Risk Factors for Deep Vein Thrombosis (DTV) and Venous Thromboembolism (VTE)

I've written about blood clots before on my blog, see DVT, blood clot, deep vein thrombosis.  I wanted to touch on this subject again because I came across a flyer from a class I once attended which introduced nurses to an excellent tool aimed at reducing the incidence of DVT by recognizing the individuals at greatest risk.  Patients need to know about this, too, so they can be vigilent and take precautions when they are at risk.

Apparently this educational endeavor is defunct because I cannot find a word about it in my Google searching.  "SCORE IT" DVT Patient Profiler for Selected Patients at Risk was presented by CARE FORCE (Clot Assessment & Risk Reduction Through Education).  The acronym SCORE IT cues the nurse to remember what patient types are at greater risk.  The more catagories that apply to a specific patient, the greater the risk and the need for higher levels of DVT prevention protocols in the hospital to be implemented in order to prevent a blood clot from developing.

I found this program compelling and want to record the information here for reference:

S . . . Surgery Patients.

• General Anesthesia is a risk factor for postsurgical DVT development.
• All surgeries are associated with risk of DVT/General and orthopedic surgeries are associated with a higher risk of developing DVT and PE (pulmonary embolus) than other types of surgery.
• Total knee or hip replacement and hip fracture orthopedic procedures are associated with the highest postsurgical (within 1 to 2 weeks) risk of DV--over 50%.

C . . . Cancer Patients and Cardiovascular Patients

• Cancer Patients
• Chemotherapy, radiotherapy, central venous catheters, and surgery contribute to the increased risk of VTE (venous thromboembolism) in patients with cancer.
• Tamoxifen or hormone replacement therapy are risk factors for DVT
• Tumors may also cause obstruction which can contribute to venous stasis.
• Cardiovascular Patients
• Acute myocardial infarction (AMI), ischemic and non-ischemic cardiomyopahy, congestive heart failure (CHF) secondary to valvular disease, and chronic idiopathic dilated cardiomyopathy may increase the risk.

O . . . Obese Patients 

• Modifiable Risk Factor
• Weight loss may decrease risk

R . . . Respiratory Failure Patients

• Acute exacerbation of chronic obstructive pulmonary disease (COPD), adult respiratory distress syndrome, moderate to severe community-acquired or nosocomial pneumonia, lung cancer, interstitial lung disease, or pulmonary hypertension are associated with increased risk.

E . . . Elderly Patients

• Bed rest, frailty, and immobility features often associated with advanced age, predispose patients to venous stasis.
• Advancing age (older than 40 years) is a risk factor for VTE.
• As the population ages, the number of cases of VTE is expected to increase.

I . . . Infection/Inflammatory Disorder/Immobile/ICU Patients

• Infection Patients
• Disseminated infections, sepsis, and serious systemic infections, including urinary tract (UTI), complicated skin and skin structure, pneumonia, and abdominal infections may lead to increased risk of DVT.
• Inflammatory Disorder Patients
• Disorders such as systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) are associated with an increased risk of IBD.
• Immobile/ICU Patients
• Venous stasis of the lower limbs may predispose a patient to thrombosis formation
• Patients confined to bedrest for fewer than 5 days had a 21% occurrence of VTE compared to a 36% occurrence in patients on bedrest for over 10 days.  [There is no source citation given for these statistics on the flyer.]
• Incidence of DVT in stroke patients with a paralyzed lower limb exceeds 50%. [No source cited.]
• Increased risk in ICU patients with medical disorders.

T . . . Trauma/Thrombophila/Thromboembolism History Patients

• Trauma Patients
• Patients with major trauma who do not receive thromboprophylaxis have a 50% risk of DVT. [No source is cited for this statistic.]
• Multiple injuries and lower extremity or pelvic fractures are associated with a higher risk of VTE.
• Thrombophilia/Thromboembolism History Patients
• Prior history of DVT/PE confers risk of a future event.
• As many as 20% of patients with confirmed thromboembolic disease have a history of DVT or PE.
• Patients with an acquired or genetic predisposition to hypercoagulable states are at risk for VTE. 

