COMPOSING A PATIENT EDUCATION PAMPHLET FOR
DEEP VEIN THROMBOSIS

By
Julie Sue Anderson, RN, BSN

Submitted in Partial Fulfillment of the Requirements

for the Master of Science in Nursing Degree

Edinboro University of Pennsylvania

Composing a patient education
pamphlet for deep uein
thrombosis / by Julie Sue
Anderson.
Thesis Nurs. 2001 A547c
c .2

Approved by:

Ju^^hScWllin& C~

; PhD

fl

(Committee Chairperson

rffet^jeisel, PhD, RN
Committee Member

Date

Table of Contents

Contents

Page

Abstract...

i

Chapter 1: Introduction.

1

Background of the Problem.

1

Evolution of Patient Education.

1

Patient Education Materials.

4

Problem Statement

5

Theoretical Framework.

5

Statement of Purpose.

..7

Assumptions

8

Definition of Terms.

8

Summary

9

11

Chapter II: Review of the Literature.

Deep Vein Thrombosis (DVT)
Pathophysiology
14

Risk Factors...
Clinical Features
Diagnosis

Treatment of DVT...

Anticoagulation....
Unfractionated heparin

ii

Low molecular weight heparin

19

Oral anticoagulation.

22

Fibrinolytic Therapy

23

Surgical Interventions.

23

Complications

24

Post-thrombotic syndrome.

24

Pulmonary embolism.

24

Recurrent DVT

25

Patient Education.

26

Definition of Patient Education.

26

Purpose of Patient Education.

26

Process of Patient Education

26

Educational process

27

ASSURE model.

28

29

Patient Education Materials (PEMs)

Self-composed PEMs.

30

Readability of PEMs

30

Principles of self-composed PEMs................

32

Models for Composing and Evaluating PEMs.

34

36

Summary....

37

Chapter III: Methodology

37

Pre-design Phase....
iii

Design Phase

37

Pilot Phase.

38

Distribution and Implementation Phase.

39

Evaluation Phase

40

Summary.

40

References

41

Appendix A: Medical Risk Factors Predisposing to Thromboembolism.

48

Appendix B: Clinical Probability of Deep Vein Thrombosis.

50

Appendix C: DVT Patient Education Pamphlet.

52

iv

COMPOSING A PATIENT EDUCATION PAMPHLET FOR

DEEP VEIN THROMBOSIS
Abstract

An estimated 1 to 5 million Americans develop a deep vein thrombosis
(DVT) each year (Kurowski, 1997). Educating patients about this health-related
problem is necessary to alter their health behavior and improve their potential for

optimal health outcomes (Falvo, 1994). Patient education is constantly changing
to meet the demands placed by today’s health care system (Bastable, 1997; Falvo,
1994; Whitman, Gliet, Graham, and Boyd, 1992). The nurse practitioner assumes

a vital role in the patient education process (Close, 1988). The use of printed
education materials (PEMs) is one method to facilitate the achievement of health.

Using Bernier and Yasko’s (1991) EPEM model for designing and
evaluating PEMs, a patient education pamphlet was designed for use with patients

diagnosed with, or who are high risk for, DVT. The purpose of the pamphlet is to
supplement and reinforce oral instructions given to the patient by the health care
provider. After construction, the pamphlet was submitted to a patient education

committee in a northwestern Pennsylvania acute care facility for evaluation. Once

the recommended changes were instituted, the PEM was relinquished to the
committee for publication and distribution throughout the institution.

i

1

Chapter 1

Introduction
This objective of this scholarly project is to create a patient education
pamphlet discussing deep vein thrombosis (DVT). Contained within this chapter

is a brief overview of the evolution of today’s patient education practices, types of

educational materials available, and the education needed by a patient with a deep
vein thrombosis. Also provided is the theoretical framework for this scholarly

project, Dorothea Orem’s (2001) Self-care Deficit Theory of Nursing. The
problem statement, the statement of purpose, the assumptions, and the definition
of terms for this project are also discussed.

Background of the Problem
Because patients in today’s acute care hospitals are admitted with higher

acuities and are being discharged home sooner, patient education continues to
gain increasing importance in today’s health care environment (Lange, 1989)
The increased demand for primary and secondary prevention, and management of

illness in the outpatient setting, also highlight the need for patient education

(Bastable, 1997). The nurse practitioner is vital to the patient education process
(Close, 1988).

Evolution of Patient Education

Whitman, Graham, Gleit, and Boyd (1992) wrote, “a more informed and

health-conscious public has been evolving for some time” (p. 4). In response to

the demands of the public and the ever-changing health care system, numerous
acts of legislatures have been instituted and revised over the last century to

2

promote patient education. The National League for Nursing Education in 1918

provided the earliest impetus by recognizing the significance of patient education
and the role of the nurse as an educator (Bastable, 1997; Boyd, 1992a).

Consequently, nurse practice acts incorporated patient education as a function of
nursing. In 1950, the Society of Public Health and Education was created to
promote health and education in the community (Boyd, 1992a).

By the 1970s, consumers became more involved in health care and formed
several public interest groups such as Healthright, Medicine in the Public Interest,

and the Patients’ Rights Organization (Boyd, 1992a). The private sector founded

the National Center for Health Education. The American Hospital Association
introduced the Patient’s Bill of Rights in 1973, revised in 1992, in order to

establish the right of patients to be informed about their health status (Bastable,
1997; Boyd, 1992a; Falvo, 1994). From a legislative standpoint, The National

Health Planning and Resources Development Act of 1974 was passed in order to
include health education of the public as one of the top ten priorities for the nation

(Boyd, 1992a).
In the 1980s, the Joint Commission on Accreditation of Health Care

Organizations identified the importance of nurses as patient educators (Boyd,

1992a). Also, the development of Diagnostic Related Groups (DRGs) in the

1980s sponsored the vital role in health education as a means for cost
containment. DRGs placed limits on reimbursement for the institutional care of

health problems which led to decreased lengths of stay in acute care facilities and

3

an increase in home health care, thus, highlighting the need for effective patient

education (Whitman et al., 1992).
More recently, managed care gained increasing recognition in the 1990s
(Kremer & Faut-Callahan, 1998). Managed care seeks to drive down health care
costs through such measures as prevention and health education.

Lastly, Healthy People 2000: National Promotion and Disease Prevention
Objectives was published in 1990 (United States Department of Health and

Human Services [USDHH], 1990). Healthy People 2000 indicated health

education as being essential to achieving health promotion and disease

prevention.

Released on January 25, 2000, Healthy People 2010 (USDHH, 2000)
continues the commitment to patient education. One of the goals for 2010 is to

improve the quality, availability, and effectiveness of educational and community
oriented programs created to prevent disease, and to enhance health and quality of

life. The methods of improving education in the health care setting are to provide
quality patient and family education, and to increase patient satisfaction and
community health promotion activities.

Prior to the evolution of patient education to today’s standards, patient
information was often presented in a haphazard fashion with little evaluation of

the patient’s understanding (Falvo, 1994). Patients were expected to assume a
passive role and not question their care. This attitude is now changing. The onset

of ever advancing technology has contributed to an increased life expectancy and
incidence of chronic diseases (Falvo, 1994). DRGs with their effects on health

4

care reimbursement, in-patient acuity, shorter lengths of stay, and an increase use
of home health care (Boyd, 1992a) in combination with patients acquiring a more

active role in their health care has necessitated reform in health care education
(Bastable, 1997; Boyd, 1992a; Falvo, 1994).

