Deep vein thrombosis (DVT) refers to the formation of a blood clot (thrombus) within a deep vein, usually in the leg (thigh or calf). Once the blood clot forms, it can partially or completely block blood flow through the vein. A clot can become life-threatening if it dislodges and travels to the heart and lungs, causing a pulmonary embolism.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Gas Exchange
- Ineffective Peripheral Tissue Perfusion
- Risk for Bleeding
Nursing Process
Nurses will be involved in caring for patients with DVT in the inpatient setting. Depending on the severity of the clot, patients may need to be hospitalized to receive IV anticoagulants, which require frequent lab monitoring to ensure efficacy. Nurses are aware of the risk of DVT in certain patient populations and the importance of implementing interventions to prevent the occurrence or recurrence of DVT.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to deep vein thrombosis.
Review of Health History
1. Identify the patient’s general symptoms.
Assess for the following symptoms of DVT:
- Swelling in one leg greater than the other
- Leg pain or tenderness
- Warmth over the site
- Skin discoloration
If a DVT has traveled to the lung, manifestations of a pulmonary embolism include:
- Difficulty breathing
- Cough
- Chest pain
- Syncope (fainting)
- Palpitations
2. Identify the patient’s risk factors.
Various factors can influence the risk of DVT. DVT risk factors include:
- Older age
- African American ethnicity
- Smoking
- Obesity
- Recent surgery (especially orthopedic or neurovascular procedures)
- Immobility
- A previous history of DVT
- Cancer
- Pregnancy
- Long car or plane trips
- Intravenous drug use
- Hypercoagulable disorders
3. Review the patient’s medications.
The following medications carry an increased risk of DVT:
- Oral contraceptives
- Hormone replacement therapy
- Glucocorticoids
- Tamoxifen
- Testosterone
- Antidepressants
4. Consider the patient’s medical conditions.
Chronic medical conditions may increase the risk for DVT. Inquire if the patient has any of the following conditions:
- Comorbidities such as hypertension, atherosclerosis, dyslipidemia, and diabetes may contribute to plaque buildup and hardening and narrowing of arteries.
- Malignancies and cancer treatments increase hypercoagulability.
- Heart failure weakens the pumping ability of the heart, slowing blood flow.
- Colon inflammation caused by inflammatory bowel diseases may affect clotting factors.
- Autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis cause inflammatory changes throughout the body.
5. Asses for a central catheter.
Peripherally inserted central catheters (PICCs) may double the risk of DVT compared to central venous catheters (CVCs).
Physical Assessment
1. Test for Homan’s sign.
A widely recognized indicator of DVT is the classic finding of calf pain on dorsiflexion of the foot with the knee straight (Homan’s sign).
2. Conduct a risk stratification.
Clinical decision rules like Wells’ Criteria determine a patient’s risk for PE/DVT. Risk stratification is essential to select the best diagnostic and treatment options.
3. Assess the integumentary status.
Inspect and palpate the skin over the affected site. Expect to observe:
- A tender, subcutaneous venous segment that is indurated, palpable, and cord-like
- Discoloration of the lower extremity (reddish-purple or cyanotic)
- Edema
- Petechiae
- Blanching on rare occasions
4. Assess the respiratory status.
Pulmonary embolism (PE) is a complication of DVT that could be fatal. It happens when a blood clot (thrombus) from the leg or another part of the body dislodges and travels to an artery in the lung. Symptoms will include:
- Chest pain when coughing or during inhalation
- Tachypnea
- Tachycardia
- Palpitations
- Dyspnea
- Dizziness or syncope
- Coughing up blood (hemoptysis)
Diagnostic Procedures
1. Draw blood for testing.
The following blood tests will be done to aid in the diagnosis of DVT:
- D-dimer levels are elevated with DVT due to the breakdown of fibrin from clots in the blood. A negative result can safely rule out DVT.
- A coagulation profile, including prothrombin time (PT) or activated partial thromboplastin (aPTT), evaluates hypercoagulability.
