Venous Thromboembolism Clinical Nursing Judgement

Running Head: VENOUS THROMBOEMBOLISM

Venous Thromboembolism Clinical Nursing Judgement Kimberly Muccio Youngstown State University

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Venous Thromboembolism Clinical Nursing Judgement Clinical nursing judgement is an essential skill in caring for patients in the nursing profession. Clinical nursing judgement is defined as “an interpretation and reaching a conclusion about a patient’s situation and the decision of the nurse to intervene” (Yuan, 2014). Effective clinical judgement improves the quality of nursing care and helps medical professionals make sound decisions regarding the care of their patients. Clinical nursing judgement is not only taught within the nursing curriculum, but it is also learned through many experiences in the clinical setting. This is why new graduates generally have less clinical nursing judgement than highly experienced nurses with much more intuition. Nurses will “utilize their professional knowledge and clinical experience in order to recognize subtle variations in clinical situations, interpret what they observe, and provide nursing care for individual patients” (Yuan, 2014). This skill is not limited to identifying a problem, but it also involves seeking a broad range of possibilities. Nursing judgement is important because when a nurse has the ability to critically think, they will also use this skill in the outside world and are possibly able to suspect manifestations of a disease or illness before it occurs. It is, therefore, essential for the nurse to have reasoning skills in order to make reliable clinical observations and judgements to provide the best care possible. The term venous thromboembolism is an umbrella term that describes deep vein thrombosis and pulmonary embolism. Venous thromboembolism “shares prothrombic risk factors with deep vein thrombosis and pulmonary embolism, such as personal or family history of venous thromboembolism, active malignancy, recent surgery or trauma, immobilization, inherited thrombophilia, use of oral contraceptives, infectious diseases, obesity, and cardiac or respiratory failure” (Di Minno, 2016). Deep vein thrombosis (DVT) occurs when a blood clot forms in one of the veins in the body. It generally manifests as pain, swelling, warmth, redness, cramping of the legs, or skin discoloration. The most common site for deep vein thrombosis is

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the lower calf area. Pulmonary embolism (PE) is the most severe complication of a DVT when the clot in the leg or elsewhere in the body travels up into the lung. This severe situation usually manifests as shortness of breath, but the person can also experience chest pain, tachycardia, and excessive sweating. A very recent situation occurred where I used my clinical nursing judgement skills outside of the clinical setting to observe and detect signs and symptoms of a venous thromboembolism in one of my very good friends. In high school, my friend, Kyle, was diagnosed with a DVT during basketball season of his senior year. He was experiencing pain, swelling, and cramping in his lower calf, so he went to the doctor and was diagnosed with a DVT. He had to sit out the rest of the season and was on Coumadin therapy for about 13 weeks following his diagnosis. Frequently, he had to go get his blood drawn to make sure that his INR was in therapeutic range for the medication to be working properly. Kyle was attuned to his condition and understood all of the signs and symptoms of his diagnosis. Fast forward 6 years later, me, Kyle, and some of our friends were hanging out playing video games. Without any exertion, Kyle stated to us that he was experiencing shortness of breath for about two weeks now, but he thought that he was just coming down with a cold that was going around. He was also complaining about cramping in his lower legs. Knowing that he has had a previous DVT, I used my clinical nursing judgement to come to the conclusion that Kyle was at a very high risk for yet another DVT or PE, especially if he was exhibiting these signs and symptoms. I told Kyle that he needed to go to the doctor as soon as possible and explained to him why he is at a higher risk because he has had this condition before and that shortness of breath without exertion was a huge red flag. He went to the doctor the next day and was taken by ambulance to St. Elizabeth’s in Boardman. Kyle had a CT scan done to check for the presence of clots and was diagnosed with multiple small pulmonary embolisms and many DVTs. He was closely monitored and

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placed on a heparin drip in the hospital for a couple of days. He was visited by numerous doctors and specialists to make sure that his condition was under control. When one of the doctors visited him, he asked Kyle why he did not show up to his appointment 6 months ago. Kyle explained to him that he forgot to reschedule and the doctor made sure that he promised to continue with his appointments so that they could ensure that he would not be in this lifethreatening situation again. He is out of the hospital as of last week and he must visit his hematology doctor every 6 months for check-ups and to ensure that his prescribed medication is effective in treating his condition. Kyle was prescribed life-long therapy of Apixaban (Eliquis). Apixaban (Eliquis) is “an oral factor Xa inhibitor administered in fixed doses without the need for laboratory monitoring” (Liu, 2015). Compliance is very important with all drugs, but especially life-long therapy medications. Eliquis is preferred over other oral anticoagulant therapy because there is no laboratory monitoring and the risk of non-compliance is much less. In a study that compared to enoxaparin and warfarin, “apixaban reduces all-cause hospitalizations, resulted in a lower number of hospitalized patients, and reduces the mean length of hospital stays” (Liu, 2015). The nurses and doctors spent much of his hospital stay teaching the risks and possible complications of the prescription of Eliquis like the risk for bleeding or ease of bruising. They also described the importance of making all of his appointments and not skipping doses of his medication. In conclusion, clinical nursing judgement is vitally important inside and outside of the clinical setting. Clinical judgement allows the nurse to associate these pieces of information, explore them, establish known facts, and to analyze and interpret symptoms at hand form a clinical and rational perspective. This situation allowed me to associate the signs and symptoms that Kyle was experiencing with the condition of venous thromboembolism. Without anyone to tell Kyle that he could have been experiencing signs and symptoms, he might not have went to

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the doctor and could have had a much worse outcome. This situation as well as so many others is the reason why it is vitally important for medical professionals to have sound clinical nursing judgment.

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Di Minno, M. N. D., Ambrosino, P., Ambrosini, F., Tremoli, E., Di Minno, G., & Dentali, F. (2016). Prevalence of deep vein thrombosis and pulmonary embolism in patients with superficial vein thrombosis: a systematic review and meta‐analysis. Journal of Thrombosis and Haemostasis, 14(5), 964-972 Liu, X., Johnson, M., Mardekian, J., Phatak, H., Thompson, J., & Cohen, A. T. (2015). Apixaban Reduces Hospitalizations in Patients With Venous Thromboembolism: An Analysis of the Apixaban for the Initial Management of Pulmonary Embolism and Deep‐Vein Thrombosis as First‐Line Therapy (AMPLIFY) Trial. Journal of the American Heart Association, 4(12), e002340. Yuan, H. B., Williams, B. A., & Man, C. Y. (2014). Nursing students' clinical judgment in highfidelity simulation based learning: a quasi-experimental study. Journal of Nursing Education and Practice, 4(5), 7.