Increase Anticoagulant Effects	Decrease Anticoagulant Effects
• Alcohol (may increase or decrease) • Anabolic steroids (e.g., testosterone [Delatestryl] • Analgesics: (e.g., salicylates [e.g., aspirin], acetaminophen [Tylenol]), nonsteroidal antiinflammatory drugs [e.g., ibuprofen]) • Antibiotics (azithromycin [Zithromax], cephalosporins, ciprofloxacin [Cipro], erythromycin [Romycin], penicillins, sulfonamides, tetracycline [Sumycin]) • Antiseizure drugs (e.g., phenytoin [Dilantin]) • Antidysrhythmics (e.g., amiodarone [Cordarone], diltiazem [Cardizem], propranolol [Inderal]) • Chemotherapy agents (e.g., fluorouracil [Adrucil], gemcitabine [Gemzar], paclitaxel [Taxol]) • chloral hydrate (Somnote) • cimetidine (Tagamet) • disulfiram (Antabuse) • Diuretics (e.g., metolazone [Zaroxolyn]) • entacapone (Comtan) • Fish oil (omega-3 fatty acids) • Foods: grapefruit, mango • isoniazid (INH) • levothyroxine (Synthroid) • Lipid lowering agents: fenofibrate (Antara), fluvastatin (Lescol), gemfibrozil (Lopid), simvastatin (Zocor) • omeprazole (Prilosec) • Oral hypoglycemic agents (e.g., acarbose [Precose]) • orlistat (Alli) • ropinirole (Requip) • sulfinpyrazone (Anturane) • tamoxifen (Nolvadex) • Thrombolytics (e.g., alteplase [Activase]) • tolterodine (Detrol) • trastuzumab (Herceptin) • Vitamins: D and E • zileuton (Zyflo)	• Antiseizure drugs (e.g., barbiturates, carbamazepine [Tegretol]) • Antifungals (e.g., itraconazole [Sporanox], griseofulvin [Gris-PEG]) • bosentan (Tracleer) • cholestyramine (Questran) • Coenzyme Q10 • dicloxacillin • Estrogens (e.g., estradiol [Alora]) • Foods: avocado, green leafy vegetables, soy milk, sushi with seaweed • Influenza vaccine • Immunosuppressants (e.g., azathioprine [Imuran], cyclosporine [Gengraf], mercaptopurine [Purinethol]) • mesalamine (Asacol) • Minerals: iron, magnesium, zinc • raloxifene (Evista) • rifampin (Rifadin) • ritonavir (Norvir) • Sedatives (e.g., chlordiazepoxide [Librium], ethchlorvynol [Placidyl]) • sucralfate (Carafate) • sulfasalazine (Azulfidine) • telmisartan (Micardis) • ubidecarenone • Vitamins: multivitamin, C, and K

Increase Anticoagulant Effects

Decrease Anticoagulant Effects

• Alcohol (may increase or decrease)

• Anabolic steroids (e.g., testosterone [Delatestryl]

• Analgesics: (e.g., salicylates [e.g., aspirin], acetaminophen [Tylenol]), nonsteroidal antiinflammatory drugs [e.g., ibuprofen])

• Antibiotics (azithromycin [Zithromax], cephalosporins, ciprofloxacin [Cipro], erythromycin [Romycin], penicillins, sulfonamides, tetracycline [Sumycin])

• Antiseizure drugs (e.g., phenytoin [Dilantin])

• Antidysrhythmics (e.g., amiodarone [Cordarone], diltiazem [Cardizem], propranolol [Inderal])

• Chemotherapy agents (e.g., fluorouracil [Adrucil], gemcitabine [Gemzar], paclitaxel [Taxol])

• chloral hydrate (Somnote)

• cimetidine (Tagamet)

• disulfiram (Antabuse)

• Diuretics (e.g., metolazone [Zaroxolyn])

• entacapone (Comtan)

• Fish oil (omega-3 fatty acids)

• Foods: grapefruit, mango

• isoniazid (INH)

• levothyroxine (Synthroid)

• Lipid lowering agents: fenofibrate (Antara), fluvastatin (Lescol), gemfibrozil (Lopid), simvastatin (Zocor)

