DVT Nursing Diagnosis: Comprehensive Guide for Nurses

Introduction to Deep Vein Thrombosis (DVT)

Deep vein thrombosis (DVT) is a serious medical condition characterized by the formation of a blood clot, known as a thrombus, in a deep vein within the body. This typically occurs in the legs, either in the thigh or calf, but can also develop in other deep veins. The formation of a DVT can lead to partial or complete obstruction of blood flow through the affected vein. A significant danger associated with DVT is the potential for the clot to detach and travel through the bloodstream to the heart and lungs, causing a life-threatening pulmonary embolism (PE).

Nurses play a critical role in the care of patients with DVT, particularly in inpatient settings. The severity of DVT can vary, and hospitalization may be necessary for patients requiring intravenous anticoagulants. These medications necessitate close monitoring through frequent lab tests to ensure therapeutic efficacy and prevent complications. Recognizing patient populations at higher risk for DVT and implementing preventive measures are essential nursing responsibilities to reduce both the initial occurrence and recurrence of DVT.

Nursing Assessment for DVT

The initial phase of nursing care involves a comprehensive nursing assessment. This process is crucial for gathering essential physical, psychosocial, emotional, and diagnostic information. Understanding both subjective and objective data is vital for accurately assessing a patient who may be experiencing deep vein thrombosis.

Review of Health History

1. Identify the patient’s general symptoms. A thorough assessment begins with identifying and documenting the patient’s presenting symptoms. Common symptoms of DVT include:

• Unilateral Leg Swelling: Swelling in one leg that is noticeably greater than the other is a hallmark sign of DVT.
• Leg Pain or Tenderness: Pain or tenderness in the leg, often described as a cramping or aching sensation.
• Warmth Over the Site: Increased warmth to the touch in the area of the suspected clot.
• Skin Discoloration: Changes in skin color, such as redness or bluish discoloration, in the affected leg.

If the DVT has progressed and a pulmonary embolism has occurred, patients may exhibit the following symptoms:

• Dyspnea (Difficulty Breathing): Shortness of breath or labored breathing, often sudden in onset.
• Cough: May be present, sometimes with hemoptysis (coughing up blood).
• Chest Pain: Often sharp and pleuritic, worsening with deep breaths or coughing.
• Syncope (Fainting): Loss of consciousness due to reduced blood flow to the brain.
• Palpitations: Sensation of rapid or irregular heartbeat.

2. Identify the patient’s risk factors. Assessing for risk factors is crucial in identifying individuals susceptible to DVT. Several factors can elevate DVT risk:

• Advanced Age: Risk increases with age, particularly over 60 years.
• Ethnicity: African Americans have been observed to have a higher incidence of DVT.
• Smoking: Nicotine and other chemicals in cigarettes damage blood vessels and increase blood clot risk.
• Obesity: Excess weight can contribute to venous stasis and increased clotting factors.
• Recent Surgery: Especially orthopedic, neurovascular, or major abdominal surgeries, significantly elevate DVT risk due to immobility and surgical trauma.
• Immobility: Prolonged periods of inactivity, such as extended bed rest, paralysis, or long journeys, slow blood flow and increase clot risk.
• Previous History of DVT or PE: Individuals with a prior venous thromboembolism are at higher risk for recurrence.
• Active Cancer: Certain cancers and cancer treatments increase hypercoagulability.
• Pregnancy: Hormonal changes and pressure on pelvic veins during pregnancy elevate DVT risk.
• Prolonged Travel: Long car or plane trips with limited movement can lead to venous stasis.
• Intravenous Drug Use: Can damage veins and increase risk of clot formation and infection.
• Hypercoagulable Disorders: Inherited or acquired conditions that predispose individuals to blood clotting, such as Factor V Leiden, Protein C or S deficiency, and antiphospholipid syndrome.

3. Review the patient’s medications. Certain medications are associated with an increased risk of DVT:

• Oral Contraceptives: Estrogen-containing contraceptives can increase clotting factors.
• Hormone Replacement Therapy (HRT): Similar to oral contraceptives, HRT can elevate DVT risk, especially estrogen-based therapies.
• Glucocorticoids: Prolonged use can increase blood viscosity and clotting factors.
• Tamoxifen and Raloxifene: Selective estrogen receptor modulators (SERMs) used in breast cancer treatment and prevention carry a DVT risk.
• Testosterone: Testosterone therapy may increase hematocrit and blood viscosity, potentially raising DVT risk.
• Antidepressants (Certain Types): Some antidepressants, particularly tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), have been linked to a slightly increased DVT risk, although the association is less clear and requires further research.

4. Consider the patient’s medical conditions. Chronic medical conditions can significantly increase the risk of DVT. Inquire about conditions such as:

• Heart Failure: Impaired cardiac function can lead to venous stasis.
• Chronic Obstructive Pulmonary Disease (COPD): Can cause polycythemia and increased blood viscosity.
• Inflammatory Bowel Disease (IBD): Conditions like Crohn’s disease and ulcerative colitis are associated with hypercoagulability.
• Nephrotic Syndrome: Protein loss in urine can lead to increased clotting factors.
• Myeloproliferative Neoplasms: Conditions like polycythemia vera and essential thrombocythemia increase blood cell production and clotting risk.
• Varicose Veins: Dilated veins can promote venous stasis.
• Autoimmune Disorders: Conditions like lupus and rheumatoid arthritis can increase hypercoagulability.

5. Assess for a central catheter. The type of central venous access device can impact DVT risk.

• Peripherally Inserted Central Catheters (PICCs): PICCs are associated with a higher risk of upper extremity DVT compared to centrally inserted central venous catheters (CVCs). Studies suggest PICCs may double the risk of DVT due to their insertion location and smaller vein size in the arm.

Image alt text: Diagram illustrating deep vein thrombosis (DVT) in the leg, highlighting the location of the blood clot within a deep vein and its effect on blood flow.

Physical Assessment

1. Test for Homan’s sign. Historically, Homan’s sign (calf pain upon dorsiflexion of the foot with the knee extended) was used to screen for DVT. However, Homan’s sign is neither sensitive nor specific for DVT and is not a reliable diagnostic test. It is important to note that the absence of Homan’s sign does not rule out DVT, and its presence is not definitively indicative of DVT. Modern DVT assessment relies more heavily on symptom evaluation, risk factor assessment, and diagnostic imaging.

