Deep Vein Thrombosis (DVT) is a serious medical condition characterized by the formation of a blood clot (thrombus) in a deep vein, most commonly in the leg, either in the thigh or calf. This clot can impede or completely obstruct blood flow within the affected vein. Critically, a DVT becomes life-threatening if the clot breaks loose and travels through the bloodstream to the heart and lungs, potentially causing a pulmonary embolism.
Nurses play a pivotal role in the care of patients with DVT, especially in hospital settings. The severity of DVT dictates the treatment approach; some patients require hospitalization for intravenous anticoagulation, which necessitates diligent laboratory monitoring to ensure therapeutic effectiveness. A fundamental aspect of nursing practice is recognizing DVT risk factors in susceptible patient populations and proactively implementing preventive measures to minimize the occurrence or recurrence of DVT.
This guide provides a comprehensive overview of DVT nursing diagnosis, encompassing essential aspects of nursing assessment, interventions, and care planning. It aims to equip nurses with the knowledge and skills necessary to deliver optimal care to patients at risk for or diagnosed with deep vein thrombosis.
Nursing Assessment for DVT
The nursing process begins with a thorough nursing assessment. This crucial phase involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to form a holistic understanding of the patient’s condition. For DVT, this assessment focuses on identifying both subjective and objective indicators of the condition.
Review of Health History
A detailed review of the patient’s health history is paramount in identifying potential DVT.
1. Identify Presenting Symptoms. Carefully assess for the hallmark symptoms of DVT:
- Unilateral Leg Swelling: Noticeable swelling in one leg compared to the other is a key indicator.
- Leg Pain or Tenderness: Patients may describe pain, aching, or tenderness, often localized to the calf or thigh.
- Localized Warmth: Increased warmth to the touch over the affected area can be present.
- Skin Discoloration: Changes in skin color, such as redness or bluish discoloration, may be observed.
It’s also vital to inquire about symptoms suggestive of pulmonary embolism (PE), which indicates DVT complications:
- Shortness of Breath (Dyspnea)
- Cough, potentially with hemoptysis (coughing up blood)
- Chest Pain, which may worsen with breathing
- Syncope (fainting) or near-syncope
- Palpitations or rapid heart rate
2. Identify Risk Factors for DVT. A multitude of factors can elevate an individual’s risk of developing DVT. Thoroughly explore the patient’s history for the following risk factors:
- Advanced Age: Older adults are at increased risk.
- Ethnicity: African Americans have been shown to have a higher incidence of DVT.
- Smoking History: Smoking significantly increases DVT risk.
- Obesity: Excess weight is a major risk factor for DVT.
- Recent Surgical Procedures: Especially orthopedic, neurovascular, or major abdominal surgeries.
- Immobility: Prolonged periods of inactivity, such as extended bed rest or paralysis.
- Previous DVT History: Individuals with a prior DVT are at higher risk of recurrence.
- Active Cancer or Cancer Treatment: Cancer and certain cancer treatments increase hypercoagulability.
- Pregnancy and Postpartum Period: Pregnancy and the postpartum period are associated with increased DVT risk.
- Prolonged Travel: Long car or plane trips with limited mobility.
- Intravenous Drug Use: Can damage veins and increase clotting risk.
- Hypercoagulable Disorders: Inherited or acquired conditions that predispose to blood clots.
3. Medication Review. Certain medications are associated with an elevated risk of DVT. Review the patient’s current medication list for:
- Oral Contraceptives
- Hormone Replacement Therapy (HRT)
- Glucocorticoids (steroids)
- Tamoxifen and Raloxifene
- Testosterone
- Antidepressants (certain types)
4. Assess for Underlying Medical Conditions. Chronic medical conditions can significantly increase DVT risk. Inquire about the presence of:
- Active Cancer
- Heart Failure
- Inflammatory Bowel Disease (IBD)
- Myeloproliferative Disorders
- Nephrotic Syndrome
- Systemic Lupus Erythematosus (SLE)
5. Central Venous Catheter Assessment. The presence of central venous catheters, particularly peripherally inserted central catheters (PICCs), increases DVT risk. PICCs have been reported to double the risk compared to centrally placed CVCs.
