DVT Nursing Diagnosis Care Plan: Comprehensive Guide for Nurses

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 legs, either in the thigh or calf. This clot can obstruct blood flow, leading to pain and swelling. More critically, a DVT poses a significant risk if the clot breaks loose and travels through the bloodstream to the lungs, causing a potentially fatal pulmonary embolism.

Nurses play a crucial role in the care of patients with DVT, particularly in hospital settings. The severity of DVT dictates the treatment approach, with some patients requiring hospitalization for intravenous anticoagulation therapy and close monitoring. Recognizing patient populations at high risk for DVT and implementing preventive measures are essential nursing responsibilities.

Nursing Process in DVT Management

The nursing process provides a structured framework for managing patients with DVT. It encompasses assessment, diagnosis, planning, implementation, and evaluation. This article will guide nurses through each stage of the nursing process in the context of DVT care.

Nursing Assessment for DVT

The initial nursing assessment is vital for gathering comprehensive patient data. This involves collecting subjective and objective information related to the patient’s physical, psychosocial, emotional, and diagnostic status. Understanding the difference between subjective and objective data is fundamental in this process.

Review of Health History

1. Elicit General Symptoms of DVT. Assess for the following common signs and symptoms of DVT:

• Unilateral Leg Swelling: Swelling in one leg that is noticeably greater than the other is a primary indicator.
• Leg Pain or Tenderness: Patients may describe pain, cramping, or tenderness, often in the calf or thigh.
• Warmth Over the Affected Site: The skin over the DVT may feel warmer to the touch compared to the surrounding area.
• Skin Discoloration: Changes in skin color, such as redness or bluish discoloration (cyanosis), may be present.

It is also crucial to assess for symptoms indicative of pulmonary embolism (PE), which can occur if the DVT has migrated to the lungs:

• Dyspnea (Difficulty Breathing): Sudden onset or worsening shortness of breath.
• Cough: May be dry or productive.
• Chest Pain: Often pleuritic, meaning it worsens with breathing, and may resemble chest pain (angina).
• Syncope (Fainting): Loss of consciousness due to reduced blood flow to the brain, also related to syncope.
• Palpitations: Awareness of rapid or irregular heartbeat.

2. Identify DVT Risk Factors. Numerous factors can elevate a patient’s risk of developing DVT. Inquire about the presence of the following risk factors:

• Advanced Age: Risk increases with age, particularly over 60.
• Ethnicity: African Americans have a higher incidence of DVT.
• Smoking: Smoking damages blood vessels and increases blood clot risk.
• Obesity: Excess weight, or obesity, is linked to increased DVT risk due to impaired circulation and other factors.
• Recent Surgery: Especially orthopedic, neurovascular, or major abdominal surgeries.
• Immobility: Prolonged bed rest, paralysis, or limited mobility significantly increase risk.
• Previous History of DVT or PE: Individuals with a prior venous thromboembolism are at higher risk of recurrence.
• Cancer: Certain cancers and cancer treatments can increase hypercoagulability, as explained in cancer nursing diagnosis.
• Pregnancy: Pregnancy increases DVT risk due to hormonal changes and pressure on pelvic veins.
• Prolonged Travel: Long car or plane trips with extended periods of sitting can lead to venous stasis.
• Intravenous Drug Use: Can damage veins and increase clot risk.
• Hypercoagulable Disorders: Inherited or acquired conditions that predispose to blood clotting.

3. Medication Review for DVT Risk. Certain medications are associated with an elevated risk of DVT. Review the patient’s medication list, noting the use of:

• Oral Contraceptives: Estrogen-containing birth control pills.
• Hormone Replacement Therapy (HRT): Estrogen and progesterone therapy.
• Glucocorticoids (Steroids): Prednisone and similar medications.
• Tamoxifen and Raloxifene: Selective estrogen receptor modulators (SERMs) used in breast cancer treatment and prevention.
• Testosterone: Hormone replacement therapy for men.
• Antidepressants: Some antidepressants, particularly SSRIs, have been linked to a slightly increased risk.