Patient Education Materials
Patient education materials consist of videotapes, audiotapes, slides, films,

closed circuit television, movies, pamphlets, books, and fact sheets (Boyd, 1992b;
Hainsworth, 1997; Falvo, 1994; Pohl, 1981). In recent years, computer based

education has also been developed (Homer et al., 2000). Although these materials

are many and varied, Falvo (1994) and Boyd (1992b) cautioned the nurse
practitioner to use teaching aids to reinforce and illustrate information, not in lieu
of practitioner-patient interaction.

Printed education materials (PEMs) are the most accessible and widely

used (Hainsworth, 1997; Mathis, 1989). PEMs are less expensive than other
forms of patient education materials and have the advantage of being portable and

serve as a take home reference (Bernier & Yasko, 1991, Boyd, 1992b). Pohl

(1981) noted that PEMs are the most valuable of patient education materials

because they may be presented either to the patient before the topic is discussed,
to arouse interest, or may serve as reinforcement and provide supplementary

information.
The utilization of commercially available PEMs is less time consuming;

however, Hainsworth (1997) proposed using self-composed PEMs to increase
ld readability of content, and to decrease cost. In addition,
accuracy, adequacy, am

5

self composed PEMs can be tailored to meet the specific teaching needs of the

targeted patient population (Falvo, 1994; Farrell-Miller & Gentry, 1989;

Hainsworth, 1997; Pohl, 1981).
Problem Statement

An estimated 1 to 5 million Americans develop a deep vein thrombosis
(DVT) each year (Kurowski, 1997), and DVT is estimated to account for more

than 600,000 hospitalizations annually (Yeager & Matheny, 1999). An acute
DVT is a serious and potentially fatal illness that can complicate the hospital
course of inpatients as well as affect outpatients and otherwise healthy persons

(Lensing & Prandoni, 1999). DVT is associated with several complications
(Kurowski, 1997; Lensing & Prandoni, 1999; Gorman, Davis, & Donnelly, 2000)
and the management of DVT is costly (Boccalon, Elias, Chale, Cadene & Gabriel,
2000). Ineffective patient education compounds these costs and complications

(Falvo, 1994).
Theoretical Framework
For the purpose of this project, Dorothea Orem’s (2001) Self-Care Deficit

Theory of Nursing will be utilized as the theoretical framework. In her theory,

Orem described three key theoretical concepts, self-care deficit, self-care

(dependent care), and nursing systems.
A self-care deficit speaks to the relationship between the ability of the
person to care for one’s self and the care that is demanded (Orem, 2001). If the

patient is unable to meet the required self-care demand, a self-care deficit exists.

6

Self care, on the other hand, occurs when individuals initiate and perform
acts on their own behalf to maintain life, health, and well-being (Orem, 2001).

Dependent care occurs when another individual must perform these activities for

someone who is socially dependent such as a child.
Finally, nursing systems is the sum of all the actions and interactions of

the nurse and patient (Orem, 2001). This concept incorporates the theories of

self-care deficit and self-care. The nurse is capable of determining if nursing help
is necessary by examining the actual or potential deficit relationships between the

abilities of the patient and the need for action by the patient to maintain or achieve
health. An individual benefits from nursing because of health related limitations
in providing care for self.

The goal of the nursing system is to maximize the individual’s ability to

meet a health need or to decrease the demand through the methods of helping
(Orem, 2001). Orem identified the following as methods of helping: (a)

performing for another, (b) guiding and leading another, (c) administering

physical and psychological support, (d) providing an environment that encourages

development, and (e) teaching. Thus, through these acts, the nurse assists the
patient in achieving self-care requirements.
Teaching is an important function of the nurse (Orem, 2001). Orem
wrote, teaching another who requires instruction to develop specific knowledge or
skills is a valid method of helping. In order to effectively teach, the nurse must

identify the patient’s background, lifestyle, and modes of thinking and

understanding, as well as self-care requisites. The nurse utilizes this information

7

to provide personalized patient instruction that will best assist the patient to
achieve self-care.
When applying Orem’s theory of nursing to this project, the patient with a

DVT is the self-care agent. The nurse practitioner, using the supportive-educative

nursing system, identifies the patient’s self-care knowledge deficits. The

practitioner then instructs and provides printed education material about DVT to
assist the patient in achieving self-care requisites.

Statement of Purpose

Patient education is a means of improving the health of the American

people (Whitman et al, 1992). By teaching patients about their illness, treatment,
and preventative measures, patients achieve an increased ability to make choices
about their health (Falvo, 1994; Orr, 1990). The use of printed education

materials (PEMs) is one method to facilitate the achievement of health (Falvo,

1994). Patients with DVTs provide one such opportunity for the use of PEMs for
health improvement.
The purpose of this project is to create a patient education pamphlet
addressing the risks, signs and symptoms, diagnosis, complications, and treatment

of DVT including preventative measures. The pamphlet is to be used to

supplement verbal instructions given by the nurse practitioner to the patient with a
DVT.

8

Assumptions
For the purposes of this project, the following assumptions were

identified:

1 The patient has been diagnosed with or is at risk for deep vein

thrombosis.

2. The patient has a self-care knowledge deficit.
3. The patient is able to read and comprehend English at a minimum of the
seventh grade level.

4. The patient is motivated to learn.
5. The patient is able to apply learning to alleviate self-care deficit.
6. Nurse practitioners are effective patient educators.

Definition of Terms

For the purposes of this research project, the following terms have been

identified:
1. The patient is a receiver of care including education (Orem, 2001).

2. Teaching is a deliberate act that involves the planning and delivery of
instructional activities and experiences to meet intended learner objectives

(Bastable, 1997).
3. Learning is the process through which change in a person’s behavior,

knowledge, skill, or attitudes occurs in response to exposure to environmental
stimuli (Bastable, 1997; Boyd, 1992b; Pohl, 1981).

9

4. Patient education is the process by which persons acquire health-related

behaviors that are assimilated into daily life with the goal of obtaining optimal
health and independent self-care (Bastable, 1997; Orem, 2001)

5. Deep vein thrombosis (DVT) is the occurrence of a blood clot within or

between the deep veins of an extremity which leads to venous obstruction and
damage to the valves of the vein (Gorman, Davis, & Donnelly, 2000).
6. Heparin is an anticoagulant that acts by preventing the conversion of

prothrombin to thrombin and the liberation of thromboplastin from platelets

(Thomas, 1997).

7. Standard unfractionated heparin (UFH) is intravenous heparin with an
average molecular weight of 15 kilodaltons (Fitzgerald, 1999).

8. Low molecular weight heparin is subcutaneous heparin with a
molecular weight between 4 to 6.5 kilodaltons (Fitzgerald, 1999).
Summary
Patient education is constantly changing to meet the demands placed by

today’s health care system (Bastable, 1997; Falvo, 1994; Whitman et al, 1992).
Many acts, laws, and regulations have been passed that reflect this dynamic

process. Subsequently, a multitude of commercially prepared patient education
materials have been produced (Bastable, 1997; Boyd, 1992b; Falvo, 1994; Pohl,
1981). These materials, however, often do not meet the needs of the targeted

patient population (Falvo, 1994; Farrell-Miller & Gentry, 1989; Hainsworth,

1997; Pohl, 1981).

10

Dorothea Orem’s Self-care Deficit Theory of Nursing (2001) recognizes

that the ill patient may have self-care knowledge deficits. Patient education is a
means to improve the health of the ill patient (Whitman et al., 1992). DVT is a

serious and potentially fatal illness that provides an opportunity for education and
health improvement (Lensing & Prandoni, 1991). In this instance, the nurse

practitioner may wish to use self-composed education materials.
Finally, this chapter identified six basic assumptions of this project.
Terms germane to this project were also defined.

11

Chapter 2

Review of the Literature
Included in this chapter is a general discussion of deep vein thrombosis
(DVT). The pathophysiology, risk factors, clinical features, diagnosis, treatment,

and complications of DVT are discussed within the context of a review of the
literature.