Physical Assessment for DVT
A focused physical examination is crucial in assessing for DVT.
1. Assess for Homan’s Sign. While not highly sensitive or specific, Homan’s sign involves assessing for calf pain upon dorsiflexion of the foot with the knee extended. While historically used, it’s important to note that a positive Homan’s sign is not a definitive indicator of DVT and its absence does not rule out DVT.
2. DVT Risk Stratification. Employ clinical decision rules like the Wells’ Criteria for DVT to formally assess the pretest probability of DVT. Risk stratification is essential for guiding diagnostic testing and treatment decisions.
3. Integumentary Assessment. Carefully inspect and palpate the skin of the potentially affected limb. Expect to observe:
- Palpable Venous Cord: A tender, subcutaneous vein that feels indurated, palpable, and cord-like.
- Lower Extremity Discoloration: Reddish-purple (erythema) or bluish (cyanosis) discoloration of the affected limb.
- Edema: Unilateral edema, often pitting edema, in the affected leg or ankle.
- Petechiae: Small, pinpoint red or purple spots on the skin.
- Blanching (rarely): In some cases, blanching of the skin may be observed.
4. Respiratory Status Assessment. Given the serious complication of pulmonary embolism, assess respiratory status meticulously. Signs and symptoms of PE include:
- Chest Pain: Often pleuritic, worsening with coughing or deep inspiration.
- Tachypnea: Increased respiratory rate.
- Tachycardia: Increased heart rate.
- Palpitations
- Dyspnea: Shortness of breath, ranging from mild to severe.
- Dizziness or Syncope
- Hemoptysis: Coughing up blood.
Diagnostic Procedures for DVT
Diagnostic procedures are essential to confirm a suspected DVT.
1. Blood Tests. Specific blood tests aid in DVT diagnosis:
- D-dimer Assay: D-dimer levels are typically elevated in the presence of DVT due to the breakdown of fibrin in blood clots. A negative D-dimer result in a low-risk patient can effectively rule out DVT.
- Coagulation Profile: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may be assessed to evaluate for underlying hypercoagulability, although they are not diagnostic for acute DVT.
2. Vein Visualization Studies. Imaging studies are crucial for visualizing clots and assessing blood flow:
- Duplex Venous Ultrasonography: This is the most widely used initial diagnostic test for DVT. It is non-invasive, readily available, and highly sensitive and specific for detecting proximal DVT (thigh).
- Venography: Involves injecting contrast dye into the veins, followed by X-ray imaging to visualize the veins and identify any obstructions caused by clots. It is more invasive and less frequently used than ultrasonography.
- Magnetic Resonance Venography (MRV): MRV is a highly sensitive and specific imaging technique for DVT detection, particularly in the pelvis and thigh. However, it is more expensive and less accessible than ultrasound and may be contraindicated in patients with certain implants or allergies to contrast dye (although contrast-free MRV is also available). It is useful in patients with contraindications to contrast dyes used in traditional venography.
Nursing Interventions for DVT
Nursing interventions are integral to the effective management and recovery of patients with DVT.
1. Initiate Anticoagulation Therapy. Anticoagulation is the cornerstone of DVT treatment. The primary goals of anticoagulation are threefold:
- Prevent clot propagation (further growth).
- Prevent embolization (clot breaking off and traveling to the lungs).
- Reduce the risk of DVT recurrence.
2. Administer Medications with Caution and Implement Bleeding Precautions. Anticoagulants and thrombolytic agents (clot-dissolving drugs) inherently increase the risk of bleeding. Closely monitor coagulation profiles (PT/INR, aPTT) and implement comprehensive bleeding precautions:
- Use a soft-bristled toothbrush for oral care.
- Minimize invasive procedures (e.g., intramuscular injections, unnecessary venipunctures).