4. Chronic Medical Conditions and DVT Risk. Inquire about pre-existing medical conditions that can increase DVT susceptibility, such as:

• Active Cancer
• Heart Failure
• Chronic Obstructive Pulmonary Disease (COPD)
• Inflammatory Bowel Disease (IBD)
• Nephrotic Syndrome
• Myeloproliferative Neoplasms
• Systemic Lupus Erythematosus (SLE)
• Antiphospholipid Syndrome

5. Assess for Central Catheters. Note the presence of central venous catheters, particularly peripherally inserted central catheters (PICCs). PICCs are associated with a higher DVT risk compared to centrally inserted CVCs.

Physical Assessment for DVT

1. Evaluate for Homan’s Sign. Traditionally, Homan’s sign (calf pain upon dorsiflexion of the foot with the knee extended) was used to screen for DVT. However, it is not a reliable or sensitive indicator and has low diagnostic value. Its absence does not rule out DVT, and its presence is not specific to DVT.

2. Perform DVT Risk Stratification. Utilize clinical decision rules like the Wells’ Criteria for DVT to formally assess pretest probability of DVT. Risk stratification tools are crucial for guiding diagnostic testing and treatment decisions.

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

• Palpable Venous Cord: A tender, subcutaneous venous segment that feels indurated, palpable, and cord-like upon palpation.
• Skin Discoloration: Reddish-purple or cyanotic discoloration of the lower extremity.
• Edema: Unilateral edema in the affected leg, as detailed in edema nursing diagnosis.
• Petechiae: Small, pinpoint red or purple spots on the skin, indicating capillary bleeding.
• Blanching: Rarely, the skin may appear pale or blanched.

4. Respiratory Assessment for Pulmonary Embolism. Given the serious risk of PE as a DVT complication, a thorough respiratory assessment is essential. Assess for:

• Pleuritic Chest Pain: Chest pain that worsens with deep breathing or coughing.
• Tachypnea: Increased respiratory rate (rapid breathing).
• Tachycardia: Increased heart rate, also discussed in tachycardia nursing diagnosis.
• Palpitations: Irregular or forceful heartbeats.
• Dyspnea: Shortness of breath, further explained in dyspnea nursing diagnosis.
• Dizziness or Syncope: Lightheadedness or fainting episodes, related to dizziness nursing diagnosis.
• Hemoptysis: Coughing up blood.
• Crackles or Wheezing: Abnormal lung sounds upon auscultation.
• Decreased Breath Sounds: Reduced air entry into the lungs.

Diagnostic Procedures for DVT

1. Blood Tests. Several blood tests are used in the diagnostic workup for DVT:

• D-dimer: This blood test measures a protein fragment (D-dimer) produced when blood clots break down. Elevated D-dimer levels are highly sensitive for DVT and PE, but not specific, as they can be elevated in other conditions. A negative D-dimer result is very helpful in ruling out DVT in low-risk patients.
• Coagulation Profile: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) assess the blood’s clotting ability and may be used to monitor anticoagulation therapy.

2. Venous Imaging. Imaging studies are crucial for visualizing veins and detecting blood clots:

• Duplex Venous Ultrasonography: This is the primary imaging modality for diagnosing DVT. It is non-invasive, readily available, and highly accurate for detecting clots in proximal veins (thigh and groin). It uses sound waves to visualize blood flow and vein structure.
• Venography: Involves injecting contrast dye into leg veins and taking X-rays to visualize the venous system. Venography is more invasive and less commonly used than ultrasound but may be considered in specific situations where ultrasound is inconclusive.
• Magnetic Resonance Venography (MRV): MRV provides detailed images of veins using magnetic fields and radio waves. It is highly sensitive and specific for DVT, particularly in pelvic and proximal veins, but is more expensive and less accessible than ultrasound. MRV is useful for patients with contraindications to contrast dye used in venography.

Nursing Interventions for DVT

Nursing interventions are critical for managing DVT and preventing complications. The goals of DVT treatment are:

1. Prevent clot propagation: Stop the existing clot from growing larger.
2. Prevent pulmonary embolism: Prevent the clot from breaking loose and traveling to the lungs.
3. Reduce recurrence risk: Minimize the likelihood of future DVT episodes.