• omeprazole (Prilosec)

• Oral hypoglycemic agents (e.g., acarbose [Precose])

• orlistat (Alli)

• ropinirole (Requip)

• sulfinpyrazone (Anturane)

• tamoxifen (Nolvadex)

• Thrombolytics (e.g., alteplase [Activase])

• tolterodine (Detrol)

• trastuzumab (Herceptin)

• Vitamins: D and E

• zileuton (Zyflo)

• Antiseizure drugs (e.g., barbiturates, carbamazepine [Tegretol])

• Antifungals (e.g., itraconazole [Sporanox], griseofulvin [Gris-PEG])

• bosentan (Tracleer)

• cholestyramine (Questran)

• Coenzyme Q10

• dicloxacillin

• Estrogens (e.g., estradiol [Alora])

• Foods: avocado, green leafy vegetables, soy milk, sushi with seaweed

• Influenza vaccine

• Immunosuppressants (e.g., azathioprine [Imuran], cyclosporine [Gengraf], mercaptopurine [Purinethol])

• mesalamine (Asacol)

• Minerals: iron, magnesium, zinc

• raloxifene (Evista)

• rifampin (Rifadin)

• ritonavir (Norvir)

• Sedatives (e.g., chlordiazepoxide [Librium], ethchlorvynol [Placidyl])

• sucralfate (Carafate)

• sulfasalazine (Azulfidine)

• telmisartan (Micardis)

• ubidecarenone

• Vitamins: multivitamin, C, and K

^*List is not all-inclusive.

eTABLE 38-2

SAMPLE VENOUS THROMBOEMBOLISM PROTOCOL/ORDER SET

Low Risk	Moderate Risk	High Risk
• Ambulatory patient without additional VTE risk factors or expected length of stay <2 days • Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 min) Early ambulation*	• Patients who are not in either the low- or high-risk group (see VTE risk factor table below) Select one pharmacologic* option: • Enoxaparin† 40 mg SQ q24hr • UFH 5000 units SQ q8 hr • UFH 5000 units SQ q12hr (use only if wt <50 kg or >75 yrs) or • No pharmacologic prophylaxis because of contraindication ________________________ (see table below) • No pharmacologic prophylaxis because it is optional in this special population (GYN surgery) Sequential compression device aka SCDs (Optional for these patients if they are on pharmacologic prophylaxis, mandatory if not) SCDs to • Both lower extremities • Right leg only • Left leg only • Patient intolerant or has skin lesions on both legs, do not use SCDs	• Elective hip or knee arthroplasty • Acute spinal cord injury with paresis • Multiple major trauma • Abdominal or pelvic surgery for cancer Select one pharmacologic* option: • Enoxaparin* 40 mg SQ q24hr • Enoxaparin* 30 mg SQ q12hr (knee replacement) • Warfarin _______ mg PO daily, target INR 2-3; hold INR >3 or • UFH 5,000 units SQ q8hr (only if creatinine clearance is <30, SCr >2, and warfarin is not an option) • No pharmacologic prophylaxis because of contraindication _______________________ (see table below) and SCDs to • Both lower extremities • Right leg only • Left leg only • Patient intolerant or has skin lesions on both legs, do not use SCDs
Source: University of California, San Diego Medical Center; VTE Risk Assessment and Prophylaxis Orders (version of computerized order set)
*See contraindications in table below.
†Enoxaparin should only be used in patients with CrCl >30 and SCr <2; do not use if epidural/spinal catheter is in place.
SCDs should be used in all patients for whom pharmacologic prophylaxis is contraindicated and in all high-risk patients unless patient is intolerant or with contraindications to SCDs.
Note: Enoxaparin is the USCD Medical Center formulary low molecular weight heparin (LMWH); other LMWHs are considered equivalent.
VENOUS THROMBOEMBOLISM RISK FACTORS
• Age >50 yr • Myeloproliferative disorder • Dehydration • Congestive heart failure • Active malignancy • Hormonal replacement • Moderate to major surgery	• Prior history of VTE • Impaired mobility • Inflammatory bowel disease • Active rheumatic disease • Sickle cell disease • Estrogen-based contraceptives • Central venous catheter	• Acute or chronic lung disease • Obesity • Known thrombophilic state • Varicose veins/chronic stasis • Recent post-partum with immobility • Nephrotic syndrome • Myocardial infarction
CONTRAINDICATIONS OR OTHER CONDITIONS TO CONSIDER WITH PHARMACOLOGIC VTE PROPHYLAXIS
Absolute	Relative	Other Conditions
• Active hemorrhage • Severe trauma to head or spinal cord with hemorrhage in the last 4 weeks • Other _________________	• Intracranial hemorrhage within last year • Craniotomy within 2 wk • Intraocular surgery within 2 wk • Gastrointestinal, genitourinary hemorrhage within the last month • Thrombocytopenia (<50K) or coagulopathy (prothrombin time >18 sec) • End stage liver disease • Active intracranial lesions/neoplasms • Hypertensive urgency/emergency • Post-operative bleeding concerns*	• Immune mediated heparin-induced thrombocytopenia • Epidural analgesia with spinal catheter (current or planned)
*Scheduled return to OR within the next 24 hr: major ortho: 24 hr leeway; spinal cord or ortho spine: 7 days leeway; general surgery, status post transplant, status post trauma admission: 48 hr leeway.

