Risk for Venous Thromboembolism: A Comprehensive Nursing Diagnosis and Care Plan

Venous thromboembolism (VTE) represents a significant health concern, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is characterized by the formation of a blood clot within a deep vein, commonly in the leg, obstructing blood flow. If this clot dislodges and travels to the lungs, it can cause a life-threatening pulmonary embolism. Nurses play a crucial role in identifying patients at risk for VTE, implementing preventive measures, and providing comprehensive care to those diagnosed with this condition. This article delves into the nursing diagnosis of “Risk for Venous Thromboembolism,” outlining essential assessments, interventions, and a detailed care plan to enhance patient outcomes and safety.

Understanding Venous Thromboembolism (VTE) and Risk Factors

Venous thromboembolism (VTE) is a condition where a blood clot forms in a vein, most often in a deep vein in the leg, groin, or arm (deep vein thrombosis, DVT). A significant danger arises when this clot breaks free and travels to the lungs, causing a pulmonary embolism (PE). Understanding the risk factors for VTE is paramount for nurses in proactively identifying vulnerable patients and implementing preventive strategies.

Several factors elevate an individual’s susceptibility to VTE. These risk factors can be broadly categorized and include:

• Age and Ethnicity: Older age is a significant risk factor, with incidence increasing with each decade. African Americans also have a higher incidence of VTE compared to Caucasians.
• Lifestyle Factors: Smoking and obesity are modifiable risk factors that significantly increase VTE risk.
• Medical History:
  • Previous VTE: A history of DVT or PE dramatically increases the likelihood of recurrence.
  • Cancer: Active cancer and certain cancer treatments are strong risk factors for VTE.
  • Hypercoagulable Disorders: Inherited or acquired conditions that predispose to blood clotting.
  • Chronic Medical Conditions: Conditions like heart failure, lung disease, and inflammatory bowel disease are associated with increased VTE risk.
• Situational Risks:
  • Surgery and Trauma: Major surgery, particularly orthopedic, neurosurgical, and cancer-related surgeries, as well as trauma, elevate VTE risk.
  • Immobility: Prolonged immobility from bed rest, paralysis, or long periods of sitting (travel) significantly increases risk due to venous stasis.
  • Pregnancy: Pregnancy and the postpartum period are associated with a higher risk of VTE due to hormonal changes and increased venous stasis.
  • Central Venous Catheters: Especially peripherally inserted central catheters (PICCs), increase the risk of upper extremity DVT.
• Medications: Certain medications, including oral contraceptives, hormone replacement therapy, glucocorticoids, tamoxifen, testosterone, and antidepressants, can increase the risk of VTE.

Recognizing these risk factors enables nurses to perform thorough risk assessments and implement targeted preventive measures, significantly reducing the incidence of VTE in at-risk populations.

Nursing Assessment for VTE Risk

A comprehensive nursing assessment is the first crucial step in identifying patients at risk for venous thromboembolism. This assessment involves gathering subjective and objective data to determine a patient’s individual risk profile.

Review of Health History

1. Identify General Symptoms: Although DVT can be asymptomatic, nurses should assess for and document any reported symptoms, including:

• Unilateral leg swelling (difference in circumference between legs)
• Leg pain or tenderness, often described as cramp-like
• Warmth and erythema over the affected area
• Skin discoloration (redness or bluish hue)

If a pulmonary embolism is suspected, assess for symptoms such as:

• Sudden onset of dyspnea (shortness of breath)
• Cough, potentially with hemoptysis (coughing up blood)
• Pleuritic chest pain (sharp chest pain worsened by breathing)
• Syncope (fainting) or dizziness
• Palpitations and tachycardia

2. Identify Risk Factors: A detailed health history should include a thorough evaluation of the patient’s risk factors for VTE. This involves inquiring about:

• Age and ethnicity
• Smoking history
• Body mass index (BMI) and history of obesity
• Past medical history of DVT or PE
• Recent surgeries or planned procedures (type and duration)
• Mobility status and any conditions causing immobility
• History of cancer or current cancer treatment
• Pregnancy status or recent childbirth
• Prolonged travel history (car or plane)
• History of intravenous drug use
• Known hypercoagulable disorders or family history of clotting disorders

3. Medication Review: Document all current medications, paying close attention to those known to increase VTE risk:

• Oral contraceptives and hormone replacement therapy
• Glucocorticoids
• Selective estrogen receptor modulators (SERMs) like tamoxifen
• Testosterone and anabolic steroids
• Certain antidepressants

4. Medical Conditions: Inquire about pre-existing medical conditions that elevate VTE risk:

• Heart failure
• Chronic obstructive pulmonary disease (COPD) and other lung diseases
• Inflammatory bowel disease (IBD)
• Nephrotic syndrome
• Myeloproliferative neoplasms

5. Central Venous Catheters: Assess for the presence of central venous catheters, particularly PICCs, and document the insertion date and location.

