Nursing Diagnosis Care Plans for DVT: A 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 life-threatening pulmonary embolism (PE).

This article provides an in-depth guide for nurses on developing effective nursing diagnosis care plans for patients with DVT. We will explore the essential aspects of nursing assessment, relevant nursing interventions, and detailed care plans for common nursing diagnoses associated with DVT.

Nursing Process in DVT Management

Nurses are integral to the care of patients with DVT, particularly in hospital settings. The severity of DVT dictates treatment, with some patients requiring hospitalization for intravenous (IV) anticoagulation therapy. This therapy necessitates vigilant laboratory monitoring to ensure optimal efficacy and safety. Recognizing the heightened risk of DVT in specific patient populations, nurses are crucial in implementing preventive measures and managing existing cases to prevent recurrence.

Nursing Assessment for DVT

The cornerstone of effective nursing care is a thorough nursing assessment. This process involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s condition fully. Here, we delve into both subjective and objective data collection pertinent to deep vein thrombosis.

Review of Health History

1. Identify Presenting Symptoms: Begin by asking the patient about any symptoms they are experiencing that might suggest DVT:

• Unilateral Leg Swelling: Is one leg noticeably more swollen than the other?
• Leg Pain or Tenderness: Describe the location and nature of any pain or tenderness in the leg.
• Warmth: Is there increased warmth to the touch over the affected area?
• Skin Discoloration: Note any redness, bluish discoloration, or other changes in skin color.

It is also vital to inquire about symptoms indicative of a pulmonary embolism (PE), should the DVT have migrated to the lungs:

• Dyspnea (Difficulty Breathing): Assess for shortness of breath or labored breathing.
• Cough: Note the presence and characteristics of any cough.
• Chest Pain: Evaluate the nature, location, and intensity of chest pain.
• Syncope (Fainting) or Dizziness: Ask about episodes of fainting or lightheadedness.
• Palpitations: Inquire about any sensations of rapid or irregular heartbeat.

2. Identify Risk Factors for DVT: A detailed history of risk factors is crucial in assessing DVT likelihood. Explore the following risk factors with the patient:

• Advanced Age: Older individuals have an increased risk.
• Ethnicity: African Americans are observed to have a higher incidence.
• Smoking History: Smoking significantly elevates DVT risk.
• Obesity: Excess weight is a contributing factor.
• Recent Surgery: Especially orthopedic, neurovascular, or major procedures.
• Immobility: Prolonged periods of inactivity, such as bed rest or paralysis.
• Prior DVT History: A personal or family history of DVT or PE increases risk.
• Cancer: Certain cancers and their treatments can elevate DVT risk.
• Pregnancy: Pregnancy and the postpartum period are associated with increased risk.
• Prolonged Travel: Long car or plane journeys with limited movement.
• Intravenous Drug Use: IV drug use can damage veins and increase clot risk.
• Hypercoagulable Disorders: Inherited or acquired conditions that predispose to clotting.

3. Medication Review: Certain medications are associated with an elevated risk of DVT. Obtain a thorough medication history, specifically noting the use of:

• Oral Contraceptives: Estrogen-containing birth control pills.
• Hormone Replacement Therapy (HRT): Estrogen and progesterone therapies.
• Glucocorticoids: Corticosteroid medications like prednisone.
• Tamoxifen and Raloxifene: Selective estrogen receptor modulators (SERMs).
• Testosterone Therapy: Testosterone replacement or anabolic steroids.
• Antidepressants: Some antidepressants, particularly SSRIs, have been linked to increased risk.

4. Assess for Chronic Medical Conditions: Certain pre-existing medical conditions increase the likelihood of DVT. Ask the patient if they have been diagnosed with:

• Active Cancer: Especially metastatic cancer.
• Heart Failure: Chronic heart failure.
• Respiratory Failure: Chronic lung diseases.
• Inflammatory Bowel Disease (IBD): Crohn’s disease or ulcerative colitis.
• Systemic Lupus Erythematosus (SLE): Lupus.
• Myeloproliferative Disorders: Conditions causing overproduction of blood cells.
• Paroxysmal Nocturnal Hemoglobinuria (PNH): Rare blood disorder.
• Nephrotic Syndrome: Kidney disorder causing protein loss.