If you find yourself among those at highest risk of developing a blood clot and you you are hospitalized, ask your doctor and nurse what precautions they are going to take to prevent you from developing blood clots.  The options for prevention include tight white stockings on the legs (TED hose) that help improve the circulation; "squeezy" wraps to the lower legs that inflate and deflate via an electric pump (many name brands for this type of equipment); injections of blood thinning medication into the skinfolds of your abdomen (Lovenox or Fragmin); or they may simply suggest "early ambulation"--which means you are up and out of bed quickly, in a chair and walking in the hallways.  If they haven't suggested any of these options, insist that they come up with a plan for you.  This is required by the Joint Commision, the authority that accredits hospitals.

Patients--be concerned about pain and swelling in your legs.  Often a blood clot will first appear in the back of one of the lower legs.  This can occur while you are in the hospital or even a few weeks after you get home.  Also be concerned about any sharp pain in the chest, wheezing breath sounds and frequent moist cough; those signs could suggest a small blood clot has gone to the lungs.


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Discharge Instructions: Trans Urethral Resection of the Prostate (English and Spanish version)

*(Looking for other types of discharge instructions in English or Spanish? Click here).

I Hope You Were Given Some Discharge Instructions . . .

Waste not, want not.  I'm reviewing my collection of patient educational materials which includes brochures and flyers that I've picked up over the last 14 years.  This entry is a transcription of an undated, uncopyrighted, no author given, flyer that we used at Providence Memorial Hospital in El Paso, Texas as discharge instructions for our "TURP" patients (Trans Urethral Resection of the Prostate).  El Paso County is roughly 90% Hispanic with Spanish being the primary language so it was essential to have discharge instructions available in both languages.  I've included the Spanish version here and have linked (at bottom) to another blog post I created with LOTS of Spanish discharge instructions. 

Looking at these TURP discharge instructions now, I'm surprised at what BASIC information our patients were given. 

***TURP Patients:  Be sure to look at the information you were provided at discharge to ensure you are following YOUR physician's post-op recommendations.***


Trans Urethral Resection of the Prostate, “Discharge Instructions”

What do I need to remember when I go home?

1. Eat well-balanced meals.
2. Drink at least eight (8) glasses of liquids per day, preferably water.
3. NO heavy lifting.
4. NO heavy straining.
5. Take a mild laxative if you have difficulty with bowel eliminiation.
6. NO strenuous exercise.
7. Keep all follow-up appointments with your physician.
8. Call your physician if you have:

• Fever (101 degrees F or over) and/or chills
• Persistent, heavy bleeding and/or clots
• Inability to urinate
• Severe Pain

Questions that you need to ask your physician:

1. When can I drive a car?
2. When can I go back to work?
3. When can I engage in sexual activity?

What should I do if I have bleeding?

Blood in the urine is a natural product of the healing process. You should drink ample amounts of fluid to “flush out the system” and prevent clots from forming.
If bleeding persists and clots form, call your physician.

Any Other Specific Instructions?


 ______________________________________________________


Reseccion Trans Uretral De La Prostata, “Instrucciones Para Cuidado En Casa” 

¿Que Debo Recordar Al Irme A Casa?

1. Coma comidas bien balanciadas.

2. Tome por lo menos 8 vasos de liquidos al día, preferiblemente agua.

3. NO levante cosas pesadas.

4. NO se esfuerze en exceso.

5. Tome un laxante suave si Ud. tiene estreñimiento.

6. NO haga ejercicio rigueroso.

7. Asista a las citas con su doctor.

8. Llame a su doctor si Ud. Tiente:

• Calentura (101 F o mas) y/o escalofrios
• Sangrado persistente o coagulos
• Inhabilidad de orinar
• Dolor severo

Preguntas Que UD. Debe Hacarle a Su Doctor:

1. Cuando puedo empezar a manejar el coche?

2. Cuando puedo regresar a mi empleo?

3. Cuando puedo resumir actividades sexuales?

¿Que Debo Hacer Si Hay Sangrado?

