Anticoagulation Therapy and Management

Healthcare Disparities

• Health disparities are gaps in health and healthcare quality among different population groups.
• These disparities involve socioeconomic status, race/ethnicity, and education level.
• Health disparities include differences in quality of care, not just access.

Definitions of Health Disparities

• Whitehead's View: Health disparities are avoidable, unavoidable, unfair, and unjust.
• Carter-Pokras: Health disparities involve differences in health status between disadvantaged groups and those with more social justice and equity.
• Dahlgren & Whitehead Rainbow Model includes social determinants of health, predicts health inequities, and uses a prevention-focused approach.
• Social determinants of health in the Dahlgren & Whitehead Rainbow Model include environment, education, employment, and healthcare access.

Scope of Health Disparities

• Unavoidable & Acceptable: A significant number of elderly people visit the ED; no nursing concern.
• Unavoidable & Unacceptable: High diabetes risk in Hispanic populations, but lack of proper management; a nursing concern.
• Avoidable & Acceptable: Natural disasters causing temporary health access issues are rare occurrences.
• Avoidable & Unacceptable: Lack of healthcare access and bias in clinical decision-making are most concerning for nurses.

Common Health Disparities

• Lack of health insurance often leads to delayed diagnosis and no access to medications.
• Ineffective provider-patient communication can result in medical errors and poor outcomes.
• Bias in clinical decision-making leads to disparities in care based on sex, race, or ethnicity.
• Lack of transportation can cause missed follow-ups and poor chronic disease management.
• Language barriers can contribute to medication errors and non-compliance.
• Patient mistrust or refusal can result in late-stage disease diagnosis.

Examples of Health Disparities

• Unequal receipt of early and adequate prenatal care
• Unequal receipt of recommended immunizations
• Unequal pain management
• Unequal breast cancer screening
• Unequal quality of palliative care
• Lack of mental health services

Health Disparity Impact on Specific Diseases

• Cardiovascular disease has higher mortality in minority populations.
• Diabetes has higher rates in Hispanic & Black populations, but lower access to management.
• Obesity is more prevalent in lower-income populations.
• Mental health services have limited access in minority communities.
• Cancer screenings have lower rates of Pap smears, mammograms, and prostate exams.

Consequences of Health Disparities

• Decreased patient satisfaction
• Increased miscommunication
• Decreased adherence to treatment
• Delays in healthcare access are caused by poor doctor-patient communication and a lack of insurance.

Interpreters & Language Barriers

• Understanding medical terms and simplifying them are key qualities of an interpreter.
• Patient advocacy is a key responsibility of interpreters.
• Interpreters use verbal and nonverbal cues and deliver clear teaching instructions.
• Dangers of using an unqualified interpreter include miscommunication, increased medical errors, violation of patient rights, and lack of proper follow-up care.

Best Practices When Working With an Interpreter

• Speak slowly and clearly.
• Maintain eye contact with the patient.
• Use simple, non-medical language.
• Speak in short sentences for easy translation.
• Use the teach-back method to ensure understanding.
• Plan for the visit to take twice as long.
• Document translator use in the medical record.

Liver Cirrhosis

• Cirrhosis is an end-stage liver disease involving progressive degeneration and scarring of liver tissue, leading to impaired liver function.

Causes of Cirrhosis

• The most common causes are chronic hepatitis C and alcoholic liver disease.
• Other causes include malnutrition, obesity, biliary cirrhosis (autoimmune bile duct damage), and cardiac cirrhosis (from right-sided heart failure).

Early Symptoms of Cirrhosis

• Fatigue
• Enlarged liver
• Lab values may be normal early in the disease

Late Symptoms of Cirrhosis

• Jaundice (from bilirubin buildup)
• Peripheral edema & ascites
• Skin changes: Petechiae, spider angiomas, palmar erythema
• Endocrine problems: Gynecomastia, menstrual changes
• Neurological: Altered mental status

Complications of Cirrhosis

• Portal hypertension: Increased venous pressure in liver circulation causing splenomegaly, varices, and ascites.
• Varices (Esophageal & Gastric): High risk of rupture, leading to life-threatening bleeding.
• Signs of bleeding: Hematemesis and black, tarry stools (melena).
• Ascites: Accumulation of fluid in the peritoneal cavity causing abdominal distention and weight gain.
• Signs of ascites: Dehydration, hypokalemia
• Management of ascites: Sodium restriction, diuretics, paracentesis (temporary relief), and TIPS if refractory.
• Hepatic Encephalopathy: Caused by ammonia buildup due to liver failure.
• Symptoms of Hepatic Encephalopathy: Confusion, behavior changes, and asterixis (flapping tremor).
• Treatment of Hepatic Encephalopathy: Lactulose (removes ammonia via stool) and antibiotics (reduce ammonia-producing bacteria).
• Hepatorenal Syndrome: Kidney failure due to severe liver disease.
• Signs Hepatorenal Syndrome: Oliguria, azotemia, and intractable ascites.
• Definitive Treatment for Hepatorenal Syndrome: Liver transplant

Modifiable vs. Non-Modifiable Risk Factors

• Modifiable DIC risks involve managing underlying conditions, preventing infections, and detecting early cancer.
• Modifiable cirrhosis risks involve alcohol cessation, weight management, and hepatitis prevention.
• Non-modifiable DIC risks include cancer, sepsis, and tissue trauma.
• Non-modifiable cirrhosis risks include genetic predisposition and chronic hepatitis C/B.