5. Central Catheter Assessment: Assess for the presence of central venous catheters. Peripherally inserted central catheters (PICCs) are known to double the risk of DVT compared to central venous catheters (CVCs).

Physical Assessment

1. Homan’s Sign (Limited Diagnostic Value): Historically, Homan’s sign (calf pain on dorsiflexion of the foot with the knee straight) was used to assess for DVT. However, it is neither sensitive nor specific and is not a reliable indicator. Its absence does not rule out DVT, and its presence is not diagnostic. While you may still encounter this in practice or literature, understand its limited clinical utility.

2. Risk Stratification with Wells’ Criteria: Employ clinical decision rules like Wells’ Criteria for DVT to formally assess pre-test probability of DVT. This validated scoring system helps categorize patients into low, moderate, or high risk for DVT and PE, guiding appropriate diagnostic testing and treatment pathways.

3. Integumentary Assessment: Carefully inspect and palpate the skin of the affected limb, noting:

• Palpable Venous Cord: A tender, subcutaneous venous segment that feels indurated, palpable, and cord-like along the affected vein.
• Skin Discoloration: Reddish-purple (erythema) or cyanotic discoloration of the lower extremity.
• Edema: Unilateral edema in the affected leg, comparing limb circumferences.
• Petechiae: Small, pinpoint hemorrhages under the skin.
• Blanching (Rare): In rare cases, blanching of the skin may occur.

4. Respiratory Assessment (PE Signs): Be vigilant for signs of pulmonary embolism, a potentially fatal complication of DVT. Assess for:

• Pleuritic Chest Pain: Chest pain that worsens with coughing or deep inhalation.
• Tachypnea: Rapid breathing rate.
• Tachycardia: Rapid heart rate.
• Palpitations: Awareness of heartbeats, often rapid or irregular.
• Dyspnea: Shortness of breath, even at rest or with minimal exertion.
• Dizziness or Syncope: Lightheadedness or fainting spells.
• Hemoptysis: Coughing up blood.

Diagnostic Procedures

1. Blood Tests:

• D-dimer: This blood test measures a protein fragment present after a blood clot is broken down. Elevated D-dimer levels suggest clot formation but are not specific to DVT (can be elevated in other conditions). A negative D-dimer is highly sensitive for ruling out DVT in low-risk patients.
• Coagulation Profile (PT/aPTT): Prothrombin time (PT) and activated partial thromboplastin time (aPTT) assess the blood’s clotting ability and can help evaluate for underlying hypercoagulable states. These are also crucial for monitoring anticoagulant therapy.

2. Venous Imaging:

• Duplex Venous Ultrasonography: The most common and often first-line imaging test for DVT. It is non-invasive, readily available, and uses sound waves to visualize veins and blood flow, directly detecting clots.
• Venography: Invasive procedure involving injecting contrast dye into veins, followed by X-rays to visualize the venous system and identify blockages. Less common now due to ultrasound availability but may be used in specific situations.
• Magnetic Resonance Venography (MRV): Highly sensitive and specific for DVT, particularly in the pelvic and thigh veins. Useful for patients with contrast dye allergies or when ultrasound is inconclusive, but more expensive and less accessible than ultrasound.

Nursing Interventions for DVT

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

1. Prevent Clot Propagation: Stop the existing clot from growing larger.
2. Prevent Embolization: Prevent the clot from breaking off and traveling to the lungs (PE).
3. Prevent Recurrence: Reduce the risk of future DVT episodes.

1. Initiate Anticoagulation Therapy: Anticoagulation is the cornerstone of DVT treatment.

2. Medication Administration and Bleeding Precautions: Administer prescribed anticoagulants and thrombolytics meticulously. These medications increase bleeding risk. Implement and maintain strict bleeding precautions:

• Soft Toothbrush: Use a soft-bristled toothbrush for oral care.
• Minimize Invasive Procedures: Avoid unnecessary injections, IV insertions, and other invasive procedures.
• Avoid Forceful Nose Blowing/Straining: Teach gentle nose blowing and prevent straining during bowel movements.
• Fall Prevention: Implement fall precautions to prevent injuries.
• Electric Razors: Use electric razors for shaving.
• Pressure After Injections/IV Removal: Apply prolonged pressure to puncture sites.
• Monitor for Bleeding: Regularly assess for signs of bleeding (gums, nosebleeds, bruising, petechiae, hematuria, melena, etc.).