Also addressed in this chapter is patient education. Through a review of

the literature, the definition, purpose, and principles of patient education are

identified. Additionally, the development of printed education materials (PEMs)
and self-composed PEMs are reviewed. Finally, emphasis is placed on the
readability of PEMs as well as two models for designing and evaluating PEMs,

are discussed.
Deep Vein Thrombosis (DVT)
DVT accounts for greater than 600,000 hospital admissions annually in
the United States (Yeager & Matheny, 1999). DVT is often asymptomatic

(Gorman, Davis, & Donnelly, 2000), yet substantial suffering may also occur
(Rodriguez, 1998). This potentially fatal disease may affect both outpatients and

the hospitalized (Lensing & Prandoni, 1999).
An estimated 1 to 5 million Americans develops deep vein thrombosis

(DVT) each year (Kurowski, 1997). The true incidence of DVT is not easily

established (Lensing & Prandoni. 1999). This difficulty is due to the under use of
standardized diagnostic procedures in some studios, and the fact that patients with
DVT are often asymptomatic. The incidence of DVT, however, is rare in young

12

persons. As the U.S. population ages, the risk of DVT increases, thus,
highlighting the importance of accurate treatment and prevention (Rodriguez,

1998).

Nordstrom, Lindblad, and Kjellstrom (1992) completed a prospective
study of the incidence of DVT within the defined urban population of Malmo,

Sweden in 1992. The study revealed an incidence of DVT of 1.6 per 1000

inhabitants per year. This finding is similar to the incidence of 1.8 per 1000
observation-years discovered in a longitudinal study of men bom in 1913

(Hansson, Werlin, Tibbin, & Eriksson, 1997). These studies are reflective of
predominantly white populations.

Pathophysiology

A century of research has been performed to establish the etiology of

DVT (Rodriguez, 1998). Virchow’s triad is the accepted explanation for the

formation of a venous thrombosis (Burroughs, 1999; Lensing & Prandoni, 1999;
Rodriguez, 1998). Virchow’s triad consists of three elements that predispose an
individual to venous thrombosis: (a) a hypercoagulable state, (b) damage to the
vascular intima, and (c) venous stasis.
Hypercoagulable states include deficiencies of antithrombin, proteins C

and S, factor V Leiden, and plasminogen; resistance to activated protein C;

mutation in the factor II gene, mutation in the factor V gene, and increased levels

of factors VIII, IX, or XI or Fibrinogen (Lensing & Prandoni, 1999; Kurowski,

1997; Rodriguez, 1998; Seligshon & Lubetsky, 2001). Less commonly, increased
levels of homocystein may also result in hypercoagulation (Seligsohn &

13

Lubetsky, 2001). Recently, a genetic link has been established for these

hypercoagulable states. Approximately 40% to 60% of patients presenting with a
first episode of DVT have one or more of the aforementioned hypercoagulable

states (Lensing & Prandoni, 1999).
Damage to the vascular intima usually results from trauma or surgery

(Rodriguez, 1998). Surgeries with the greatest risk for DVT are orthopedic
surgery, especially involving the hip and knee, neurosurgery, urological and
gynecological surgeries (Estrada & McElligott, 1999; Gorman et al., 2000;

Kurowski, 1997).
Venous stasis is the most common predisposing factor (Rodriguez, 1998).
Those patients who have limited or no mobility are at highest risk.
The venous system is comprised of deep and superficial veins (Tortora &

Anagnostakos, 1987). The superficial veins of the upper extremities are the
cephalics, basilics, and median antebrachials and of the lower extremities are the
great and small saphenous veins. The deep veins of the upper extremities are the

radials, ulnars, brachials, axillaries, and subclavians and of the lower extremities
are the posterior and anterior tibials, popliteal, and femorals. The majority of
thrombi begin in the valve cusps of deep calf veins (Beers & Berkow, 1999).
Gorman et al. (2000) described thrombus formation in the lower extremity

in the following manner. First, the thrombosis usually forms secondary to venous
stasis or the slowing of the flow of blood around venous valve sinuses. Then,
extension of the primary thrombus between the deep and superficial veins of the

14

leg occurs. The resulting thrombus

causes venous obstruction, injury to valves,

and possible thromboembolism.

Risk Factors
The risk factors for DVT are numerous and varied. Rodriguez (1998)

presents a comprehensive listing of risk factors following Virchow's triad of

hypercoagulability, stasis, and vascular injury (Appendix A).
Most sources agree on the following risk factors: (a) advanced age, (b)

malignancy, (c) surgery, (d) immobilization; (e) fractures, (f) pregnancy and

puerperium, (g) use of estrogen, (h) presence of varicosities, (i) hypercoagulable
states, and (j) previous DVT (Huffman, 1998; Gorman et al, 2000; Kurowski,

1997; Lensing & Prandoni, 1999; Rodriguez, 1998). Lensing and Prandoni

(1999) noted that obesity is not a clearly established independent risk factor.
Clinical Features
The predominant symptom of a unilateral DVT is asymmetrical lower

extremity swelling of 48 to 72 hours in duration (Hunt, 1999). The affected lower
extremity is often three centimeters larger in comparison to the unaffected lower
extremity. Other clinical signs of a DVT are (a) pain, (b) discoloration, (c)
warmth, (d) superficial venous distension, (e) palpable cords, (f) distal lower

extremity edema, (g) Homan’s sign and (h) superficial thrombophlebitis (Hunt,
1999; Gorman et al, 2000). Two florid presentations can also occur, phlegmasia

cerulea dolens-the blue leg, and phlegmasia alba dolens-the white leg (Hunt,
1999).

15

The clinical signs and symptoms of DVT vary greatly and clinical

assessment alone is not reliable in diagnosing DVT (Huffman, 1998; Hunt, 1999;
Rodriguez, 1998). The sole utilization of clinical judgment to diagnose DVT is

accurate in approximately 50% of cases (Hobson, Minz, & Jamil, 1990;

Kurowski, 1997). Thus, clinical evaluation and diagnostic testing should be used
in combination to increase accurate identification of DVT (Huffman, 1998; Hunt,
1999; Rodriguez, 1998).

Diagnosis
There are several available diagnostic tests for DVT (Gorman et al, 2000;

Hunt, 1999; Kurowski, 1997; Lensing & Prandoni, 1999; & Rodriquez, 1998).
The most common are contrast venography, compression ultrasonography with

doppler, and impedance plethsmography.
The gold standard for the diagnosis of DVT is contrast venography

(Gorman et al. 2000; Hunt, 1999; Kurowski, 1997; Lensing & Prandoni, 1999; &
Rodriquez, 1998). This invasive procedure involves visualization of targeted

veins using a contrast medium and roentenography (Thomas, 1997). Contrast
venography is not the first line diagnostic test for DVT due to its invasive nature,
cost, technical difficulty, time-consuming nature, discomfort to the patient, and

risks of phlebitis, thromboembolism, and allergic reaction to contrast medium

(Gorman, et al. 2000; Hunt, 1999). Contrast venography is recommended when
the results of clinical findings and noninvasive tests are unconvincing (Hunt,

1999) and for diagnosing thromboses arising below the knee (Rodriguez, 1998).

16

Compression ultrasonography with doppler imaging is the most widely
used diagnostic test for DVT (Gorman, et al., 2000; Hunt, 1999; Lensing &

Prandoni, 1999; Miller, 1999; & Rodriquez, 1998). Ultrasonography is
nomnvasive, safer, and less costly than venography. Ultrasonography involves
the compression of the proximal veins with the ultrasound transducer (Lensing &

Prandoni, 1999). The inability to compress a vein is indicative of a deep vein

thrombosis. Duplex and color-coded doppler imaging may be added to assess
venous flow, however, there is some disagreement as to the usefulness of doppler

studies in establishing the diagnosis of a DVT.