2. Conduct a risk stratification. Clinical decision rules, such as Wells’ Criteria for DVT and Pulmonary Embolism, are valuable tools for stratifying a patient’s risk of venous thromboembolism (VTE). Wells’ Criteria incorporate clinical factors to estimate pre-test probability of DVT or PE, guiding decisions on further diagnostic testing and treatment. Risk stratification is essential to select the most appropriate diagnostic and treatment strategies, ensuring efficient and effective patient care.

3. Assess the integumentary status. Careful inspection and palpation of the skin over the suspected DVT site are essential. Expected findings include:

• Palpable Venous Segment: A tender, subcutaneous venous segment that feels indurated (hardened), palpable, and cord-like upon examination.
• Skin Discoloration: The lower extremity may exhibit discoloration, ranging from reddish-purple to cyanotic (bluish), due to impaired blood flow.
• Edema: Swelling in the affected limb, often unilateral, due to venous obstruction and fluid accumulation.
• Petechiae: Small, pinpoint red or purple spots on the skin, indicating superficial bleeding, may sometimes be observed.
• Blanching: Rarely, blanching (paleness) of the skin may occur if arterial flow is also compromised.

4. Assess the respiratory status. Pulmonary embolism (PE) is a critical and potentially fatal complication of DVT. It occurs when a thrombus from the leg or another part of the body dislodges, travels through the bloodstream, and lodges in a pulmonary artery, obstructing blood flow to the lungs. Prompt recognition of PE symptoms is vital. Assess for:

• Pleuritic Chest Pain: Sharp chest pain that worsens with coughing or deep inhalation, a classic PE symptom.
• Tachypnea: Rapid breathing rate (over 20 breaths per minute) as the body attempts to compensate for reduced oxygenation.
• Tachycardia: Elevated heart rate (over 100 beats per minute) as the heart works harder to circulate oxygen.
• Palpitations: Awareness of rapid or irregular heartbeats.
• Dyspnea: Shortness of breath or difficulty breathing, often sudden and unexplained.
• Dizziness or Syncope: Lightheadedness or fainting due to reduced cerebral blood flow and oxygenation.
• Hemoptysis: Coughing up blood, indicating lung tissue damage or bleeding.

Diagnostic Procedures

1. Draw blood for testing. Blood tests play a crucial role in both diagnosing DVT and managing anticoagulation therapy.

• D-dimer Levels: D-dimer is a fibrin degradation product, elevated in the blood when clots break down. A highly sensitive test, a negative D-dimer result can effectively rule out DVT in low-risk patients. However, D-dimer is not specific for DVT and can be elevated in other conditions (surgery, infection, pregnancy, cancer). A positive D-dimer requires further diagnostic imaging to confirm DVT.
• Coagulation Profile: Includes tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT). These tests evaluate the blood’s clotting ability and are used to monitor the effectiveness of anticoagulant medications like heparin and warfarin. Abnormalities in these tests can indicate hypercoagulability or bleeding risk.

2. Visualize the vein. Imaging studies are essential for confirming the diagnosis of DVT and determining the location and extent of the clot.

• Duplex Venous Ultrasonography: The most common and often first-line imaging test for DVT. Non-invasive, widely available, and relatively inexpensive, duplex ultrasound uses sound waves to visualize veins and assess blood flow. It can detect the presence of clots and obstruction in deep veins.
• Venography: Involves injecting a contrast dye into the veins of the affected limb, followed by X-ray imaging. Venography can visualize blood clots as filling defects in the veins. While highly accurate, it is more invasive than ultrasound, carries risks associated with contrast dye (allergy, nephrotoxicity), and is less frequently used as the initial diagnostic test.
• Magnetic Resonance Venography (MRV): Utilizes magnetic fields and radio waves to create detailed images of veins. MRV is highly sensitive and specific for DVT, especially in the pelvic and thigh veins, and is useful in patients with contraindications to contrast dye used in venography (e.g., contrast allergy, renal insufficiency). However, MRV is more expensive, less widely available, and may not be suitable for patients with metallic implants or claustrophobia.

Image alt text: Image depicting a duplex ultrasonography procedure being performed on a patient’s leg to diagnose deep vein thrombosis (DVT), showing the ultrasound probe and screen displaying vein images.

Nursing Interventions for DVT

Nursing interventions are crucial for managing DVT, preventing complications, and promoting patient recovery. Nursing care focuses on anticoagulation management, symptom relief, patient education, and preventing DVT recurrence.

1. Start anticoagulation. Anticoagulation is the cornerstone of DVT treatment. The primary goals of anticoagulation therapy in DVT are:

1. Prevent clot propagation: To stop the existing blood clot from growing larger and further obstructing blood flow.
2. Prevent pulmonary embolism: To prevent the clot from breaking loose and traveling to the lungs, causing a PE.
3. Reduce the risk of recurrent DVT: To minimize the likelihood of future DVT episodes.

2. Administer medications cautiously as ordered. Anticoagulants and thrombolytics (clot-busting drugs) increase the risk of bleeding, a major complication. Nurses must implement careful medication administration and monitoring, including:

• Monitoring Coagulation Profile: Regularly check PT/INR for warfarin and aPTT for unfractionated heparin to ensure therapeutic ranges and adjust dosages accordingly.
• Bleeding Precautions: Implement and reinforce bleeding precautions for all patients on anticoagulants:
  • Use a soft-bristle toothbrush and avoid vigorous brushing.
  • Avoid invasive procedures (injections, venipunctures) when possible; use smallest gauge needles and apply prolonged pressure after needle sticks.
  • Advise against forceful sneezing or nose blowing; teach gentle techniques.
  • Implement fall prevention strategies and ensure a safe environment to minimize injury risk.
  • Use electric razors for shaving to prevent skin cuts.
  • Apply direct pressure for a longer duration when removing IV lines or after any puncture.
  • Educate patients to report any signs of bleeding (unusual bruising, nosebleeds, gum bleeding, blood in urine or stool, prolonged bleeding from cuts).

