 Altered blood clotting
 Continuous bleeding
 Abnormal vital signs

Nursing Diagnosis
 Acute Pain related to Hemarthrosis
 Acute Pain related to traumatic injury to muscles
 Impaired Physical Mobility related to pain and discomfort with the onset of
bleeding episodes
 Impaired Physical Mobility related to Hemarthrosis
 Compromised Family Coping related to inadequate or incorrect information or
understanding
  Compromised Family Coping related to prolonged disease or disability
progression that exhausts the physical and emotional supportive capacity of
caretakers
 Risk for Bleeding related to decreased concentration of clotting factors
circulating in the blood
 Risk for Injury related to decreased clotting factor

Nursing Care Planning & Goals

 Absence of complications and pain
 Prevention of injury and bleeding
 Improved physical mobility
 Understanding of the disease conditions and its management

Nursing Interventions
 Assess the location, characteristics, and rate of pain (use pain scale).
 Assess for joint swelling and ability to move affected limb.
 Immobilize joints and apply elastic bandages to the affected joint if indicated;
elevate affected and apply a cold compress to active bleeding sites, but must
be used cautiously in young children to prevent skin breakdown.
 Provide bed cradle over painful joints and other sites of bleeding.
 Maintain immobilization of the affected extremity during the acute phase (24 to
48 hours); apply a splint or sling to the affected extremity if indicated.
 Perform range of motion 48 hours after the acute bleeding episode and pain
has subsided.
 Administer medications as indicated.
 Administer factor VIII or other prescribed factor component immediately.
 Educate child about cause of pain and
 interventions to relieve it; how medications must be administered via per orem,
while injections are not advised; to avoid taking aspirin or aspirin product for
pain.
 Instruct child to support and protect painful areas and in the importance of
immobilization.
 Assess signs and symptoms of bleeding hemarthrosis (stiffness, tingling, or
pain); subcutaneous and intramuscular hemorrhage; oral bleeding; epistaxis (is
not a frequent sign); petechiae (are uncommon).
 Advise adolescents to use an electric shaver versus manual razor devices (with
blades).
 Utilize appropriate toys (soft, not pointed or small sharp objects); for infants,
may need to use padded bed rail sides on crib; avoid rectal temperatures.
 Provide appropriate oral hygiene (use of a water irrigating device; use of a soft
toothbrush or softening the toothbrush with warm water before brushing; use of
sponge-tipped toothbrush).
  Substitute the subcutaneous route for intramuscular injections; utilize
venipuncture blood drawing technique for all required blood testing samples
versus the use of a finger or heel puncture.
 Recommend non-contact sports activities such as swimming, hiking, or
bicycling.
 Avoid contact sports such as football, soccer, ice hockey, karate.
 Limit use of helmets and padding of cause joints during participation in contact
sports activities.
 Maintain close supervision during play time to minimize injuries.

Evaluation
 The patient was able to display homeostasis as evidenced by absence of
bleeding

Sources
Belleza, M. (March 17, 2017). Deep Vein Thrombosis. Retrieved
September 22, 2019 from https://nurseslabs.com/deep-vein-
thrombosis/#Description
Ellis, M. E. (2018, September 29). Cerebrovascular Accident:
Symptoms, Treatment, and Prevention. Retrieved from
https://www.healthline.com/health/cerebrovascular-accident#diagnosis
Ellis, M. E. (2018, September 29). Cerebrovascular Accident:
Symptoms, Treatment, and Prevention. Retrieved from
https://www.healthline.com/health/cerebrovascular-accident#diagnosis
What is Hemophilia | CDC. (n.d.). Retrieved from
https://www.cdc.gov/ncbddd/hemophilia/facts.html
Figure 2f from: Irimia R, Gottschling M (2016) Taxonomic revision of
Rochefortia Sw. (Ehretiaceae, Boraginales). Biodiversity Data Journal 4:
e7720. https://doi.org/10.3897/BDJ.4.e7720. (n.d.). doi:
10.3897/bdj.4.e7720.figure2f