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New Graduate Nurse Program / Acute Care Nursing Program:  Clinical Case Study   Jamie Ranse    16 April 2003 1
Background You are currently employed as a Registered Nurse at the Canberra Hospital. You have completed nine months of th...
Patient Notes <ul><li>ED Report:  Rider of motor bike. Involved in a multiple vehicle accident. Travelling at approximatel...
Medications Morphine Maxalon Keflin Endone 7.5mg 10mg 1g 240mg 10 - 15mg 1g IV/PO SC/IM PO IV IV IV PO q30mins PRN TDS PRN...
Time:  0900 You are attending to your patients antibiotics - he tells you that he has been experiencing cramping and burni...
  Deep Vein The term venous thrombosis, sometimes called  thrombophlebitis,  describes the presence of thrombus within a v...
  Triad Virchows Virchows Triad Blood Flow Endothelium Coagulability 7
  Triad Virchows Endothelium Endothelial Injury Normal Blood Flow Laminar Flow Clear Plasma Zone Site of Injury 8
Blood Flow Virchows   Triad Clear Plasma Zone Laminar Flow 9
  Triad Virchows Abnormal Blood Flow - Turbulance - Venous Stasis Red Blood Cells White Cells and Platelets Blood Flow 10
  Triad Virchows Coagulability 11 Coagulation Cascade:
  Triad Virchows Vitamin K dependent Thrombin Intrinsic Common / Final Extrinsic Pathways Coagulability 11
DVT Diagnosis Clinical History: Significant history. Clinical Hx 12
DVT Diagnosis Clinical History: Doppler ultrasound is a highly sensitive and specific test for deep-vein thrombosis. It co...
Time:  1000 Morning Shift 10 December Your patient has gone to the medical imaging department for a Doppler ultrasound. Ti...
Time:  1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery .  14
  Post Op 13 December 1. ORIF Pelvis 2. Anterior transverse incision along abdomen and repair of bladder Orders: 1. Contin...
Time:  1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery .  - PCA of morphine  [1...
Time:  1000 Morning Shift Your enter your patients room to find him short of breath and holding his chest ……  What are you...
19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2   99%  3LPM  via NP SpO 2   99%  3LPM  via NP SpO 2   96%  R/A SpO 2   9...
19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2   99%  3LPM  via NP SpO 2   99%  3LPM  via NP SpO 2   96%  R/A SpO 2   9...
19/12 20/12 21/12 06 06 06 12 12 18 18 20 20 P SpO 2   99%  3LPM  via NP SpO 2   99%  3LPM  via NP SpO 2   96%  R/A SpO 2 ...
  ECG This ECG shows slight PR depression You attend to a 12 lead ECG:   21 December 21
Blood Results   21 December FiO 2     21 pH   7.46 pCO 2   40 HCO 3 -  27.8 pO 2   24 FBC / UEC / Coagulation: All within ...
  CXR   21 December The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of ...
What are you thinking? 24
Pulmonary Embolus Pulmonary embolism [PE] develops when a bloodborne substance lodges in a branch of the pulmonary artery ...
V/Q Scan: V/Q scans visualise the ventilation and perfusion [gas exchange] within the lungs by using radiopaque gases. per...
Time:  1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. 27
V/Q Scan   Ventilation 28
V/Q Scan   Perfusion 29
Time:  1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. The radiolog...
V/Q Scan: CTPA [ CT Pulmonary Angiogram]: V/Q scans visualise the ventilation and perfusion [gas exchange] in the lungs by...
  CTPA   Diagnosis 32
Morning Shift 21 December Time:  1200 Your patient returns to the ward and the results from Medical Imaging are with him: ...
Treatment is generally targeted at preventing further clot formation and allowing the normal coagulation process to lyse t...
Anticoagulation Therapy:   Anticoagulation Heparin is the primary anticoagulant used. Heparin binds to and activates antit...