3. Monitor aPTT with unfractionated heparin (UFH). For inpatient treatment of acute DVT, intravenous UFH may be initiated. Close monitoring is essential:

• Frequent aPTT Monitoring: Nurses monitor aPTT levels typically every 6 hours or as per hospital protocol, especially in the initial phase of UFH therapy.
• Dosage Adjustment: Based on aPTT results and facility-specific guidelines, nurses adjust the UFH infusion rate to maintain the aPTT within the therapeutic range (usually 1.5-2.5 times the control value).

4. Administer low molecular weight heparin (LMWH). LMWH options, such as enoxaparin, dalteparin, and tinzaparin, are commonly used for DVT treatment and prophylaxis. Advantages of LMWH include subcutaneous administration (often outpatient), predictable dose response, and less frequent lab monitoring compared to UFH. LMWH is used to prevent new clot formation and extension of existing clots.

5. Monitor for therapeutic international normalized ratio (INR) levels. Warfarin is an oral anticoagulant often used for long-term DVT management.

• Warfarin Initiation and Overlap: If warfarin is prescribed for outpatient continuation, it is typically initiated while the patient is still on another anticoagulant (UFH or LMWH). This “overlap” is necessary because warfarin’s full anticoagulant effect takes several days to develop.
• INR Monitoring: Regular INR monitoring is crucial for patients on warfarin to ensure the INR is within the therapeutic range, typically 2.0-3.0 for DVT treatment. Dosage adjustments are made based on INR values.

6. Consider a vena cava filter. An inferior vena cava (IVC) filter is a mechanical device placed in the IVC to trap large emboli before they reach the lungs, reducing the risk of PE. IVC filters are considered in specific situations:

• Contraindication to anticoagulation: When a patient has an absolute contraindication to anticoagulant medications (e.g., active major bleeding).
• Recurrent PE despite anticoagulation: In patients who experience recurrent pulmonary emboli despite being adequately anticoagulated.
• High risk of PE: In patients with massive proximal DVT who are at very high risk of PE and have temporary contraindications to anticoagulation (e.g., immediately post-surgery).
• Prophylactic use in high-risk trauma patients: In certain trauma patients at very high risk of VTE, particularly if anticoagulation is contraindicated.
• It’s important to note that IVC filters are not a long-term solution and are ideally temporary measures. They do not prevent DVT formation, only PE. The risks and benefits of IVC filter placement should be carefully considered for each patient. Removal of retrievable IVC filters is recommended once the risk of PE has subsided and anticoagulation is no longer contraindicated.

7. Apply compression stockings. Graduated compression stockings (GCS) and intermittent pneumatic compression devices (IPC) are used to improve venous circulation and reduce venous stasis in the legs.

• Compression Stockings: Apply graduated compression stockings to promote venous return, reduce edema, and decrease the risk of postthrombotic syndrome (PTS), a long-term complication of DVT. Stockings should be properly fitted and applied correctly.
• Intermittent Pneumatic Compression (IPC) Devices: IPC devices, also known as sequential compression devices (SCDs), inflate and deflate air bladders around the legs to provide intermittent compression, further enhancing venous flow. IPC may be used, particularly in hospitalized patients with limited mobility, for DVT prophylaxis and to reduce edema.

8. Advise the patient to ambulate and change positions frequently. Prolonged immobility is a major DVT risk factor.

• Promote Ambulation: Encourage patients to ambulate as soon as medically stable. Even short walks can improve circulation.
• Frequent Position Changes: For patients with limited mobility, instruct them to change positions frequently in bed or chair to avoid prolonged venous stasis.
• Leg Exercises: Teach patients bed-bound or sitting for long periods to perform leg exercises regularly, such as ankle pumps, foot circles, and knee flexion/extension, to stimulate calf muscle pump and improve venous return.
• Avoid Prolonged Sitting/Standing: Advise patients to avoid prolonged periods of sitting or standing still. During long drives or flights, encourage regular breaks to stand, walk, and stretch.

9. Promote DVT prophylaxis as ordered. Pharmacological DVT prophylaxis is essential for high-risk patients, particularly in hospital settings.

• Factor Xa Inhibitors: Newer oral anticoagulants like rivaroxaban, apixaban, edoxaban, and betrixaban are increasingly used for DVT prevention. They offer convenience of oral administration and predictable dosing, often without routine lab monitoring.
• Other Prophylactic Agents: LMWH and low-dose UFH are also commonly used for DVT prophylaxis in hospitalized patients. The choice of agent depends on individual patient risk factors, clinical situation, and institutional guidelines.
• Mechanical Prophylaxis: In conjunction with or as an alternative to pharmacological prophylaxis (when contraindicated), mechanical methods like compression stockings and IPC devices are used for DVT prevention.

10. Emphasize the need for strict medication adherence and testing. Patient education on medication management is crucial for successful DVT treatment and prevention of recurrence.

• Medication Adherence: Stress the importance of taking anticoagulant medications exactly as prescribed, without missing doses. Non-adherence can lead to subtherapeutic anticoagulation and increased risk of clot progression or recurrence.
• Duration of Therapy: Explain the typical duration of anticoagulation therapy, which is at least three months for an initial DVT episode and may be longer (e.g., 6 months, 1 year, or even lifelong) for recurrent DVT or in patients with ongoing risk factors.
• INR Monitoring (Warfarin): For patients on warfarin, emphasize the necessity of regular INR blood tests to monitor therapeutic levels and the need for dose adjustments based on INR results. Educate on factors that can affect INR (diet, other medications, illness).

11. Discuss surgical options. In certain cases of severe DVT, surgical or catheter-based interventions may be considered to remove the clot and restore venous flow.

• Thrombectomy: Surgical removal of the thrombus from the vein. May be considered for acute, extensive DVT in iliofemoral veins (major veins in the pelvis and thigh) causing severe symptoms and limb-threatening ischemia (phlegmasia cerulea dolens).
• Catheter-Directed Thrombolysis: Involves inserting a catheter into the vein at the site of the clot and delivering thrombolytic drugs directly to dissolve the clot. May be used for extensive proximal DVT in select patients to reduce long-term complications like PTS.
• Angioplasty and Stenting: In cases of chronic DVT with persistent venous obstruction and PTS symptoms, angioplasty (balloon dilation of the vein) and stenting (placement of a metallic stent to keep the vein open) may be considered to improve venous outflow.