- Advise against forceful sneezing or nose blowing.
- Implement fall prevention strategies to minimize trauma.
- Use electric razors for shaving.
- Apply prolonged pressure after IV line removal or blood draws.
3. Monitor aPTT During Unfractionated Heparin (UFH) Therapy. Patients receiving inpatient DVT treatment may be initiated on intravenous UFH. Nurses must monitor aPTT levels, typically every 6 hours, and adjust the UFH infusion rate according to established facility protocols and physician orders to maintain therapeutic anticoagulation.
4. Administer Low Molecular Weight Heparin (LMWH). LMWH, such as enoxaparin, dalteparin, or tinzaparin, are commonly used for DVT treatment and prophylaxis. They offer advantages over UFH, including subcutaneous administration and less frequent laboratory monitoring. They are effective in preventing the formation of new blood clots and are often used for outpatient DVT management.
5. Monitor INR Levels for Warfarin Therapy. For patients prescribed warfarin for long-term outpatient anticoagulation, it is crucial to monitor the International Normalized Ratio (INR). Warfarin therapy is typically initiated concurrently with another anticoagulant (e.g., LMWH or UFH) and overlapped until the INR reaches the therapeutic range, typically between 2.0 and 3.0.
6. Consider Vena Cava Filter Placement. An inferior vena cava (IVC) filter is a mechanical device placed in the vena cava to trap large emboli and prevent them from reaching the lungs, thus reducing the risk of pulmonary embolism. However, it does not prevent new clot formation. IVC filters are typically considered for patients who:
- Have absolute contraindications to anticoagulation.
- Experience recurrent DVT or PE despite adequate anticoagulation.
7. Apply Compression Therapy. Compression stockings and intermittent pneumatic compression devices are valuable adjuncts in DVT management. They help prevent venous stasis, reduce leg edema, and may decrease the risk of post-thrombotic syndrome and recurrent DVT.
8. Encourage Ambulation and Frequent Position Changes. Prolonged immobility is a major DVT risk factor. Patients should be encouraged to ambulate as soon as medically stable. For patients with limited mobility, frequent position changes and leg exercises (ankle pumps, foot circles, knee flexion/extension) are essential to promote venous circulation. Bed rest solely for fear of clot dislodgement is generally not recommended and is often contraindicated.
9. Promote DVT Prophylaxis. Pharmacological DVT prophylaxis is crucial for at-risk patients. Factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban, betrixaban) and other anticoagulants are frequently used for DVT prevention, particularly in postoperative and medically ill patients. Factor Xa inhibitors offer the convenience of oral administration and typically do not require routine laboratory monitoring for efficacy.
10. Emphasize Medication Adherence and Monitoring. Patient education on the importance of strict medication adherence is paramount. Anticoagulant therapy typically lasts for at least three months, and longer durations (e.g., a year or indefinitely) may be necessary for recurrent DVT or persistent risk factors. Patients on warfarin require regular INR monitoring to ensure therapeutic anticoagulation and safety.
11. Discuss Surgical and Catheter-Based Interventions. In cases of extensive DVT causing severe symptoms or limb-threatening ischemia (e.g., phlegmasia cerulea dolens), surgical thrombectomy (surgical clot removal) or catheter-directed thrombolysis (delivery of thrombolytic agents directly to the clot via catheter) may be considered to restore venous blood flow and prevent limb loss. Angioplasty and stenting may be used to treat underlying venous stenosis contributing to DVT.
12. Prepare Reversal Agents for Anticoagulation. In the event of serious bleeding complications related to anticoagulation, reversal agents are essential. Protamine sulfate is the antidote for heparin (UFH). Vitamin K is used to reverse warfarin’s effects. For factor Xa inhibitors, specific reversal agents like andexanet alfa and ciraparantag are available, although their use is typically reserved for life-threatening bleeding due to their limited availability and cost. In many cases, discontinuation of the factor Xa inhibitor and supportive measures may suffice due to their relatively short half-lives.