2. Visualize the vein.
Prepare for the following tests to visualize clots or obstructed blood flow:
- Duplex venous ultrasonography is the most common test for identifying a DVT. It is non-invasive and widely accessible.
- Venography utilizes injecting a contrast dye into the veins to check for any blood clots that may partially or fully obstruct blood flow.
- Magnetic resonance venography (MRV) is very sensitive and specific for DVT but costly and less widely available than other methods. This imaging technique is useful in patients who are allergic to contrast dyes.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with deep vein thrombosis.
1. Start anticoagulation.
The cornerstone of DVT treatment is anticoagulation. DVT treatment has three primary goals:
- Stop the clot from getting bigger.
- Stop the clot from dislodging and moving onto the lungs.
- Lessen the likelihood of another DVT.
2. Administer medications cautiously as ordered.
Anticoagulants and clot busters (thrombolytics) can increase the risk of bleeding. Monitor the coagulation profile (PT/INR, aPTT) and implement the following bleeding precautions:
- Use a soft bristle toothbrush
- Avoid invasive procedures if possible
- Avoid forceful sneezing or blowing the nose
- Prevent falls and injuries
- Shave with electric razors
- Apply pressure when removing IV lines
3. Monitor aPTT with unfractionated heparin (UFH).
The patient receiving inpatient treatment for DVT may receive IV UFH. The nurse monitors the aPTT every 6 hours and adjusts the infusion rate per facility guidelines.
4. Administer low molecular weight heparin (LMWH).
Common LMWH options include enoxaparin, apixaban, and rivaroxaban, and are used to prevent the formation of new blood clots.
5. Monitor for therapeutic international normalized ratio (INR) levels.
If the patient is prescribed warfarin to continue outpatient, the medication is overlapped with another anticoagulant until the international normalized ratio (INR) reaches the therapeutic range of 2-3.
6. Consider a vena cava filter.
The inferior vena cava (IVC) filter stops large emboli from reaching the lungs. Although an IVC filter can lessen the risk of pulmonary embolism, it cannot stop additional blood clots from developing. An IVC filter is inserted in patients who:
- Cannot take blood-thinning drugs
- Experience recurrent blood clots despite anticoagulation
7. Apply compression stockings.
Compression stockings and intermittent pneumatic compression devices prevent blood from pooling in the legs and reduce edema, which reduces the risk of recurrent DVT and postthrombotic syndrome.
8. Advise the patient to ambulate and change positions frequently.
Staying in one position for a long time increases DVT risk, such as through prolonged sitting (such as driving), prescribed bed rest, or paralysis. Bed rest for fear of dislodging a clot in the extremities is unfounded and not recommended. If the patient is limited in movement, they should be instructed to move their legs as applicable by flexing the feet, rotating the ankles, and lifting the knees.
9. Promote DVT prophylaxis as ordered.
Factor Xa inhibitors are newer oral anticoagulants that prevent DVT and do not require routine lab testing to determine efficacy. Examples include:
- Rivaroxaban
- Apixaban
- Dabigatran
- Edoxaban
- Betrixaban
10. Emphasize the need for strict medication adherence and testing.
Patients will need to continue anticoagulant therapy for at least three months, with recurring episodes of DVT requiring a year of treatment. Patients on warfarin must adhere to laboratory testing to ensure INR levels are therapeutic.
11. Discuss surgical options.
For clots that completely occlude a vein with the potential of causing ischemia, surgical options such as thrombectomy, angioplasty, and stenting are considered.
12. Prepare reversal agents.
If severe bleeding occurs from anticoagulation, reversal agents must be administered. The antidote for heparin is protamine sulfate. Vitamin K is the antidote for warfarin. Xa inhibitors have a short half-life, and discontinuation may suffice in reversal.
