Deep Vein Thrombosis Nursing Care Plan: Comprehensive Guide for Nurses

Nursing Process for Deep Vein Thrombosis (DVT)

Nurses play a critical role in the care of patients diagnosed with deep vein thrombosis (DVT), a condition characterized by the formation of a blood clot (thrombus) within a deep vein, most commonly in the legs. Effective nursing care is essential in preventing clot enlargement, reducing the risk of pulmonary embolism (PE), and minimizing the chances of DVT recurrence. Hospitalized patients, particularly those requiring intravenous (IV) anticoagulants, necessitate vigilant nursing monitoring and intervention to ensure treatment efficacy and patient safety. This nursing care plan for DVT provides a structured approach to patient care, encompassing assessment, interventions, and expected outcomes.

Nursing Assessment for DVT

The initial step in providing comprehensive nursing care is a thorough nursing assessment. This involves gathering both subjective and objective data to understand the patient’s condition, risk factors, and overall health status. A detailed assessment forms the foundation for accurate nursing diagnoses and effective care planning.

Health History Review

1. Elicit Presenting Symptoms: Begin by exploring the patient’s current symptoms, as these can provide crucial clues to a DVT diagnosis. Key symptoms to assess include:

• Unilateral Leg Swelling: Inquire if the patient has noticed swelling in one leg that is significantly greater than the other. This is a hallmark sign of DVT as the clot obstructs venous return, leading to fluid accumulation.
• Leg Pain or Tenderness: Assess for leg pain, which may range from a mild ache to severe discomfort. Tenderness to palpation, particularly along the course of the deep veins in the calf or thigh, is also a significant finding.
• Warmth Over the Affected Area: Ask if the patient has noticed increased warmth in the affected leg compared to the other. Inflammation associated with the clot can increase local temperature.
• Skin Discoloration: Observe for any changes in skin color, such as redness (erythema) or bluish discoloration (cyanosis), which can indicate altered blood flow.

If there is suspicion of pulmonary embolism (PE), a potentially life-threatening complication where the DVT clot travels to the lungs, assess for the following symptoms:

• Shortness of Breath (Dyspnea): Inquire about any sudden onset of breathing difficulty or feeling short of breath, especially with exertion or at rest.
• Cough: Assess for the presence of cough, which may be dry or productive.
• Chest Pain: Characterize any chest pain, noting its location, intensity, and whether it worsens with breathing or coughing. Pulmonary embolism often presents with pleuritic chest pain, sharp pain that intensifies with inspiration.
• Syncope (Fainting) or Dizziness: Ask about any episodes of lightheadedness, dizziness, or loss of consciousness, which can occur due to reduced oxygenation and cardiac output.
• Palpitations: Assess for awareness of rapid or irregular heartbeats, as the body attempts to compensate for reduced oxygen levels.

2. Identify DVT Risk Factors: A comprehensive risk assessment is crucial as certain factors significantly increase the likelihood of DVT development. Inquire about the following risk factors:

• Advanced Age: Older individuals have a higher risk of DVT due to age-related changes in blood vessels and coagulation.
• Ethnicity: African Americans have been shown to have a higher incidence of DVT compared to other ethnic groups.
• Smoking History: Smoking damages blood vessels and increases blood viscosity, promoting clot formation.
• Obesity: Excess weight contributes to venous stasis and increased pressure in the veins, elevating DVT risk.
• Recent Surgery: Surgical procedures, particularly orthopedic, neurovascular, and major abdominal surgeries, are major risk factors due to immobility and surgical trauma.
• Immobility: Prolonged periods of inactivity, such as bed rest, paralysis, or long periods of sitting, slow blood flow and increase the risk of clot formation.
• Previous DVT or Pulmonary Embolism: A personal history of DVT or PE significantly increases the risk of recurrence.
• Cancer: Certain cancers and cancer treatments increase hypercoagulability, making individuals more prone to blood clots.
• Pregnancy: Pregnancy increases venous stasis and hypercoagulability due to hormonal changes and pressure on pelvic veins.
• Prolonged Travel: Extended car or plane trips involving prolonged sitting can lead to venous stasis and increased DVT risk, often referred to as “economy class syndrome.”
• Intravenous Drug Use: Injection drug use can damage veins, leading to inflammation and increasing the risk of DVT.
• Hypercoagulable Disorders: Inherited or acquired conditions that predispose individuals to excessive blood clotting, such as Factor V Leiden or antiphospholipid syndrome.

3. Medication Review: Certain medications can increase the risk of DVT by affecting blood clotting mechanisms or contributing to venous stasis. Review the patient’s current medication list, paying particular attention to:

• Oral Contraceptives: Estrogen-containing oral contraceptives can increase levels of clotting factors, elevating DVT risk.
• Hormone Replacement Therapy (HRT): Similar to oral contraceptives, HRT containing estrogen can increase DVT risk.
• Glucocorticoids (Steroids): These medications can promote hypercoagulability and are associated with increased DVT risk.
• Tamoxifen and Raloxifene: Selective estrogen receptor modulators (SERMs) like tamoxifen and raloxifene, used to treat breast cancer and osteoporosis, respectively, carry a risk of DVT.
• Testosterone Therapy: Testosterone replacement therapy has been linked to increased blood viscosity and potential DVT risk.
• Antidepressants (Certain SSRIs): Some selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased risk of bleeding and potentially clotting abnormalities.

4. Medical Condition Assessment: Chronic medical conditions can significantly increase the risk of DVT. Inquire about the presence of conditions such as:

• Heart Failure: Heart failure can lead to venous stasis and reduced blood flow, increasing DVT risk.
• Chronic Obstructive Pulmonary Disease (COPD): COPD can lead to polycythemia (increased red blood cell count), which can increase blood viscosity and DVT risk.
• Inflammatory Bowel Disease (IBD): Conditions like Crohn’s disease and ulcerative colitis are associated with hypercoagulability and increased DVT risk.
• Nephrotic Syndrome: This kidney disorder can lead to protein loss, including antithrombin III, increasing the risk of blood clots.
• Systemic Lupus Erythematosus (SLE): SLE is an autoimmune disorder that can increase the risk of blood clots due to inflammation and hypercoagulability.
• Varicose Veins: Varicose veins can contribute to venous stasis and increase the risk of DVT in superficial veins, which can sometimes extend into deep veins.