13. Counsel on Lifestyle Modifications. Lifestyle changes are crucial for long-term DVT risk reduction:
- Smoking Cessation: Smoking significantly increases DVT risk.
- Blood Pressure Management: Hypertension can contribute to vascular damage.
- Weight Management: Obesity is a major DVT risk factor.
- Regular Exercise: Promotes venous circulation and overall vascular health.
- Avoidance of Constrictive Clothing: Tight clothing can impede venous return.
- Adequate Hydration: Dehydration can increase blood viscosity.
- Consider Natural Blood Thinners (with caution and medical advice): While some foods and supplements (e.g., vitamin E, ginger, cayenne pepper, garlic, turmeric, cinnamon) have mild anticoagulant properties, they should not replace prescribed anticoagulation medications and should be discussed with a healthcare provider due to potential interactions and bleeding risks.
14. Provide Dietary Guidance. Patients taking warfarin should receive specific dietary education, particularly regarding vitamin K intake. Consistent intake of vitamin K-rich foods, such as green leafy vegetables, is important, as drastic fluctuations in vitamin K consumption can affect warfarin’s anticoagulation effect and INR levels. Patients do not need to avoid vitamin K-rich foods, but rather maintain a consistent intake.
15. Educate on When to Seek Immediate Medical Attention. Patients on anticoagulants must be educated about the signs and symptoms of bleeding and when to seek immediate medical attention. This includes:
- Unexplained bleeding (e.g., nosebleeds, gum bleeding, unusual bruising, blood in urine or stool, heavy menstrual bleeding).
- Severe headache or dizziness, which could indicate intracranial bleeding.
- Any significant injury, especially head trauma.
- Signs of pulmonary embolism (chest pain, shortness of breath).
Common Nursing Diagnoses Related to DVT
Once a comprehensive nursing assessment is complete, nurses formulate nursing diagnoses. These diagnoses guide the development of individualized nursing care plans, prioritizing assessments and interventions to achieve both short-term and long-term patient goals. Here are common nursing diagnoses relevant to deep vein thrombosis:
Decreased Cardiac Output related to Pulmonary Embolism
Decreased cardiac output in the context of DVT often arises when a thrombus dislodges and embolizes to the pulmonary arteries, causing pulmonary embolism. This obstruction impairs blood flow to the lungs and subsequently reduces cardiac output.
Nursing Diagnosis: Decreased Cardiac Output
Related Factors:
- Pulmonary Embolism secondary to DVT
- Mechanical obstruction of blood flow to the lungs
- Reduced cardiac preload and contractility due to PE
- Increased pulmonary vascular resistance and right ventricular afterload
As Evidenced By:
- Tachycardia
- Cardiac dysrhythmias
- Sudden onset of chest pain
- Decreased oxygen saturation (SpO2)
- Acute dyspnea (shortness of breath)
- Tachypnea
- Altered level of consciousness, ranging from restlessness to confusion
- Dizziness or lightheadedness
- Syncope (fainting)
- Prolonged capillary refill time (>3 seconds)
Expected Outcomes:
- Patient will maintain blood pressure and heart rate within acceptable limits for their baseline.
- Patient will report absence of chest pain and shortness of breath.
- Patient will maintain adequate peripheral perfusion and mentation.
Nursing Assessments:
1. Recognize Critical Symptoms. Immediate intervention is required for patients presenting with acute chest pain, sudden dyspnea, tachypnea, and hypoxia, as these are cardinal signs of pulmonary embolism and decreased cardiac output.
2. Monitor Cardiovascular Function. Pulmonary embolism resulting from DVT significantly impairs cardiovascular function. Assess for signs of right ventricular strain, such as jugular venous distension, peripheral edema, and new-onset murmurs. Monitor for hypotension, tachycardia, and irregular heart rhythms. The clot in the pulmonary arteries increases pulmonary vascular resistance, leading to increased right ventricular workload and potential right heart failure, ultimately reducing blood flow and oxygen delivery to the systemic circulation.