Weinmann & Salzman (1994) noted compression ultrasonography with
doppler to have both a sensitivity and specificity of 97%. The sensitivity and

specificity of compression ultrasonography is enhanced with the addition of Ddimer testing and the use of clinical scores (Gorman et al., 2000; Hunt, 1999;

Lensing & Prandoni, 1999).

D-dimer is a byproduct of fibrin production (Gorman et al., 2000). The
elevation of the serum concentration of D-dimer is indicative of a thrombosis, but
the elevated D-dimer is not specific for DVT (Gorman et al., 2000, Hunt, 1999,
Lensing & Prandoni, 1999). D-dimer may also be elevated as a nonspecific
response to a concurrent illness, not just a thrombosis (Gorman et al., 2000). D-

dimer is best used in combination with compression ultrasonography for the

diagnosis of DVT. The sensitivity of this combination is 98% with a high negative

predictive value for ruling out DVT.

17

Combining the use of clinical scoring with compression ultrasonography
increases diagnostic accuracy. (Gorman et al., 2000; Hunt, 1999). Wells, Hirsch,
and Anderson (1995) created a method of clinical scoring that categorizes the
patient as having a high or low probability of DVT based on established clinical

points (Appendix B).
Another noninvasive diagnostic test for DVT is impedance

plethysmography (Hunt, 1999; Rodriguez, 1998). Rodriquez (1998) described

impedance plethysmography gas measuring “the maximal filling of the venous
system in the leg after extrinsic venous compression with a thigh cuff and venous

emptying during the first 3 seconds after its release” (p. 715).

Treatment of DVT
Treatment of DVT includes anticoagulation, fibinolytic therapy, and

surgery. Germane to all treatment modalities is anticoagulation. Regardless of

the method, the goal of treatment is to reduce symptoms and prevent
complications (Gorman et al., 2000).

Anticoagulation

Anticoagulation of an acute DVT is a necessary treatment (Burroughs,

1999; Estrada et al., 2000; Gorman et al., 2000; Hunt, 1999; Kurowski, 1997;
Lensing & Prandoni, 1999; Rodriguez, 1998; Yeager & Matheny, 1999).

Anticoagulation therapy is available as unfractionated heparin, low molecular

weight heparin, and warfarin.

18

1)^ Traditional treatment of an acute DVT has
been hospitalization for 5 to 7 days and intravenous administration of UFH with

an overlap of oral anticoagulation (Burroughs, 1999; Estrada et al., 2000; Gorman

et al., 2000; Hunt, 1999; Kurowski, 1997; Lensing & Prandoni, 1999; Rodriguez,

1998; Yeager & Matheny, 1999). The development of low molecular weight
heparin (LMWH) has made the traditional role of UFH less clear (Gorman et al.,

2000; Hunt, 1999; Lensing & Prandoni, Yeager & Matheny, 1999). These

researchers note that UFH should be reserved for complicated DVT.
UFH establishes rapid anticoagulation by inactivating thrombin and

preventing the conversion of fibrinogen to fibrin (Thomas, 1997). An intravenous
bolus of UFH followed by a continuous infusion should be initiated immediately
upon diagnosis of a DVT (Gorman et al., 2000; Hunt, 1999; Kurowski, 1997;

Lensing & Prandoni, 1999; Rodriguez, 1998; Yeager & Matheny, 1999). The

infusion is titrated to maintain an activated partial thromboplastin time (aPTT) of
1.5 to 2.5 times control. This requires frequent, daily monitoring of the aPTT

utilizing an algorithm to adjust the dose of heparin.
There are associated side effects with the use of heparin therapy,
regardless of the molecular weight, and absolute contraindications (Kurowski,

1997). The main side effects of heparin are bleeding and thrombocytopenia. The
absolute contraindications are: (a) known major bleeding diatheses, (b) central
nervous system or eye surgery within the last 6 weeks, (c) known hypersensitivity

to heparin, and (d) major abdominal or chest surgery within the last 48 hours.

19

LMWH in combination with
oral anticoagulation is FDA approved for the inpatient treatment of acute DVT

with and without pulmonary embolism (Yeager & Matheny, 1999). LMWH can
also be used for the outpatient treatment of acute DVT without pulmonary
embolism.

LMWH inhibits factor Xa, augments tissue-factor-pathway inhibitor, and
minimally effects antithrombin thereby eliminating the measurement of aPTT as

seen with UFH (Yeager & Matheny, 1999). When compared to UFH, LMWH
has greater bioavailability and minimal inter-patient and intra-patient variability

in response to a given dose. These differences result from the decreased ability of
LMWH to bind to plasma proteins, endothelium, and macrophages.

Consequently, the dosage for LMWH is calculated using body weight without the
need for monitoring laboratory values. Also, several studies have demonstrated

efficacy, safety, and cost-effectiveness of the use of LMWH in the treatment of
uncomplicated DVT (Yeager & Matheny, 1999).
Two large Canadian clinical trials conducted by Harrison, McGinnis,

Crowther, Ginsberg, and Hirsh (1998) confirmed that the use of LMWH for
outpatient treatment of DVT is safe and effective. The research design was a

prospective cohort study of consecutive patients presenting to two
thromboembolism clinics in an Ontario metropolis. The rate of fatal embolism
was 1%,

the rate of recurrent DVT or pulmonary embolism was 6%, and the

incidence of a major bleeding episode was 1%. These clinical trials also

demonstrated that more than 75% of patients with diagnosed DVT referred to the

20

two tertiary care centers eou!d be treated at home, thus, decreasing the overall

cost of care. This percentage was confirmed by another Canadian study by Wells
et al. (1998). In this study, 194 of 233 consecutive patients at atertiaty care
hospital were eligible for outpatient treatment of acute DVT. The researchers

noted that more than 80% of patients at the studied tertiary care hospital could
have received outpatient treatment for DVT.

The Tinzaparine ou Heparine Standard: Evaluations dans 1’Embolie

Pulmonaire (THESEE) study in France, the Columbus Investigators study in the
Netherlands, and the American-Canadian Thrombosis Study Group were

conducted to evaluate the efficacy and safety of LMWH in comparison to UFH
(Saunders, 2000). All the studies revealed LMHW to be at least as effective and

safe as UFH.

Estrada, Mansfield, and Heudebert (2000) designed a decision model in
which a cohort of 1,000 patients with DVT of the lower extremity was

categorized by treatment with UFH in an inpatient setting or LMWH in the
outpatient setting in North Carolina. The clinical outcomes measured were, (a)
recurrent thrombosis, (b) mortality, (c) direct medical costs, and (d) marginal
cost-effectiveness ratios from the payer’s perspective. The results per 1,000

patients were: (a) 10 fewer eases of recurrent thrombosis, (b) 1.2 fewer deaths, (c)
14% reduction in cost of care, and (d) the cost-effectiveness ratio was J9,667 and

$80,685 per recurrent thrombosis or death prevented, respeedvely, in favor of
LMWH.

21

The Vascular Midi-Pyrenees Study compared hospital versus home

treatment of DVT with LMWH (Boccalon, Elias, Chale, Cadene, & Gabriel,
2000). The study was conducted with 201 patients presenting with a proximal

DVT. The patients were randomized to receive LMWH and warfarin either as an
inpatient for the first 10 days of therapy (n=102) or as an outpatient from the

outset (n=99). This research revealed a cost savings of 56% with home treatment.