5. Central Catheter Assessment: The presence of central venous catheters, particularly peripherally inserted central catheters (PICCs), is a significant risk factor for upper extremity DVT. Assess for:

• Presence of PICC or Central Venous Catheter (CVC): Determine if the patient has a central line and note its location and duration of insertion. PICCs, inserted in the arm, are associated with a higher risk of DVT in the arm compared to CVCs inserted in the neck or chest.

Physical Examination

1. Homan’s Sign (Limited Diagnostic Value): While historically used, Homan’s sign (calf pain upon dorsiflexion of the foot with the knee extended) is no longer considered a reliable or sensitive indicator of DVT. It is not recommended as a primary diagnostic tool due to its low sensitivity and specificity. A positive Homan’s sign can be present in other conditions, and a negative sign does not rule out DVT.

2. Risk Stratification with Wells’ Criteria: Utilize clinical decision rules such as the Wells’ Criteria for DVT to formally assess the patient’s pre-test probability of DVT. The Wells’ score incorporates clinical features like active cancer, paralysis or recent immobilization, bedridden status, localized tenderness, leg swelling, calf swelling, pitting edema, and previously documented DVT. Risk stratification is crucial for guiding diagnostic testing and treatment decisions, helping to identify patients who require further investigation with imaging studies.

3. Integumentary Assessment: Careful inspection and palpation of the skin over the suspected DVT site are essential. Expected findings may include:

• Palpable Venous Cord: A tender, subcutaneous venous segment that feels indurated, palpable, and cord-like along the affected vein. This represents the thrombosed vein.
• Skin Discoloration: Observe for changes in skin color, which may range from reddish-purple to cyanotic (bluish), reflecting venous congestion and impaired circulation.
• Edema: Assess for edema (swelling), noting its extent, location (calf, ankle, thigh), and whether it is pitting or non-pitting. Unilateral edema is a key indicator of DVT.
• Petechiae: Small, pinpoint red or purple spots on the skin (petechiae) may be present due to increased venous pressure.
• Blanching (Rare): In rare cases, blanching (paleness) of the skin may occur due to arterial spasm secondary to the venous thrombus.

4. Respiratory Assessment for Pulmonary Embolism (PE): Given the serious risk of PE as a DVT complication, a thorough respiratory assessment is vital. Assess for signs and symptoms of PE, including:

• Pleuritic Chest Pain: Sharp chest pain that worsens with deep inspiration or coughing, indicating irritation of the pleura (lining of the lungs).
• Tachypnea: Increased respiratory rate (rapid breathing), often a compensatory mechanism for hypoxemia.
• Tachycardia: Increased heart rate, also a compensatory response to reduced oxygenation and cardiac strain.
• Palpitations: Awareness of rapid or irregular heartbeats.
• Dyspnea: Shortness of breath, ranging from mild to severe, depending on the extent of pulmonary artery obstruction.
• Dizziness or Syncope: Lightheadedness or fainting episodes, suggesting decreased cerebral perfusion due to reduced cardiac output and oxygenation.
• Hemoptysis: Coughing up blood, indicating lung tissue damage or bleeding into the airways, although less common in PE.

Diagnostic Procedures

1. Blood Tests: Blood tests play a crucial role in DVT diagnosis and management.

• D-dimer Assay: D-dimer is a protein fragment produced when blood clots break down. An elevated D-dimer level suggests recent or ongoing clot formation and breakdown, making it sensitive but not specific for DVT. A negative D-dimer in a low-risk patient can effectively rule out DVT. However, a positive D-dimer requires further investigation with imaging studies as it can be elevated in other conditions (e.g., infection, inflammation, pregnancy).
• Coagulation Profile (PT/aPTT): Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are measures of blood clotting time. These tests are used to evaluate the patient’s baseline coagulation status and to monitor the therapeutic effect of anticoagulants like heparin and warfarin. Elevated PT or aPTT may indicate underlying coagulopathy or the effect of anticoagulant medication.

2. Venous Imaging: Imaging studies are essential for confirming the diagnosis of DVT and visualizing the location and extent of the clot.

• Duplex Venous Ultrasonography: This non-invasive, readily available, and cost-effective imaging technique is the gold standard for diagnosing DVT. It uses ultrasound waves to visualize blood flow and identify clots within deep veins. Duplex ultrasound can detect vein compressibility (or lack thereof in the presence of a clot) and assess blood flow patterns.
• Venography (Contrast Venography): Involves injecting a contrast dye into the veins of the affected limb and taking X-rays to visualize the venous system. Venography is highly accurate but is invasive, more costly, and carries a risk of allergic reaction to contrast dye and contrast-induced nephropathy. It is less commonly used now due to the widespread availability of duplex ultrasound.
• Magnetic Resonance Venography (MRV): MRV uses magnetic fields and radio waves to create detailed images of veins. It is highly sensitive and specific for DVT, particularly in the pelvic and thigh veins, and can be useful when ultrasound results are inconclusive or technically limited. MRV is more expensive and less widely available than ultrasound and may not be suitable for patients with pacemakers or metallic implants. It is advantageous for patients with contrast dye allergies as it can be performed without iodinated contrast.

Nursing Interventions for DVT

Nursing interventions are crucial for managing DVT, preventing complications, and promoting patient recovery. The primary goals of DVT treatment are to:

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. The choice of anticoagulant and route of administration depends on the patient’s clinical status, risk of bleeding, and comorbidities.