La sangre en la orina es un producto natural del proceso de sanamiento. Ud. Debe tomar cantidades amplias de liquidos parea “enjuagar el sistema” y prevenir la formación de coagulos.

Si el sangrado persiste y coagulos se forman, llame a su doctor.

¿Otras Instrucciones Especificas?

*Click here: to link to my blog post with many more links to discharge instructions in Spanish *


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Patient Education Brochures and Booklets are Still Essential Despite the Internet: Where to Find Them?

A Small Cost to the Provider, but Invaluable to the Public and the Patient

I mentioned in another blog post that I'm a bag lady when it comes to medical brochures.  I expect to pick up something of interest if I happen to visit a health fair or health-related event.  The vendors are not going to attract my interest by merely displaying a poster or a table-top video display.  I want to pick up something that I can read when I'm ready.  "Readiness to learn," after all, is a basic fundamental in the teaching-learning realm of education.  

While the internet offers vast opportunities to find what we seek in the way of health information, I still have a desire for the traditional illustrated pamphlets that were so long a staple of patient education.  I can attest that even now, in large hospitals that promote themselves as cutting edge, the lack of a patient educational handout means the lack of patient teaching.  Period and end of story.  I have never seen any patient willingly turn the TV to the patient education channel to learn more about their health needs.  A patient sick enough to be bedfast in the hospital is typically not online to search for health-related information.  And many patients can't afford the luxury of a laptop to bring to the hospital--or perhaps they are not internet savvy to begin with. 

There is a real need, in my opinion to preserve the traditional patient education tools. In a pre-op or post-op teaching situation, computer based learning is not conducive to the one-on-one, individualized teaching that needs to take place.  The patient brochures are awesome adjucts to this type of patient education interaction.  Hospitals--start stocking more patient education brochures and making distribution of them a priority--please!! 

Patient Education Publishers of Note

One of my favorite patient education brochures that I've kept is by the Channing Bete publishing company.  Channing Bete has been in this business for decades and now boast a host of patient education products and services.  I've had this booklet so long that I see it's been replaced by an updated version.  The one I have (in two versions, English and Spanish):  "Sooo . . . You're going to have an OPERATION" and "De mondo que . . . le van a OPERAR!"  And the newest versions:  About Having Surgery, About Ambulatory Surgery, and for kids: Same Day Surgery:  A Coloring and Activity Book.  Honestly, these publications are sublime in their simplicity and ability to communicate the need-to-know basics of surgery day to patients and their loved ones.

Krames Education Products and Services is an offshoot of a larger company called Staywell.  My old favorite publication by Krames is called, "Pressure Ulcers, Your Role in Prevention and Treatment" (aimed at nurses.)  Now there is a newer version on their website called,  "Pressure Ulcers Prevention and Treatment." These are great publications for caregivers with wonderfully detailed illustrations and excellent explanations.  Find other worthwhile topics for patient education from their catalog:
Krames Patient Education Print Materials

One thing about physician's offices these days--there are not a lot of actual nurses in these settings.  Nurses are more expensive than medical technicians, so physicians tend to employ more of these unlicensed assistants.  The loss of professional nurses in that setting allows for a gap in patient teaching.  Often in pre-surgery teaching sessions bewildered patients who had already been with their physicians for a previous appointment to determine that surgery was necessary, would admit that they had no real idea what their upcoming surgery entailed.  And for some of the complicated surgeries they didn't know how to spell the procedure correctly in order to search for appropriate information online.  I found that Colen Publishing offers a dozen or so titles to explain surgical procedures (often ones that are in the neurosurgery realm), these titles cover Craniotomy, Laminectomy, Ventricular Shunt, Cervical Fusions and more.  See an example of one of their Tri-Fold Surgery Cards: Anterior Cervical Discectomy and Fusion. I think it would be a great service for a patient anticipating surgery to have one of these nice explanatory tri-folds instead of trying to (alone) search out information online that may or may not pertain to their particular situation and surgery.