eNursing Care Plan 38-1 Patient With Peripheral Artery Disease of the Lower Extremities

Nursing Diagnosis

Ineffective peripheral tissue perfusion related to deficient knowledge of contributing factors as evidenced by intermittent claudication or rest pain, diminished or absent peripheral pulses, pallor or blanching on elevation of limb, hyperemia when limb is dependent

Patient Goals

1. Identifies activities that promote and impair circulation

2. Maintains adequate peripheral tissue perfusion

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Perfusion: Peripheral • Capillary refill toes _____ • Extremity skin temperature _____ • Right femoral pulse strength _____ • Left femoral pulse strength _____ • Right pedal pulse strength _____ • Left pedal pulse strength _____ • Numbness _____ • Pallor _____ • Rubor _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	Circulatory Care: Arterial Insufficiency • Perform comprehensive assessment of peripheral circulation (e.g., check peripheral pulses, edema, capillary refill, color, and temperature) to establish baseline status. • Monitor degree of discomfort or pain with exercise, at night, or while resting as these are indicators of worsening peripheral perfusion. • Provide warmth (e.g., additional bed clothes, increasing the room temperature) to promote vasodilation and increased circulation. • Encourage patient to exercise to enhance O₂ utilization in the tissues and decrease ischemic pain. • Instruct patient on proper foot care to maintain skin integrity. • Instruct patient on factors that interfere with circulation (e.g., smoking, constrictive clothing, exposure to cold temperatures, and crossing of legs and feet) to prevent worsening peripheral perfusion and to decrease ischemic pain. • Administer antiplatelet or anticoagulant medications to promote circulation and pain-free walking.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Perfusion: Peripheral

• Capillary refill toes _____

• Extremity skin temperature _____

• Right femoral pulse strength _____

• Left femoral pulse strength _____

• Right pedal pulse strength _____

• Left pedal pulse strength _____

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Circulatory Care: Arterial Insufficiency

• Perform comprehensive assessment of peripheral circulation (e.g., check peripheral pulses, edema, capillary refill, color, and temperature) to establish baseline status.

• Monitor degree of discomfort or pain with exercise, at night, or while resting as these are indicators of worsening peripheral perfusion.

• Provide warmth (e.g., additional bed clothes, increasing the room temperature) to promote vasodilation and increased circulation.

• Encourage patient to exercise to enhance O₂ utilization in the tissues and decrease ischemic pain.

• Instruct patient on proper foot care to maintain skin integrity.

• Instruct patient on factors that interfere with circulation (e.g., smoking, constrictive clothing, exposure to cold temperatures, and crossing of legs and feet) to prevent worsening peripheral perfusion and to decrease ischemic pain.

• Administer antiplatelet or anticoagulant medications to promote circulation and pain-free walking.