3. Monitor aPTT with Unfractionated Heparin (UFH): For patients receiving intravenous UFH, closely monitor aPTT levels as per hospital protocols, typically every 6 hours, and adjust infusion rates based on these values and physician orders.

4. Low Molecular Weight Heparin (LMWH) Administration: LMWH agents like enoxaparin (Lovenox), dalteparin, and fondaparinux are commonly used for DVT treatment and prophylaxis. They are often administered subcutaneously and have a more predictable response than UFH, often allowing for outpatient treatment.

5. Monitor INR with Warfarin Therapy: If warfarin (Coumadin) is prescribed for long-term outpatient anticoagulation, overlap it with another anticoagulant (like LMWH) until the INR reaches the therapeutic range (typically 2.0-3.0). Regular INR monitoring is crucial to maintain therapeutic anticoagulation and prevent bleeding or clotting complications.

6. Vena Cava Filter Consideration: An inferior vena cava (IVC) filter may be considered in specific situations to trap large emboli and prevent PE. IVC filters are typically reserved for patients:

• Contraindications to Anticoagulation: Patients who cannot take blood thinners due to active bleeding or high bleeding risk.
• Recurrent DVT/PE Despite Anticoagulation: Patients who develop new clots despite adequate anticoagulation.

7. Compression Therapy:

• Compression Stockings: Graduated compression stockings help reduce venous stasis, promote venous return, and minimize edema, reducing the risk of post-thrombotic syndrome and recurrent DVT.
• Intermittent Pneumatic Compression Devices (IPCDs): Pneumatic compression devices can be used, especially for immobile patients, to improve circulation and prevent venous stasis.

8. Encourage Ambulation and Position Changes: Prolonged immobility significantly increases DVT risk.

• Promote Ambulation: Encourage patients to ambulate as soon as medically stable.
• Frequent Position Changes: For bedridden patients, assist with frequent position changes.
• Leg Exercises: Teach leg exercises (ankle pumps, foot circles, knee flexion/extension) for patients with limited mobility.

9. DVT Prophylaxis: Implement DVT prophylaxis measures for at-risk patients as ordered, which may include:

• Pharmacological Prophylaxis: LMWH, low-dose unfractionated heparin, factor Xa inhibitors (rivaroxaban, apixaban, fondaparinux), or direct thrombin inhibitors (dabigatran).
• Mechanical Prophylaxis: Compression stockings, IPCDs.

10. Medication Adherence and Monitoring Education: Emphasize the importance of strict medication adherence and scheduled laboratory monitoring (especially INR for warfarin). Anticoagulant therapy duration varies but is typically at least three months, and potentially longer for recurrent DVT or persistent risk factors.

11. Surgical and Interventional Options: In cases of extensive DVT causing limb-threatening ischemia (e.g., phlegmasia cerulea dolens) or in selected cases of proximal DVT, surgical thrombectomy, catheter-directed thrombolysis, or angioplasty and stenting may be considered to remove the clot and restore blood flow.

12. Reversal Agents Availability: Ensure availability of reversal agents for anticoagulants in case of severe bleeding.

• Protamine Sulfate: Antidote for heparin and LMWH.
• Vitamin K: Antidote for warfarin.
• Idarucizumab: Reversal agent for dabigatran.
• Andexanet alfa: Reversal agent for factor Xa inhibitors (rivaroxaban, apixaban).