3. Obtain Electrocardiogram (ECG). While not definitively diagnostic for PE, ECG findings can be suggestive. Sinus tachycardia is the most common ECG abnormality in PE. Other potential findings include right bundle branch block, ST-segment elevation in right ventricular leads, premature atrial contractions, and T-wave inversions in anterior leads.
Nursing Interventions:
1. Initiate Immediate Anticoagulation. If pulmonary embolism is suspected, rapid anticoagulation is critical. Administer intravenous unfractionated heparin, low molecular weight heparin, or fondaparinux as per physician orders and established protocols.
2. Consider Thrombolytic Therapy. For hemodynamically unstable patients with massive PE, thrombolytic therapy (e.g., alteplase, tenecteplase) may be considered to dissolve the clot and restore pulmonary blood flow. Thrombolysis carries a risk of bleeding and is typically reserved for high-risk PE.
3. Prepare for Advanced Interventions. In patients with hemodynamic instability or contraindications to thrombolysis, prepare for potential surgical or catheter-based embolectomy. Surgical embolectomy involves surgically removing the clot from the pulmonary arteries. Catheter embolectomy utilizes specialized catheters to break up or remove the clot percutaneously. These interventions are considered in cases of severe right ventricular dysfunction, cardiac necrosis, or hemodynamic collapse.
4. Manage Hypotension and Shock. Pulmonary embolism can lead to rapid hemodynamic decompensation and hypotension. Manage shock aggressively. Careful fluid resuscitation may be necessary, but avoid overhydration, which can exacerbate right ventricular overload. Vasopressors (e.g., norepinephrine) may be required to restore and maintain adequate blood pressure and systemic perfusion.
Deficient Knowledge related to DVT Management and Prevention
Patients often have limited understanding of DVT, its risk factors, management, and prevention strategies. Education is essential to empower patients to actively participate in their care and reduce the risk of recurrence.
Nursing Diagnosis: Deficient Knowledge
Related Factors:
- Lack of prior exposure to information about DVT
- Misinformation or misunderstanding of DVT and its management
- Cognitive limitations or learning barriers
- Low health literacy
As Evidenced By:
- Verbalizes questions or expresses concerns about DVT diagnosis, treatment, or prevention
- Demonstrates errors in medication administration (e.g., incorrect dose or timing)
- Poor adherence to recommended follow-up laboratory monitoring (e.g., INR testing for warfarin)
- Recurrent DVT episodes due to lack of preventative measures
Expected Outcomes:
- Patient will verbalize accurate understanding of DVT diagnosis, treatment plan, and prognosis.
- Patient will articulate the importance of prescribed medications, including dosage, frequency, potential side effects, and necessary follow-up lab tests.
- Patient will identify their individual DVT risk factors and describe at least three strategies to prevent DVT recurrence.
Nursing Assessments:
1. Assess Baseline Knowledge. Evaluate the patient’s current understanding of DVT, risk factors, and preventive measures. Avoid assumptions about pre-existing knowledge. Directly ask open-ended questions to gauge their understanding.
2. Evaluate Medication Knowledge and Adherence Readiness. Anticoagulants are high-risk medications requiring careful management. Assess the patient’s understanding of their prescribed anticoagulant regimen, including medication names, dosages, frequency, administration route, and potential side effects. Evaluate their readiness to adhere to the medication plan and identify any potential barriers to adherence.
3. Assess Understanding of Follow-Up Care. For patients requiring ongoing anticoagulation, particularly warfarin, assess their understanding of the necessity for regular INR monitoring and follow-up appointments. Determine if they comprehend the importance of maintaining therapeutic INR levels and the potential consequences of inadequate monitoring or non-adherence.
Nursing Interventions:
1. Explain Pulmonary Embolism Signs and Symptoms. Thoroughly educate the patient about the signs and symptoms of pulmonary embolism, including sudden chest pain, tachycardia, acute shortness of breath, tachypnea, and unexplained anxiety or restlessness. Emphasize that PE is a medical emergency requiring immediate attention and instruct them to seek prompt medical help if these symptoms develop.