12. Prepare reversal agents. In the event of severe bleeding complications from anticoagulation, reversal agents are necessary to counteract the anticoagulant effects.

• Protamine Sulfate: The antidote for heparin (UFH) and partially reverses the effects of LMWH.
• Vitamin K: The antidote for warfarin. Administered intravenously or orally to reverse warfarin’s anticoagulant effect.
• Factor Xa Inhibitor Reversal Agents: Andexanet alfa is a specific reversal agent for rivaroxaban and apixaban. For edoxaban and betrixaban, prothrombin complex concentrates (PCCs) may be used for reversal, although their effectiveness is less well-established. For dabigatran (direct thrombin inhibitor), idarucizumab is a specific reversal agent.
• Discontinuation: For some Factor Xa inhibitors with shorter half-lives, simply discontinuing the medication may be sufficient for reversal in less severe bleeding cases, as their effects will wear off relatively quickly.

13. Encourage the patient to make lifestyle changes. Lifestyle modifications can significantly reduce the risk of DVT recurrence. Advise patients on:

• Smoking Cessation: Smoking damages blood vessels and increases clotting risk. Strongly encourage smoking cessation.
• Blood Pressure Control: Hypertension can contribute to vascular damage. Manage blood pressure through diet, exercise, and medication if needed.
• Weight Management: Obesity increases DVT risk. Achieve and maintain a healthy weight through diet and exercise.
• Regular Exercise: Promote regular physical activity to improve circulation and overall cardiovascular health.
• Loose Clothing: Avoid tight clothing that can restrict blood flow, particularly around the legs and waist.
• Hydration: Adequate fluid intake helps maintain blood viscosity and reduces risk of clot formation. Encourage drinking plenty of water.
• Natural Blood Thinners: While not substitutes for prescribed anticoagulants, some natural substances may have mild blood-thinning properties. Patients should discuss with their healthcare provider before using these, especially if on anticoagulants. Examples include:
  • Vitamin E (caution advised, high doses may increase bleeding risk)
  • Ginger
  • Cayenne pepper
  • Garlic
  • Turmeric
  • Cinnamon

14. Educate on dietary changes. Patients taking warfarin need specific dietary guidance.

• Vitamin K Intake: Warfarin works by interfering with vitamin K-dependent clotting factors. Consistent vitamin K intake is important for stable warfarin anticoagulation. Patients should avoid drastic changes in vitamin K consumption, particularly from green leafy vegetables (spinach, kale, broccoli, collard greens, etc.), as fluctuations can affect INR levels. Educate patients to maintain a relatively consistent intake of vitamin K-rich foods rather than eliminating them.

15. Advise the patient when to seek immediate medical attention. Patients on anticoagulants must be vigilant for signs of bleeding.

• Bleeding Signs: Educate patients to monitor for and immediately report signs of bleeding:
  • Unusual bruising or easy bruising
  • Nosebleeds
  • Gum bleeding
  • Blood in urine (pink or red urine)
  • Blood in stool (black, tarry stools or bright red blood)
  • Prolonged bleeding from cuts or injuries
  • Heavy menstrual bleeding
  • Vomiting blood or coffee-ground emesis
  • Severe headache, dizziness, or weakness (signs of intracranial bleeding)
• Emergency Department Visit: Instruct patients that if bleeding is significant or cannot be controlled, they should go to the emergency department immediately to prevent severe blood loss and receive prompt medical attention.

Nursing Care Plans for DVT

Once nursing diagnoses are identified, nursing care plans are developed to prioritize assessments and interventions, establishing both short-term and long-term goals for patient care. Here are examples of nursing care plans for common DVT-related nursing diagnoses.

Decreased Cardiac Output

Decreased cardiac output in the context of DVT typically arises from a pulmonary embolism, where a clot migrates to the heart or lungs, obstructing pulmonary blood vessels and subsequently reducing blood flow and oxygenation.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Pulmonary Embolism secondary to DVT
• Obstruction of blood flow to the lungs
• Altered cardiac muscle contractility due to hypoxia
• Increased cardiac workload on the right ventricle

As evidenced by:

• Tachycardia (rapid heart rate)
• Dysrhythmias (irregular heart rhythms)
• Sudden onset of chest pain
• Decreased oxygen saturation (SpO2 < 90%)
• Sudden shortness of breath (dyspnea)
• Tachypnea (rapid breathing)
• Alteration in level of consciousness (confusion, lethargy)
• Dizziness or lightheadedness
• Restlessness, anxiety
• Syncope (fainting)
• Prolonged capillary refill time (> 3 seconds)

Expected outcomes:

• Patient will maintain blood pressure and pulse rate within normal limits for their baseline.
• Patient will report absence or relief of chest pain and shortness of breath.
• Patient will demonstrate improved oxygen saturation (SpO2 ≥ 95% or patient’s baseline).

Assessment:

1. Recognize abnormal symptoms. Prompt recognition of PE symptoms is critical. Patients reporting sudden chest pain, acute dyspnea, tachypnea, and hypoxia require immediate nursing intervention and medical evaluation.

2. Monitor cardiac function. PE significantly impairs cardiac function. Clot obstruction in pulmonary arteries increases pulmonary vascular resistance and right ventricular afterload, leading to right ventricular dysfunction, lung congestion, fluid retention, and potential arrhythmias. The increased workload on the right side of the heart reduces effective cardiac output and oxygen delivery to the heart muscle itself.

3. Obtain ECG. Electrocardiogram (ECG) findings in PE may vary. Sinus tachycardia is the most common ECG abnormality. Other potential findings include non-specific ST-T wave changes, right axis deviation, right bundle branch block, atrial fibrillation, premature atrial contractions, and T wave inversions in anterior leads. ECG is not diagnostic for PE but can provide supportive evidence and help rule out other cardiac conditions.

Interventions:

1. Begin immediate anticoagulation. If PE is suspected, immediate anticoagulation is paramount. Initial anticoagulation typically involves intravenous unfractionated heparin (UFH), low molecular weight heparin (LMWH), or fondaparinux administered in therapeutic doses to prevent further clot propagation and recurrent embolism. Rapid-acting anticoagulation is crucial while further diagnostic workup is underway.