13. Lifestyle Modification Counseling: Educate patients on lifestyle changes to minimize DVT recurrence:

• Smoking Cessation: Strongly encourage smoking cessation.
• Blood Pressure Control: Manage hypertension.
• Weight Management: Achieve and maintain a healthy weight.
• Regular Exercise: Promote daily physical activity.
• Avoid Restrictive Clothing: Wear loose-fitting clothing.
• Hydration: Increase daily fluid intake.
• Dietary Considerations: Discuss potential interactions with warfarin and vitamin K-rich foods (for patients on warfarin).

14. Dietary Education (Warfarin Specific): For patients on warfarin, educate about maintaining consistent intake of vitamin K-rich foods (green leafy vegetables) rather than eliminating them, as drastic changes can affect INR levels.

15. Emergency Warning Signs Education: Instruct patients on when to seek immediate medical attention:

• Signs of Bleeding: Unexplained bleeding (nosebleeds, gum bleeding, excessive bruising, blood in urine or stool, heavy menstrual bleeding).
• Signs of PE: Sudden chest pain, shortness of breath, dizziness, coughing up blood.

Nursing Care Plans for DVT

Once nursing diagnoses are identified, nursing care plans guide care delivery. Here are examples of nursing care plans for common DVT-related nursing diagnoses.

Decreased Cardiac Output

Decreased cardiac output related to DVT is a critical concern when a clot embolizes to the pulmonary circulation, causing a pulmonary embolism. This obstruction reduces blood flow to the lungs and heart, impairing oxygenation and cardiac function.

Nursing Diagnosis: Decreased Cardiac Output

Related Factors:

• Pulmonary Embolism secondary to DVT
• Mechanical obstruction of pulmonary blood flow
• Reduced preload and increased afterload on the right ventricle
• Impaired myocardial contractility (in severe PE)

As Evidenced By:

• Hypotension
• Tachycardia (initially, may progress to bradycardia in severe cases)
• Dysrhythmias
• Sudden, sharp chest pain
• Decreased oxygen saturation (SpO2 < 90%)
• Sudden onset of dyspnea
• Tachypnea
• Altered mental status (confusion, agitation, lethargy)
• Dizziness or lightheadedness
• Restlessness, anxiety
• Syncope
• Prolonged capillary refill (> 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 or significant reduction in chest pain and shortness of breath.
• Patient will maintain adequate oxygen saturation (SpO2 ≥ 95% or patient’s baseline).

Nursing Assessments:

1. Rapid Recognition of PE Symptoms: Immediately assess patients presenting with sudden chest pain, acute dyspnea, tachypnea, hypoxia, and signs of shock. These are red flags for PE and require emergency intervention.

2. Continuous Cardiac Monitoring: Monitor heart rate, rhythm, and blood pressure continuously. PE can cause significant hemodynamic instability.

3. ECG Monitoring: Obtain a 12-lead ECG. While not diagnostic for PE, ECG changes such as sinus tachycardia, right bundle branch block, ST-segment changes, or T-wave inversions can support the diagnosis and rule out acute myocardial infarction.

Nursing Interventions:

1. Emergency Anticoagulation: If PE is suspected, initiate immediate anticoagulation as per protocol – typically with IV unfractionated heparin, LMWH, or fondaparinux while awaiting diagnostic confirmation.

2. Consider Thrombolytic Therapy: For hemodynamically unstable patients with massive PE (hypotension, shock), thrombolytic therapy (e.g., alteplase, tenecteplase) may be considered to dissolve the clot and restore pulmonary blood flow. Carefully weigh risks and benefits, considering contraindications to thrombolysis.

3. Prepare for Surgical/Catheter Embolectomy: In patients with massive PE who are contraindicated for or unresponsive to thrombolysis, surgical embolectomy (open surgical removal of the clot) or catheter embolectomy (clot removal via catheter) may be necessary.

4. Shock Management: Be prepared to manage cardiogenic shock.

   • Oxygen Therapy: High-flow oxygen or mechanical ventilation may be needed to support oxygenation.
   • Fluid Resuscitation (Cautious): Administer IV fluids cautiously, as excessive fluid can worsen right ventricular overload. Monitor for signs of fluid overload.
   • Vasopressors/Inotropes: Vasopressors (e.g., norepinephrine) and inotropes (e.g., dobutamine) may be needed to support blood pressure and cardiac output.
   • Pulmonary Vasodilators: Inhaled nitric oxide or prostacyclin may be used to reduce pulmonary artery pressure and improve right ventricular function.