There was no statistical difference (p< 0.20) between the groups in terms of
clinical outcomes. The research concluded, “home treatment using a low-

molecular-weight heparin is an effective, safe, and cost-saving strategy” (p.
1769).
O’Brien et al. (1999) conducted a study of the cost-effectiveness of

outpatient treatment of DVT with LMWH in Hamilton, Ontario. Data were
collected prospectively on resource use and health related quality of life from the
300 patients in the trial. The sample was created by selecting the first 300 to

present as outpatients with the diagnosis of proximal DVT. The patients were
then randomized to receive hospitalization and UFH (n=l 51) or to receive

LMWH as outpatients (n=149). This economic study revealed a mean cost per
patient who received UFH to be 5323 Canadian dollars as compared to 227

Canadian dollars for LMWH.
These research studies have demonstrated LMWH to be an efficacious,
safe, and cost-effective alternative to the use of traditional UFH. Other advantages
to LMWH in comparison to UFH are ease of administration (subcutaneous route

versus intravenous route), decrease in heparin-induced thrombocytopenia,

22

decrease incidence of bleeding, and lack of need for laboratory monitoring
(Lensing & Prandoni, 1999).
Oral anticoagulation. Regardless of the method of initial anticoagulation,

oral anticoagulation therapy is required (Burroughs, 1999; Gorman et al., 2000;
Hunt, 1999; Kurowski, 1997; Lensing & Prandoni, 1999; Rodriguez, 1998;

Yeager & Matheny, 1999). Warfarin is an oral anticoagulant that inhibits the
production of vitamin K- dependent coagulation factors (Levine, 1999). Warfarin

is initiated concomitantly with either UFH or LMWH (Burroughs, 1999; Gorman
et al., 2000; Hunt, 1999; Kurowski, 1997; Lensing & Prandoni, 1999; Rodriguez,

1998; Yeager & Matheny, 1999). Frequent monitoring of the international
normalized ratio (INR) is required and dosage of warfarin is adjusted until an INR

of 1.5 times the control is achieved. Periodic assessment of the INR is required

until warfarin treatment is discontinued. Non-oral forms of anticoagulation are
discontinued once the INR is stabilized within the range of 2.0 to 3.0.

There are no definitive guidelines for the optimal duration of

anticoagulation therapy (Lensing & Prandoni, 1999; Solymoss, 1999). The
duration of oral anticoagulation is guided by the temporary or persistent risk

factors of recurrent DVT weighed against the risk of bleeding. Warfarin should be
continued 3 months in an uncomplicated episode of DVT or 6 months for a

complicated DVT (Gorman et al., 2000; Lensing & Prandoni, 1999; Kurowski,

1997; Rodriguez, 1998). Lifelong therapy should be considered in those patients
with a risk of recurrent thrombosis exceeding the risks associated with prolonged
anticoagulation (Gorman et al., 2000, Kurowski, 199 )

23

Fibrinolytic Therapy
Another treatment option for acute DVT is fibrinolytic therapy
(Burroughs, 1999; Kurowski, 1997; Lensing & Prandoni, 1999). Catheter-

directed infusion of a fibrinolytic agent such as t-PA, streptokinase, or urokinase

accelerates the lysis of the venous thrombi. Early lysis of the thrombus is more
likely to preserve valve function than other treatments. The infusion must be

accompanied by the intravenous infusion of UFH with subsequent warfarin
therapy.

Because fibrinolytic therapy is associated with a 3 to 4 fold increased risk
of bleeding, fibrinolytic therapy is recommended only for patients with massive
limb-threatening ischemia (Lensing & Prandoni, 1999). Burroughs (1999) also

recommended the use of catheter directed lysis in those patients with suspected
vascular anomalies.

Surgical Interventions
Surgical interventions may also be employed to treat an acute DVT

(Gorman et al., 2000; Kurowski, 1997; Lensing & Prandoni, 1999). Inferior vena
cava filters and thrombectomy are two surgical procedures that may be

implemented.
For patients who have contraindications to or failure of anticoagulation

therapy or have recurrent pulmonary embolism despite adequate anticoagulation,
an inferior vena cava filter is indicated (Gorman et al, 2000; Kurowski, 1997;

Lensing & Prandoni, 1999). Inferior vena cava filters will decrease the incidence

of pulmonary embolism but have no effect on other DVT complications.

24

Thrombectomy is not a routine treatment of an acute DVT (Gorman et al.,
2000; Lensing & Prandoni, 1999). Only those patients with life threatening or
massive venous thrombosis unresponsive to other treatments are candidates for

thrombectomy.
Complications
An acute DVT may give rise to several complications (Gorman et al.,
2000; Kurowski, 1997; Lensing & Prandoni, 1999; Miller, 1999; Rodriguez,
1998; Saunders, 2000). The most common complications are post-thrombotic

syndrome, pulmonary embolism, and recurrent DVT.

Post-thrombotic syndrome
Post-thrombotic syndrome results from venous hypertension, caused by

prolonged venous obstruction and damage to venous valves, and from abnormal

microcirculation (Gorman et al., 2000; Lensing & Prandoni, 1999). The clinical
manifestations are pain, dermatitis, ulceration, and lifelong swelling of the
affected extremity (Kurowski, 1997). Lensing and Prandoni noted that the exact

incidence of post-thrombotic syndrome after DVT is not precisely known due to
limited or biased studies. Gorman et al. estimated the occurrence to be 50% to

75%.

Pulmonary embolism
Pulmonary embolism (PE) is the most serious complication of DVT

(Rodriguez, 1998). Approximate!, 30% to 40% of patients with clinical DVT

25

develop PE (Kurowski, 1997), and an estimated 50,000 Americans yearly die

from PE (Rodriguez, 1998). Miller (1999) estimated more than 600,000

Americans a year are diagnosed with PE which results in the death of one sixth of
these patients. Kurowski noted PE to be the third leading cause of immediate
death in the United States.

Approximately 80% of pulmonary emboli originate from a lower
extremity DVT (Miller, 1999). The thrombi from the deep leg veins are

transported to a pulmonary artery causing the obstruction of blood flow to one or

both lungs (Saunders, 2000). The obstruction of pulmonary blood flow causes the
failure of the right ventricular. Death from PE is usually secondary to right

ventricular failure.

Recurrent DVT
Recurrent DVT is another complication of DVT (Gorman et al., 2000;

Lensing & Prandoni, 1999). Lensing and Prandoni noted the diagnosis of a
recurrent DVT is difficult due to the nonspecific nature of clinical diagnosis and

limitations of available diagnostic testing. An estimated one-third of patients with
an initial episode of DVT will present within the following year with signs and
symptoms suggestive of a recurrent DVT. Only one in three of these patients will

have a confirmed recurrent DVT.
Accurate diagnosis and treatment of DVT is important in order to prevent
serious, even fatal, complications (Falvo, 1994). Patient education about the

many facets of their health-related problem is necessary to improve their potential
for optimal health outcomes and minimize complicatio

26

Patient Education
The issue of cost containment of health expenditures has led to decreased

lengths of stay in acute care facilities, increased home health care, and outpatient
management of illness (Whitman, Graham, Gleit, & Boyd, 1992). In response to
the changing health care system, the role of patient education has gained

increased importance.
Definition of Patient Education

Patient education, as described by Bastable (1997), is the process of
assisting individuals to learn health behaviors in order to integrate them into

everyday life. Whitman et al. (1992) wrote that patient education is implemented
for those persons, their families, and significant others who are dependent on the

health care system for diagnosis, treatment, or rehabilitation.
Purpose of Patient Education

Whitman et al. (1992) noted that the purpose of patient education is to
improve the health status of the American public. Bastable (1997) concurred by

writing the purpose of patient education is achieving optimal health and

independent self-care. Patient education increases the patient’s knowledge about a
health-related condition, treatment, or measures of prevention with the purpose of
increasing the patient’s ability to make decisions pertaining to healthy behaviors
(Falvo, 1994).
Process of Patient Education

Patient education is an orderly, sequential, and deliberate course of action
comprised of teaching and learning (Babble, 1997). Teachtng and .earning are

27

interdependent and fom a continuous cycle. The edutational process is |ikened to
the nursing process (Boyd, 1992b; Falvo, 1994). Assessment, plamting,

implementation, and evaluation are necessary elements of effective patient

education.
Educational process. The educational process begins with assessment
(Boyd, 1992b; Falvo, 1994; Whitman, Graham, Gleit, & Boyd, 1992)) and is the

key to effective patient education (Close, 1988). Assessment involves collecting

data and identifying needs and objectives (Boyd, 1992b; Falvo, 1994; FarrellMiller & Gentry, 1989; Mathis, 1989; Pohl, 1981). The following patient factors

are considered in the assessment phase: (a) motivation, (b) readiness to learn, (c)
social influences, (d) cultural influences, (e) health beliefs, (f) health needs, (g)

life stage, (h) educational background, and (i) personality traits. The environment
in which the patient learns, and any interfering medical treatments, should be

identified.

