Effect of Implementing Nursing Educational Protocol on Reducing Deep Venous Thrombosis among Orthopedic Surgery Patients

Introduction

Deep vein thrombosis (DVT) is the formation of thrombi in the deep veins, most commonly the large veins of the legs or pelvis. Pulmonary embolism (PE) develops when thrombi dislodge from clots in vein walls and travel through the heart to pulmonary arteries. There is a 50% chance for patients with untreated proximal DVT to develop symptomatic PE within 3 months. For 25% of patients, the presenting manifestation of PE is sudden death Phillippe (2017).

Patients undergoing major orthopedic surgery including total hip replacement, total knee replacement and hip fracture surgery , are at particular risk of developing post-operative venous thromboembolism (VTE) (Francis, 2013).

Orthopedic patients are at higher risk among all patients for DVT and venous thromboembolism (VTE)  , the incidence of DVT ranges up to 40%to 60% in major orthopedic surgeries. Death within one month of diagnosis occurs in approximately 6% of DVT patients and approximately 12% of pulmonary embolism patients (Flevas et al., 2018).

Deep vein thrombosis (DVT) is an important cause of morbidity and mortality. The risk of DVT is highest in patients undergoing major orthopedic surgery, particularly hip and knee arthroplasty (Akpinar, Hoşgün, Akan, Ateş, & Gülhan, 2013).

Major surgery or traumas of the lower extremities trigger the coagulation cascade and the physiologic equilibrium between factors promoting, and retarding coagulation is disturbed resulting in a hypercoagulable state. In these patients, a reduced venous  flow and impaired endothelial function further increase the risk of developing deep-vein  thrombosis and pulmonary embolism (Dahl,   2013 ) .

The most common symptoms of DVT occur at the site of the clot. They include swelling, warmth, pain or tenderness, and redness of the skin. Deep vein thrombosis can also occur with no symptoms (Thompson, 2015).

Patients undergoing major orthopedic surgery should receive thromboprophylactic interventions, including health education, properly implemented basic prevention strategies, physical prevention strategies, and appropriate antithrombotic drugs. Ideally, these interventions should be patient-centered in order to encourage patient participation and adherence(Xu, Zhao, & Chen, 2018).

Nurses caring for patients at risk for DVT need to consider their health history, family history, current illness, current medications, and physical assessment data. To effectively advocate for patients and prevent DVT, nurses have a responsibility to assess the patient's risk factors and identify and promptly report abnormal physical assessment findings (D'Alesandro, 2016).

Significance of the study

DVT is  more common in orthopedic patients than in the general population, with DVT rates ranging from 40% to 60% in major orthopedic surgeries. In approximately 6% of DVT patients and approximately 12% of pulmonary embolism patients, death occurs within one month of diagnosis (Flevas et al., 2018). DVT incidence rates without prophylaxis have been observed to range from 40% to 60% (Rahman et al., 2020).

Deep venous thrombosis (DVT) is the primary cause of pulmonary embolism (PE) (Schellack, Modau, & Schellack, 2016). Pulmonary embolism (PE) is a life-threatening condition or complication and might be one of the worst nightmares for most surgeons. The embolus that causes the obstruction usually travels through the venous system from a distant site.PE causes symptoms such as dyspnea, chest pain or collapse .Moreover, the clinical severity of PE can vary, ranging from asymptomatic cases to sudden death (Attia, Ali, Al Amory, & Othman, 2015).

Among people who had a DVT, 50% will have long-term complications (post thrombotic syndrome) such as extremity pain, venous dilation, edema, pigmentation, and venous ulcers (D'Alesandro, 2016).

From the researcher’s review of literatures ,It was found that that majority of orthopedic patients return with deep venous thrombosis which can be reduced through mechanical methods such as range of motion ,exercises, and elastic stocking wearing .So, this study will be conducted to reduce deep venous thrombosis among orthopedic surgery patientsby application of nursing educational protocolto those patients.

Aim of the Study:

The aim of this study was to evaluate the effect of implementing nursing educational protocol on reducing deep vein thrombosis among orthopedic surgery patients.

Research Hypothesis:

The occurrence of deep venous thrombosis will be reduced among orthopedic surgery patients who are following nursing education protocol. 

Research Design:

Quasi experimental research design was utilized in this study (study and control group).

Subjects:

A purposive sample of 72 adult patients who admitted to orthopedic unit for lower limb orthopedic surgery. The determination of the sample size based upon the following sample calculation formula Sample size is calculated by using Naing,  Winn, & Rusli , (2006) formula which is computed as (n=z²×p(1-p)/d²) (Naing, Winn, & Rusli Bin, 2006) .

Setting:

The study was conducted at Orthopedic department and Orthopedic out Patient Clinic at Minia University Hospital. 

Study Duration:

The total data collections were collected over a period of ten months starting from November 2019 to August 2020.

Tools of data collection

Three tools were used for data collection of this study:

 Tool I: Patient's Assessment Sheet for DVT

This tool aimed to assess the patients' risk factors for development of DVT and it consisted of three parts:-

• Part 1: Demographic data of the patient: Such as age, sex, educational level , family history, etc.
• Part 2: Patient medical sheet: This part was developed to assess patient medical diagnosis, hospital stay ,type of surgery, duration of surgery ,type of anesthesia , type of medications used  and patient's hydration state.
• Part 3: the Autar DVT risk assessment scale(Autar, 2003) .