Deficient Knowledge

Patients with DVT often have knowledge deficits regarding the condition, its management, and prevention strategies.

Nursing Diagnosis: Deficient Knowledge (related to DVT and its management)

Related Factors:

• New diagnosis of DVT
• Lack of prior exposure to information about DVT
• Misinformation or misunderstanding of DVT and its risks
• Cognitive limitations, language barriers, or low health literacy

As Evidenced By:

• Verbalizes questions or expresses concerns about DVT diagnosis, treatment, or prevention.
• Demonstrates inaccurate follow-through with medication regimens (e.g., incorrect dosing, missed doses).
• Poor adherence to recommendations for follow-up lab work (e.g., INR monitoring).
• Development of recurrent DVT due to modifiable risk factors.

Expected Outcomes:

• Patient will verbalize accurate understanding of DVT, its causes, treatment, and potential complications.
• Patient will correctly describe their prescribed medications, including purpose, dosage, frequency, and potential side effects.
• Patient will identify their individual risk factors for DVT and articulate at least three strategies to prevent recurrence.

Nursing Assessments:

1. Assess Baseline Knowledge: Elicit the patient’s current understanding of DVT, risk factors, treatment, and prevention. Use open-ended questions.

2. Medication Regimen Comprehension: Evaluate the patient’s understanding of their anticoagulant medication regimen, including drug name, dose, timing, administration route, and duration of therapy.

3. Follow-up Care Understanding: Assess the patient’s knowledge of required follow-up care, including lab monitoring (INR if on warfarin), physician appointments, and signs/symptoms to report.

Nursing Interventions:

1. PE Warning Signs Education: Clearly explain the signs and symptoms of pulmonary embolism (sudden chest pain, dyspnea, palpitations, dizziness, hemoptysis). Emphasize that PE is a medical emergency requiring immediate attention.

2. Individualized Risk Factor Discussion: Identify the patient’s specific DVT risk factors and discuss modifiable risk factors (smoking, obesity, sedentary lifestyle, medication-related risks). Provide tailored advice on risk reduction.

3. Comprehensive Medication Education: Provide detailed education about all prescribed medications:

   • Drug Name and Purpose: Explain what each medication is and why it is prescribed.
   • Dosage and Administration: Provide clear instructions on dose, frequency, route, and timing (e.g., with or without food).
   • Duration of Therapy: Explain how long they will need to take the medication.
   • Potential Side Effects: Discuss common and serious side effects, particularly bleeding risks.
   • Drug Interactions: Inform about potential drug and food interactions (especially vitamin K and warfarin).
   • Importance of Adherence: Stress the critical need for consistent medication taking as prescribed.

4. Recurrence Prevention Strategies: Educate on lifestyle modifications to prevent DVT recurrence:

   • Avoid Prolonged Sitting/Standing: Encourage regular movement, leg exercises during prolonged sitting (travel, work).
   • Hydration: Promote adequate fluid intake.
   • Weight Management: Discuss weight loss if overweight or obese.
   • Smoking Cessation: Provide resources and support for quitting smoking.
   • Compression Stockings: If prescribed, instruct on proper application and wear.
   • Leg Elevation: Elevate legs when sitting or lying down to promote venous return.
   • Avoid Crossing Legs: Discourage crossing legs at the knees or ankles, as this can impede circulation.

Impaired Gas Exchange

Impaired gas exchange in the context of DVT typically arises from a pulmonary embolism, where the clot obstructs pulmonary arteries, hindering blood flow to the lungs and impairing oxygen and carbon dioxide exchange.