13. Encourage the patient to make lifestyle changes.
There are various lifestyle modifications that the patient needs to consider to decrease the recurrence of DVT. These include:
- Avoiding smoking
- Blood pressure control
- Weight management
- Daily exercise
- Wearing loose clothing
- Increasing water intake
- Consuming natural blood thinners (if prescribed) like:
- Vitamin E
- Ginger
- Cayenne pepper
- Garlic
- Turmeric
- Cinnamon
14. Educate on dietary changes.
Patients who take warfarin are advised to avoid or limit their intake of green leafy vegetables that are high in vitamin K as they may interfere with the medication.
15. Advise the patient when to seek immediate medical attention.
When taking blood thinners, emphasize the need to monitor for signs of bleeding (such as nosebleeds and blood in the stool). If bleeding cannot be controlled, advise the patient to immediately go to the emergency department to prevent severe blood loss.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for deep vein thrombosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for deep vein thrombosis.
Decreased Cardiac Output
Decreased cardiac output associated with deep vein thrombosis can be caused by a clot traveling from the legs to the heart or lungs, obstructing blood vessels and reducing blood flow and oxygenation.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- DVT traveling to heart/lungs
- Blood flow obstruction
- Altered cardiac muscle contractility
- Increased cardiac workload
As evidenced by:
- Tachycardia
- Dysrhythmias
- Sudden chest pain
- Decreased oxygen saturation
- Sudden shortness of breathing (dyspnea)
- Tachypnea
- Alteration in the level of consciousness
- Dizziness or lightheadedness
- Restlessness
- Syncope (fainting)
- Prolonged capillary refill time
Expected outcomes:
- Patient will manifest blood pressure and pulse rate within normal limits.
- Patient will not report chest pain or shortness of breath.
Assessment:
1. Recognize abnormal symptoms.
Patients who report chest pain, sudden difficulty breathing, tachypnea, and hypoxia require immediate intervention.
2. Monitor cardiac function.
DVT that travels to the heart or lungs causes reduced cardiac function, lung congestion, fluid and water retention, and irregular heartbeats. The blood clot increases blood flow resistance and right-side cardiac workload, resulting in decreased blood and oxygen to the heart.
3. Obtain ECG.
Sinus tachycardia is the most common finding on ECG related to pulmonary embolism. Other findings may include right bundle branch block, ST elevation, premature atrial contractions, and T wave inversions.
Interventions:
1. Begin immediate anticoagulation.
If PE is suspected, immediate anticoagulation with IV unfractionated heparin, low molecular weight heparin, or fondaparinux is administered.
2. Consider thrombolytics.
If the patient is hemodynamically unstable, thrombolytic therapy may be considered to dissolve the clot and restart blood flow to the heart.
3. Prepare for surgical interventions.
Surgical or catheter embolectomy is advised if the patient cannot receive or is not responding to medications. Surgical removal of the clot is necessary if the patient is hemodynamically unstable or experiencing severe right ventricular dysfunction or cardiac necrosis.
4. Treat shock.
The patient can quickly decompensate and become hypotensive. Interventions may include careful fluid administration so as not to cause right ventricular overload and vasopressors to restore perfusion.
Deficient Knowledge
Patients require education on the risk, management, and prevention of DVT.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with diagnosis or prevention
- Poor knowledge of risk factors
- Lack of interest
As evidenced by:
- Verbalization of questions about diagnosis
- Misadministraction of medications
- Poor follow-through with routine lab work
- Recurrent DVT
Expected outcomes:
- Patient will verbalize an understanding of diagnosis and treatment.
- Patient will verbalize the importance of medications and follow-up lab tests.
- Patient will identify their risk factors and three ways to prevent recurrent DVT.
Assessment:
1. Assess knowledge about risk factors.
Patients may be aware that they are at risk for DVT, but unsure of how to lower their risk. On the other hand, they may not have any knowledge of what the risk factors are. Don’t assume the patient understands and assess their knowledge by asking questions.
2. Evaluate readiness to adhere to medications.
Anticoagulants are potentially high-risk medications and the patient should have a thorough understanding of their regimen and side effects.
3. Assess understanding of follow-up care.
Certain anticoagulants such as warfarin require weekly INR testing to ensure therapeutic levels. Assess the patient’s knowledge and understanding of the importance of this testing.