2. Consider thrombolytics. Thrombolytic therapy (fibrinolytic therapy or “clot busters”) may be considered in hemodynamically unstable patients with massive PE causing hypotension, shock, or right ventricular dysfunction. Thrombolytics like alteplase (tPA) aim to rapidly dissolve the clot and restore pulmonary blood flow, potentially improving cardiac output and survival. However, thrombolytics carry a significant bleeding risk and are contraindicated in patients with active bleeding or high bleeding risk.

3. Prepare for surgical interventions. Surgical embolectomy (surgical removal of the clot) or catheter embolectomy (catheter-based clot removal) may be necessary in patients with massive PE who are hemodynamically unstable and either cannot receive or are not responding to thrombolytic therapy. Surgical embolectomy is reserved for critical situations, such as severe right ventricular dysfunction, cardiac necrosis, or when thrombolysis is contraindicated or has failed.

4. Treat shock. PE can lead to rapid hemodynamic decompensation and shock. Patients may develop hypotension, hypoxemia, and decreased tissue perfusion. Management of shock includes:

• Oxygen Therapy: High-flow oxygen administration to maximize oxygen saturation.
• Fluid Resuscitation: Careful intravenous fluid administration to support blood pressure and preload, but avoid overhydration, which can worsen right ventricular overload.
• Vasopressors: Vasopressor medications (e.g., norepinephrine) may be needed to restore adequate blood pressure and systemic perfusion in hypotensive patients.
• Inotropic Support: Inotropic agents (e.g., dobutamine) may be used to improve right ventricular contractility in patients with right ventricular dysfunction and low cardiac output.
• Mechanical Circulatory Support: In extreme cases of massive PE with cardiogenic shock, mechanical circulatory support devices like extracorporeal membrane oxygenation (ECMO) may be considered as a bridge to recovery or definitive therapy.*

Image alt text: Medical illustration showing a pulmonary embolism, depicting a blood clot lodged in a pulmonary artery in the lung, obstructing blood flow.

Deficient Knowledge

Patients diagnosed with DVT require comprehensive education regarding the condition, its management, risk factors, prevention strategies, and the importance of adherence to treatment regimens.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Unfamiliarity with DVT diagnosis, treatment, or prevention strategies
• Inadequate knowledge of personal risk factors for DVT
• Lack of interest in learning or health information
• Cognitive limitations or learning barriers

As evidenced by:

• Patient verbalization of questions or misconceptions about DVT diagnosis, treatment, or prevention
• Misadministration of anticoagulant medications (incorrect dose, timing, or frequency)
• Poor adherence to recommended follow-up lab work (e.g., INR monitoring for warfarin)
• Recurrent DVT episodes, potentially due to inadequate preventive measures
• Failure to verbalize understanding of DVT risk factors, treatment plan, or preventive strategies

Expected outcomes:

• Patient will verbalize accurate understanding of DVT diagnosis, treatment plan, and prognosis.
• Patient will verbalize the importance of prescribed medications, including dosage, administration, potential side effects, and the need for follow-up lab tests (if applicable).
• Patient will accurately identify their individual DVT risk factors and describe at least three specific strategies to prevent recurrent DVT.
• Patient will demonstrate appropriate self-management behaviors related to DVT care, such as medication adherence and lifestyle modifications.

Assessment:

1. Assess knowledge about risk factors. Evaluate the patient’s current understanding of DVT risk factors. Some patients may be aware of general risk factors but not recognize their personal risk profile. Others may have minimal to no prior knowledge. Avoid assumptions about patient understanding; proactively assess their knowledge base by asking open-ended questions about DVT risk factors and their personal susceptibility.

2. Evaluate readiness to adhere to medications. Anticoagulant medications are high-risk and require diligent patient adherence and understanding to ensure safety and efficacy. Assess the patient’s readiness and ability to learn about their medication regimen, including:

• Medication name, purpose, dosage, frequency, and route of administration
• Potential side effects and adverse reactions, particularly bleeding risks
• Drug interactions with other medications, food, or supplements
• Importance of consistent medication timing and avoiding missed doses
• Strategies to enhance medication adherence (pill organizers, reminders)
• Patient’s perceived barriers to medication adherence (cost, complexity, forgetfulness)

3. Assess understanding of follow-up care. For patients on certain anticoagulants like warfarin, regular INR monitoring is essential to maintain therapeutic anticoagulation. Assess the patient’s knowledge and understanding of:

• The purpose of INR testing and its role in warfarin management
• Frequency of INR testing and where to get tested
• Importance of keeping scheduled lab appointments
• How INR results will be communicated and acted upon (dose adjustments)
• Potential consequences of inadequate INR monitoring or failure to maintain therapeutic INR levels.

Interventions:

1. Explain the signs of pulmonary embolism. Provide clear and concise education on the signs and symptoms of pulmonary embolism (PE), a critical complication of DVT. Instruct patients to recognize symptoms such as sudden onset of chest pain, unexplained shortness of breath, rapid heart rate (tachycardia), tachypnea, dizziness, lightheadedness, syncope, and anxiety. Emphasize that PE is a medical emergency requiring immediate attention and instruct patients to seek immediate medical care (call 911 or go to the nearest emergency department) if they experience any of these symptoms.

2. Discuss individual risk factors. Help the patient identify their specific risk factors for DVT based on their health history, lifestyle, and medical conditions. Tailor the discussion to their individual circumstances and provide personalized advice on risk reduction strategies. For example:

• For smokers, emphasize smoking cessation resources and the link between smoking and DVT risk.
• For obese patients, discuss weight management strategies, healthy eating, and regular physical activity.
• For patients with limited mobility, recommend strategies to increase activity, leg exercises, and use of compression devices.
• For patients planning long travel, advise on frequent breaks to walk, leg exercises during travel, and hydration.

3. Provide education about medications. Conduct thorough medication education, providing both verbal and written instructions. Review each prescribed medication in detail, ensuring patient understanding of:

• Medication name, purpose (anticoagulation), and expected benefits.
• Correct dosage, frequency, and route of administration.
• Potential side effects, particularly bleeding risks, and signs to report to their healthcare provider.
• Drug and food interactions (e.g., vitamin K and warfarin).
• Importance of consistent medication adherence and strategies to remember doses.
• Proper storage of medications.
• Answer patient questions and address concerns about medications.