1. Initiate Anticoagulation Therapy. Anticoagulation is the cornerstone of DVT treatment. It prevents further clot formation and reduces the risk of PE.

2. Medication Administration and Bleeding Precautions. Administer anticoagulants and thrombolytics (clot-dissolving medications) as prescribed. These medications increase bleeding risk, necessitating careful monitoring and implementation of bleeding precautions:

• Monitor Coagulation Profile: Regularly check PT/INR and aPTT levels, as indicated.
• Soft Bristle Toothbrush: Use a soft toothbrush to minimize gum bleeding.
• Avoid Invasive Procedures: Limit intramuscular injections and venipunctures when possible.
• Gentle Nose Care: Advise against forceful sneezing or nose blowing.
• Fall Prevention: Implement measures to prevent falls and injuries.
• Electric Razor: Use electric razors for shaving to avoid skin cuts.
• Pressure After IV Removal: Apply prolonged pressure after removing IV lines to ensure hemostasis.

3. Monitor aPTT with Unfractionated Heparin (UFH). For hospitalized patients receiving intravenous UFH, monitor aPTT every 6 hours and adjust the infusion rate according to established protocols to maintain therapeutic anticoagulation.

4. Administer Low Molecular Weight Heparin (LMWH). LMWH options such as enoxaparin, dalteparin, and tinzaparin are frequently used for DVT treatment and prophylaxis. They are administered subcutaneously and have a more predictable anticoagulant effect than UFH. Apixaban and rivaroxaban are oral factor Xa inhibitors that can also be used for DVT treatment and prevention.

5. Monitor INR with Warfarin. If warfarin is prescribed for long-term anticoagulation, monitor INR regularly to ensure it reaches and remains within the therapeutic range (typically 2.0-3.0 for DVT). Warfarin requires careful monitoring and dietary considerations.

6. Consider Vena Cava Filter. An inferior vena cava (IVC) filter may be placed in patients at high risk of PE or those with contraindications to anticoagulation. The IVC filter traps large emboli, preventing them from reaching the lungs. However, it does not prevent new clot formation and is not a substitute for anticoagulation when possible. IVC filters are indicated for:

• Contraindications to anticoagulation.
• Recurrent DVT or PE despite anticoagulation.

7. Apply Compression Therapy. Compression stockings and intermittent pneumatic compression devices are used to improve venous circulation, reduce edema, and minimize the risk of post-thrombotic syndrome and recurrent DVT.

8. Encourage Ambulation and Position Changes. Prolonged immobility increases DVT risk. Encourage patients to ambulate as tolerated and change positions frequently. Bed rest solely for fear of embolization is not recommended. For patients with limited mobility, advise leg exercises such as ankle pumps, foot circles, and knee flexion/extension.

9. Implement DVT Prophylaxis. For patients at risk, implement DVT prophylaxis measures, which may include:

• Pharmacological Prophylaxis: Low-dose LMWH, UFH, fondaparinux, or oral factor Xa inhibitors (rivaroxaban, apixaban, betrixaban).
• Mechanical Prophylaxis: Intermittent pneumatic compression devices, graduated compression stockings.

10. Emphasize Medication Adherence and Monitoring. Educate patients about the importance of adhering to their anticoagulant regimen and necessary laboratory monitoring (e.g., INR for warfarin). Anticoagulation therapy typically lasts for at least 3 months, and longer durations may be needed for recurrent DVT or persistent risk factors.

11. Discuss Surgical or Interventional Options. In cases of extensive DVT causing limb-threatening ischemia (e.g., phlegmasia cerulea dolens), surgical thrombectomy or catheter-directed thrombolysis may be considered to remove the clot and restore blood flow. Angioplasty and stenting may be used to treat underlying venous stenosis.

12. Prepare Reversal Agents. Have reversal agents readily available in case of severe bleeding from anticoagulation. Protamine sulfate is the antidote for heparin and LMWH. Vitamin K is used to reverse warfarin. Factor Xa inhibitors have shorter half-lives, and discontinuation may be sufficient in many bleeding situations; however, specific reversal agents (andexanet alfa, ciraparantag) are available for certain factor Xa inhibitors in severe bleeding scenarios.