Interventions:
1. Explain the signs of pulmonary embolism.
Instruct on the signs of pulmonary embolism such as sudden chest pain, tachycardia, sudden shortness of breath, tachypnea, and restlessness. Explain why this is a medical emergency and to seek immediate medical attention.
2. Discuss individual risk factors.
Help the patient recognize their risk factors for developing DVT and discuss ways they can decrease their risk. Smoking is a huge, preventable risk factor for DVT. Immobility can also lead to the development of DVT so patients can be encouraged to ambulate frequently or adhere to compression devices if unable.
3. Provide education about medications.
Review medications to continue at discharge thoroughly. Ask the patient to verbalize each medication and to explain the proper dose, frequency, and reason for each one to evaluate effective teaching.
4. Teach ways to prevent a recurrence.
Instruct on easy ways patients can decrease their risk of recurrent DVT. Do not sit with legs or ankles crossed as this can hinder circulation. Higher altitudes such as when flying can increase the risk of DVT as well as sitting on long car rides. Stand and walk frequently on long flights and stop for rest breaks to stretch the legs on car rides.
Impaired Gas Exchange
Impaired gas exchange associated with deep vein thrombosis can be caused by obstruction of blood flow to the lungs due to a traveling clot that compromises gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ventilation perfusion imbalance
- Lack of oxygenated blood
- Poor blood supply to the lungs
- Development of pulmonary embolism
As evidenced by:
- Dyspnea worsened by exertion
- Sudden chest pain
- Cough with bloody mucus
- Tachypnea
- Dizziness
- Syncope
- Change in level of consciousness
- Change in skin color (pale and cyanotic)
- Tachycardia
- Palpitations
- Anxiety
- Restlessness
Expected outcomes:
- Patient will demonstrate oxygen saturation and breathing patterns within normal limits.
- Patient will report relief of chest pain, difficulty breathing, and lightheadedness.
- Patient will not lose consciousness.
Assessment:
1. Recognize symptoms of PE.
The most severe DVT complication is pulmonary embolism (PE). PE happens when a clot passes from another part of the body (often the leg) to the lungs. The patient may report sudden dyspnea, sharp chest pain, a racing heart, and a sense of anxiety.
2. Auscultate the lung sounds.
The presence of crackles or decreased breath sounds when auscultating the lungs could signal the possibility of a pulmonary embolism.
3. Monitor for any change in mentation.
A decrease in blood supply to the brain due to clots in the lungs may cause changes in consciousness, confusion, restlessness, and dizziness.
4. Utilize the Pulmonary Embolism Rule-Out Criteria (PERC).
The following eight criteria can be used when PE is suspected, but the patient is low-risk. If negative, further testing is not necessary.
- Age 50 or older
- Heart rate of 100 or greater
- Oxygen saturation of < 95% on room air
- Hemoptysis
- Prior DVT or PE
- Unilateral leg edema
- Hormone replacement or oral contraceptives
- Surgery or trauma within the previous four weeks
Interventions:
1. Obtain a V/Q scan.
A ventilation/perfusion scan measures how air moves into and out of the lungs and the circulation of blood in the lungs. A V/Q scan can diagnose a PE if the patient is exhibiting symptoms.
2. Apply oxygen.
Supplemental oxygen should be applied to keep oxygen saturation >90%.
3. Implement nonpharmacologic interventions.
Apply compression stockings to prevent further thromboembolisms. Activity is recommended as tolerated, and early ambulation is encouraged over bed rest.
4. Prepare for respiratory support.
Severe hypoxemia or respiratory failure may require intubation and mechanical ventilation.
Ineffective Peripheral Tissue Perfusion
Patients with deep vein thrombosis have ineffective peripheral tissue perfusion due to decreased blood flow and damage to the vessels.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Venous stasis
- Damage to the vessel wall
- Blood hypercoagulability
As evidenced by:
- Edema
- Pain
- Increased warmth to the site of the clot
- Tenderness
Expected outcomes:
- Patient will be free of pulmonary embolism as evidenced by the absence of shortness of breath or chest pain.