Nursing Diagnosis: Impaired Gas Exchange

Related Factors:

• Ventilation-perfusion mismatch due to pulmonary embolism
• Reduced pulmonary blood flow
• Alveolar dead space
• Physiological shunting
• Inflammatory response in the lungs

As Evidenced By:

• Dyspnea (sudden onset or worsening)
• Pleuritic chest pain
• Cough, possibly with hemoptysis
• Tachypnea
• Hypoxemia (SpO2 < 90% or below patient’s baseline)
• Cyanosis (late sign)
• Altered mental status (restlessness, confusion, anxiety)
• Dizziness, syncope
• Tachycardia
• Palpitations

Expected Outcomes:

• Patient will achieve and maintain adequate oxygen saturation (SpO2 ≥ 95% or patient’s baseline).
• Patient will report reduced or absent dyspnea, chest pain, and dizziness.
• Patient will maintain normal breathing pattern and respiratory rate within acceptable limits.
• Patient will maintain baseline level of consciousness.

Nursing Assessments:

1. Rapid Recognition of PE Symptoms: Be alert to sudden onset of dyspnea, chest pain, and hypoxemia, which are hallmark signs of PE. Prompt assessment is crucial.

2. Auscultate Lung Sounds: Assess breath sounds. Crackles, wheezes, or diminished breath sounds may be present in PE, although lung sounds can also be normal in some cases.

3. Monitor Mental Status: Changes in mental status (confusion, restlessness, agitation, lethargy) can indicate hypoxemia and reduced cerebral perfusion secondary to PE.

4. Pulmonary Embolism Rule-Out Criteria (PERC) Assessment: Utilize PERC to assess low-risk patients for PE. If all PERC criteria are negative, PE is highly unlikely, and further testing may be avoided. PERC criteria include:

   1. Age < 50 years
   2. Heart rate < 100 bpm
   3. SpO2 ≥ 95% on room air
   4. No hemoptysis
   5. No recent trauma or surgery (within 4 weeks)
   6. No prior DVT/PE
   7. No hormone use (oral contraceptives, estrogen replacement)
   8. No unilateral leg swelling

Nursing Interventions:

1. Ventilation/Perfusion (V/Q) Scan Preparation: Prepare the patient for a V/Q scan, if ordered. A V/Q scan assesses airflow and blood flow in the lungs and can help diagnose PE by identifying ventilation-perfusion mismatches.

2. Oxygen Therapy Administration: Administer supplemental oxygen (nasal cannula, face mask, non-rebreather mask) to maintain SpO2 > 90% (or as ordered). Titrate oxygen as needed based on SpO2 monitoring and arterial blood gas (ABG) results.

3. Non-pharmacological Interventions:

   • Positioning: Elevate the head of the bed to improve lung expansion and reduce dyspnea.
   • Breathing Exercises: Teach deep breathing and coughing exercises to improve ventilation and clear secretions.
   • Pulmonary Hygiene: Encourage incentive spirometry to promote lung expansion.

4. Respiratory Support Preparation: Be prepared for potential respiratory decompensation and the need for advanced respiratory support:

   • Intubation and Mechanical Ventilation: If severe hypoxemia, respiratory failure, or hemodynamic instability develops, prepare for endotracheal intubation and mechanical ventilation.
   • Non-invasive Ventilation (NIV): In select patients with less severe respiratory distress, NIV (e.g., BiPAP, CPAP) may be considered to support breathing and avoid intubation.

Ineffective Peripheral Tissue Perfusion

Ineffective peripheral tissue perfusion in DVT arises from the venous obstruction caused by the thrombus, impeding blood flow out of the affected limb and leading to venous stasis and impaired tissue oxygenation and nutrient delivery.

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion

Related Factors:

• Venous obstruction from deep vein thrombosis
• Venous stasis
• Edema formation
• Inflammatory response in the vessel wall
• Potential for compartment syndrome (in rare, severe cases)

As Evidenced By:

• Edema in the affected extremity (unilateral swelling)
• Pain or tenderness in the affected limb
• Increased warmth to touch in the area of the clot
• Skin discoloration (erythema, cyanosis)
• Palpable venous cord
• Possible changes in peripheral pulses (usually palpable, but may be diminished due to edema)
• Slowed capillary refill (though less reliable in presence of edema)

Expected Outcomes:

• Patient will maintain adequate peripheral tissue perfusion in the affected limb, as evidenced by:

  • Reduction in edema
  • Decreased pain level
  • Skin color returning to baseline
  • Warmth of extremity within normal limits
  • Palpable peripheral pulses
  • Capillary refill < 3 seconds

• Patient will remain free from complications of impaired tissue perfusion, such as skin breakdown or ulceration.