13. Lifestyle Modifications for DVT Prevention. Counsel patients on lifestyle changes to reduce DVT recurrence risk:

• Smoking Cessation: Smoking cessation is crucial.
• Blood Pressure Control: Manage hypertension.
• Weight Management: Achieve and maintain a healthy weight.
• Regular Exercise: Engage in daily physical activity.
• Loose Clothing: Avoid tight clothing that can restrict circulation.
• Hydration: Increase water intake to maintain adequate hydration.
• Natural Blood Thinners (with caution): Discuss with a healthcare provider before using natural blood thinners like vitamin E, ginger, cayenne pepper, garlic, turmeric, and cinnamon, as these may interact with prescribed anticoagulants or have limited evidence of effectiveness.

14. Dietary Considerations with Warfarin. For patients taking warfarin, educate them about the importance of consistent vitamin K intake. Large fluctuations in dietary vitamin K, particularly from green leafy vegetables, can affect warfarin’s anticoagulant effect. Patients do not need to avoid vitamin K-rich foods entirely but should maintain a consistent level of intake.

15. When to Seek Immediate Medical Attention. Instruct patients to promptly seek medical attention if they experience signs of bleeding (e.g., nosebleeds, unusual bruising, blood in urine or stool, heavy menstrual bleeding) or symptoms of PE (sudden chest pain, shortness of breath, dizziness, cough).

DVT Nursing Care Plans and Diagnoses

Nursing care plans are essential tools for organizing and delivering patient-centered care. Based on the nursing assessment, several nursing diagnoses may be relevant for patients with DVT. These diagnoses guide the development of individualized care plans with specific goals and interventions. Common nursing diagnoses for DVT include:

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to pulmonary embolism (PE) secondary to DVT.

Related Factors:

• DVT embolization to the heart or lungs.
• Obstruction of pulmonary blood flow.
• Altered cardiac muscle contractility due to hypoxia.
• Increased right ventricular workload.

As Evidenced By:

• Tachycardia
• Dysrhythmias (e.g., atrial fibrillation, right bundle branch block)
• Sudden onset of chest pain
• Decreased oxygen saturation (SpO2 < 90%)
• Sudden shortness of breath (dyspnea)
• Tachypnea (respiratory rate > 20 breaths/min)
• Altered level of consciousness (confusion, lethargy)
• Dizziness or lightheadedness
• Restlessness, anxiety
• Syncope (fainting)
• Prolonged capillary refill time (> 3 seconds)
• Hypotension (late sign)

Expected Outcomes:

• Patient will maintain blood pressure and heart rate within acceptable limits.
• Patient will report absence of chest pain and shortness of breath.
• Patient will maintain adequate oxygen saturation (SpO2 ≥ 95%).

Nursing Assessments:

1. Recognize PE Symptoms: Promptly identify patients exhibiting signs and symptoms of PE, such as sudden chest pain, dyspnea, tachypnea, and hypoxia, as these require immediate intervention.
2. Monitor Cardiac Function: Assess for signs of reduced cardiac output, including hypotension, tachycardia, jugular venous distention, peripheral edema, and abnormal heart sounds. PE can lead to right ventricular strain and failure, decreasing cardiac output and oxygen delivery.
3. Obtain ECG: Electrocardiogram (ECG) findings in PE may include sinus tachycardia, ST-segment changes, T-wave inversions, right bundle branch block, or atrial arrhythmias. ECG can help rule out myocardial infarction but is not diagnostic for PE.

