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114 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

around 10% of hospital deaths in Australia. 80,82 Patients
TABLE 6.9 Monitoring pressure ulcers with VTE may also develop post-thrombotic syndrome
where tissue injury occurs leading to pain, paraesthesia,
Factor Actions pruritis, oedema, venous dilatation and venous ulcers. 79,81
Size ● Objectively assess length, width and It is important to consider the individual patient (age,
depth. BMI) and their history (previous VTE, coagulation disor-
Stage/grading ● Use a standardised measure to grade the ders) along with their current condition whether it be
ulcer (e.g. International NPUAP & EPUAP surgical or medical and features of their treatment (immo-
Pressure Ulcer Classification System). bilisation) when determining risks for VTE. 80,81,84-86 Both
Documentation ● Note the absence/presence/location of the risk assessment and the patient’s current condition
pressure ulcers on admission and will determine the most appropriate VTE prophylaxis
discharge. strategy. 80,81 Prophylaxis consists of a combination of
● Keep a record of nursing interventions pharmacological and mechanical interventions that may
and treatments used to treat pressure
ulcers. be used together or separately according to the degree of
risk for VTE and/or contra-indications to particular thera-
Treatment ● Monitor response to therapy by pies. The use of combined therapies is supported by
assessing the size and stage/grade of 80,84,86
the pressure ulcer on a daily basis. recent reviews and guidelines. It is important to be
guided by current best evidence in choosing the most
Observing other ● Dependent areas of the body are appropriate prophylaxis regimen for your patient. The
sites susceptible: sacrum, heels, back of the
head, hips, shoulders, elbows, knees. NHMRC Clinical practice guideline for the prevention of
● Areas of the body where equipment is venous thromboembolism (deep vein thrombosis and pulmo-
causing pressure are susceptible: nose, nary embolism) in patients admitted to Australian hospitals
80
ears, corners of the mouth, fingertips. provides a comprehensive guide to risks and manage-
● Areas of the body where tissue perfusion ment relating to VTE for critical care in Australia.
is poor are susceptible: extremities.
Low molecular weight heparin or unfractionated heparin
is the most common pharmacological therapy prescribed
Rotational Therapy in Australia, while other medications will be prescribed
for patients according to individual factors. 80,87 Special
Continuous Lateral Rotation Therapy (CLRT) or Kinetic consideration of an appropriate regimen for pharmaco-
bed therapy is an intervention in which the patient is logical prophylaxis will need to be given to patients with
rotated continually, on a specialised bed, through a set renal and hepatic impairment. Heparin-induced throm-
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number of degrees; it helps to relieve pressure areas and bocytopenia (HIT) may develop in some patients so as
88
can significantly improve oxygenation. 75-77 Continual with all heparin therapy, close monitoring of the patient’s
lateral rotational therapy may reduce the prevalence of platelet count and assessing for signs of bleeding such as
ventilator-associated pneumonia in patients requiring bruising or haematuria will form part of the nurse’s role
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long-term ventilation. Appropriate evaluation of the in managing VTE prophylaxis.
benefits and suitability of the patient for CLRT should be
undertaken by the team and the therapy implemented In principle, it is advised that graduated compression
75
according to local protocols. In implementing this stockings are used for all general, cardiac, thoracic and
therapy, the goal is to achieve continuous rotation through vascular surgical patients until full mobility is achieved
the maximum angle that the patient tolerates for 18 irrespective of pharmacological prophylaxis. 80,86 Mechan-
hours per day. 75,78 ical prophylaxis is provided through a range of graduated
compression stockings and various pneumatic venous
Venous Thromboembolism (VTE) Prophylaxis pump or sequential compression devices. 80,81,84,86,89,90 It is
important to make sure that the relevant devices are
Deep vein thrombosis (DVT) and pulmonary embolism
(PE) are separate conditions collectively referred to as fitted correctly and monitored closely. Comparisons
venous thromboembolism (VTE). 79,80 DVT is a blood clot between a number of pneumatic pumps have been
88-90
in a major vein of the lower body, i.e. leg, thigh, pelvis, studied with all displaying relative effectiveness. The
which causes disruption to venous blood flow and is availability of battery-operated sequential compression
often first noticed by pain and swelling of the leg. The devices can assist with the continuous application of the
blood clot forms due to poor venous flow, endothelial therapy during patient transports away from their bedside,
injury to the vein or increased blood clotting which may such as to the imaging department for radiological
90
be caused by trauma, venous stasis or coagulation disor- procedures.
81
ders. Pulmonary emboli occur when a part of a throm- Along with pharmacological and mechanical venous
bosis moves through the circulation and lodge in the thromboembolism prophylaxis, maintaining patients’
pulmonary circulation. VTE is a major risk factor for hos- hydration and implementing early mobilisation are key
pitalised patients 80-83 in general and critically ill patients components of care in preventing VTE. 79,80,84 Rauen et al.
79
in particular, due to blood vessel damage, coagulation describe the most common reasons cited for lack of
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disorders and limited mobility leading to venous stasis. proper VTE prophylaxis as being lack of knowledge
Further, around 50% of patients with DVT will also suffer among healthcare providers and under-estimation of risk
a pulmonary embolism, which can be fatal causing of VTE along with over-estimation of the potential risk of