4. Teach ways to prevent a recurrence. Educate patients on practical and actionable strategies to reduce the risk of recurrent DVT. Provide specific recommendations, including:

• Lifestyle modifications: smoking cessation, weight management, regular exercise, hydration, loose clothing.
• Avoid prolonged immobility: frequent ambulation, leg exercises during prolonged sitting or standing, breaks during long travel.
• Compression stockings: proper use and wearing schedule.
• Medication adherence: reinforce the importance of taking prescribed anticoagulants as directed.
• Recognize and manage risk factors: encourage management of underlying medical conditions that increase DVT risk.
• Follow-up care: emphasize the importance of scheduled follow-up appointments and lab work.

Impaired Gas Exchange

Impaired gas exchange related to DVT is primarily a consequence of pulmonary embolism. When a DVT embolizes to the lungs, it obstructs pulmonary arteries, leading to ventilation-perfusion mismatch and compromised oxygenation.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Ventilation-perfusion imbalance in the lungs
• Reduced pulmonary blood flow due to embolism
• Physiological dead space in alveoli
• Alveolar hypoventilation and atelectasis
• Shunting of blood away from ventilated lung areas

As evidenced by:

• Dyspnea (shortness of breath), particularly worsened by exertion
• Sudden onset of chest pain, often pleuritic
• Cough, potentially with bloody mucus (hemoptysis)
• Tachypnea (rapid breathing)
• Dizziness, lightheadedness
• Syncope (fainting)
• Change in level of consciousness (confusion, restlessness, lethargy)
• Change in skin color (pallor, cyanosis)
• Tachycardia (rapid heart rate)
• Palpitations
• Anxiety, restlessness
• Abnormal arterial blood gas (ABG) values (hypoxemia, hypocapnia or hypercapnia)
• Decreased oxygen saturation (SpO2 < 90%)
• Adventitious breath sounds (crackles, wheezes – may be present but not always)

Expected outcomes:

• Patient will demonstrate oxygen saturation (SpO2) and breathing patterns within normal limits for their baseline, or ≥ 95%.
• Patient will report relief or significant reduction in chest pain, dyspnea, and lightheadedness.
• Patient will maintain baseline level of consciousness without episodes of syncope or confusion.
• Patient will exhibit clear breath sounds bilaterally upon auscultation.
• Patient will demonstrate arterial blood gas values within acceptable parameters for their condition.

Assessment:

1. Recognize symptoms of PE. Early recognition of PE symptoms is critical for prompt intervention. Be vigilant for sudden onset of dyspnea, sharp pleuritic chest pain, palpitations, tachycardia, anxiety, and restlessness. These symptoms, especially in patients with DVT risk factors, should raise immediate suspicion of PE and prompt further assessment and diagnostic evaluation.

2. Auscultate the lung sounds. Auscultation of lung sounds is an important component of respiratory assessment. In PE, lung sounds may vary. Crackles (rales) or decreased breath sounds in affected lung areas may be present due to atelectasis, pulmonary edema, or pleural effusion. However, lung sounds can also be normal in PE, particularly in smaller emboli. Abnormal lung sounds are suggestive but not definitive for PE; their absence does not rule out PE.

3. Monitor for any change in mentation. Changes in mental status, such as confusion, restlessness, agitation, lethargy, or decreased level of consciousness, can be early indicators of hypoxemia and reduced cerebral oxygen delivery secondary to PE. These subtle neurological changes should not be overlooked and warrant prompt assessment of oxygenation and potential PE.

4. Utilize the Pulmonary Embolism Rule-Out Criteria (PERC). The PERC rule is a clinical decision tool used to assess the probability of PE in low-risk patients presenting with symptoms suggestive of PE. The PERC rule consists of eight criteria. If all eight criteria are NEGATIVE, the probability of PE is very low, and further diagnostic testing for PE may be safely withheld. The PERC rule is designed to reduce unnecessary testing and radiation exposure in low-risk patients. The eight PERC criteria are:

1. Age ≥ 50 years
2. Heart rate ≥ 100 beats per minute
3. Oxygen saturation (SpO2) < 90% on room air
4. Hemoptysis (coughing up blood)
5. Prior history of DVT or PE
6. Unilateral leg edema (swelling in one leg only)
7. Hormone replacement therapy (HRT) or oral contraceptive (OCP) use
8. Recent surgery or trauma requiring hospitalization within the previous four weeks

If any of these criteria are POSITIVE, the patient is considered PERC-positive, and further evaluation for PE (e.g., D-dimer testing, CT pulmonary angiography) is warranted.

Interventions:

1. Obtain a V/Q scan. Ventilation/perfusion (V/Q) scan is a nuclear medicine test used to assess airflow (ventilation) and blood flow (perfusion) in the lungs. A V/Q scan can help diagnose PE by identifying areas of the lung that are ventilated but not perfused (mismatched V/Q). While CT pulmonary angiography (CTPA) is often the preferred imaging modality for PE diagnosis, V/Q scan may be an alternative, particularly in patients with contraindications to CT contrast dye (e.g., renal insufficiency, contrast allergy) or in pregnant women to minimize radiation exposure.

2. Apply oxygen. Supplemental oxygen therapy is a primary intervention for patients with PE and impaired gas exchange. Administer oxygen to maintain oxygen saturation (SpO2) at or above 90%, or at the patient’s baseline if higher. Oxygen delivery methods may range from nasal cannula to face mask, non-rebreather mask, or mechanical ventilation, depending on the severity of hypoxemia.

3. Implement nonpharmacologic interventions. Nonpharmacologic measures can complement medical management in improving gas exchange and preventing further thromboembolism:

• Positioning: Elevate the head of the bed to improve lung expansion and ventilation.
• Deep breathing and coughing exercises: Encourage deep breaths and controlled coughing to improve alveolar ventilation and clear secretions.
• Pulmonary hygiene: Chest physiotherapy, postural drainage, and suctioning may be needed in patients with significant atelectasis or secretions.
• Compression stockings: Continue use of compression stockings to promote venous return and reduce the risk of further DVT/PE.
• Activity as tolerated: Encourage activity and early ambulation as tolerated to improve overall respiratory function and prevent complications of immobility.