Of course the American Cancer Society and National Cancer Institute offer many wonderful publications about cancer, but please don't overlook the three that are available free from the Patient Resource Cancer Guides (3 titles available free to patients & in bulk to hospitals or clinics.) Place your order today:  Patient Resource.Net. 

Some other worthwhile sources of hard-copy patient educational brochures:

• National Institue of Health Publications for Consumers, see also titles in Spanish. 
• American Cancer Society free brochures
• Public Health Foundation Learning Resource Center
• National Cancer Institute, "What you need to know about . . . " (various cancer topics)

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ERCP (Endoscopic Retrograde Cholangiopancreatography)

The Society of Gastroenterology Nurses and Associates (SGNA), Inc. distributed this patient education handout back in the mid-1990's and I have always found it to be very useful.  Certainly there are many easily accessed patient education tools about ERCP via the internet, for example this one this one courtesy of the Jackson/Siegelbaum Gastroenterology Group in Camp Hill, PA is especially nice.

Because my copy of the pre-internet ERCP patient information handout distributed by the SGNA is tattered and of poor quality, I'm transcribing this helpful patient education handout below. It's undated, no author listed and lacks a copyright statement. (Today I inquired with Kathleen O'Brien from SGNA via their online support suite chat feature and received no objection to transcribing this information here for the purposes of my blog readers.)

Patient Education:  ERCP (Endoscopic Retrograde CholangioPancreatography)

After careful medical assessment, your doctor has recommended that ERCP be performed for further evaluation and treatment of your condition.  ERCP is a valuable examination of the diagnosis of many diseases of the pancreas, bile ducts, liver and gallbladder.  ERCP allows the doctor to perform necessary treatments such as enlarging a bile duct opening, removing gallstones lodged in the bile duct, inserting a stent (drain) in the duct or taking a biopsy specimen (tiny bit of tissue).

A flexible fiberoptic tube (duodenoscope) is passed through the mouth, esophagus (food tube) and stomach into the duodenum (first part of the small intestine.)  The ampulla (opening where the bile and pancreatic ducts empty into the duodenum) is then identified.  A small plastic tube (cannula) is passed through the duodenoscope into the ampulla. X-ray dye is injected through the cannula into the ducts.  X-rays are then taken to study the ducts.  Any necessary treatments can be performed at this time.

Dentures and eyeglasses must be removed prior to the start of the procedure.  You may prefer to remove contact lenses at this time.

You will be asked to sign a consent form authorizing the doctor to perform the procedure.

Be sure to tell the doctor and the GI nurse if you are allergic to any medicines, x-ray dyes or iodine products.

A needle for intravenous (IV) medicines and fluids will be placed in your arm vein.  Medicine will be injected through the IV needle that will make you sleepy and relaxed.  Your doctor may also spray your throat or ask you to gargle with a numbing medicine.

You will lie on an x-ray table on your left side and  a small plastic mouthpiece will be placed between your teeth.  You will be able to breathe normally.  The doctor will help you to swallow the lubricated flexible duodenoscope tube.  When the tube is present in the duodenum, you will be helped to turn onto your abdomen with your head turned to the right.

During the procedure you may feel some abdominal fullness or bloating due to the air which the doctor puts into the duodenum.  As the X-ray dye is injected into the ducts, you may feel some mild discomfort.  These feelings should be completely tolerable and not painful.

After the duodenoscope is removed, you may be asked to move into various positions so that more X-rays can be taken.

Many people do not recall any of the procedure because of the effect of the medicine. After the procedure you will probably feel drowsy and may sleep for a short time.  After you have rested, the doctor will discuss the findings with you.

If you have any questions please feel free to ask the doctor, the GI nurse, or the technician.

More ERCP factsheets for patients:

"A+" link:  http://www.gastro.org/wmspage.cfm?parm1=860 from the American Gastroenterologic Association
National Institues of Health Factsheet on ERCP

GI Care Endoscopy Center, ERCP
PDF format with excellent format and info for patient teaching


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