Preparing for DischargePain Management and Anticoagulation Therapy

Justina Lehman- Lane, FNP, DNP

Pain Management

The major goal in the management of pain is minimizing the dose of medication to lessen the side effects while still providing adequate pain relief.

Effective Pain Management

• Early ambulation• Decrease risk for complications • Sleep• Improved Mood

Ineffective Pain Management

• Impairs sleeping • Ability to perform deep respirations and

coughing • Ambulation• Mood • Performing general activities

Alternative Pain Management Interventions

• Music Therapy• Massage Therapy • Guided Imagery and Relaxation Techniques • Ice Therapy

Pain Management: What patients need to know

• Reviewing the prescribed medication• Dosing their pain medication• Uncontrolled pain • Pain medication and constipation • Pain medication and rehabilitation

Anti-coagulation Therapy

• Lovenox • Coumadin• Aspirin combined with mechanical devices

Anti-coagulation Patient Education• Encourage moderation and consistency in eating foods high in Vitamin K.

Limit intake of herbs than interfere with warfarin, such as Vitamin C, green tea, cranberry juice, garlic, ginger, ginseng, and goldenseal (Crowther & McCourt, 2005).

• Be moderate in consuming alcohol. Large amounts add to Coumadin’s anticoagulant effect (Lippincott, Williams, and Wilkens, 2012).

• Contact their medical provider prior to any invasive dental or surgical procedure.

• Exercise extreme caution to avoid bruising and injuries that may cause bleeding.

• Keep routine laboratory appointments related to Coumadin management. • Avoid concurrent use with aspirin or NSAIDs as they increase the risk for

bleeding.

Complications

• Deep Vein Thrombosis (DVT)• Pulmonary Embolus (PE)

DVT

• The formation of a blood clot (thrombus) inside a deep vein. Most commonly seen in the thigh or calf.

• Usually caused by sluggish or disturbed blood flow, secondary to a recent surgery or restricted mobility.

• If left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung (PE).

Statistics

• DVT is one of the most prevalent medical problems today, with an annual incidence of 80 cases per 100,000 patients (Patel & Brenner, 2011). Each year in the U.S., more than 200,000 people develop a DVT; of those 50,000 cases are complicate by a PE (Patel & Brenner, 2011).

Clinical Presentation• DVTs are often asymptomatic, and thus

often challenging to recognize. When a DVT does produce symptoms, the following are signs and symptoms that may be present:– Redness, warmth, and swelling in the

affected extremity.– Unilateral pitting edema with collateral

venous engorgement, localized warmth and erythema.

– Dilated superficial veins in the affected extremity.

– Pain, tenderness, or a dull ache, particularly in the calf of the affected extremity.

(Matharu & Porter, 2010)

Image provided courtesy of Wikimedia Commons and made available under the Free Documentation License, Retrieved October 1st, 2012 from http://en.wikipedia.org/wiki/File:DVT2012.JPG

Strategizing Risk

Low level: A 10% risk for DVT-Minor surgery in patients younger than 40 years of

age, immobilization lasting less than 30 minutes.Moderate level: A 30% risk for DVT

-Minor surgery for patients aged 40-60 years and major surgery in patients younger than 40 years of age. High level: A 60% risk for DVT

- Minor surgery in patients older than 60 years of age or major surgery in patients older than 40 years of age. This category includes patients who have multiple risk factors, such as THA, TKA, or major orthopedic trauma, especially a spinal cord injury. (National Clearinghouse, 2006)

Diagnosis & Management of DVT

• Diagnosis -Diagnostic Imaging- ultrasound

• Pharmacological Management-Anticoagulants -Thrombolytics

PE

• PE’s are a life-threatening complication caused by emboli obstructing pulmonary arteries and thereby increasing the workload of the heart. The heart may be unable to maintain sufficient circulation to support blood pressure, resulting in hypovolemic shock.

• Over 90% of PE’s are caused by a DVT, usually in the legs (Goldsmith, 2006).

Signs and Symptoms of a PE• Dyspnea• Tachypnea• Tachycardia• Chest Pain• Anxiety• Cough• Hemoptysis• Fever • Arrhythmias• Hypertension• Syncope • Diaphoresis

Image provided courtesy of Wikimedia Commons and made available under the Free Documentation License, Retrieved October 1st, 2012 from http://en.wikipedia.org/wiki/File:DVT2012.JPG

Diagnosis and Management of a PE

Diagnosis- Diagnostic Imaging- Blood Test

Pharmacological Management-Anticoagulants -Thrombolytics

Questions ?

CONFLICT OF INTEREST

I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.