2. Administer Anticoagulant Medications Cautiously: Anticoagulants and thrombolytics (clot-dissolving medications) increase the risk of bleeding. Implement and maintain bleeding precautions meticulously:

• Monitor Coagulation Profile: Regularly monitor PT/INR (for warfarin), aPTT (for unfractionated heparin), and anti-Xa levels (for LMWH and factor Xa inhibitors) as ordered to ensure therapeutic ranges and detect over-anticoagulation.
• Bleeding Precautions:
  • Soft Bristle Toothbrush: Use a soft toothbrush to prevent gum bleeding.
  • Avoid Invasive Procedures: Minimize or avoid intramuscular injections, arterial punctures, and unnecessary venipunctures. When necessary, apply prolonged pressure to puncture sites.
  • Gentle Nasal Care: Advise against forceful sneezing or nose blowing.
  • Fall Prevention: Implement fall prevention measures, especially for elderly or patients with mobility issues, to minimize trauma risk.
  • Electric Razor Shaving: Recommend using electric razors for shaving to prevent skin cuts.
  • Pressure at IV Sites: Apply firm pressure for a longer duration when removing IV lines or peripheral catheters.
  • Medication Reconciliation: Review all medications, including over-the-counter drugs and supplements, for potential interactions that may increase bleeding risk (e.g., NSAIDs, aspirin, garlic, ginger).

3. Monitor aPTT with Unfractionated Heparin (UFH): For hospitalized patients receiving IV UFH, frequent aPTT monitoring is essential to maintain therapeutic anticoagulation.

• aPTT Monitoring: Monitor aPTT levels typically every 6 hours or as per hospital protocol.
• Dosage Adjustment: Adjust the UFH infusion rate based on aPTT results and facility-specific nomograms to maintain the aPTT within the therapeutic range (typically 1.5-2.5 times the control value).

4. Administer Low Molecular Weight Heparin (LMWH): LMWH, such as enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep), is frequently used for DVT treatment and prophylaxis.

• Subcutaneous Administration: LMWH is administered subcutaneously, typically once or twice daily, depending on the specific LMWH and indication.
• Predictable Anticoagulation: LMWH provides more predictable anticoagulation compared to UFH, often requiring less frequent lab monitoring (anti-Xa levels may be checked in specific populations like obese or renally impaired patients).

5. Monitor INR with Warfarin Therapy: Warfarin (Coumadin) is an oral anticoagulant often used for long-term DVT management.

• INR Monitoring: Regular INR monitoring is crucial to ensure the INR is within the therapeutic range, typically 2.0-3.0 for DVT treatment.
• Overlap Therapy: When initiating warfarin, it is overlapped with another anticoagulant (UFH or LMWH) for at least 5 days and until the INR is therapeutic for 24-48 hours. This is because warfarin initially has a procoagulant effect before achieving therapeutic anticoagulation.
• Dietary Considerations: Educate patients on maintaining consistent Vitamin K intake as fluctuations can affect warfarin’s effectiveness.

6. Consider Vena Cava Filter Insertion: An inferior vena cava (IVC) filter is a mechanical device placed in the IVC to trap large emboli and prevent them from reaching the lungs, thus reducing the risk of PE. IVC filters are typically considered for patients who:

• Contraindications to Anticoagulation: Have absolute contraindications to anticoagulant therapy due to active bleeding or high bleeding risk.
• Recurrent PE Despite Anticoagulation: Experience recurrent PE despite adequate anticoagulation.
• Massive PE: Have massive PE where further embolization could be fatal.
• Temporary Protection: May be used as a temporary measure in high-risk patients (e.g., trauma patients) until anticoagulation can be safely initiated. Retrievable filters are preferred and should be removed once the risk of PE has decreased.

7. Apply Compression Therapy: Compression stockings and intermittent pneumatic compression devices (IPCDs) are used to improve venous circulation, reduce venous stasis, and minimize edema.

• Compression Stockings: Prescribe graduated compression stockings (typically 20-30 mmHg or 30-40 mmHg) to be worn daily, especially during ambulation. Ensure proper fitting and patient education on application and wear.
• Intermittent Pneumatic Compression (IPC): IPCDs, inflatable cuffs applied to the legs that sequentially inflate and deflate, can be used, particularly for hospitalized patients with limited mobility, to promote venous return.

8. Encourage Ambulation and Position Changes: Promoting mobility is crucial to prevent venous stasis.

• Early Ambulation: Encourage early ambulation as tolerated. Bed rest solely to prevent clot dislodgement is not recommended and is detrimental.
• Frequent Position Changes: For patients with limited mobility, encourage frequent position changes in bed and active or passive leg exercises (ankle pumps, leg rotations, knee flexion/extension) to stimulate venous flow.
• Avoid Prolonged Sitting/Standing: Advise patients to avoid prolonged periods of sitting or standing still. During long car or plane trips, encourage frequent breaks to walk around and stretch their legs.

9. Implement DVT Prophylaxis: Prophylactic measures are essential, especially for high-risk patients (post-surgical, immobile).

• Pharmacological Prophylaxis: Consider pharmacological prophylaxis with LMWH, UFH, fondaparinux, or direct oral anticoagulants (DOACs) like rivaroxaban, apixaban, or edoxaban, based on risk assessment and guidelines.
• Mechanical Prophylaxis: Utilize mechanical prophylaxis (compression stockings, IPCDs) alone or in combination with pharmacological prophylaxis, especially in patients with bleeding risks.

10. Emphasize Medication Adherence and Monitoring: Patient education on medication adherence and the importance of follow-up monitoring is critical for long-term DVT management.

• Medication Education: Provide comprehensive education on prescribed anticoagulants, including dosage, frequency, administration technique (for injectables), duration of therapy, potential side effects (bleeding), and drug interactions.
• INR Monitoring (Warfarin): Stress the importance of regular INR monitoring for patients on warfarin and maintaining scheduled appointments.
• Duration of Therapy: Explain the typical duration of anticoagulant therapy (at least 3 months for provoked DVT, longer or indefinite for unprovoked or recurrent DVT).

11. Discuss Surgical and Interventional Options: In certain situations, surgical or interventional procedures may be considered.

• Thrombectomy: Surgical removal of the clot may be indicated for patients with extensive iliofemoral DVT (DVT in the iliac and femoral veins) causing severe limb ischemia (phlegmasia cerulea dolens) or in patients with acute PE who are hemodynamically unstable and thrombolysis is contraindicated or has failed.
• Catheter-Directed Thrombolysis: Involves inserting a catheter directly into the clot and delivering thrombolytic medication to dissolve it. May be considered for proximal DVT (iliofemoral) in patients with low bleeding risk to reduce the risk of post-thrombotic syndrome.
• Angioplasty and Stenting: In cases of chronic venous obstruction or stenosis post-DVT, angioplasty (balloon dilation) and stenting may be used to restore venous patency.