Planning requires the prioritization of educational needs and the

organization of teaching (Boyd, 1992b; Falvo, 1994). Goals and objectives are

identified during this phase.
Objectives define the behavior the patient is expected to achieve, how the
patient will acquire the behavior, and the criteria by which the successful
performance of the behavior will be evaluated (Bastable, 1997; Boyd, 1992b;

Rega, 1993; Pohl, 1981). Objectives must be patient oriented and realistic

(Bastable, 1997; Rega, 1993).

28

Implementation follows the planning phase (Boyd, 1992b; Falvo, 1994).

During this phase, the teaching plan is put into action.
Evaluation is the final stage in the educational process (Boyd, 1992b;

Close, 1988, Falvo, 1994; Farrell-Miller & Gentry, 1989; Lange, 1989; Mathis,

1989). Evaluation is an ongoing process. Each phase of the educational process
should be evaluated according to the predetermined objectives.

ASSURE model. Rega (1993) proposed the ASSURE model for patient

education. This model also corresponds to the nursing process.
“ASSURE is an acronym for: analyze learners, state objectives, select

media and materials, utilize materials, require learner performance, and
evaluate/revise the learning and teaching process” (Rega, 1993, p. 477). The goal
of this model is to change the patient’s behaviors and attitudes to facilitate the

achievement of self-care.

Analysis of the learner is the most important function of the nurse
practitioner in providing effective education (Rega, 1993). The determination of
the patient’s learning style, reading level, past experiences, capability to learn, as

well as social and cultural influences will assist the nurse practitioner in the

development of a productive educational tool.

Effective objectives are clear, attainable, and measurable (Rega, 1993).
Objectives may be classified as (a) cognitive, involving intellectual assimilation
of new information, (b) affective, involving attitudes, feelings, and emotions, or

(c) psychomotor, involving motor skills.

29

The basis for the selection and utiiization of materials is the enhancement

of patient learning (Rega, 1993). The educational materials should be specific to
the patient and adaptable to the teaching environment.
In order to achieve the learning objectives, the patient must be an active

participant (Rega, 1993). The patient must comprehend and internalize the
behavior in accordance with the objectives.

Evaluation is an ongoing process integral to the education process

(Bastable, 1997; Boyd, 1992b; Pohl, 1981; Rega, 1993). The ability of the printed
education material (PEM) to meet the patient’s educational objectives is the

standard the PEM is evaluated against. Evaluation detects the efficacy of the

PEM and misinformation contained within the PEM. Evaluating the patient is
equally important to determine the level and accuracy of comprehension as well

as the needs of the patient. The evaluation process serves to reinforce the
objectives and as a means to acquire feedback about the PEM

Printed Education Materials (PEMs)

PEMs are among the most economical and most widely employed
methods for teaching individuals about health issues (Bastable, 1997, Bemier &
Yasko, 1991; Pohl, 1981). PEMs consist of handouts, leaflets, books, pamphlets,

brochures, and instruction sheets.
The virtues of PEMs are that they are portable, flexible, cost-effective, and

accessible (Bastable, 1997; Bernier & Yasko, 1991; Farrell-Miller & Gentry,
1989; Lange, 1989). When using PEMs, patients can control the time and rate of

learning as »efi as share the .nformation with significant otters (Lange, 1989).

30

The written word is permanent and can, therefore, be need as a referenda and as a

means of clarification of oral instruction (Bastable, 1997; Bernier & Yasko, 1991;

Farrell-Miller & Gentry, 1989; Lange, 1989).
Self-composed PEMs
Despite the plethora of commercially available PEMs, the nurse

practitioner may find that these materials do not meet the identified patient
teaching needs (Bastable, 1997; Farrell-Miller & Gentry, 1989; Lange, 1989;

Pohl, 1981; Whitman et al., 1992). Self-composed PEMs allows the nurse
practitioner to create an education medium that is specific and unique for the

provider-patient relationship. In addition, self-composed PEMs provide the nurse

practitioner with an opportunity to create a teaching tool for which no previous
literature exists (Lange, 1989) or to create a more readable PEM (Bastable, 1997;

Boyd, 1992b; Davis, Michielutte, Askov, Willliams & Weiss, 1998; Doak &
Doak, 1980; Falvo, 1994; Murphy, Chesson, Walker, Arnold, & Chesson, 2000;

Whitman et al., 1992).
Readability of PEMs

A common problem among both commercially prepared and self­

composed PEMs is readability (Bastable, 1997, Boyd, 1992b, Davis et al., 1998,
Doak&Doak, 1980; Falvo, 1994; Murphy et al„ 2000; Whitman « al„ 1992),

Readability is determined by the patient’s ability to comprehend the material.
Patient education is effective only if the patient is able to receive and comprehend
■he message the nurse practitioner is deiivering (Falvo, 1994). Gemta„e to tins

concept is the patient’s literacy level. Literate persons are those who can read at

31

or above the eighth grade ievel (Boyd, 1987; Doak & Doak, J9S0; Whit™ « al,

1992).

Approximately 20% of American adults cannot read or understand health
care literature (Doak & Doak, 1996; Miles & Davis, 1995; Kirsch, Jungeblut,
Jenkins, & Kolstad, 1993; Williams et al., 1995). The average reading level of

adults in the United States is at or below the eighth grade (Boyd, 1987; Farrell-

Miller & Gentry, 1989; Lange, 1989; Whitman et al., 1992).
Murphy et al. (2000) conducted the Rapid Estimate of Adult Literacy in

Medicine (REALM) test using participants in a patient education study. In

concurrence with the U.S. average, the result was an average reading score of
seventh to ninth grade. Forty percent of the participants were reading below the
ninth grade level.

Doak & Doak (1980) assessed the readability of 100 PEMs in an acute
care facility. The study revealed the mean level of material to be at the tenth
grade level. Similar studies revealed that between 60% and 92% of PEMs were

composed above the eighth grade reading level (Boyd, 1987).
The readability of PEMs can be determined by applying readability

formulas (Boyd, 1987; Doak & Doak, 1980; Farrell-Miller & Gentry, 1989;
Lange, 1989; Whitman et al., 1992). Some examples are the Fry, Fog, and Smog
readability formulas.

The Fry readability formula involves using a graph to indicate the reading

level. The average sentence length and the number of syhables for each word are

plotted on the graph to yield the reading grade level (Fry, IW

32

With the Fog formula, 100 words are counted in succession (Gunning,

1968). This number is divided by the number of complete sentences found within

the 100 words. Next, the number of words that are three or mor. syllables are
added. Finally, the result is multiplied by a constant of 0 .04. This number equals
the reading grade level.

