Introduction
This case study is based on the report of a 58-year-old patient who frequently visits the clinic for periodic checkups after sustaining a left foot fracture. Brian was given an orthopedic “moon boot” and instructed to engage in mild weight-bearing exercises. However, he must attend the clinic every two days to have his pressure injury examined and dressed.
On the last day of his visit, he reports feeling ill and having trouble moving. Consequently, an A-G assessment is done on Brian to reveal the normal and abnormal findings. Therefore, using the case scenario, this case study will investigate the clinical manifestations of venous thromboembolism (VET), its pathogenesis, risk factors, prevention, and complications if left untreated.
Collected Cues
Brian reported that he was not “feeling well 100%” because of the pain from his fractured foot. On a scale from 0-10, he rates his pain as a 7. His respiratory rate was determined to be 22 breaths per minute. The normal adult respiratory rate is 12–20b/m; hence, a rate of 22b/m is abnormally high (Flenady et al., 2017).
Brian’s blood pressure measurement of 129/67 mm Hg is within the normal range. The normal range for systolic blood pressure is 120 to 129, while diastolic pressure should be less than 80 (Hoare et al., 2018). Brian’s slight decrease in diastolic pressure (67) may be symptomatic of a fluid volume deficiency. He claims he does not hydrate well; therefore, it is prudent to underline the need to increase oral fluid consumption.
A check of Brian’s lower extremities reveals his left foot is swollen. In addition, the left calf is red and warm to the touch, and the patient complains of cramping in the calf. Indicators of venous thromboembolism include calf swelling, discomfort, and a temperature rise.
Airway, breathing, circulation, disability, and exposure (ABCDE) are relevant for quick evaluation and treatment in all clinical emergencies. The strategy is generally recognized by emergency medicine specialists and is expected to enhance patient outcomes by allowing medical personnel to concentrate on life-threatening patient conditions (Chambers et al., 2022). This assessment method is crucial, particularly in critical care units, since it may immediately detect life-threatening illnesses. Therefore, this assessment is essential for examining Brian’s vital signs.
Another critical assessment that needs to be conducted on Brian is the risk of sepsis. Sepsis is a life-threatening illness that develops when the body’s reaction to infection causes tissue and organ damage. It may cause multiple organ failure, shock, and death. Organ failure is likely to occur if sepsis is not rapidly diagnosed and treated. Despite advancements in modern medicine, such as vaccinations and antibiotics, millions worldwide die annually from sepsis (Australian Sepsis Network, 2021).
Patients with sepsis suffer a greater risk of complications, higher healthcare expenses, and longer treatment duration. Any infection may cause sepsis; therefore, it is essential to be conscious of sepsis signs such as fever, muscle discomfort, and fast breathing, which Brian displayed. These symptoms appear similar to VET and may thus yield a differential diagnosis, making this assessment type relevant.
Process Information
Venous thromboembolism (VTE) is a disorder characterized by the formation of blood clots in a vein. The initiation of venous thrombosis occurs in the valve or venous sinus. Venous thrombosis begins as tiny fibrin aggregates in low-flow regions. The patches of deposits subsequently expand through apposition to obstruct blood vessels and ultimately initiate the coagulation cascades.
Similarly, postoperative or trauma-related endothelial damage might also precipitate this fibrin nidus. Antithrombotic proteins like thrombomodulin are sensitive to hypoxic environments and inflammation and are locally expressed on the valves. Stasis at the valve sinus has been associated with hypoxia and elevated hematocrit, which creates a hypercoagulable microenvironment. These circumstances, particularly acute inflammation, result in the thrombomodulin proteins’ downregulation, promoting thrombus formation.
Hypoxia may also cause the overexpression of procoagulants like P-selectin (an adhesion agent) and tissue factor on endothelium, which results in the influx of monocyte-derived leukocyte microparticles carrying tissue factors. The tissue factor is regarded as the starter of coagulation, and P-selectin is a crucial aspect of thrombosis. Fibrin accumulation activates clotting factors in the absence of adequate blood flow; blood coagulation inhibitors are depleted in the absence of an input of new inhibitors.
When left untreated, VET can lead to life-threatening complications. Chronic thromboembolic pulmonary hypertension (CTEPH) is a pre-capillary pulmonary hypertension that develops following pulmonary obstruction with a clot and organized fibrous tissue in conjunction with pulmonary arteriopathy. Chronic thromboembolic pulmonary hypertension prevalence after acute pulmonary embolism is 3.4% (Tran et al., 2019).
Untreated CTEPH is associated with a poor prognosis, with a 5-year mortality rate of 30% (Tran et al., 2019). Medical therapy aimed at vasodilating the pulmonary vasculature and endarterectomy is used to treat CTEPH. In addition, one in three VET patients develops post-thrombotic syndrome (PTS) (Tran et al., 2019). Symptoms include swelling, pain, lipodermatosclerosis in a limb with a history of VET, and hyperpigmentation.