Physical Assessment

1. Homan’s Sign (Limited Value): While historically taught, Homan’s sign (calf pain on dorsiflexion) is neither sensitive nor specific for DVT and should not be relied upon for diagnosis.

2. Risk Stratification Tools: Utilize validated risk stratification tools such as the Wells score for DVT and PE or the Padua Prediction Score for hospitalized medical patients. These tools help quantify a patient’s risk level and guide further diagnostic and prophylactic decisions.

3. Integumentary Assessment: Inspect and palpate the skin of the extremities, noting:

• Palpable, tender, indurated subcutaneous venous segment, feeling like a cord.
• Skin discoloration in the lower extremity (erythema, cyanosis, or pallor in rare cases).
• Edema (unilateral or bilateral).
• Petechiae or superficial thrombophlebitis.

4. Respiratory Assessment: If PE is suspected, perform a thorough respiratory assessment:

• Auscultate lung sounds for adventitious sounds (crackles, wheezes) or decreased breath sounds.
• Assess respiratory rate, depth, and effort.
• Monitor oxygen saturation (SpO2).
• Note any cough, hemoptysis, or pleuritic chest pain.

Diagnostic Procedures

If DVT or PE is suspected based on risk assessment and clinical findings, diagnostic testing is essential.

1. Blood Tests:

• D-dimer: An elevated D-dimer level is sensitive but not specific for VTE. A negative D-dimer in a low-risk patient can effectively rule out VTE.
• Coagulation Profile (PT, aPTT, INR): Baseline coagulation studies are important, especially prior to initiating anticoagulation therapy. They may also be useful in identifying underlying hypercoagulable states.

2. Venous Imaging:

• Duplex Venous Ultrasonography: The primary imaging modality for DVT diagnosis. It is non-invasive, readily available, and highly accurate for proximal DVT.
• Venography: Invasive procedure using contrast dye to visualize veins, reserved for cases where ultrasound is inconclusive or technically difficult.
• Magnetic Resonance Venography (MRV): Highly sensitive and specific, particularly for pelvic and proximal DVT, and useful in patients with contrast allergies.
• Computed Tomography Pulmonary Angiography (CTPA): The gold standard for diagnosing PE.
• Ventilation-Perfusion (V/Q) Scan: An alternative for PE diagnosis when CTPA is contraindicated (e.g., contrast allergy, pregnancy).

Alt text: Clinical presentation of unilateral leg swelling, a key indicator of potential deep vein thrombosis (DVT), emphasizing the importance of assessing for leg circumference discrepancies in nursing assessments.

Nursing Diagnosis: Risk for Venous Thromboembolism

Based on the comprehensive assessment, the primary nursing diagnosis may be Risk for Venous Thromboembolism, defined as vulnerability to developing a venous thrombus, which may compromise health.

Related to (Risk Factors):

• Advanced age
• Obesity
• Smoking
• Immobility (e.g., prolonged bed rest, paralysis, long travel)
• Major surgery (especially orthopedic, neuro, cancer)
• Trauma
• Active cancer or cancer treatment
• Previous history of VTE
• Pregnancy or postpartum period
• Use of oral contraceptives or hormone replacement therapy
• Central venous catheters (PICC lines)
• Hypercoagulable disorders
• Certain medical conditions (heart failure, COPD, IBD, nephrotic syndrome)

Goals and Expected Outcomes:

• Patient will remain free from clinical manifestations of VTE during hospitalization and at discharge.
• Patient will verbalize understanding of individual risk factors for VTE and strategies for risk reduction.
• Patient will demonstrate adherence to prescribed VTE prophylaxis measures.

Nursing Interventions for VTE Risk Reduction

Nursing interventions are crucial in preventing VTE in at-risk patients. These interventions are focused on both pharmacological and non-pharmacological approaches.

1. Pharmacological Prophylaxis:

• Anticoagulants: Administer prophylactic anticoagulation as prescribed based on risk stratification. Common options include:
  • Low Molecular Weight Heparin (LMWH) (e.g., enoxaparin, dalteparin)
  • Unfractionated Heparin (UFH) (low-dose subcutaneous)
  • Fondaparinux
  • Direct Oral Anticoagulants (DOACs) (e.g., rivaroxaban, apixaban, edoxaban) for select patients.
• Monitor for Bleeding: Assess for signs of bleeding (e.g., bruising, epistaxis, gingival bleeding, hematuria, melena). Monitor platelet count and coagulation studies as indicated. Implement bleeding precautions.