Nursing Interventions:

1. Immediate Anticoagulation: If PE is suspected, initiate immediate anticoagulation with intravenous unfractionated heparin, low molecular weight heparin, or fondaparinux as per physician orders and established protocols.
2. Consider Thrombolytic Therapy: In hemodynamically unstable patients with massive PE, thrombolytic therapy (e.g., alteplase, tenecteplase) may be considered to dissolve the clot and restore pulmonary blood flow. Weigh risks and benefits carefully due to bleeding risk.
3. Prepare for Surgical/Catheter Embolectomy: For patients with massive PE who are contraindicated for or unresponsive to thrombolysis, surgical embolectomy (surgical removal of the clot) or catheter-directed embolectomy (clot removal via catheter) may be necessary.
4. Manage Shock: PE can lead to cardiogenic shock. Manage hypotension with intravenous fluids (carefully, to avoid right ventricular overload) and vasopressors (e.g., norepinephrine) to maintain blood pressure and tissue perfusion. Monitor hemodynamic status closely with invasive monitoring (arterial line, central venous catheter) if needed. Provide supplemental oxygen and consider mechanical ventilation if respiratory failure develops.

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to DVT diagnosis, treatment, and prevention.

Related Factors:

• Unfamiliarity with DVT and its management.
• Misinformation or lack of information about risk factors.
• Lack of interest in learning (less common).
• Cognitive limitations (consider patient’s learning ability).

As Evidenced By:

• Verbalized questions and concerns about DVT diagnosis and treatment.
• Misunderstanding of medication regimen (e.g., incorrect dosage, timing).
• Poor adherence to follow-up appointments or lab testing.
• Recurrent DVT episodes due to lack of preventive measures.
• Inaccurate statements about DVT or its management.

Expected Outcomes:

• Patient will verbalize understanding of DVT diagnosis, treatment plan, and prognosis.
• Patient will accurately describe medication regimen, including purpose, dosage, frequency, and side effects.
• Patient will identify personal risk factors for DVT and demonstrate at least three strategies to prevent recurrence.
• Patient will verbalize the importance of follow-up care and lab monitoring (if applicable).

Nursing Assessments:

1. Assess Knowledge of Risk Factors: Evaluate the patient’s understanding of DVT risk factors. Do not assume pre-existing knowledge. Ask open-ended questions to assess their current level of understanding.
2. Evaluate Medication Adherence Readiness: Assess the patient’s understanding of their anticoagulant medications, including the importance of adherence, potential side effects (especially bleeding), and interactions with other medications or foods. Identify any barriers to medication adherence (e.g., cost, complexity of regimen, forgetfulness).
3. Assess Understanding of Follow-up Care: Determine the patient’s understanding of required follow-up care, including INR monitoring (if on warfarin), follow-up appointments, and signs/symptoms to report to their healthcare provider.

Nursing Interventions:

1. Explain Pulmonary Embolism (PE) Signs: Educate the patient about the signs and symptoms of PE (sudden chest pain, shortness of breath, rapid heart rate, dizziness, coughing up blood). Emphasize that PE is a medical emergency requiring immediate medical attention. Provide clear instructions on what to do if these symptoms occur (call 911 or go to the nearest emergency room).
2. Discuss Individual Risk Factors: Review the patient’s specific risk factors for DVT. Tailor education to address modifiable risk factors (e.g., smoking cessation, weight management, hydration, avoiding prolonged immobility). Provide personalized advice and resources.
3. Medication Education: Provide comprehensive education about prescribed anticoagulants. Include:
   • Name of medication, dosage, frequency, and route of administration.
   • Purpose of medication and how it works to prevent blood clots.
   • Potential side effects, especially bleeding risks, and signs/symptoms of bleeding to watch for.
   • Drug-drug and drug-food interactions (especially for warfarin and vitamin K-rich foods).
   • Importance of medication adherence and not stopping medication without consulting their healthcare provider.
   • Proper storage and handling of medication.
   • For warfarin, explain the need for regular INR blood tests and how the dosage may be adjusted based on these results.
4. Recurrence Prevention Strategies: Teach patients practical strategies to reduce DVT recurrence risk:
   • Leg exercises during prolonged sitting (ankle pumps, calf raises).
   • Regular ambulation and avoiding prolonged immobility.
   • Staying hydrated.
   • Avoiding crossing legs for extended periods.
   • Wearing compression stockings as prescribed.
   • Lifestyle modifications: smoking cessation, weight management, regular exercise.
   • For long travel (plane or car), advise frequent breaks to stand and walk around, stay hydrated, and consider wearing compression stockings.

Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to pulmonary embolism (PE) secondary to DVT.

Related Factors:

• Ventilation-perfusion mismatch in the lungs.
• Reduced blood flow to oxygenate blood in the lungs.
• Pulmonary embolism obstructing pulmonary arteries.

As Evidenced By:

• Dyspnea (shortness of breath), especially with exertion.
• Sudden onset of chest pain (pleuritic).
• Cough, possibly with hemoptysis (bloody sputum).
• Tachypnea (rapid breathing).
• Dizziness, lightheadedness.
• Syncope (fainting).
• Change in level of consciousness (confusion, restlessness).
• Cyanosis (bluish discoloration of skin and mucous membranes) or pallor.
• Tachycardia (rapid heart rate).
• Palpitations.
• Anxiety, restlessness.
• Abnormal arterial blood gas values (hypoxemia, hypocapnia initially, later hypercapnia).
• Decreased SpO2 (oxygen saturation < 90%).
• Adventitious breath sounds (crackles, wheezing) or decreased breath sounds.

Expected Outcomes:

• Patient will achieve and maintain adequate oxygen saturation (SpO2 ≥ 95%) and breathing pattern within normal limits (respiratory rate 12-20 breaths/min, unlabored respirations).
• Patient will report relief or reduction of chest pain, dyspnea, and dizziness.
• Patient will maintain baseline level of consciousness without episodes of syncope.
• Patient’s arterial blood gas values will be within acceptable limits for their baseline.

Nursing Assessments:

1. Recognize PE Symptoms: Be vigilant for signs and symptoms of PE, as early recognition is critical for timely intervention. PE is a life-threatening complication of DVT.
2. Auscultate Lung Sounds: Assess lung sounds for abnormalities such as crackles (rales), wheezing, or decreased breath sounds, which may indicate PE or secondary conditions like pulmonary edema. However, lung sounds may be normal in PE.
3. Monitor Mental Status: Changes in mental status (confusion, restlessness, lethargy, anxiety) can be early indicators of hypoxemia due to PE. Reduced oxygen delivery to the brain can alter neurological function.
4. Pulmonary Embolism Rule-Out Criteria (PERC): Utilize PERC rule to assess low-risk patients with suspected PE. If all PERC criteria are negative, PE is highly unlikely, and further testing may not be needed. PERC criteria include:
   • Age < 50 years
   • Heart rate < 100 bpm
   • SpO2 ≥ 95% on room air
   • No hemoptysis
   • No prior DVT or PE
   • No unilateral leg edema
   • No hormone use (estrogen or oral contraceptives)
   • No recent surgery or trauma requiring hospitalization within the past 4 weeks

Nursing Interventions:

1. Obtain V/Q Scan or CTPA: Prepare the patient for diagnostic testing to confirm or rule out PE. Ventilation-perfusion (V/Q) scan and Computed Tomography Pulmonary Angiography (CTPA) are common imaging studies used to diagnose PE. CTPA is generally preferred due to higher sensitivity and specificity.
2. Administer Oxygen Therapy: Apply supplemental oxygen (nasal cannula, face mask, non-rebreather mask) to maintain SpO2 > 90% or as ordered. Titrate oxygen flow rate based on SpO2 monitoring and arterial blood gas results.
3. Non-Pharmacological Interventions:
   • Position patient in semi-Fowler’s or high-Fowler’s position to promote lung expansion (if tolerated and not contraindicated).
   • Encourage deep breathing and coughing exercises (if not contraindicated by pain or other conditions).
   • Apply compression stockings or pneumatic compression devices to prevent further thromboembolism from lower extremities.
   • Encourage activity as tolerated, and promote early ambulation to improve ventilation and circulation.
4. Prepare for Respiratory Support: Anticipate the need for advanced respiratory support in patients with severe hypoxemia or respiratory failure due to massive PE. Prepare for possible intubation and mechanical ventilation. Have resuscitation equipment readily available.

Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to venous obstruction secondary to DVT.