Readability using the Smog formula requires counting 10 consecutive
sentences from the beginning of the material, 10 sentences from the middle, and

10 sentences from the end (McLaughlin, 1969). Next, the number of three syllable

words is counted. The square root of this number plus the constant of three equals
the reading grade level.

The reading level of PEMs can be reduced using the following guidelines:

(a) write short, simple sentences with one idea per sentence; (b) write in the active

voice; (c) write in second person; (d) use no greater than two syllable words; (e)
minimize eye span to a maximum of 60 to 70 characters; (f) use ample spacing,

(g) avoid using jargon; (h) avoid using all capital letters, (i) use no less than 12
font; and (j) color can be used to illustrate key points (Bastable, 1997; Boyd,

1987;Falvo, 1994; Farrell-Miller & Gentry, 1989; Whitman et al., 1992). FarrellMiller & Gentry also recommend using examples to reinforce general or abstract

concepts.
Principles of Self-composed PEMs
This review of literature established concordance among sources regarding

the principles of composing PEMs. The hey principles ar. cont.nl, layout,

33

organization, illustration,, and readnbdit,

comprehensjon

Boyd. 1992b; Falvo. ,994; Farrell-Miller & Gentry, 1989; Mathis, 1989),

Composing a FEM begins with the identification of the knowledge, skills,
attitudes, or behavior the FEM will assist the patient to achieve (Bastable, 1997;

Boyd, 1992b; Falvo, 1994; Farrell-Miller & Gentry, 1989; Mathis, 1989). These
issues formulate the content for the PEM. The content of the PEM should be

accurate, brief, objective, and focused on what the patient needs and wants to
know. Also, the content must be reflective of the learning objectives.

The layout of the PEM is advised to contain adequate use of white space

and headings (Bastable, 1997; Boyd, 1992b; Farrell-Miller & Gentry, 1989;
Mathis, 1989). Color can be used to set off headings or key material, but black ink
is easier to read. Additionally, using serif type and a print size of at least 12 point
is recommended. The objective of the layout is to facilitate readability of the

content.
Both the content and layout must be presented in an organized and

thoughtful manner (Bastable, 1997; Boyd, 1992b; Falvo, 1994; Farrell-Miller &
Gentry, 1989; Mathis, 1989). The headings must reflect the information contained
beneath them and follow a logical progression. Each paragraph requires a topic

sentence indicative of the information to be discussed.
The purpose of illustrations is to enhance the understanding of key or
complex points, filustrations ar. best utilized when they immediately Mow the

relevant information and demonstrate a singie concept (Bastable, 1997; Falvo,
1994; Farrell-Miller & Gentry, 1989; Mathis, 1989).

34

In order to facilitate the readability of a self-composed PEM, the read!
mg
level of the target audience should be identified (Bastable, 1997; Boyd. 1987;
Boyd. 1992b; Falvo, 1994; Farrell-MiUet & Gentry, 19S9; Mathis. 1989). Since
writing consistently on a specific reading level is difficult, a range of reading

levels simplifies the writing process (Boyd, 1987).
Comprehension of the health issue is the goal of self-composed PEMs
(Bastable, 1997; Boyd, 1992b; Falvo, 1994; Farrell-Miller & Gentry, 1989;

Mathis, 1989). Specificity, repetition, conciseness, and organization are central
components to enhancing comprehension. Boyd (1992b) also noted that patients
remember the first one-third and the last one-fourth of information the best.

Therefore, the nurse practitioner is advised to insert the chief health information

within the beginning or end of the PEM.
Models for Composing and Evaluating PEMs
The use of a model for composing PEMs assists the nurse practitioner to

organize the patient education process (Rega, 1993). Bernier and Yasko s (1991)
model for Evaluating Printed Education Materials (EPEM) and Lange’s (1989)
model will be discussed.

Bernier and Yasko (1991) developed the EPEM model to identify and
validate the creation and evaluation of PEMs. A pre-design phase, design phase,

pilot phase, distribution and implementation, and evaluation are the components
of the EPEM model.
During the pre-design phase, the nurse practitioner performs a needs

assessment (Bemier & Yasko, 1991). Careful consideration is given to the

35

identification of an educational need, th. puqMse ofthe pEM md

outcomes.
Writing ofthe first draft is the design phase (Bernier & Yasko, 1991). The

educational content, structure and format of the text and illustrations, as well as
organization are developed during this phase.
The pilot phase involves employing a draft ofthe PEM (Bernier & Yasko,
1991). Bernier and Yasko suggested testing the PEM with current and former

patients, experts, and health care professionals involved with the care ofthe
patient for whom the PEM is intended.

Distribution and implementation is the next phase ((Bernier & Yasko,
1991). This phase requires the identification of the means by which the PEM will
be made available to the target patient population. The PEM is then distributed.

The evaluation process requires the examination of the learning outcomes

identified during the pre-design phase (Bernier & Yasko, 1991). If an outcome

has not been achieved, the PEM is revised by the nurse practitioner.

Lastly, Lange (1989) described a less formal model for developing PEMs.
Her model begins with the identification of a learning need. Then support, both
administrative and financial, is sought for the development of the PEM

Following the definition of goals, the available resources are examined The next

step is selecting content that is (a) appropriate for th. reader’s educational level,

(b) win stimulate the reader’s interest, and (c) will faciiitatethe retention of key
information. The nurse practitioner should then write a draft. Finally, the PEM is

36

evaluated to ascertain if the original needs were met, the content is appropriate,
and the PEM is cost-effective.
Summary

This review of literature presented an overview of the pathophysiology,
risk factors, and clinical features of DVT. Treatment options and complications

of DVT were provided. Also included in this review of literature was patient

education as a means for improved health status for a person with an illness such
as DVT. The process, purpose and principles of patient education, including the

ASSURE model, were identified. Additionally, PEMs and self-composed PEM’s
were discussed. Readability was discussed as an important attribute of PEMs.
Finally, two models for composing and evaluating PEMs were reviewed.

37

Chapter 3

Methodology
The purpose of this research project was to create a patient education
pamphlet addressing the definition, risks, signs and symptoms, diagnosis,

complications, and treatment of DVT including preventative measures. The

EPEM model (Bernier & Yasko, 1991) for the development and evaluation of

PEMs was utilized. The phases of pre-design, design, pilot, distribution and
implementation, and evaluation were applied to the development process.
Pre-design Phase

A patient education committee in a northwestern Pennsylvania community
hospital identified the need for a PEM addressing DVT to be utilized in both the
inpatient and outpatient settings. This PEM will serve to supplement and reinforce

the oral education taught by the health care provider. The PEM, in the form of a
pamphlet, is targeted toward patients diagnosed with DVT or who are at high risk

for developing DVT. After reading the pamphlet, the patient will be able to

identify the following: (a) what a DVT is, (b) why thromboses occur, (c) risk
factors for DVT, (d) signs and symptoms of a DVT, (e) how a DVT is diagnosed,

(f) treatment options for DVT, (g) complications of DVT, and (h) prevention of
DVT.

Design Phase
After the identification of the learning objectives, a thorough review of

literature was conducted. The gathered information was organized in a logical

38

progression, presenting only the most essential data. The information considered
to be most relevant to the targeted audience was presented first.

Readability was enhanced by using short, simple sentences, topic
headings, second person, active voice, diagrams to explain complex ideas, no less
than a 12 font print size. Limiting eye span to 60-70 characters, one idea per

paragraph, and use of three syllable words also improved readability. By
applying the Fog formula (Gunning, 1968), the readability of the PEM was

determined to be at the seventh grade level.