Treatment 08/12 N/Saline 500ml var 25,000 IU Heparin Sodium   Anticoagulation 36
Treatment Warfarin Therapy: Warfarin is a compound that competes with vitamin K and depletes vitamin K-dependent clotting ...
Treatment If PEs ocurr despite therapeutic anticoagulation therapy, then an inferior vena cava filter should be considered...
Outcome Due to your increased knowledge and evidence base regarding: - Physiology of DVT and PE, - Diagnostic test for DVT...
References Bonno, N. B., (1999)  Deep Vein Thrombosis (DVT) .  Clinical Reference System .  United States. Dahlback, B., (...
Images Govan, D. T., Macfarlane, P. S., and Callander, R., (1995)  Pathology Illustrated  (4 th  ed.) . Churchill Livingst...
The End
New Graduate Nurse Program / Acute Care Nursing Program:  DVT / PE Clinical Case Study   Jamie Ranse   16 April 2003
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DVT and PE: A case study

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Presentation as a requirement for the Graduate Nurse Program - Canberra Hospital, April 2003

  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    History
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.
    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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DVT and PE: A case study

  1. 1. New Graduate Nurse Program / Acute Care Nursing Program: Clinical Case Study Jamie Ranse 16 April 2003 1
  2. 2. Background You are currently employed as a Registered Nurse at the Canberra Hospital. You have completed nine months of the New Graduate Nurse Program and are currently on a clinical rotation on the Orthopaedic Trauma Ward. You are allocated a group of patients with a high acuity. You take particular interest in one of the patient’s clinical history and current condition. You sit down to read through his notes. 2
  3. 3. Patient Notes <ul><li>ED Report: Rider of motor bike. Involved in a multiple vehicle accident. Travelling at approximately 60 kilometres per hour when a car suddenly stoped in front of him. The pt was thrown from his bike, nil loss of consciousness, and has full recollection of events. After an examination and diagnostic tests the following diagnoses were reported: </li></ul><ul><li>- Pelvic fracture, </li></ul><ul><ul><ul><li>Bladder perforation. </li></ul></ul></ul>Orthopaedic Team: - Admit to ward. - Patient to rest in bed till theatre on 13 December. 08 December 3
  4. 4. Medications Morphine Maxalon Keflin Endone 7.5mg 10mg 1g 240mg 10 - 15mg 1g IV/PO SC/IM PO IV IV IV PO q30mins PRN TDS PRN QID q4-6hrly PRN QID Daily q30mins PRN Ampicillin Gentamicin Paracetamol 1g 08/12 08/12 08/12 08/12 08/12 08/12 08/12 4
  5. 5. Time: 0900 You are attending to your patients antibiotics - he tells you that he has been experiencing cramping and burning sensations in his legs. What are you thinking? Is it muscle spasm? Is it a DVT? Has he had this cramping before? What alleviated it? When did he last have pain relief? Morning Shift 10 December 5
  6. 6. Deep Vein The term venous thrombosis, sometimes called thrombophlebitis, describes the presence of thrombus within a vein and the accompanying inflammatory response in the vessel wall. Thrombi can be superficial or in the deep veins. Deep Vein Thrombosis [DVT] most commonly occur in the lower extremities. DVT is a serious condition, complicated by Pulmonary Embolism. Thrombosis Porth (1998): 355 Definition 6
  7. 7. Triad Virchows Virchows Triad Blood Flow Endothelium Coagulability 7
  8. 8. Triad Virchows Endothelium Endothelial Injury Normal Blood Flow Laminar Flow Clear Plasma Zone Site of Injury 8
  9. 9. Blood Flow Virchows Triad Clear Plasma Zone Laminar Flow 9
  10. 10. Triad Virchows Abnormal Blood Flow - Turbulance - Venous Stasis Red Blood Cells White Cells and Platelets Blood Flow 10
  11. 11. Triad Virchows Coagulability 11 Coagulation Cascade:
  12. 12. Triad Virchows Vitamin K dependent Thrombin Intrinsic Common / Final Extrinsic Pathways Coagulability 11
  13. 13. DVT Diagnosis Clinical History: Significant history. Clinical Hx 12
  14. 14. DVT Diagnosis Clinical History: Doppler ultrasound is a highly sensitive and specific test for deep-vein thrombosis. It combines the ability Doppler Ultrasound: Significant history. to detect changes in venous flow and venous collapse under the ultrasound probe pressure using colour doppler visual display. 12 Ultrasound