Related Factors:

• Venous stasis (slow blood flow in veins).
• Damage to the inner lining of the vein wall (endothelial injury).
• Hypercoagulability of blood (increased tendency to clot).

As Evidenced By:

• Edema (swelling) in the affected extremity (unilateral).
• Pain or tenderness in the affected limb.
• Increased warmth of the skin over the clot site.
• Skin discoloration (redness, cyanosis).
• Palpable venous cord (hardened vein).
• Changes in peripheral pulses (may be diminished but often normal initially).
• Delayed capillary refill (may be prolonged, > 3 seconds).
• Heaviness or aching sensation in the leg.

Expected Outcomes:

• Patient will remain free from pulmonary embolism (PE), as evidenced by absence of chest pain, shortness of breath, and normal respiratory rate and oxygen saturation.
• Patient will demonstrate improved peripheral tissue perfusion in the affected extremity, as evidenced by:
  • Reduction in edema.
  • Decreased pain or pain at a manageable level (using pain scale).
  • Skin temperature returning to normal.
  • Normal skin color.
  • Capillary refill time < 3 seconds.
  • Palpable peripheral pulses (dorsalis pedis, posterior tibial).

Nursing Assessments:

1. Assess for DVT Signs and Symptoms: Regularly assess for signs and symptoms of DVT in at-risk patients. Even if asymptomatic, DVT can be present. Pay close attention to unilateral leg swelling, pain, warmth, and skin changes.
2. Identify Risk Factors: Thoroughly assess for predisposing risk factors for DVT, as early identification of at-risk individuals allows for preventive measures. Risk factors include immobility, surgery, trauma, malignancy, hypercoagulable states, pregnancy, oral contraceptives, hormone replacement therapy, and prolonged travel. Consider dehydration nursing diagnosis as a contributing factor.
3. Measure Leg Circumference: If DVT is suspected, measure and compare the circumference of both legs at standardized points (e.g., 10 cm below tibial tuberosity and 10 cm above the patella). A difference of > 2-3 cm may suggest DVT, but this is not definitive and should be used in conjunction with other assessment findings and diagnostic tests.

Nursing Interventions:

1. Administer Anticoagulants: Administer prescribed anticoagulants (e.g., heparin, LMWH, warfarin, direct oral anticoagulants) promptly to prevent clot propagation and PE. Monitor for therapeutic effects and side effects (bleeding).
2. Apply Compression Therapy: Apply graduated compression stockings (GCS) as ordered. Ensure proper fit and application. GCS promote venous return, reduce edema, and decrease venous stasis. Intermittent pneumatic compression (IPC) devices may be used, especially for immobile patients, in addition to or instead of GCS.
3. Ensure Adequate Hydration: Maintain adequate hydration to reduce blood viscosity and promote venous blood flow. Encourage oral fluid intake or administer intravenous fluids as prescribed. Dehydration can worsen venous stasis and increase clot risk.
4. Prepare for Doppler Ultrasound: If DVT is suspected, prepare the patient for duplex Doppler ultrasound, the primary imaging modality to confirm DVT. Explain the procedure and address any patient concerns. Bedside Doppler ultrasound may be used for initial assessment and monitoring.

Risk for Bleeding

Nursing Diagnosis: Risk For Bleeding related to anticoagulant therapy.

Related Factors:

• Anticoagulant medication administration (heparin, LMWH, warfarin, DOACs).
• Underlying conditions affecting blood clotting (e.g., thrombocytopenia, liver disease, kidney disease).
• Invasive procedures (surgery, injections, central line placement).
• Trauma or injury.
• History of bleeding disorders.
• Advanced age.
• Polypharmacy (multiple medications, increasing drug interactions).

As Evidenced By:

A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.

Expected Outcomes:

• Patient will maintain therapeutic levels of anticoagulation without signs or symptoms of excessive bleeding.
• Patient will verbalize understanding of bleeding precautions and safety measures to minimize bleeding risk.
• Patient will remain free from clinically significant bleeding complications (e.g., hemorrhage, intracranial bleed).