2. Mechanical Prophylaxis:

• Compression Stockings (Graduated Compression Stockings – GCS): Apply and ensure proper fit of GCS to promote venous return and reduce venous stasis.
• Intermittent Pneumatic Compression (IPC) Devices: Utilize IPC devices as prescribed, especially for patients at high risk of bleeding or when anticoagulation is contraindicated. Ensure correct application and patient tolerance.

3. Promote Mobility and Position Changes:

• Early Ambulation: Encourage early and frequent ambulation post-surgery or during hospitalization, as tolerated.
• Leg Exercises: For patients with limited mobility, instruct and assist with leg exercises such as ankle pumps, foot rotations, and knee flexion/extension to promote venous circulation.
• Frequent Position Changes: Encourage frequent changes in position, avoiding prolonged periods of sitting or standing still. Elevate legs when sitting or lying down to enhance venous return.

4. Lifestyle Modifications and Patient Education:

• Smoking Cessation: Counsel patients on the risks of smoking and its contribution to VTE risk. Provide resources and support for smoking cessation.
• Weight Management: Educate obese patients on the relationship between obesity and VTE risk. Encourage weight loss through diet and exercise.
• Hydration: Ensure adequate hydration to maintain optimal blood viscosity. Encourage fluid intake, especially in patients at risk of dehydration.
• Avoidance of Constrictive Clothing: Advise patients to avoid tight clothing that can impede venous return, particularly around the legs and waist.

5. Patient Education:

• Risk Factor Education: Educate patients about their individual risk factors for VTE and the importance of preventive measures.
• Signs and Symptoms of VTE: Instruct patients on the signs and symptoms of DVT and PE and when to seek immediate medical attention. Emphasize the urgency of seeking care for symptoms like sudden onset of dyspnea, chest pain, or leg swelling and pain.
• Medication Adherence: If anticoagulation is prescribed at discharge, provide thorough education on medication administration, dosage, frequency, duration, and potential side effects. Emphasize the importance of adherence and follow-up lab monitoring (e.g., INR for warfarin).
• Travel Precautions: Advise patients on preventive measures during prolonged travel, such as frequent ambulation, leg exercises, hydration, and considering compression stockings for high-risk individuals.

Alt text: Illustration of compression stockings, a key component of DVT prevention, demonstrating their mechanism in promoting venous circulation and reducing the risk of blood clot formation in the legs.

Nursing Care Plans Related to Potential VTE Complications

While the primary diagnosis is “Risk for VTE,” it is essential to also consider potential complications that may arise if VTE develops. Nursing care plans should address these potential issues proactively.

Risk for Decreased Cardiac Output (Related to Potential Pulmonary Embolism)

Nursing Diagnosis: Risk for Decreased Cardiac Output related to potential pulmonary embolism.

Related to:

• Risk of DVT traveling to the pulmonary circulation
• Potential for pulmonary artery obstruction
• Compromised cardiac preload and contractility

Expected Outcomes:

• Patient will maintain stable vital signs, including heart rate and blood pressure, within normal limits.
• Patient will maintain adequate oxygen saturation (SpO2 ≥ 95%).
• Patient will report absence of chest pain or shortness of breath.

Nursing Interventions:

• Continuous Monitoring: Closely monitor vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
• Respiratory Assessment: Regularly auscultate lung sounds and assess for signs of respiratory distress.
• Early Recognition of PE: Be vigilant for signs and symptoms of PE (sudden dyspnea, chest pain, tachycardia, syncope). Report any concerning findings immediately.
• Prepare for Emergency Measures: In case of suspected PE, be prepared to administer oxygen, initiate rapid response protocols, and assist with diagnostic and therapeutic interventions (e.g., anticoagulation, thrombolysis, embolectomy).

Risk for Impaired Gas Exchange (Related to Potential Pulmonary Embolism)

Nursing Diagnosis: Risk for Impaired Gas Exchange related to potential pulmonary embolism.

Related to:

• Risk of pulmonary artery obstruction
• Ventilation-perfusion mismatch
• Reduced alveolar gas exchange

Expected Outcomes:

• Patient will maintain adequate oxygen saturation (SpO2 ≥ 95%).
• Patient will exhibit normal breathing patterns and respiratory rate.
• Patient will report absence of dyspnea or chest pain.