Nursing Assessments:

1. Comprehensive Limb Assessment: Thoroughly assess the affected limb, comparing it to the unaffected limb:

   • Edema: Measure and document limb circumference at consistent points (e.g., calf, thigh). Assess for pitting edema.
   • Pain: Assess pain location, intensity (using pain scale), character, and aggravating/relieving factors.
   • Skin Color and Temperature: Observe skin color (redness, pallor, cyanosis). Palpate skin temperature (warmth, coolness).
   • Pulses: Palpate peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral) in both limbs and compare quality and strength.
   • Capillary Refill: Assess capillary refill time in toes of affected and unaffected limbs. Note that edema can affect reliability.
   • Palpable Venous Cord: Assess for tenderness and palpability of a cord-like vein.

2. Risk Factor Assessment: Re-assess for contributing risk factors for DVT (immobility, recent surgery, medications, medical conditions) to guide ongoing prevention strategies.

3. Leg Circumference Measurement: Measure leg circumference at consistent points (e.g., below tibial tuberosity, above patella) to quantify edema and monitor changes over time. A difference of > 3 cm between limbs may indicate DVT.

Nursing Interventions:

1. Anticoagulant Administration: Administer prescribed anticoagulants promptly and monitor for therapeutic effect and side effects (bleeding).

2. Compression Therapy Application:

   • Compression Stockings: Apply graduated compression stockings as ordered, ensuring proper fit and patient education on application and wear.
   • Pneumatic Compression Devices: If ordered, apply and maintain intermittent pneumatic compression devices, particularly for immobile patients.

3. Hydration Management: Promote adequate hydration to reduce blood viscosity and improve circulation. Encourage oral fluids or administer IV fluids as ordered.

4. Elevate Affected Limb: Elevate the affected leg above heart level when patient is sitting or lying down to promote venous return and reduce edema.

5. Pain Management: Administer analgesics as prescribed to manage pain. Non-pharmacological pain relief measures (positioning, cool compresses) can also be used.

6. Monitor for Compartment Syndrome: In rare cases of massive DVT, monitor for signs of compartment syndrome (severe pain, tense swelling, pain with passive motion of toes, paresthesias, pallor, pulselessness – late sign). Report any concerns immediately.

7. Skin Care: Maintain skin integrity. Keep skin clean and dry. Avoid restrictive clothing or devices that could further impair circulation.

8. Patient Education on Positioning and Activity: Educate patient on importance of leg elevation, avoiding prolonged standing/sitting, and performing leg exercises to improve circulation.

9. Ultrasound Follow-up: Prepare patient for follow-up Doppler ultrasound studies to monitor clot resolution and assess for chronic venous insufficiency.

Risk for Bleeding

Patients receiving anticoagulant therapy for DVT are at significant risk for bleeding, a major complication of this treatment.

Nursing Diagnosis: Risk for Bleeding

Related Factors:

• Anticoagulant medication therapy (heparin, LMWH, warfarin, direct oral anticoagulants)
• Underlying coagulopathy or thrombocytopenia
• Invasive procedures (IV insertion, injections)
• Trauma or injury
• Gastrointestinal ulcers or other bleeding risks
• Lack of knowledge about bleeding precautions

As Evidenced By:

A “Risk for” diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. The evidence is the presence of risk factors.

Expected Outcomes:

• Patient will remain free from signs and symptoms of bleeding throughout anticoagulant therapy.
• Patient will maintain therapeutic levels of anticoagulation (e.g., INR within target range for warfarin) without excessive anticoagulation.
• Patient will verbalize and demonstrate understanding of bleeding precautions and safety measures to minimize bleeding risk.

Nursing Assessments:

1. Vital Signs and Hemodynamic Monitoring: Monitor vital signs (blood pressure, heart rate) for signs of hypovolemia secondary to bleeding (hypotension, tachycardia). Assess for dizziness, lightheadedness, weakness.