4. Prepare for respiratory support. Severe hypoxemia, respiratory distress, or respiratory failure due to massive PE may necessitate advanced respiratory support. Be prepared for potential interventions including:

• Intubation and mechanical ventilation: For patients with severe hypoxemia, hypercapnia, or respiratory muscle fatigue, endotracheal intubation and mechanical ventilation may be required to maintain adequate oxygenation and ventilation.
• Non-invasive ventilation (NIV): In select patients with less severe respiratory distress, NIV (e.g., CPAP, BiPAP) may be trialed to support breathing and avoid intubation.
• Advanced therapies: In cases of massive PE with refractory hypoxemia despite conventional measures, advanced therapies such as extracorporeal membrane oxygenation (ECMO) may be considered as a rescue measure to provide temporary cardiopulmonary support.

Ineffective Peripheral Tissue Perfusion

Ineffective peripheral tissue perfusion in DVT is a direct result of venous obstruction caused by the thrombus. This obstruction impedes venous outflow, leading to venous stasis, increased hydrostatic pressure, and reduced blood flow to the affected limb.

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion

Related to:

• Venous stasis in the affected extremity
• Obstruction of venous blood flow by thrombus
• Edema formation and increased tissue pressure
• Potential for impaired arterial inflow due to severe venous congestion (in phlegmasia cerulea dolens)
• Inflammation and endothelial damage in the affected vein

As evidenced by:

• Edema in the affected extremity (unilateral swelling)
• Pain or tenderness in the affected leg
• Increased warmth to the site of the clot compared to surrounding tissue and contralateral limb
• Skin discoloration (redness, cyanosis)
• Palpable cord-like vein
• Heaviness or aching sensation in the affected limb
• Positive Homans’ sign (calf pain on dorsiflexion – note: low specificity)
• Decreased or absent peripheral pulses in severe cases (rare, but possible with severe venous congestion)
• Delayed capillary refill in the affected extremity (in severe cases)
• Skin changes: taut, shiny skin; potential for skin breakdown with prolonged edema

Expected outcomes:

• Patient will be free of pulmonary embolism throughout hospitalization and follow-up period, as evidenced by absence of shortness of breath, chest pain, and normal respiratory status.
• Patient will maintain optimal peripheral tissue perfusion in the affected extremity, as evidenced by:
  • Reduction in edema and limb swelling
  • Report of decreased pain or pain relief
  • Palpable peripheral pulses (dorsalis pedis, posterior tibial) of at least 2+ strength
  • Capillary refill time < 3 seconds in toes of affected limb
  • Warm and dry skin in the affected extremity
  • Absence of skin discoloration or ulceration

Assessment:

1. Assess for signs and symptoms. Conduct a thorough assessment for clinical manifestations of DVT in the affected limb. Focus on:

• Visual inspection: Observe for unilateral leg swelling, skin discoloration (redness, cyanosis), venous distention, skin changes (shiny, taut skin).
• Palpation: Palpate for warmth, tenderness along the course of the deep veins, palpable cord-like vein. Assess peripheral pulses (dorsalis pedis, posterior tibial) in both legs and compare strength. Assess capillary refill in toes.
• Patient report: Inquire about pain characteristics (location, intensity, type), heaviness, aching, cramping, tenderness.
• Measurement: Measure and compare leg circumferences at consistent points (e.g., calf, thigh) bilaterally to quantify edema.

2. Assess the patient’s risk factors. Re-evaluate and document the patient’s individual DVT risk factors. This helps contextualize the current DVT and guide preventive strategies. Consider:

• Immobility (recent surgery, prolonged bed rest, paralysis, long travel)
• Hypercoagulable states (inherited thrombophilia, active cancer, pregnancy, estrogen therapy)
• Vascular trauma (surgery, catheter insertion, injury)
• Medical comorbidities (heart failure, COPD, IBD, nephrotic syndrome, varicose veins)
• Lifestyle factors (smoking, obesity)
• Past history of VTE.

3. Measure leg circumference. Serial leg circumference measurements are valuable to monitor edema progression or reduction in response to treatment. Measure and document leg circumference at standardized points (e.g., 10 cm below tibial tuberosity, 10 cm above patella) in both legs. A difference of ≥ 2-3 cm between legs at the same measurement point is suggestive of unilateral edema and potential DVT. Leg circumference measurements provide objective data to track edema changes over time.

Interventions:

1. Administer anticoagulants as ordered. Anticoagulation is the primary medical intervention to improve peripheral tissue perfusion in DVT. Anticoagulants prevent clot propagation, reduce the risk of PE, and allow endogenous thrombolytic mechanisms to work on clot resolution over time. Administer prescribed anticoagulants (e.g., heparin, LMWH, fondaparinux, warfarin, DOACs) promptly and monitor for therapeutic effects and bleeding complications. Ensure therapeutic anticoagulation is achieved and maintained by monitoring relevant lab values (aPTT for heparin, INR for warfarin, anti-Xa levels for some LMWH/DOACs if indicated).

2. Apply compression stockings as ordered. Graduated compression stockings (GCS) are a key adjunctive measure to enhance venous return, reduce venous stasis, and improve peripheral tissue perfusion in DVT. Apply GCS to the affected leg as prescribed. Ensure proper fit and application. Teach patients correct application technique and wearing schedule. Compression stockings help reduce edema, alleviate symptoms, and may decrease the risk of postthrombotic syndrome.

3. Ensure adequate hydration. Dehydration can increase blood viscosity, potentially exacerbating venous stasis and impaired tissue perfusion. Ensure the patient is adequately hydrated. Encourage oral fluid intake if appropriate. Administer intravenous fluids as ordered if the patient is dehydrated or unable to maintain adequate oral intake. Adequate hydration promotes optimal blood viscosity and circulation.

4. Obtain an ultrasound. Doppler ultrasound (duplex venous ultrasonography) is the primary imaging modality to confirm DVT diagnosis and assess venous blood flow. If DVT is suspected but not yet confirmed, or if there is a change in patient symptoms, prepare the patient for a Doppler ultrasound of the affected limb as ordered. Bedside ultrasound may be used in some settings for rapid assessment. Ultrasound helps visualize the veins, detect thrombus, and evaluate the extent and location of DVT, guiding treatment decisions.