Nursing Interventions:

• Oxygen Therapy: Administer supplemental oxygen as needed to maintain SpO2 within the target range.
• Respiratory Monitoring: Monitor respiratory rate, depth, and effort. Assess lung sounds regularly.
• Positioning: Position patient to optimize lung expansion (e.g., semi-Fowler’s or high-Fowler’s).
• Deep Breathing and Coughing Exercises: Encourage deep breathing and coughing exercises to promote alveolar ventilation and prevent atelectasis.

Risk for Ineffective Peripheral Tissue Perfusion (Related to Potential Deep Vein Thrombosis)

Nursing Diagnosis: Risk for Ineffective Peripheral Tissue Perfusion related to potential deep vein thrombosis.

Related to:

• Risk of venous stasis in lower extremities
• Potential for thrombus formation in deep veins
• Compromised venous blood flow

Expected Outcomes:

• Patient will maintain adequate peripheral tissue perfusion in lower extremities, evidenced by warm and dry skin, palpable peripheral pulses, and capillary refill < 3 seconds.
• Patient will report absence of leg pain, swelling, or tenderness.

Nursing Interventions:

• Peripheral Vascular Assessment: Regularly assess peripheral pulses, skin temperature, color, and capillary refill in lower extremities.
• Edema Monitoring: Monitor for edema in lower extremities, noting any unilateral swelling or increase in leg circumference.
• Promote Venous Return: Implement measures to promote venous return, such as leg elevation, avoiding crossing legs, and encouraging ambulation or leg exercises.
• Application of Compression Stockings/IPC: Ensure proper application and use of mechanical prophylaxis devices as prescribed.

Risk for Bleeding (Related to Anticoagulation Therapy)

Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy.

Related to:

• Prophylactic or therapeutic use of anticoagulants (heparin, LMWH, warfarin, DOACs)
• Potential for medication side effects

Expected Outcomes:

• Patient will remain free from signs and symptoms of bleeding.
• Patient will maintain coagulation studies within therapeutic ranges (if applicable).
• Patient will verbalize understanding of bleeding precautions and safety measures.

Nursing Interventions:

• Bleeding Risk Assessment: Assess patient’s risk for bleeding (e.g., history of bleeding disorders, thrombocytopenia, recent surgery).
• Monitor Coagulation Studies: Monitor PT/INR, aPTT, and platelet count as ordered, especially for patients on warfarin or heparin.
• Bleeding Precautions: Implement bleeding precautions:
  • Use soft toothbrush and electric razor.
  • Avoid invasive procedures when possible.
  • Minimize venipunctures and injections.
  • Apply pressure to puncture sites.
  • Educate patient on avoiding activities that increase bleeding risk.
• Patient Education on Bleeding Signs: Educate patient and family on recognizing signs of bleeding (e.g., unusual bruising, nosebleeds, bleeding gums, hematuria, melena, dizziness, weakness) and when to report them immediately.

Deficient Knowledge (Related to VTE Risk and Prevention)

Nursing Diagnosis: Deficient Knowledge related to VTE risk and prevention.

Related to:

• Lack of prior exposure to information
• Misinformation
• Lack of recall

Expected Outcomes:

• Patient will verbalize understanding of individual risk factors for VTE.
• Patient will describe strategies for VTE prevention.
• Patient will demonstrate adherence to recommended preventive measures.

Nursing Interventions:

• Assess Learning Needs: Assess patient’s current knowledge level regarding VTE, risk factors, and prevention.
• Provide Education: Provide clear, concise, and age-appropriate education on:
  • Individual risk factors for VTE.
  • Importance of VTE prevention.
  • Pharmacological and non-pharmacological preventive measures.
  • Signs and symptoms of DVT and PE and when to seek medical attention.
  • Medication regimen (if applicable), including dosage, administration, side effects, and follow-up.
• Use Various Teaching Methods: Utilize various teaching methods, such as verbal instruction, written materials, visual aids, and demonstration, to enhance learning and retention.
• Evaluate Understanding: Evaluate patient’s understanding through teach-back methods and answer any questions. Provide resources for further information and support.

Conclusion

Nurses are at the forefront of VTE prevention and management. By conducting thorough risk assessments, implementing evidence-based preventive measures, and providing comprehensive patient education, nurses play a pivotal role in reducing the incidence of VTE and improving patient outcomes. A proactive approach, centered around the nursing diagnosis of “Risk for Venous Thromboembolism,” is essential to safeguard patients from this potentially life-threatening condition and promote optimal health and well-being.

References

(Same references as original article)