The DVT pamphlet was designed using Microsoft Publisher®. The
design was chosen using a brochure format that allowed for ample spacing of text
and easy flow of information. Black ink was selected for the lettering, using a 14
font and bold lettering for headings, and 12 font for text. A colored border was
added to the top margin to enhance the presentation of the pamphlet. The
pamphlet was then printed on 11” x 14” paper and folded according to pamphlet

style.

Pilot Phase

During the pilot phase, a draft of the DVT pamphlet was presented to the
patient education committee. This committee consisted of a nurse from each of
the following hospital units: medical-surgical, medical-cardiac, orthopedic,

pediatric, neonatal intensive care unit (ICU), medical-cardiac ICU, surgical ICU,

maternity, emergency room, preadmission patient teaching, endoscopy, and same
day surgery. Also included on this committee were a pharmacist, respiratory

therapist, patient education coordinator, and an outpatient-primary care provider

39

coordinator. In addition to the patient education committee, the pamphlet was

presented to two laypersons.
Both the committee and laypersons were asked to evaluate the pamphlet
using the following criteria: (a) clarity of meaning, (b) readability, (c)
completeness, (d) accuracy, and (e) further suggestions. Recommendations from

the committee were the use of bold lettering to highlight the diagnostic tests being

discussed, the addition of cancer and previous DVT to the list of risk factors, and
explanation of an intravenous infusion of heparin. The laypersons offered no

suggestions for change. The committee and the laypersons agreed that the
information was clear, progressed logically, easy to read, complete, concise, and

pertinent.

The recommended changes from the committee were instituted. The
revised pamphlet (Appendix C) was reviewed by the committee and approved for

printing and distribution.

Distribution and Implementation Phase
Once the recommended changes were incorporated, the DVT pamphlet
was relinquished to the patient education coordinator of the northwestern
Pennsylvania community hospital. The coordinator arranged for the mass

printing and distribution of the pamphlet throughout the institution and affiliated
provider offices with the purpose of providing supplemental and reinforcement

education to the oral teaching provided by the providers and staff for those
patients with or at high risk for DVT.

40

Evaluation Phase
This final phase is an ongoing process (Bernier & Yasko, 1991). The

patient education committee at the northwestern Pennsylvania hospital where the
DVT pamphlet is implemented routinely reviews, evaluates, and updates patient
education materials in use throughout the facility. Thus, the accuracy and

relevance of PEMs is assured as well as the provision of up-to-date medical

knowledge.
A proposed method of evaluation is to conduct a formal patient evaluation

of the PEM via oral comments or a written survey. Evaluation criteria would
include clarity of purpose, readability, relevance of content, achievement of

intended outcomes, and suggestions for improvement.

Summary
This chapter described the creation of a patient education pamphlet

designed to supplement and reinforce oral education given by the health care

provider to patients with DVT or who are at high risk for DVT. Bernier and
Yasko’s (1991) EPEM model for designing and evaluating PEMs provided the
framework for the creation of the pamphlet. The phases of pre-design, design,

pilot, distribution and implementation, and evaluation were incorporated into the

development process.

41

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48

Appendix A
Medical Risk Factors Predisposing to Thromboembolism (Rodriguez, 1998)

General Factors

Advancing age
Cancer

Obesity

Pregnancy and puerperium
Prior thromboembolism

Sepsis
Hypercoagulabi 1 ity
Antithrombin III deficiency
Disorders of plasminogen and plasminogen activation

Dysfibrinogenemia
Estrogen therapy
Lupus anticoagulant

Polycythemia

Protein C deficiency
Protein S deficiency

Resistance to activated protein C
Stasis

Cardiomyopathy
Chronic obstructive pulmonary disease

Congestive heart failure

49

Myocardial infarction
Nephrotic syndrome

Paralysis

Prolonged immobilization
Stroke

Vascular injury

Trauma
Venous catheterization

50

Appendix B

Clinical Probability of Deep Vein Thrombosis (Wells, Hirsh, & Anderson, 1995)
Major clinical points

Active cancer
Calf swelling 3 centimeters >asymptomatic side

Localized tenderness along the deep venous system
Paralysis, paresis, or recent limb cast

Recently bedridden and /or major surgery within 4 weeks

Strong family history of DVT
Thigh and calf swollen (measured)
Minor clinical points

Dilated superficial veins in the symptomatic side only
Erythema

History of recent trauma to the affected leg

Hospitalization within previous 6 months
Pitting edema, affected leg only

Clinical Probability with each indicator equal to one point
High (80%-85%)

>3 major points and no alternative diagnosis
2 major points plus 2 minor points, and no alternative diagnosis

Low (<5%)

0 major points, >3 minor points, and an alternative diagnosis

0 major points, > 2 minor points, and no alternative diagnosis

51

1 major point, > 2 minor points, and an alternative diagnosis

1 major point, > 1 minor points, and no alternative diagnosis

52

Appendix C

DVT Patient Education Pamphlet

Deep Vein
Thrombosis
(DVT)

Julie S. Anderson, RN,
Student Family Nurse Practitioner
Edinboro University of Pennsylvania

53

What is a DVT?
A deep vein thrombosis (DVT) is a

blood clot (thrombosis) that forms

in the veins that are found deep
within the muscles. These veins re­
turn 90% of the body’s blood back

to the heart. DVT most often occurs

in the deep veins in your legs.

Why do clots occur?
Blood clots can form if there has
been

damage to the vein
decrease in blood flow

o

clotting disorders

Who is at risk?
You are at risk for DVT if you:
»

have recently had surgery

®

are overweight

are pregnant

54

•

have cancer of any kind

•

have had a DVT in the past
have limited or no movement of
legs for long periods of time

have varicose veins
©

have recently broken or badly

bruised your leg
0

use estrogen

have a blood clotting disorder

What are the symptoms of

DVT?
About 50% of people with a DVT

have no symptoms. However, the
most common symptoms of DVT
are
0

pain in one leg
swelling of one leg

o

warmth of one leg

Call your doctor or nurse if you
notice any of these symptoms.

56

°

Blood thinners-yuu may be given
blood thinners to allow the blood to
flow easier around the clot and to
prevent new clots from forming.
Blood thinners can be given as a pill
or intravenously (IV) into your vein
or through a shot into your skin.
Your doctor or nurse will choose the
best combination for you. The length
of time that you will take the blood
thinners will be based on the severity
of the blood clot and your risk fac­
tors.

o

Thrombolytics-]£ you have a large
DVT you may be given a clot busting
drug call a thrombolytic to dissolve
the clot.

•

Surgery-surgery to remove the clot is
rarely needed. It is considered when
the other treatments fail.

What are the possible
complications of DVT?
Some of the possible problems with
DVT are:
g

Pulmonary embolism-occurs when
the clot becomes dislodged and

57

travels from the legs to the lungs.

Post-thrombotic syndrome-rssvAts
from the decrease in blood flow to
the leg. This can cause swelling or
ulcers in the leg.
•

Recurrent DVT-yow may get another
DVT.

How can you prevent DVT?
•

Exercise-if you must sit or stand for
long periods of time, break up these
periods by taking short walks. This
prevents the blood from pooling in
your legs and returns the blood back
to the heart.

®

Support stockings-your doctor or
nurse may order special support
stockings for your legs. These stock­
ings help return the blood from your
legs back to your heart.

•

Blood thinners-\f you are at high risk
for a DVT, your doctor or nurse may
choose to give you blood thinners
every day to prevent a DVT from oc­
curring.

58

Remember to call your doc­
tor or nurse if you notice
any tenderness, swelling, or
warmth in your leg.

If you have any questions, your
doctor or nurse will be glad to
answer them.

59

1

Julie S. Anderson, RN,
Student Family Nurse Practitioner
Edinboro University of Pennsylvania
Edinboro, PA 16444

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