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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How to Take Care of Your JP Drain at Home (Jackson-Pratt Surgical Drain)

It's not unusual to be sent home from the hospital after surgery with a surgical drain still in place. Typically a nurse will have taught you (or your loved one, if you’re squeamish) how to take care of  the drain at home and they probably gave you some paperwork with instructions.  Sometimes, however, such teaching is given after surgery when the patient is groggy or in pain and family members are tired and ready to just get on the road towards home.  The instructions may get lost in the shuffle of paperwork you were handed at discharge.  For this reason I wanted to make a blog entry that includes some basic information about the JP drain and includes links to patient education sheets from reputable physicians and hospitals.

About the Jackson-Pratt (JP) Drain . . .

The JP drain is a soft, pliable bulb drain that is either tunneled directly into a surgical incision, or more often into another smaller "stab" incision right next to the main incision. The purpose of the JP drain is to allow the large surgical incision to heal well by draining blood and thin serous material that can build up behind fresh incisions.


The bulb part of the JP drain is connected to the surgical incision by means of a long plastic tube that’s sutured in place on the skin where it enters the body. When the bulb is compressed (squeezed together), it provides constant suction that draws any accumulating fluids such as blood, pus, or other thin drainage from the incision, through the tube and into the bulb. On a regular basis (at least once a day), the fluid that is collected in the bulb is emptied by opening the small plug in the top and squeezing the fluid into a measuring cup.  While the empty drain is still unplugged, the drain is squeezed together to remove as much air as possible so it is mostly “flattened.”  Then the plug is recapped. The flattened bulb gently expands as it again slowly suctions fluid from the incision.


Keep Track of the Amount of Fluid . . .


The amount of fluid, date and time, and any ususual details about the fluid (color, thickness, clots, smell) is written on a paper for the doctor to review at your appointment, then the drainage is emptied into the toilet and flushed away.  Keeping track of the amount of fluid emptied from the bulb is important. This information allows the physician to know if the wound is healing according to schedule . . . or if there are complications that require further attention such as an unusual amount of blood coming from the wound, a foul smell to the discharge, or an unusually large volume of fluid. When the drainage falls to a certain level, usually a few days after surgery, the drain is easily removed by a physician or nurse at the doctor's office.


I’m by no means an artist, but I’m including a couple of my own sketches here. The websites (at bottom) often include great drawings or photos of the drains and their care, but of course they have  copyrights to their art and photos so I’ll give you just a basic idea.


Parts of the JP Drain

Drain reservoir bulb—about the size and shape of a large lemon or (in my mind) a hand-grenade. Made of soft flexible semi-transparent silicone with an attached drainage tube that is sutured into a slit on the body near the surgical incision. In order to collect drainage from the tubing, the bulb plug must be opened, air is squeezed out until the bulb appears mostly flat. While still squeezing the bulb flat, the plug is replaced. As the bulb fills with fluid, it may expand. The bulb is emptied at least daily or when full and the drainage is measured and recorded and reported to the physician.


Drain aperture—the hole with a plug, this is where you empty the drainage that is collected. It reminds me of a beach-ball plug and works exactly the same way.


Drain tubing—hollow tubing made of a soft semi-transparent silicone. It’s connected to the drain reservoir bulb. Sometimes the tubing may accumulate drainage that becomes a clot which blocks the drainage.  This can be cleared by a gentle pinching motion of the tubing just above the clot, away from the body and towards the bulb, it is usually recommended to “milk” the tubing in this way when needed to keep it draining freely.


Surgeries that result in a drain . . .

. . . includes just about any that may result in a large incision, for example, breast surgery, thyroid operations, weight loss surgery, abdominal surgeries, and operations on the kidneys or bladder.  There are other types of surgical drains as well, but the JP is one of the most common.


Keep the JP Drain from Pulling on the Incision


To keep the weight of the drain from pulling on the incision, a flap of tape is applied near the bulb. A safety pin is pinned through this tape flap and then pinned to the patients clothing in such a way as to take up the slack of the tubing. (If you have more than one drain, they will each be numbered for easy reference on the tape flap.)  Be careful not to poke a hole through the tubing of your drain!


I don't seek advertising or any funding for my blogging, but I do point out commercial products that may be helpful to my readers.  Here are two products that I came across created by patients in order to more comfortably manage their JP drains post-operatively.

• Surgishorts is a unisex garment that has pockets specifically for the JP bulbs:  http://www.surgishorts.com/. 
• The drain pouch management gown is a unique hospital gown created with the post-op breast surgery patient in mind: Sage Solutions Drain Pouch Gown. 

Links to Reputable Websites with Instructions on JP Drain Care (including log sheets to record drainage).  Most of these include log sheets you can copy to record your drain output . . . or you can just write it on a piece of notebook paper--that would be just fine, too, as long as you include the date/time/amount (and drain number if you have more than one.)