2. Discuss Individualized Risk Factors and Mitigation Strategies. Help the patient identify their specific risk factors for DVT. Provide tailored education on modifiable risk factors and strategies to mitigate them. For example, for smokers, strongly emphasize smoking cessation. For immobile patients, educate on the importance of regular leg exercises and the appropriate use of compression devices.
3. Comprehensive Medication Education. Provide detailed education about all prescribed medications, including anticoagulants. Review medication names, purpose, dosage, frequency, administration technique (if applicable), potential side effects, drug-drug and drug-food interactions, and duration of therapy. Use the teach-back method to verify patient understanding.
4. Teach DVT Recurrence Prevention Strategies. Instruct patients on practical measures to reduce the risk of DVT recurrence. Advise against prolonged sitting with legs crossed, as this can impede circulation. For long periods of sitting, such as during travel, recommend frequent standing, walking, and leg stretches. Discuss the importance of adequate hydration, weight management, and regular physical activity.
Impaired Gas Exchange related to Pulmonary Embolism
Impaired gas exchange is a direct consequence of pulmonary embolism. The embolus obstructs pulmonary blood flow, creating a ventilation-perfusion mismatch, leading to hypoxemia and impaired gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
Related Factors:
- Ventilation-perfusion mismatch due to PE
- Reduced pulmonary blood flow
- Alveolar dead space and intrapulmonary shunting
- Physiological effects of hypoxemia
As Evidenced By:
- Dyspnea, particularly with exertion
- Sudden onset of chest pain
- Cough, potentially productive of blood-tinged sputum (hemoptysis)
- Tachypnea
- Dizziness or lightheadedness
- Syncope
- Changes in level of consciousness (confusion, restlessness, lethargy)
- Cyanosis (bluish discoloration of skin and mucous membranes) or pallor
- Tachycardia
- Palpitations
- Anxiety and restlessness
Expected Outcomes:
- Patient will achieve and maintain oxygen saturation (SpO2) within their normal baseline range.
- Patient will demonstrate normal breathing pattern and respiratory rate.
- Patient will report relief of chest pain, dyspnea, and dizziness.
- Patient will maintain baseline level of consciousness and orientation.
Nursing Assessments:
1. Recognize Pulmonary Embolism Symptoms. Prompt recognition of PE is critical. Be vigilant for the sudden onset of dyspnea, pleuritic chest pain, tachycardia, and anxiety, which are hallmark symptoms of PE.
2. Auscultate Lung Sounds. Auscultation of lung sounds is an important assessment for PE. Crackles (rales) or decreased breath sounds may be indicative of pulmonary congestion or atelectasis associated with PE. However, lung sounds may be normal in some patients with PE.
3. Monitor Neurological Status. Hypoxemia secondary to PE can impair cerebral oxygen delivery, leading to neurological changes. Closely monitor for any alterations in mental status, including confusion, restlessness, agitation, lethargy, or dizziness. Changes in mentation can be early indicators of worsening gas exchange.
4. Utilize Pulmonary Embolism Rule-Out Criteria (PERC). For patients with suspected PE who are deemed low-risk based on clinical assessment, the PERC rule can be a valuable tool to guide decision-making. The PERC rule comprises eight criteria. If all criteria are negative, the probability of PE is very low, and further diagnostic testing may be safely deferred. The PERC criteria include:
- Age < 50 years
- Heart rate < 100 bpm
- Oxygen saturation ≥ 95% on room air
- Absence of hemoptysis
- No prior history of DVT or PE
- No unilateral leg edema
- No hormone replacement therapy or oral contraceptive use
- No recent surgery or trauma requiring hospitalization within the past 4 weeks
Nursing Interventions:
1. Prepare for Ventilation/Perfusion (V/Q) Scan or CT Pulmonary Angiography (CTPA). A V/Q scan or CTPA are diagnostic imaging studies used to confirm or exclude pulmonary embolism. A V/Q scan assesses airflow and blood flow in the lungs to detect ventilation-perfusion mismatches characteristic of PE. CTPA is the preferred imaging modality in most centers, providing high-resolution images of the pulmonary arteries to directly visualize emboli.