  15. 15. Time: 1000 Morning Shift 10 December Your patient has gone to the medical imaging department for a Doppler ultrasound. Time: 1130 Time: 1530 Your patient returns to the ward and the results of the ultrasound are with him: You finish your shift and go home. You are able to sleep during the night knowing that your patient does not have a DVT. You have 2 days off. Ultrasound Results - No Abnormalities Detected 13
  16. 16. Time: 1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery . 14
  17. 17. Post Op 13 December 1. ORIF Pelvis 2. Anterior transverse incision along abdomen and repair of bladder Orders: 1. Continue IV antibiotics 2. Jordan Frame lift or roll to Right side 3. X-ray / FBC / UEC tomorrow 15
  18. 18. Time: 1600 Afternoon Shift 13 December Your patient returns to the ward after 5 hours of surgery . - PCA of morphine [1mg/1ml, 1.5mg bolus, 5 minute lock- out] - IVT [over 6/24] - 4 exu-drains He has the following attached: 16
  19. 19. Time: 1000 Morning Shift Your enter your patients room to find him short of breath and holding his chest …… What are you immediate actions? 12 lead ECG Give O 2 Calm and reassure the patient Set of General Observation: - Pulse, Respirations, BP, Oxygen Saturation Notify the RMO ?Call a MET Get some assistance Blood work-up Mobile CXR Cardio-pulmonary assessment 21 December 17
  20. 20. 19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A 06
  21. 21. 19/12 20/12 21/12 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 83% R/A 10 06
  22. 22. 19/12 20/12 21/12 06 06 06 12 12 18 18 20 20 P SpO 2 99% 3LPM via NP SpO 2 99% 3LPM via NP SpO 2 96% R/A SpO 2 97% R/A SpO 2 98% R/A SpO 2 98% R/A SpO 2 98% R/A 10 SpO 2 83% R/A 10 SpO 2 95% 15LPM via NRB
  23. 23. ECG This ECG shows slight PR depression You attend to a 12 lead ECG: 21 December 21
  24. 24. Blood Results 21 December FiO 2 21 pH 7.46 pCO 2 40 HCO 3 - 27.8 pO 2 24 FBC / UEC / Coagulation: All within normal limits ABG: The ABG shows a slight Metabolic Alkalosis with inadequate Oxygenation    22
  25. 25. CXR 21 December The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of clot in those arteries 23
  26. 26. What are you thinking? 24
  27. 27. Pulmonary Embolus Pulmonary embolism [PE] develops when a bloodborne substance lodges in a branch of the pulmonary artery and obstructs blood flow. Almost all PEs result from deep vein thrombosis in the lower extremities. Porth (1998): 550 Definition 25
  28. 28. V/Q Scan: V/Q scans visualise the ventilation and perfusion [gas exchange] within the lungs by using radiopaque gases. perfusion without ventilation = shunt normal ventilation and perfusion venous blood arterial blood airway alveolus ventilation without perfusion = dead space Diagnosis Embolus Pulmonary 26
  29. 29. Time: 1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. 27
  30. 30. V/Q Scan Ventilation 28
  31. 31. V/Q Scan Perfusion 29
  32. 32. Time: 1030 Morning Shift 21 December Your patient has gone to the medical imaging department for a V/Q scan. The radiologist is unhappy with the results and suggests an additional diagnostic test. 30
  33. 33. V/Q Scan: CTPA [ CT Pulmonary Angiogram]: V/Q scans visualise the ventilation and perfusion [gas exchange] in the lungs by using radiopaque gases. The pulmonary angiogram is the &quot;gold standard&quot; test for diagnosing pulmonary embolism. A contrast is used for the diagnosis. The aim of the CTPA is to look for cut-offs in the vascular tree. Embolus Pulmonary Diagnosis 31
  34. 34. CTPA Diagnosis 32
  35. 35. Morning Shift 21 December Time: 1200 Your patient returns to the ward and the results from Medical Imaging are with him: V/Q Scan - Decreased ventilation and perfusion in right lung CTPA - Large PE in right main pulmonary artery Time: 1030 Your patient has gone to the medical imaging department for a V/Q scan. 33
  36. 36. Treatment is generally targeted at preventing further clot formation and allowing the normal coagulation process to lyse the clot. Under certain clinical situations, it may be appropriate to accelerate clot lysis by using fibrinolytic agents. Treatment Pulmonary Embolus 34
  37. 37. Anticoagulation Therapy: Anticoagulation Heparin is the primary anticoagulant used. Heparin binds to and activates antithrombin III and deactivates thrombin to inhibit further clot formation. Heparin works here, it keeps platelets from aggregating on an embolus. Treatment 35 The usual treatment dose for Heparin is a loading dose of 5,000 units followed by an infusion of approximately 1,000 units per hour.