- Patient will maintain optimal tissue perfusion in the affected area as evidenced by decreased pain, sufficient capillary refill, and strong peripheral pulses.
Assessment:
1. Assess for signs and symptoms.
DVT may be asymptomatic but some patients show signs and symptoms in the affected area. Assess for edema, pain, tenderness, color changes and temperature of the skin, capillary refill, and palpate pulses.
2. Assess the patient’s risk factors.
Assess for possible causes of DVT such as recent surgery, immobility, trauma, obesity, pregnancy, and dehydration. Since some patients are asymptomatic, assessing risk factors is important for early detection.
3. Measure leg circumference.
Measure the affected leg below the tibial tuberosity and above the patella. If there is a difference of more than 3 cm, it may indicate DVT in some patients. This is useful for determining the need for additional testing such as ultrasound and lab work.
Interventions:
1. Administer anticoagulants as ordered.
Anticoagulants are ordered to prevent clot formation. Patients may receive IV heparin while in the hospital and then transition to PO medications they can take at home. Therapeutic levels must be achieved and maintained by evaluating the patient’s lab values routinely.
2. Apply compression stockings as ordered.
The use of compression stockings and pneumatic compression devices promotes venous circulation and decreases venous stasis. This is important to help decrease inflammation and reduce the risk of blood clot formation.
3. Ensure adequate hydration.
Dehydration causes increased blood viscosity, which can contribute to venous stasis and blood clot formation. Ensure the patient is adequately hydrated to reduce blood viscosity. Encourage the patient to drink adequate amounts of water or other hydrating fluids or administer IV fluids if they are not able to consume liquids.
4. Obtain an ultrasound.
A Doppler ultrasound can be performed at the bedside and is useful in determining abnormalities in blood flow as well as the presence of DVT.
Risk for Bleeding
Patients with deep vein thrombosis are at risk for bleeding due to anticoagulant treatment.
Nursing Diagnosis: Risk For Bleeding
Related to:
- Use of anticoagulants
- Abnormal blood profiles
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain therapeutic levels of blood clotting factors.
- Patient will verbalize safety measures to prevent bleeding.
- Patient will not experience bleeding.
Assessment:
1. Assess vital signs and symptoms of bleeding.
Hypotension, tachycardia, hypothermia, and dizziness are signs of bleeding. Other outward signs of bleeding include nosebleeds, gum bleeding, and bruising.
2. Monitor labs.
Patients with deep vein thrombosis receiving anticoagulant therapy will need regular labs drawn to monitor clotting factors. Monitor platelet count and coagulation profiles (PT, PTT, INR) to reduce the patient’s risk of bleeding.
3. Monitor heparin-induced platelet aggregation (HIPA) status.
Heparin reduces a patient’s platelet count, which puts them at increased risk for bleeding. HIPA causes heparin-induced thrombocytopenia (HIT) which is characterized by a sudden drop in platelets.
Interventions:
1. Provide education to reduce bleeding risk.
Educate the patient on ways to reduce their risk of bleeding. Instruct patients to use a soft toothbrush, only use electric razors for shaving, and avoid forceful coughing or nose blowing.
2. Take immediate action if bleeding occurs.
If a patient is on IV heparin and bleeding is found, the nurse should immediately stop the heparin infusion, notify the doctor, evaluate labs (PTT), and re-evaluate the heparin dosage based on lab results.
3. Provide education on bleeding precautions.
If continuing to take oral anticoagulants at home, stress the importance of safety as the patient may easily bruise and bleed if they cut themselves or bump into something. If a head injury occurs the patient must seek immediate assistance as this can become a life-threatening brain bleed.
4. Have antidotes available to reverse anticoagulants.
Protamine sulfate reverses the effect of heparin and vitamin K reverses the effect of warfarin. These should be available in the event of severe bleeding.
References
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