2. Administer Supplemental Oxygen. Hypoxemia is a primary concern in PE. Administer supplemental oxygen via nasal cannula, face mask, or non-rebreather mask as needed to maintain oxygen saturation above 90% or as ordered by the physician.
3. Implement Non-Pharmacological Measures. Position the patient to optimize lung expansion (e.g., semi-Fowler’s or high-Fowler’s position). Encourage deep breathing and coughing exercises (if appropriate) to promote alveolar ventilation. Apply compression stockings to prevent further thromboembolism formation and promote venous return. Encourage activity as tolerated, and promote early ambulation when medically stable.
4. Prepare for Respiratory Support. In cases of severe hypoxemia, respiratory failure, or hemodynamic instability, be prepared to provide advanced respiratory support. This may include non-invasive positive pressure ventilation (NIPPV) or endotracheal intubation and mechanical ventilation if necessary.
Ineffective Peripheral Tissue Perfusion related to Venous Obstruction
In DVT, the thrombus obstructs venous blood flow, leading to venous stasis, increased venous pressure, and impaired peripheral tissue perfusion in the affected limb.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related Factors:
- Venous stasis due to deep vein thrombosis
- Mechanical obstruction of venous blood flow
- Inflammatory process within the vein
- Potential for compartment syndrome in severe cases
As Evidenced By:
- Unilateral edema in the affected extremity
- Pain or tenderness in the affected limb
- Increased warmth to touch in the area of the clot
- Skin discoloration (erythema or cyanosis)
- Palpable venous cord
- Diminished or absent peripheral pulses in severe cases (less common in DVT alone, more indicative of arterial occlusion or phlegmasia cerulea dolens)
Expected Outcomes:
- Patient will remain free from pulmonary embolism, as evidenced by the absence of new onset shortness of breath or chest pain.
- Patient will demonstrate improved peripheral tissue perfusion in the affected extremity, as evidenced by reduction in edema, decreased pain, palpable peripheral pulses, and improved skin color and temperature.
Nursing Assessments:
1. Assess for Signs and Symptoms of Impaired Perfusion. Thoroughly assess the affected limb for signs and symptoms of ineffective peripheral tissue perfusion. Evaluate for edema (unilateral swelling), pain, tenderness, skin color changes (redness, pallor, cyanosis), temperature (warmth or coolness), capillary refill time, and peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral).
2. Assess DVT Risk Factors. Identify and document the patient’s individual risk factors for DVT. This is crucial for understanding the underlying etiology and guiding preventive strategies. Risk factors include recent surgery, immobility, trauma, obesity, pregnancy, hypercoagulable states, and dehydration. In patients who are asymptomatic, risk factor assessment may be the key to early detection.
3. Measure Leg Circumference. In cases of suspected DVT, measure the circumference of both legs at standardized points (e.g., below the tibial tuberosity and above the patella). A difference of more than 2-3 cm in circumference between legs may suggest DVT, although this finding is not definitive and should be correlated with other clinical findings and diagnostic tests. Leg circumference measurements can be useful for monitoring changes in edema over time.
Nursing Interventions:
1. Administer Anticoagulants as Prescribed. Administer prescribed anticoagulants promptly to prevent clot propagation and embolization. Ensure therapeutic anticoagulation levels are achieved and maintained by monitoring relevant laboratory parameters (e.g., aPTT for heparin, INR for warfarin).
2. Apply Compression Therapy. Apply compression stockings or pneumatic compression devices as ordered. Compression therapy promotes venous circulation, reduces venous stasis, and decreases edema in the affected limb. Ensure proper stocking size and application technique.