Nursing Diagnosis

Activity intolerance related to imbalance between oxygen supply and demand as evidenced by intermittent claudication

Patient Goals

1. Describes plans for a walking program

2. Demonstrates increased activity tolerance

Outcomes (NOC)	Interventions (NIC) and Rationales
Activity Tolerance • Walking pace _____ • Walking distance _____ • Ease of performing ADLs _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Exercise Promotion • Determine patient’s motivation to begin/continue exercise program to plan interventions. • Instruct patient about appropriate type of exercise for level of health, in collaboration with physician and/or exercise physiologist, to meet needs and to prevent injury during exercise. • Instruct patient about desired frequency, duration, and intensity of the exercise program so endurance can be increased and oxygen utilization in the tissues enhanced. • Instruct patient on proper warm-up and cool-down exercises to avoid injury.

Outcomes (NOC)

Interventions (NIC) and Rationales

Activity Tolerance

• Walking pace _____

• Walking distance _____

• Ease of performing ADLs _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Exercise Promotion

• Determine patient’s motivation to begin/continue exercise program to plan interventions.

• Instruct patient about appropriate type of exercise for level of health, in collaboration with physician and/or exercise physiologist, to meet needs and to prevent injury during exercise.

• Instruct patient about desired frequency, duration, and intensity of the exercise program so endurance can be increased and oxygen utilization in the tissues enhanced.

• Instruct patient on proper warm-up and cool-down exercises to avoid injury.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge of disease and self-care measures as evidenced by questions about disease process, wound, and treatment

Patient Goal

Verbalizes key elements of the therapeutic regimen, including knowledge of disease, treatment plan, reduction of risk factors, and proper ulcer/foot care

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Treatment Regimen • Description of specific disease process _____ • Description of self-care responsibilities for ongoing treatment _____ • Description of prescribed exercise and procedures _____ • Description of benefits of disease management _____ Measurement Scale 1 = None 2 = Limited 3 = Moderate 4 = Substantial 5 = Extensive	Teaching: Individual • Identify factors that influence learning, such as perception of severity of illness, available support systems, cognitive ability, and physical ability, so that teaching plan can be individualized. Teaching: Disease Process • Appraise patient’s and caregiver’s current level of knowledge of disease related to specific disease process to determine extent of problem and plan appropriate intervention. • Describe disease process to facilitate patient’s and caregiver’s understanding of illness. • Describe common signs and symptoms so patient and caregiver can better manage illness. • Discuss therapy/treatment options so patient and caregiver will be less anxious, be more cooperative with treatment plan, and make accurate adjustments in lifestyle. • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process (e.g., smoking cessation, foot care) so patient can modify risk factors related to peripheral artery disease.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Treatment Regimen

• Description of specific disease process _____

• Description of self-care responsibilities for ongoing treatment _____

• Description of prescribed exercise and procedures _____

• Description of benefits of disease management _____

• Identify factors that influence learning, such as perception of severity of illness, available support systems, cognitive ability, and physical ability, so that teaching plan can be individualized.

Teaching: Disease Process

• Appraise patient’s and caregiver’s current level of knowledge of disease related to specific disease process to determine extent of problem and plan appropriate intervention.

• Describe disease process to facilitate patient’s and caregiver’s understanding of illness.

• Describe common signs and symptoms so patient and caregiver can better manage illness.

• Discuss therapy/treatment options so patient and caregiver will be less anxious, be more cooperative with treatment plan, and make accurate adjustments in lifestyle.

• Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process (e.g., smoking cessation, foot care) so patient can modify risk factors related to peripheral artery disease.

Nursing Diagnosis

Risk for impaired skin integrity related to decreased peripheral circulation, altered sensation, and increased susceptibility to infection

Patient Goal

Experiences intact skin, free of infection, on lower extremities

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes • Skin temperature _____ • Sensation _____ • Tissue perfusion _____ • Skin integrity _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Circulatory Precautions • Instruct patient and caregiver on protection from injury of affected area as tissue is very fragile and wounds heal poorly because of poor circulation. • Instruct patient to test bath water before entering to avoid burning skin because sensation may be diminished. • Instruct patient on foot and nail care to avoid injury and infection of the extremity. • Maintain adequate hydration to prevent increased blood viscosity. • Monitor extremities for areas of heat, redness, pain, or swelling to detect infection. Skin Care: Topical Treatments • Apply emollients to affected area to keep skin moist and avoid cracking.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous Membranes

• Skin temperature _____

• Sensation _____

• Tissue perfusion _____

• Skin integrity _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Circulatory Precautions

• Instruct patient and caregiver on protection from injury of affected area as tissue is very fragile and wounds heal poorly because of poor circulation.