12. Prepare Reversal Agents for Anticoagulants: Have reversal agents readily available in case of severe bleeding complications.

• Protamine Sulfate: Antidote for heparin (UFH and LMWH).
• Vitamin K: Antidote for warfarin.
• Idarucizumab (Praxbind): Specific reversal agent for dabigatran (Pradaxa).
• Andexanet alfa (Andexxa): Reversal agent for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban).
• Activated Charcoal: May be used to reduce absorption of oral anticoagulants if administered shortly after ingestion.

13. Encourage Lifestyle Modifications: Educate patients on lifestyle changes to reduce DVT recurrence risk.

• Smoking Cessation: Strongly advise smoking cessation.
• Blood Pressure Control: Manage hypertension.
• Weight Management: Achieve and maintain a healthy weight.
• Regular Exercise: Encourage regular physical activity to improve circulation.
• Loose Clothing: Advise wearing loose-fitting clothing to avoid constricting blood flow.
• Hydration: Promote adequate fluid intake to maintain blood viscosity.
• “Natural Blood Thinners” (Caution): While some foods and supplements have mild anticoagulant properties (e.g., vitamin E, ginger, cayenne pepper, garlic, turmeric, cinnamon), their effect is weak and should not replace prescribed anticoagulation. Patients should discuss the use of any supplements with their healthcare provider, especially if on anticoagulants, due to potential interactions.

14. Dietary Education for Warfarin Patients: Provide specific dietary guidance for patients taking warfarin.

• Vitamin K Consistency: Advise patients to maintain a consistent intake of vitamin K-rich foods (green leafy vegetables like spinach, kale, broccoli) rather than drastically restricting them. Sudden changes in vitamin K intake can affect INR stability.
• Alcohol Moderation: Advise moderation in alcohol consumption as it can potentiate warfarin’s effects.
• Drug-Food Interactions: Educate about potential interactions between warfarin and certain foods and beverages (e.g., grapefruit juice, cranberry juice).

15. Advise on When to Seek Immediate Medical Attention: Educate patients on recognizing and responding to signs of bleeding and PE.

• Bleeding Signs: Instruct patients to watch for and report signs of bleeding, such as unusual bruising, nosebleeds, gum bleeding, prolonged bleeding from cuts, blood in urine or stool, coughing up blood, severe headache, dizziness, or weakness.
• Pulmonary Embolism Symptoms: Reiterate the symptoms of PE (sudden shortness of breath, chest pain, dizziness, cough, palpitations) and emphasize the need to seek immediate emergency medical attention if these symptoms develop.

Nursing Care Plans for DVT

Nursing care plans provide a structured framework for organizing and delivering patient care. Here are examples of nursing care plans for common nursing diagnoses associated with DVT:

Nursing Care Plan 1: Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to potential pulmonary embolism secondary to deep vein thrombosis.

Related to:

• DVT embolization to the pulmonary circulation
• Physical obstruction of pulmonary blood flow
• Reduced cardiac preload and contractility
• Increased pulmonary vascular resistance

As evidenced by:

• Hypotension
• Tachycardia (heart rate > 100 bpm)
• Dysrhythmias (e.g., atrial fibrillation, premature atrial contractions)
• Sudden onset of chest pain (pleuritic or substernal)
• Decreased oxygen saturation (SpO2 < 90%)
• Sudden shortness of breath (dyspnea) at rest or with minimal exertion
• Tachypnea (respiratory rate > 20 breaths per minute)
• Altered level of consciousness (restlessness, confusion, lethargy)
• Dizziness or lightheadedness, syncope
• Prolonged capillary refill time (> 3 seconds)
• Weak peripheral pulses

Expected Outcomes:

• Patient will maintain blood pressure and heart rate within acceptable limits for their baseline.
• Patient will report absence of chest pain and shortness of breath.
• Patient will maintain adequate oxygen saturation (SpO2 ≥ 95% or patient’s baseline).
• Patient will demonstrate stable cardiac rhythm and rate.

Nursing Assessments:

1. Recognize and Respond to Critical Symptoms: Immediate recognition of signs and symptoms suggestive of PE is paramount. Patients presenting with sudden chest pain, acute dyspnea, tachypnea, hypoxia, and hemodynamic instability require immediate intervention. These are emergency situations requiring rapid response and escalation of care.

2. Continuous Cardiac Monitoring: Closely monitor vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, at frequent intervals (e.g., every 15-30 minutes initially, then hourly as stable). Continuous ECG monitoring is essential to detect dysrhythmias and ST-segment changes that may indicate cardiac ischemia or strain.

3. Assess for Signs of Right Ventricular Dysfunction: PE can cause acute right ventricular strain and failure. Assess for signs such as jugular venous distention (JVD), peripheral edema, and new onset murmur consistent with tricuspid regurgitation. These findings suggest significant hemodynamic compromise.

4. Obtain 12-Lead ECG: Obtain a 12-lead ECG to assess for cardiac ischemia or strain patterns. Sinus tachycardia is a common finding in PE. Other ECG changes may include right bundle branch block, ST-segment elevation in inferior or anterior leads, T-wave inversions in anterior leads, and atrial arrhythmias. However, ECG findings in PE are often non-specific and may be normal.

Nursing Interventions:

1. Initiate Immediate Anticoagulation: If PE is suspected, initiate immediate anticoagulation as per physician orders. This typically involves IV unfractionated heparin, subcutaneous LMWH, or fondaparinux. Prompt anticoagulation is crucial to prevent further clot propagation and recurrent embolization.

2. Consider Thrombolytic Therapy: For hemodynamically unstable patients with confirmed or high-probability PE, thrombolytic therapy (e.g., alteplase, reteplase, tenecteplase) may be considered to dissolve the clot and restore pulmonary blood flow. Thrombolysis is associated with a significant bleeding risk and requires careful patient selection and monitoring.