Key Treatments & Nursing Considerations for DIC

• Bleeding precautions
• Heparin is used for chronic DIC only.
• Blood products are used for life-threatening hemorrhage.

Key Treatments & Nursing Considerations for Cirrhosis

• Avoid NSAIDs, alcohol, and aspirin to reduce bleeding risk.
• Monitor ammonia levels for hepatic encephalopathy.
• Monitor for signs of infection due to peritonitis risk with ascites.

Venous Thromboembolism (VTE)

• VTE is an umbrella term for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
• Pathophysiology: Formation of a thrombus (blood clot) in a deep vein, causing inflammation and potential embolization.

Virchow's Triad (3 Major Risk Factors for VTE)

• Venous Stasis (Slow or pooled blood flow)
• Risk factors: Obesity, pregnancy, chronic heart failure (CHF), atrial fibrillation (A-fib), immobility.
• Endothelial Damage (Vessel wall injury)
• Causes: Surgery, trauma, chemotherapy, diabetes.
• Triggers platelet activation & clot formation.
• Hypercoagulability of Blood (Increased clotting tendency)
• Risk factors: Cancer, polycythemia, anemias, sepsis, estrogen use (oral contraceptives, pregnancy), smoking.

Risk Factors for VTE

• Non-Modifiable Risk Factors: Genetics (coagulation disorders), Age (>60 years old), Cancer (increased clot risk), History of VTE, Major surgery or trauma.
• Modifiable Risk Factors: Obesity and Smoking.
• Other Risk Factors: Oral contraceptive or hormone therapy, Sedentary lifestyle, Dehydration, Prolonged immobility (travel, hospitalization).

Signs & Symptoms of VTE

• Superficial Vein Thrombosis: Leg or arm veins (varicose veins) exhibit tenderness, redness, warmth, pain, and cord-like appearance.
• Deep Vein Thrombosis (DVT): Deep veins of legs, arms, vena cava, pulmonary system exhibit unilateral swelling, tenderness, pain, redness, dilated veins, warmth, and fever (>100.4°F).
• Pulmonary Embolism (PE): Lungs (embolized clot from DVT) exhibit sudden SOB, chest pain (pleuritic), coughing blood (hemoptysis), anxiety, tachycardia, and hypotension.

Complications of VTE

• Post-Thrombotic Syndrome (PTS): Occurs in 8-70% of VTE patients due to chronic venous inflammation.
• Symptoms of PTS: Pain, swelling, fatigue, cramps, itching, tingling.
• Manifestations of PTS: Persistent edema, spider veins, venous ulcers, and skin discoloration.
• Phlegmasia Cerulea Dolens (PCD): Severe complication of lower extremity VTE causing total venous occlusion.
• Symptoms of PCD: Massive swelling, deep pain, and major cyanosis.
• If untreated, PCD leads to gangrene.

Important Labs & Diagnostic Tests for VTE

• D-Dimer: Detects clot breakdown (>250 possible VTE), Normal Range < 250 ng/mL
• aPTT (Activated Partial): Monitors heparin therapy, Therapeutic Range 30-40 seconds
• INR (International Normalized Ratio): Monitors warfarin therapy, therapeutic range: 2-3
• ACT (Activated Clotting Time): Monitors clotting ability, Normal Range 70-150 seconds
• Hgb (Hemoglobin): Low in anemia (increased clot risk), Normal Range 12-18 g/dL
• Platelet Count: Elevated in clotting disorders, Normal Range 150,000-400,000 cells/mcL

Diagnostic Imaging for VTE

• Duplex Ultrasound: First-line test for DVT
• CT Venography (CTV): Detects clots in pelvis, thighs, and calves
• MRI Venography: Highly accurate for pelvic & proximal veins
• Pulmonary Angiography: Gold standard for diagnosing PE
• Ventilation-Perfusion (V/Q) Scan: Detects PE when CT is contraindicated

Treatment Plan for VTE

• Non-Pharmacological Treatment: Early & aggressive mobilization
• Bed rest: Flex & extend feet, knees, hips every 2 hours.
• Walk 4-6x/day.
• Use compression stockings unless DVT is present.
• Inferior Vena Cava (IVC) Filter prevents emboli from traveling to lungs in high-risk patients.

Pharmacological Treatment for VTE

• Warfarin (Coumadin): Long-term anticoagulation
• Monitor INR (2-3) when using Warfarin.
• Vitamin K is the antidote for Warfarin.
• Enoxaparin (Lovenox) prevents & treats VTE: Do not expel air bubble, Monitor CBC, Avoid in renal disease.
• Protamine sulfate is the antidote for Heparin.
• tPA (Tissue Plasminogen Activator) is a thrombolytic (clot buster) used in high-risk PE.
• tPA is contraindicated in high bleeding risk patients.

Nursing Care & Patient Education for VTE

• Prevent VTE with mobilization (gold standard), compression stockings, avoiding prolonged sitting/crossing legs, and encouraging hydration.
• Monitor for bleeding while on anticoagulants: No IM injections, avoid NSAIDs/aspirin/fish oil/garlic/ginkgo biloba, and report signs of bleeding.
• Educate on lifestyle modifications: Smoking cessation, weight loss, exercise regularly, avoid prolonged immobility, and limit vitamin K intake if on warfarin.

Test your knowledge of anticoagulation medications, including monitoring parameters like INR and aPTT. Questions cover drug administration, antidote usage, and special considerations for patients with renal disease or pulmonary embolism. Assess your proficiency in managing anticoagulation therapy.