• Instruct patient to test bath water before entering to avoid burning skin because sensation may be diminished.

• Instruct patient on foot and nail care to avoid injury and infection of the extremity.

• Maintain adequate hydration to prevent increased blood viscosity.

• Monitor extremities for areas of heat, redness, pain, or swelling to detect infection.

Skin Care: Topical Treatments

• Apply emollients to affected area to keep skin moist and avoid cracking.

Nursing diagnoses listed in order of priority.

ADLs, Activities of daily living.

eNursing Care Plan 38-2 Patient After Surgical Repair of the Aorta

Nursing Diagnosis

Risk for peripheral neurovascular dysfunction related to graft thrombosis, embolism, prolonged aortic cross-clamping, hypotension, and/or blood loss

Patient Goal

Maintains effective peripheral tissue perfusion

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Perfusion: Peripheral • Capillary refill toes _____ • Extremity skin temperature _____ • Femoral pulse strength (right) _____ • Femoral pulse strength (left) _____ • Pedal pulse strength (right) _____ • Pedal pulse strength (left) _____ • Mean blood pressure _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range • Muscle weakness _____ • Localized extremity pain _____ • Numbness _____ • Tingling _____ • Pallor _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Circulatory Care: Arterial Insufficiency • Perform a comprehensive assessment of peripheral circulation (e.g., check peripheral pulses, edema, capillary refill, color, and temperature of extremities), to establish baseline status and detect altered peripheral perfusion. • Maintain adequate hydration to prevent increased blood viscosity. • Avoid applying direct heat to the extremity because burns can occur if numbness is present. • Administer antiplatelet or anticoagulant medications as appropriate to prevent thrombus formation. Neurologic Monitoring • Monitor vital signs: temperature, blood pressure, pulse, and respirations for changes in neurovascular status. • Monitor invasive hemodynamic parameters to identify changes from baseline. • Monitor for paresthesia: numbness and tingling as a sign of neurologic impairment.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Perfusion: Peripheral

• Capillary refill toes _____

• Extremity skin temperature _____

• Femoral pulse strength (right) _____

• Femoral pulse strength (left) _____

• Pedal pulse strength (right) _____

• Pedal pulse strength (left) _____

• Mean blood pressure _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

• Muscle weakness _____

• Localized extremity pain _____

Circulatory Care: Arterial Insufficiency

• Perform a comprehensive assessment of peripheral circulation (e.g., check peripheral pulses, edema, capillary refill, color, and temperature of extremities), to establish baseline status and detect altered peripheral perfusion.

• Maintain adequate hydration to prevent increased blood viscosity.

• Avoid applying direct heat to the extremity because burns can occur if numbness is present.

• Administer antiplatelet or anticoagulant medications as appropriate to prevent thrombus formation.

Neurologic Monitoring

• Monitor vital signs: temperature, blood pressure, pulse, and respirations for changes in neurovascular status.

• Monitor invasive hemodynamic parameters to identify changes from baseline.

• Monitor for paresthesia: numbness and tingling as a sign of neurologic impairment.

Nursing Diagnosis

Risk for ineffective renal perfusion related to graft thrombosis, embolism, hemorrhage, and/or prolonged aortic cross-clamping

Patient Goal

Maintains effective renal perfusion

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Perfusion: Abdominal Organs • Mean blood pressure _____ • Urine output _____ • Urine specific gravity _____ • Blood urea nitrogen _____ • Plasma creatinine _____ • Electrolyte and acid-base balance _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Assessment: Cardiovascular System Nursing Management: Musculoskeletal Problems Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Vascular Disorders Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Perfusion: Abdominal Organs

• Mean blood pressure _____

• Urine output _____

• Urine specific gravity _____

• Blood urea nitrogen _____

• Plasma creatinine _____

• Electrolyte and acid-base balance _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range