3. Prepare for Surgical or Catheter Embolectomy: In cases of massive PE with hemodynamic instability, contraindications to thrombolysis, or failure of thrombolysis, surgical embolectomy (surgical removal of the clot from the pulmonary arteries) or catheter embolectomy (clot removal using specialized catheters via percutaneous access) may be necessary. These are high-risk procedures reserved for life-threatening situations.

4. Manage Hemodynamic Instability and Shock: Patients with massive PE can rapidly develop cardiogenic shock. Management includes:

• Oxygen Therapy: Administer high-flow oxygen via non-rebreather mask or mechanical ventilation to maintain adequate oxygenation.
• Fluid Management: Careful fluid resuscitation may be needed to improve preload, but avoid overhydration, which can worsen right ventricular overload. Monitor fluid status closely.
• Vasopressors and Inotropes: Vasopressors (e.g., norepinephrine) may be needed to support blood pressure. Inotropic agents (e.g., dobutamine) may be used to improve right ventricular contractility.
• Mechanical Circulatory Support: In severe cases of cardiogenic shock, mechanical circulatory support devices (e.g., extracorporeal membrane oxygenation – ECMO) may be considered as a bridge to recovery or definitive treatment.

Nursing Care Plan 2: Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to deep vein thrombosis diagnosis, treatment, and prevention.

Related to:

• New diagnosis of DVT
• Lack of prior exposure to information about DVT
• Misinformation or misunderstanding of DVT and its management
• Cognitive limitations or learning barriers
• Low health literacy

As evidenced by:

• Patient verbalizes questions about DVT diagnosis, treatment, and prevention.
• Patient demonstrates misunderstanding of medication regimen (e.g., incorrect dosage, timing, or purpose).
• Patient exhibits poor adherence to follow-up appointments or laboratory monitoring.
• Patient experiences recurrent DVT episodes due to lack of preventive measures.
• Patient expresses anxiety or fear related to DVT and its potential complications.

Expected Outcomes:

• Patient will verbalize accurate understanding of DVT diagnosis, treatment plan, and prognosis.
• Patient will correctly state the purpose, dosage, frequency, and potential side effects of prescribed medications.
• Patient will verbalize the importance of medication adherence and scheduled follow-up laboratory tests (e.g., INR monitoring).
• Patient will identify their individual risk factors for DVT recurrence and describe at least three strategies to prevent future episodes.
• Patient will demonstrate confidence in managing their DVT and reducing recurrence risk.

Nursing Assessments:

1. Assess Patient’s Baseline Knowledge: Evaluate the patient’s current understanding of DVT, risk factors, treatment options, and prevention strategies. Use open-ended questions to assess their knowledge level without making assumptions. “Tell me what you know about deep vein thrombosis.” “What has your doctor told you about your condition and treatment?”

2. Determine Learning Needs and Readiness: Identify specific knowledge deficits and learning needs. Assess the patient’s readiness to learn, considering factors like anxiety, pain, fatigue, and emotional state. Learning is most effective when patients are receptive and motivated.

3. Evaluate Health Literacy and Learning Style: Assess the patient’s health literacy level (ability to understand health information) and preferred learning style (visual, auditory, kinesthetic). Tailor teaching methods and materials to match their needs and abilities. Use plain language, avoid medical jargon, and provide written materials at an appropriate reading level.

4. Identify Barriers to Learning: Assess for potential barriers to learning, such as language differences, cultural beliefs, cognitive impairments, sensory deficits (hearing or visual impairments), and emotional distress. Address these barriers to ensure effective patient education. Utilize interpreters, visual aids, and involve family members as needed.

Nursing Interventions:

1. Explain DVT, PE, and Treatment Plan Clearly: Provide clear, concise, and accurate information about DVT, pulmonary embolism, and the patient’s specific treatment plan. Use visual aids, diagrams, and models to enhance understanding. Explain the pathophysiology of DVT in simple terms, emphasizing the importance of anticoagulation in preventing clot progression and PE.

2. Medication Education: Provide thorough medication education, including:

• Drug Name and Purpose: Clearly state the name of each medication and its purpose in treating DVT.
• Dosage and Frequency: Explain the correct dosage and frequency of administration.
• Route of Administration: Demonstrate proper administration technique, especially for subcutaneous injections (LMWH).
• Potential Side Effects: Discuss common and serious side effects, particularly bleeding risks, and instruct on how to recognize and report them.
• Drug Interactions: Review potential drug interactions, including over-the-counter medications, supplements, and foods.
• Importance of Adherence: Emphasize the critical importance of medication adherence and not stopping or altering doses without consulting their healthcare provider.

3. Teach Signs and Symptoms of Pulmonary Embolism: Educate patients about the signs and symptoms of pulmonary embolism (sudden shortness of breath, chest pain, dizziness, cough, palpitations) and instruct them to seek immediate medical attention if these occur. Emphasize that PE is a medical emergency requiring prompt treatment.

4. Risk Factor Modification and Prevention Strategies: Discuss the patient’s individual risk factors for DVT and provide specific strategies to reduce recurrence risk:

• Lifestyle Modifications: Reinforce the importance of smoking cessation, weight management, regular exercise, and adequate hydration.
• Travel Precautions: Advise on measures to prevent travel-associated DVT, such as leg exercises during long flights or car rides, frequent breaks to walk, and wearing compression stockings.
• Medication Adherence: Reiterate the importance of taking prescribed anticoagulants as directed.
• Follow-up Care: Emphasize the need for regular follow-up appointments and laboratory monitoring (INR for warfarin) to ensure treatment effectiveness and safety.

5. Provide Written Materials and Resources: Supplement verbal teaching with written materials, pamphlets, websites, and support group information. Provide resources in the patient’s preferred language and reading level. Reinforce key information and provide a reference for patients to review at home.

6. Assess Understanding and Provide Reinforcement: Use teach-back methods to assess the patient’s understanding of the information provided. Ask them to explain back to you their diagnosis, medications, and prevention strategies in their own words. Correct any misunderstandings and reinforce key points. Encourage questions and address concerns.

Nursing Care Plan 3: Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to ventilation-perfusion mismatch secondary to pulmonary embolism.