Using an accepted evidence-based approach, a patient who may be at risk for VTE is promptly assessed for risk to decide if they need VTE prevention. The outcome is recorded during evaluation in a simple location for all clinicians engaged in the patient’s treatment to access. Hospitalizations for patients with obesity (BMI more than 30 kg/m2), concurrent medications, and other comorbidities increase their chance of getting VTE (ACSQHC, 2020). The risk of VTE for surgical patients also varies depending on the operation done. Surgery of any kind increases the risk of VTE, but knee and hip replacement surgery and hip fracture surgery have the highest risks.
A patient at increased risk for VTE gets individualized information and education on VTE and how to avoid it, as well as participation in developing their VTE prevention strategy. The healthcare staff must educate and inform the client about blood clots and clarify why they may be in danger (ACSQHC, 2020). Information on prospective blood clot prevention methods will be customized to the patient’s risk factors and delivered so they can comprehend that they may participate in care choices and preventive activities.
Nursing Action
Following the patient’s recovery deterioration, nurses must respond swiftly and competently while reporting their findings to the doctor. Verbal and written communication is crucial when conveying to the orthopedic surgeon the clinical findings of Brian’s worsening health. Verbal communication is related to the spoken word and is crucial in healthcare. When reporting, it is essential always to strive to express oneself accurately. This ensures that the most pressing concerns of the patient are taken into account. On the other hand, written communication is as crucial as verbal communication.
When reporting the findings to the orthopedic surgeon, the appropriate instrument for prompt communication based on the situation’s urgency is the SBAR toolkit. The situation, background, assessment, and recommendation (SBAR) approach is a strategy that may be included in a professional healthcare program to strengthen nurses’ capacity to present information logically and succinctly (Brust-Sisti et al., 2019).
The first section, the introduction, consists of a short explanation of oneself to the doctor, designation, and roles. This is followed by the situation, which comprises conveying the most crucial data about the patient’s condition to the doctor. Following the assessment, Brian’s most significant concern was cramping on the left leg, which looked red on observation and warm on touch. These are the crucial findings that must be presented to the doctor.
Following the situation is the background information, which contains details that may have contributed to the patient’s health decline. In this situation, the calf swelling and cramps might have been caused by the ‘moon boot.’ In the assessment part, the suspected concern is reported; in Brian’s case, the risk of VET is the main concern. Lastly, the recommendation involves the probable steps taken to remedy the problem. Following the removal of Brian’s “moon boot,” consideration should be given to anticoagulant medication.
Effective clinical communication, cooperation, and teamwork are essential for guaranteeing the safety of practices in contexts as complicated and dynamic as health care. The Australian Commission on Safety and Quality in Health Care is crucial in promoting and sustaining cooperation, teamwork, and effective clinical communication within the Australian health care system. Understanding the data through which new data and experiences are organized and recorded is a crucial communication skill (ACSQHC, 2020). This involves knowing the aim and significance of healthcare communication and the many facets of successful communication in healthcare.
Conclusion
Venous thromboembolism continues to be a significant health problem with considerable socioeconomic consequences. Due to trauma-related comorbidities, trauma patients are more likely to develop venous thrombosis early in their hospitalization. Often marked by thromboembolism and pulmonary embolism, vascular disease continues to be a leading cause of death and morbidity.
The case study examines the important assessment types performed on a patient (Brian) suspected of having VTE. The skin on Brian’s left calf looked red and warm, and he complained that it felt like he had a constant cramp in it. This subjective and objective data draws a close picture of the clinical manifestations of VET.
References
Australian Commission on Safety and Quality Health Care. (2020). Venous Thromboembolism Prevention Clinical Care Standard. Web.
Australian Commission on Safety and Quality in Health Care. (2020). Communicating for Safety: Improving clinical communication, collaboration and teamwork in Australian health services. Web.
Australian Sepsis Network. (2021). Healthdirect Australia. Web.
Brust-Sisti, L. A., Sturgill, M., & Volino, L. R. (2019). Situation, background, assessment, recommendation (SBAR) technique education enhances pharmacy student communication ability and confidence. Currents in Pharmacy Teaching and Learning, 11(4), 409–416. Web.
Chambers, S., Spooner, A., Parker, C., Jack, L., Schnitker, L., Beattie, E., Yates, P., & MacAndrew, M. (2022). Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review. Journal of Nursing Scholarship. Web.
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Tran, H. A., Gibbs, H., Merriman, E., Curnow, J. L., Young, L., Bennett, A., Wee, T. C., Chunilal, S. D., Ward, C. M., Baker, R., & Nandurkar, H. (2019). New guidelines from the thrombosis and haemostasis society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Medical Journal of Australia, 210(5), 227–235. Web.