Nursing Assessments:

1. Assess Bleeding Risk Factors: Identify patients at increased risk of bleeding. This includes those receiving anticoagulants, those with pre-existing bleeding disorders, thrombocytopenia, liver or kidney disease, recent surgery or trauma, history of falls, advanced age, and polypharmacy.
2. Monitor Vital Signs and Bleeding Signs: Regularly monitor vital signs for indicators of bleeding (hypotension, tachycardia, dizziness, weakness, pallor, cool/clammy skin). Assess for overt and covert signs of bleeding:
   • Overt bleeding: nosebleeds (epistaxis), gum bleeding, bruising (ecchymosis), petechiae, hematoma formation, hematemesis (vomiting blood), hemoptysis, melena (black, tarry stools), hematuria (blood in urine), vaginal bleeding, prolonged bleeding from venipuncture sites or wounds.
   • Covert bleeding: unexplained decrease in hemoglobin and hematocrit, fatigue, weakness, dizziness, abdominal pain, back pain, change in mental status.
3. Monitor Coagulation Labs: Regularly monitor relevant laboratory values:
   • Platelet count: Assess for thrombocytopenia.
   • PT/INR (for warfarin): Ensure INR is within therapeutic range (typically 2.0-3.0 for DVT) and not excessively elevated.
   • aPTT (for heparin): Monitor aPTT and adjust heparin infusion rate to maintain therapeutic range.
   • Anti-Factor Xa levels (for LMWH and factor Xa inhibitors): May be monitored in specific patient populations (e.g., obese, renal insufficiency, pregnant).
   • Hemoglobin and hematocrit: Monitor for trends indicating blood loss.
4. Assess Heparin-Induced Thrombocytopenia (HIT) Risk: Be aware of the risk of HIT in patients receiving heparin. Monitor platelet count regularly (especially between days 5-10 of heparin therapy). Suspect HIT if platelet count drops significantly (e.g., > 50% reduction from baseline) or if new thrombosis develops despite anticoagulation. If HIT is suspected, stop heparin immediately and notify physician.

Nursing Interventions:

1. Bleeding Risk Education: Educate patients and families about bleeding risks associated with anticoagulants and preventive measures:
   • Use a soft-bristled toothbrush and avoid aggressive brushing.
   • Use an electric razor for shaving.
   • Avoid activities with high risk of trauma or falls.
   • Be cautious with sharp objects (knives, scissors).
   • Avoid forceful coughing or nose blowing.
   • Wear shoes or slippers to prevent foot injuries.
   • Inform all healthcare providers (including dentists) about anticoagulant use.
   • Carry identification (medical alert bracelet or card) indicating anticoagulant use.
   • Know signs and symptoms of bleeding and when to seek medical attention.
2. Immediate Action for Bleeding: If bleeding occurs:
   • Assess and quantify the extent of bleeding.
   • Apply direct pressure to bleeding sites.
   • For IV heparin infusion, stop the infusion immediately if significant bleeding occurs and notify the physician STAT.
   • Monitor vital signs and hemodynamic status closely.
   • Draw blood for coagulation studies (PT/INR, aPTT, platelet count, hemoglobin, hematocrit) as ordered.
   • Prepare to administer reversal agents as ordered (protamine sulfate for heparin, vitamin K for warfarin, andexanet alfa or ciraparantag for factor Xa inhibitors if applicable).
   • Anticipate the need for blood product transfusion in cases of significant blood loss.
3. Bleeding Precautions Implementation: Implement bleeding precautions for all patients receiving anticoagulants:
   • Minimize invasive procedures. If necessary, use small gauge needles and apply prolonged pressure to puncture sites. Avoid intramuscular injections if possible.
   • Handle patients gently and avoid bumping or bruising.
   • Ensure safe environment to prevent falls (clear pathways, adequate lighting, side rails up if indicated).
   • Avoid constricting clothing or restraints.
   • Monitor urine and stool for occult blood.
4. Antidote Availability: Ensure reversal agents for prescribed anticoagulants are readily available in the patient care area. Know the protocols for administration of reversal agents in case of bleeding emergencies.

References

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