Related to:

• Physical obstruction of pulmonary arterial blood flow by thrombus
• Reduced alveolar perfusion and impaired gas exchange
• Ventilation-perfusion mismatch (V/Q mismatch)
• Increased alveolar dead space
• Potential for hypoxemia and hypercapnia

As evidenced by:

• Dyspnea (shortness of breath), especially with exertion, or at rest
• Sudden onset of sharp chest pain, often pleuritic
• Cough, possibly productive of bloody sputum (hemoptysis)
• Tachypnea (respiratory rate > 20 breaths per minute)
• Dizziness, lightheadedness, syncope
• Change in level of consciousness (restlessness, confusion, anxiety)
• Cyanosis (bluish discoloration of skin and mucous membranes) or pallor
• Tachycardia (heart rate > 100 bpm), palpitations
• Anxiety, restlessness
• Decreased oxygen saturation (SpO2 < 90%)
• Abnormal arterial blood gas (ABG) values (e.g., decreased PaO2, increased PaCO2)
• Adventitious breath sounds (e.g., crackles, wheezes – may be present but not always)

Expected Outcomes:

• Patient will demonstrate improved gas exchange as evidenced by oxygen saturation (SpO2) within acceptable limits (≥ 95% or patient’s baseline).
• Patient will exhibit normal breathing patterns (respiratory rate 12-20 breaths per minute, regular rhythm, and depth).
• Patient will report relief or reduction of dyspnea and chest pain.
• Patient will maintain baseline level of consciousness and orientation.
• Patient will have arterial blood gas (ABG) values within normal limits for their baseline.

Nursing Assessments:

1. Recognize and Prioritize Symptoms of PE: Prompt recognition of PE symptoms is critical. Sudden onset of dyspnea, chest pain, and hypoxemia are hallmark signs requiring immediate attention. Treat PE as a medical emergency.

2. Auscultate Lung Sounds: Assess lung sounds for abnormalities. While lung sounds may be normal in PE, crackles (rales) or decreased breath sounds may be present, particularly in areas of atelectasis or pulmonary infarction. Wheezing is less common but can occur. However, lung auscultation alone is not sensitive or specific for PE.

3. Monitor Respiratory Rate, Depth, and Effort: Assess respiratory rate, depth, and effort frequently. Tachypnea is common in PE. Observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions.

4. Continuous Pulse Oximetry: Continuously monitor oxygen saturation (SpO2) using pulse oximetry. Hypoxemia is a common finding in PE. Note trends and report any desaturation promptly. However, SpO2 may be normal in some patients with PE, especially if the embolus is small.

5. Assess Level of Consciousness and Neurological Status: Hypoxemia and reduced cerebral blood flow due to PE can lead to changes in mental status. Assess level of consciousness, orientation, alertness, and presence of restlessness, confusion, or anxiety. Neurological changes can be early indicators of worsening gas exchange.

6. Monitor for Signs of Cyanosis: Observe for cyanosis, particularly in the mucous membranes, nail beds, and skin. Cyanosis is a late sign of hypoxemia and indicates severe oxygen desaturation.

7. Obtain Arterial Blood Gases (ABGs): Obtain arterial blood gas (ABG) samples as ordered to assess oxygenation (PaO2), carbon dioxide levels (PaCO2), and acid-base balance. ABGs provide a more accurate assessment of gas exchange than pulse oximetry alone. Common ABG findings in PE include hypoxemia (decreased PaO2) and hypocapnia (decreased PaCO2) due to hyperventilation. However, in severe PE, PaCO2 may be normal or elevated due to respiratory fatigue.

Nursing Interventions:

1. Administer Supplemental Oxygen: Apply supplemental oxygen immediately to treat hypoxemia and maintain SpO2 above 90% (or as per physician orders). Oxygen can be delivered via nasal cannula, face mask, or non-rebreather mask, depending on the severity of hypoxemia.

2. Elevate Head of Bed: Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position to improve lung expansion and reduce dyspnea, unless contraindicated.

3. Monitor Respiratory Status Closely: Continue to monitor respiratory rate, depth, effort, SpO2, lung sounds, and level of consciousness frequently (e.g., every 1-2 hours initially, then as needed). Report any worsening respiratory distress or changes in mental status promptly.

4. Administer Anticoagulation Therapy: Ensure prompt administration of prescribed anticoagulation therapy (heparin, LMWH, fondaparinux, DOACs) to prevent clot propagation and recurrent embolization.

5. Prepare for Advanced Respiratory Support: Be prepared to assist with advanced respiratory support measures if hypoxemia persists or worsens despite supplemental oxygen. This may include:

• Non-invasive Positive Pressure Ventilation (NIPPV): Bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) may be used to improve oxygenation and reduce work of breathing in patients with moderate to severe hypoxemia without respiratory failure.
• Intubation and Mechanical Ventilation: For patients with severe hypoxemia, hypercapnia, respiratory failure, or hemodynamic instability, endotracheal intubation and mechanical ventilation may be necessary to support oxygenation and ventilation.

6. Promote Pulmonary Hygiene: Encourage coughing and deep breathing exercises to promote alveolar expansion and prevent atelectasis. If the patient is able, encourage incentive spirometry to improve lung volumes. Consider chest physiotherapy if indicated to mobilize secretions, although routine chest physiotherapy is not typically recommended for PE unless there is coexisting pneumonia or mucus plugging.

7. Provide Emotional Support: Dyspnea and chest pain can be frightening for patients. Provide reassurance, emotional support, and anxiety-reducing measures. Explain procedures and treatments clearly and calmly. Consider relaxation techniques and anxiety medications as ordered.

Nursing Care Plan 4: Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to venous obstruction secondary to deep vein thrombosis.