2. Bleeding Assessment: Regularly assess for any signs of bleeding:

   • Overt Bleeding: Nosebleeds (epistaxis), gum bleeding, easy bruising, petechiae, purpura, hematomas, hematuria (blood in urine), hematemesis (vomiting blood), melena (black, tarry stools), hemoptysis (coughing up blood), vaginal bleeding (abnormal or excessive).
   • Covert Bleeding: Monitor for signs of internal bleeding (abdominal pain, back pain, unexplained drop in hemoglobin/hematocrit, change in mental status).

3. Laboratory Monitoring: Closely monitor relevant coagulation studies:

   • PT/INR: For warfarin therapy. Ensure INR is within therapeutic range (typically 2.0-3.0) and not excessively elevated.
   • aPTT: For unfractionated heparin therapy. Monitor aPTT levels as per protocol.
   • Platelet Count: Monitor platelet count, especially if heparin-induced thrombocytopenia (HIT) is a concern.
   • Hemoglobin and Hematocrit: Monitor for trends that may indicate blood loss.

4. Heparin-Induced Thrombocytopenia (HIT) Monitoring: If patient is on heparin, monitor platelet count trends. A sudden drop in platelets (typically > 50% from baseline) should raise suspicion for HIT. Assess for signs of new thrombosis, which can occur with HIT despite thrombocytopenia.

Nursing Interventions:

1. Bleeding Risk Education: Educate the patient and family about bleeding risks associated with anticoagulants and necessary precautions:

   • Soft Toothbrush and Electric Razor: Use a soft-bristled toothbrush and electric razor.
   • Avoid Forceful Activities: Avoid forceful nose blowing, straining during bowel movements.
   • Medication Adherence: Emphasize importance of taking medications exactly as prescribed and not doubling doses.
   • INR Monitoring (Warfarin): If on warfarin, stress the importance of regular INR blood tests and follow-up appointments.
   • Dietary Considerations (Warfarin): Educate about maintaining consistent vitamin K intake and avoiding drastic dietary changes.
   • Alcohol Caution: Advise limiting alcohol intake, as it can increase bleeding risk and interact with warfarin.
   • OTC Medication Caution: Advise against taking aspirin, NSAIDs (ibuprofen, naproxen), or herbal supplements without consulting their healthcare provider, as these can increase bleeding risk.

2. Bleeding Precautions Implementation:

   • Minimize Invasive Procedures: Avoid unnecessary venipunctures, injections, and invasive procedures. Use smallest gauge needles when necessary.
   • Pressure Application: Apply prolonged pressure to venipuncture and injection sites.
   • Fall Prevention: Implement fall precautions to prevent injuries.
   • Safe Environment: Ensure a safe environment free of clutter and hazards to prevent accidental bumps or injuries.

3. Action for Bleeding Episodes: Provide clear instructions on what to do if bleeding occurs:

   • Minor Bleeding (e.g., small cut): Apply direct pressure for 10-15 minutes. If bleeding does not stop, contact healthcare provider.
   • Significant Bleeding (e.g., nosebleed not stopping, heavy bleeding, head injury): Seek immediate medical attention – go to emergency room.
   • Medication Adjustment: If bleeding occurs, notify physician immediately. Be prepared to hold or adjust anticoagulant dose as ordered.

4. Antidote Availability: Ensure availability of reversal agents for anticoagulants:

   • Protamine Sulfate: For heparin and LMWH overdose.
   • Vitamin K: For warfarin overdose.
   • Fresh Frozen Plasma or Prothrombin Complex Concentrate (PCC): May be used in severe warfarin-related bleeding.
   • Idarucizumab (Praxbind): Specific reversal agent for dabigatran.
   • Andexanet Alfa (Andexxa): Specific reversal agent for factor Xa inhibitors (rivaroxaban, apixaban).

By implementing these nursing care plans, nurses can provide comprehensive and effective care for patients with deep vein thrombosis, addressing key nursing diagnoses and promoting optimal patient outcomes.

References

(References would be listed here as in the original article, ensuring proper formatting if needed for specific guidelines.)