3. Ensure Adequate Hydration. Dehydration can increase blood viscosity, contributing to venous stasis and clot formation. Ensure the patient is adequately hydrated by encouraging oral fluid intake or administering intravenous fluids as prescribed. Monitor fluid balance and urine output.
4. Prepare for Doppler Ultrasound. Prepare the patient for duplex Doppler ultrasound of the affected limb. Doppler ultrasound is a non-invasive bedside procedure that assesses venous blood flow and can detect the presence and location of DVT. Explain the procedure to the patient and provide reassurance.
Risk for Bleeding related to Anticoagulation Therapy
Anticoagulation, the mainstay of DVT treatment, inherently increases the risk of bleeding. Nurses play a vital role in minimizing bleeding risks through careful monitoring, patient education, and implementation of safety precautions.
Nursing Diagnosis: Risk for Bleeding
Related Factors:
- Pharmacological anticoagulation therapy (heparin, warfarin, LMWH, factor Xa inhibitors, direct thrombin inhibitors)
- Underlying coagulopathies or thrombocytopenia
- Invasive procedures (surgery, biopsies, central line placement)
- Trauma or injury
- History of bleeding disorders
As Evidenced By:
A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are directed at prevention.
Expected Outcomes:
- Patient will maintain coagulation parameters within therapeutic ranges (e.g., therapeutic INR for warfarin, therapeutic aPTT for heparin).
- Patient will verbalize understanding of bleeding precautions and safety measures to minimize bleeding risk.
- Patient will not experience clinically significant bleeding complications.
Nursing Assessments:
1. Assess for Signs and Symptoms of Bleeding. Regularly assess for signs and symptoms of bleeding, which can be overt or occult. Monitor vital signs for hypotension, tachycardia, and hypothermia, which may indicate blood loss. Assess for overt bleeding, such as nosebleeds (epistaxis), gum bleeding, easy bruising (ecchymosis), hematuria (blood in urine), melena (black, tarry stools), hematemesis (vomiting blood), or hemoptysis.
2. Monitor Coagulation Laboratory Values. Closely monitor relevant coagulation laboratory values, including platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and International Normalized Ratio (INR), as ordered. Notify the physician of any abnormal or out-of-therapeutic-range values.
3. Monitor Heparin-Induced Thrombocytopenia (HIT). For patients receiving heparin therapy, monitor platelet counts regularly to assess for heparin-induced thrombocytopenia (HIT). HIT is a serious complication of heparin therapy characterized by a paradoxical decrease in platelet count and increased risk of thrombosis. Be alert for a sudden drop in platelet count, new thrombosis, or skin necrosis at heparin injection sites.
Nursing Interventions:
1. Patient Education on Bleeding Risk Reduction. Provide comprehensive patient education on strategies to minimize bleeding risk. Instruct patients to use a soft-bristled toothbrush, use an electric razor for shaving, avoid forceful coughing or nose blowing, and take precautions to prevent falls and injuries.
2. Implement Immediate Action for Bleeding Episodes. In the event of bleeding, initiate immediate interventions. If a patient on intravenous heparin is bleeding, immediately stop the heparin infusion, notify the physician promptly, assess the aPTT level, and anticipate potential heparin dose adjustment based on laboratory results and clinical assessment.
3. Educate on Bleeding Precautions for Home Management. For patients discharged on oral anticoagulants, reinforce the importance of bleeding precautions at home. Emphasize safety measures to prevent trauma and injury. Advise patients to seek immediate medical attention for any significant injury, particularly head trauma, or signs of uncontrolled bleeding.
4. Ensure Availability of Antidotes. Ensure that reversal agents for prescribed anticoagulants are readily available. Protamine sulfate is the antidote for heparin. Vitamin K is the reversal agent for warfarin. Specific reversal agents for factor Xa inhibitors (andexanet alfa, ciraparantag) and direct thrombin inhibitors (idarucizumab) should be accessible if these medications are used.