• National Institute of Health Patient Education: JP Drain (English) and  in Spanish  
• Breast Reconstructive Surgery.
• UCS Breast Center: JP Drains
• Jackson-Pratt Drain Care
• Health AtoZ: JP Drain pdf
• Carolina Breast Cancer Information
• Dr. Holmes MD Patient Resources
• Cheboygan Surgical
• UCS Drain Record Sheet

Youtube Videos

 

Youtube doesn't have many videos about care of the JP drain.  I'm surprised.  I did find two amateur videos posted there by breast cancer patients who are demonstrating emptying their JP drains at home.  These brave ladies are doing a service by posting their experiences to help others.  I applaud their willingness to do so and want to include links to their videos here.  These are not professional videos, but they give you a glimpse of other people at home with their JP drains in real life:

• An amateur video in which Deborah demonstrates emptying and measuring the contents of her four surgical drains.  Note: Deborah is wearing a brassiere, but does have some skin of her upper torso (not breasts) exposed. I know my blog readers come from all walks of life, so if exposed female flesh is offensive to you, this is not a video for you.  I think it is interesting to see how the output of each of Deborah's drains varies slightly in amount, color, and consistency.
• Sylvia Soo demonstrates emptying of her two JP drains.  This amateur video starts out SLOW and very playful, but if you hang in there for a few seconds, Sylvia comes on camera to show how she cares for her two drains. She does a good job of demonstrating “milking” the drain to remove clots and measuring the drain “output.” Sylvia is completely covered by clothing in this video, so not to worry if bare skin offends you.   

. . . ..(All rights reserved, Carolyn Cooper, MPH, RN, 2009) . .

Blenderized Diet . . . Fractured Jaw Diet . . . No Chewing Allowed

(See below at bottom fourth of the article, I have a number of links to reliable websites for those needing to temporarily follow a blenderized diet.)

For some reason a former patient popped into my mind a while ago. I was working at the pre-op clinic when this slender young teen was about to commence her summer vacation by undergoing corrective jaw surgery that would require her to follow a blenderized, or fractured jaw, diet for at least 4 weeks.

Her mother was concerned about keeping weight on the young lady's size-zero frame during the recovery phase. The purpose of our pre-op teaching and health-history-gathering was to deal with specific issues and concerns such as these. The dietitian was unable to join our meeting, but we did put in a consult for her expert advice for the period in which the patient was to be in the hospital. However, advance planning was also in order.

Our hospital's hand-out on blenderized diets was woefully disappointing to the mother. This many-times-over photocopied, one-page handout was meant to help a patient determine how they would take oral sustenance for 6 weeks . . . The mom was right, our information sheet lacked so much that it was embarrassing. The good news is, better resources are available online.

Fractured Jaw or Jaw Surgery

We rest a broken jaw in order for the bones to knit, just as we rest a fractured arm or leg. Stressing the healing bones with chewing is painful and interferes with healing. Often during the recovery phase, the jaw is wired closed for a period of weeks. Some hospitals are better than others at providing good information about the importance of continuing oral care as well as providing specific suggestions for promoting optimal nutrition when a liquid diet is required during convalescence.

Advanced preparation--more than purchasing a blender

Before I was a nurse, my husband had jaw surgery. Advance preparation for the procedure included purchasing a blender. We were given a very simple handout from the surgeon's office with a few suggestions. There was no Internet to go to for advice, so my husband's blenderized diet was boring, repetitive and did not provide him with the level of calories and protein he needed. He lost a LOT of weight during the recovery phase--and he didn't have any extra weight to spare . . .

What am I going to feed [my kid, myself, my spouse, etc.] on a blenderized diet?

I want to begin by stressing the absolute necessity of consulting with a dietitian at the hospital if you or your loved one has special, underlying nutritional issues such as the need to also follow other diet restrictions including gluten-free, diabetic, vegetarian, bariatric,  etc.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) addresses post-operative nutritional concerns on their website. They specifically caution about the importance of taking in adequate amounts of free water and calories. The AAOMS recommends keeping a journal to record fluid volumes taken in and calories consumed to ensure these needs are being properly met. They also suggest planning blenderized meals in advance. It's hard to "wing it" unless you have all sorts of options available in your kitchen to make the blenderized meal appealing.

When restricted to a blenderized died, it's important to understand that liquids are digested more quickly than solids. In order to maintain energy and keep up with the body's metabolism during recuperation, blenderized meals should be given more frequently than a standard diet. (It may be necessary to take a blenderized meal from 4 to 6 times daily). Protein shakes are recommended for all blenderized diets. (I have some links to follow below for specific recipes.)

For the lactose intolerant, the milk-based tendency for blenderized diets may seem a bit disconcerting at first glance, but there are lactose-free options in the form of soy milk, and nutritional supplements such as Ensure, Boost, or Osmolite.

Web pages with blenderized diet information

I recommend looking at every one of these. They all offer good advice, but you will find some great suggestions that are unique to each specific site.

1. Dartmough-Hitchcock Medical Center fractured jaw diet
2. Dartmough-Hitchcock Medical Center blenderized diet information
3. Aspirus-Wausau Hospital Diet for Jaw Surgery (Blenderized Diet)
4. Ohio State University Medical Center Blenderized Diet for Jaw Wiring
5. Kaiser-Permanente, "No Chewing Required," Blenderized Diet

Interesting products

I have no commercial interest in any medical products and don't receive or seek any income or favors from anything I've written on my blog. In looking for my fractured-jaw, blenderized diet information, I learned about commercial products that assist the wired-jaw patient take nutrition without sucking through a straw.  Actually the products do have straws, but the liquid-filled bag or bottle is squeezed with the hand to force the contents up through the straw and into the mouth.  These products can be used to clean and rinse the mouth as well as to easily take in fluids. This product looks like it would be very useful, particularly in the first few post-operative days.  Check out a variety of nutrition squeeze pouches and squeeze bottles at Craino Rehab.com (their NutriSqueeze bottles look good) and Dinner Through a Straw.net. 

Do you have suggestions?

Please let me know of other good tips and sources of information for people on blenderized diets. I'll be happy to post your suggestions or links here. I'd particularly like to know about blenderized diet recommendations and resources for individuals on special diets like gluten-free and diabetic diets.
Please click on the comments section to read Shirley Taylor's comments and suggestion. Thank you, Shirley!


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