Risk for Bleeding

Patients receiving anticoagulant therapy for DVT are inherently at increased risk for bleeding complications due to the medication’s mechanism of action, which inhibits blood clotting.

Nursing Diagnosis: Risk for Bleeding

Related to:

• Anticoagulant medication therapy (heparin, LMWH, warfarin, DOACs)
• Underlying medical conditions that may increase bleeding risk (e.g., thrombocytopenia, bleeding disorders, peptic ulcer disease, recent surgery, trauma)
• Invasive procedures (venipunctures, injections)
• Lack of awareness of bleeding precautions
• Abnormal blood profiles (e.g., thrombocytopenia, coagulopathies)

As evidenced by:

A “Risk for” nursing diagnosis is not evidenced by actual signs and symptoms because the problem has not yet occurred. Evidence for a risk diagnosis comes from the presence of risk factors that make the patient susceptible to the problem. In this case, the primary risk factor is anticoagulant use.

Expected outcomes:

• Patient will maintain blood clotting factors within therapeutic ranges, as evidenced by appropriate aPTT, INR, and platelet counts.
• Patient will verbalize understanding of safety measures and bleeding precautions to minimize bleeding risk.
• Patient will remain free from clinically significant bleeding episodes during anticoagulant therapy.
• Patient will promptly report any signs or symptoms of bleeding to healthcare providers.

Assessment:

1. Assess vital signs and symptoms of bleeding. Regularly monitor vital signs for indicators of bleeding, such as:

• Hypotension (decreased blood pressure)
• Tachycardia (increased heart rate)
• Hypothermia (decreased body temperature – in severe blood loss)
• Dizziness or lightheadedness (orthostatic hypotension)
  Assess for overt signs of bleeding:
• Nosebleeds (epistaxis)
• Gum bleeding
• Easy bruising (ecchymosis)
• Petechiae (small, pinpoint red spots on skin)
• Hematuria (blood in urine – pink or red urine)
• Melena (black, tarry stools) or hematochezia (bright red blood in stool)
• Hemoptysis (coughing up blood)
• Vomiting blood (hematemesis) or coffee-ground emesis
• Unusual or prolonged bleeding from cuts or puncture sites.

2. Monitor labs. Regularly monitor relevant laboratory values, especially in patients receiving anticoagulants:

• Platelet count: Thrombocytopenia (low platelet count) increases bleeding risk. Monitor platelet counts, especially if heparin-induced thrombocytopenia (HIT) is a concern with heparin use.
• Coagulation profiles: PT, PTT, INR. Monitor aPTT for heparin therapy, INR for warfarin therapy. Ensure values are within therapeutic ranges and adjust anticoagulant dosages as needed based on lab results.
• Hemoglobin and hematocrit: Monitor for decreases, which may indicate blood loss.

3. Monitor heparin-induced platelet aggregation (HIPA) status. Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy characterized by a paradoxical decrease in platelet count and increased risk of thrombosis. Monitor platelet counts in patients receiving heparin. Be alert for a sudden drop in platelets (typically > 50% from baseline) occurring 5-10 days after heparin initiation. If HIT is suspected, promptly discontinue heparin, perform appropriate diagnostic testing (HIT antibody tests), and initiate alternative anticoagulation (non-heparin anticoagulants) as ordered.

Interventions:

1. Provide education to reduce bleeding risk. Patient education is crucial for minimizing bleeding risk at home and in the hospital. Educate patients and caregivers on:

• Bleeding precautions: Use soft toothbrush, electric razor, avoid forceful nose blowing and straining during bowel movements, avoid high-impact activities, wear shoes to prevent foot injuries.
• Medication adherence: Take anticoagulants exactly as prescribed, do not double doses, do not stop or change doses without consulting healthcare provider.
• Drug interactions: Inform healthcare providers of all medications, supplements, and herbal remedies being taken to avoid potential drug interactions that could increase bleeding risk.
• Dietary considerations: For warfarin patients, maintain consistent vitamin K intake and avoid drastic dietary changes.
• Signs and symptoms of bleeding: Review signs and symptoms of bleeding and instruct patients to report any bleeding promptly to their healthcare provider.
• Safety measures: Create a safe home environment to prevent falls and injuries (remove tripping hazards, good lighting, handrails).

2. Take immediate action if bleeding occurs. If bleeding is detected, implement immediate nursing actions:

• Assess and quantify the bleeding: Determine the source, location, and severity of bleeding.
• Apply direct pressure: For external bleeding, apply firm, direct pressure to the bleeding site for 10-15 minutes.
• Stop heparin infusion (if applicable): If patient is on IV heparin and bleeding is significant, immediately stop the heparin infusion and notify the physician.
• Notify physician promptly: Inform the physician of any bleeding episode, especially if significant or unexpected.
• Evaluate labs: Review recent coagulation labs (PTT, INR, platelet count) and report abnormal values to the physician.
• Prepare for potential interventions: Be prepared to administer reversal agents (protamine for heparin, vitamin K for warfarin), transfuse blood products, or administer other treatments as ordered by the physician.

3. Provide education on bleeding precautions. Reinforce bleeding precautions for patients continuing oral anticoagulants at home. Emphasize:

• Safety in daily activities: Be cautious with activities that may cause injury (shaving, cooking, gardening, home repairs).
• Medical alert bracelet: Consider wearing a medical alert bracelet or carrying a card indicating anticoagulant use.
• Dental and surgical procedures: Inform dentists and surgeons about anticoagulant use prior to any procedures. Anticoagulant management may need to be adjusted temporarily.
• Head injury risk: Advise patients to seek immediate medical attention for any head injury, even minor, due to the risk of intracranial bleeding, which can be life-threatening in anticoagulated patients.

4. Have antidotes available to reverse anticoagulants. Ensure that reversal agents for prescribed anticoagulants are readily available in the clinical setting in case of severe bleeding:

• Protamine sulfate: Have protamine sulfate available to reverse heparin (UFH) and partially reverse LMWH effects.
• Vitamin K: Have vitamin K available to reverse warfarin effects.
• Specific reversal agents for DOACs: For patients on dabigatran, idarucizumab should be available. For rivaroxaban and apixaban, andexanet alfa (or prothrombin complex concentrates in some cases) should be available. Familiarize yourself with institutional protocols for reversal agent administration.