Related to:

• Venous stasis and impaired venous return
• Mechanical obstruction of venous blood flow by thrombus
• Increased venous pressure distal to the thrombus
• Potential for edema, pain, and impaired tissue oxygenation

As evidenced by:

• Unilateral lower extremity edema (swelling), particularly in the affected leg
• Leg pain or tenderness in the affected extremity
• Increased warmth to touch in the affected area compared to the unaffected limb
• Erythema (redness) or cyanosis (bluish discoloration) of the affected extremity
• Palpable venous cord (induration along the vein)
• Positive Homans’ sign (calf pain on dorsiflexion – low specificity, not a primary diagnostic sign)
• Decreased or absent peripheral pulses in the affected extremity (less common, usually with severe DVT)
• Changes in skin temperature (increased warmth) and color
• Delayed capillary refill in the affected extremity (less common in typical DVT)

Expected Outcomes:

• Patient will achieve and maintain adequate peripheral tissue perfusion in the affected extremity as evidenced by:
  • Reduction in edema and leg circumference measurements.
  • Report of decreased pain or pain controlled to a tolerable level (pain scale score ≤ 3/10).
  • Skin color and temperature within normal limits for the patient.
  • Palpable peripheral pulses in the affected extremity (if pulses were initially diminished).
  • Capillary refill < 3 seconds.
• Patient will be free from complications of impaired tissue perfusion, such as skin breakdown or ulceration.
• Patient will remain free from pulmonary embolism.

Nursing Assessments:

1. Comprehensive Assessment of Affected Extremity: Perform a thorough assessment of the affected limb, including:

• Edema Assessment: Assess for edema, noting location, extent (calf, ankle, thigh), and degree (pitting vs. non-pitting). Measure leg circumference at standardized points (e.g., below tibial tuberosity, above patella) and compare to the unaffected leg. Document baseline measurements and monitor for changes.
• Pain Assessment: Assess pain characteristics (location, intensity, quality, aggravating and relieving factors) using a pain scale (0-10). Note if pain is constant or intermittent, and its relationship to activity or rest.
• Skin Color and Temperature: Inspect skin color (erythema, cyanosis, pallor) and palpate skin temperature (warmth, coolness) comparing to the unaffected limb. Increased warmth and redness are common in acute DVT.
• Palpate Peripheral Pulses: Palpate peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral) in both legs and compare strength and quality. While pulses are usually present in DVT, they may be diminished in severe cases or if there is arterial compromise.
• Capillary Refill: Assess capillary refill time in the toes of the affected and unaffected extremities. Capillary refill is usually normal in DVT but may be delayed if arterial flow is compromised.
• Assess for Venous Cord: Palpate along the course of the deep veins (femoral, popliteal, calf veins) to assess for a palpable, tender, cord-like vein, which indicates thrombosed vein.

2. Assess Risk Factors for DVT: Review and document the patient’s risk factors for DVT (immobility, surgery, malignancy, hypercoagulable state, etc.) to understand contributing factors and guide preventive measures.

3. Monitor for Signs and Symptoms of PE: Continuously monitor for signs and symptoms of pulmonary embolism (sudden dyspnea, chest pain, cough, dizziness, syncope, palpitations) as PE is a major complication of DVT.

Nursing Interventions:

1. Administer Anticoagulant Therapy as Ordered: Ensure timely administration of prescribed anticoagulants (heparin, LMWH, warfarin, DOACs) to prevent clot propagation and promote venous patency. Monitor for therapeutic effects and bleeding complications.

2. Elevate Affected Extremity: Elevate the affected leg above heart level when the patient is resting or in bed to promote venous drainage and reduce edema. Use pillows to support the leg and ankle.

3. Apply Compression Therapy: Apply graduated compression stockings as prescribed. Ensure proper fit and application. Teach the patient how to apply and remove stockings correctly and to wear them daily, especially when ambulating. Consider intermittent pneumatic compression (IPC) devices for hospitalized patients with limited mobility.

4. Promote Gentle Exercise and Ambulation: Encourage gentle leg exercises (ankle pumps, leg rotations) and ambulation as tolerated to promote venous return and prevent venous stasis. Avoid prolonged standing or sitting. Advise patients to take frequent short walks and breaks during periods of sitting or standing.

5. Pain Management: Assess and manage pain effectively. Administer analgesics as prescribed (e.g., acetaminophen, NSAIDs, or opioids for severe pain). Non-pharmacological pain relief measures include elevation, cool compresses (avoid prolonged cold application), and positioning.

6. Monitor Skin Integrity: Assess skin integrity regularly, especially in edematous areas, for signs of breakdown or ulceration. Provide meticulous skin care, keep skin clean and dry, and protect from pressure and friction.

7. Ensure Adequate Hydration: Encourage adequate fluid intake to maintain blood viscosity and promote circulation, unless contraindicated by other medical conditions. Dehydration can increase blood viscosity and potentially worsen venous stasis.

8. Monitor Leg Circumference and Edema: Regularly measure leg circumference at predetermined points to assess for changes in edema. Document and report any significant increase in edema or worsening symptoms.

9. Patient Education on Self-Care: Educate patients on self-care measures to promote peripheral tissue perfusion and prevent DVT recurrence:

• Importance of Compression Therapy: Reinforce the need to wear compression stockings as prescribed.
• Leg Elevation: Instruct on leg elevation at home.
• Exercise and Activity: Encourage regular exercise and avoiding prolonged immobility.
• Hydration: Advise on maintaining adequate hydration.
• Smoking Cessation: If applicable, strongly encourage smoking cessation.
• Weight Management: If applicable, advise on weight management strategies.
• Signs and Symptoms to Report: Instruct on recognizing and reporting worsening symptoms, signs of bleeding, or symptoms of PE.

Nursing Care Plan 5: Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy for deep vein thrombosis.

Related to:

• Pharmacological anticoagulation (heparin, LMWH, warfarin, DOACs)
• Underlying coagulopathy or bleeding disorders
• Invasive procedures (venipuncture, injections)
• Trauma or injury
• Lack of knowledge about bleeding precautions

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcomes:

• Patient will maintain therapeutic levels of anticoagulation within the prescribed range, minimizing the risk of both bleeding and thrombosis.
• Patient will verbalize understanding of bleeding precautions and safety measures to minimize bleeding risk.
• Patient will remain free from signs and symptoms of excessive bleeding during anticoagulant therapy.
• Patient will demonstrate adherence to safety measures and bleeding precautions.