  38. 38. Treatment 08/12 N/Saline 500ml var 25,000 IU Heparin Sodium Anticoagulation 36
  39. 39. Treatment Warfarin Therapy: Warfarin is a compound that competes with vitamin K and depletes vitamin K-dependent clotting factors. Warfarin therapy can begin on day one of heparin therapy and is monitored using the International Normalised Ratio (INR). An INR of 2.0 - 3.0 is considered therapeutic. Warfarin Warfarin works here by inhibiting Vitamin K. 37
  40. 40. Treatment If PEs ocurr despite therapeutic anticoagulation therapy, then an inferior vena cava filter should be considered. Filter 38
  41. 41. Outcome Due to your increased knowledge and evidence base regarding: - Physiology of DVT and PE, - Diagnostic test for DVT and PE - Treatment options for DVT and PE Your patient receives the most appropriate management and is on the way to a full recovery. 39
  42. 42. References Bonno, N. B., (1999) Deep Vein Thrombosis (DVT) . Clinical Reference System . United States. Dahlback, B., (2000) Blood Coagulation . The Lancet 9215(355), 1627-1632. Marieb, E. N., (1998) Human Anatomy and Physiology (4 th ed.) . Benjamin Cummings Science Publishing. California. Milto, L. D., (1999) Deep Vein Thrombosis . Gale Encyclopaedia of Medicine (1 st ed.) . United States. Proctor M. C. and, Greenfield L. J., (1997) Justifying inferior vena caval filter placement . Internal Medicine, May:85-89 Porth, C. M. (1998) Pathophysiology: Concepts of Altered Heath States (5 th ed.). Lippincott.
  43. 43. Images Govan, D. T., Macfarlane, P. S., and Callander, R., (1995) Pathology Illustrated (4 th ed.) . Churchill Livingston. New York. [Abnormal Blood Flow, and Endothelial Injury] Grrenfield Vena Cava Filter http://www.greenfieldfilter.com/ [Filter] Porth, C. M. (1998) Pathophysiology: Concepts of Altered Heath States (5 th ed.). Lippincott. [V/Q Scan, Normal Blood Flow] Miller, I. (2003) ImpactED Nurse. http://www.impactednurse.com [Background] The Canberra Hospital - Emergency Department Education http://www.canberrahospital.act.gov.au/ [ECG - PR Depression] The Canberra Hospital - Intranet http://tchi/ [Header] Virtual Hospital: The diagnosis of Pulmonary Embolus http://www.vh.org/adult/provider/radiology/electricpe/electricpe.html [Dolplar Ultrasound, Ventilation Scan, Perfusion Scan, Pulmonary Angiogram]
  44. 44. The End
  45. 45. New Graduate Nurse Program / Acute Care Nursing Program: DVT / PE Clinical Case Study Jamie Ranse 16 April 2003

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