The Autar DVT scale was developed to proactively identify patients at risk for DVT, the Autar DVT scale comprised seven subscales (Age specific group, Mobility, Trauma, Build/Body mass index, Special risk factor, High risk disease,  Surgical intervention)

Scoring system of The Autar DVT risk assessment scale

Tool II: Deep vein thrombosis evaluation sheet

This tool was modified by the researcher to assess the development of DVT in order to evaluate the effectiveness of the nursing protocol application. It included three parts:

• Part 1: Deep Vein Thrombosis Manifestations: This part was used to assess DVT manifestations. It assessed the patient in the following five items: calf pain, calf tenderness, calf circumstance, skin color, and warmth of the calf muscle.
• Part 2: Doppler Ultrasound: This test was done to assess the blood supply in the veins of the lower limbs. The Doppler findings indicate the occurrence of DVT. It was done only for patients presented withDeep Vein Thrombosis manifestations.

Educational brochure:

It was formulated by investigator after extensive literature review and revised by experts. It was included  an overview about deep venous thrombosis ,steps of application of elastic stocking , four types of exercise and four types of range of motion for  strengthening thigh and calf muscles. Also, instructions regard duration and frequency to ensure that the patients perform these exercises accurately after their hospital discharge (4-6 weeks) and at home.

Tools validity:

The tools were tested for validity by a jury of five experts in the field of the study and the necessary modifications were done.

Reliability of tools

To establish reliability, alpha Cronbach’s was used to check the stability of the internal consistency of the study instruments which revealed that the tools of the study were reliable as indicated by the value of (0.87).    

Pilot Study

A pilot study was carried out on 10% (7 patients) of the total sample to test feasibility, objectivity, and applicability of the data collection tools  & scales.  Based on results of the pilot study refinement and modifications was done by the researcher. So that the researcher was found more applicable to current study to use a standardized scale as (Autar DVT Risk Assessment Scale) .

Ethical Consideration

Approval was obtained from the ethical committee in the faculty of Nursing, the director of Orthopedic Surgical Unit. Oral consents were obtained from subjects, and explanation about the study was given to them included the aim of the study. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data.

Procedure

Data collection for this study was carried out through ten months starting from November 2019 to August 2020 (3 to 4 days per week) during morning or evening shift. Firstly, the investigator introduced her-self to the patients , explained the general purpose of the study & asked them to give an oral consent for their participation.

The data was collected by the investigator in the first interview which took about 5 – 10 minutes from each client at the previous mentioned settings, after that the content of the educational brochure introduced for them concerning the educational protocol regarding post orthopedic surgery discharge  instructions.

Session plan

Data collection for study sample was done in inpatient orthopedic department first during their hospitalization (ranged from 1to5 days) then in outpatient clinic  for follow-up. The total number of sessions for data collection & training session for the study group was 4-5 sessions. The duration of each session about 5 – 10 minutes according  to  patient tolerance. At the end of each session discussion and feedback will be made.

At the end  of  the  session,  the researcher gave the study participants a  handout (Photo  brochure) as  educational  information and  training  practices for  post orthopedic  surgery discharge instructions,  it was formulated by researcher after reviewing related literature. It was included  an overview about deep venous thrombosis ,steps of application of elastic stocking , four types of exercise and four types of range of motion  for  strengthening thigh and calf muscles. Also, instructions regard duration and frequency to ensure that the patients perform these exercises accurately after their hospital discharge (4-6 weeks) and at home.

Statistical analysis of data:

Data were analyzed using the statistical package for social science (SPSS) version 20. Numerical data were expressed as means and SD. Quantitative data were expressed as frequency and percentage. For quantitative data; comparison between two variables were done using t-test, and comparison between more than two variables used ANOVA test paired t-test. Relations between different numerical variables were tested using Pearson correlation. Probability(P-value) less than 0.05 was considered significant and less than 0.01 was considered highly significant .    

Results

Table 1 :Distribution of study and control groups regarding  demographic  and medical data  n= 72

Chi-Square Tests             *=Significant difference  *p≤0.05

**= highly significance  *p≤0.01          Ns= Non significant difference  P˃0.05

Table 1: Shows that more than half  (58.3 %) of study group were females, while more than half of patients in the control group(58.3 %) were males with mean age for the study and control groups  (43.63±12.49 and 39.94±10.29 years) respectively. The majority of both control and study groups were married. The highest percentage in both control and study group of patients had diagnosed with tibia fracture.

Table 2 : Comparison between study and control  groups regarding  risk factors n= 72

Chi-Square Tests             *=Significant difference  *p≤0.05   

 **= highly significance  *p≤0.01          Ns= Non significant difference  P˃0.05

Table 2: Regarding the risk factors of developing deep venous thrombosis among orthopedic surgical patients; the current study clarify that half of  patients’ age in the control group was ranging between 40 – 50 years while more than quarter of the study group ranging between 30 -40 years and other quarter ranging between 50 -60  years old. Regarding the mobility; the present study shows that more than half of both study and control group experience a very limited and limited mobility respectively. Regarding the trauma risk injury; the majority of both two groups of patients (94.4% and 100%) had lower limb injury. Regarding body mass index the present study revealed that more than one third in both study and control groups experience over weight and obesity respectively (38.9% and 44.4%). Regarding chronic diseases; More than one quarter in the study group (27.8 %) had chronic heart disease while the highest percentage in the control group had anemia (sickle cell anemia) and varicose vein. All patients (100%) in both study and control groups were performing orthopedic surgeries with high risk category.

Table 3 : Deep venous thrombosis evaluation among study and control groups n= 72

Table 3: demonstrates that there is a statistical significant difference between study and control group regarding signs and symptoms of DVT in calf muscle regarding redness, swelling and absence of signs with p.value (0.012*, 0.001**, and 0.002**) respectively. While in thigh muscle presence of swelling show a statistical significant difference with p.value (0.005**) between the two groups.

Table 4 : Comparison between study and control groups regading Doppler finding n= 72

Table 4: Shows that there is a statistical significant difference between study and control groups regarding the occurrence of DVT especially Left limb DVT p.value (0.027*) after application of the nursing educational protocol.