Nursing Assessments:

1. Assess for Risk Factors for Bleeding: Identify and document patient-specific risk factors for bleeding, including:

• Medication History: Review current medications, including anticoagulants, antiplatelet agents (aspirin, clopidogrel), NSAIDs, and herbal supplements that may increase bleeding risk.
• Past Medical History: Assess for history of bleeding disorders, thrombocytopenia, peptic ulcer disease, recent surgery or trauma, liver disease, renal insufficiency, or history of falls.
• Age: Older adults are at increased bleeding risk due to age-related changes in coagulation and increased comorbidities.
• Laboratory Values: Monitor baseline and ongoing coagulation studies (PT/INR, aPTT, platelet count).

2. Monitor Vital Signs for Signs of Bleeding: Regularly monitor vital signs, particularly blood pressure and heart rate, for signs of bleeding. Hypotension and tachycardia can be early indicators of significant blood loss. Also, monitor for orthostatic hypotension.

3. Assess for Overt and Covert Bleeding: Conduct systematic assessments for signs and symptoms of bleeding:

• Overt Bleeding: Assess for obvious bleeding such as:
  • Nosebleeds (Epistaxis)
  • Gum Bleeding
  • Bruising (Ecchymosis)
  • Petechiae
  • Hematoma formation
  • Hematuria (blood in urine)
  • Melena (black, tarry stools) or hematochezia (bright red blood in stools)
  • Hemoptysis (coughing up blood)
  • Vomiting blood (hematemesis)
  • Excessive bleeding from venipuncture or IV sites
  • Menorrhagia (heavy menstrual bleeding) in women
• Covert Bleeding: Assess for subtle signs of bleeding, such as:
  • Fatigue, weakness, pallor (signs of anemia)
  • Dizziness, lightheadedness, syncope
  • Headache, confusion, neurological changes (signs of intracranial hemorrhage)
  • Abdominal pain or distention (signs of retroperitoneal bleed)
  • Unexplained drop in hemoglobin or hematocrit

4. Monitor Laboratory Values: Regularly monitor relevant laboratory values:

• Coagulation Studies (PT/INR, aPTT): Monitor PT/INR for warfarin therapy and aPTT for heparin therapy to ensure therapeutic ranges and detect over-anticoagulation.
• Platelet Count: Monitor platelet count, especially if heparin-induced thrombocytopenia (HIT) is a concern. A sudden drop in platelets during heparin therapy should prompt investigation for HIT.
• Hemoglobin and Hematocrit: Monitor hemoglobin and hematocrit levels to detect anemia secondary to blood loss.

Nursing Interventions:

1. Implement Bleeding Precautions: Implement and reinforce bleeding precautions for all patients receiving anticoagulants:

• Minimize Invasive Procedures: Avoid intramuscular injections, arterial punctures, and unnecessary venipunctures. Use smallest gauge needles possible for injections and venipunctures. Apply prolonged pressure to puncture sites.
• Gentle Care: Handle patients gently to minimize trauma.
• Safety Measures: Implement fall precautions, ensure clear pathways, and provide assistance with ambulation as needed.
• Oral Hygiene: Use a soft-bristle toothbrush and avoid dental floss if gums bleed easily.
• Shaving: Use electric razors for shaving.
• Avoid Forceful Activities: Advise patients to avoid forceful coughing, sneezing, straining during bowel movements, and nose blowing.
• Medication Administration: Administer medications carefully and avoid crushing pills if possible.

2. Educate Patient and Family on Bleeding Precautions: Provide comprehensive education to the patient and family on bleeding risks and safety measures:

• Signs and Symptoms of Bleeding: Instruct patients and family members to recognize and report signs of bleeding immediately (bruising, nosebleeds, gum bleeding, blood in urine or stool, etc.).
• Safety Measures at Home: Reinforce safety measures at home, such as removing tripping hazards, using handrails, and wearing shoes.
• Medication Adherence: Emphasize the importance of taking anticoagulants exactly as prescribed and not altering doses without consulting their healthcare provider.
• Dietary Considerations (Warfarin): Educate patients on maintaining consistent vitamin K intake if taking warfarin.
• Alcohol Moderation: Advise moderation in alcohol consumption.
• Medical Alert Bracelet: Recommend wearing a medical alert bracelet indicating anticoagulant use.
• Emergency Contact Information: Provide contact information for the healthcare provider and instructions on when to seek emergency medical care.

3. Monitor Laboratory Values and Adjust Anticoagulant Dosage: Closely monitor coagulation studies (PT/INR, aPTT) and platelet counts. Collaborate with the physician to adjust anticoagulant dosages based on lab results and clinical assessment to maintain therapeutic anticoagulation while minimizing bleeding risk.

4. Promptly Report and Manage Bleeding: If bleeding occurs, take immediate action:

• Stop Anticoagulant Infusion (if applicable): If the patient is on IV heparin, stop the infusion immediately and notify the physician.
• Assess Bleeding Severity: Assess the location, amount, and severity of bleeding. Obtain vital signs and assess hemodynamic status.
• Notify Physician: Immediately notify the physician of any bleeding episode.
• Administer Reversal Agents as Ordered: Prepare to administer reversal agents (protamine sulfate for heparin, vitamin K for warfarin, specific reversal agents for DOACs) as ordered by the physician in cases of severe bleeding.
• Monitor Hemoglobin and Hematocrit: Monitor hemoglobin and hematocrit levels and prepare for blood transfusion if significant blood loss occurs.
• Local Hemostasis Measures: Apply direct pressure to bleeding sites, use topical hemostatic agents as ordered, and consider pressure dressings if needed.

5. Heparin-Induced Thrombocytopenia (HIT) Monitoring: Be vigilant for signs of HIT in patients receiving heparin therapy. Monitor platelet counts regularly (e.g., every 2-3 days while on heparin). Suspect HIT if there is a significant drop in platelet count (e.g., > 50% reduction from baseline) or new thrombosis develops during heparin therapy. If HIT is suspected, stop heparin immediately, notify the physician, and obtain appropriate diagnostic testing (HIT antibody assay). Initiate alternative anticoagulation (non-heparin anticoagulant) as ordered if HIT is confirmed.

References

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